C\u00f3 r\u1ea5t nhi\u1ec1u tri\u1ec7u ch\u1ee9ng ho\u1eb7c d\u1ea5u hi\u1ec7u c\u1ee7a t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i, c\u00f3 th\u1ec3 l\u00e0m ch\u1eadm qu\u00e1 tr\u00ecnh ch\u1ea9n \u0111o\u00e1n v\u00e0 \u1ea3nh h\u01b0\u1edfng \u0111\u00e1ng k\u1ec3 \u0111\u1ebfn t\u1ef7 l\u1ec7 t\u1eed vong c\u1ee7a b\u1ec7nh [1].<\/p>\n
- \n
- C\u00e1c tri\u1ec7u ch\u1ee9ng bao g\u1ed3m kh\u00f3 th\u1edf (ph\u1ed5 bi\u1ebfn), gi\u1ea3m kh\u1ea3 n\u0103ng g\u1eafng s\u1ee9c, m\u1ec7t m\u1ecfi, h\u1ed3i h\u1ed9p, ng\u1ea5t, \u0111au ng\u1ef1c, ph\u00f9 chi, c\u1ed5 tr\u01b0\u1edbng, v\u00e0 kh\u00e0n ti\u1ebfng (ch\u00e8n \u00e9p d\u00e2y thanh qu\u1ea3n do t\u0103ng \u0111\u01b0\u1eddng k\u00ednh \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i) [2]. Ngo\u00e0i ra, b\u1ec7nh nh\u00e2n c\u00f2n c\u00f3 th\u1ec3 \u0111au ng\u1ef1c, ho khan [1].<\/li>\n
- Ch\u00f3ng m\u1eb7t c\u00f3 th\u1ec3 x\u1ea3y ra khi v\u1eadn \u0111\u1ed9ng khi c\u00f3 cung l\u01b0\u1ee3ng tim gi\u1ea3m ho\u1eb7c n\u1ebfu c\u00f3 r\u1ed1i lo\u1ea1n nh\u1ecbp tim [1][2].<\/li>\n
- Nghe tim c\u00f3 t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i bao g\u1ed3m T2 \u0111anh v\u1edbi ti\u1ebfng P2, th\u1ea5t ph\u1ea3i ti\u1ebfng T3, h\u1edf van 3 l\u00e1 v\u00e0 r\u00ec r\u00e0o ph\u1ebf nang gi\u1ea3m [2].<\/li>\n
- D\u1ea5u hi\u1ec7u suy tim ph\u1ea3i: \u00e1p l\u1ef1c t\u0129nh m\u1ea1ch t\u0103ng cao, gan to, ti\u1ebfng th\u1ed5i \u1edf gan, ph\u00f9 chi, c\u1ed5 tr\u01b0\u1edbng [2].<\/li>\n
- Kh\u00e1m th\u1ef1c th\u1ec3 n\u00ean t\u1eadp trung v\u00e0o vi\u1ec7c x\u00e1c \u0111\u1ecbnh c\u00e1c \u0111\u1eb7c \u0111i\u1ec3m c\u01a1 b\u1ea3n li\u00ean quan \u0111\u1ebfn t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i [2]:<\/li>\n
- Thay \u0111\u1ed5i da c\u1ee7a x\u01a1 c\u1ee9ng b\u00ec.<\/li>\n
- D\u1ea5u hi\u1ec7u c\u1ee7a b\u1ec7nh gan.<\/li>\n
- Ng\u00f3n tay d\u00f9i tr\u1ed1ng (b\u1ec7nh tim b\u1ea9m sinh).<\/li>\n
- Ti\u1ebfng th\u1edf b\u1ea5t th\u01b0\u1eddng (b\u1ec7nh nhu m\u00f4 ph\u1ed5i)<\/li>\n<\/ul>\n
![\"\"](\"http:\/\/noithathoaphat.in\/ctv\/wp-content\/uploads\/2023\/04\/1-9.png\")
C\u00e1c tri\u1ec7u ch\u1ee9ng l\u00e2m s\u00e0ng \u1edf b\u1ec7nh nh\u00e2n t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i<\/figcaption><\/figure>\n <\/p>\n
2. C\u1eadn l\u00e2m s\u00e0ng c\u1ee7a t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i<\/h2>\n
2.1. C\u00e1c c\u1eadn l\u00e2m s\u00e0ng ch\u1ea9n \u0111o\u00e1n h\u00ecnh \u1ea3nh<\/strong><\/p>\n
X quang v\u00e0 CT scan ng\u1ef1c r\u1ea5t h\u1eefu \u00edch trong ch\u1ea9n \u0111o\u00e1n.\u00a0 Ph\u00ecnh c\u00e1c \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i ch\u00ednh b\u00ean ph\u1ea3i v\u00e0 b\u00ean tr\u00e1i l\u00e0 ph\u1ed5 bi\u1ebfn; ph\u00ecnh t\u00e2m th\u1ea5t ph\u1ea3i v\u00e0 t\u00e2m nh\u0129 ph\u1ea3i, \u0111\u01b0\u1ee3c t\u00ecm th\u1ea5y trong b\u1ec7nh ti\u1ebfn tri\u1ec3n [1].<\/p>\n
- \n
