PHU PHOI CAP

PGS TS BS VO THANH NHAN

MUC TIEU
1. 2. 3. 4. 5. 6. 7. Trnh bay c c che sinh ly benh cua phu phoi. Trnh bay c phan loai phu phoi cap da tren c che ban au. Trnh bay c lam sang va can lam sang cua phu phoi cap do tim. Trnh bay c cac tieu chuan e phan biet phu phoi cap vi hen phe quan. Trnh bay c cac tieu chuan e phan biet phu phoi cap do tim vi khong do tim. Trnh bay c phac o ieu tr benh nhan phu phoi cap do tim. Trnh bay c lam sang, can lam sang va ieu tr phu phoi cap khong do tim

AI CNG

3 the lam sang cua suy tim cap:

Phu phoi cap do tim Choang tim t mat bu cap cua suy tim trai man.

Phai phan oan nhanh, chan oan sm va ieu tr tch cc, kp thi T le t vong trong vong mot nam cua nhng benh nhan PPC vt qua 50% neu benh ly goc khong c chan oan va ieu tr triet e.

SINH LY BENH

SINH LY BENH

Phu phoi la tnh trang ong dch ngoai long mach: trong khoang mo ke phoi va trong phe nang. Xay ra khi co mat can bang gia cac lc:

gi nc lai trong long mach keo nc ra khoi long mach.

SINH LY BENH

lc cua Starling

Cac

QIV IT = K [(PIV - PIT) - (IV - IT)]

IT PIT

PIV

IV

: Ap tham keo P : Ap lc thuy tnh IV: Noi mach IT: Mo ke K: Dan lc nc : Ch so phan xa protein QIV IT: Lu lng dan lu cua he bach mach

Bnh thng: s tham dch lien tuc t mao mach ra khoang mo ke phoi khoang 500 ml/ngay (20ml/gi/70kg) he bach mach dan lu ve nh phai.

SINH LY BENH

bach mach

He

Co chc nang dan lu dch, chat hoa tan va chat keo thoat ra t cac mao mach Kha nang dan lu:

Khi ap lc mao mach phoi tang cao ot ngot > 20 25 mmHg (trong suy tim trai cap):

Bnh thng: 20ml/gi/70kg, co the 200ml/gi/70 kg khi can. Tang ap lc nh trai man tnh: co the hn 200ml/gi/70 kg.

lng dch va protein thoat qua lp noi mac mao mach > ngng dan lu cua he bach mach tch tu lai khoang mo ke phu phoi V khoang mo ke long leo quanh cac phe quan va mach mau co khang lc thap hn, o dan n cao hn mo ke quanh phe nang dch thoat co khuynh hng tch tu quanh phe quan va mach mau trong giai oan au chen ep cac mach mau va phe quan nho

SINH LY BENH

giai oan tu dch phoi

Cac

Giai oan 1:

Lng dch thoat < kha nang dan lu cua he bach mach khong tu dch trong khoang ke, the tch khoang ke khong tang.
Lng dch thoat > kha nang dan lu cua he bach mach dch bat au tch tu khoang mo ke long leo quanh tieu phe quan, ong mach, tnh mach. The tch khoang ke bat au tang. Giai oan 3a: Lng dch tch tu > kha nang cha cua khoang mo ke long leo tran vao khoang mo ke chat quanh phe nang Giai oan 3b: dch tran vao phe nang gay phu phe nang

Giai oan 2:

Giai oan 3:

SINH LY BENH

phoi theo trong lc

Phu

Qua trnh phu phoi khong xay ra ong bo tren toan bo phoi ma xay ra t ay len nh di tac dung cua trong lc. Ap lc ti mau hieu qua giam 1cmH2O/cm chieu cao t ay len nh phoi. Ap lc mang phoi Ppl giam 0.25cmH2O/cm chieu cao t ay len nh phoi Cac mao mach phe nang chu ap lc phe nang PA khong thay oi t nh xuong ay phoi Cac mao mach va cac mach ngoai phe nang chu ap lc cua mang phoi von thay oi t ay len nh phoi.

