PH-PE Final

7/30/2019 PH-PE Final

1/53

HIPERTENSI PULMONAL

& EDEMA PARU

Dr. Taufik Indrajaya, dr.,SpPD.,K-KV,FINASIM


2/53
http://upload.wikimedia.org/wikipedia/commons/3/3e/Lungs_anatomy.pnghttp://upload.wikimedia.org/wikipedia/commons/3/3e/Lungs_anatomy.png


3/53
http://upload.wikimedia.org/wikipedia/commons/b/b2/Gray490.pnghttp://upload.wikimedia.org/wikipedia/commons/e/e7/Gray503.pnghttp://upload.wikimedia.org/wikipedia/commons/b/b2/Gray490.pnghttp://upload.wikimedia.org/wikipedia/commons/d/db/Illu_bronchi_lungs.jpg


4/53
http://upload.wikimedia.org/wikipedia/commons/d/db/Illu_bronchi_lungs.jpghttp://upload.wikimedia.org/wikipedia/commons/d/db/Illu_bronchi_lungs.jpg


5/53
http://upload.wikimedia.org/wikipedia/commons/5/53/Illu_pulmonary_circuit.jpghttp://upload.wikimedia.org/wikipedia/commons/5/53/Illu_pulmonary_circuit.jpg


6/53
http://upload.wikimedia.org/wikipedia/commons/4/46/Alveolus_diagram.svghttp://upload.wikimedia.org/wikipedia/commons/4/46/Alveolus_diagram.svg


7/53
http://upload.wikimedia.org/wikipedia/commons/d/db/Alveoli_diagram.pnghttp://upload.wikimedia.org/wikipedia/commons/d/db/Alveoli_diagram.png


8/53
http://en.wikipedia.org/wiki/File:Alveoli.svghttp://en.wikipedia.org/wiki/File:Alveoli.svg


9/53

pons (apneuistic and pneumotaxic)
http://en.wikipedia.org/wiki/Ponshttp://upload.wikimedia.org/wikipedia/commons/3/36/Gray768.pnghttp://en.wikipedia.org/wiki/Pons


10/53

Definition

High BP in the arteries that supply the

lungs is called

Pulmonary hypertension (PH) orPulmonary arterial hypertension

(PAH).

The BP measured on arm isnt directly

related to the pressure in lungs.


11/53

The blood vessels constrict and the wallsthicken, cant carry much blood, then

pressure builds up and backs up.

The heart works harder, trying to force theblood through.

If the pressure is high enough, the heart

cant keep up, and less blood can circulatethrough the lungs to pick up oxygen.

Pts tired, dizzy and short of breath.


12/53

Secondary PH -- If there is a pre-existingdisease triggered the PH - a left heart or

lung disorder.

Congenital Heart Disease (VSD or ASD)can cause PH thats similar to PH when

the cause isnt known (idiopathic PAH).

The problem is due to scarring in the

small arteries in the lung.


13/53

So, Its important to repair congenitalheart problems (when possible)

before permanent PH develop.

Intracardiac L-to-R shunts (VSD or

ASD) can cause too much blood flowthrough the lungs, sometimes called

Eisenmenger complex.


14/53

In the past, the holes cant be repaireddue to increased stress on the heart

produced by the high pressures in the

scarred lung blood vessels.

Now, this situation is changing with the

availability of new medicines.

Heart valve conditions, such as MS, can

also cause secondary PH. Fixing the valve

usually reverses the PH.


15/53

Cyanosis due to PH with Congenital HD

In ASD, VSD, AVSD or PDA, blood goes

from the low oxygen chamber or vessel to

the high one. The pts who was once

acyanotic becomes cyanotic.

One way the body compensates is to

increase the ability of the blood to carry

oxygen by increasing the number of RBC

(secondarypolycythemia).


16/53

Symptoms that may prompt to recommend

phlebotomy: headaches, excessive

fatigue and worsening exercise tolerance.

Before this is performed, it is important to

test for iron deficiency.

Phlebotomy is preferably performed in a

center with experience in adult congenital

disease.


17/53

Treating PH

Once PH has been diagnosed, often

more medical therapy is needed.

These will require regular follow-up

with a cardiologist or pulmonologisttrained in caring for patients with this

condition.


