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VIEM PHE QUAN CAP I DAI CIFCTNG V iem phe quan cap la tin h tra n g vie m nhiem cap tin h cua cac phe quan, nguyen nhan thu’a n g nhiem virus, vi khua n ho a c ca hai loai II chAn d o An C h an d o an xac djnh T h e dien hinh: vie m phe q ua n cap virus a L a m s a n g - K h a i phat bang vie m long d u a n g ho hap tren v a i sot nhe, vie m m ui hong ( h it i, so m ui, dau rat hong), co the vie m m ui m u, vie m xoang, viem am idan, vie m tai g iu a ; sau lan xuon g - phe quan - Sot nhe h oa c sot cao, n hieu tru a n g h a p khong co sot - Ho khan n h u n g nga y dau, co ho ong ong, ho tu n g c a n , dai d in g , cam giac rat bong sau x u a n g uc, khan tieng Sau do, ho khac d a m nhay, d a m vang m il hoa c d in h m au - C o the co kho th a ta n g dan - K h£m phoi lu c dau b in h th u a n g , sau co the thay ran rit va ran - T ru a n g h a p nang: n g o a i n h u ’ng trieu chipng tren thay kho th a ro ret, co keo c a ho hap, tim , nhip th a nhanh tren 25 la n /p h u t a n g u a i la n b C an lam s a n g - X q uang phoi b in h th u a n g hoa c co the thay phe quan day - X et nghiem : co th e co so lu a n g bach cau va toe m au lin g tang C h an d o an phan b ie t - Hen phe quan: co th e co c a dja dj irng Ho, kho th a th a n h c a n th u a n g ve dem va thay doi th a i tiet, kho th a ra, co tie n g co cip, sau c a n hen thi het cac trie u chipng D a p ipng to t v a i lieu phap corticoid v£ thuoc gian phe quan - G ian phe q ua n boi nhiem : tien sip ho khac d a m keo dai, co cac d o t n hiem khua n tai dien, nghe phoi co ran no, ran am hai ben C h u p c i t la p vi tin h n g u c la p m ong 1m m phan giai cao g iiip chan doan xac djnh benh - Dj vat d u o n g th a : tien sip co hoi c h u n g xam nhap, benh nhan co ho khac d a m hoac ho m au, viem phoi tai dien nhieu d o t sau cho t i c dj vat C h yp c i t la p vi tinh ngu c, soi phe quan co the phat hien dj vat - Lao phoi: co tien sip tie p xuc v a i n g u a i m lc lao, ho khac d a m keo dai, co th e ho m au X q u a n g phoi t h iy ton th u a n g kieu lao Soi, c ly BK d a m co vi k h u ln lao - U ng th u phoi, p h e quan: tie n sip hut th u o c la, th u o c lao nhieu nam Lam sang benh nhan ho m au dau n g u c , gay sut can X q u a n g va /h o a c c i t la p vi tin h n g u c co ton th u o n g d an g dam m a hoa c xep phoi Npi soi p h e q u a n va sin h th ie t cho c h in doan xac dinh H u o n g dAn c h A n o o A n vA oiEu t r i b£nh N O i k h o a 348 - D o t cap suy tim sung huyet: tien s u co benh tim m ach (TH A , benh van tim , benh m ach vanh benh c o tim , ), nghe phoi co ran am , ran rit, ran X q uang phoi bong tim to phoi u huyet D ien tim cb cac dau hieu c h i diem S ieu am tim cho chan doan xac dinh C h an doan n g u yen nhan a V iru s - V iem phe quan ca p viru s chiem 50% to i 90% cac tru ’d n g ho’P vie m phe quan cap C ac virus thu’O’ng g ap nhat la cac m yxo viru s (virus cum va virus a cum), ca c rh ino virus coronavirus virus dai th y c bao du’o n g ho hap (re sp ira to ry syn c y tia l virus), adenovirus, enterovirus (coxsackie va e cho virus) va mot so chung h e rp e s virus (cyto m e g a lo viru s, va rice lla e) - Lam sang th a y cac dau hieu nhiem virus khong dac hieu - C han doan xac dinh can nguyen virus d u a vao vie c tim th a y viru s d cac benh pha m d ira n g ho hap qua nuoi cay te bao, k i th u a t hien vi m ien dich huynh quang hoa c hu ye t th a n h chan doan nhung tren th u c te khong lam tr u tron g cac vu d|ch Ion b Vi kh u an - it gap h o n cac tru d n g h o p viem phe quan cap virus - T h u d n g gap nhat la nho m cac vi khua n khong dien h in h , tro n g te b a o n h u M ycoplasm a v£ C hlam ydiae, cac vi khua n gay m u hiem gap hon - Do phe cau, H e m o p h illu s influenza e, it gap d n g u d i Idn hay di kem v d i sot va cac dau hieu ngoai d u d n g ho hap X e t n gh iem vi khua n th u d n g am tinh c Viem p h e q u a n ca p h it p h a i h o i doc K hi S 2, clo, a m o niac, acid, dung m oi cong nghiep, h o i doc ch ien tran h, kh o i ch a y nha cung g3y vie m phe quan cap III O l£U TR| - O’ n g u d i Idn vie m phe quan cap d o n thuan co the tu khoi khon g can die u tri - D ie u tri trieu c h u n g : + N ghi n g o i tai g iu o n g + B ao dam du n u d e uong, dinh d u d n g + C ac th u o c giam dau cho n g viem khong phai corticoid + Ho khan nhieu, gay m at ngu co the cho cac th u o c giam ho n h u : • Terpin code in 15- 30m g /2 gid , hoac ■ D e xtro m e th o rp h a n 10-2 m g /2 g id d n g u d i Idn, hoa c + C o rtico id d u d n g uong (p re d n is o lo n : ,5 m g /k g /n g a y ) tro n g d e n ng a y (n e u khon g co chong ch i dinh) + N eu co co th a t phe quan: th u o c gian phe quan c u d n g 02 d u d n g p hu n h it (V entolin, B ricanyl) hoSc dung V e nto lin 5m g x 2- nan g/2 g id hoac uong S a lb u ta m o l m g x 2-4 vie n /2 gid - K hong can dung khan g sinh cho vie m phe quan cap d o n th u a n d n g u d i b in h th u d n g - N eu co khac d d m m u thi dung: + M ot khan g sinh nho m p e n icilin A n h u am o xicilin lieu -3 g /2 g id , h oa c + M acrolid: e ryth ro m ycin 1,5g x 10 ngay, a z ith ro m ycin 500 m g x la n /n g a y x (tranh dung th u o c v d i th u o c g ian phe quan nhom xanthin, th u o c nhom IM A O ) + C e p h a lo sp o rin e th e he 1: ce p h a le xin 2-3 g /2 gid - Ket h o p v d i th u o c long d d m co a ce tylcyste in 200 m g x g o i/2 g id H u O n g dAn c hA n d o A n vA bi£u t r i b£nh NOi khoa 349 - D ie u tri b en h li o nhiem kh&c - N h u n g tru ’d n g h a p vie m tieu phe quan cap d tre nho, c a dia suy ho hap m an tinh, c o n co t h lt phe quan nSng can ch o nhap vien, th d oxy, dieu chinh n u d e dien giai, tiem tru ye n khang sinh, co the dung corticoid kem th e o p ho ng dien bien nang IV PHONG BENH - Loai bo yeu to kich th ich : khon g hut thuoc, tranh khoi bui trong, ngoai nha, m oi tru d n g o nhiem , g iu I m vao m ua lanh - Tiem va ccin phong cum , phe cau, dac biet d n h u n g tru d n g h a p co benh phoi m an tinh, suy tim , c it lach, tuoi tren 65 - D ieu tri cac nhiem tru n g tai m ui hong, rang ham m at, tin h tran g suy giam m ien dich - V e sinh rang m ieng t A i l ie u t h a m k h A o A a g a a rd E, G o n z a le s R (2004), "M a n a g e m e n t o f a cu te b ro