小動物疾病系統

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肺水腫
作者
陳柏達、賴政宏、鄭豐邦
中文病名 肺水腫
英文病名 Pulmonary edema
疾病描述

病因:

    肺水腫由於肺部血管內的液體滲出至血管外,導致肺實質部水腫。其水腫機制如一般水腫相同,包含:微血管內膠體滲透壓(plasma oncotic pressure)下降低、微血管內靜水壓(hydrostatic pressure)增加、微血管壁通透性增加、靜脈(venous)或淋巴(lymphatic)回流受阻。其導致原因如下表所示:

表一、導致肺水腫的原因

 

( Hawkins, 2014) 表一、導致肺水腫的原因

 

不管導致的原因為何,在病程上,滲出的肺液一開始會先積聚在組織間隙中,再來便充滿於肺泡中,到病程後期甚至會積聚至呼吸道中,所以呼吸功能的影響是首當其衝的。肺泡的擠壓及表面活性劑濃度的下降,導致至肺順應性下降及肺擴張不全等問題。細支氣管的狹窄也因此造成呼吸阻力上升。肺泡的換氣/灌流比例的失衡也導致低血氧的情形。 臨床症狀: 呼吸急促、呼吸困難、咳嗽、喘息、不安、乾嘔,以及伸頸、開口及腹式呼吸症狀等為典型臨床症狀。嚴重的病例在肺部的聽診可明顯聽見爆裂聲(crackles)。

診斷方法

 胸腔放射線影像學檢查可以發現典型的影徵,再搭配病史、理學檢查、心臟超音波檢查以及血清生化檢查(特別是白蛋白濃度)可以幫助確診病鑑別出潛在原因。

    初期的肺水腫在胸腔放射線影像學上,會呈現間質型影徵(interstitial pattern),隨著病程的演進,會轉變成肺泡型影徵(alveolar pattern)。在犬的病例,若肺水腫的原因是心衰竭造成,影像上往往可見最嚴重的部位會在肺們區附近;在貓的病例,影像上往往可看見阻塞性(opacity)上升的斑狀(patchy)影徵,且分布不一;若是由於血管通透性上升所造成的肺水腫,影像上往往可見最嚴重的部位會在肺臟頭-腹側部位。

    基本上,胸腔放射線影像學檢查除了看肺臟異常外,還必須要檢查是否有心臟疾病、靜脈鬱血(venous congestion)、瘤週水腫(peritumoral edema)、胸腔積液(pleural effusion)及胸腔團塊(mass lesion)等異常,以助於鑑別出潛在原因,其中若發現有心臟方面的異常,進行心臟超音波對於確診心臟疾病有很大的幫助。

    而血清生化檢查,特別是白蛋白濃度,可以鑑別出是否有膠體滲透壓下降的情形。但單純地僅由低白蛋白血症所造成的肺水種病例,往往是少見的,通常血管炎(vasculitis)或是體積超負荷(volume overload)會是可能的潛在原因。

治療方法

 肺水腫液體滲出的預防,相較於移除已經存在肺組織間的滲出液是相對容易的,所以肺水腫的治療在初期是要採舉激進的方式,一旦肺水腫狀況有所改善,身體原本的代償機制便會一併改善,而原本干預治療的因子也會同時下降,使治療效率相對提升。

    肺水腫的患畜在治療階段,是建議要在降低緊迫的狀況下,於籠內靜養;而有低血氧情形的患畜,尚需要給予氧氣治療,嚴重的病例甚至還要搭配給予正壓換氣(positive-pressure ventilation)及支氣管擴張劑(bronchodilators);支氣管擴張劑可減少支氣管痙攣及呼吸肌疲乏的情形,但是部分病例有出現給予支氣管擴張劑後,反而加劇了換氣/灌流比的不平衡(V/Q mismatch),所以若要支氣管擴張劑,則必須要謹慎觀察患畜的反應。

    利尿劑Furosemide是個肺水腫指標性的治療藥物,它可以有效並快速的將肺部滲出液移除,但是絕對要避免患畜在臨床上有出現脫水及低血壓的情形。原則上Furosemide不建議用在低血壓的動物身上,因為低血壓的動物是實際上是更需要保留體內水分的,如果真的有必要使用Furosemide在具有心輸出障礙或是低膠體滲透壓的患畜身上,則建議搭配使用正性肌力強心劑(positive inotropic agents)或是血漿輸液(plasma infusions)。同樣地,低白蛋白血症所造成的肺水腫,也是建議使用血漿或膠體溶液輸液(plasma or colloid infusions)