SINH LY BENH Phu phoi theo trong lc

PA > Pa > PV

Pa > PA > PV

nh phoi (Vung 1): ti mau khong ang ke. Gia phoi (Vung 2): ti mau phu thuoc o chenh Pa va PA ay phoi (Vung 3): ti mau phu thuoc o chenh Pa va PV

Pa > PV > PA

SINH LY BENH Phu phoi theo trong lc

Ti mau bnh thng nhieu nhat vung ay phoi

Khi tang ap tnh mach phoi hoac v mang phe nang mao mach phu se thanh lap nhanh va nhieu nhat vung ay chen ep mach mau ay mau se don len nh hnh anh tai phan phoi tuan hoan phoi. Khi co tang ap lc nh trai man, he bach mach phat trien phu mo ke t va oi khi khong co phu phe nang.

PHAN LOAI

PHAN LOAI PHU PHOI DA TREN C CHE BAN AU

Mat can bang cac lc starling Tang ap lc mao mach phoi:

Giam ap tham keo (giam albumine mau)

Do suy tim trai Khong do suy tim trai (hep hai la) Do tang ap ong mach phoi chu ong (do tang ti mau phoi) Do benh than, gan, ruot, da, dinh dng

Tang ap lc am mo ke:

Tang ap tham keo mo ke:

Choc thao tran kh mang phoi nhanh vi ap lc am manh Ap lc am nhieu trong tac ng th cap kem tang the tch cuoi ky th ra (hen phe quan) cha co mo hnh lam sang hay thc nghiem

PHAN LOAI PHU PHOI DA TREN C CHE BAN AU

Roi loan tnh tham mang phe nang mao mach

Nhiem trung Chat oc (phosgene, ozone, chlor, khoi teflon, NO2, khoi) Chat la lu hanh (noc ran, noi oc to vi trung) Ht cac chat acid t da day Viem phoi cap do xa Chat van mach noi sinh (histamins, kinines) ong mau noi mach lan toa Mien dch, viem phoi qua man, thuoc Hoi chng phoi choang Viem tuy xuat huyet cap

PHAN LOAI PHU PHOI DA TREN C CHE BAN AU

Suy he bach mach Sau ghep phoi Carcinom dang viem bach mach (Lymphangitic carcinoma) Viem bach mach x hoa (trong benh bui phoi)

PHAN LOAI PHU PHOI DA TREN C CHE BAN AU

Khong ro c che Phu phoi do o cao Phu phoi do c che than kinh Qua lieu heroin Lap mach phoi Tien san giat, san giat Sau chuyen nhp (cardioversion) Sau gay me Sau chay tim phoi nhan tao

PHU PHOI CAP DO TIM

CHAN OAN PHU PHOI CAP DO TIM

Chan oan phu phoi cap la mot chan oan lam sang. a so benh nhan a biet benh tim t trc nhng cung co trng hp trieu chng phu phoi la bieu hien au tien cua benh ly goc. Chan oan xac nh da tren: benh s + kham lam sang + hnh anh dch tren phim Xquang ngc. Cac xet nghiem khac khong can thiet cho viec xac nh chan oan.

CHAN OAN CAC GIAI OAN PHU PHOI THEO C CHE SINH LY BENH

Giai oan I: (tang lu lng dan lu he bach mach)

Kho th khi gang sc t rales am cuoi ky th ra Kho th, th nhanh do kch thch thu the sc cang (thu the J) mo ke Co the co ran rt do co that phe quan phan xa Giam oxy mau: mc o tng ng tang ap lc mao mach phoi (PCP) trong NMCTC cap Sung huyet ron phoi, b cac mach mau mat sac net day cac vach tieu phan thuy ( ng Kerley B)

Giai oan II: (phu mo ke long leo)

CHAN OAN CAC GIAI OAN PHU PHOI THEO C CHE SINH LY BENH

Giai oan III (phu mo ke chat va phu phe nang):

Roi loan trao oi kh a ro: O2 mau giam. Phu phe nang lan ra cac tieu phe quan khac ra bot hong Dung tch song va cac the tch khac cua phoi giam Shunt phai trai trong phoi do ti mau cac phe nang a phu CO2 mau thng giam nhng co the tang kem toan huyet trong cac trng hp nang hoac cac benh nhan co kem COPD dung morphin phai can than v co the gay ngng th.

