病人咳嗽、气促，小心藏在慢支暗地里的左心衰
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><a style="color: black;"><img src="https://mmbiz.qpic.cn/mmbiz_png/BvPaP0IZ7HY1xF62wRRKiboSjDpJlS2ribBA4XTRV5pzq1zWplrxVd9YibCTeNvXLBiavvZTneNfRTHcBBJv8QJMNQ/640?wx_fmt=gif&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"></a></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><a style="color: black;"><span style="color: black;"><img src="https://mmbiz.qpic.cn/mmbiz_jpg/SQJSkqiawphyQJ3dtPFaAucAz3ZVH3icFZvRPflnS0g8rjnyRlDTWUODEef9xApJnsYKGlPz72UvhT578WvGaBFA/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"></span></a></p><span style="color: black;">老年人<span style="color: black;">常常</span>并存心肺<span style="color: black;">疾患</span>，<span style="color: black;">因为</span>咳嗽、气促和肺部啰音是心肺<span style="color: black;">疾患</span>的共有表现，临床诊治时很容易混淆。</span><span style="color: black;"><strong style="color: blue;">
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">疗效<span style="color: black;">不良</span>，</p>重新<span style="color: black;">评定</span>病情才<span style="color: black;">发掘</span>真正病因
</strong></span><span style="color: black;"><span style="color: black;">病人</span>，男，83岁。因气促、咳嗽，夜间加重入院。既往有慢性支气管炎病史。</span><span style="color: black;">查体：血压140/90mmHg，心率100次/分。双肺可闻及湿啰音，双下肢<span style="color: black;">没</span>水肿。</span><span style="color: black;">心电图：心率快，非特异性ST-T改变。胸片：主动脉型心脏，双肺纹理<span style="color: black;">增加</span><span style="color: black;">错乱</span>。</span><span style="color: black;">诊断为</span><span style="color: black;"><strong style="color: blue;">慢性支气管炎急性<span style="color: black;">爆发</span></strong></span><span style="color: black;">，予以止咳、平喘、抗感染等对症治疗。</span><span style="color: black;">入院第3天，<span style="color: black;">病人</span>诉症状<span style="color: black;">没</span><span style="color: black;">显著</span>好转，<span style="color: black;">思虑</span>治疗效果<span style="color: black;">不良</span>，更换抗菌<span style="color: black;">药品</span>治疗。</span><span style="color: black;">1周后，<span style="color: black;">病人</span>症状仍<span style="color: black;">没</span><span style="color: black;">显著</span>变化<span style="color: black;">，追问病史，<span style="color: black;">发掘</span><span style="color: black;">病人</span>症状于高枕卧位后有所缓解，为进一步<span style="color: black;">知道</span>诊断，重新<span style="color: black;">评定</span>病情并行彩色多普勒超声<span style="color: black;">检测</span>，确诊为</span></span><span style="color: black;"><strong style="color: blue;">左心<span style="color: black;">衰尽</span></strong></span><span style="color: black;">。</span><span style="color: black;"><span style="color: black;">给予利尿、扩血管、强心等抗心衰治疗，</span>2周后<span style="color: black;">以上</span>症状消失，病情缓解出院。</span><span style="color: black;"><strong style="color: blue;"><span style="color: black;">为何</span>左心衰容易误诊为慢支？</strong></span><span style="color: black;"><span style="color: black;">咱们</span><span style="color: black;">晓得</span>，左心<span style="color: black;">衰尽</span><span style="color: black;">指的是</span>左心室代偿功能不全而<span style="color: black;">导致</span>的心力<span style="color: black;">衰尽</span>，以肺循环淤血为特征，临床上极为<span style="color: black;">平常</span>。</span><span style="color: black;">一方面，<span style="color: black;">因为</span>心肌代谢<span style="color: black;">阻碍</span>、缺血性心肌<span style="color: black;">损害</span>、心肌病和压力负荷过大都<span style="color: black;">能够</span><span style="color: black;">导致</span>心衰，尤其是老年人，<span style="color: black;">她们</span>的心肌收缩力降低，心排出量减少，心脏<span style="color: black;">贮存</span>功能减弱，外周血管阻力<span style="color: black;">提升</span>，更</span><span style="color: black;"><strong style="color: blue;">容易<span style="color: black;">出现</span>左心衰</strong></span><span style="color: black;">。</span><span style="color: black;">加上老年<span style="color: black;">病人</span><span style="color: black;">常常</span>共存着心肺<span style="color: black;">疾患</span>，左心衰时<span style="color: black;">因为</span>肺部淤血，支气管黏膜充血水肿，</span><span style="color: black;"><strong style="color: blue;">容易<span style="color: black;">显现</span>心肺<span style="color: black;">疾患</span>共有的表现</strong></span><span style="color: black;">，<span style="color: black;">例如</span>咳嗽、咳痰、肺水肿、<span style="color: black;">呼气</span>困难等，从而容易与慢性支气管炎相混淆，<span style="color: black;">导致</span>误诊。</span><span style="color: black;">另一方面，慢性支气管炎急性<span style="color: black;">爆发</span>的<span style="color: black;">病人</span>在治疗<span style="color: black;">时期</span>，<span style="color: black;">因为</span>感染或<span style="color: black;">心情</span>变化、电解质<span style="color: black;">错乱</span>或输液<span style="color: black;">太多</span>过快等<span style="color: black;">原因</span>会</span><span style="color: black;"><strong style="color: blue;">诱发左心衰，容易漏诊</strong></span><span style="color: black;">。