- CT scan ng\u1ef1c ch\u1ee7 y\u1ebfu \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 ph\u00e1t hi\u1ec7n c\u00e1c d\u1ea5u hi\u1ec7u tr\u1ef1c ti\u1ebfp ho\u1eb7c gi\u00e1n ti\u1ebfp c\u1ee7a t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i huy\u1ebft kh\u1ed1i m\u1ea1n t\u00ednh, ch\u1eb3ng h\u1ea1n nh\u01b0 l\u1ea5p \u0111\u1ea7y c\u00e1c khuy\u1ebft thu\u1ed1c (bao g\u1ed3m c\u1ea3 huy\u1ebft kh\u1ed1i b\u00e1m v\u00e0o th\u00e0nh m\u1ea1ch), m\u00e0ng ho\u1eb7c d\u1ea3i trong , co r\u00fat\/gi\u00e3n \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i, m\u1edf r\u1ed9ng \u0111\u1ed9ng m\u1ea1ch ph\u1ebf qu\u1ea3n. \u0110i\u1ec1u quan tr\u1ecdng l\u00e0 \u0111\u1ed9 ch\u00ednh x\u00e1c ch\u1ea9n \u0111o\u00e1n c\u1ee7a CTPA \u0111\u1ed1i v\u1edbi t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch huy\u1ebft kh\u1ed1i m\u1ea1n t\u00ednh b\u1ecb h\u1ea1n ch\u1ebf (\u0111\u1ed9 nh\u1ea1y v\u00e0 \u0111\u1ed9 \u0111\u1eb7c hi\u1ec7u l\u1ea7n l\u01b0\u1ee3t l\u00e0 76% v\u00e0 96%) [3].<\/li>\n
- Ch\u1ee5p CT ng\u1ef1c v\u00e0 PFTs (Pulmonary function test) c\u0169ng h\u1eefu \u00edch trong vi\u1ec7c x\u00e1c \u0111\u1ecbnh nguy\u00ean nh\u00e2n g\u00e2y t\u0103ng \u00e1p ph\u1ed5i cho b\u1ec7nh nh\u00e2n nh\u00f3m 3 (t\u0103ng \u00e1p ph\u1ed5i do b\u1ec7nh ph\u1ed5i) [1].<\/li>\n
- Tr\u00ean PFTs, s\u1ef1 k\u1ebft h\u1ee3p c\u1ee7a FVC b\u00ecnh th\u01b0\u1eddng khi \u0111o ph\u1ebf dung, TLC b\u00ecnh th\u01b0\u1eddng khi \u0111o th\u1ec3 t\u00edch ph\u1ed5i v\u00e0 kh\u1ea3 n\u0103ng khu\u1ebfch t\u00e1n gi\u1ea3m \u0111\u00e1ng k\u1ec3 c\u00f3 th\u1ec3 g\u1ee3i \u00fd v\u1ec1 t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i (nh\u00f3m 1) [1].<\/li>\n
- FVC v\u00e0 TLC c\u0169ng c\u00f3 th\u1ec3 b\u1ecb gi\u1ea3m trong t\u0103ng \u00e1p ph\u1ed5i do b\u1ec7nh ph\u1ed5i (nh\u00f3m 3) [1].<\/li>\n<\/ul>\n
Ch\u1ee5p m\u1ea1ch CT n\u0103ng l\u01b0\u1ee3ng k\u00e9p (DECT)<\/strong> ph\u1ea3n \u00e1nh t\u01b0\u1edbi m\u00e1u ph\u1ed5i, do \u0111\u00f3 c\u00f3 th\u1ec3 t\u0103ng \u0111\u1ed9 ch\u00ednh x\u00e1c ch\u1ea9n \u0111o\u00e1n cho t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i huy\u1ebft kh\u1ed1i m\u1ea1n t\u00ednh.\u00a0 M\u1eb7c d\u00f9 ng\u00e0y c\u00e0ng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng nhi\u1ec1u, gi\u00e1 tr\u1ecb ch\u1ea9n \u0111o\u00e1n c\u1ee7a DECT c\u1ee7a b\u1ec7nh nh\u00e2n v\u1edbi t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i ch\u01b0a \u0111\u01b0\u1ee3c th\u1ed1ng nh\u1ea5t [3].<\/p>\n
Ch\u1ee5p m\u1ea1ch x\u00f3a n\u1ec1n k\u1ef9 thu\u1eadt s\u1ed1 (DSA)<\/strong> ch\u1ee7 y\u1ebfu \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 x\u00e1c nh\u1eadn ch\u1ea9n \u0111o\u00e1n t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i huy\u1ebft kh\u1ed1i m\u1ea1n t\u00ednh v\u00e0 \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 c\u00e1c l\u1ef1a ch\u1ecdn \u0111i\u1ec1u tr\u1ecb (t\u1ee9c l\u00e0 kh\u1ea3 n\u0103ng ho\u1ea1t \u0111\u1ed9ng ho\u1eb7c kh\u1ea3 n\u0103ng ti\u1ebfp c\u1eadn \u0111\u1ed1i v\u1edbi nong m\u1ea1ch ph\u1ed5i b\u1eb1ng b\u00f3ng). H\u1ea7u h\u1ebft c\u00e1c trung t\u00e2m s\u1eed d\u1ee5ng DSA hai ho\u1eb7c ba m\u1eb7t ph\u1eb3ng th\u00f4ng th\u01b0\u1eddng. Tuy nhi\u00ean, h\u00ecnh \u1ea3nh CT C-arm c\u00f3 th\u1ec3 cung c\u1ea5p \u0111\u1ed9 ph\u00e2n gi\u1ea3i kh\u00f4ng gian cao h\u01a1n, c\u00f3 kh\u1ea3 n\u0103ng x\u00e1c \u0111\u1ecbnh nhi\u1ec1u m\u1ea1ch m\u1ee5c ti\u00eau h\u01a1n cho nong m\u1ea1ch ph\u1ed5i b\u1eb1ng b\u00f3ng [3].<\/p>\n