   心因性的肺水種,除了針對肺水腫的症狀解除外,需要再針對潛在的心臟問題去治療;醫源性過度輸液所造成的肺水種,則是要停止輸液或是調整輸液內容;血管通透性上升所造成的肺水腫,是相對較難處理治療的,除了給予氧氣支持治療,甚至是呼吸器輔助呼吸之外,還是會另外給予Furosemide以及Glucocorticoids。儘管Furosemide對於血管通透性上升的治療沒有直接幫助,Glucocorticoids也沒有明確的醫療幫助,但對於部分的病例,仍是有改善病情的效果。

    倘若肺水腫患畜已經有急性肺損傷(acute lung injury, ALI)或是急性呼吸窘迫症候群(acute respiratory distress syndrome, ARDS),則治療效果往往反應不佳,即便給予呼氣末陽壓呼吸器治療(ventilator therapy with positive end expiratory pressure, PEEP)以及激進的支持治療,患畜的死亡率仍高。

預防控制方法
相關圖片 <p><b><span style="font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
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mso-font-kerning:1.0pt;mso-ansi-language:EN-US;mso-fareast-language:ZH-TW;
mso-bidi-language:AR-SA">圖一、</span><span style="font-size:12.0pt;mso-bidi-font-size:
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mso-ansi-language:EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">患犬之臨床症狀。</span></b><br />
<a id="fck_paste_padding">  <span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體;
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EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">圖片說明:可見呼吸急促、喘息及乾嘔,以及伸頸、開口及腹式呼吸症狀。</span></a></p>
Close<p><b><span style="font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;;mso-bidi-font-family:&quot;Times New Roman&quot;;
mso-font-kerning:1.0pt;mso-ansi-language:EN-US;mso-fareast-language:ZH-TW;
mso-bidi-language:AR-SA">圖一、</span><span style="font-size:12.0pt;mso-bidi-font-size:
11.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:
&quot;Times New Roman&quot;;mso-bidi-font-family:&quot;Times New Roman&quot;;mso-font-kerning:1.0pt;
mso-ansi-language:EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">患犬之臨床症狀。</span></b><br />
<a id="fck_paste_padding">  <span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體;
mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;;
mso-bidi-font-family:&quot;Times New Roman&quot;;mso-font-kerning:1.0pt;mso-ansi-language:
EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">圖片說明:可見呼吸急促、喘息及乾嘔,以及伸頸、開口及腹式呼吸症狀。</span></a></p>

<p><b><span style="font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;;mso-bidi-font-family:&quot;Times New Roman&quot;; mso-font-kerning:1.0pt;mso-ansi-language:EN-US;mso-fareast-language:ZH-TW; mso-bidi-language:AR-SA">圖一、</span><span style="font-size:12.0pt;mso-bidi-font-size: 11.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family: &quot;Times New Roman&quot;;mso-bidi-font-family:&quot;Times New Roman&quot;;mso-font-kerning:1.0pt; mso-ansi-language:EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">患犬之臨床症狀。</span></b><br /> <a id="fck_paste_padding"> <span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體; mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;; mso-bidi-font-family:&quot;Times New Roman&quot;;mso-font-kerning:1.0pt;mso-ansi-language: EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">圖片說明:可見呼吸急促、喘息及乾嘔,以及伸頸、開口及腹式呼吸症狀。</span></a></p>


<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖二、</span></b><b><span style="font-family: 標楷體;">胸腔放射線影像學檢查。</span></b><br />
<span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體;
mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;;
mso-bidi-font-family:&quot;Times New Roman&quot;;mso-font-kerning:1.0pt;mso-ansi-language:
EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">圖片說明:於右側躺照下,可見肺部呈現低穿透性、較均質樣之棉絮樣影像,即空氣</span><span lang="EN-US" style="font-size: 12pt; font-family: 'Times New Roman', serif;">-</span><span style="font-size: 12pt; font-family: 標楷體;">支氣管影像(</span><span lang="EN-US" style="font-size: 12pt; font-family: 'Times New Roman', serif;">Air-bronchial patter</span><span style="font-size: 12pt; font-family: 標楷體;">)分佈在心臟周圍,難以分辨心臟之界線。</span></p>
Close<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖二、</span></b><b><span style="font-family: 標楷體;">胸腔放射線影像學檢查。</span></b><br />
<span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體;
mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;;
mso-bidi-font-family:&quot;Times New Roman&quot;;mso-font-kerning:1.0pt;mso-ansi-language:
EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">圖片說明:於右側躺照下,可見肺部呈現低穿透性、較均質樣之棉絮樣影像,即空氣</span><span lang="EN-US" style="font-size: 12pt; font-family: 'Times New Roman', serif;">-</span><span style="font-size: 12pt; font-family: 標楷體;">支氣管影像(</span><span lang="EN-US" style="font-size: 12pt; font-family: 'Times New Roman', serif;">Air-bronchial patter</span><span style="font-size: 12pt; font-family: 標楷體;">)分佈在心臟周圍,難以分辨心臟之界線。</span></p>