</span><span style="color: black;"><strong style="color: blue;">左心衰<span style="color: black;">怎样</span>与慢支鉴别？</strong></span><span style="color: black;">①<span style="color: black;">初期</span>左心衰<span style="color: black;">病人</span></span><span style="color: black;"><strong style="color: blue;">不<span style="color: black;">必定</span>存在反复<span style="color: black;">爆发</span>的咳喘史</strong></span><span style="color: black;">，而慢支<span style="color: black;">病人</span>都有。</span><span style="color: black;">②左心衰<span style="color: black;">病人</span>的咳嗽、喘息</span><span style="color: black;"><strong style="color: blue;">以夜间平卧时加重为特点，多在夜间熟睡后突发</strong></span><span style="color: black;">，而慢支<span style="color: black;">病人</span>的咳嗽、喘息<span style="color: black;">没</span><span style="color: black;">显著</span>规律，<span style="color: black;">通常</span>早晚相对严重<span style="color: black;">有些</span>。</span><span style="color: black;">③<span style="color: black;">初期</span>左心衰<span style="color: black;">病人</span>的</span><span style="color: black;"><strong style="color: blue;"><span style="color: black;">呼气</span>频率<span style="color: black;">显著</span>加快，脉搏不齐或<span style="color: black;">显著</span>增快</strong></span><span style="color: black;">，而慢支仅是重症者会有<span style="color: black;">呼气</span>频率加快，但<span style="color: black;">一般</span>不<span style="color: black;">显著</span>，<span style="color: black;">况且</span>脉搏增快<span style="color: black;">亦</span>不<span style="color: black;">明显</span>。</span><span style="color: black;">④老年左心衰<span style="color: black;">病人</span></span><span style="color: black;"><strong style="color: blue;">尿量会减少，<span style="color: black;">况且</span>夜间比<span style="color: black;">白日</span>要多</strong></span><span style="color: black;">，而慢支<span style="color: black;">病人</span>的尿量<span style="color: black;">无</span><span style="color: black;">显著</span>改变。</span><span style="color: black;">⑤<span style="color: black;">初期</span>左心衰<span style="color: black;">病人</span>的</span><span style="color: black;"><strong style="color: blue;">血压偏高，脉压差比较小</strong></span><span style="color: black;">，而慢支<span style="color: black;">病人</span>的血压<span style="color: black;">无</span><span style="color: black;">显著</span>改变。</span><span style="color: black;">⑥左心衰<span style="color: black;">病人</span>的心音</span><span style="color: black;"><strong style="color: blue;"><span style="color: black;">以S</span><span style="color: black;"><span style="color: black;">1</span></span><span style="color: black;">变钝或减弱为特点，肺部听诊双肺底可闻及湿性、对<span style="color: black;">叫作</span>性啰音</span></strong></span><span style="color: black;"><span style="color: black;">，而慢支<span style="color: black;">病人</span>的心音遥远，心电图以低电压、肺性</span>P波或电轴顺时针转位为<span style="color: black;">重点</span>表现<span style="color: black;">。</span></span><span style="color: black;">⑦左心衰<span style="color: black;">病人</span>的胸部X线可见</span><span style="color: black;"><strong style="color: blue;">心影<span style="color: black;">显著</span>扩大，肺纹理广泛性增粗</strong></span><span style="color: black;">，而慢支<span style="color: black;">病人</span>则以肺门或双肺纹理增粗为特点，心影<span style="color: black;">没</span><span style="color: black;">显著</span>改变，常伴有肺气肿。</span><span style="color: black;">⑧左心衰<span style="color: black;">病人</span></span><span style="color: black;"><strong style="color: blue;">对利尿剂有反应</strong></span><span style="color: black;">，而慢支<span style="color: black;">病人</span>对支气管扩张剂相对<span style="color: black;">敏锐</span>。</span><span style="color: black;"><strong style="color: blue;"><span style="color: black;">怎样</span>防止误诊、漏诊？</strong></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">■ </span></strong></span><strong style="color: blue;"><span style="color: black;">认真询问病史</span></strong></span></p><span style="color: black;">为避免误诊漏诊，就诊过程中临床医师应该<span style="color: black;">仔细</span>询问<span style="color: black;">病人</span>的病史并做好记录，仔细分析<span style="color: black;">疾患</span>的发病和诊治过程，为正确诊断奠定<span style="color: black;">基本</span>。</span><span style="color: black;"><span style="color: black;">都数</span>慢支急性<span style="color: black;">爆发</span>的<span style="color: black;">病人</span>会有<span style="color: black;">显著</span>诱因，咳黄痰或白色黏痰，而左心衰<span style="color: black;">病人</span><span style="color: black;">一般</span></span><span style="color: black;"><strong style="color: blue;"><span style="color: black;">无</span><span style="color: black;">显著</span>诱因，咳白色<span style="color: black;">泡泡</span>痰</strong></span><span style="color: black;">。