Si\u00eau \u00e2m tim<\/strong> th\u01b0\u1eddng d\u00f9ng trong nghi\u00ean c\u1ee9u s\u00e0ng l\u1ecdc [2]. \u0110\u00e1nh gi\u00e1 th\u1ea5t ph\u1ea3i \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n b\u1eb1ng c\u00e1ch \u0111o k\u00edch th\u01b0\u1edbc v\u00e0 ch\u1ee9c n\u0103ng th\u1ea5t ph\u1ea3i c\u0169ng nh\u01b0 \u00e1p l\u1ef1c t\u00e2m thu th\u1ea5t ph\u1ea3i, \u0111\u01b0\u1ee3c \u01b0\u1edbc t\u00ednh d\u1ef1a tr\u00ean v\u1eadn t\u1ed1c ph\u1ea3n l\u1ef1c ba l\u00e1 v\u00e0 \u00e1p l\u1ef1c t\u00e2m nh\u0129 ph\u1ea3i. Ngo\u00e0i ra, si\u00eau \u00e2m tim r\u1ea5t h\u1eefu \u00edch \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 b\u1ec7nh tim ti\u1ec1m \u1ea9n (v\u00ed d\u1ee5: t\u0103ng huy\u1ebft \u00e1p ph\u1ed5i do b\u1ec7nh tim tr\u00e1i) [3].<\/p>\n
Si\u00eau \u00e2m \u1ed5 b\u1ee5ng <\/strong><\/p>\n
- \n
- Ki\u1ec3m tra si\u00eau \u00e2m b\u1ee5ng n\u00ean \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n trong qu\u00e1 tr\u00ecnh ch\u1ea9n \u0111o\u00e1n to\u00e0n di\u1ec7n cho b\u1ec7nh nh\u00e2n t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i m\u1edbi \u0111\u01b0\u1ee3c ch\u1ea9n \u0111o\u00e1n, \u0111\u1eb7c bi\u1ec7t n\u1ebfu nghi ng\u1edd b\u1ec7nh gan.<\/li>\n
- M\u1ee5c ti\u00eau ch\u00ednh l\u00e0 t\u00ecm ki\u1ebfm b\u1ec7nh gan v\u00e0\/ho\u1eb7c t\u0103ng huy\u1ebft \u00e1p t\u0129nh m\u1ea1ch c\u1eeda, ho\u1eb7c shunt c\u1eeda ch\u1ee7 (d\u1ecb d\u1ea1ng Abernethy). Trong qu\u00e1 tr\u00ecnh di\u1ec5n bi\u1ebfn b\u1ec7nh, b\u1ec7nh nh\u00e2n PH c\u00f3 th\u1ec3 ph\u00e1t tri\u1ec3n r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng c\u01a1 quan th\u1ee9 c\u1ea5p, ch\u1ee7 y\u1ebfu \u1ea3nh h\u01b0\u1edfng \u0111\u1ebfn gan v\u00e0 th\u1eadn. \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n n\u00e0y, si\u00eau \u00e2m b\u1ee5ng l\u00e0 c\u1ea7n thi\u1ebft \u0111\u1ec3 ch\u1ea9n \u0111o\u00e1n ph\u00e2n bi\u1ec7t v\u00e0 \u0111\u00e1nh gi\u00e1 m\u1ee9c \u0111\u1ed9 t\u1ed5n th\u01b0\u01a1ng c\u01a1 quan.<\/li>\n<\/ul>\n
MRI<\/strong>\u00a0tim<\/strong> \u0111\u00e1nh gi\u00e1 ch\u00ednh x\u00e1c v\u00e0 t\u00e1i t\u1ea1o k\u00edch th\u01b0\u1edbc, h\u00ecnh th\u00e1i v\u00e0 ch\u1ee9c n\u0103ng c\u1ee7a t\u00e2m nh\u0129 v\u00e0 t\u00e2m th\u1ea5t. cMRI c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 \u0111o l\u01b0u l\u01b0\u1ee3ng m\u00e1u trong \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i, \u0111\u1ed9ng m\u1ea1ch ch\u1ee7 v\u00e0 t\u0129nh m\u1ea1ch ch\u1ee7, cho ph\u00e9p \u0111\u1ecbnh l\u01b0\u1ee3ng th\u1ec3 t\u00edch nh\u00e1t b\u00f3p (SV), shunt trong tim v\u00e0 d\u00f2ng ch\u1ea3y ng\u01b0\u1ee3c.V\u00ec chi ph\u00ed v\u00e0 t\u00ednh s\u1eb5n c\u00f3 c\u1ee7a k\u1ef9 thu\u1eadt ng\u0103n c\u1ea3n vi\u1ec7c \u1ee9ng d\u1ee5ng \u00a0trong ch\u1ea9n \u0111o\u00e1n s\u1edbm t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i, nh\u01b0ng n\u00f3 r\u1ea5t nh\u1ea1y c\u1ea3m trong vi\u1ec7c ph\u00e1t hi\u1ec7n c\u00e1c d\u1ea5u hi\u1ec7u s\u1edbm c\u1ee7a t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i v\u00e0 ch\u1ea9n \u0111o\u00e1n suy tim suy huy\u1ebft.<\/p>\n