18/53

As long as the underlying disease exists -it will keep causing PAH.

Once have PAH, curing the disease thatcaused it may not make the high BP goaway.

In that case, PAH usually need specialtreatment.

While PH is a serious illness, treatmentsare available.


19/53

The treatment are: oxygen,

agents to help heart pump better,

diuretics,

anticoagulants and

medications to lower PAH and reverse thescarring in the blood vessels in the lung.

Sometimes lung transplants also are donefor PAH, but in congenital heart disease -usually heart and lung transplantation.


20/53

A diagnosis of PAH doesnt mean ptscant have an active, fulfilling life.

PAH is a lifelong illness that can be

made worse by a variety of factors,

such as smoking or traveling to highaltitude.


21/53

Once PAH has been diagnosed -- advice

about physical activity, should be as active

as physically possible.

Strenuous physical activity -- is associated

with serious increases in PA pressure.

Avoid isometric exercises and activities like

heavy lifting, or bench press that can

produce dangerous symptoms, such as

chest pain or dizziness.

A supervised cardiopulmonary rehabilitation

program may help promote conditioning.


22/53

Most medications often used to treatcoexistent illnesses are safe for people

with PAH.

Anesthetics or sedatives -- hazardous.Discuss -- decongestant cold medicines.

Pregnancy is not recommended in women

with PH. The changes associated withpregnancy and delivery produce changes

that can seriously endanger the life of the

mother and baby.


23/53

Important for women with PH to use amore permanent but safe contraception.

Because estrogencan aggravate PH, its

important to avoid any contraceptioncontaining estrogen. Progesterone forms

of contraception are preferable.

Recommended that women with PH have

tubal ligation or use the Mirena IUD.


24/53

Additional precautions are often taken withPAH pts. These include :

Supplemental oxygen during air travel,

AB for significant respiratory tract infections, pneumococcal pneumonia vaccine and flu

vaccines.

Also avoid conditions in which the ambient

oxygen concentration may be decreased,

such as high altitude and travel in

unpressurized airplane cabins.


25/53

Finally, if has begun medical treatment forPAH, stopping any medicines withoutphysicians approval can be extremely

dangerous. Medical therapy has significantly improved

the outlook for most patients with PH, butit doesnt cure it.

Dont stop medical therapies unless thephysician recommends doing so.


26/53

Preventing Endocarditis

People with PH and certain

underlying congenital heart defectsmay need AB before certain dental

procedures to prevent endocarditis.


27/53

Primary or Unexplained PH

AHA Recommendation There is extremely wide variability in the

severity of PH among various patients.

Evaluating, accurately diagnosing andtreating the condition is also very complex.

Pts with symptoms suggest PH requirethorough evaluation at a medical center

with expertise and experience in PH.


28/53

Primary PH

Primary or unexplained PH (PPH) is a rarelung disorder in which the BP in thepulmonary artery rises far above normallevels for no apparent reason.

The pulmonary artery is a blood vesselcarrying oxygen-poor blood from the RV to

the lungs. In the lungs, the blood picks upoxygen, then flows to the heart's left side,where the LV pumps it to the rest of thebody through the aorta.


29/53

HTN is a medical term for abnormally high BP. Normal average ("mean") pulmonary artery

pressure is about 14 mm Hgat rest.

In PPH, the average is > 25 mmHg at rest and >

30 mmHg during exercise. This abnormally highpressure (PH) is linked with changes in the smallblood vessels in the lungs.

These changes increase resistance to blood

flowing through the vessels. This increasedresistance puts a strain on the RV, which nowmust work harder than usual to move enoughblood through the lungs.


30/53

Causes of PPH

Don't know the cause.

The low incidence makes learning moreabout the disease extremely difficult.

Studies of PPH also have been difficult

because a good animal model of the

disease hasn't been available.


31/53

Thougt that in most people who developPPH, the blood vessels are very sensitiveto certain factors that trigger this diseaseto develop.

For examples :

People with Raynaud's syndrome seem morelikely than others to develop PPH.

In addition, appetite suppressants, cocaineand HIV are some factors believed to triggerthe constriction, or narrowing, of thepulmonary artery.


