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7 cor pulmonale


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7 cor pulmonale

  1. 1. Cor Pulmonale (Pulmonary Heart Disease) Guo Yubiao, M.D & Ph.D Pulmonary & Critical Care Medicine The first Affiliated Hospital of Sun-Yat Set University
  2. 3. Presentation Outline <ul><li>Definition </li></ul><ul><li>Epidemiology/Classification </li></ul><ul><li>Clinical manifestations </li></ul><ul><ul><li>Symptoms </li></ul></ul><ul><ul><li>Signs </li></ul></ul><ul><li>Diagnostic workup & Differential Diagnosis </li></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Differential Diagnosis </li></ul></ul><ul><li>Treatment & Prevention </li></ul><ul><li>Summary </li></ul>
  3. 4. Classification <ul><li>Acute Cor Pulmonale </li></ul><ul><ul><li>Massive pulmonary embolism </li></ul></ul><ul><li>Chronic Cor Pulmonale </li></ul>
  4. 5. Epidemiology <ul><li>High prevalence(1992, 4.42 ‰) </li></ul><ul><li>District difference </li></ul><ul><li>Smoking </li></ul><ul><li>Acute exacerbation </li></ul>
  5. 6. Definition of Chronic Cor Pulmonale <ul><li>Hypertrophy and dilatation of the right ventricle </li></ul><ul><li>Secondary to the pulmonary hypertension </li></ul><ul><li>Caused by disease of the pulmonary parenchyma, and/or chest wall, and/or pulmonary vascular system </li></ul><ul><li>With or without right heart failure </li></ul><ul><li>Exclusion the causes of congenital heart disease and left heart disease </li></ul>
  6. 7. Etiology <ul><li>Pulmonary parenchyma disease </li></ul><ul><ul><li>COPD80%~90%,asthma,bronchiectasis,severe </li></ul></ul><ul><ul><li>tuberculosis, idiopathic interstitial pneumonia, sarcoidosis, eosinophilic granuloma,silicosis, etc . </li></ul></ul><ul><li>Disorders of the neuromuscular apparatus and chest wall </li></ul><ul><ul><li>Poliomyelitis ,Guillain-Barr é syndrome, Kyphoscoliosis </li></ul></ul>
  7. 8. Etiology <ul><li>Pulmonary vascular disorders </li></ul><ul><ul><li>chronic pulmonary thromboembolism, pulmonary arteriolitis, allergic granulomatosis, primary pulmonary hypertension </li></ul></ul><ul><li>Others </li></ul><ul><ul><li>primary alveolar hypoventilation, sleep apnea syndromes </li></ul></ul>
  8. 9. Pathophysiology <ul><li>The formation of pulmonary hypertension </li></ul><ul><ul><li>Functional factors of increase of vascular resistance </li></ul></ul><ul><ul><li>Anatomical factors of increase of vascular resistance </li></ul></ul><ul><ul><li>Increased blood volume and hyperviscosity </li></ul></ul><ul><li>Cardiac disorders and heart failure </li></ul><ul><li>Damage to other vital organs </li></ul>
  9. 10. Functional factors of increase of vascular resistance <ul><li>Hypoxia is the most important factor for pulmonary hypertention. </li></ul><ul><li>Hypoxic pulmonary vasoconstriction </li></ul><ul><ul><li>Determined mostly by the ratio of vasoconstrictive substances to vasodilative substances </li></ul></ul><ul><ul><li>Leukotriene, 5-HT, Ang II, PAF,EDCF/ NO, PGI 2 ,EDRF </li></ul></ul><ul><li>Direct effect of hypoxia on the increase of the smooth muscular cell membrane permeability to Ca 2+ </li></ul><ul><li>Acidosis increases the sensitivity of vasoconstriction to hypoxia </li></ul>
