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Cor pulmonale

COR PULMONALE

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1. Definitie

- chronisch lijden van rechter ventrikel door decompensatie, dilatatie of hypertrofie. 
- oorzaken: chronische pulmonale hypertensie tgv longziekten (emfyseem, fibrose, silicose of recidiverende embolen), thoraxmisvorming (kyfoscoliose, pectus excavatum), ziekten van de longvaten, chronische inspiratoire obstructie (vb tonsilhypertrofie)

 

2. Oorzaken

rechter ventrikelfalen
- rechter ventrikel dilatatie of hypertrofie
- oorzaken pulmonale hypertensie
- cardiovasculair:
- linker ventrikel falen (mitralisstenose, collageen vaatziekten)
- links-rechts shunt (congenitale hartafwijkingen)
- bloed:
- chronische hypoxie (veroorzaakt stijging van de vaatweerstand)
tgv van  COPD, chronische aanwezigheid op grote hoogte, slaapapnee, ernstige anemie.
- verhoogde viscositeit van het bloed (leukemie, polycytemia vera)
- longen:
- primaire pulmonale hypertensie
- verhoogde intrathoracale druk (COPD, mechanische ventilatie- peep, thoraxmisvorming-kyfoskoliose, obesitas, cystische fibrose)
- pulmonale venoöcclusieve ziekte

- longembolen

 

3. Diagnostiek

-anamnese
- verhaal van progressieve dyspnee (hoest, heesheid), gewichtstoename, zwakte (vermoeidheid, syncope), perifere oedemen.
- vraag steeds na:gebruikte medicatie en MVG
- kliniek
- ademhaling (dyspnee, hoest, hempotysis, wheezing, heesheid)
- gastroenterologisch (gewichtstoename, ascites, hepatomegalie)
- beeld van overload (opzetting halsvenen, perifere oedemen)
- pulse oximetrie
- labo
- bloedgassen (PO2 in rust 40-60 mm Hg, PCO2 in rust 40-70 mm Hg)
- Hb en hematocriet
- B-natriuretisch peptide (DD biventriculair lijden of respiratoir lijden)
-Electrocardiogram
- asdeviatie naar rechts (door rechter ventrikel hypertrofie)
- P-toppen zijn groot en gepiekt
- T afvlakking thv rechter precordialen
- ST depressie thv II, III en aVf
- beeldvorming
- RX-thorax: tekenen van pulmonale hypertensie (grote pulmonale arteries > 16- 18 mm, vergroot silhouet rechter ventrikel), zijn er longeffusies?
- Echocardio: rechter ventrikel (dilatatie en hypertrofie), linker ventrikel (nromaal), meting met doppler (meten tricuspidalis regurgitatie, druk arteria pulmonalis, rechter ventrikel ejectiefractie)
- ventilatie/perfusiescan
- CT of MRI: grootte van de ventrikels en pulmonale arteriën, opsporen van longembolen
- hartcatheterisatie

- rechter hart: geeft goede drukmetingen

 

4. DD

- primair linker hartlijden
- congenitale hartafwijkingen
- hypothyroidie
- cirrhose

 

 

Eerste opvang

- ABC
- O2 geven tot 90% saturatie
- IV-lijn
- monitoring (hart, bloeddruk, pulse oxymetrie)
- indien bronchospasmen: aerosol
- voorkom hypotensie, dus ten velden geen vasodilatatoren, geen cedocard en geen diuretica
- soms is intubatie vereist

 

Spoeddienst

- Zuurstof: streef naar 90% saturatie
- betere oxygenatie geeft minder pulmonale vasoconstrictie en dus een verbeterde cardiac output
- cave CO2-retentie: geregeld pCO2 controleren.  Te hoge pCO2 geeft ademhalingsdepressie en geeft ook acidose.
- bronchodilatatie: beta-2-mimetica
- aerosols Ventolin
- Theophylline (Euphillin) 1 amp IV.  Max dagdosis is 900 mg/dag
- Diuretica: Lasix
- Bij acute COPD decompensatie: vroegtijdig steroidtherapie, antibiotica

- restrictie: vocht, zout

 

REFERENTIES:

 

 