LAM SANG PHU PHOI CAP DO TIM

Trieu chng c nang
Cam giac ngop th nhieu, tang len khi nam nen benh nhan phai ngoi th. Lo lang, hot hoang v cam giac sap chet ngop Vat va

LAM SANG PHU PHOI CAP DO TIM

Trieu chng thc the

Nhn:

Th nhanh, va mo hoi Dung c ho hap phu Ho, khac bot hong au chi tm tai Mach nhanh au chi lanh Huyet ap tang do tang trng lc giao cam, tang huyet ap dan ti PPC hiem gap hn la PPC gay tang huyet ap trieu chng. Th on ao, co tieng loc soc Phoi: ran am, bot, rt t ay dang nhanh len nh, tran ngap hai phe trng Tim: kho nghe do ran phoi, co the nghe T3 that phai, P2 manh

S:

Nghe:

CAN LAM SANG PHU PHOI CAP DO TIM X quang ngc thang

Hnh anh phu mo ke: sm nhat

nhoa b cac mach mau phoi, chu yeu la vung ron phoi tai phan phoi tuan hoan phoi dan goc ong mach phoi.

Phu vach ngan cac tieu phan thuy: khi AL tnh mach phoi tang cao hn:

ng Kerley B: nhng ng ngang khoang 10 mm ay phoi, ro nhat cac goc sn hoanh, ng Kerley A dai hn, vung gia va nh phoi, hng ve ron phoi.
co the co tran dch mang phoi: mat goc sn hoanh.

Phu phe nang: giai oan cuoi cung

hnh anh m dang not tu lai vi nhau nh bong tuyet, lan toa t ron phoi ra ngoai nh hnh canh bm.

Phu mo ke

Phu phe nang

CAN LAM SANG PHU PHOI CAP DO TIM X quang ngc thang

Cac bien oi tren phim Xquang khong nhat thiet phai lan toa ca hai phe trng ma co the ch khu tru thuy di hoac ch mot ben phoi. Hnh anh PPC tren phim Xquang cai thien cham hn trieu chng lam sang, co khi ca tuan sau, nen khong dung e theo doi ap ng ieu tr cua PPC.

CAN LAM SANG PHU PHOI CAP DO TIM

ECG Dau hieu nhoi mau c tim cap, loan nhp tim, ph ai that. Sieu am tim Benh van tim, cac not sui tren van, roi loan chuyen ong vung, giam phan xuat tong mau Xa hnh tim anh gia chc nang that trai va xac nh luong thong t trai sang phai BN NMCT cap co bien chng thung vach lien that.

CAN LAM SANG PHU PHOI CAP DO TIM

Thong tim trai va chup mach vanh:

Trong NMCT cap

AL mao mach phoi giup chan oan phan biet PPC do tim vi PPC khong do tim. Cung lng tim, ap lc va o bao hoa oxy mot so buong tim Song v khong lo ng bieu dien ap lc mao mach phoi (h van 2 la cap). Cac luong thong t trai sang phai (thung vach lien that hoac h van hai la cap trong NMCT cap). Theo doi hieu qua cua ieu tr tuy khong la bien phap bat buoc.

Thong tim phai vi ong thong Swan Ganz:

CAN LAM SANG PHU PHOI CAP DO TIM

Xet nghiem sinh hoc Ion o BUN va creatinine mau Protein mau: giam albumin mau ? Cong thc mau Kh mau ong mach

Tong phan tch nc tieu.

giam CO2 mau va kiem mau do tang thong kh 50% BN PPC co CO2 mau bnh thng hoac hi tang > 80 % BN toan mau nhe

CHAN OAN PHAN BIET PHOI CAP HEN PHE QUAN CAP
Ca hai eu co

PHU

Kho th nhieu Mach nghch Phai ngoi mi de th hn Ran rt lan toa hai phoi

Hen phe quan benh nhan thng:

Biet mnh b hen phe quan t trc. Khong o mo hoi nhieu Long ngc cang phong nhieu, go vang S dung c ho hap phu ro rang Ran rt tan so cao hn, dang am nhac hn, ran ngay va ran am t hn Giam O2 mau thng khong nhieu en mc gay tm tai

CHAN OAN PHAN BIET PHU PHOI TIM VA KHONG DO TIM

Phu Phoi Cap Benh s Kham + Cung lng tim giam + T3 + Tnh mach co noi + Ran am + Benh ly goc ngoai tim: Do Tim sau mot s co tim mach cap chi lanh (+) (+) Co nhieu Thng khong co thieu mau / nhoi mau c tim m t ron phoi ra co the tang >18mmHg nho (t) <0.5 khong co

