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1、CHRONIC COR PULMONALE,Right heart,Left heart,Pulmonary circulation,Systemic circulation,Cor pulmonale,Acute cor pulmonale,Chronic cor pulmonale,Right ventricle enlargement,Right ventricle hypertrophy and/or enlargement,PTE,ARDS,肺循环和右心的生理学特征,肺循环特点：低压、低阻、高流量系统 肺动脉压力： 收缩压：22mmHg 舒张压：10mmHg 平均压：15mmHg 右
2、心室特点 壁薄、高顺应性,PAP=CO(PVRA+PVRC+PVRV),pulmonary arterial hypertension,resulting from diseases affecting the structure and/or the function of the lungs results in right ventricular enlargement (hypertrophy and/or dilatation) and may lead with time to right heart failure,肺动脉高压是肺心病的始动环节,PAP RV后负荷 RV室壁张力
3、心肌耗氧量 ，冠脉的阻力 心肌血流减少，顺应性下降，而损害右室功能 右心室可发挥代偿功能以克服肺动脉的阻力，其结果逐渐发生右室肥厚 随着病情的进展，肺动脉压力持续升高，超过右心室的负荷，右心失代偿，右心排血量下降，右心收缩期末残留血量增加，舒张末压增高。促使右心室扩大和右心室功能衰竭,Definition,Pulmonary hypertension complicating chronic respiratory disease is generally defined by the presence of a resting mean pulmonary artery pressure (
4、PAP) 20 mmHg This is slightly different from the definition of idiopathic pulmonary hypertension (PAP 25 mmHg) In young ( 20 mmHg is always abnormal,Definition,In the “natural history” of COPD, pulmonary hypertension is often preceded by an abnormally large increase in PAP during exercise, defined b
5、y a pressure 30 mmHg for a mild level of steady state exercise The term “exercising” pulmonary hypertension has been used by some authors Chronic obstructive pulmonary disease (COPD) is the main cause of cor pulmonale,Definition of cor pulmonale,Enlargement or hypertrophy of the RV Secondary to abno
6、rmalities of Lungs Thorax Pulmonary ventilation Circulation Sometimes leads to RV failure,Background,The term “cor pulmonale” is still very popular in the medical literature Its definition varies and there is presently no consensual definition Forty years ago an expert committee of the World Health
7、Organization defined cor pulmonale as “hypertrophy of the right ventricle resulting from diseases affecting the function and/or structure of the lungs . . .” This pathological definition is in fact of limited value in clinical practice,Background,It has been proposed to replace the term “hypertrophy
8、” by “alteration in the structure and function of the right ventricle” It has also been proposed to define clinically cor pulmonale by the presence of edema in patients with respiratory failure,Epidemiology,肺心脏是我国呼吸系统的一种常见病 我国在70年代普查结果，14岁人群肺心病患病率为4.8 1992年在北京、湖北、辽宁的农村调查102230居民的肺心病患病率为4.42，占15岁人群的6
9、.72 肺心病的患病率存在地区差异，东北、西北、华北患病率高于南方地区，农村患病率高于城市，并随年龄增高而增加 吸烟者比不吸烟者患病率明显增多,男女无明显差异 冬、春季节，气候骤变是肺心病急性发作的重要诱因,Etiology: which chronic lung disease may lead to cor pulmonale?,four major groups of diseases,limitation to airflow (COPD and other causes of chronic bronchial obstruction) restriction of pulmonar
10、y volumes from extrinsic or parenchymatous origin (restrictive lung diseases) poor ventilatory drive (respiratory insufficiency of “central” origin) Pulmonary vascular disease (pulmonary embolism),Etiology: which chronic lung disease may lead to cor pulmonale?,COPD is the major cause of chronic resp
11、iratory insufficiency and cor pulmonale It probably accounts for 8090% of the cases COPD includes chronic obstructive bronchitis and emphysema which are often associated Among the restrictive lung diseases kyphoscoliosis, idiopathic pulmonary fibrosis, and pneumoconiosis are the main causes of cor p
12、ulmonale Among the etiologies of respiratory insufficiency of “central” origin the obesityhypoventilation syndrome is a relatively frequent cause of cor pulmonale,Mechanisms,alveolar hypoxia acute hypoxia causes pulmonary vasoconstriction chronic longstanding hypoxia induces pulmonary vascular remod
13、elling,Mechanisms of cor pulmonale,Hypoxic pulmonary vasoconstriction (HPV) is localized in the small precapillary arteries Its precise mechanism is not fully understood. Pulmonary hypertension is generally observed in respiratory patients exhibiting pronounced chronic hypoxaemia (PaO2 5560 mm Hg) C
14、hronic alveolar hypoxia leads to remodelling of the pulmonary vascular bed hypertrophy of the muscular media of the small pulmonary arteries The remodelling leads to elevation of PVR and to pulmonary hypertension,Mechanisms of cor pulmonale,Hypercapnic acidosis and hyperviscosity caused by polycytha
15、emia, their role seems small when compared to that of alveolar hypoxia the increase of PVR induced by IPF is caused by anatomical factors: loss of pulmonary vascular bed or compression of arterioles and capillaries by the fibrosing process,肺动脉高压参与右心和左心衰竭的 主要病理生理学因素,Clinical signs,肺、心功能代偿期 症状 咳嗽、咳痰、气
16、促，活动后心悸、呼吸困难、乏力和劳动耐力下降。急性感染可使上述症状加重。少有胸痛或咯血 体征 不同程度的紫绀 肺气肿体征：桶状胸，语颤减弱；两肺叩诊过清音，心界缩小，肺下界下移；听诊呼吸音减弱，偶有干湿性啰音，心音遥远. 肺动脉高压体征：P2A2，三尖瓣区可出现收缩期杂音或剑突下心脏搏动增强，提示有右心室肥厚。部分患者因肺气肿使胸内压升高，阻碍腔静脉回流，可有颈静脉充盈。,Clinical signs,肺、心功能失代偿期 呼吸衰竭 症状 呼吸困难加重，夜间为甚，常有头痛、失眠、食欲下降，但白天嗜睡，甚至表情淡漠，神志恍惚、谵妄等肺性脑病的表现 体征 明显紫绀，有球结膜充血、水肿，严重时可有视网膜血管扩张，视乳头水肿等颅内压升高的表现。腱反射减弱或消失，出现病理反射。因高碳酸血症可出现周围血管扩张的表现，如皮肤潮红，多汗 右心衰竭 症状 气促更明显，心悸、食欲不振、腹胀、恶心等。 体征 紫绀更明显，颈静脉怒张，心率增快，可出现心律失常，剑下可闻及收缩期杂音，甚至出现舒张期杂音。肝脏肿大且有压痛，肝颈回流征阳性，下肢浮肿，
