BPCO/COPD. Andrea Bellone UOC di Pronto Soccorso Ospedale Sant'Anna di Como

Transcription

1 BPCO/COPD Andrea Bellone UOC di Pronto Soccorso Ospedale Sant'Anna di Como

2 Definition of COPD (1) COPD is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible

3 Definition of COPD (2) The airflow limitation is usually progressive and is associated with an abnormal infiammatory response of the lungs to noxious particles or gases, primarly caused by cigarette smoking

4 Diagnosis of COPD (1) The diagnosis of COPD should be considered in any patient who has the following: symptoms of cough, sputum production, or dyspnea; or hystory of exposure to risk factors for the disease

5 Diagnosis of COPD (2) The diagnosis requires spirometry; a post-bronchodilator forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) < 0.7 confirms the presence of airflow limitation that is not fully reversible

6 Spirometric classification of COPD Severity FEV 1 % pred Mild COPD > 80 Moderate COPD Severe COPD Very severe COPD < 30

7 Epidemiology 1) COPD is a leading cause of morbidity and mortality 2) COPD is the fifth cause of global mortality 3) 5-15% of adults in industrialised countries have COPD

8 Epidemiology (2) Death and disability from COPD were related to a loss of more than 50 ml per year in the FEV1

9 Risk factors for COPD Host factors Genetic factors Sex Hyperreactivity IgE and asthma Exposures Smoking Recurrent bronchopulmonary events Childhood illness Socio-economic status and occupation

10 Pathology in COPD COPD comprises pathological changes in four different compartments of the lung (central airways, peripheral airways, lung parenchyma and pulmonary vasculature)

11 Pathophysiology PINK PUFFERS BLUE BLOATERS <20% BMI >20% Absent EDEMA Present >70 mmhg PaO2 <55 mmhg <40 mmhg PaCO2 >45 mmhg ++++ Dyspnea ++ Absent Policitemia Present Absent IAP Present V/Q Perfusion Deficit ventilarory

12 Pathogenesis of COPD (1) 1) Loss of elasticity and the destruction of the alveolar attachments of airways >> closure of small airways during expiration 2) Narrowing of small airways as a result of inflammation 3) Blocking of the lumen of small airways with mucous secretions

13 Pathogenesis (2) 1) There is a significant association between the severity of FEV1 and the thickness of the walls of small airways 2) The increase airway thickness results from infiltration by inflammatory cells as well as structural changes, including increases in smooth muscle and fibrosis under the epithelium

14 Differential diagnosis of COPD Asthma Allergy, rhinitis and/or eczema, airflow limitation reversible Congestive heart failure Volume restriction not airflow limitation, pulmonary edema Bronchiectasis Tubercolosis Large volume of purulent sputum Lung infiltrate on Chest Xray Bronchiolitis Younger onser, CT suggestive

15 COPD treatment Smoking cessation Pharmacological therapy Long-term oxygen therapy Pulmonary rehabilitation Nutrition Surgery

16 LTOT prescription PaO2 < 55 mmhg PaO2= fra i 55 ed i 59 mmhg + cor pulmonale, polycythemia, with optimal medical treatment

17 Which oxygen flow? Rest > SpO2 > 90% Exertion > add 1 L/min Sleep > add 1 L/min

18 Lung Volume Reduction: Who? Nonhomogenous emphysema Upper lobe predominant emphysema Limited exercise performance after rehabilitation

19 Bronchodilators/steroids Short acting B2/anticholinergic Long-acting B2/anticholinergic Add inhaled steroids

20 BODE (prognostic index) B (BMI) O (Obstruction) D (Dyspnea) E (exercise)

21 Riabilitazione Respiratoria - Riduce la dispnea - Aumenta l'autonomia funzionale -Migliora la qualità di vita

22 Ruolo Fisioterapista - Personalizzare l'approccio al paziente -Gestire la relazione

23 -Anamnesi -Obiettività -Ascultazione Ruolo Fisioterapista respiratorio -Lettura spirometria -Lettura EGA -ECO? -Allenamento allo sforzo, disostruzione, educazione

24 Exacerbation of COPD An exacerbation of COPD is an event in the natural course of the disease characterised by a change in the patient s baseline dyspnea, cough and/or sputum beyond dayto-day variability sufficient to warrant a change in management

25 Causes of COPD exacerbation Exacerbation may be triggered by a variety of factors including viral or bacterial infection and air pollution

