Classification
Anatomical
All the pathogens that cause HPS can be divided into three groups:
Diseases that damage the airways and alveoli of the lungs (chronic bronchitis with emphysema, tuberculosis, sarcoidosis, fibrosis, systemic connective tissue diseases, muskoviscedoza etc..)
diseases that hamper the movements of the chest wall (kyphoscoliosis, significant pleural adhesion, prolonged neuromuscular paralysis, excessive obesity),
diseases that primarily attack the pulmonary blood supply (multiple pulmonary embolism, primary pulmonary hypertension, arteritis, or pressure on the pulmonary blood vessels, as well as in different granulomas, carcinosis of the lungs, aortic aneurysm, sarcoidosis, etc..).
Functional (the predominant pathogenic cause):
• alvealna hypoventilation (chronic obstructive emphysema, neuromuscular disease, kyphoscoliosis, obesity - Peekwik syndrome);
• reduction of pulmonary blood vessels (alveolar-capillary block, recurrent pulmonary embolism and other causes that damage blood network).
Symptoms and diagnosis
In the compensatory stage of chronic pulmonary heart is still prevalent symptoms of primary pulmonary disease. There are frequent "cold" with cough and expectoration of small or large quantities purulent sputum, dyspnea on exertion or at rest. These symptoms last for 2-3 months, usually in winter, repeat for years.
There may be other pulmonary symptoms (eg haemoptysis.). If pulmonary hypertension is manifest at this stage can also aggravate symptoms: dyspnea even more pronounced in peace and in motion, sometimes anginal pain due to myocardial ischemia and anoxia. However, based on symptoms alone it is impossible to distinguish this stage of the more uncomplicated primary pulmonary disease.
In later, more late stage, joining the above symptoms and right heart failure symptoms: extreme fatigue, gastrointestinal disturbances due to delays and swelling feet.
The physical signs
Signs of primary pulmonary disease are:
• dyspnea, cyanosis and central type drumstick fingers, active auxiliary breathing muscles. The chest in the inspiratory position ("barrel"), expanding the "en bloc". Lung volume hipersonor, impaired breathing, vesicular, prolonged expiratory; bronchitic litter, they are usually high-pitched. It is significantly narrowed or disappeared silence heart, quiet heart sounds, and the liver is extremely lowered.
Signs of impaired heart function and blood flow
• Before the manifestation right heart failure, physical signs of chronic pulmonary heart are very scarce. Pulmonary hypertension may give salience pumonary second tone, right ventricular hypertrophy and visible pulsations epigastrium.
Difficult pulmonary emphysema may mask the signs, and even an early appearance Brake heart failure.
Clinical diagnosis of chronic pulmonary heart when it is easier to set up a fully developed signs of right heart failure: the swollen veins in the neck, significant increase in liver, edema of the legs and ascites. At heart, except for tachycardia, findings may be normal, but can be heard and right gallop and systolic murmur as a sign of relative tricuspid insufficiency.
Rtg
Characteristic radiological signs of chronic pulmonary heart does. Heart, even when something is increased due to larger chest may appear normal in size.
In advanced cases, we extended arc of the pulmonary artery, and lateral positions to see the enlarged right ventricle and right atrium. Besides the foregoing, x-ray may help to identify a type of lung disease.
ECG
easily in chronic pulmonary heart there is no pathognomonic ECG curve, changes in ECG were very valuable in diagnosing and proving the evolution of the disease. At first it may appear reversible changes, such as P-pulmonale, electrical axis deviation to the right, with a deep over the left heart, a negative T waves over the right precordial leads.
As it progresses, and compensatory and decompensated cor pulmonale found ECG signs of right ventricular hypertrophy, which are usually irreversible. There is often a tendency to low voltage. In a minority of cases there is a right bundle branch block.
For the purpose of uniform interpretation of electrocardiographic curve, the WHO expert committee has developed criteria for right ventricular hypertrophy, which can be applied in chronic pulmonary heart.
They are as follows:
• The existence of the wave QR intrinsic deflection greater than 0.03 seconds in the drain V1 or in leads V3R and V4R. This finding himself particularly for applications in a reliable sign of right ventricular hypertrophy.
• If there is no sign as described above, then the existence of two of the following criteria:
ratio R / S is less than 1 in lead V5,
dominant S wave in D1,
incomplete right bundle branch block.
Functional signs
Tests for lung function (spirography) and analysis of gases in arterial blood can indicate the type and degree of respiratory failure.
Cardiac catheterization can be defined as pulmonary hypertension has clinical signs of chronic pulmonary heart are manifested. In the compensated stage, the pressure in the pulmonary artery in peace can be normal
(25-30 mmHg), but the load can go up to 60 mmHg, and more.
In the decompensated phase of pressure is already elevated in peace (usually 40-60 mmHg), and the load reaches a much higher value. Pulmonary hypertension in an effort may be one of the earliest signs of chronic pulmonary heart.
The finding of elevated venous pressure (above 10-12 cm H2O) is an important diagnostic and differential
- A diagnostic sign of right heart failure.
Laboratory signs of
Arterial oxygen saturation is reduced, usually below 80%, while the partial pressure of CO2 in arterial blood above 60 mmHg.
In odmaklijim stages of lung disease in the compensated stage of chronic pulmonary heart there is a distinct hypervolaemia. In the decompensated stage of blood volume usually decreases, although there may be higher than normal. There polycythemia and increased hematocrit. SE has slowed.
The minimal diagnostic program
Symptoms and diagnosis of chronic pulmonary heart is based on:
• a history, physical and functional signs of primary pulmonary disease. To this end, in addition to detailed history and accurate physical examination, should make a radiograph and pulmonary functional tests (spirometry). In contentious cases are needed, and additional tests (arterial blood saturation with O2, CO2 partial pressure).
• electrocardiographic signs of right ventricular hypertrophy with signs of right heart failure, or without them.
• Careful clinical and other examinations, and possibly heart catheterization, in order to turn off left heart disease or congenital heart disease.
Pathophysiology
The occurrence of chronic pulmonary heart is the result of increased right ventricle, which occurs with increased resistance in the pulmonary blood vessels and the pulmonary hypertension.
The most important factors in the occurrence of these phenomena are:
• general alveolar hypoventilation,
• reduction of pulmonary sudovne network
• 'vascular intrapulmonary shunts, and
• myocardial factors.
Hypoxia due to alveolar hypoventilation leads to a number of disorders: increased output, polycythemia, pulmonary vasoconstriction of blood vessels which ultimately produce pulmonary hypertension.
This set of factors, certain are irreversible, and the second reversible. The latter often causes respiratory infections, and its removal can be partly repaired and hemodynamic disturbances.
Forecast
Forecast of chronic pulmonary heart depends mainly on the primary lung disease. As it is, generally, anatomically ireversible, it is possible to correct only the reversible functional disorders (prevention of infection, bronchospasm, respiratory dysfunction, normalization of metabolic disorders, etc..). The current available resources do not allow the correction of the functional integral.
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