Warm and pulmonary insufficiency – the dekompensirovanny stage of pulmonary heart proceeding with sharp or chronic right ventricular heart failure. It is characterized by short wind, tachycardia, pain in heart, peripheral hypostases, a gepatomegaliya, cyanotic coloring of skin, swelling of veins of a neck. Tool diagnostics is based on assessment of radiological, electrocardiographic and echocardiographic data. Treatment of warm and pulmonary insufficiency includes therapy of those diseases which caused development of a syndrome, application vazodilatiruyushchy, antigipertenzivny, diuretics, oxygenotherapy.
Warm and pulmonary insufficiency
The Warm and Pulmonary Insufficiency (WPI) – a clinical syndrome which cornerstone pulmonary hypertensia, a hypertrophy or dilatation of the right ventricle with the phenomena of insufficiency of blood circulation is. Develops at pathology of bronchopulmonary system, pulmonary vessels and torakodiafragmalny area. In pulmonology warm and pulmonary insufficiency, sometimes designate the term "pulmonary heart" (HP), however these concepts are not identical. It is necessary to understand only a dekompensirovanny phase of pulmonary heart (the III stage of pulmonary hypertensia) as warm and pulmonary insufficiency. The I stage (preclinical) and II stage (stable) of pulmonary hypertensia proceed without signs of right ventricular insufficiency therefore are regarded as the compensated pulmonary heart.
The persistent pulmonary hypertensia at a certain stage causing failure of compensatory mechanisms therefore the hypertrophied right ventricle ceases to cope with pumping of the blue blood coming to it is the cornerstone of formation of warm and pulmonary insufficiency. Right ventricular dysfunction can be caused by three groups of the reasons: bronchopulmonary, vascular, torakodiafragmalny.
The first group of the reasons includes more than 20 known nozologiya, 80% of all cases of pulmonary heart fall to its share. The most frequent among them are the diseases breaking airfilling of alveoluses: obstructive bronchitis, BEB, bronchial asthma, krupozny pneumonia, fibroziruyushchiya alveolit, tuberculosis of lungs, a pneumoconiosis, a pneumosclerosis, Beck, , lungs. Development of warm and pulmonary insufficiency of bronchopulmonary genesis is possible at collagenases (system red a wolf cub, a system sklerodermiya, a dermatomiozita, etc.). In certain cases extensive resections of a lung act as the reason of a decompensation of pulmonary heart.
The second group of factors mentions defeat of the pulmonary vascular course. In most cases formation of warm and pulmonary insufficiency is preceded by TELA, a sdavleniye of pulmonary veins and a pulmonary artery tumoral educations, pulmonary vaskulita, crescent and cellular anemia.
The states which are followed by restriction of mobility of a thorax and a diaphragm concern to the third group of the reasons. Among them – various deformations of a thorax and a curvature of a backbone (, ), massive pleurisy, multiple fractures of edges, ankiloziruyushchiya spondiloartrit, Pikvik's syndrome (obesity hypoventilation cm). Violations of mobility of a diaphragm are characteristic of chronic neuromuscular diseases (a myasthenia, poliomyelitis), botulism, paresis and paralysis of a diaphragm. Diseases of the second and third groups totally become the reason of pulmonary heart in 20% of cases.
Warm and pulmonary insufficiency can carry a sharp, subsharp and chronic current. So, sharp pulmonary heart always has dekompensirovanny character, subsharp and chronic – can proceed both with existence of right ventricular insufficiency, and without it.
Development of sharp warm and pulmonary insufficiency usually happens against the background of a massive thrombembolia of a pulmonary artery, valvate pheumothorax, emphysema of a sredosteniye, the asthmatic status. Sharp the HP is formed within several hours owing to sharp and sudden increase in pressure in a pulmonary artery, is followed by expansion of a cavity (dilatation) of the right ventricle, thinning of its walls. A subsharp and chronic form are characteristic of other vascular, bronchopulmonary and torakodiafragmalny defeats. In these cases chronic the HP develops within several months and even years and is followed by the expressed hypertrophy of a myocardium of the right ventricle.
Warm and pulmonary insufficiency can proceed in various clinical types: by respiratory, cerebral, anginozny, abdominal, kollaptoidny option with prevalence of these or those symptoms. In clinic of a respiratory form dekompensirovanny HP prevail short wind, suffocation episodes, cough, rattles, cyanosis. At cerebral option to the forefront there are symptoms of encephalopathy: excitability, aggression, euphoria, sometimes – psychoses or, on the contrary, - drowsiness, slackness, apathy. Dizzinesses and persistent headaches can disturb; in hard cases there are faints, spasms, decrease in intelligence.
The Anginozny type of warm and pulmonary insufficiency reminds clinic of angina pectoris with characteristic severe pains in heart without irradiation and suffocation. The abdominal option dekompensirovanny HP proceeds with pains in an epigastriya, nausea and vomiting, sometimes – development of stomach ulcer, caused by a hypoxia of bodies of a GIT. The passing episodes of arterial hypotonia which are followed by sharp weakness, pallor, profuzny sweating, a cold snap of extremities, tachycardia and threadlike pulse are typical for kollaptoidny option.
Symptoms of warm and pulmonary insufficiency
Sharp warm and pulmonary insufficiency is characterized by the sudden beginning and sharp deterioration in a condition of the patient literally in several minutes or hours. There are pains in heart which are followed by the expressed short wind, feeling of suffocation and fear of death. Cyanosis, arterial hypotonia is characteristic. The listed symptoms amplify in a standing position or sitting that is connected with reduction of inflow of blood to the right half of heart. Death can come from fibrillation of ventricles and cardiac arrest in a few minutes.