n c h itis in h e a lth y a d u lts ”, Infect Dis C lin N orth A m , 18 (4): 919-37 K n u tso n D, B rau n C (2002), "D iagn osis a n d m a n a g e m e n t o f a cu te b ronchitis", A m Fam Physician, (1 ): 2039-4 T h o m a s J M a rrie (2 0 ), “A cu te bronchitis", F is h m a n ’s P u lm o n a ry D ise a se s and D isorder (4th ed), M cG w -H ill, -2 W ark P (2004), “B ro n c h itis (acute)", C lin Evid, 1923-32 VIEM PHOI MAC PHAI CONG DONG f _ I OAl C U O N G V iem phoi m lc phai d cong dong la tin h trang nhiem khua n cu a nhu m o p ho i xay d ngoai benh vien, bao gom vie m phe nang, ong va tui phe nang, tieu phe q ua n tan ho a c vie m to chipc ke cua ph6i T ac nhan gay vie m phoi co the la cac vi khuan, virus, ki sinh vat, nam , n h u n g khong phai tn/c khua n lao ii c h An o o An C h an doan xac djnh a Lam sang - K h d i phat dot ngo t v d i sot cao 39°C -40°C , ret run - D a u n g u c: th u d n g co, doi la trieu c h u n g noi bat, dau ben ton th u o n g - Ho m d i xu a t hien, tang dan, luc dau ho khan, ve sau ho co d d m dac, m au vang, xanh hoSc m^u gi s it C o non, tru ’d n g bung, dau bung - K ho th d : th d nhanh, tim m oi dau chi - Hoi c h u n g nhiem trung: sot cao, th d hoi, m oi kho lu d i ban - Hoi chipng dong dac d phoi, ran am , ran no ben ton th u o n g - D au hieu g o i y vie m phoi phe cau: m gn herpes d m ep, m oi, ca n h m ui, - T ru d n g h o ’P d a c biet: n g u d i nghien ru o u co the co lii lan, tre co co giat, n g u d i cao tuoi tn$u chipng th u d n g kho n g ram ro, co bat dau b ln g lii lan, m e sang (ti le tip vo n g ca o suy ho hap cap, nhiet do) - T h e khong dien hinh: bieu hien ho khan, nhipc dau, dau c o K h a m th u d n g khon g ro hoi ch irn g dong dac; thay rai rac ran Im , ran no X q u a n g phoi ton th u o n g kho n g d ien h in h (m d khon g dong deu gicn han khong ro h in h thuy) b C an lam s a n g - C ong th u c m au: so lu o n g bach cau tang > 10 G iga/I, bach cau da nhan tru n g tin h tang tren 75% Khi so lu o n g bach c iu giam < 4,5 G iga/I: h u d n g td i vie m phoi virus - Toe lin g m au tang, C R P tang > 0,5 - C ly m au ho a c d d m co the thay vi khua n g a y benh - X q u a n g phoi: dam m d h inh ta m giac dinh d p h ia ron phoi, day d p h ia n go ho$ c cac dam m d cb hinh phe quan ho i, co th e m d goc s u d n hoanh - C h up cat Idp vi tin h n g u c: co hoi c h u n g li p day phe nang v d i dau hieu p h e q ua n hoi, thuy phoi viem khon g giam the tich , bong m d phe nang hoa c m o ke ton th u o n g m d i xu a t hien d m ot ben ho5c ca hai ben, co the kem th e o tra n djch m ang phoi H i/ O n g d An ch An o o An v A o i £u tri b £n h NQi khoa 351 C h a n d o a n p h a n b i£ t a L a o p h o i - Tien s u tie p xu c v o i ngu’d’i m lc lao - H o kh a c d o m keo dai, co the ho m au, sot nhe ve chieu, g a y sut can - X q u a n g phoi chu yeu la n h u n g not m o tham nhiem vung don hai ben, co the thay hinh hang So It tru d n g h o p ton th u o n g d u o i dang dam m o hoac tham chi h in h tam g ia c v o i day qua y ngoai giong viem phoi - C han d oa n xa c dinh: tim th a y tru e khuan lao d o m hoa c dich phe quan b N h o i m a u p h o i - C o yeu to nguy co : benh nhan sau de, sau phau th u a t d vung tieu khung, sau chan th u o n g , gay x u o n g , bat d on g lau ngay, vie m tac tin h m ach chi d u o i, dung th u o c tran h thai, - O au n g u c d u doi, ho m au, kho th d , co the co dau hieu soc - D ie n tam co the th a y dau hieu tam phe cap: S sau d D , Q sau d D3, true phai, bloc nhanh phai - K hi m au co the th a y ta n g th o n g khi: P a giam va P a C giam - D -d im e r m au ta n g cao - C h up c i t Idp vi tin h co tiem th u o c can quang tTnh m ach co th e p h a t hien vj tri nhoi m au c U n g thu> p h o i - T h u d n g g a p d n g u d i > 50 tuoi, co tien s u nghien th u o c la, th u o c lao - Ho khac d d m lan m au, g a y sut can - X q uang phoi co dam m d - C h yp c i t Idp vi tin h n g u c , soi phe quan v& sinh th ie t ch o chan d oa n xac djnh - N en chu y nhu’ng tru d n g h o p nghi n g d hoac sau dieu trj het nhiem khuan m a ton th u o n g phoi khong cai thien tre n m ot th a n g ho a c vie m phoi tai phat d cung m ot vj tri d G ian p h e q u a n b p i n h ie m - B ^n h nhan co tien s u ho khac d d m m u keo dai, co sot K ham phoi: co ran am , ran no co djnh - C an chup phim c i t Id p vi tin h long n g u c Idp m ong 1m m phan giai ca o co ton th u o n g dien hinh C h in d o a n n g u y e n n h a n - D u a v£ o xet n g h ie m vi sin h v a t d d m , m au hoa c djch phe quan - C £c vi khua n g a y vie m phoi dien hinh: S tre p to co ccu s p n e u m o n ia e , H e m o p h ilu s influenza e - C £c vi khua n g a y vie m phoi khong dien hinh: L e g io n e lla p n e u m o n ia e , M y co p la sm a p ne um o nia e, C hlam ydiae p n e u m o n ia e - C £c vi khua n gay vie m phoi nang: S ta p h ylo co ccu s aureus, K le b s ie lla p n e u m o n ia e , P se u d o m o n a s aeruginosa, vi khua n ye m - M ot so tru ’d n g h o p virus, nam , ki sinh trung C h a n d o a n m u c d o n a n g : C U R B - C: roi loan y th u c - U: ure > m m o l/L - R: tan so th d £ 30 la n /p h u t - B: hu ye t ap: + H u ye t ap ta m thu < m m H g ho£c + H u ye t ap ta m tru o n g £ m m H g - T uo i £ 65 H iT O n g dA n c h A n o o A n vA oiCu t r i b £n h 352 NOi khoa M oi bieu hien tren d irg e tin h diem , td danh gia m d c nang cua vie m ph o i n h ir sau - V iem phoi nhe: C U R B = 0-1 diem : dieu tri ngoai tru - V iem phoi trun g binh: C U R B = diem : dieu tri tai benh vien - V iem phoi nang: C U R B = 3-5 diem : dieu tri tai benh vien III O l£U TR| N g u yen t i c ch u n g - X d tri tu y th e o m d c nang - D ieu tri trieu chipng - D ieu tri ngu yen nhan: Iga chon khang sinh theo can nguyen gay benh, n h irn g ban dau th i/d n g theo kinh ngh iem lam sang, yeu to dich te, m d c nang cua benh, tuoi benh nhan, cac benh kem theo cac tu’a n g tac, ta c d yn g phu cua thuoc - T h a i gian dung khan g sinh: tir den 10 neu cac ta c nhan gay vie m phoi dien hinh 14 neu cac ta c nhan khon g dien hinh, try c khua n m u xanh D ieu trj a D ie u t r i n g o a i tru : C U R B 0-1 diem -A m o x ic illin 500 m g-1g: uong lan/ngay - H oac c la rith ro m ycin 500 m g x lan/ngay - H oac a m o xicilin m g /kg /n g a y + m acrolid (e ryth ro m ycin g /n g a y ho a c c la rith ro m ycin 500mg x la n/n gay) nghi vi khua n khong dien hinh - H oac co th e dung (3 - la c ta m /irc che m en (3 - la cta m a se (a m o xicilin - cla v u la n a t) ket h o p von mpt thuoc nhom m acro lid (clin d a m ycin : 500m g x la n/n gay hoa c a z ith ro m y c in 0 m g /n g a y) - H oac dung nhom c e p h a lo sp o rin the he 2: ce fu ro xim ,5 g /lin x la n /n g a y hocic ket h g p vcri mpt th u o c nhom m acrolid - D a m bao can b in g nu’a c - dien giai va thang b in g kiem - toan b D ie u t r j v ie m p h o i tru n g b in h : C U R B = diem - Khang sinh + A m o xicilin - acid cla vula nic: 1g x la n/n gay (u o n g ) ket h o p v d i m ot th u o c nhom macroM (clin dam ycin: 500m g x la n /n g a y hoac a zith ro m ycin 50 m g /n g a y) + Neu khong uong d iro c : am o xicilin - acid clavula nic: 1g x la n /n g a y (tiem tin h m ach) ket hop v d i m ot th u o c nhom m a cro lid dung th e o du’d n g tin h m ach (clin d a m ycin : 500 m g x lan/ngay hoac a zith ro m ycin 0 m g /n g a y) + H oac le vo flo xa cin 0 m g /n g a y hoa c m o xiflo xa xin 400 m g /n g a y - D a m bao can b ln g nu’d c - dien giai va thang b in g kiem - toan - D ung th u o c sot nhiet > 38.5°C c D ie u t r j v ie m p h o i n a n g : C U R B = 3-5 diem - Khang sinh + Ket h o p am o xillin - acid cla vu la n ic g/lan x lln /n g a y (tiem tin h m a ch ) ket h o p them : clarithrom ycin 500m g (tiem tTnh m ach la n /n g a y) hoa c le vo flo xa cin 500 m g/nga y + H oac c e p h a lo sp o rin rong (ce fo ta xim 1g x la n /n g a y ho a c ce ftria xo n 1g x lan/ngay ho&c ce fta zid im 1g x la n /n g a y) ket h o p v d i m acro lid hoa c a m in o g ly c o s id ho a c flu o ro q u in o lo n (levc^oxacin 0,5g/ngay, m o xiflo xa cin 0 m g /n g a y) + X em xet thay doi khan g sinh tu y th e o dien bien lam sang va khan g sin h d o neu co - T h d oxy, th o n g nhan tao neu can, dam bao huye t dong, dieu tri cac bien c h irn g neu co H i / cJ n g d An c h An o o A n VA B l f u TRI b En h NQi khoa 353 D ie u trj m o t s viem phoi dsic biet (Phcic d ieu tri ch o benh nhan n |n g khoang 60kg) a Viem p h o i P s e u d o m o n a s aeru g in o s a : ce fta zid im 2g x la n /n g a y + gen tam icin hoac to b m yc in e ho $ c a m ika cin v o i lieu th ich hop Lieu phap th a y the: cip ro flo xa cin 500m g x la n/n gay + p ip e cilin 4g x la n /n g a y + g e n tam icin hoac to bram ycin hog c a m ika cin v d i lieu th ich hop b Viem p h o i L e g io n e lla : cla rith ro m ycin 0,5g x la n /n g a y ± rifam p icin 0,6g x 1- lan/n gay x 14 - 21 H o |c flu o ro q u in o lo n (cip ro flo xa cin , ofloxa cin, le vofloxacin, m o xiflo xa cin ) c Viem p h o i tu c a u van g - Tu cau va n g nhay ca m v o i m e th icillin: oxacilin 1g x la n /n g a y ± rifam p icin 0,6g x 1- lan/ngay - V iem phoi tu cau va n g khan g v o i m ethicillin: v a n co m ycin e 1g x lan/ngay d Viem p h o i v iru s cu m - D ieu tri trieu c h u n g la ch in h : sot, giam dau - Tam iflu 75m g x v ie n /n g a y uong chia lan Tru’d n g h o p nang co the dung lieu gap doi - D ung khang sinh co bieu hien boi nhiem vi khuan e M o t s o viem p h o i k h a c - Do nam : d un g m o t so th u o c chon g nam nhu : a m p h o te ricin B, itraconazol - P n e u m o cystis ca rin ii: co trim o x a z o l + su lfa m e th o xa zo n m g x 2-4 vien/ngdy - Do a m ip: m e tro n id a z o l 0,5g x lo /ng ay truyen tin h m ach chia lan IV PHONG B 6N H - D ieu tri to t cac o n h ie m tru n g tai m ui hong, rang ham m at - T iem va ccin p ho ng cum m oi nam lan, phong phe cau nam lan ch o n h u n g tru’d n g h o p co benh ph6i m gn tin h , suy tim , tu o i tre n 65 hogc da cat lach - Loai bo nhu’ng yeu to k ic h th ic h dpc hai: th u o c Id, th u o c lao - G iu am co, n g y c tro n g m ua lanh TAl LIEU TH A M khAo A n to n i T o rres, R o s a rio M e n y n d e z, R ich a rd W u n d e rin k (2010), “P y o g e n ic B a c te ria l P n e u m o n ia a n d L u n g A b ce ss", M u rra y and N a d e l’s T extbook o f R e sp ira to ry M e d ic in e (5th ed), Saunder A rm ita g e K, W o o d head M (2007), “N e w g u id e lin e s fo r the m a n a g e m e n t o f a d u lt co m m u n itya c q u ire d p n e u m o n ia ”, C u rr O pin Infe ct Dis, 20 (2): 170-6 C u n h a B A (20 ), ‘ S e ve re C o m m u n ity -a c q u ire d P n e u m o n ia in the C h tic a l C are U n it”, Infe ctious D ise a se in C ritica l C a re M e d ic in e 2nd Ed, N e w York: Info rm a H e a lth ca re , 157-168 C u n h a B A C u n h a B A (e d ) (2008), P n e u m o n ia E sse n tia ls 2nd Ed, R o yal O ak, M l: P h ysicians P ress, 55-63 T h o m a s J M a rrie (20 ), °C o m m u n ity -a c q u ire d p n e u m o n ia ”, F is h m a n ’s P u lm o n a ry D iseases and D is o rd e r (4th ed), M cG raw -H ill, -2 1 Ap x e p h o i I D A I C ira N G A p xe phoi la o m u tron g nhu m o phoi vie m nhiem hoai tu cap tin h kho n g phai lao, sau pc mu tao hang A p xe phoi co the co m ot hoac nhieu o Khi dieu tri noi kh o a qua tuan th a t bai thi gpi la ap xe phoi m an tinh II chAn An C han doan xac djnh a Trieu chu’n g lam sa n g - Sot: 38,5°C - 39°C h oa c cao hon , co the kem ret run hoa c khong - D a u n g y c ben ton th u ’o n g , co the co dau bung d n h u n g benh nhan ap xe phoi thuy d u d i - Ho khac d d m co m u, d d m thu’d n g co m ui hoi hoac thoi, co th e khac m u so lu o n g nhieu (oc mu), doi co th e khac m u lan m au hoac tham chi co ho m au nhieu, co chi ho khan - K ho th d , co the co bieu hien suy ho hap: th d nhanh, tim m oi, dau chi, P a giam , S a giam - K ham phoi: co th e th a y ran ngay, ran no, ran am, co th a y hoi c h u n g hang, hoi c h u n g dong (J3c b C an lam s a n g - C o ng th u c m au: th u d n g thay so lu o n g bach cau > g ig a /lit, toe d o m au lang tang - X q u a n g phoi: h inh hang th u d n g co th a n h tu o n g doi deu v d i m u c n u d e ho i C o the co mpt hay nhieu o ap xe, m ot ben hoa c hai ben C an chup phim X q u a n g phoi ngh ieng (co phai ch u p c i t Id p vi tin h ) de xac djnh ch in h xac vi tri ap xe giup chon p h u o n g phap dan lu u m u phu hop - C ay m au tim vi khua n tron g tru d n g h o p sot > 38,5°C va lam kh a n g sinh (neu co dieu ki£n) - N h uom soi tru e tiep va nuoi cay vi khuan tu d d m , djch phe