  • MacNee W. Pathophysiology of cor pulmonale in chronic obstructive pulmonary disease. Part One. Am J Respir Crit Care Med 1994; 150:833.
  • Budev MM, Arroliga AC, Wiedemann HP, Matthay RA. Cor pulmonale: an overview. Semin Respir Crit Care Med 2003; 24:233.
  • MacNee W. Pathophysiology of cor pulmonale in chronic obstructive pulmonary disease. Part two. Am J Respir Crit Care Med 1994; 150:1158.
  • Simonneau G, Gatzoulis MA, Adatia I, et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol 2013; 62:D34.
  • Naeije R. Pulmonary hypertension and right heart failure in chronic obstructive pulmonary disease. Proc Am Thorac Soc 2005; 2:20.
  • McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: developed in collaboration with the American College of Chest Physicians, American Thoracic Society, Inc., and the Pulmonary Hypertension Association. Circulation 2009; 119:2250.
  • Bradley TD, Rutherford R, Grossman RF, et al. Role of daytime hypoxemia in the pathogenesis of right heart failure in the obstructive sleep apnea syndrome. Am Rev Respir Dis 1985; 131:835.
  • Yildiz OA, Onen ZP, Sen E, et al. Predictors of long-term survival in patients with chronic obstructive pulmonary disease. Saudi Med J 2006; 27:1866.
  • Song JW, Song JK, Kim DS. Echocardiography and brain natriuretic peptide as prognostic indicators in idiopathic pulmonary fibrosis. Respir Med 2009; 103:180.
  • Baudouin SV. Oedema and cor pulmonale revisited. Thorax 1997; 52:401.
  • Morrison DA, Klein C, Welsh CH. Relief of right ventricular angina and increased exercise capacity with long-term oxygen therapy. Chest 1991; 100:534.
  • Mesquita SM, Castro CR, Ikari NM, et al. Likelihood of left main coronary artery compression based on pulmonary trunk diameter in patients with pulmonary hypertension. Am J Med 2004; 116:369.
  • Han MK, McLaughlin VV, Criner GJ, Martinez FJ. Pulmonary diseases and the heart. Circulation 2007; 116:2992.
  • Watz H, Waschki B, Meyer T, et al. Decreasing cardiac chamber sizes and associated heart dysfunction in COPD: role of hyperinflation. Chest 2010; 138:32.
  • Incalzi RA, Fuso L, De Rosa M, et al. Electrocardiographic signs of chronic cor pulmonale: A negative prognostic finding in chronic obstructive pulmonary disease. Circulation 1999; 99:1600.
  • CAIRD FI, STANFIELD CA. The electrocardiogram in asphyxial and in embolic acute cor pulmonale. Br Heart J 1962; 24:313.
  • Burrows B, Kettel LJ, Niden AH, et al. Patterns of cardiovascular dysfunction in chronic obstructive lung disease. N Engl J Med 1972; 286:912.
  • Benza R, Biederman R, Murali S, Gupta H. Role of cardiac magnetic resonance imaging in the management of patients with pulmonary arterial hypertension. J Am Coll Cardiol 2008; 52:1683.
  • Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med 1980; 93:391.
  • Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Report of the Medical Research Council Working Party. Lancet 1981; 1:681.
  • Timms RM, Khaja FU, Williams GW. Hemodynamic response to oxygen therapy in chronic obstructive pulmonary disease. Ann Intern Med 1985; 102:29.
  • Weitzenblum E, Sautegeau A, Ehrhart M, et al. Long-term oxygen therapy can reverse the progression of pulmonary hypertension in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1985; 131:493.
  • Sliwiński P, Hawrylkiewicz I, Górecka D, Zieliński J. Acute effect of oxygen on pulmonary arterial pressure does not predict survival on long-term oxygen therapy in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1992; 146:665.
  • Selinger SR, Kennedy TP, Buescher P, et al. Effects of removing oxygen from patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1987; 136:85.
  • Hoeper MM, Andreas S, Bastian A, et al. Pulmonary hypertension due to chronic lung disease: updated Recommendations of the Cologne Consensus Conference 2011. Int J Cardiol 2011; 154 Suppl 1:S45.
  • Polić S, Rumboldt Z, Dujić Z, et al. Role of digoxin in right ventricular failure due to chronic cor pulmonale. Int J Clin Pharmacol Res 1990; 10:153.
  • Mathur PN, Powles P, Pugsley SO, et al. Effect of digoxin on right ventricular function in severe chronic airflow obstruction. A controlled clinical trial. Ann Intern Med 1981; 95:283.
  • Lee-Chiong TL, Matthay RA.. The heart in the stable COPD patient.. In: Clinical management of chronic obstructive pulmonary disease., Similowski T, Whitelaw WA, Derenne JP. (Eds), Marcel Dekker, Inc., New York 2002. p.475.
  • Lahm T, McCaslin CA, Wozniak TC, et al. Medical and surgical treatment of acute right ventricular failure. J Am Coll Cardiol 2010; 56:1435.
  • Vizza CD, Rocca GD, Roma AD, et al. Acute hemodynamic effects of inhaled nitric oxide, dobutamine and a combination of the two in patients with mild to moderate secondary pulmonary hypertension. Crit Care 2001; 5:355.
  • Bradford KK, Deb B, Pearl RG. Combination therapy with inhaled nitric oxide and intravenous dobutamine during pulmonary hypertension in the rabbit. J Cardiovasc Pharmacol 2000; 36:146.
  • Khazin V, Kaufman Y, Zabeeda D, et al. Milrinone and nitric oxide: combined effect on pulmonary artery pressures after cardiopulmonary bypass in children. J Cardiothorac Vasc Anesth 2004; 18:156.
  • Campo A, Mathai SC, Le Pavec J, et al. Outcomes of hospitalisation for right heart failure in pulmonary arterial hypertension. Eur Respir J 2011; 38:359.

 

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