Understand morbid condition which is characterized by an overload and a hypertrophy and/or dilatation of the right departments of heart — owing to hypertensia of a small circle of blood circulation at patients with diseases of the bronchopulmonary device, vessels of lungs or torakodiafragmalny disturbances as "pulmonary heart".
Classification of a pulmonary heart
On an etiology: • Bronkhopulmonalnoye (at the diseases which are initially affecting the bronchopulmonary device — chronic bronchitis, bronchial asthma, a pneumoconiosis, etc.). • Vascular — at the diseases which are initially affecting pulmonary vessels (primary pulmonary hypertensia, a nodular periarteritis and other vasculites, fibrinferments and thromboembolisms of a pulmonary artery and its branches). • Torakodiafragmalnoye — at the diseases leading to disturbance of ventilation owing to pathological changes of mobility of a thorax (a kyphoscoliosis, pleural fibrosis, chronic neuromuscular diseases, an ankylosing spondylitis, Pikvik's syndrome, etc.).
On a current (depending on speed of development of clinical manifestations): • acute (minutes, hours); • subacute (days, weeks); • chronic (months, years).
On a condition of compensation: • compensated; • dekompensirovanny.
Reasons of development of a pulmonary heart. The thromboembolism of a trunk and large vessels of a pulmonary artery, sudden increase of intrathoracic pressure are the reasons of development of an acute pulmonary heart (pheumothorax), the heavy asthmatic status, widespread pneumonia.
The subacute pulmonary heart develops at repeated thromboembolisms in system of a pulmonary artery, the asthmatic status, a lymphogenous carcinomatosis of lungs, valve pheumothorax, and also at chronic hypoventilation of the central and peripheral origin that happens at botulism, poliomyelitis, a myasthenia, etc.
Lead 3 groups of morbid conditions to development of a chronic pulmonary heart: • the diseases which are initially affecting the bronchopulmonary device (a chronic obstructive pulmonary disease, a pneumoconiosis, diffusion damages of lungs); • primary defeats of pulmonary vessels (primary pulmonary hypertensia, chronic thromboembolism of small branches of a pulmonary artery, vasculites); • the pathological changes of a musculoskeletal system leading to ventilation disturbance (kyphoscolioses, myasthenias, Pikvik's syndrome).
Diagnostic criteria of a pulmonary heart. Diagnostic criteria of a pulmonary heart are: • existence of etiological factors of a pulmonary heart; • pulmonary hypertensia; • hypertrophy and/or dilatation of a right ventricle; • heart failure on right ventricular type.
The clinical picture is explained by fast development of insufficiency of a right ventricle against pulmonary hypertensia. There are expressed short wind, diffusion cyanosis, swelling of cervical veins, pathological pulsations (precardiac and epigastric), expansion of a zone of absolute and relative cordial dullness to the right, tachycardia, an embryocardia, accent and thawing of the II tone over a pulmonary artery, increase and morbidity of a liver. On an ECG there is a "pulmonary" tooth P and signs of an overload of a right ventricle, S-Qm syndrome.
Treatment of a pulmonary heart.
Medical tactics at an acute and subacute pulmonary heart consists first of all in carrying out urgent therapeutic actions, especially at an acute pulmonary heart, syndromic treatment and treatment of the basic disease which led to development of an acute and subacute pulmonary heart.
Etiological treatment first of all is directed to treatment of the basic disease which led to forming of a chronic pulmonary heart. At a bronchopulmonary infection the basis of treatment is made by use of antibacterial agents. At bronkhoobstruktivny processes the main drugs are bronkhodilatiruyushchy means. In case of a thromboembolism of a pulmonary artery apply straight lines, and then — indirect anticoagulants, in special cases — thrombolytic drugs.
Pathogenetic therapy is directed to lowering of degree of LG. For this purpose apply the oxygenotherapy promoting considerable decrease in pulmonary vascular resistance and increase in fraction of emission of a right ventricle; the Euphyllinum (2,4% solution in a dose of 5-10 ml intravenously 2 — 3 times a day) or theophylline (in candles on 0,2 g 2 times a day or in tablets on 0,3 g 2 times a day) repeated courses for 7-10 days, Good effect gives treatment by peripheral vazodilatator: nitrates (Nitrosorbidum on 20 mg 4 times a day, Sustac on 2,6 mg 3 times a day), especially at patients with an ischemic heart disease; blockers of calcium channels (nifedipine on 10 — 20 mg 3 times a day); apressine and Nepresolum. It should be noted that nifedipine reduces the general pulmonary vascular resistance much more actively, than system. Use of nifedipine is effective not only at short-term, but also at long appointment; the prolonged forms are preferable. From antagonists of calcium drugs of the choice are generation dihydropyridines III — amlodipin, isradipin, latsidipin, possessing exclusively high affinity to smooth muscles of pulmonary vessels exceeding that at nifedipine.
However the best drugs are beta2-adrenomimetik which not only expand a vascular bed of lungs, but also increase sokratitelny ability of a myocardium of a right ventricle (salbutamol in tablets on 8 mg 2 times a day).
For improvement of microcirculation appoint by courses subcutaneously heparin on 5000 PIECES 2 — 3 times a day before increase of the activated partial tromboplastinovy time by 1,5 — 1,7 times in comparison with control. Low-molecular heparins (enoksaparin, nadoparin, etc.) which are fragments of standard heparin with a molecular weight from 1000 to 10 of 000 dalton are more effective. Change of molecular weight significantly changed pharmacokinetics of drugs: the majority of proteins of a blood plasma do not contact them, and it is expressed in excellent bioavailability at use of low-molecular heparins in small doses and "predictability" of anticoagulating effect at the fixed dose.
At the expressed hyperglobulia apply repeated bloodlettings on 200 — 300 ml with injections of solutions with low viscosity, for example, of a reopoliglyukin. In therapy of sick LG use also prostaglandins — powerful endogenous vazodilatator with the whole range of additional effects — anti-aggregation, anti-proliferative, to the cytoprotective which are in essence directed to prevention of remodeling of pulmonary vessels: reduction of damage of endothelial cells and hypercoagulation.
The important role in therapy of LG was got now by antagonists of receptors of endothelin — bozentan. It is known that endothelin-1 — the powerful vasoconstrictor of an endothelial origin having proliferative and profibrotichesky effects plays an important pathogenetic role in development of LG. Its level in blood is increased at patients at all LG forms.
At emergence of symptoms of acidosis Natrii hydrocarbonas solution infusions are applied. At development of right ventricular insufficiency use diuretics — saluretics and kaliysberegayushchy drugs (veroshpiron, Triamterenum, etc.). Cardiac glycosides (a bowl of only 0,5 — 1 ml of 0,06% of solution of Korglykonum) enter intravenously 1 — 2 time a day in case of accession of a left ventricular failure.
For improvement of metabolic processes in a myocardium purpose of Mildronate (inside on 0,25 g 2 times a day) in combination with orotaty potassium or Pananginum (asparkam) is shown. Complex therapy of patients with a pulmonary heart includes respiratory gymnastics, massage of a thorax, LFK, hyperbaric oxygenation.