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Abstract: The patient described that he had dyspnea after activity for 13 years and gradually worsened after activity for 2 months. 10 years ago, he was admitted to a local hospital for worsening dyspnea, and the echocardiogram showed a whole heart enlargement, congenital tricuspid dysplasia, and tricuspid valve insufficiency (moderate). She was admitted to the hospital, and was given medication + high-flow oxygen, and was discharged after 10 days of hospitalization.
Basic information】Female, 55 years old
Disease Type】Pulmonary hypertension, type II respiratory failure
Hospital】The Second Hospital of Harbin Medical University
Date of consultation】January 2022
Treatment plan】Intravenous medication (torasemide injection, amoxicillin sodium for injection, prostaglandin injection, sildenafil citrate tablets, furosemide tablets) + high-flow oxygen (oxygen flow rate 40L/min)
Treatment period】Inpatient treatment for 10 days, regular outpatient follow up
Treatment effect】Significant improvement of symptoms and successful discharge from the hospital
I. Initial consultation
The patient was wheeled into the consultation room, and his lips were obviously cyanotic. The patient reported: 13 years ago, he had dyspnea after activity, with abdominal distension and lower limb edema, but no chest pain, hemoptysis, black dawn, syncope, or nocturnal paroxysmal dyspnea. 10 years ago, the patient visited a local hospital for worsening dyspnea. Systolic pressure was about 100 mmHg, left ventricular ejection fraction was 71%, and the diagnosis was cardiac insufficiency, pulmonary hypertension, and congenital tricuspid dysplasia. He was hospitalized about once a year, and his activity tolerance gradually decreased. The patient’s arterial blood gas showed pH: 7.37, partial pressure of carbon dioxide: 60 mmHg, partial pressure of oxygen: 55 mmHg, actual carbonate: 31.4 mmol/L, lactate: 0.9 mmol/L. The patient was considered to have fever to be investigated and pulmonary hypertension, and was given nasal catheter oxygenation, and was admitted to our department for further treatment. The patient was poor in spirit and sleep, and could not lie down at night.
II. Treatment history
After admission, cardiac ultrasound and echocardiography were completed, and the results suggested: pulmonary hypertension (estimated pulmonary artery systolic pressure of about 109 mmHg), severe enlargement of the right heart, enlargement of the left atrium, thickening of the right ventricular wall, dilatation of the main pulmonary artery, tricuspid regurgitation (severe), and hypoechoic right ventricular function. The following treatment was then administered.
1, symptomatic treatment: hospitalization was given with torasemide injection pumped in diuretic; anti-infective treatment with injectable amoxicillin sodium was given.
2. Treatment of the cause: It was clear that the patient had pulmonary hypertension, so sildenafil citrate tablets were given orally, and prostilbestrol injection was added after 3 days of medication. The result of blood gas analysis was type II respiratory failure, so high-flow oxygen was given (oxygen flow rate 40L/min), and if the decrease of carbon dioxide was not obvious, it was changed to non-invasive mechanical ventilation, and blood gas analysis, urine volume, ions and other indicators were monitored at any time.
After 10 days of hospitalization, the patient’s symptoms improved and was given discharge with medication, including furosemide tablets and sildenafil citrate tablets, and was instructed to perform home oxygen therapy on his own.
III. Treatment results
The patient’s diagnosis was clear, and since congenital tricuspid dysplasia could not be dealt with temporarily, the main treatment goals at present were: to improve right heart insufficiency, to reduce pulmonary hypertension, and to improve oxygenation. After 3 days of diuretic treatment, the swelling of both lower extremities was not reduced significantly. Since the patient was a severe pulmonary hypertension, he was also given treatment to reduce pulmonary hypertension, oral sildenafil citrate tablets and intravenous prostil injection for 1 week to reduce the swelling of lower extremities. The patient had high risk factors for thrombosis, so he was given prophylactic anticoagulation. Since the patient had fever before admission, he was considered to have infectious factors and was given antibiotics for 3 days, and the symptoms of fever, cough and yellow sputum decreased. According to the patient’s blood gas analysis, the partial pressure of oxygen increased and carbon dioxide decreased after giving non-invasive breathing and treatment. After 10 days of treatment, the overall symptoms were relieved compared with those before admission. The patient was advised to continue oral medication and non-invasive mechanical ventilation after discharge, and was successfully discharged 10 days after admission.
IV. Notes
We are glad to see that the patient’s symptoms have improved after treatment, but because of pulmonary hypertension due to congenital tricuspid dysplasia, the patient’s post-discharge care and self-management are equally important: 1.
1, after discharge, it is recommended that basic treatment to improve the right heart function, including the appropriate use of digitalis drugs under the guidance of doctors, long-term use of diuretics, as far as possible bedside activities to prevent thrombosis, if necessary, oral new anticoagulant drugs, etc.; currently give the patient sildenafil citrate tablets orally; if after a period of treatment, symptoms still can not be alleviated or even worsen, you can consider the combination of prostacyclin class drug treatment, whether the specific need to adjust the drug, need to go to the clinic for regular review.
2, life, patients should choose low salt, low fat, light, nutritious diet, recommended to eat fresh fruits, vegetables; avoid overeating, avoid high salt, high sugar, high fat, fried food intake, quit smoking and alcohol. Keep a good state of mind, choose appropriate activities, such as walking, to improve their resistance and ensure sufficient sleep. In addition, patients are recommended to have home oxygen therapy or non-invasive ventilator therapy at home.
V. Personal insight
The clinical etiology of pulmonary hypertension is very diverse, and it is divided into the following 5 major categories according to the different causes.
1, arterial pulmonary hypertension, including hereditary pulmonary hypertension, drugs and related factors, such as connective tissue disease, congenital heart disease.
2. pulmonary hypertension due to left heart disease.
3, pulmonary hypertension associated with lung disease or hypoxia, clinically common in chronic obstructive pulmonary disease (COPD), interstitial lung disease, sleep apnea hypoventilation syndrome, etc.
4. chronic pulmonary thromboembolic pulmonary hypertension.
5, unnamed causes or multifactorial pulmonary hypertension, such as HIV infection, portal hypertension, etc.
Therefore, when pulmonary hypertension is found, it is necessary to search for the cause according to the classification, careful history taking and improvement of relevant examinations, and then to treat according to the cause. The patient in this case belongs to pulmonary hypertension caused by congenital cardiac insufficiency, and the opportunity for surgery was lost due to untimely treatment, so the current treatment goal is symptomatic treatment, centering around pulmonary hypertension and the resulting right heart insufficiency to slow down the disease progression as much as possible, and home care is mainly to avoid colds, improve hypoxia and reduce cardiac load through non-invasive mechanical ventilation.