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pulponari
*
Y
Capilare 'l
Vene pulmonare
*--- \
_ Capifare '+
a. brongice v
Vene sistemice -=t Sunt fizioloqic dr-stq (pand la 3O% din DCJ
- brongiectazii
- fibrozi
chistici
NORMAL
PRES. A. PULMONARA - sist. 18 - 25 mmHg - diast. 6 - 10 mmHg - medie 12 - 16 mm Hg PRES. V. PULMONARE -2-10mmHg REZIST.VASC.PULM. = 1 ng din REZIST.SISTEMICA
NORMAL A. SISTEMICE - media 20-25% din diam. vasului A. PULMONARE - media<10-5% din diam.vasului Arteriolele pufmonare nu au tunica medie si nu contribuie la rezistenta vasculara
VD - fluxul coronarian cel mai mare in sistola - depinde de gradientul pres. pulm.- aorta Pres. VD creste - gradientul scade - fluxul coronar drept scade - ischemie VD
,*
NORMAL
PRES. A. PUTMONARA - sist. 18 - 25 mmHg - diast. 6 - 10 mmHg - medie 12 - 16 mm Hg PRES. V. PULMONARE - 2 - 10
mmHg
'*
TPERTE NS I UN EA
PRES.A.PULMONARA - sist > 30-35 mmHg - medie >20-25 mmHg - diast. >15 mmHg
IULMONA RA (HTP)
HIPOXIA CRONTCA
1. Extensia musculaturii netede in peretele arterelor din periferia
pldminilor
VASODILATATIE
- Alcaloza
- PROSTAGLANDINE lr gi E
Fzo
Acidoza
gi Az
- PROSTAGLANDINE
- HISTAM|NA - Hl
- SEROTONINA ? - ANG|OTENStNAz
- BLOCAN|I o
- STIMULARE B
(f
SoPRoTERENOL)
- ACETILCOLINA
(prin EDRF?)
. ALTITUDINE
pulmonari
La 10000 m altitudine TA pulmonari medie = 25 mmHg in repaus
> 50 mmHg la efoft
HTP SECUNDARA
pufiaoNAR
A. CRE$TEREA pREStUNlt DTASTOLTCE
VENTRICULARE B. HIPERTENSIUNEA ATRtalA srArucA
vnseutAR PULMorunn
A. BOLI ALE PARENCHIMULUI PULMONAR
B. SINDRO[ii EISENMENGER c, ALTE coNDrnr AsocrATE cu ScADEREA SEcTIUNII PATTJI-uI VAScULAR
MA PULMONARE
A. TROMBOEMBOLISMUL PUTMONAR B. srENozA DE A.puLMoNanA pERrFEnrcA c. ABSENTA coNGEbrrAlA pE A.puLmorunnA uNr sAU eiinrenniA
Ir
(recrutare de vase) ,t 7 mmHg - cregte presiunea in a.pulmonari (ftuxul t_ ramane constant; gradientul rimdne constant) +
> 25 mmHg - cregtere dispropor,tionati de presiune in
I i Y
I
cii
pope rt uzat
(i
nfa
rct)
Fvolumul sanguin pulmonar (depinde de debitul celor 2 ventriculi gi de distensibilitatea vaselor pulmonare )
MODIFIGARI ANATOMIGE
MODIFICART ANATOMICE celule endoteliale capilare umflate membrane bazale capilare ingrogate edem interstilial rupturi de membrane bazale - transsudare de eritrocite hemosiderozd alveole fibroase destindere de limfatice
CAUZE A. CRE$TERE.A PRES|UNil DTASTOLTCE VENTRTCULARE 1. prsFuNeTtE vs stsToLtcA - cregte volumul telesistolic - cregte presiunea telediastolicd - cregte pasiv presiunea in AS, venele pulmonare...
Boli valvulare ale inimii stingi Card!omiopatii 2. DISFUNGTIE VENTRICULARA DIASTOLICA - cre$te presiunea telediastolici - cregte pasiv presiunea in AS
' . . '
HTA BCI
. .
3. PERtCARptTA CONSTRICTIVA
parul
. . .