32/53

Symptoms of PPH

The first symptom is often fatigue or tiredness. Difficulty in breathing, dizziness and even

fainting spells can occur.

Swelling in the ankles or legs, bluishdiscoloration of the lips and skin, and chest

pain more often occur later in the disease.

One of the great difficulties in treating PPH isthat the diagnosis is often delayed due to the

slowly progressive and insidious onset of the

symptoms.


33/53

Evaluation a patient with PPH

Significant advances in PPH therapy --markedly affected the survival and

quality of life for people with PPH.

The optimal medical and/or surgical

treatment for pts with PPH dependsupon a thorough evaluation at a

medical center with expertise in PH.


34/53

The evaluation includes a right heart

cardiac catheterization.

This is the only way to measure the

pressure in the pulmonary artery and

find out what medical therapy isappropriate for a given patient.


35/53

Therapy for PPH

Choose from a variety of drugs that help

lower BP in the lungs and improve heart

performance in many patients.

Physicians now know that patients with

PPH respond differently to the different

medications that dilate or relax bloodvessels and that no one drug is

consistently effective in all patients.


36/53

Because individual reactions vary,different drugs have to be tried beforechronic or long-term treatment begins.

During the course of the disease, theamount and type of medicine alsomay have to be changed.

To find out which medicine works best fora particular patient, doctors evaluate thedrugs during cardiac catheterization.


37/53

At present, about one-quarter of patients can betreated with calcium channel-blocking drugsgiven orally.

Prostacyclin IV Is a vasodilator, helps pts who don't respond to

CCB given by mouth.

Improves PH and permits increased physical

activity. This improves the quality of life for pts ofall ages.

Is sometimes used as a bridge to help ptswaiting for a transplant. In other cases it's usedfor long-term treatment.


38/53

Besides oral CCB and chronic IVprostacyclin, clinical trials are under way toevaluate new drugs to improve thetreatment of PPH.

Some patients also do well by takingmedicines that make the right ventricle'swork easier. Anticoagulants - decrease the tendency of the blood

to clot, thus permitting the blood to flow more freely.

Diuretics - reduce the amount of fluid in the body,reducing the amount of work the heart has to do.


39/53

Some patients also require supplemental

oxygen delivered through nasal prongs ora mask if breathing becomes difficult.Some need oxygen around the clock.

Transplantation (heart-lung or lung) isreserved for pts who don't respond tomedical therapy. The decision whether a

patient requires heart-lung transplantationor lung transplantation is made after athorough evaluation at a lungtransplantation center.


40/53

The long-term prospects for ps with PPH

Despite the complexity of some of thevarious medical therapies, accurate, early

diagnosis and initiation of treatment have

saved the lives of many pts with PPH. With optimal medical and/or surgical

therapy, pts can often return to a virtually

normal lifestyle, including running ahousehold, returning to school and

participating in many physical activities.


41/53


42/53

PULMONARY EDEMA


43/53

Is fluid accumulation in the lungs.

Impaired gas exchange and may causerespiratory failure.

It is due to either failure of the heart to removefluid from the lung circulation ("cardiogenicpulmonary edema") or a direct injury to the lungparenchyma ("noncardiogenic pulmonaryedema").

Treatment depends on the cause, but focuseson maximizing respiratory function and removingthe cause.
http://upload.wikimedia.org/wikipedia/commons/5/5a/APO.jpg


44/53

Acute pulmonary edema
http://upload.wikimedia.org/wikipedia/commons/5/5a/APO.jpghttp://upload.wikimedia.org/wikipedia/commons/5/5a/APO.jpg


45/53

Signs and symptoms

Include difficulty breathing, coughing up

blood, excessive sweating, anxiety, and

pale skin.