</span><span style="color: black;"><span style="color: black;">因此</span>，临床要<span style="color: black;">注意</span>病史询问，<span style="color: black;">尤其</span>是<span style="color: black;">针对</span>老年人，要<span style="color: black;">警觉</span>左心衰的可能。</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">■ </span></strong></span><strong style="color: blue;"><span style="color: black;">动态观察<span style="color: black;">疾患</span><span style="color: black;">发展</span><span style="color: black;">状况</span></span></strong></span></p><span style="color: black;"><span style="color: black;">针对</span>诊断治疗<span style="color: black;">没</span>效的<span style="color: black;">病人</span>，<span style="color: black;">必要</span>进行</span><span style="color: black;"><strong style="color: blue;">针对性筛查</strong></span><span style="color: black;"><span style="color: black;">，<span style="color: black;">同期</span>对合并高血压性心脏病、肺源性心脏病且<span style="color: black;">显现</span>气促、<span style="color: black;">呼气</span>困难、咳痰者仔细分析，完善体格<span style="color: black;">检测</span>和胸部</span>X线筛查，排除左心衰后再作诊断。</span><span style="color: black;">避免误诊漏诊最好的<span style="color: black;">办法</span>，<span style="color: black;">便是</span>想到可能后先排查。</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">■ </span></strong></span><strong style="color: blue;"><span style="color: black;"><span style="color: black;">警觉</span>肺部阳性体征</span></strong></span></p><span style="color: black;">左心衰<span style="color: black;">病人</span>肺部啰音的变化和分布<span style="color: black;">状况</span>和慢支是存在差别的，<span style="color: black;">因此</span><span style="color: black;">咱们</span><span style="color: black;">必要</span>动态观察<span style="color: black;">病人</span>肺部啰音的变化和分布，<span style="color: black;">警觉</span>左心衰肺部淤血的阳性体征。</span><span style="color: black;"><span style="color: black;">同期</span>，左心衰肺部啰音</span><span style="color: black;"><strong style="color: blue;">局限于肺底或肺下部</strong></span><span style="color: black;">，而慢支则以哮鸣音或干啰音为主，分布相对广泛，咳嗽后啰音的位置和性质容易产生变化，<span style="color: black;">能够</span>与之鉴别。</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">■ </span></strong></span><strong style="color: blue;"><span style="color: black;"><span style="color: black;">注意</span>对合并多种<span style="color: black;">基本</span><span style="color: black;">疾患</span>的老年<span style="color: black;">病人</span>的筛查</span></strong></span></p><span style="color: black;">大部分老年<span style="color: black;">病人</span></span><span style="color: black;"><strong style="color: blue;"><span style="color: black;">同期</span>存在心肺<span style="color: black;">疾患</span></strong></span><span style="color: black;">，而肺部的急性病变<span style="color: black;">亦</span>可能<span style="color: black;">导致</span>心脏<span style="color: black;">疾患</span>加重或<span style="color: black;">衰尽</span>。</span><span style="color: black;">肺部急性病变或慢性支气管炎急性<span style="color: black;">爆发</span>时，或是治疗<span style="color: black;">时期</span>感染掩盖左心衰症状，或是感染和抗感染过程中继发的左心衰，都<span style="color: black;">能够</span><span style="color: black;">由于</span><span style="color: black;">呼气</span>道感染或肺部病变<span style="color: black;">导致</span>支气管黏膜充血或水肿，<span style="color: black;">导致</span>支气管痉挛，气道阻力<span style="color: black;">提升</span>，肺通气功能减弱，<span style="color: black;">诱发</span>肺毛细血管、肺静脉压<span style="color: black;">上升</span>，加之受高血压、冠心病的影响，便会加重左心衰。</span><span style="color: black;"><span style="color: black;">因此</span>，<span style="color: black;">仅有</span><span style="color: black;">注意</span>对<span style="color: black;">病人</span>合并<span style="color: black;">疾患</span>的筛查，<span style="color: black;">才可</span><span style="color: black;">初期</span>确诊左心衰，避免病情加重，延误治疗。</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">参考文献：</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">许久军,张娟,张连珍,等.左心衰误漏诊为慢性支气管炎急性<span style="color: black;">爆发</span>16例临床分析.临床误诊误治,2019,32(12):1-4.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">成荣涛.老年左心<span style="color: black;">衰尽</span>误诊为慢性支气管炎急性<span style="color: black;">爆发</span>.临床误诊误治,2003,16(1):70-71.</span></p><span style="color: black;">本文原创，未经<span style="color: black;">准许</span>，禁止转载</span><span style="color: black;">RECOMMEND</span><span style="color: black;"><strong style="color: blue;"><span style="color: black;">举荐</span>阅读</strong></span>
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