Ch\u1ee5p ph\u1ed5i th\u00f4ng kh\u00ed\/t\u01b0\u1edbi m\u00e1u (V\/Q) (ch\u1ee5p c\u1eaft l\u1edbp vi t\u00ednh ph\u00e1t x\u1ea1 ph\u1eb3ng ho\u1eb7c \u0111\u01a1n photon [SPECT]) <\/strong>\u0111\u01b0\u1ee3c khuy\u1ebfn ngh\u1ecb trong qu\u00e1 tr\u00ecnh ch\u1ea9n \u0111o\u00e1n b\u1ec7nh nh\u00e2n nghi ng\u1edd ho\u1eb7c m\u1edbi \u0111\u01b0\u1ee3c ch\u1ea9n \u0111o\u00e1n PH, \u0111\u1ec3 lo\u1ea1i tr\u1eeb ho\u1eb7c ph\u00e1t hi\u1ec7n c\u00e1c d\u1ea5u hi\u1ec7u c\u1ee7a t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i huy\u1ebft kh\u1ed1i m\u1ea1n t\u00ednh. Trong tr\u01b0\u1eddng h\u1ee3p kh\u00f4ng c\u00f3 b\u1ec7nh nhu m\u00f4 ph\u1ed5i, x\u1ea1 h\u00ecnh t\u01b0\u1edbi m\u00e1u b\u00ecnh th\u01b0\u1eddng lo\u1ea1i tr\u1eeb t\u0103ng \u00e1p t\u0129nh m\u1ea1ch ph\u1ed5i huy\u1ebft kh\u1ed1i m\u1ea1n t\u00ednh v\u1edbi gi\u00e1 tr\u1ecb d\u1ef1 \u0111o\u00e1n \u00e2m t\u00ednh l\u00e0 98%.<\/p>\n
\u1ede h\u1ea7u h\u1ebft b\u1ec7nh nh\u00e2n m\u1eafc t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i, x\u1ea1 h\u00ecnh V\/Q b\u00ecnh th\u01b0\u1eddng ho\u1eb7c hi\u1ec3n th\u1ecb d\u1ea1ng l\u1ed1m \u0111\u1ed1m nh\u01b0ng kh\u00f4ng c\u00f3 khi\u1ebfm khuy\u1ebft t\u01b0\u1edbi m\u00e1u \u0111i\u1ec3n h\u00ecnh \u0111\u1eb7c tr\u01b0ng c\u1ee7a thuy\u00ean t\u1eafc ph\u1ed5i ho\u1eb7c t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i huy\u1ebft kh\u1ed1i m\u1ea1n t\u00ednh, trong khi khi\u1ebfm khuy\u1ebft V\/Q ph\u00f9 h\u1ee3p c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c t\u00ecm th\u1ea5y \u1edf b\u1ec7nh nh\u00e2n m\u1eafc b\u1ec7nh ph\u1ed5i (t\u1ee9c l\u00e0 t\u0103ng \u00e1p ph\u1ed5i nh\u00f3m 3). C\u00e1c khi\u1ebfm khuy\u1ebft t\u01b0\u1edbi m\u00e1u kh\u00f4ng ph\u00f9 h\u1ee3p t\u01b0\u01a1ng t\u1ef1 nh\u01b0 \u0111\u00e3 th\u1ea5y trong t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i huy\u1ebft kh\u1ed1i m\u1ea1n t\u00ednh c\u00f3 th\u1ec3 xu\u1ea5t hi\u1ec7n \u1edf 7\u201310% b\u1ec7nh nh\u00e2n m\u1eafc PVOD\/PCH ho\u1eb7c t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i.<\/p>\n
![\"\"](\"http:\/\/noithathoaphat.in\/ctv\/wp-content\/uploads\/2023\/04\/3-7.png\")
C\u00e1c th\u00f4ng s\u1ed1 si\u00eau \u00e2m tim qua th\u00e0nh ng\u1ef1c trong \u0111\u00e1nh gi\u00e1 t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i<\/figcaption><\/figure>\n 2.2. Th\u0103m d\u00f2 ch\u1ee9c n\u0103ng ph\u1ed5i.<\/strong><\/p>\n
2.2.1. Th\u0103m d\u00f2 c\u00e1c dung t\u00edch ph\u1ed5i<\/strong> \u0111\u00e1nh gi\u00e1 r\u1ed1i lo\u1ea1n th\u00f4ng kh\u00ed t\u1eafc ngh\u1ebdn (VD: b\u1ec7nh ph\u1ed5i t\u1eafc ngh\u1ebdn m\u00e3n t\u00ednh,\u2026) ho\u1eb7c r\u1ed1i lo\u1ea1n th\u00f4ng kh\u00ed h\u1ea1n ch\u1ebf (VD: b\u1ec7nh ph\u1ed5i k\u1ebd,\u2026) [2].<\/p>\n
2.2.2. DLCO (Diffusing capacity for carbon monoxide)<\/strong> th\u01b0\u1eddng gi\u1ea3m trong b\u1ec7nh nhu m\u00f4 ph\u1ed5i, nh\u01b0ng gi\u1ea3m nh\u1eb9 – trung b\u00ecnh \u0111\u01a1n \u0111\u1ed9c th\u01b0\u1eddng g\u1eb7p trong t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i [2].<\/p>\n
2.2.3. Kh\u00ed m\u00e1u \u0111\u1ed9ng m\u1ea1ch<\/strong><\/p>\n
B\u1ec7nh nh\u00e2n b\u1ecb t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i th\u01b0\u1eddng c\u00f3 \u00e1p su\u1ea5t ri\u00eang ph\u1ea7n oxy \u0111\u1ed9ng m\u1ea1ch (PaO2) b\u00ecnh th\u01b0\u1eddng ho\u1eb7c gi\u1ea3m nh\u1eb9. Gi\u1ea3m PaO2 nghi\u00eam tr\u1ecdng c\u00f3 th\u1ec3 l\u00e0m t\u0103ng kh\u1ea3 n\u0103ng c\u00f2n l\u1ed7 b\u1ea7u d\u1ee5c, b\u1ec7nh gan, c\u00e1c b\u1ea5t th\u01b0\u1eddng kh\u00e1c v\u1edbi shunt t\u1eeb ph\u1ea3i sang tr\u00e1i (v\u00ed d\u1ee5: khi\u1ebfm khuy\u1ebft v\u00e1ch ng\u0103n) ho\u1eb7c c\u00e1c t\u00ecnh tr\u1ea1ng li\u00ean quan \u0111\u1ebfn DLCO th\u1ea5p [3].<\/p>\n