  10. 11. Anatomical factors of increase of vascular resistance <ul><li>Vasculitis </li></ul><ul><li>Emphysema, increased intra-alveolar pressure, compressed pulmonary capillaries </li></ul><ul><li>Reduction in pulmonary capillary bed </li></ul><ul><li>Pulmonary vascular remodeling </li></ul><ul><li>Multiple pulmonary micro-arteriole thrombosis </li></ul>
  11. 12. Increased blood volume and hyperviscosity <ul><li>Secondary polycythemia and hyperviscosity </li></ul><ul><li>Water and sodium retention </li></ul><ul><ul><li>Aldosterone </li></ul></ul><ul><ul><li>Renal arteriole constriction </li></ul></ul>
  12. 13. Cardiac disorders and heart failure <ul><li>Right ventricular hypertrophy secondary to pulmonary hypertension. </li></ul><ul><li>Sustained pulmonary hypertension exceeds the compensation of right ventricle, and causes the increase of right ventricular end diastolic pressure, and dilation and failure of right ventricle. </li></ul><ul><li>A few may develop left heart failure. </li></ul>
  13. 14. Damages to other vital organs <ul><li>Hypoxia and acidosis can also do damages to other vital organs, e.g. brain,liver,kidney,gastrointestine, </li></ul><ul><li>endocrine system . </li></ul>
  14. 15. Pulmonary diseases Hypoxia, hypercapnia/acidosis Pulmonary Destruction of capillary bed Blood volume ↑ vasoconstrition Blood viscosity ↑ Pulmonary hypertension Right heart workload ↑ Right ventricular hypertrophy Right heart failure Impaired Toxic effect from bacteria Cardiac myocardial function on myocardium arrythmia Myocardial hypoxia Recurrent Electrolytic and Accumulation of lactate pneumonia acid-base disturbance
  15. 16. Clinical manifestations <ul><li>Compensatory stage of the respiratory and cardiac function </li></ul><ul><li>De-compensatory stage of the respiratory and cardiac function </li></ul>
  16. 17. Compensatory stage of the respiratory and cardiac function <ul><li>Symptoms: cough, sputum, short of breath, dyspnea and palpitation on exertion, fatigue and decrease of exercise tolerance </li></ul><ul><li>more severe in acute exacerbation. A few with chest pain or hemoptysis . </li></ul>
  17. 18. Compensatory stage of the respiratory and cardiac function <ul><li>Signs: cyanosis, signs of emphysema, moist rales and/or rhonchi, </li></ul><ul><li>distal heart sound, systolic murmur of tricuspid area , P2>A2 , subxiphoid visible/palpable cardiac impulse, distended jugular venous pulsation </li></ul>
  18. 19. De-compensatory stage of the respiratory and cardiac function <ul><li>Respiratory failure </li></ul><ul><li>Symtoms : severe dyspnea,especially at night, headache, insomnia,inappetence, </li></ul><ul><li>somnolence, dizziness,confusion, even delirium. </li></ul><ul><li>Signs : congunctiva congestion and edema, retinal vasodilatation, optic papillary edema. weakness or disappear of deep reflexes, pathological reflexes, redness, sweaty </li></ul>
  19. 20. Right heart failure <ul><li>Symptoms: predominant short of breath,palpitation, inappetence,nausea </li></ul><ul><li>Signs: cyanosis,tachycardia,arrhythmia,subxiphoid systolic murmur or even diastolic murmur. Tender hepatomegaly,Hepatojugular reflux, lower extremity edema, ascites </li></ul>
  20. 21. signs
  21. 22. Chest radiography <ul><li>Signs of pulmonary hypertension: </li></ul><ul><li>Enlarged right descending pulmonary artery with diameter ≥15mm </li></ul><ul><li>The ratio of the diameter of right descending pulmonary artery to trachea≥1.07 </li></ul><ul><li>Bulge of pulmonary artery/with the height≥3mm </li></ul><ul><li>dilation of the main pulmonary artery and its branches with concurrent underperfusion of the peripheral branches </li></ul><ul><li>Signs of right ventricular enlargement </li></ul><ul><li>Signs of underlying diseases and infection </li></ul>