A classic sign of pulmonary edema is the

production of pink frothy sputum. If left

untreated, it can lead to coma and even

death, in general, due to its maincomplication ofhypoxia.
http://en.wikipedia.org/wiki/Shortness_of_breathhttp://en.wikipedia.org/wiki/Haemoptysishttp://en.wikipedia.org/wiki/Haemoptysishttp://en.wikipedia.org/wiki/Diaphoresishttp://en.wikipedia.org/wiki/Anxietyhttp://en.wikipedia.org/wiki/Pallorhttp://en.wikipedia.org/wiki/Sputumhttp://en.wikipedia.org/wiki/Hypoxia_(medical)http://en.wikipedia.org/wiki/Hypoxia_(medical)http://en.wikipedia.org/wiki/Sputumhttp://en.wikipedia.org/wiki/Pallorhttp://en.wikipedia.org/wiki/Anxietyhttp://en.wikipedia.org/wiki/Diaphoresishttp://en.wikipedia.org/wiki/Haemoptysishttp://en.wikipedia.org/wiki/Haemoptysishttp://en.wikipedia.org/wiki/Shortness_of_breath


46/53

If pulmonary edema has been developing

gradually, symptoms of fluid overload may be

elicited.

These include nocturia, ankle edema (swellingof the legs, in general, of the "pitting" variety,

wherein the skin is slow to return to normal when

pressed upon), orthopnea (inability to lie down

flat due to breathlessness), and paroxysmalnocturnal dyspnea (episodes of severe sudden

breathlessness at night).
http://en.wikipedia.org/wiki/Nocturiahttp://en.wikipedia.org/wiki/Edemahttp://en.wikipedia.org/wiki/Orthopneahttp://en.wikipedia.org/wiki/Paroxysmal_nocturnal_dyspneahttp://en.wikipedia.org/wiki/Paroxysmal_nocturnal_dyspneahttp://en.wikipedia.org/wiki/Paroxysmal_nocturnal_dyspneahttp://en.wikipedia.org/wiki/Paroxysmal_nocturnal_dyspneahttp://en.wikipedia.org/wiki/Orthopneahttp://en.wikipedia.org/wiki/Edemahttp://en.wikipedia.org/wiki/Nocturia


47/53

Diagnosis

Is suspected due to findings in the medical history, suchas previous cardiovascular disease.

Physical examination: End-inspiratory crackles (soundsheard at the end of a deep breath) on auscultation arecharacteristic for pulmonary edema. The presence of a

third heart sound (S3) is predictive of cardiogenic PE. Blood tests are performed forelectrolytes (sodium,

potassium) and markers ofrenal function (creatinine,urea). Liver enzymes, inflammatory markers (usually

CRP) and a complete blood count as well as coagulationstudies (PT, aPTT) are typically requested. B-typenatriuretic peptide (BNP) ,low levels of BNP (


48/53

The diagnosis is confirmed on X-ray of the lungs, which

shows increased fluid in the alveolar walls. Kerley Blines, increased vascular filling, pleural effusions, upperlobe diversion (increased blood flow to the higher partsof the lung) may be indicative of cardiogenic PE,whereas patchy alveolar infiltrates with air bronchograms

are more indicative of noncardiogenic edema. Low oxygen saturation and disturbed arterial blood gas

readings may strengthen the diagnosis and providegrounds for various forms of treatment.

If urgent echocardiography is available, this maystrengthen the diagnosis, as well as identify valvularheart disease. In rare occasions, insertion of a Swan-Ganz cathetermay be required to distinguish betweenthe two main forms of pulmonary edema.
http://en.wikipedia.org/wiki/X-rayhttp://en.wikipedia.org/wiki/Kerley_B_lineshttp://en.wikipedia.org/wiki/Kerley_B_lineshttp://en.wikipedia.org/wiki/Pleural_effusionhttp://en.wikipedia.org/wiki/Oxygen_saturationhttp://en.wikipedia.org/wiki/Arterial_blood_gashttp://en.wikipedia.org/wiki/Echocardiographyhttp://en.wikipedia.org/wiki/Swan-Ganz_catheterhttp://en.wikipedia.org/wiki/Swan-Ganz_catheterhttp://en.wikipedia.org/wiki/Swan-Ganz_catheterhttp://en.wikipedia.org/wiki/Swan-Ganz_catheterhttp://en.wikipedia.org/wiki/Swan-Ganz_catheterhttp://en.wikipedia.org/wiki/Echocardiographyhttp://en.wikipedia.org/wiki/Arterial_blood_gashttp://en.wikipedia.org/wiki/Oxygen_saturationhttp://en.wikipedia.org/wiki/Pleural_effusionhttp://en.wikipedia.org/wiki/Kerley_B_lineshttp://en.wikipedia.org/wiki/Kerley_B_lineshttp://en.wikipedia.org/wiki/X-rayhttp://en.wikipedia.org/wiki/X-rayhttp://en.wikipedia.org/wiki/X-ray


49/53

Pulmonary Alveolar Edema. There is extensive, bilateral

airspaces disease with fluid in the

minor fissure (blue arrow) and bilateral pleural effusions

(ref arrows). Although the heart is not

enlarged, the cause was still on a cardiogenic basis.