\u00c1p su\u1ea5t ri\u00eang ph\u1ea7n c\u1ee7a carbon dioxide \u0111\u1ed9ng m\u1ea1ch (PaCO2) th\u01b0\u1eddng th\u1ea5p h\u01a1n b\u00ecnh th\u01b0\u1eddng do t\u0103ng th\u00f4ng kh\u00ed ph\u1ebf nang. PaCO2 th\u1ea5p khi ch\u1ea9n \u0111o\u00e1n v\u00e0 theo d\u00f5i th\u01b0\u1eddng g\u1eb7p \u1edf b\u1ec7nh nh\u00e2n t\u0103ng \u00e1p ph\u1ed5i v\u00e0 c\u00f3 ti\u00ean l\u01b0\u1ee3ng x\u1ea5u. PaCO2 t\u0103ng cao l\u00e0 \u0111i\u1ec1u r\u1ea5t b\u1ea5t th\u01b0\u1eddng \u1edf b\u1ec7nh nh\u00e2n t\u0103ng \u00e1p ph\u1ed5i v\u00e0 ph\u1ea3n \u00e1nh t\u00ecnh tr\u1ea1ng gi\u1ea3m th\u00f4ng kh\u00ed ph\u1ebf nang [3].<\/p>\n
2.2.4. Test 6 ph\u00fat \u0111i b\u1ed9<\/strong> (6MWD \u2013 6 minute walk distance)<\/p>\n
2.2.5. \u0110o \u0111\u1ed9 b\u00e3o h\u00f2a oxy trong \u0111\u00eam<\/strong>: N\u1ebfu gi\u1ea3m g\u1ee3i \u00fd h\u1ed9i ch\u1ee9ng ng\u01b0ng th\u1edd khi ng\u1ee7 [2].<\/p>\n
2.3. C\u00e1c x\u00e9t nghi\u1ec7m kh\u00e1c<\/strong><\/p>\n
2.3.1. C\u00f4ng th\u1ee9c m\u00e1u<\/strong> th\u01b0\u1eddng b\u00ecnh th\u01b0\u1eddng [1]<\/p>\n
2.3.2. BNP ho\u1eb7c Pro-BNP<\/strong> c\u00f3 th\u1ec3 t\u0103ng cao [1].<\/p>\n
2.3.3<\/strong>. \u0110i\u1ec7n t\u00e2m \u0111\u1ed3<\/strong><\/p>\n
- \n
- Th\u01b0\u1eddng b\u00ecnh th\u01b0\u1eddng ngo\u1ea1i tr\u1eeb b\u1ec7nh ti\u1ebfn tri\u1ec3n, trong \u0111\u00f3 c\u00f3 th\u1ec3 ghi nh\u1eadn h\u00ecnh \u1ea3nh ph\u00ec \u0111\u1ea1i th\u1ea5t ph\u1ea3i (l\u1ec7ch tr\u1ee5c ph\u1ea3i, block nh\u00e1nh ph\u1ea3i kh\u00f4ng ho\u00e0n to\u00e0n), ph\u00ec \u0111\u1ea1i nh\u0129 ph\u1ea3i (s\u00f3ng P \u0111\u1ec9nh \u1edf chuy\u1ec3n \u0111\u1ea1o b\u00ean d\u01b0\u1edbi v\u00e0 b\u00ean ph\u1ea3i), block nh\u00e1nh ph\u1ea3i nh\u01b0ng nh\u1eefng ph\u00e1t hi\u1ec7n n\u00e0y c\u00f3 \u0111\u1ed9 nh\u1ea1y th\u1ea5p trong t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i [1][2].<\/li>\n
- \u0110i\u1ec7n t\u00e2m \u0111\u1ed3 b\u00ecnh th\u01b0\u1eddng kh\u00f4ng lo\u1ea1i tr\u1eeb s\u1ef1 hi\u1ec7n di\u1ec7n c\u1ee7a t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i, nh\u01b0ng \u0111i\u1ec7n t\u00e2m \u0111\u1ed3 b\u00ecnh th\u01b0\u1eddng k\u1ebft h\u1ee3p v\u1edbi c\u00e1c d\u1ea5u \u1ea5n sinh h\u1ecdc b\u00ecnh th\u01b0\u1eddng (BNP\/ NT-proBNP) th\u00ec kh\u1ea3 n\u0103ng t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i th\u1ea5p \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n nghi ng\u1edd t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i ho\u1eb7c c\u00f3 nguy c\u01a1 t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i (t\u1ee9c l\u00e0 sau thuy\u00ean t\u1eafc ph\u1ed5i c\u1ea5p t\u00ednh) [3].<\/li>\n<\/ul>\n
![\"\"](\"http:\/\/noithathoaphat.in\/ctv\/wp-content\/uploads\/2023\/04\/2-9.png\")
\u0110i\u1ec7n t\u00e2m \u0111\u1ed3 b\u1ea5t th\u01b0\u1eddng \u1edf b\u1ec7nh nh\u00e2n v\u1edbi t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i<\/figcaption><\/figure>\n 2.3.4. T\u0103ng huy\u1ebft \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i v\u00e0 c\u00e1c d\u1ea1ng t\u0103ng huy\u1ebft \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i n\u1eb7ng kh\u00e1c<\/strong> c\u00f3 th\u1ec3 li\u00ean quan \u0111\u1ebfn r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng tuy\u1ebfn gi\u00e1p. Do \u0111\u00f3, x\u00e9t nghi\u1ec7m s\u00e0ng l\u1ecdc n\u00ean bao g\u1ed3m \u00edt nh\u1ea5t hormone k\u00edch th\u00edch tuy\u1ebfn gi\u00e1p [3].<\/p>\n