<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">圖二、</span></b><b><span style="font-family: 標楷體;">胸腔放射線影像學檢查。</span></b><br /> <span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體; mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;; mso-bidi-font-family:&quot;Times New Roman&quot;;mso-font-kerning:1.0pt;mso-ansi-language: EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">圖片說明:於右側躺照下,可見肺部呈現低穿透性、較均質樣之棉絮樣影像,即空氣</span><span lang="EN-US" style="font-size: 12pt; font-family: 'Times New Roman', serif;">-</span><span style="font-size: 12pt; font-family: 標楷體;">支氣管影像(</span><span lang="EN-US" style="font-size: 12pt; font-family: 'Times New Roman', serif;">Air-bronchial patter</span><span style="font-size: 12pt; font-family: 標楷體;">)分佈在心臟周圍,難以分辨心臟之界線。</span></p>


<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖三、</span></b><b><span style="font-family: 標楷體;">胸腔放射線影像學檢查。</span></b><br />
<span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體;
mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;;
mso-bidi-font-family:&quot;Times New Roman&quot;;mso-font-kerning:1.0pt;mso-ansi-language:
EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">圖片說明:於腹背照下,肺部區域有低穿透性之棉絮樣影像,即空氣</span><span lang="EN-US" style="font-size: 12pt; font-family: 'Times New Roman', serif;">-</span><span style="font-size: 12pt; font-family: 標楷體;">支氣管影像(</span><span lang="EN-US" style="font-size: 12pt; font-family: 'Times New Roman', serif;">Air-bronchial patter</span><span style="font-size: 12pt; font-family: 標楷體;">),推測有嚴重肺水腫及左心擴張之現象。</span></p>
Close<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖三、</span></b><b><span style="font-family: 標楷體;">胸腔放射線影像學檢查。</span></b><br />
<span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體;
mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;;
mso-bidi-font-family:&quot;Times New Roman&quot;;mso-font-kerning:1.0pt;mso-ansi-language:
EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">圖片說明:於腹背照下,肺部區域有低穿透性之棉絮樣影像,即空氣</span><span lang="EN-US" style="font-size: 12pt; font-family: 'Times New Roman', serif;">-</span><span style="font-size: 12pt; font-family: 標楷體;">支氣管影像(</span><span lang="EN-US" style="font-size: 12pt; font-family: 'Times New Roman', serif;">Air-bronchial patter</span><span style="font-size: 12pt; font-family: 標楷體;">),推測有嚴重肺水腫及左心擴張之現象。</span></p>

<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">圖三、</span></b><b><span style="font-family: 標楷體;">胸腔放射線影像學檢查。</span></b><br /> <span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體; mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;; mso-bidi-font-family:&quot;Times New Roman&quot;;mso-font-kerning:1.0pt;mso-ansi-language: EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">圖片說明:於腹背照下,肺部區域有低穿透性之棉絮樣影像,即空氣</span><span lang="EN-US" style="font-size: 12pt; font-family: 'Times New Roman', serif;">-</span><span style="font-size: 12pt; font-family: 標楷體;">支氣管影像(</span><span lang="EN-US" style="font-size: 12pt; font-family: 'Times New Roman', serif;">Air-bronchial patter</span><span style="font-size: 12pt; font-family: 標楷體;">),推測有嚴重肺水腫及左心擴張之現象。</span></p>


<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖四、</span></b><b><span style="font-family: 標楷體;">彩色都卜勒心臟超音波學檢查。</span></b></p>
<p class="MsoNormal"><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖片說明:導致肺水腫常見的原因之一,為心臟二尖瓣逆流,因血液蓄積於左心房,使左心房壓力升高及左心室代償性的擴張,造成左心鬱血性心衰竭,導致肺部之微血管靜水壓增加,最終引發肺水腫。患犬左心室內可見大量黃綠色之血液擾流,此外二尖瓣及三尖瓣於收縮期皆有血液逆流回心房。</span><span lang="EN-US" style="font-family: 'Times New Roman', serif;"><o:p></o:p></span></p>
Close<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖四、</span></b><b><span style="font-family: 標楷體;">彩色都卜勒心臟超音波學檢查。</span></b></p>
<p class="MsoNormal"><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖片說明:導致肺水腫常見的原因之一,為心臟二尖瓣逆流,因血液蓄積於左心房,使左心房壓力升高及左心室代償性的擴張,造成左心鬱血性心衰竭,導致肺部之微血管靜水壓增加,最終引發肺水腫。患犬左心室內可見大量黃綠色之血液擾流,此外二尖瓣及三尖瓣於收縮期皆有血液逆流回心房。</span><span lang="EN-US" style="font-family: 'Times New Roman', serif;"><o:p></o:p></span></p>