DO
Khong do Tim

chi nong (-) (-) co t/khong co co bnh thng m ngoai bien bnh thng <18mmHg ln (nhieu) >0.7

Can lam sang + ECG: + X-Quang phoi: + Men tim: + Ap lc mao mach phoi + Shunt trong phoi: + Protein dch phu/ serum

IEU TR PHU PHOI CAP DO TIM

ieu tr trieu chng ieu tr cac yeu to thuc ay ieu tr benh ly goc gay PPC

IEU TR TRIEU CHNG ieu tr ho tr ban au

Oxy lieu phap

Nang PaO2 60 mmHg Mat na khong th lai co the at FiO2 90%, co the kem th vi ap lc dng ngat quang at noi kh quan va th may: neu PaO2 van < 50 mmHg khi th oxy 100% qua mat na co th lai

Th vi ap lc dng cuoi ky th ra (PEEP): neu PaO2 van khong at ti 80 mmHg, hoac ch vi FiO2 > 60% PEEP co the lam giam cung lng tim do lam giam lng mau tnh mach o ve tim

IEU TR TRIEU CHNG ieu tr ho tr ban au

T the thoai mai cho benh nhan

Ngoi hoac quay au ging cao: cai thien thong kh, tang tre mau he tnh mach.

Giam cong cua tim

Ngh ngi tuyet oi Dung thuoc giam au Dung thuoc an than nhe e giam lo lang

IEU TR TRIEU CHNG ieu tr bang thuoc

Morphine sulphate Tac dung:

giam lo lang

dan tnh mach phoi va tnh mach ngoai bien giam lng mau tr ve tim giam kho th do sung huyet phoi

Lieu: 2 5mg TM / 10 25 phut en luc hieu qua hoac xuat hien tac dung phu. Can than BN COPD v c che ho hap co the gay ngng th.

IEU TR TRIEU CHNG ieu tr bang thuoc

Furosemide tnh mach Tac dung

Lieu

dan mach: li tieu: xay ra sau khi co tac dung dan mach giam hau tai nhe Khi au
10 20mg TM cham BN cha tng dung qua furosemide 40 80 mg TM cham BN a co dung furosemide

Toi a 200mg Cha ap ng: truyen TM lien tuc 10 40 mg/gi tuy theo chc nang than. Khong ap ng vi furosemide n oc: furosemide 100 mg TM + chlorothiazide 500 mg TM

IEU TR TRIEU CHNG bang thuoc

ieu tr

Thuoc dan mach

Nitroglycerin va cac nitrates: Tac dung: dan tieu tnh mach, giam lng mau tnh mach tr ve tim, giam ap lc mao mach phoi va ap lc that trai cuoi tam trng, giam tien tai, dan n cac mach bang he cua ong mach vanh. Lieu nitroglycerin truyen TM:

Theo doi sat mach, huyet ap.

khi au la 0,2 g /kg/phut tang dan 0,1-0,2 g /kg/phut moi 5 phut en luc trieu chng kho th hoac co tac dung phu.

Trong luc ch at ng truyen: ngam nitroglycerin 0,4 mg di li moi 5 phut (#truyen TM 1,5 g /kg/phut) Neu co mach cham khi dung nitrates: Atropine 0.5 1mg TM Lu y cac chong ch nh cua nitrates::

Mach > 110 lan/phut hoac di 50 lan/phut Huyet ap tam thu < 90 mmHg Nhoi mau c tim that phai

IEU TR TRIEU CHNG ieu tr bang thuoc

Thuoc dan mach
Nitroprusside: Rat hu ch trong phu phoi cap do h van hai cap hoac tang huyet ap

Can than: hien tng an cap mau cac mach vanh a ton thng.

Theo doi ap lc ong mach phoi va ap lc ong mach ngoai bien Lieu dung

Nitroprusside chuyen hoa thanh cyanide va sau o thanh thyocyanate. Ngo oc thiocyanate (khi ham lng trong mau >10mg/dL)

khi au: 0,2 g /kg/phut tang dan lieu 0,1-0,2 g /kg/phut moi 5 phut cho en khi at hieu qua mong muon lieu toi a 5 g /kg/phut (300 400 g/phut)

xay ra khi lieu cao keo dai > 3 ngay hoac BN suy than phai theo doi ham lng thiocyanate mau trong khi dung nitroprusside. trieu chng: buon non, d cam, roi loan tam than, au bung, co giat.