  22. 24. Electrocardiography <ul><li>Right-axis deviation with a frontal plane axis greater than +90 ° </li></ul><ul><li>Marked clockwise rotation of the electrical axis </li></ul><ul><li>R v1 +S v5 ≥ 1.05mv </li></ul><ul><li>P-pulmonale pattern </li></ul><ul><li>Incomplete or rarely complete right bundle branch block </li></ul><ul><li>Low voltage QRS </li></ul><ul><li>Occasional large Q wave or QS in V1,V2, even V3,suggesting healed myocardial infarction </li></ul>
  23. 25. Electrocardiography of Chronic Cor Pulmonale
  24. 26. Echocardiography <ul><li>The right ventricular outflow ≥ 30 m m </li></ul><ul><li>The right ventricular internal dimension ≥20mm </li></ul><ul><li>Anterior RV wall thickness </li></ul><ul><li>Ratio of left to right ventricular internal dimension <2 </li></ul><ul><li>Increased right pulmonary artery or pulmonary artery dimension (Peak systolic pulmonary artery pressure) </li></ul><ul><li>Increased right atrium dimension </li></ul>
  25. 27. Arterial blood gas analysis <ul><li>Hypoxemia and/or hypercapnia </li></ul><ul><li>Respiratory failure: </li></ul><ul><li>PaO2<60mmHg </li></ul><ul><li>PaCO2>50mmHg </li></ul>
  26. 28. Serum assessment <ul><li>Increased RBC count and Hemoglobin </li></ul><ul><li>Increased blood and plasma viscosity </li></ul><ul><li>Increased WBC count and neutrophilic ratio when infection occurs </li></ul><ul><li>Change of renal or hepatic function </li></ul><ul><li>Electrolyte imbalance </li></ul>
  27. 29. Others <ul><li>Pulmonary function test </li></ul><ul><ul><li>For early stage or non-exacerbation stage patients </li></ul></ul><ul><li>Sputum culture </li></ul><ul><ul><li>For guidance of antibiotics selection in patients with acute exacerbation stage </li></ul></ul>
  28. 30. Diagnosis <ul><li>History of COPD and pulmonary parenchymal or chest wall or pulmonary vascular disease, </li></ul><ul><li>Symptoms and signs of pulmonary hypertension and right heart dilation or failure, </li></ul><ul><li>combined with the signs of right heart hypertrophy and dilation by ECG, X-ray,UCG. </li></ul>
  29. 31. Differential Diagnosis <ul><li>Coronary atherosclerotic heart diseases </li></ul><ul><ul><li>History of left heart failure, hypertension, hyperlipoidemia ; </li></ul></ul><ul><ul><li>Symtoms of angina pectoris, myocardial infarction </li></ul></ul><ul><ul><li>Left ventricular hypertrophy in P.E. and X-ray, myocardial ischemia in ECG </li></ul></ul><ul><li>Rheumatic heart diseases </li></ul><ul><ul><li>History of rheumatic arthritis and myocarditis </li></ul></ul><ul><ul><li>Usu. involving other cardiac valves </li></ul></ul><ul><ul><li>Special signs in X-ray, ECG and UCG </li></ul></ul><ul><li>Primary cardiomyopathy </li></ul><ul><ul><li>No history of chronic pulmonary diseases </li></ul></ul><ul><ul><li>Enlargement of entire heart </li></ul></ul><ul><ul><li>No signs of pulmonary hypertension in X-ray </li></ul></ul>
  30. 32. Therapy <ul><li>S tage of Acute exacerbation </li></ul><ul><ul><li>Control of infection </li></ul></ul><ul><ul><li>Oxygen therapy </li></ul></ul><ul><ul><li>Control of heart failure </li></ul></ul><ul><ul><li>Control of cardiac arrythmia </li></ul></ul><ul><ul><li>Anticoagulatory therapy </li></ul></ul><ul><ul><li>Patient care </li></ul></ul>