quan ho a c m u o ap xe Lam khang sinh neu thay vi khuan C h an doan n g u yen nhan V ie c xac djnh can n gu yen phai d y a vao xet ngh iem vi sin h vat d d m , djch phe quan, m au h o d : benh pham khac C ac ta c nhan g a y ap xe phoi th u d n g la S ta p h ylo co ccu s aureus, K le b s ie lla p n e u m o n ia e , Pseudom onas aeruginosa, E Coli, P ro teus, vi khua n yem khi, S tre p to c o c c u s p n e u m o n ia e , H e m o p h ilu s influenzae M ot so tru d n g ho’P nam , ki sinh trun g (am ip) C an tim cac yeu to th u a n lo i n h u ngh ien ru o u , suy giam m ie n djch H IV h o le cac th u o c u c ch& m ien djch, tim cac o n hiem khua n nguyen phat rang, ham , m at, tai, mOi, hong, H u O n g d A n c h A n o o A n vA o i£ u t r i b £ n h N oi k h o a 355 C h in docin phan biet - U ng th u p ho i ap xe hoa: + B enh nhan th u d n g > tuoi, tien s u nghien th u o c la, th u o c lao + Ben canh trieu c h u n g ap xe phoi, co the thay cac trieu c h u n g khac n h u nuot nghen, noi khan, m ong tay khum , ngon dui trong, phu ao khoac, dau cac kh d p , + P him X q u a n g phoi th a y hang co day, th u d n g lech tam , xung quanh co cac tua gai, it co hinh anh m u c n u d e ho i Soi phe quan va sinh th ie t co the chan d oa n xa c dinh d u o c - Ken phoi boi nhiem : + Bieu hien lam sang g iong ap xe phoi + X q uang phoi: h inh hang th a n h m ong < 1m m, co m u c n u d e h o i va sau dieu trj n h u m ot ap xe phoi thi ken van ton tai - G ian phe quan h inh tui cue bo: + Tien s u ho, khac d d m hoa c co ho m au keo dai nhieu nam , nghe phoi co ran am, ran no ton tai lau + H inh anh X q u a n g phoi: co nhieu o sang xen ke vung m d khon g deu, chup c i t Idp vi tin h long n g u c Idp m ong 1m m phan giai cao hoa c chup phe quan can quang g iup chan doan xac dinh - Lao phoi co hang: + Lao ph o i th u d n g tie n trie n t u t u v d i to a n tra n g g a y su t suy sup, so t ve ch ie u , ho kh a c d d m , hoac m au + C o tiep xuc v d i n g u d i m ac lao + T im th a y tru e k h u a n kh a n g khan g toan (A F B ) tro n g d d m (lay m au d d m lien tu c tro n g buoi sang) + Phan u n g m a n to u x v d i tu b e rcu lin nhieu tru d n g h o p d u o n g tin h m anh + M au lin g tang + X quang phoi: tren nen ton th u o n g tham nhiem hoac x o hoa co m ot hoa c nhieu hang, th u d n g khu tru d dinh phoi ill e i£ u TRj D ieu trj noi kho a a D ieu trj k h a n g s in h N g uyen tSc d u n g k h a n g sinh - D ung khan g sinh sd m , th e o khang sinh - Phoi h o p tu khan g sinh, th e o d u d n g tin h m ach hoa c tiem bap N eu d d m co m ui thoi dung khang sinh chong vi khua n kj khi: m e tro n id a zo l 500m g x lo /ng ay tru ye n tin h m ach chia sang, toi - Lieu ca o nga y tu dau - S u dgng th u o c n ga y sau lay d u g c benh pham chan doan vi sinh vat - T y doi khan g sin h d u a th e o dien bien lam sang va khan g sinh neu co - T h d i g ia n d u n g k h a n g sin h it n h a t tu a n (co th e ke o d a i d e n tu a n tu y th e o la m sa n g va X q u a n g p h o i) - C a c loai kha n g sin h co th e dung n h u sau: + P e n icilin G - trie u d o n vj th e o tin h trang va can nang cua benh nhan, pha tru ye n tinh m ach c h ia - lan/ngay, ket h o p v d i khang sinh nhom a m in o g lyco sid e : H 356 u Cj n g d An ch An An v A o i Eu t r i b E n h N oi k h o a ■ G e n ta m icin -5 m g /kg /n g a y tiem b lp lan ■ A m ika cin m g /kg /n g a y tiem b ip lan hoa c pha tru ye n tTnh m ach tro n g 25 m l dung dich natri clo ru a 0,9% + Neu nghi vi khua n tie t b e ta la cta m a se thi th a y p e n icilin G b ln g a m o xicillin + acid cla vunalic hodc a m picillin + sulbactam , lieu dung -6 g /ngay (cac biet du’oc: A u g m e n tin , C u m , U nasyn ) + N eu nghi n g d ap xe phoi vi khuan G ram am thi d un g ce p h a lo s p o rin th e he n h u cefotaxim - 6g/ngay, ce fta zid im - 6g/ngay, ket h o p v d i khang sinh nhom a m in o g ly c o s id v d i lieu tu o n g tt/ nhir da neu d tren + N eu nghi n g d ap xe phoi vi khuan yem thi ket h o p nhom beta la cta m + acid clavunalic vcri m e tro n id a zo l lieu 1- 1,5g/ngay, truye n tin h m ach chia 2-3 la n /n g a y h od c p e n icillin G - trieu don vj ket h o p m e tro n id a zo l -1 ,5 g/ngay truye n tin h m ach hoac p e n icilin G - trieu d o n vi ket hop clin d a m ycin 1,8 g /n g a y tru ye n tin h m ach + N eu nghi n g d ap xe phoi tu cau: o xa cillin - 12g /ng ay hoa c va n c o m y c in 1-2g/ngay, ket hop v&i a m ika cin nghi d o ty cau khan g thuoc + N eu dp xe phoi a m ip thi dung m e tro n id a zo l 1,5g/ngay, tru ye n tTnh m ach chia lin /n g a y ket h o p v d i khan g sinh khac + C hu y xe t n g h ie m cre a tin in m au lan m ot tuan doi v d i benh nhan co s u dung thuoc nhom a m ino glyco side b D a n lu’u o a p x e - D an lu-u tir the, vo rung long ngu c: d y a vao phim ch u p X q u a n g p ho i th in g ngh ie n g hodc chup d t Idp vi tin h long n g u c, ch o n tu the benh nhan de dan lu u tu th e ket h o p v d i vo rung long nguc Dan li/u t u th e nhieu lan/ngay, de benh nhan d tu the cho o ap xe d u o c dan lu u to t nhat, luc dau thdi gian n g ln vai phut, sau keo dai dan th d i gian tu y th u o c vao kha nang ch ju d u n g cua benh nhan co the den - phu t/lan V o rung dan lu u tu the m oi 2-3 lan - C o the noi soi phe quan ong m em de hut m u d phe quan dan lu u o ap xe S oi phe quan ong mem giu p pha t hien cac ton th u o n g gay tac phe quan va g lp bo dj va t p h e quan neu co - C h o c dan lu u m u q u a th a n h n g u c: ap dung doi v d i nhu’ng o ap xe ph o i d ngoai vi, o ap xe kh&ng th o n g v d i phe quan; o dp xe d sat th a n h n g u c hoac d in h v d i m a n g i S u d un g ong thong cd 7-14F, dat vao o dp xe de hut dan lu u m il qua he thong hut lien tuc c C ac d ieu trj k h a c - D a m bao ch e dinh d u d n g cho benh nhan - D a m bao can b in g n u d e dien giai, thang b ln g kie m toan - G iam dau, hg sot O i§u trj p h iu th u a t M o c i t phan th u y ph o i ho a c th u y phoi hod c ca ben phoi tu y th e o m u c lan rong v d i the trang benh nhan vd c h u c ndng ho h ip tro n g g id i han cho phep (FEV1 > lit so v d i so li thuyet) - dp xe > 10cm - Ap xe phoi m an tinh dieu trj noi khoa khong ket qua - Ho m du tai p h a t hoa c ho m au nang de doa tin h m ang - Ap xe phoi hop vdi gian phe quan khu tru