CAUZE
A. BOLI ALE PARENCHIMULUI PULMONAR 1. BOLI OBSTRUCTIVE CRONICE 2. BOLI RESTRICTIVE DE PLAMAN 3. BOLI DE COLAGEN: LED, PR, SCLERODERMTE 4, REACTil F|BROT|CE (HAMMAN-R|CH, HEMOSTDEROZA) 5. SARCOIDOZA 6. NEOPLASM
7. PNEUMONIE 8. REZECTII PULMONARE 9. HIPOP LAZ'E PULMONARA CONGENITALA B. S/wDROM EISENMENGER {defect septal atrial gi ventricular, patent ri l rnf r re, a rtarinrr sv, rc\ rvr
MODIFICARI ANATOMICE GR. | - hipeftrofia mediei arterelor mici musculare GR. ll - + proliferarea intimei GR. lll - + fibrozd concentrici cu obliterare de vase GR. lV - "leziuni plexiforme", dilata{ii, trombi GR. V - compiexe plexiforme, ieziuni angiomatoase gi carvenoase gi hialin izarea fibrozei i ntimale GR. Vl - aderitd necrozantd c. ALTE CONDTTE ASOCTATE CU SCADEREA SECT|UNIT qATULUT
VASCULAR
1.
nutrifional)
2. PERSISTEruTA CIRCULATIET FETALE LA NOU NASCUT
922 153
oF puLMoNARy HypERTENstoN
PuLnonary venous thrombosis or obstruction nance imaging Congenital intracardiac shunts Increased left atrial pressure secondarv to mitral or aortic vah'e disease, Ieft ventricular dvsfunction, or svstemic hvpertension Pulmonar-v ainvay disease (e.g., chronic bronchitis and emphvsema)
rvith contrast
lo.ft_igl"-!. pressure (via -or patent foramen ovale) (>15 mm Hg and LYEDP) Respiratorl' function tests (FVC/FEV, chest x-ray)
H1'poxic pulmonary hvpertension associated rvith (1) impaired ventilation, either central (CNS) or peripheral Ichest n'all problems or upper ainvay obstructionJ and (2) residence at high altitude Interstitial lung disease, pneumoconioses, and fibrosis (e.9.. silicosis, rheumatoid disease, and sarcoidosis) Collagen-r'ascular disease (e.9., SLE, polvarteritis nodosa, sclerooermaJ
tests
-t
'-.
,
Parasitic disease (schistosomiasis or filariasis) Cirrhosis rvith portal hypertension Peripheral pulmonarl' arterlr stenosis (ipcluding ease and fibrosing rrrecliastinitis)
" .; resolution chest computed tonrographv Serological and irnmunogenetic studies; skin, nruscle, o. otherl tissue biopsl'; esophageal motiiitv studies ,r Rectal biops'r', complement fixation, skin tests, blood smears :il Liver function tests, ultrasonographv, computed tornographv ..:i Selective puln:onary angiography or pressure gradienl ui ."tU*l
Erlthroclteniorphology,hemoglobinelectrophoresis',-.j
terizatior.r
svstem; FEYr = fofced expirator\ volunre irr 1 st-.con<i: IjVC = lbrced tital capacitr,: SLE : svstemic lupus erflhematosus. .'i It{odified from Weir EK: Diagnosis and managetnctit of prinrarl pulnronar-r'lrvperlcnsion. ,fn \Veir EK, Reeves ]T: Pulrnonarv Hvpertension. Mt Kisc6,i NY, Futura, 1984, p 141.
':;lai '-it:t\i
,,i.i"l
Familial
Secondary
Other
HiV infection
Drugs/toxins Anorexigens Other Persistent pulmonarv hypertensiorr of the nel'born Other Pulrnonarv venous hvpertension Left-sided atrial or ventricular heart disease Left-sided valvular heart disease Extrinsic compression of central pulmonar-"- r'eins Fibrosing mediasti nitis
In situ thrombosis
Sickle cell disease Pulruonarl' hvpertension caused b1' disorders directll'
.-,,1*^-^-.,,.^-^.,1^1,,- lature plr lmonar\' \'ascu a
Inflammatorv
Schistosomiasis Sa rcoi dosis
Adenopathy/tumors
Pulmonary venoocclusive disease Other
Other
Pulmonarl' capillarv
hemangiomatosis
Pulmonary hypertension associated rvith disorders of the respira^-,t /^- nvl)oremla rory s)'stem and/or L, Chronic obstructive pulmonarv disease From Rich S [ed): Priman'Pulmonuv Hlpertension: Erec:utile.summan from the \Vorld Si'mposiunt-PrimarY Fulmonarl
Available from the lVorld Health Organization f ia the lnternet (http://rlrlrr'.rlho,int/ncd/cvd/pph.html).
,;
RX IN HTP
Normal
Flux crescut in lobii inferiori Gravitafie Presiuni diferite intra alveotare Raport A/B = 1,2 : 1
c $vase.
.
Rx 113
- 15 mm birbafi = I - 14 mm femei
10
KY
Pvenoasd>8-12mm
'
Rx
ff
inversare a aspectului normal (cefatizarea fluxului arterial gi venos) P venoasd > 25 mm . Edem pulmonar
Mecanisme ' sechestrare de lichid interstifial in lobii inferioari
'
. . . . .
presiune interstifiali O
I
complian{a pulmonari
I
\r