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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:

 

 

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