PHU PHI CP

TS.BS. inh Hiu Nhn

I. INH NGHIA

(1)

(2)
(3)
(4)

Phu phi cp la tinh trang thoat dich t mach

mau phi vao trong m ke va ph nang phi.
C ch:
Mt cn bng cua lu t Starling (tng ap lc mao
mach phi, giam ap lc keo huyt tng, giam ap
lc m ke.)
(2) Tn thng hang rao ph nang mao mach.
(3) Tc nghen h thng bach huyt.
(4) V cn hay khng bit c ch.

Phu phi cp do tim.

La b n h canh cp
cu thng g p 15-20,000 trng
hp nh p vi n
mi nm tai Anh.
T vong 15-20%.

II. SINH LY B NH HOC

Trao i kh tai ph nang

tight junctions

small gaps between

endothelial cells
Microvascular fluid exchange in lung

Peribronchovascular
Lymphatic
Interstitium
Drainage

Tng ap lc cui tm trng

tht trai va tng ap lc nhi trai
Tng nhanh ap lc thuy tinh
tai mao mach phi tng thm
thu dich ngang qua thanh
mach mau gy phu phi cp
do tim ( qua tai v th tich).

LAP 18 ~ 25mmHg

LAP > 25mmHg

Phu phi cp do tim

Qua tai dich

Phu phi khng do tim thng

do tn thng thanh mach mau
tng tinh thm thanh mach
mau.
Noncardiogenic pulmonary edema has a high
protein content because the vascular
membrane is more permeable to the outward
movement of plasma proteins. The net
quantity of
accumulated pulmonary edema is determined
by the balance between the rate at which fluid
is filtered into the lung and the rate at which
fluid
is removed from the air spaces and lung
interstitium.

Phu phi cp khng do tim

IMPAIRED

Tng ap lc tm tht trai va

tng ap lc nhi trai mt bu

Tng ap lc tinh mach phi

Phu m ke

Phu ph nang

Three Stages of Pulmonary

Edema

Stage 1 - Fluid transfer is increased into the

lung interstitium; because lymphatic flow also
increases, no net increase in interstitial volume
occurs.
Stage 2 - The capacity of the lymphatics to drain
excess fluid is exceeded and liquid begins to
accumulate in the interstitial spaces that
surround the bronchioles and lung vasculature
(which yields the roentgenographic pattern of
interstitial pulmonary edema).

Three Stages of Pulmonary

Edema
Stage 3 - As fluid continues to build up,
increased pressure causes it to track into
the interstitial space around the alveoli.
Fluid first builds up in the periphery of the
alveolar capillary membranes and finally
floods the alveoli .
During stage 3 the x-ray picture of alveolar
pulmonary edema is generated and gas
exchange becomes impaired.

Three Stages of Pulmonary

Edema

Stage 3 cont. Additionally gravity exerts an

important influence on the fluid mechanics of
the lung.
Blood is much denser than air and aircontaining tissue
Under normal circumstances more perfusion
occurs at the lung bases than at the apices;
however, when pulmonary venous pressures
rise and when fluid begins to accumulate at
the lung bases the blood flow begins to be
redistributed toward the apices.

III. NGUYN NHN

Tng ap lc mao mach phi:

Tim:
BTTMCB, HC mach vanh cp, cac bin chng c hoc cua NMCT cp nh h
van 2 la cp, v vach lin tht, suy tim cp.
B nh ly van tim: Hep van 2 la, hep van MC kht, H van cp, vim NTMNT.

Cn Tng huyt ap.

Ri loan nhip tim, vd Rung nhi.
Vim c tim cp.
U nhy nhi trai.
Chen ep tim cp.
Boc tach ng mach chu.

B nh c tim. Vd. B nh c tim chu sinh.

Thuc: c ch c tim, gy qua tai dich.

Th n :
Suy th n cp, suy th n man.

Hep ng mach th n.

Qua tai dich do thy thuc.

Suy tim cung lng tim cao, Vd . Cn bao giap, thiu vitamin B1, shunt (AVF, PDA
v.v)
Tng tinh thm mao mach phi:

Acute respiratory distress syndrome (ARDS)

cao cao

Vim phi ht, c cht.

Phong xa.

Thuyn tc i, thuyn tc phi, thuyn tc m.

Tc nghen h bach huyt , vd U trung tht.

IV. BIU HI N LM SANG

Chu y: bnh s khng phai khi nao cung tin c y

c.
Cn phi hp LS + CLS co chn oan chinh xac.

B nh s

Phu m ke Th nhanh va kho th.

Phu ph nang Giam Oxy mau, ho, khac am bot hng.
Chu y tim b n h ly c ban.
NN do tim: Cn kho th kich phat v m, kho th khi nm.
BTTMCB, NMCT
t mt bu cua suy tim.
B nh ly van 2 la , van ng mach chu.
Chu y tinh trang qua tai th tich.
Vim c tim cp.

NN khng do tim: Tri u chng va du hi u nhim trung, chn thng.

Vim phi, nhim trung huyt, vim phi hit.

Lm sang

Triu chng va du hi u LS:

Ht hoang, lo s, ngi b t d y, bt rt
Kho th, co keo c h hp phu, xanh xao, va m hi,
th nhanh, ting th n ao, th rt,.
Co th co tm mi va u chi,
TM c ni
SpO2 thng giam <90%.
Nhip tim nhanh, co th co ting gallop T3, m thi
tim lin quan n b nh ly van tim.
HA thay i, co th tng HA hay ha HA, thiu ni u.
Ran m 2 ay phi dng ln. Ho, khac am bot hng
Phu, gan to.