nang - C o bien c h u n g ro phe q ua n - khoang m ang phoi H uong d An c h An d o An v A b i £ u t r i b En h N i khoa 393 + N en tien hanh chpn lieu oxy cho benh nhan a benh vien B it dau v o i lieu th a p 0,5 -1 lit/phu t Lam lai m au sau g ia - N eu P a < m m H g (hoac S a < 90% ): tang oxy them 0,5 lit D ieu chinh nhu1vay cho den dat m uc tieu - N eu P a > m m H g (h o a c S a > 92% ) va P a C > m m H g : giam lieu oxy m oi 0,5 lit, cho den dat m u c tieu - N eu P a < m m H g (h o a c S a < 90% ) va P a C > m m H g : xet ch i dinh th a m ay khong xam nhap (BIPAP ) T h u o c I om tieu - T h u o c la i tieu: nen dung 3-5 co phu chan, gan to, tTnh m ach co noi: fu ro se m id 40m g x vie n /n g a y (uong buoi sang) T ru’a n g h a p phu nang: co the dung fu ro se m id 20m g x 1-2 ong (tiem tTnh m ach) tro n g nga y dau, sau ch uye n sang dung fu ro se m id m g x vie n /n g a y tu th u hai tra di Dung kem kali clorid 0,6g x vien uong, hoac kali clorid 2g x goi (pha uong) - C a c la i tieu khac co th e dung: sp irom id (dang ket h p p khan g a ld o ste ro l - fu ro se m id ), spiron ola ton 25m g x 1-2 vie n /n g a y x 3-5 K h ong d u n g th u o c - M orphin, g a rd e n a l va ca c th u o c an than khac vi gay u c che tru n g tam ho hap - K hong d un g th u o c g ia m ho C h ich m au C hi djnh h e m a to c rit la n h a n 60% Lay khoang 300m l m oi lan O idu trj cac t r u a n g ho,p khac a K h i co d p i b o i n h ie m : b e n h n h a n dwcrc c h i djn h d u n g k h a n g sin h Khang sinh d u p e c h i d inh tron g d p t boi nhiem T h u o c khan g sinh co th e dung: penicillin, am picillin, am oxilin, a m o xilin + acid cla vu la n ic, cac ce p h a lo sp o rin the he 1-2-3, q u in olon b Tam p h e m a n c a c b e n h p h o i co ro i lo an th o n g k h i tac n g h e n (tha m kh a o them bai dieu trj benh phoi t i c ngh en m an tin h va bai hen phe quan) N en dung th e m cac th u o c co rtico id dang phun h it va th u o c gian phe quan C orticoid: - D ang xjt: b e c lo m e th a s o n (B ecotid e); b u d esonid (Infla m m id e) - D ang dung: b u d e so n id (P u lm icort); be clo m e -th a so n - D ang vien: p re d n iso lo n ; p re d n iso n ; m e th yl-p re d n iso n - D ang tiem : d e p e rso lo n ; m e th ylp re d n iso n T hu oc gian phe quan: - C ac ch a t c u a n g g ia o cam : sa lbutam ol, terb uta lin , fe n o te ro l - Khang ch o lin e rg iq u e : ip tro p iu m brom id v a i biet d u p e la A tro v e n t d an g phun xit, dung, hoac tiem tin h m ach - M e th ylxa n th in : th e o p h y llin , diaphyllin c Tam p h e m a n h e n p h e quan D ung co rtico id d an g phun hit s a m va keo dai d Tam p h e m a n x a p h o i: th u a n g khong co u tre C 2, nen ch i can th a oxy rong rai va cho corticoid H u o n g d a n c h A n o o A n vA o i£ u t r i bEnh N i k h o a 394 e Tam p h e m a n b eo p h i: cho an che lam giam can g Tam p h e m a n g u c o t son g, d i d an g lo n g ngisc: tap th a , ch o n g boi nhem phoi co the dieu tri ch inh h inh ti> sa m h Tap th& : lam ta n g g ian n a cua phoi va long n g y c , ta n g th o n g k h i p h e nang, nha t la th a b3ng c a hoanh i L o a i bo n h u ’n g y e u to kich thich: K hong hut th u o c lao, th u o c la, tra n h khoi, bui cong nghiep t A i l ie u t h a m k h A o D ana M c G lo th lin , Teresa De M arco (2010), “C o r P u lm onale", M u rra y and N a del's Textbook of R e sp ira to ry M e d ic in e (5th ed), Saunder Han M K , M c L a u g h lin W , C rin e r G J, M a rtin e z FJ (2007J, “P u lm o n a ry D ie a se s a n d the heart', C ircu lation , 116: 299 -3 0 S h u ja a t A, M in k in R, Eden E (2007), “P u lm o n a ry h y p e rte n s io n a n d c h ro n ic c o r Pulm onale in CO PD ", Int J C h ro n O b stru ct P ulm on Dis, 2(3): 273-82 W e itze n b lu m E, C h a o u a t A (2009), “C o rp u lm o n a le ", C h ro n R e sp ir D is, 6(3): 177-85 W ie d e m a n n HP, M a tth ay RA (1989), “The m a n a g e m e n t o f a c u te a n d c h ro n ic c o r pulmonale", H e a rt-L u n g In te ctio n s in H ealth and D isease, N ew York, NY: M a rce l D ekker, 915 HO RA MAU I O Al C U O N G H o m au la m ot cap c u u noi khoa M au tu d u a n g ho hap d u a i d u a c ho, khac, trao, pc ngoai qua d u a n g m ieng m ui Ho m au la m ot dau hieu lien quan ta i nhieu benh: phoi, phe quan (nhiem khuan, ung th u ), benh li tim m ach, ch a n th u a n g long n g u c, cac benh t u m iin , cac th u o c hoa c doc to va di vat d u a n g ho hap d u a i H o m au cung co the la bien c h u n g cua cac thu th u a t can th ie p a phe quan - phoi ii c h An o o An C h an d o an x a c djn h a L a m s a n g - Ho m au: luc dau m au tu a i, co bot lln d a m , sau ch uye n dan sang sam m au - Kham : + C ac trieu c h u n g lien q ua n den benh li phoi, phe quan: sot, kho th a , dau n g u c, ran no, ran am + T hieu m au neu ho m au nang: da xanh, niem m ac n h a t, m ach nha nh, huye t a p , + Suy ho hap cap th u o c m ire ho m au va tinh trang benh li phoi: nhip th a nhanh, tim moi, dau chi b C an la m s a n g - X q uang tim phoi th in g , ngh ieng : co the thay h inh anh gian phe qua n, h inh kin h m a , dong dac nhu m o phoi, h inh hang, th a m n hiem nhu mo, - C hup c i t la p vi tin h phoi: ch o thay ro cac ton th u a n g neu tren N goai pha t hien cac ton th u a n g nho, ton th u a n g gan tru n g th a t khong thay d u a c tren X q u a n g phoi th u a n g quy - C hup c i t la p vi tin h n g u c da dau (M S C T ) 64 day co the xac dinh cac bat th u a n g m ach m au phoi n h u t i c dong m ach phoi, dj dang dong m ach phoi, th o n g dong tin h m ach p h o i - C hup dong m ach phe quan: chi dinh tru a n g h a p ho m au nang de pha t hien gian dong m ach phe quan va gay b it t ic - Soi phe quan ong m em : can th u c hien s a m de xac dinh vj tri ch a y m au dong th a i ru a phe quan, phe nang, hut djch lam xet n g h ie m te bao, vi khua n (tim lao, nam , vi khu a n th o n g th u a n g ) - X e t ngh iem d a m : tim te b a o ung th u , A F B , soi va nuoi cay tim vi kh u a n th o n g th u a n g - P han u n g M a ntoux: g p i y chan doan lao M a n to u x > 12m m , ho a c co san n u a c - X e t n g h ie m m au: co n g th u c m au, dong m au c a ban, sinh hoa m au de danh gia m u c thieu m au, benh li m au, benh li gan th a n co the gay ho m au - C a c