<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">圖四、</span></b><b><span style="font-family: 標楷體;">彩色都卜勒心臟超音波學檢查。</span></b></p> <p class="MsoNormal"><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">圖片說明:導致肺水腫常見的原因之一,為心臟二尖瓣逆流,因血液蓄積於左心房,使左心房壓力升高及左心室代償性的擴張,造成左心鬱血性心衰竭,導致肺部之微血管靜水壓增加,最終引發肺水腫。患犬左心室內可見大量黃綠色之血液擾流,此外二尖瓣及三尖瓣於收縮期皆有血液逆流回心房。</span><span lang="EN-US" style="font-family: 'Times New Roman', serif;"><o:p></o:p></span></p>


<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖五、</span></b><b><span style="font-family: 標楷體;">連續性都卜勒超音波(</span></b><b><span lang="EN-US" style="font-family: 'Times New Roman', serif;">Continuous wave Doppler echo</span></b><b><span style="font-family: 標楷體;">)檢查。</span></b></p>
<p class="MsoNormal"><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖片說明:導致肺水腫常見的原因之一,為心臟二尖瓣逆流,因血液蓄積於左心房,使左心房壓力升高及左心室代償性的擴張,造成左心鬱血性心衰竭,導致肺部之微血管靜水壓增加,最終引發肺水腫。患犬被偵測到偵測大量高流速之逆流血液,二尖瓣回流速度為</span><span lang="EN-US" style="font-family: 'Times New Roman', serif;"> 5.11 m/sec</span><span style="font-family: 標楷體;">、壓力梯度</span><span lang="EN-US" style="font-family: 'Times New Roman', serif;"> 105 mmHg</span><span style="font-family: 標楷體;">。</span><span lang="EN-US" style="font-family: 'Times New Roman', serif;"><o:p></o:p></span></p>
Close<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖五、</span></b><b><span style="font-family: 標楷體;">連續性都卜勒超音波(</span></b><b><span lang="EN-US" style="font-family: 'Times New Roman', serif;">Continuous wave Doppler echo</span></b><b><span style="font-family: 標楷體;">)檢查。</span></b></p>
<p class="MsoNormal"><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖片說明:導致肺水腫常見的原因之一,為心臟二尖瓣逆流,因血液蓄積於左心房,使左心房壓力升高及左心室代償性的擴張,造成左心鬱血性心衰竭,導致肺部之微血管靜水壓增加,最終引發肺水腫。患犬被偵測到偵測大量高流速之逆流血液,二尖瓣回流速度為</span><span lang="EN-US" style="font-family: 'Times New Roman', serif;"> 5.11 m/sec</span><span style="font-family: 標楷體;">、壓力梯度</span><span lang="EN-US" style="font-family: 'Times New Roman', serif;"> 105 mmHg</span><span style="font-family: 標楷體;">。</span><span lang="EN-US" style="font-family: 'Times New Roman', serif;"><o:p></o:p></span></p>

<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">圖五、</span></b><b><span style="font-family: 標楷體;">連續性都卜勒超音波(</span></b><b><span lang="EN-US" style="font-family: 'Times New Roman', serif;">Continuous wave Doppler echo</span></b><b><span style="font-family: 標楷體;">)檢查。</span></b></p> <p class="MsoNormal"><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">圖片說明:導致肺水腫常見的原因之一,為心臟二尖瓣逆流,因血液蓄積於左心房,使左心房壓力升高及左心室代償性的擴張,造成左心鬱血性心衰竭,導致肺部之微血管靜水壓增加,最終引發肺水腫。患犬被偵測到偵測大量高流速之逆流血液,二尖瓣回流速度為</span><span lang="EN-US" style="font-family: 'Times New Roman', serif;"> 5.11 m/sec</span><span style="font-family: 標楷體;">、壓力梯度</span><span lang="EN-US" style="font-family: 'Times New Roman', serif;"> 105 mmHg</span><span style="font-family: 標楷體;">。</span><span lang="EN-US" style="font-family: 'Times New Roman', serif;"><o:p></o:p></span></p>


參考文獻

 1.          Hawkins EC, Disorders of the pulmonary parenchyma and vasculature. In: Nelson RW, Couto CG. Small Animal Internal Medicine, 5th ed, Elsevier Mosby, Missouri, 333-335, 2014.

2.          Buckley G, Rozanski E, Pulmonary parenchymal disease. In: Fuentes VL, Johnson L, Dennis S. BSAVA manual of canine and feline cardiorespiratory medicine, 2nd ed. BSAVA, UK, 286-290, 2010.

3.          圖片來源:

國立中興大學教學動物醫院民國97年臨床病例報告。

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