C n lm sang
Mau:

Ure, creatinine, Ion , glucose, Men tim, chc

nng gan, CTM, ng mau toan b .
Kh mau n g mach.
Brain natriuretic peptides (BNPs) / Nt-ProBNP
ECG: Ri loan nhip tim, NMCT.

Hinh anh i n tm

BNP

< 100 pg/ml: t kha nng co suy tim

(negative predictive value > 90%)

> 500 pg/ml: Suy tim

(positive predictive value > 90%)

100 ~ 500 pg/ml Kt hp thm LS

BNP levels can be elevated in critically ill patients even in the absence of heart failure.
2004;32:1643-7

Tung et al. CCM

BNP is most useful in critically ill patients if < 100pg/ml

BNP also higher in renal failure (< 200 pg/ml if GFR < 60 ml/min), acute pulmonary embolism, cor
pulmonale, pulmonary hypertension.

Hinh anh X Quang

Kerleys B lines

Air bronchograms

Phu m ke

Hinh anh phu m ke cho thy s tch tu dich

gia cac phn thuy phi.
ng Kerley

A
B
C

X Quang phi
Kerley A lines
Deep

Kerley

septal line 4cm

B lines

interlobular

line 1 cm

Phu
m ke

Phu
m
ke

A
B

Phu
m ke

Phu
m ke

Hinh anh X Quang phi thng

Siu m tim

anh gia chc nng tim va van tim.

Chu y: chc nng tim binh thng cung khng loai bo phu phi cp do
tim. Vd, Suy tim vi chc nng tm thu bao tn ( Suy tim tm trng)

Siu m tim
Cn phai xac inh:

Kch thc va phn xut tng mau tm tht trai ( EF)

Chc nng tm thu va tm trng cua tim

B nh ly van tim

Ap lc n g mach phi

Thng tim: Swan-Ganz catheters

(tiu chun vang)

Ap lc ng mach phi bit

- NN do tim: cao > 18 mmHg
- NN khng do tim: binh thng hay thp
<=18 mmHg
Theo doi lu lng tim.
(Pulmonary-artery wedge pressure):

Cac bc tip c n
chn oan

Phu phi cp

OAP khng do tim

OAP do tim

Hoi b nh s, kham LS va XN CLS

Du hi u cua b nh ly
phi. BNP < 100 pg/ml

X Quang phi

Bong tim binh thng,

khng phu m ke

Du hi u NMCT, Suy tim,

BNP > 500pg/ml
Bong tim to, phu ph nang,
phu m ke

Siu m tim
Kch thc bung tim binh
thng, EF binh thng

Ap lc M phi bit < 18mmHg

Dan ln bung tim , EF giam

Thng tim

Ap lc M phi bit > 18mmHg

V. IU TRI

A. Cac bin phap chung

1.Cung cp oxy nhm iu chinh giam oxy

mau:- Th oxy qua m t na.
2. t ng truyn tinh mach.
3. t b n
h nhn t th nm u cao hay t
th ngi.
4. t monitor theo doi lin tuc: nhip tim,
huyt ap, ECG, SpO2.
5. Thc hi n
cac xet nghi m
cn thit.

B. Cac thuc iu tri

1. Furosemide.
Tim tinh mach 20 80mg, l p lai liu sau 30 60 phut tuy theo
ap ng lm sang.

C ch: gy gian mach, giam tin tai, gy li tiu.

2. Nitrate.
Ng m di li Nitroglycerine ( 3 ln), truyn tinh mach
Nitroglycerin liu 10g/ phut tng dn liu mi 5 phut tuy theo
ap ng trn lm sang ( chu y: gi HA tm thu 90mmHg ).
C ch: Giam tin tai, giam h u tai, giam thiu mau cuc b c tim.

3. Morphin sulphate.
Tim tinh mach 2 5mg
C ch: Giam bt rt v t va, giam tin tai do
gian mach.
Cn th n: c ch h hp gy ngng th

C. Cac thuc khac

Cn cn nhc khi s dung cac thuc sau, chi
nn s dung khi co chi inh.
1. Cac thuc tng sc co bop c tim:
Dopamine.
Dobutamine.
Digoxin

2. Thuc gian ph quan:

Ventolin.
Aminophylline.
3. Nesiritide.

ESC GUIDELINE 2012

D. Cac phng phap h tr

1.

Thng kh h tr: th may.

D. Cac phng phap h tr

1.
2.
3.
4.

t bong n i ng mach chu (IABP)

Garrot 3 chi lun phin mi 15 phut (???).
Han ch dich truyn va mui natri.
t thng tiu theo doi lng nc tiu

E. iu tri nguyn nhn va cac

yu t thuc y

Tng HA.
Thiu mau c tim / NMCT.
Ri loan nhip tim.
Thiu mau.
Cng giap.
Nhim trung.
Cac thuc gy gi mui - nc nh steroid, khang
vin khng steroid. Thuc co tac dung giam sc
co tm tht trai nh c ch bta, thuc iu tri ri
loan nhip, thuc chng ung th.

Tin lng
T vong = 15%

TOM TT

iu tri: LMNOP

L Lasix:

M Morphine:

Gian tinh mach

O Oxygen:

Gian tinh mach

Giam tin tai, giam bt rt

N Nitrate:

Tim TM : gy gian mach, li tiu

Qua mask hay thng kh h tr

P Position:

Ngi thong chn.

Giam tin tai