  31. 33. Control of infection <ul><li>Antibiotics based on sputum culture </li></ul><ul><li>Before the culture, based on infection acquired location and sputum smear gram stain </li></ul><ul><li>CAP: G positive; HAP:G negative </li></ul><ul><li>Penicillins, aminoglycerides,quinolones and cephalosporins </li></ul><ul><li>Secondary fungal infection </li></ul>
  32. 34. Oxygen therapy <ul><li>Clearance of respiratory tract </li></ul><ul><li>Correction of hypoxia and hypercapnia </li></ul>
  33. 35. Control of heart failure <ul><li>Different to heart failure caused by other cardiac disease </li></ul><ul><li>May be improved after control of infection and normality of blood gas </li></ul><ul><li>Diuretics </li></ul><ul><li>Vasodilators </li></ul><ul><li>Positive inotropic agents-digitalis </li></ul>
  34. 36. Diuretics <ul><li>Reduction of blood volume and right heart load,elimination of edema </li></ul><ul><li>Small dosage and short period </li></ul><ul><li>Moderate degree:HCT .antisterone;Severe cases: furosemide </li></ul><ul><li>Adverse effect: </li></ul><ul><ul><li>alkalosis with low K + &CL - </li></ul></ul><ul><ul><li>thickened sputum </li></ul></ul><ul><ul><li>blood condensation </li></ul></ul>
  35. 37. Vasodilators <ul><li>Reduction of cardiac pre- and after- load and oxygen consumption, improve the myocardial contractibility. </li></ul><ul><li>Adverse effect: low blood pressure, tachycardia and hypoxemia and hypercapnia </li></ul>
  36. 38. Positive inotropic agents-digitalis <ul><li>Low tolerance to digitalis due to chronic hypoxia and infection: arrhythmia </li></ul><ul><li>Correction of hypoxia and hypokalemia before use </li></ul><ul><li>Low dosage, fast action and fast metabolite agents: lanatoside C(cedilanid),strophanthin K </li></ul><ul><li>Indications: </li></ul><ul><ul><li>refractory edema after improvement of infection and respiratory function and no effect on diuretics </li></ul></ul><ul><ul><li>right heart failure without obvious infection </li></ul></ul><ul><ul><li>acute left heart failure </li></ul></ul>
  37. 39. <ul><li>Control of arrhythmia:usually self-limited </li></ul><ul><li>Anticoagulatory therapy:heparin or low molecular weight heparin </li></ul><ul><li>Intensive patient care:monitoring, airway secretion aspiration </li></ul>
  38. 40. Stage of non-exacerbation <ul><li>Combined with Chinese medicine </li></ul><ul><li>Long-term home oxygen therapy </li></ul><ul><li>Pulmonary Rehabilitation </li></ul><ul><li>Regulation of immune system </li></ul><ul><li>Nutrition </li></ul>
  39. 41. Complications <ul><li>Pulmonary encephalopathy </li></ul><ul><li>Acid-base and electrolyte disturbance </li></ul><ul><li>Cardiac arrhythmia:af,aF,at </li></ul><ul><li>Shock </li></ul><ul><li>Gastrointestional haemorrhage </li></ul><ul><li>Disseminated intravascular coagulation </li></ul>
  40. 42. Prognosis <ul><li>Recurrent acute exacerbation, progressing with gradually impairment of pulmonary function </li></ul><ul><li>Motality of 10%-15% </li></ul><ul><li>Prolong lifespan and improve quality of life </li></ul>
  41. 43. Prevention <ul><li>Smoking cessation </li></ul><ul><li>Treatment of the predisposing factors </li></ul><ul><ul><li>respiratory tract infection, inhalation of noxious gases, occupational protection, etc </li></ul></ul><ul><li>Education </li></ul>
  42. 44. <ul><li>Thank You! </li></ul>