PHUØ PHOÅI CAÁP ACUTE PULMONARY EDEMA OEDEME ARTERE PULMONAIRE

1. PHUØ PHOÅI CAÁPACUTE PULMONARY EDEMAOEDEME ARTERE PULMONAIRE TS.BS. LEÂ THANH LIEÂM TK TIM MAÏCH BV CHÔÏ RAÃY

2. I. ÑÒNH NGHÓA- PHUØ phổicấplAØtìnhtrạngtíchtụnướcvAØdịchtrongkhoangngoạimạchcủaphổi DO NGUYEÂN NHAÂN TIM MAÏCH VAØ NGOAØI TIM

3. II.CÔ THEÅ HOÏC SINH LYÙ HOÏC

9. Giaûiphaåubeänh

10. Giaûiphaåubeänh

11. III.SINH LYÙ BEÄNH

12. III.SINH LYÙ BEÄNH 3 giai ñoaïn: • GÑ 1: môû vaø daõn caùc m/m phoåi- chöa aûnh höôûng ñeán trao ñoåi khí • GÑ 2: nöôùc vaø dòch tích tuï trong khoaûng keû quanh m/m cheøn eùp caùc tieåu PQ gaây thieáu O2 nheï, thôû nhanh do J type R. • GÑ3: nöôùc vaø dòch tieáp tuïc traøn vaøo caùc khoaûng keû khoâng daõn nôû (500ml) neáu tieáp tuïc taêng nöôùc dòch seõ traøn vaøo PN

13. III.NGUYEÂN NHAÂN • Do tim: • NMCT • THA • Beänhlyù van tim • Beänhcôtim • Roáiloaïnnhòptim • Ngoaøitim: • Vieâmphoåi • ARDS • BeänhThaän, • Ñoäctoá: Chlorine Amonia • Phaûnöùngthuoác: Heroine, Cocaine, Aspirin, hoùatròlieäu • Hôingaït • Cao ñoä: >2400m • Cheátñuoái • TaécmaïchLympho:

14. CAÙC YEÁU TOÁ THUÙC ÑAÅY

15. IV.LAÂM SAØNG

16. LAÂM SAØNG

18. V. CAÄN LAÂM SAØNG • XQ TIM PHOÅI : • ECG: • SIEÂU AÂM TIM: • KMÑM: • BNP vaø NT pro BNP BNP 100pg/ml ñoä chính xaùc81,4%,ñoä nhaïy 90%, ñoä chuyeân bieät 75%, NT proBNP 300-450pg/ml 98% giaù trò tieân ñoaùn aâm Half life: NT proBNP 120p BNP 20p >80t : BNP> 250pg/ml

22. VI. ÑIEÀU TRÒ • Nhaäp CCU • Thôû O2 (NPSV(CPAP-biPAP, )(PEEP) • Giaûm taûi: Lôïi tieåu, Nitroglyceùrine, Niseùritide Nitroprusside, Morphine • Vaän maïch: Digoxin,ARB agonist PDE inhibitor • ACE inhibitor ARB, Aldosterone antagonist • Duïng cuï hoå trôï tim

24. Stevenson. Circulation 2003;108:492-7

25. cAMP independent agents Cardiac glycosides Calcium salts Liothyronine (T3) -AR agonists Calcium sensitizers cAMP dependent agents β-adrenergic agonists Epinephrine Dobutamine Dopaminergic agonists Dopamine Dopexamine Phosphodiesterase inhibitors Milrinone Inamrinone Olprinone Positive inotropic drugs

26. Drugs that decrease mortality: -AR blockers ACE inhibitors Angio receptor blockers Aldosterone antagonists Isosorbide and hydralazine in blacks Drugs that may improve symptoms without worsening outcome: Cardiac glycosides Loop diuretics Drugs that increase mortality: Dobutamine Xamoterol Pimobendan Flosequinan Vesnarinone Ibopamine Inamrinone Milrinone Enoximone Chronic therapy and outcomes in HF

27. Anti-adrenergic Moxonidine (MOXCON) Prazosin (V-HeFT 1) Anti-cytokine Anti-TNF (ATTACH) Etanercept (RENEWAL) Ineffective therapies in CHF

28. Ñieàutrò

31. Drug Interactions • Drugs can interact additively, synergistically, or antagonistically • Interaction between -AR agonists and PDE inhibitors is at least additive, possibly synergistic • Interaction between Ca salts and -AR agonists is antagonistic • Interaction between dobutamine (partial agonist) and epinephrine (full agonist) can be antagonistic