xet n g h ie m g iup ch a n doan benh li tu m ien: tong phan tich n u a c tieu, khan g the khang nhan, khang th e kha n g D N A C h a n d o an m ire ho m au - N he: lu p n g m au < 50m l - T rung binh: 50 - 200 m l - N ang: > 200m l H i/ P 396 ng d An c h An o o An v A o i E u t r i b En h NOi khoa - R at nang: > 0 m l/2 gio - Ho m au tac nghen: la ho m au nang kem th e o suy ho hap ca p tin h C h an doan phan biet - Chay mau benh li tai, mui, hpng: kham, noi soi tai mui hpng thay diem chay mau, u, polyp bat thuang mach mau, chan thu’O’ng so nao - C h ay m au benh li rang ham m at: viem , ap xe q ua nh rang, ung th u lu a i - E3pnh li tieu hoa: loet da day, ung thu- da day, th u c quan, gian v a tTnh m ach c u a a benh nhan xa gan B enh nhan th u a n g non m au lan th u c an, m au sam C h an doan n g u yen nhan B ang C ac n g u y e n n h a n h o m a u Nguyen nhan ho mau Ung th u phe qu3n, phoi Gian phe qu2n Can lam sang Lam sang Cac yeu to goi y Xquang phoi, chup c3t Idp vi tin h phoi co flam mo, Tien siir hut thuoc, tuoi > Cd the cd mong tay 40, ho mau, gay sut can khum, ngon tay dui hinh tua gai, cd the cd hach trung that Soi phe trong, cd tieng rit khu qu3n co the thay u long PQ Sinh thiet ton tru phe quan thuong cho chan doan x^c dinh Ho, khac dom thudng Nghe phoi cd ran no, ran Chup dong lau, gay xuong, sau mang phoi, tieng th o i d 500ng/m l Sieu am tim cd tang ganh that ptiai phau th u a tv u n g c h a u tim Dau hieu t3c mach Chup MSCT phoi cd the phat hien huyet kho 5ong Trieu chUng: dau nguc, kho chi dudi (sung, dau b5p mach phoi thd, ho mau c h a n ) xac djnh TSc mach phoi Di dang mach phoi Tien s iih o mau tai phat Chup MSCT phoi cd the phat hien di danq mach nhieu lan mau Hoi chufng xuat huyet, viem Trieu chufng ban cap, cd Ran no lan toa ben, Mau I3ng, CRP tang, khang the khang n h i" mach the thay dai mau, noi ban, loet niem mac, ban to dang thap cd th e ( + ) dau khdp tren da Tien surco hdi chung xam Viem phoi, phe quan nhap Co the ho khac ddm tung dot sau tac: ran no, ran am, Di vat duong ho hap duoi hdi chimg dong dac Soi phe quJn phat hien va lay di vat y& H U N G D A N c h A n o o A n V A O l f U TRI B f N H N p i K H O A 397 III O lE U T R ! N g u y e n t i c d ie u trj - P hai du’O’c lam cac th am chan doan va dieu trj s a m tai benh vien - D o n g th a i dieu trj cam m au va dieu trj nguyen nhan - Hoi s u e dam b a o th o n g phe nang, cung cap du oxy, boi phu du m au, djch H i s Cpc - K hai th o n g du’a n g ho hap, dam bao thong phe nang: hut m au, cac chat tie t tron g du’a n g ho hap O at noi kh i quan, m a kh i qua n, th a oxy, th a m ay neu co suy ho hap nang - Boi phu khoi lu’a n g tu a n hoan: dat du’a n g truye n c a la n, tru ye n m au de bu du lu’a n g m au m at, dam bao khoi lu’a n g tu a n hoan, boi phu dien g iai C h am s o c ch u n g - T h a o xy tu y th e o m ire kho th a , m u’c giam S p - N im n gh i tu y e t doi a n a i yen tin h , tranh van dong m anh B enh nhan ho m au nang on djnh cho n im ngh ie n g ve ben phoi ton th u ’a n g de phong nguy c a sac m au vao ben phoi lanh - A n long, uong nu’a c m a t lanh - D ung th u o c an th a n nhe: d ia z e p a m lieu thap Neu dung lieu cao co ngu y c a sac ho m au nhieu va che lap cac dau hieu suy ho hap - D ung khan g sin h p h o n g boi nhiem C ac th u c lam g ia m ho m au - T h u o c phien ho a c cac ch e pham : M orphin ong 10m g, tie m b ip ong ho m au nang - T h u o c g ia m ho: Terpin co d e in uong vie n /n g a y chia lan D i§u ch in h c a c r6i lo an d o n g m au, c im m au - T ruyen h u ye t tu ’a n g t u a i neu co roi loan dong m au, IN R keo dai, tru ye n tieu cau so lu’a n g , chat lu’a n g tieu cau giam S u y g a n ho a c th ie u vitam in K dung vita m in K ong 10m g tie m b ip hoac tin h m ach cham 1-4 o n g /n g a y (25 - m g /n g a y) - A d re n o c h ro m (a d re n o xyl, ado na, a d reno sem ): tang cu’a n g s ire de khan g th a n h m ach Lieu dung: vien 10m g uong 1-2 vie n /n g a y, ong 50m g truye n tin h m ach - C a c th u o c chon g tie u s a i h u ye t (acid tra n e xa m iq u e ): tru’a n g h a p cap c u u tie m tin h m ach cham ong 0,5g m oi g ia Khi b en h nhan on djnh: vie n 250 m g x vien, ch ia lan/ngay - D e sm o p re ssin : la p e p tid to n g h a p giong horm on cho n g bai nieu, d im e c h i d inh tron g tru a n g h a p b ^nh H e m o p h ili A m u’c tru n g binh, benh W ilbra nd, suy th a n m an v a i th a i gian chay m au keo dai C a c can th ie p de c h in d o a n va d ilu trj ho m au - Soi p h e q u a n ong m em : g iu p kiem soat du’a n g th a b ln g cach ch e n ong soi tai n a i chay m au hoac dat noi q ua n rieng ben lanh, dot dien dong cao tan cam m au, nhe t gac co ta m th u o c cam m au vao phe q ua n ch a y m au - N eu ch a y m au nhieu, th a t bai v a i cac dieu trj npi khoa, can ch i dinh d at noi kh i quan, khai thong du’a n g th a , de co th a i g ia n th u c hien tie p cac can th ie p sau: - D £ t noi q ua n C a rle n nong de co lap ben phoi chay m au va th o n g kh i phoi lanh chay m au m a kho n g xa c din h d u a c d ie m chay m au - D a t ong th o n g F o g a rty q u a ong soi phe quan de ta m th a i gay b it t i c phe quan n a i chay m au - C h i d inh c h y p d o n g m ach phe quan: H i / O n g d A n c h A n o o A n v A o i C u TR| BENH 398 Noi khoa + Ho m au nhieu > 200m l + T t bai v o i cac bien phap dieu tri noi khoa - C h i dinh phau th u a t cap ciku: + C h ay m au nhieu a m ot ben phoi khon g co dieu kien ch u p dong m ach phe quan gay bit tdc + Ho m au nang sau gay b it tac dong m ach phe quan + Ho m au nang anh h u o n g to i huyet dong, gay suy ho hap - C hi dinh ngoai khoa tien hanh d benh nhan co ton th u o n g khu tru, tin h trang toan than, chtrc nang ho hap cho phep - C h ong ch i dinh phau th uat d benh nhan ung th u phoi giai doan kho n g p h iu thuat d u o c hodc benh nhan co c h u c nang ho hap tru o c ho m au qua kem khon g cho phep cdt phoi D ieu trj n g u yen nhan D ie u tri ca c can n g u y e n g a y ho m au n h u lao i, g ian p h e q u a n , ung th u p h e q ua n phoi phu p h o i c a p t A i l ie u t h a m k h A o H e m o ty p s is (2010), “The W ashington M a n u a l o f M e d ic a l T h e p e u tics (33rd e d j’ Lippincott W illia m s & W ilkins, 334-341 K evin M O ’N eil, A n g e lin e A