In other cases the picture of sharp warm and pulmonary insufficiency can be developed not so violently. The breast pains connected with breath, a blood spitting, tachycardia join short wind. At the progressing right ventricular insufficiency there are expressed pains in the right podreberye caused by increase in a liver and stretching of its fibrous cover. Owing to increase in the central venous pressure swelling of cervical veins appears.
Chronic warm and pulmonary insufficiency develops gradually and is reflection of stagnation of blood in system of veins of a big circle of blood circulation. Tolerance to physical activity decreases, short wind has constant character. Cyanosis of a nasolabial triangle, tip of a nose, chin, ears, finger-tips pays attention. There are attacks of zagrudinny pains (pulmonary "angina pectoris") which are not stopped by nitroglycerine reception, but decreasing later introductions of an eufillin.
Patients with chronic warm and pulmonary insufficiency note fatigue, bystry fatigue, drowsiness. At physical activity there can be faints. On a decompensation chronic HP also specify weight and morbidity in the right podreberye, a nikturiya, peripheral hypostases. In late stages the edematous syndrome, , ascites, a warm kakheksiya comes to light.
Diagnostic search at development of warm and pulmonary insufficiency is directed to detection of the main disease, and also decompensation degree assessment. For the correct interpretation of fizikalny and tool data of the patient needs survey of the pulmonologist and cardiologist. At objective inspection at patients with warm and pulmonary insufficiency barrel-shaped deformation of a thorax, a gepatomegaliya, pastosity of feet and shins is noted. At a palpation of prekardialny area the warm push is defined, at percussion - expansion of limits of relative dullness of heart. Decrease HELL, frequent arrhythmic pulse is typical. Auskultativny data are characterized by muting of tones of heart, accent of the II tone over a pulmonary artery, the splitting or bifurcation of the II tone, emergence of pathological III and IV tones, systolic noise indicating trikuspidalny insufficiency.
The most valuable laboratory criteria of warm and pulmonary insufficiency are indicators of gas composition of blood: decrease r02, increase rs02, respiratory acidosis. The X-ray analysis of bodies of a thorax allows to find not only damage of lungs, but also signs of a kardiomegaliya and pulmonary hypertensia. And ventilating a stsintigrafiya of lungs are shown to Angiopulmonografiya at suspicion on TELA.
Research FVD at warm and pulmonary insufficiency is applied to assessment of character and expressiveness of violations of ventilation, identification of a bronchospasm. Elektrokardiogarfiya at sharp allows HP authentically will define signs of an overload of the right departments of heart, and at chronic HP – to reveal direct and indirect markers of a hypertrophy of the right ventricle.
serves as the main noninvasive method allowing to estimate intracardial haemo dynamics, to determine the sizes of cavities of heart and a wall of the right ventricle, to establish degree of pulmonary hypertensia. In some cases, at impossibility to establish the fact of elevated pressure in a pulmonary artery, resort to a kateterization of the right departments of heart. Sometimes for verification of genesis of warm and pulmonary insufficiency the transbronchial or transthoracic biopsy of lungs is carried out.
Treatment of warm and pulmonary insufficiency
Therapy of the sharp warm and pulmonary insufficiency caused by TELA is performed in the conditions of ORIT. As the most important components of treatment serve oxygenotherapy, knocking over of a painful attack, performing thrombolytic therapy (an urokinaza, streptokinase, fabric the activator of a plazminogen), antikoagulyantny (heparin, ) and antiagregantny therapy (). Surgical tactics – a tromboembolektomiya from a pulmonary artery is in certain cases shown.
At the warm and pulmonary insufficiency which developed against the background of bronchopulmonary pathology, the principles of therapy are defined by the main disease. So, in case of HOBL and bronchial asthma bronkholitichesky, mukolitichesky, expectorant means are applied; at tuberculosis of lungs – specific antitubercular antibiotics; at interstitsialny pulmonary diseases — glucocorticoids, cytostatics, interferon etc.
At all stages of therapy of warm and pulmonary insufficiency oxygen inhalations are performed. For the purpose of decrease in pulmonary vascular resistance and pressure in a pulmonary artery vazodilatator are used (, antagonists of calcium, nitrates, APF inhibitors). To patients with an edematous syndrome diuretics under control of water and electrolytic balance and KShchS are appointed. The question of expediency of purpose of warm glycosides at warm and pulmonary insufficiency remains disputable. As a palliative measure the repeated bloodlettings for a while improving a condition of the patient are used.
By the patient with pulmonary hypertensia, refractory to conservative treatment, surgeries can be carried out: balloon predserdny septostomiya, simpatektomiya, reduction of pulmonary fabric, transplantation of lungs or heart lungs complex.
Forecast and prevention
The forecast at development of warm and pulmonary insufficiency is very serious. Sharp pulmonary heart poses a direct threat of life of the patient. Chronic warm and pulmonary insufficiency has the progressing character. Life expectancy of patients with chronic does not exceed HP in a stage of a decompensation 2,5–5 years. After transplantation of lungs 3-year survival makes 55-60%. Primary prevention of warm and pulmonary insufficiency consists in timely recognition and treatment of causal diseases, refusal of smoking, an exception of the risk factors promoting HNZL aggravation.