2.3.5. Test g\u1eafng s\u1ee9c tim ph\u1ed5i (CPET)<\/strong> l\u00e0 m\u1ed9t ph\u01b0\u01a1ng ph\u00e1p h\u1eefu \u00edch \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 c\u00e1c c\u01a1 ch\u1ebf sinh l\u00fd b\u1ec7nh c\u01a1 b\u1ea3n d\u1eabn \u0111\u1ebfn kh\u00f4ng gi\u1eefa \u0111\u01b0\u1ee3c kh\u1ea3 n\u0103ng g\u1eafng s\u1ee9c [3].<\/p>\n
2.3.6. B\u1ec7nh nh\u00e2n m\u1eafc t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i<\/strong> bi\u1ec3u hi\u1ec7n \u0111i\u1ec3n h\u00ecnh, v\u1edbi \u00e1p su\u1ea5t ri\u00eang ph\u1ea7n kh\u00ed th\u1edf ra th\u1ea5p c\u1ee7a kh\u00ed carbon dioxide (PETCO2), t\u01b0\u01a1ng \u0111\u01b0\u01a1ng kh\u00ed th\u1edf v\u1edbi kh\u00ed carbon dioxide cao (VE\/VCO2), xung oxy th\u1ea5p (VO2\/HR) v\u00e0 m\u1ee9c h\u1ea5p thu oxy cao nh\u1ea5t ( VO2).<\/p>\n
Nh\u1eefng ph\u00e1t hi\u1ec7n n\u00e0y c\u1ea7n nhanh ch\u00f3ng xem x\u00e9t b\u1ec7nh m\u1ea1ch m\u00e1u ph\u1ed5i. \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n m\u1eafc b\u1ec7nh tim Tr\u00e1i ho\u1eb7c COPD, khuy\u1ebfn c\u00e1o nh\u01b0 v\u1eady c\u00f3 th\u1ec3 ch\u1ec9 ra m\u1ed9t gi\u1edbi h\u1ea1n c\u1ee7a m\u1ea1ch m\u00e1u ph\u1ed5i. \u1ede nh\u1eefng ng\u01b0\u1eddi c\u00f3 nguy c\u01a1 t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i, ch\u1eb3ng h\u1ea1n nh\u01b0 nh\u1eefng ng\u01b0\u1eddi m\u1eafc x\u01a1 c\u1ee9ng h\u1ec7 th\u1ed1ng, VO2 \u0111\u1ec9nh b\u00ecnh th\u01b0\u1eddng th\u00ec c\u00f3 th\u1ec3 lo\u1ea1i tr\u1eeb ch\u1ea9n \u0111o\u00e1n t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i.<\/p>\n
2.3.7. \u0110\u1eb7t \u1ed1ng th\u00f4ng tim ph\u1ea3i, v\u1eadn m\u1ea1ch, t\u1eadp th\u1ec3 d\u1ee5c v\u00e0 Fluid challenge<\/strong><\/p>\n
2.3.7.1. Th\u00f4ng tim ph\u1ea3i [3]<\/strong><\/p>\n
Th\u00f4ng tim ph\u1ea3i l\u00e0 ti\u00eau chu\u1ea9n v\u00e0ng \u0111\u1ec3 ch\u1ea9n \u0111o\u00e1n v\u00e0 ph\u00e2n lo\u1ea1i PH. Vi\u1ec7c ch\u1ea9n \u0111o\u00e1n v\u00e0 ph\u00e2n lo\u1ea1i PH, c\u00e1c ch\u1ec9 \u0111\u1ecbnh l\u00e2m s\u00e0ng bao g\u1ed3m \u0111\u00e1nh gi\u00e1 huy\u1ebft \u0111\u1ed9ng c\u1ee7a tim ho\u1eb7c c\u00e1c \u1ee9ng vi\u00ean LTx124 v\u00e0 \u0111\u00e1nh gi\u00e1 c\u00e1c shunt tim b\u1ea9m sinh.<\/p>\n
\u1ede nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 thay \u0111\u1ed5i \u00e1p l\u1ef1c trong l\u1ed3ng ng\u1ef1c l\u1edbn trong chu k\u1ef3 h\u00f4 h\u1ea5p (t\u1ee9c l\u00e0 COPD, b\u00e9o ph\u00ec, trong khi t\u1eadp th\u1ec3 d\u1ee5c), n\u00ean t\u00ednh trung b\u00ecnh trong \u00edt nh\u1ea5t ba \u0111\u1ebfn b\u1ed1n chu k\u1ef3 h\u00f4 h\u1ea5p. N\u1ebfu kh\u00f4ng th\u1ec3 thu \u0111\u01b0\u1ee3c \u0111\u01b0\u1eddng cong PAWP \u0111\u00e1ng tin c\u1eady, ho\u1eb7c n\u1ebfu c\u00e1c gi\u00e1 tr\u1ecb PAWP l\u00e0 kh\u00f4ng h\u1ee3p l\u00fd, th\u00ec n\u00ean xem x\u00e9t \u0111o b\u1ed5 sung \u00e1p su\u1ea5t cu\u1ed1i t\u00e2m tr\u01b0\u01a1ng th\u1ea5t Tr\u00e1i \u0111\u1ec3 tr\u00e1nh ph\u00e2n lo\u1ea1i sai.<\/p>\n