32. Cardiac glycosides • William Withering used foxglove to treat edema in 1785: An Account of the Foxglove, and Some of Its Medical Uses • Inhibits Na-K ATPase, intracellular Na, Ca through Na-Ca exchange • Recent studies show digoxin • Sensitizes cardiac baroreceptors • Decreases sympathetic nervous outflow • Decreases renin secretion • Neurohormonal modulator NEJM 1993;329:1-7 NEJM 2002;347:1403-11 Ann Int Med 2005;142:132-45

33. Effect of Digoxin on Mortality and Morbidity: DigoxinInvestigation Group • 6800 patients with LV EF <.45: digoxin or placebo • Mean 37 mo follow up • Similar mortality (35%) • Digoxin: fewer hospitalizations • Use it when symptoms persist despite β-blocker & ACE inhibitor % Hospitalized for Worsening HF * NEJM 1997;336:525-33 Ann Int Med 2005;142:132-45 *p<.001

35. nitroglyceùrine

36. Incontrovertible evidence of ACE-I efficacy (SOLVD-T) ACE-Is inhibit bradykinin metabolism ACE-I intolerance ACE-I and/or ARB? Angio-II catalyzed by enzymes other than ACE VALIANT shows ARB as effective as ACE-I, combination leads to more AEs ELITE 2 shows ACE-I superior to ARB in HF CHARM-Added shows benefit to adding ARB to standard Rx ACE-Is Should Generally be Used before ARBs in HF Ann Int Med 2005;142:132-45

37. McMurray Circulation 2004;110:3281-8

38. Spironolactone reduces mortality in patients with severe CHF • 1663 NYHA III & IV patients with LVEF ≤35% treated with ACE, loop diuretic, ± digoxin • 25 mg spiro vs placebo; 24 mo follow up • 30% reduced mortality; 35% reduction in hospitalization for worsening CHF, both p<.001 % mortality Pitt et al NEJM 1999;341:709-17

39. Inamrinone (1.5 mg/kg) adds to epi (30 ng/kg/min) after CPB Royster et al. Anesth Analg 1993;77:662-72 Amrinone epi Royster Plac + Plac Plac + Epi Inam + Plac Inam + Epi Minutes

40. Optime-chf trial  Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF), did not reduce hospital length of stay and was associated with a significant increase in adverse events compared with placebo.

42. Nesiritide (B-type natriuretic peptide) for acute exacerbations of HF • Nesiritide better than nitroglycerine or placebo added to standard therapy for decompensated CHF (hemodynamics, symptoms) • Nesiritide better than dobutamine for decompensated CHF (premature beats, tachycardia) • However ASCEND II show no benefit (survival, rehospitalisation) Am Heart J 2002;144:1102-8 JAMA 2002;287:1531-40 J Cardiothorac Vasc Anesth 2004;18:780-7

44. Primary and secondary three-month outcomes, FUSION-2 Am Heart J. 2007 Apr;153(4):478-84.

45. Ca sensitizing agents: levosimendan Cardiac output (L/min) • Binds to troponin C [Cai] –dependently • Does not impair diastolic relaxation • Hemodynamic effects continue 24 hours after drug stopped in CHF patients; active metabolite? • Small trials in cardiac surgery patients using 8-36 μg/kg loading doses ± 0.2-0.3 μg/kg/min infusion (↑CO, ↓SVR and ↓PVR) • Not available in USA μg/kg μg/kg Elapsed time (min) Kivikko. Circulation 2003;107:81-86 Follath. Lancet 2002;360:196-202 Nijhawan. J CV Pharmacol 1999;34:219-28 Lilleberg. Eur Heart J 1998;19:660-8

46. 203 patients Levo 24 mg/kg 10 min + 0.1 mg/kg/min vs dob 5 µg/kg/min 1o outcome: CO to ↑ 30%; PCWP ↓25% 28% Levo patients, 15% dob patients achieved primary outcome Fewer deaths with levo (HR 0.57) Levosimendanvsdobutamine for severe low-output HF (LIDO study) Levo Dob Percent surviving Time (days) Follath. Lancet 2002;360:196-202

47. BOÙNG DOÄI NGÖÔÏC ÑMC IABP(INTRA AORTIC BALOON COUNTERPULSATION)

48. SIEÂU LOÏC (ULTRAFILTRATION) UNLOAD trial