Cor Pulmonale
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Acute cor cor pulmonale adalah peregangan atau pembebanan akibat hipertensi pulmonal akut sering disebabkan oleh emboli paru masif Chronic cor pulmonale adalah hipertrofi dan dilatasi ventrikel ventrikel kanan akibat hipertensi pulmonal yang berhubungan b erhubungan dengan penyakit paru obstruktif atau restriktif restriktif
Etiologi (4) 1. Peny enyakit akit pembu pembulu luh h dar darah ah paru paru 2. Tekanan ekanan darah darah pada pada arteri arteri pulmona pulmonall oleh oleh tumor mediastinum, aneurisma, granuloma, atau fibrosis 3. Peny enyakit akit neur neurom omusk uskul ular ar dan dan dindin dinding g dada 4. Penya enyakit kit yang yang meng mengenai enai aliran aliran udar udara a paru, paru, alveoli, termasuk PPOK. Penyakit Penyakit paru lain adalah penyakit paru interstitial dan ganguan pernapasan saat tidur.
patofisiologi •
Penyakit paru kronis menyebabkan: 1. Berkurangnya vascular bed paru 2. Asidosis dan hiperkapnia 3. Hipoksia alveolar 4. Polisitemia dan hiperviskositas darah
Keempatnya menyebabkan timbulnya hipertensi pulmonal (perjalanan lambat) Jangka panjang hipertrofi dan dilatasi ventrikel kanan gagal jantung kanan
Gejala klinis •
Klinis cor pulmonale dimulai PPOK PPOK + hipertensi pulmonal PPOK+hipertensi pulmonal+gagal jantung kanan
cor pulmonale pada PPOK klinis ditemukan •
Asidosis dan hiperkapnia
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Hipoksia
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Polisitemia
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Hiperviskositas darah
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Hipertensi pulmonal
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hipertrofi/dilatasi ventrikel kanan dan gagal jantung kanan
Patofisiologi hipertensi pulmonal pada PPOK –
Normal : •
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Right Ventricle (RV) - Is A Thin Walled, Compliant Chamber That Is Better Suited To Handle Volume Overload Than Pressure Overload
Abnormal : •
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Pulmonary Hypertension - The Common Pathophysiologic Mechanism Pulmonary Hypertension That Is Sufficient To Lead To RV Dilatation, With Or Without The Development Of Concomitant RV Hypertrophy Sustained Pressure Overload Imposed By Pulmonary Hypertension, Associated With Pulmonary Vascular Resistence Will Eventually Cause The RV To Fail
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Results : •
Alterations In Cardiac Output As Well As Salt And Water Homeostasis
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Acute Cor Pulmonale :
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Sudden And Severe Stimulus, With RV Dilatation And Failure
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No RV Hypertrophy
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Such As In : Massive Pulmonary Embolitation
Chronic Cor Pulmonale : –
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With RV Dilatation & RV Hypertrophy
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Such As In : COPD, Chronic Bronchitis, Interstitial Lung Disease
Factors That Occur Intermmitently : –
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Associated With A More Slowly Evolving And Slowly Progressive Pulmonary Hypertension
Hypoxia Secondary To Alterations In Gas Exchange, Hypercapnia, Acidosis, Alterations In RV Volume Overload, Heart Rate, Polycythemia, Increased Salt And Retention
Mechanism : –
Vasoconstriction, Activation Of The Clotting Cascade, And Obliteration Of Pulmonary Arterial Vessels
Signs And Symptoms •
Dyspnea - The Most Common Symptoms –
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Such As : Overinflation With COPD
Orthopnea And Paroxysmal Nocturnal Dyspnea –
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As The Result Of The Increased Work Of Breathing Secondary To Changes In Elastic Recoil Of The Lung (Fibrosing Lung Diseases) Or Altered Respiratory Mechanics
Reflect The Increased Work Of Breathing In The Supine Position That Results From Compromised Excursion Of The Diaphragm
Tussive Or Effort Related Syncope –
In Patients With Severe Pulmonary Hypertension Because Of The Inability Of The RV To Deliver Blood Adequately To The Left Side Of The Heart
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Abdominal Pain And Ascites - Due To Right Heart Failure
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Lower Extremity Edema –
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Due To Neurohormonal Activation, Elevated RV Filling Pressures, Or Increased Levels Of Carbon Dioxide And Hypoxia, Which Can Lead To Peripheral Vasodilatation And Edema Formation
Tachypnea
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Elevated Jugular Venous Pressure –
With Prominent V Waves As A Result Of Tricuspid Regurgitation
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Hepatomegaly, Lower Extremity Edema
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RV Heave –
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Systolic Pulmonary Ejection Click –