C


50/53

Causes

Pulmonary edema is either due to direct damage to the tissue or aresult of inadequate functioning of the heart or circulatory system.

When directly or indirectly caused by increased pulmonary bloodpressure, pulmonary edema may appear when this pressureincreases from the normal 15 mmHg[3] to above 25 mmHg.[4]

Cardiogenic:

Congestive heart failure Severe heart attack with left ventricular failure

Severe arrhythmias (tachycardia/fast heartbeat or bradycardia/slowheartbeat)

Hypertensive crisis

Pericardial effusion with tamponade

Fluid overload, e.g., from kidney failure orintravenous therapy
http://en.wikipedia.org/wiki/Pulmonary_blood_pressurehttp://en.wikipedia.org/wiki/Pulmonary_blood_pressurehttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Congestive_heart_failurehttp://en.wikipedia.org/wiki/Myocardial_infarctionhttp://en.wikipedia.org/wiki/Cardiac_arrhythmiahttp://en.wikipedia.org/wiki/Hypertensive_crisishttp://en.wikipedia.org/wiki/Pericardial_effusionhttp://en.wikipedia.org/wiki/Cardiac_tamponadehttp://en.wikipedia.org/wiki/Renal_failurehttp://en.wikipedia.org/wiki/Intravenous_therapyhttp://en.wikipedia.org/wiki/Intravenous_therapyhttp://en.wikipedia.org/wiki/Renal_failurehttp://en.wikipedia.org/wiki/Cardiac_tamponadehttp://en.wikipedia.org/wiki/Pericardial_effusionhttp://en.wikipedia.org/wiki/Hypertensive_crisishttp://en.wikipedia.org/wiki/Cardiac_arrhythmiahttp://en.wikipedia.org/wiki/Myocardial_infarctionhttp://en.wikipedia.org/wiki/Congestive_heart_failurehttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Pulmonary_blood_pressurehttp://en.wikipedia.org/wiki/Pulmonary_blood_pressure


51/53

Non-cardiogenic May occur after upper airway obstruction, intravenous fluid overload,

neurogenic causes (seizures, head trauma, strangulation,electrocution). Can also be seen with ARDS (adult respiratory distresssyndrome):

Alveolar

Inhalation of toxic gases Pulmonary contusion, i.e., high-energy trauma

Aspiration, e.g., gastric fluid or in case of drowning

Reexpansion, i.e. post pneumonectomy or large volume thoracentesis

Reperfusion injury, i.e. postpulmonary thromboendartectomy orlungtransplantation

Immersion pulmonary edema[5][6] Multiple blood transfusions

Severe infection
http://en.wikipedia.org/wiki/Adult_respiratory_distress_syndromehttp://en.wikipedia.org/wiki/Adult_respiratory_distress_syndromehttp://en.wikipedia.org/wiki/Pulmonary_contusionhttp://en.wikipedia.org/w/index.php?title=High-energy_trauma&action=edit&redlink=1http://en.wikipedia.org/wiki/Pulmonary_aspirationhttp://en.wikipedia.org/wiki/Pneumonectomyhttp://en.wikipedia.org/wiki/Thoracentesishttp://en.wikipedia.org/wiki/Thromboendartectomyhttp://en.wikipedia.org/wiki/Lung_transplantationhttp://en.wikipedia.org/wiki/Lung_transplantationhttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Blood_transfusionhttp://en.wikipedia.org/wiki/Infectionhttp://en.wikipedia.org/wiki/Infectionhttp://en.wikipedia.org/wiki/Blood_transfusionhttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Lung_transplantationhttp://en.wikipedia.org/wiki/Lung_transplantationhttp://en.wikipedia.org/wiki/Thromboendartectomyhttp://en.wikipedia.org/wiki/Thoracentesishttp://en.wikipedia.org/wiki/Pneumonectomyhttp://en.wikipedia.org/wiki/Pulmonary_aspirationhttp://en.wikipedia.org/w/index.php?title=High-energy_trauma&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=High-energy_trauma&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=High-energy_trauma&action=edit&redlink=1http://en.wikipedia.org/wiki/Pulmonary_contusionhttp://en.wikipedia.org/wiki/Adult_respiratory_distress_syndromehttp://en.wikipedia.org/wiki/Adult_respiratory_distress_syndrome