26 Flow volume loops

27 Effects of dynamic hyperinflation

28 Mechanical effects of COPD exacerbation

29 Indication for hospitalisation 1) High comorbility 2) Worsening hypoxemia and hypercapnia 3) Inadequate home care 4) Inability of the patient to care for him/herself 5) Inadequate response of symptoms to outpatient management

30 Treatment for hospitalised 1) Bronchodilators patient 1) Corticosteroids 1) Antibiotics 4) Supplemental oxygen if SpO2 < 90%

31 Treatment for patients requiring intensive care As previous treatment plus noninvasive ventilation

32 Indication for NIV The institution of mechanical ventilation should be considered when despite optimal medical therapy and oxygen administration there is acidosis (ph < 7.35) and hypercapnia (PaCO2 > 45 mmhg) and respiratory frequency > 24/min

33 Indication for intubation 1) NIV failure 2) Coma/Respiratory Arrest

34 Key indicators for a diagnosis Chronic cough of COPD Chronic sputum production Progressive-persistent dyspnea History of exposure to risk factors (smoke, occupational..) Spirometry (not fully reversible airflow limitation)

35 Key indicators for a diagnosis of asthma Wheezing and breathlessness (episodic) Chest tightness Unproductive cough Spirometry (reversible airflow limitation) History of exposure to risk factors (Allergens, exercise, viral infection, emotions)

36 Asthma (definition) Asthma is a chronic infiammatory disorder of the airways characterised by an increase number of lymphocytes and eosinophilis in the airway mucosa and by subepithelial fibrosis. In susceptible individuals this inflammation causes recurrent episodes of wheezing, chest tightness, cough, particularly at night and in the early morning.

37 Severe asthma : when? 1) Accessory muscle activity 2) Paradoximal pulse > 25 mmhg 3) HR > 110/min 4) RR > 25/min 5) Limited ability to speak 6) PEF < 50% of pred 7) SpO2 < 91% (room air)

38 Clinical aspects: autopsy Patients who die from asthma have: 1) Airway narrowing 2) Extensive plugging 3) Inflammatory infiltrates 4) Hyperinflation 5) atelectasis

39 Physiologic manifestation of asthma attack (1) Non-uniform, reversible increase in airway Resistance > diminished flow rates > Premature airway closure > hyperinflation > Increase work of breathing (mean pressure developed by the inspiratory muscles per breath that increase if the elastic or resistive load imposed on muscles is increased)

40 Physiologic manifestation of asthma attack (2) Not uniform ventilation/perfusion ratio caused by an increase in airway resistances Altered arterial blood gases (respiratory alkalosis, mild-moderate hypoxemia, metabolic acidosis)

41 Bronchiectasis Bronchiectasis is an uncommon disease that results in the abnormal and permanent distortion of one or more of the conducting bronchi or airways, most often secondary to an infectious process

42 Pathophysiology (1) Bronchiectasis is an abnormal dilation of the proximal and medium-sized bronchi > 2 mm in diameter caused by the destruction of the muscolar and the elastic components of the bronchial walls. Affected areas may show transmural inflammation, edema, scarring, ulceration. It can be congenital or acquired due to microbial infection

43 Pathophysiology (2) >>> The most important functional finding of altered airway anatomy is severely impaired clearance of secretions from the bronchial tree>>colonization and infection contributing to purulent expectoration

44 Characteristics of bronchiectasis 1) Cylindrical= mucosal edema 2) Cystic= ulceration 3) Varicose= obstructive scarring

45 History (1) The classic manifestation of bronchiectasis are cough and daily muco-purulent sputum production Today, cystic fibrosis is the most common cause of bronchiectasis in children and young adults

46 History (2) Hemoptysis occurs in 50-90% of pts with bronchiectasis Bronchiectasis is a morphologic diagnosis (CT and chest X-ray) Crackles are often observed

47 Causes 1) Primary infections 2) Bronchial obstruction 3) Cystic fibrosis 4) Young syndrome 5) Allergic bronchopulmonary aspergillosis 6) Immunodeficiency states

48 Lab studies 1) Sputum analysis 2) CBC count 3) Immunoglobulin levels 4) Sweat test with pilocarpine 5) Aspergillus precipitins 6) Rheumatoid factor

49 General therapy 1) Stop smoking 2) Adequate nutritional intake 3) Immunizations for influenza, pneumococcal, measles, rubeola, pertussis 4) Oxygen 5) Psychological support

50 Therapy 1) Antibiotics (oral, parenteral or aerosolized) 2) Bronchial hygiene 3) Bronchodilators 4) Inhaled steroids? 5) Surgery