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Palpable Along The Left Sternal Border Or In The Epigastrium May Be Audible To The Left Of The Upper Sternum
Holosystolic Murmur Of The Tricuspid Regurgitation (CARVALLO'S SIGN) Cyanosis (LATE FINDINGS) –
Secondary To A Low Cardia Output With Systemic Vasoconstriction And Ventilation Perfusion Mismatches In The Lung
Chest X-Ray : –
Enlargement Of The Main Pulmonary Artery, Hilar Vessels, And The Descending Right Pulmonary Artery
EKG : P- pulmonale, RAD, RVH Echocardiography : RVH, TR, Pulm. Hypertension ABG : Hypoxemia, Hypercapnea, Respiratory acidosis CBC : polycythemia CT-scan MRI BNP Cardiac catheterization
Treatment –
Treat The Underlying Pulmonary Disease (PRIMARY GOAL OF TREATMENT)
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General Principles : •
Decrease The Work Of Breathing –
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Noninvasive Mechanical Ventilation, Bronchodilatation, And Steroids Ex. Bronchodilatation : b2 agonist (kerja cepat –salbutamol & lamaalbuterol), ipraporpium br, gol. Xantin (teofilin, aminofilin)
inflamasi : kortikosteroid
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Treating The Underlying Infection
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Adequate Oxygenation –
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Maintain Oxygen Saturation Of More Than 90 % - 92 % Which Will Also Decrease Pulmonary Vascular Resistance And Reduce The Demands On The Right Ventricles
Vasodilators –
The most effective oral vasodilators are the calcium channel blockers
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Anticoagulants -Based on small clinical trials, many clinicians recommend chronic anticoagulant therapy with warfarin in patients with primary pulmonary hypertension
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Blood Transfussion If They Are Anemic
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Phlebotomy
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If The Hematocrit Exceeds 65%
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To Reduce Pulmonary Artery Pressure
Diuretics –
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Effective In The Treatment Of Right Ventricular Heart Failure Precautions : Chronic Use Of Diuretic, May Lead To Contraction Alkalosis And Worsening Of Hypercapnea
Digoxin –
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UNCERTAIN BENEFIT - MAY LEAD TO ARRHYTHMIA In The Setting Of Tissue Hypoxia And Acidosis If Needed, It Should Be Given At The Low Doses And
case PPOK dan CPC
Pria, 79 th •
Anamnesis – –
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KU: Sesak napas Sesak napas mulai dirasakan sejak 5 th yg lalu, hilang timbul. Bertambah berat 2 minggu yg lalu. Bertambah sesak saat beraktivitas & saat tidur berbaring, berkurang bila duduk. Pasien tidur dg 5 bantal. Kaki bengkak hilang timbul sejak 5 th yg lalu. Napsu makan berkurang sejak sesak. Batuk berdahak putih sejak + 1 minggu yg lalu. Mual +, muntah RPD: hipertensi + tdk terkontrol, DM -, asma –, Tb RPK: Kebiasaan: merokok tembakau dan rokok biasa 1 bungkus/ hari selama > 50 th (BI=500) UB: minum HCT bila kaki bengkak
Pemeriksaan fisik Keadaan umum CM, sakit jelek, gizi kurang (BMI=16,5) TD : 130/80, N : 80x/mnt,R:20x/mnt, S:36,5OC
Kepala : Conjunctiva anemis-/-, sklera ikterik -/-, PCH-/-, sekret-/-, septum letak sentral Leher : trakea letak sentral, KGB TTM, JVP 5+2 cm H20
Thorax
B/U simetris , barrel chest, ICS melebar, napas abdominotorakal
Jantung : IC tidak terlihat ,batas jantung dbn, BJM+, murmur – Paru :perkusi : hipersonor, VBS ↓/↓↓, Rh -/-, Wh +/+
Pemeriksaan fisik Abdomen Datar, nyeri tekan +, perkusi tympani, BU normal, hepar teraba 3 cm BAC, lien tdk teraba
Alat kelamin & anus recktum tidak diperiksa Punggung : nyeri ketok CVA -/-
Anggota gerak : edem -/-, akral hangat, Capillary reffil time < 2” Refleks : fisiologi +/+, patologis -/-
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Diagnosis Banding •
PPOK eksaserbasi akut
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dd/ SOPT
CPC
Laboratorium • • • • • • • • •
Hb Ht Leuko Tc Na K Ur Kr GDS
: 15,4 :47,5 :8,32 : 280 :134 :3,6 : 36 : 0,8 :120
EKG omi anteroseptal
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Emphysema
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Ics melebar, tear drop
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Efusi pleura kanan minimal Fibrosis kedua paru
Diagnosis kerja •
PPOK eksaserbasi akut
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CPC
Pengobatan Non Medikamentosa RL+aminofilin 1000cc/ 24 jam 02 3LPM Diet Medikamentosa Nebu: ventolin (albuterol) & atroven (iprapropium br) 3x1 prn Levofloxacin (cravit) tab 500 mg 1x1 Furosemid (lasix) tab 20mg 1x1 Spironolakton (spirola) tab 100 mg 1x1 Metil prednisolon (hexilon) ampul 3x1/2 amp Omz tab 20 mg 2x1 • • •
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prognosa •
Ad vitam: dubia ad bonam
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Ad functonam: dubia ad malam