\u00c1p l\u1ef1c \u01b0\u1edbc t\u00ednh tr\u00ean si\u00eau \u00e2m tim t\u01b0\u01a1ng quan v\u1edbi ph\u00e9p \u0111o th\u00f4ng tim ph\u1ea3i nh\u01b0ng c\u00f3 th\u1ec3 thay \u0111\u1ed5i \u00edt nh\u1ea5t 10 mmHg trong h\u01a1n 50% tr\u01b0\u1eddng h\u1ee3p n\u00ean kh\u00f4ng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb tr\u1ef1c ti\u1ebfp. Th\u00f4ng tim \u0111\u1eb7c bi\u1ec7t h\u1eefu \u00edch trong vi\u1ec7c ph\u00e2n bi\u1ec7t t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i v\u1edbi t\u0103ng \u00e1p t\u0129nh m\u1ea1ch ph\u1ed5i b\u1eb1ng c\u00e1ch \u0111\u00e1nh gi\u00e1 s\u1ef1 s\u1ee5t gi\u1ea3m \u00e1p l\u1ef1c trong tu\u1ea7n ho\u00e0n ph\u1ed5i, c\u00f2n \u0111\u01b0\u1ee3c g\u1ecdi l\u00e0 \u0111\u1ed9 ch\u00eanh \u00e1p xuy\u00ean ph\u1ed5i.<\/p>\n
Th\u00f4ng tim Tr\u00e1i n\u00ean \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n tr\u1ef1c ti\u1ebfp \u0111o \u00e1p l\u1ef1c th\u1ea5t tr\u00e1i cu\u1ed1i t\u00e2m tr\u01b0\u01a1ng n\u1ebfu \u0111o \u00e1p l\u1ef1c t\u1eafc \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i kh\u00f4ng th\u1ec3 lo\u1ea1i tr\u1eeb b\u1ec7nh tim tr\u00e1i, \u0111\u1eb7c \u0111i\u1ec3m l\u00e0 \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n > 65 tu\u1ed5i [2].<\/p>\n
![\"\"](\"http:\/\/noithathoaphat.in\/ctv\/wp-content\/uploads\/2023\/04\/4-5.png\")
C\u00e1c bi\u1ec7n ph\u00e1p huy\u1ebft \u0111\u1ed9ng thu \u0111\u01b0\u1ee3c trong qu\u00e1 tr\u00ecnh th\u00f4ng tim ph\u1ea3i<\/figcaption><\/figure>\n 2.3.7.2. S\u1eed d\u1ee5ng v\u1eadn m\u1ea1ch [3]<\/strong><\/p>\n
- \n
- M\u1ee5c \u0111\u00edch c\u1ee7a x\u00e9t nghi\u1ec7m ho\u1ea1t t\u00ednh v\u1eadn m\u1ea1ch trong t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i l\u00e0 \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh nh\u1eefng ng\u01b0\u1eddi \u0111\u00e1p \u1ee9ng thu\u1ed1c v\u1eadn m\u1ea1ch c\u1ea5p t\u00ednh c\u00f3 th\u1ec3 l\u00e0 \u0111\u1ed1i t\u01b0\u1ee3ng cho \u0111i\u1ec1u tr\u1ecb b\u1eb1ng thu\u1ed1c ch\u1eb9n k\u00eanh canxi (CCB) li\u1ec1u cao. S\u1eed d\u1ee5ng v\u1eadn m\u1ea1ch ph\u1ed5i ch\u1ec9 \u0111\u01b0\u1ee3c khuy\u1ebfn ngh\u1ecb \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n m\u1eafc IPAH, HPAH ho\u1eb7c DPAH.<\/li>\n
- Oxit Nitric d\u1ea1ng h\u00edt ho\u1eb7c Iloprost d\u1ea1ng h\u00edt l\u00e0 c\u00e1c h\u1ee3p ch\u1ea5t th\u1eed nghi\u1ec7m \u0111\u01b0\u1ee3c khuy\u1ebfn ngh\u1ecb \u0111\u1ec3 nghi\u00ean c\u1ee9u ho\u1ea1t t\u00ednh v\u1eadn m\u1ea1ch.<\/li>\n
- Adenosine ti\u00eam m\u1ea1ch \u00a0kh\u00f4ng c\u00f2n \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o do t\u00e1c d\u1ee5ng ph\u1ee5 th\u01b0\u1eddng g\u1eb7p. \u0110\u00e1p \u1ee9ng th\u1ecfa m\u00e3n \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 gi\u1ea3m mPAP \u226510 mmHg \u0111\u1ec3 \u0111\u1ea1t gi\u00e1 tr\u1ecb tuy\u1ec7t \u0111\u1ed1i \u2264 40 mmHg, v\u1edbi CO t\u0103ng ho\u1eb7c kh\u00f4ng thay \u0111\u1ed5i. \u1ede t\u1ea5t c\u1ea3 c\u00e1c b\u1ec7nh nh\u00e2n, \u0111\u1eb7c bi\u1ec7t l\u00e0 nh\u1eefng ng\u01b0\u1eddi c\u00f3 ti\u1ec1n s\u1eed thuy\u00ean t\u1eafc ph\u1ed5i ho\u1eb7c c\u00e1c y\u1ebfu t\u1ed1 nguy c\u01a1 m\u1eafc b\u1ec7nh huy\u1ebft kh\u1ed1i t\u1eafc m\u1ea1ch, n\u00ean lo\u1ea1i tr\u1eeb t\u0103ng huy\u1ebft \u00e1p ph\u1ed5i do huy\u1ebft kh\u1ed1i thuy\u00ean t\u1eafc th\u1ee9 ph\u00e1t (nh\u00f3m 4) tr\u01b0\u1edbc khi ch\u1ea9n \u0111o\u00e1n t\u0103ng huy\u1ebft \u00e1p ph\u1ed5i v\u00f4 c\u0103n b\u1eb1ng \u00a0V\/Q ph\u1ed5i. N\u1ebfu b\u1ea5t th\u01b0\u1eddng, CT-PA ho\u1eb7c ch\u1ee5p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i l\u00e0 b\u01b0\u1edbc ti\u1ebfp theo \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh ch\u1ea9n \u0111o\u00e1n v\u00e0 thi\u1ebft l\u1eadp s\u1ef1 ph\u00e2n b\u1ed1 v\u00e0 m\u1ee9c \u0111\u1ed9 c\u1ee7a b\u1ec7nh [1].<\/li>\n<\/ul>\n