52/53

Other/unknown

Multitrauma, e.g., severe car accident

Neurogenic, e.g., subarachnoid hemorrhage

Certain types of medication, illicit drug use Upper airway obstruction, i.e. negative pressure

pulmonary edema[7][8]

Arteriovenous malformation

Hantavirus pulmonary syndrome Ascent to high altitude occasionally causes high

altitude pulmonary edema (HAPE)[9][10]
http://en.wikipedia.org/wiki/Subarachnoid_hemorrhagehttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Arteriovenous_malformationhttp://en.wikipedia.org/wiki/Hantavirushttp://en.wikipedia.org/wiki/High_altitude_pulmonary_edemahttp://en.wikipedia.org/wiki/High_altitude_pulmonary_edemahttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/High_altitude_pulmonary_edemahttp://en.wikipedia.org/wiki/High_altitude_pulmonary_edemahttp://en.wikipedia.org/wiki/Hantavirushttp://en.wikipedia.org/wiki/Arteriovenous_malformationhttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Subarachnoid_hemorrhage


53/53

Therapy Focus is initially on maintaining adequate oxygenation. The patient is given

high-flow oxygen, noninvasive ventilation (eithercontinuous positive airwaypressure (CPAP) orvariable positive airway pressure (VPAP)[11][12]) ormechanical ventilationin extreme cases.

When circulatory causes have led to pulmonary edema, treatment withintravenous nitrates (glyceryl trinitrate), and loop diuretics, such asfurosemide orbumetanide, is the mainstay of therapy. These improve bothpreload and afterload, and aid in improving cardiac function.

Viagra (Sildenafil) is used as a preventative treatment for altitude-inducedpulmonary edema[13][14], although the mechanism of action is notknown.[citation needed] While this effect has only recently been discovered,sildenafil is already becoming an accepted treatment for this condition, inparticular in situations where the standard treatment of rapid descent hasbeen delayed for some reason.[15]
http://en.wikipedia.org/wiki/Continuous_positive_airway_pressurehttp://en.wikipedia.org/wiki/Mechanical_ventilationhttp://en.wikipedia.org/wiki/Mechanical_ventilationhttp://en.wikipedia.org/wiki/Mechanical_ventilationhttp://en.wikipedia.org/wiki/Variable_positive_airway_pressurehttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Mechanical_ventilationhttp://en.wikipedia.org/wiki/Glyceryl_trinitrate_(pharmacology)http://en.wikipedia.org/wiki/Loop_diuretichttp://en.wikipedia.org/wiki/Furosemidehttp://en.wikipedia.org/wiki/Bumetanidehttp://en.wikipedia.org/wiki/Viagrahttp://en.wikipedia.org/wiki/Viagrahttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Mechanism_of_actionhttp://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Mechanism_of_actionhttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Viagrahttp://en.wikipedia.org/wiki/Viagrahttp://en.wikipedia.org/wiki/Bumetanidehttp://en.wikipedia.org/wiki/Furosemidehttp://en.wikipedia.org/wiki/Loop_diuretichttp://en.wikipedia.org/wiki/Glyceryl_trinitrate_(pharmacology)http://en.wikipedia.org/wiki/Mechanical_ventilationhttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Variable_positive_airway_pressurehttp://en.wikipedia.org/wiki/Continuous_positive_airway_pressurehttp://en.wikipedia.org/wiki/Continuous_positive_airway_pressure

Date post:	14-Apr-2018
Category:	Documents
Upload:	nur-habib-al-bangkawi
View:	221 times
Download:	0 times

PH-PE Final

Documents