IEU TR TRIEU CHNG bang thuoc Thuoc tr tim

Dobutamine

ieu tr

Tac dung: kch thch 1 va 2 hn tang co bop c tim, dan mach tang cung lng tim, giam hau tai. Lieu:

khi au 1 - 2g/kg/phut tang dan en luc co hieu qua hoac xuat hien tac dung phu (nhp tim nhanh qua mc, loan nhp that)

Khong hieu qua suy tim tam trng hoac suy tim vi cung lng tim tang

IEU TR TRIEU CHNG bang thuoc Thuoc tr tim

Thuoc c che Phospodiesterase Co tac dung dan mach manh hn Dobutamine

ieu tr

Amrinone:TM lieu au 750g/kg trong 2 3 phut, sau o truyen TM 2.5 10g/kg/phut. Milrinone:Truyen TM lieu au 50g/kg trong 10 phut, sau o truyen TM 0.375 0.750g/kg/phut . Phai giam lieu benh nhan suy than Tac dung phu: loan nhp nh, loan nhp that, giam tieu cau

IEU TR TRIEU CHNG bang thuoc Thuoc tr tim

ieu tr

Digitalis Khong con c s dung nh mot thuoc tr tim e ieu tr phu phoi cap na tuy van con c dung e ieu tr suy tim man. S dung e kiem soat nhp that nhng benh nhan phu phoi cap do nhp nhanh tren that

trong ch nh nay co thuoc khac hieu qua hn digital: chen beta, thuoc c che kenh calcium, amiodarone, sotalol, propafenone tuy tng loai nhp nhanh tren that cu the.

IEU TR TRIEU CHNG ieu tr bang thuoc

Aminophylline Ch co ch nh khi benh nhan co co that phe quan Ben canh tac dung dan phe quan aminophylline con co tac dung tr tim nhe, li tieu nhe Lieu nap la 6 mg/kg tiem mach, tiep theo o la truyen tnh mach 0,5 1 mg/kg/gi.

IEU TR TRIEU CHNG

hoan bang bien phap c hoc

Ho tr tuan

Bong noi ong mach chu (IABP) Bong c at vao ong mach chu xuong, ngay di ong mach di on trai, va c bm len hay xa xuong theo chu ky co bop cua tim (thng la ong bo vi ECG) Bong c bm len vao th tam trng, ngay sau khi van ong mach chu ong, lam tang huyet ap tam trng len cao hn ca huyet ap tam thu qua o cai thien ti mau mach vanh va cac mo khac. Bong c xa xuong vao cuoi th tam trng, ngay trc khi tam that co bop, lam giam hau tai mot cach ot ngot, qua o cai thien viec tong mau t that trai ra IABP khong cai thien c t le t vong nen ch la bien phap ho tr tam thi trong khi ch cac lieu phap khac phat huy tac dung va ch ieu tr nguyen nhan gay phu phoi cap

IEU TR TRIEU CHNG

hoan bang bien phap c hoc

Ho tr tuan

Dung cu ho tr that: May tim phoi nhan tao at qua da vi cac ong thong ln at nh phai va ong mach ui co the ho tr mot lu lng t 3 5 L/phut. That trai nhan tao hoac cac thiet b ho tr that trai kha: bien phap tam thi e on nh benh nhan trc khi ghep tim.

IEU TR CAC YEU TO THUC AY

Cac yeu to thuc ay thng gap la: Tang huyet ap Tim thieu mau cuc bo Loan nhp nhanh hoac cham mi phat Tang the tch tuan hoan (an man hoac truyen dch qua mc) Nhiem trung Thieu mau. Cng giap Cac thuoc co tac dung gi nc va muoi nh steroid, NSAID Thuoc lam giam co bop that trai: thuoc ieu tr loan nhp va thuoc ieu tr ung th Benh ly khac ngoai tim nhng co anh hng len he tim mach, v du nh suy than lam tang dch trong c the.