![\"\"](\"http:\/\/noithathoaphat.in\/ctv\/wp-content\/uploads\/2023\/04\/5-2.png\")
\u0110\u01b0\u1eddng d\u00f9ng, th\u1eddi gian b\u00e1n h\u1ee7y, li\u1ec1u l\u01b0\u1ee3ng v\u00e0 th\u1eddi gian d\u00f9ng c\u1ee7a c\u00e1c thu\u1ed1c \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o \u0111\u1ec3 ki\u1ec3m tra kh\u1ea3 n\u0103ng v\u1eadn m\u1ea1ch trong t\u0103ng huy\u1ebft \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i<\/figcaption><\/figure>\n 2.3.7.3. Fluid Challenge [3]<\/strong><\/p>\n
Fluid challenge c\u00f3 th\u1ec3 cho th\u1ea5y r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng t\u00e2m tr\u01b0\u01a1ng LV \u1edf b\u1ec7nh nh\u00e2n c\u00f3 PAWP \u226415 mmHg, nh\u01b0ng ki\u1ec3u h\u00ecnh l\u00e2m s\u00e0ng g\u1ee3i \u00fd b\u1ec7nh tim Tr\u00e1i.<\/p>\n
Ng\u01b0\u1eddi ta th\u01b0\u1eddng ch\u1ea5p nh\u1eadn r\u1eb1ng truy\u1ec1n nhanh (h\u01a1n 5\u201310 ph\u00fat) 500 mL (7\u201310 mL\/kg) n\u01b0\u1edbc mu\u1ed1i sinh l\u00fd l\u00e0 \u0111\u1ee7 \u0111\u1ec3 ph\u00e1t hi\u1ec7n s\u1ef1 gia t\u0103ng b\u1ea5t th\u01b0\u1eddng c\u1ee7a PAWP \u0111\u1ebfn \u226518 mmHg (g\u1ee3i \u00fd HFpEF).<\/p>\n
Kh\u00f4ng c\u00f3 \u0111\u1ee7 d\u1eef li\u1ec7u v\u1ec1 \u0111\u00e1p \u1ee9ng huy\u1ebft \u0111\u1ed9ng \u0111\u1ed1i v\u1edbi th\u1eed th\u00e1ch truy\u1ec1n d\u1ecbch \u1edf b\u1ec7nh nh\u00e2n m\u1eafc t\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i. G\u1ea7n \u0111\u00e2y d\u1eef li\u1ec7u cho th\u1ea5y r\u1eb1ng n\u00e2ng cao ch\u00e2n th\u1ee5 \u0111\u1ed9ng trong th\u00f4ng tim ph\u1ea3i c\u0169ng c\u00f3 th\u1ec3 gi\u00fap ph\u00e1t hi\u1ec7n ra HFpEF ti\u1ec1m \u1ea9n.<\/p>\n
Ngu\u1ed3n tham kh\u1ea3o<\/strong><\/p>\n
[1]<\/strong> Maxine A. Papadakis; Stephen J.McPhee; Michael W.Rabow: CURRENT Medical Diagnosis <\/em>& Treatment<\/em>, 2023, p301 – p302.<\/p>\n
[2]<\/strong> Hemant Godara; Angela Hirbe; Michael Nassif; Hannah Otepka; Aron Rosenstock: The Washington Manual of Medical Therapeutics 34th<\/sup> Edition<\/em>, 2014, p405 – p407.<\/p>\n
[3]<\/strong> Humbert M, Kovacs G, Hoeper MM, et al.,: Guidelines for the Diagnosis and Treatment of Pulmonary Hypertension: Developed by the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS)<\/em>, 2022.<\/p>\n","protected":false},"excerpt":{"rendered":"
T\u0103ng \u00e1p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i (Pulmonary Artery Hypertension – PAH) l\u00e0 m\u1ed9t b\u1ec7nh l\u00fd nghi\u00eam tr\u1ecdng v\u00e0 c\u1ea7n \u0111\u01b0\u1ee3c ch\u1ea9n \u0111o\u00e1n v\u00e0 \u0111i\u1ec1u tr\u1ecb k\u1ecbp th\u1eddi. PAH c\u00f3 th\u1ec3 g\u00e2y ra nhi\u1ec1u tri\u1ec7u ch\u1ee9ng kh\u00e1c nhau. Nh\u1eefng tri\u1ec7u ch\u1ee9ng n\u00e0y c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn gi\u1ea3m ch\u1ea5t l\u01b0\u1ee3ng cu\u1ed9c s\u1ed1ng v\u00e0 c\u00f3 th\u1ec3 g\u00e2y ra nguy […]<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":[],"categories":[20,33],"tags":[3],"yoast_head":"\n
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