Lazaru s (1991), "H e m o p ty s is : In d ic a tio n s fo r B ronchoscopy", Arch Intern M ed, 151:17 1-1 74 L o rd a n , JL, G a s c o ig n e , A, C o rris, PA (2003), “A s s e s s m e n t a n d m a n a g e m e n t o f massive h a e m o p tysis", T horax, 58:814 S ilverio S a n tia g o , J e ffre y Tobias, A d rin J W illia m s (1991), “A R e a p p is a l o f the Causes of H e m o p tysis", A rch Intern M ed, 151:2449-2451 T h o m p s o n , A B , Tesch eler, H, R en n ard , SI (1992), "P a th o g e n e s is , e v a lu a tio n a n d therapy for m a ssive h e m o p tysis", C lin C h e st M ed, 13:69 HO KEO DAl I OAl CU’O’NG Ho keo dai la bieu hien rat thu’a n g gap, chiem khoa ng % cac tru ’a n g h a p kham ngoai tru tai cac phong kham ho hap II chAn ooAn C h an d o a n x a c djnh Ho keo dai bao g o m nhu’ng tru ’a n g h a p ho > tuan va d im e chia thanh: - Ho ban cap: ho t u - tuan - Ho m an tin h : ho keo dai > tuan C h in d o a n n g u y e n nhan - B enh li d u a n g ho hap tren : la ngu yen nhan thu’a n g gap nhat gay ho keo dai, cac benh li th u a n g gap bao gom : vie m m ui van m ach, vie m xoang, polyp m ui - H en phe quan: la n g u ye n nhan gay ho keo dai th u hai sau benh li m ui xoang H o th u a n g xuat hien vao n u a dem ve sang, th a y doi th a i tiet, tiep xuc di nguyen, co th e th a y kho th a co c u a n h u n g tru a n g h a p dien hinh - T rao n g u a c da d a y - th u c quan: la ngu yen nhan th u a n g gap C a c bieu hien th u a n g bao gom : ho keo dai, ho tang nam , v a o lu c doi C am giac nong rat sau x u a n g u c , i, a chua, dau th u a n g vj - N hiem trun g d u a n g ho hap: m ot so it tru a n g ho’P nhiem tru n g ho hap ho keo dai (ngay ca sau da dieu trj khan g sin h hieu qua), tham ch i ho keo dai qua tuan - D ung th u o c ch e n thu th e a n g io te n sin : ho keo dai la bieu hien g a p a kh o a n g 15% cac tru a n g h a p d u a c dung th u o c ch e n thu th e an g io te n sin - B enh p ho i ta c n g h e n m an tin h - G ian phe quan - U ng th u phoi - V iem p ho i ta n g bach cau toan - M ot so n g u ye n n n hiem gap khac: dj dang dong tTnh m ach phoi, n h u ye n sun khi, phe quan, phi dgi a m in d a n , ta n g cam th a n h qua n, T ie p can c h a n d o a n ho keo dai Benh nhan ho keo dai can d u a c tien hanh: - K h th a c tie n s u d un g th u o c u c che m en chuyen - K h a m p h a t hien cac benh li d u a n g ho hap tren - Tien hanh ca c th a m p h a t hien + H e n p h e quan H u O n g d A n c h A n o o A n vA o i£ u t r i bEnh N oi k h o a 400 + G ian phe quan + B enh phoi t i c n gh en m an tinh + Trao n g u a c da day - th i/c quan - Khi khon g ro chan doan, co the tien hanh lam them m ot so th a m nhu1: te st kich th ich phe quan (m e th a ch o lin e test), pH thu-c quan - T rong tru o n g h o p c h u a ro chan doan, co the tien hanh dieu tri th u v o i hon h o p thuoc khang histam in - co m ach tron g 1-2 tuan III D I^U TRI D ieu trj n g u yen nhan - B enh li d u o n g ho hap tren - V iem m ui, xoan g d| u n g , vie m m ui van m ach: xit ru a m ui nga y 2-4 lan v o i d un g dich ru a m ui (Vesim hogc S terim a), sau dung co rticoid x|t m ui (B u d e so n id e hoa c F lixo n a se ) lieu 1-2 xit cho m oi ben mui x lan/ H o ac co the dung nang b u d esonid pha v o i 5m l dung djch natri clo ru a 0.9% , berm nhe nhang vao m ui, ket h o p th a y doi tu the 1-2 phu t/lan , cac tu th e bao gom : n im xap - gap dau, nghieng m ot ben, nam n g u a - P olyp m ui: phau th u a t c i t bo polyp - Hen phe quan (tha m khao them bai h u o n g dan chan d oa n va d ieu trj hen): hien th u o n g hay dung ket h o p th u o c d u phong c o n (flu tica so n /sa lm e te ro l, b u d e s o m d /fo rm o te ro l) v o i m ot thuoc c it can (salbu tam ol, te rb u ta lin e ) T h a y doi lieu th u o c dieu trj sau m oi th a n g Ben ca n h vie c dung thuoc, can tran h cac yeu to ngu y c o n h u : khon g nuoi cho, m eo, tranh khoi th u o c la, th u o c lao, bep than, (tham khao bai h u o n g dan chan doan va dieu tri hen phe quan) - Trao n g u a c da day - th u c quan + T ranh cac yeu to ng u y co : khong hut thuoc, tranh uong co con, g iam can, tran h Sn m a + D ung th u o c u c ch e b o m proton: o m e p zo le 20m g/ngay, e s o m e p z o l m g/ngay Dung lien tyc tron g 10 + T hu oc khac: m e to clo p m id vie n 10m g x vien/ngay, chia lan, uong tru d ’c an 30 phut Thon gian dung thuoc: tuan - Ho dung th u o c ch e n thu th e a ng iotensin: d u n g th u o c ch e n th y th e a n g io te n sin Ho th u a n g het sau d u n g th u o c - tuan C ac d ieu trj kh o n g dac hieu a C h i din h - Ho qua nhieu, khon g cam d u a c , gay m et nhieu cho benh nhan o n h u n g tru a n g h a p ho chua xac djnh ro ngu yen nhan, ho a c m ot so tru a n g h a p da xac dinh d u o c n g u ye n n n (ung th u phoi, viem phe quan, vie m phoi ke) n h u n g khon g co roi loan thong t i c - B enh nhan dang co ho m au - K h ong nen dung th u o c giam ho cho n h u n g benh nhan d an g co n h ie m tru n g d u o n g ho hap dircn n h u n g tru o n g h o p nay, benh nhan can d u o c ho de thai d a m ngoai b T h u o c d ie u t r j - T h u o c ho ta c d un g len trun g u a n g + M orp hin va cac che pham : co the dung m orp hin 5m g /la n x lan/ngay, dung tron g 2-3 Hodc Terpin code in (5m g co d e in ) x vie n /n g a y x 5-7 + D e xtro m e th o rp h a n : lieu dung m g/lan x la n /n g a y x 5-7 H U O N G D A n c h A n o o A n V A O l E U TR! B f N H NQl KHOA 401 - T h u o c h o t& c d u n g t a i c h o + C o rtico id d an g phun hit: co the dung lieu nho corticoid dang hit: b u d e so n id , flu tica so n , (P ulm icort, S ym bicort, S e re tid e ) lieu 250 - 0 m cg/ng ay x 10 + Lidocain: co th e d un g tam th a i tru a n g h a p ho nhieu, pha 2m l lid o ca in v a i 3m l dung dich natri clorua 0,9% , dung B ang Tom tat d ieu trj ho N g u ye n n h a n h o D ie u t r i Dieu tri dqc hieu Hen phequJn Thuoc gian phe quan va corticoid dang h it Viem tieu phe qudn tang bach cau toan Hit corticosteroid; thuoc khang leukotrien Viem mui di Orng Thuoc steroid xit mui, khang histamin Hoi churng trao ngUpc da day thuc quan Thuoc ufc che bom proton hoac khang histamin H2 Ho thuoc life che men chuyen DCrng thuoc va thay sang nhom khac Benh phoi tac man tinh Ngifng hut thuoc va tiep xuc khoi, bui Bieu