IEU TR NGUYEN NHAN

Tuy nguyen nhan cu the ma co bien phap ieu tr thch hp. NMCT cap: nhanh chong can thiep tai thong mach mau b tat. H van hai la cap:

Xay ra 1% benh nhan nhoi mau c tim va chiem 5% cac trng hp t vong. Thng la do t c tru sau v c nay ch c nuoi bi mot nhanh mach xuat phat t ong mach lien that sau. Phu phoi cap xuat hien nhanh chong sau khi c b t, thng la vao ngay th 2 7 sau nhoi mau c tim vung di. Benh nhan phai c on nh bang thuoc dan mach, bong noi ong mach chu va nhanh chong chuyen mo cap cu. T le t vong khi mo co the ti 10% nhng la bien phap duy nhat e cu song benh nhan.

IEU TR NGUYEN NHAN

Thung vach lien that:

Xay ra 3% cac BN NMCT cap va chiem 5% cac trng hp t vong

50% cac trng hp xay ra NMCT vung trc va thng xay ra vao ngay th 3 en th 7

Trieu chng lam sang co the gay nham lan vi h van hai la cap v ca hai trng hp eu
Benh nhan can phai mo cap cu va neu thanh cong se giam t le t vong t 94% xuong 47% theo cong trnh nghien cu GUSTO-1.

sau NMCT

co tut huyet ap, suy tim nang va co am thoi

PHU PHOI CAP DO TANG TNH THAM THANH MACH

LAM SANG

Benh canh lam sang noi bat la benh canh suy ho hap cap Giai oan sm nhat: Benh nhan co tang tan so ho hap. Giai oan ke:

BN bat au tm tai nhe, trieu chng kho th tang, nhp th tang. Kham phoi co the bnh thng, co the nghe ran am hai phoi, co the kem am thoi ong mot so vung. Trieu chng lam sang khi kham phoi khong ram ro va ien hnh nh phu phoi cap do tim. BN tang tan so ho hap nhieu PaCO2 tang va PaO2 giam nang do the tch kh lu thong giam Khi tan so ho hap = 30 lan/phut: at noi kh quan giup th.

Giai oan tre:

Kham tim va cac c quan thng khong co g ac hieu ngoai cac trieu chng cua benh ly goc.

CAN LAM SANG

Kh mau ong mach

Giai oan au: PaO2 giam, PaCO2 bnh thng hoac giam nhe Khi dien tien nang hn: PaO2 giam nhieu hn do co luong thong trong phoi va PaCO2 tang. Phu toan bo mo ke: hnh anh phoi trang Phu phe nang: hnh anh cac not trang nho, am hn, quan tu lai vi nhau ca hai phe trng Bong tim khong to. Kch thc va chc nang that trai hoan toan bnh thng tren Tang ap ong mach phoi ch xuat hien sau vai ngay.

Xquang

Sieu am tim

ECG

Khong gia tr nhieu

IEU TR

lieu phap

Oxy

Th oxy qua mat na Khi PaO2 < 60mmHg va PCO2 < 40mmHg

IEU TR

lieu phap

Oxy

Th may Ch nh:

Neu khong tang c PaO2 len 60 mmHg vi 100% oxy qua mat na, hoac Tan so ho hap > 30 lan/phut

Muc ch th may la e tang the tch phoi trung bnh trong chu ky th qua o m cac phe nang b xep.

IEU TR

lieu phap

Oxy

Th may Che o ap lc dng cuoi ky th ra (PEEP):

C: PaO2 khong cai thien hoac phai dung FIO2 > 60% keo dai Lam tang dung tch d tr chc nang cua phoi nen cai thien tnh trang giam oxy mau va giam cac luong thong (shunt) phoi. Co hai cach s dung che o PEEP:

Benh nhan c at noi kh quan, th may vi che o PEEP Benh nhan c at noi kh quan hoac mat na, t th vi PEEP (hoac CPAP: continuous positive airway pressure)
Lam tang lng dch cha phoi

Che o PEEP s dung cang ngan cang tot v:

Lam tang hau tai that phai, giam lng mau tnh mach o ve tim giam cung lng tim, giam huyet ap, giam lu lng nc tieu Co the gay bien chng do ap lc dng nh tran kh mang phoi, tran kh trung that

IEU TR

bien phap khac

Cac

Chay tim phoi nhan tao: khong lam tang t le song con Naloxon: PaCO2 tang va toan ho hap do qua lieu Morphin Dung dch bicarbonat : dung tam thi khi toan huyet nang khi ch i cac bien phap khac co hieu qua. Dung dch keo: dung khi co giam albumin mau Gi ap lc mao mach phoi mc thap nhat. ieu tr nguyen nhan neu c.

THE END