tri benh phoi tac man tinh Gian phe qui!in D anlU utU the Dieu tri cac dot nhiem trung va roi loan thong tac (neu co) Viem phe qu5n nhiem khuan Khang sinh phu hop Dieu tri trieu chdng (chi hu&ng tcfi sau da dieu tri nguyen nhan day du) Ho viem phe qu^n cap v iru s Dung thuoc bo phe dang x iro Ho keo dai, dac biet xuat hien ve dem Opiat va cac che pham Ho keo dai, kho dieu tri, benh li ac tinh Cac opiat (morphin hoac diam orphin) Thuoc giam ho dang dung tai cho t A i l ie u t h a m k h A o C h u n g K.F, W id d ic o m b e J.G , P h il D (2005) “C o u g h ” M urray & N a d e l’s T extboo k o f R e sp ira to ry M edicine, th ed “C o u g h a n d h e m o p tysis" H a rriso n 's prin cip le o f in te rn a l m edicine, 17 e dition (34) tAn g A p d o• n g m a• c h p h o i I O jNH NG HIA Tang ap dong m ach phoi (T A D M P ) la s u tang bat th u a n g ap lu c dong m ach phoi co the la hau qua cua suy tim trai, ton th u a n g nhu m o phoi hoac benh li m ach m au, h u ye t khoi t i c m ach hoac sir ket h a p cua cac yeu to tren B in h th u a n g ap lu c dong m ach phoi luc n g h i la 15m m H g, m oi nam tang them 1m m H g G oi la tang ap d on g m ach phoi ap lu c dong m ach phoi tru n g b in h a n g u a i la n > 25mmHg (khi nghi) ii chAn An C h a n d o a n x a c d jn h a L a m sa n g - Trieu c h u n g c a nang: kho th a g in g sue, m et m oi, dau n g u c - K ham th u c the: tTnh m ach co noi, b i t m ach canh yeu, nghe tim co T2 a o van dong m ach phoi m anh, tieng thoi ta m tru a n g h a van dong m ach phoi, thoi tam thu p h u t n g u a c dong vi van ba la bi h a, xanh tim ngoai vi v a /h o a c phu, gan to, co tru a n g a giai doan cu o i cu a benh b C an lam sa n g - X q uang n g u c d u a n g kin h nhanh d u a i dong m ach phoi phai (ch i so W O O D ) > 16m m - D ien tim : true phai, phi dai th a t phai, nhT phai: P phe a D ll, D ill, aV F; song P > 2/3 song R R cao V , S sau a V6, m om tim qua y sau - Sieu am tim D o p p le r g iup u a c tin h ap lu c tam thu dong m ach phoi > m m H g - T ho ng tim : la thu th u a t c a ban danh gia ch inh xac ap lu c d on g m a ch phoi C h in d o a n n g u y e n n h a n P han loai T A D M P th e o lam sang (D ana Point, 2008) a T A D M P - T u phat - Co tin h chat gia dinh - T A D M P th u o c (th u o c tra n h thai, R h um e nol, D e c o lg e n ) va d o c to - T A D M P co lien q ua n va i: + B enh m o lien ket + N hiem HIV + T an g ap he tin h m ach cu a + B enh tim bam sinh + B enh san m ang + T hieu m au tan m au m an tin h - T A D M P keo dai a tre s a sinh i H u 90% - D igoxin: lam ta n g cu n g lu a n g tim m ac du hieu qua dung keo dai khon g ro rang - D ie u trj loan nhjp tim neu co D ieu trj can n g u y e n T A D M P D ieu tri benh li gay TADM P T h u o c d ie u trj d ac hieu - T h u o c chen kenh calci: th u a n g chi djnh cho T A D M P n gu yen phat C a c th u o c th u a n g dung la N ifedipin m g g ia lan, lieu toi da 240m g/ngay D iltiaze m m g g ia lan, lieu toi da 720 m g/nga y, A m lo rd ip in 5m g x la n/n gay, lieu toi da 20m g/ngay P hai h u ye t ap tr u a c dung tu lieu th u tra di H U O N G DAN 404 chAn d o A n VA o i E u tri b £n h N i khoa va nen tang lieu t u tu 1de d at d u a c lieu toi uu C ac yeu to anh h u a n g ta i vie c tSng lieu la huyet ap va phu chi d u a i B enh nhan can d u a c th e o doi chat che ve hieu q u a va tin h an to a n cua thuoc Can danh gia lai sau thang - U c che e nzym p h o sp h o d ie ste se - 5: S ilde nafil chi djnh cho benh nhan T A D M P v a i m u c kho thcr N Y H A II, III T a c d y n g cai th ie n trieu c h u n g va kha nang g in g sue Lieu kh uye n ca o ban dau la 25mg x lan/ngay T a c dung phu th u a n g gap nhat la dau dau K hong chi dinh ch o benh nhan dang dung nitrat - K hang re ce p to r noi m ach: B o sentan cai thien trieu c h u n g va d un g nap g in g sue D ieu tn b it -4 n g /kg /p h u t T a c dung phu la n h iim trung tai cho, t i c catheter, m an do, dau x u a n g ham , tieu chay - Treprostinil, chat tu a n g tu v a i e p o p ro ste n o l n h u n g co th a i gan ban th a i dai h a n (4 gicr), on dmh a nhiet phong, co th e tru ye n tin h m ach hoac tiem d u a i da Khi tie m d u a i da g a y dau tai cho Tac dyng phu tu a n g tu v a i e p o p ro ste n o l Lieu toi u u tu 50-1 0 n g /kg /p h u t G h e p phoi C an n h ic g he p phoi cho benh nhan khon g dap u n g v a i dieu trj tru y e n pro sta cyclin C o the ghep tim - phoi, g he p m ot hoa c hai phoi TAl LIEU TH A M k h Ao “G u id e lin e s f o r th e d ia g n o s is a n d tre a tm e n t o f p u lm o n a r y h y p e r te n s io n ”, E u ro p e a n Heart Journal (2009), 30: 2493-2537 L e w is J R u b in (2010), " P u lm o n a r y v a s c u litis a n d p r im a r y p u lm o n a r y h y p e rte n s io n M urray and N adel's Textbook o f R espiratory M e dicine (5 rd ed), S aunder "P u lm o n a ry h y p e rte n s io n ’’, The W ashington M anual o f M edical Therapeutics (2010), 33'5 303-312 R u b in L J (2004), “D ia g n o s is a n d m a n a g e m e n t o f p u lm o n a r y a r te r ia l h y p e rte n s io n : A C C P e v id e n c e - b a s e d c lin ic a l p r a c tic e g u id e lin e s ”, C hest; 126 (1 S uppl): 4S -6S BENH SARCOID I O Al C U O N G Benh sarcoid la benh cua to c h u c lien ket, d u a c dac tru n g b a i s u hinh u hat d u g c tao b a i rat nhieu te bao viem va nhieu te bao lien quan, xuat hi£n a bat ki vj tri nao cua c a the S u xam nhiem te bao co the thoai lui tu phat hay tien trien seo S u ket h a p cua viem , seo va doi de doa II cuqc song chAn ooAn C h in d o an xac djnh a Trieu ch u ’n g la m s a n g - B£nh sarcoid co th e gay ton th u a n g a bat c u c a quan nao cua c a th e bieu hien d u a i dang cap, ban cap hay m an tinh - D u a n g th a tren: kho th a , sung huyet m ui, polyp, noi khan - Phoi: kho th a , ho, th a rit, co the co ho m au - Da: not, m ang - M at: giam thj lu c , s a anh sang, dau, phi dai tuyen le - K hap: dau k h a p , co th e co benh II ca - Than kinh: liet th a n kinh so, dau dau, diec, dong kinh, vie m m ang nao, benh tieu nao, ton th u a n g choan cho noi so - Tim: ngat, kho th a , roi loan dan truye n, nhjp nhanh, suy tim sung huyet - Tieu hoa: kho nuot, dau bung, vang da - Mau: phi dai hach, lach (giam tieu cau, bach cau, hong cau) - Than: suy than, ca lci hoa - N