Zdravljenje trajne KOPB Akutno poslabšanje KOPB
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1 Prof. dr.stanislav Šuškovič Univerzitetna klinika za pljučne bolezni in alergijo Bolnišnica Golnik 4204 Golnik Zdravljenje trajne KOPB Akutno poslabšanje KOPB Golnik,
2 ZDRAVLJENJE KOPB VZDRŽEVALNO ZDRAVLJENJE ZDRAVLJENJE POSLABŠANJA
3 POSPEŠENI UPAD PLJUČNE FUNKCIJE PRI KOPB učinek opustitve kajenja FEV 1 (% of value at age 25) KOPB invalidnost smrt zdravi Starost v letih stop pri 45 stop pri 65 Adapted from: Fletcher et al, Br Med J 1977.
4 STOPNJA KOPB Blaga FEV 1 /FVC < 70%, FEV 1 >= 80% Zmerna FEV 1 /FVC < 70%, 50%=<FEV 1 < 80% Težka FEV 1 /FVC < 70%, 30%=<FEV 1 < 50% Zelo težka FEV 1 /FVC < 70%, FEV 1 =< 30% ali FEV 1 <50% in kronična repiracijska insuficienca
5 Predpis zdravil po stopnjah KOPB
6 Trajno zdravljenje KOPB z zdravili PRICIP:DODAJANJE Kratkodelujoči bronhodilatator Eden ali več dolgodelujočih bronhodilatatorjev Inhalacijski glukokortikoid Trajno kisik
7 DISPNEJA JE OSREDNJI PROBLEM BOLNIKOV S KOPB UPAD TELESNE KONDICIJE DISPNEJA TELESNA NEAKTIVNOST KAJENJE DEPRESIJA DRUŽBENA IZOLACIJA
8 FEV1 ne korelira z dispnejo ali kakovostjo življenja Dispneja vs FEV1 SGRQ vs FEV1 Kreisman et al,chest1989 PW Jones, THORAX 2001
9 FEV1 ne korelira s telesno zmogljivostjo Cooper BC, Am J Med 2006
10 Hiperinflacija je osrednji patofiziološki pojav pri KOPB
11 Hiperinflacija korelira z dnevno telesno aktivnostjo Garcia-Rio F, AJRCCM 2009
12 KOPB zmanjšana elastičnost pljuč periferna obstrukcija statična ali dinamična hiperinflacija povečano dihalno delo bronhodilatatorji zmanjšujejo hiperiflacijo dispneja
13 salmeterol formoterol indakaterol + tiotropij inhalacijski glukokortikoidi? Zmanjšanje hiperiflacije Olajšanje dispneje
14 KATERO ORODJE ZA OCENO TEŽAVNOSTI KOPB JE NA VOLJO V SLOVENIJI?
15 SGRQ vs. CAT N=229 R=0.80 p<
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19 Raziskava TORCH Pogostnost obolevnosti za pljučnico placebo salmeterol flutikazon SFC Pljučnica% * 19.6* Inhalacijski glukokortikoidi povečujejo tveganje za pljučnico
20 Inhaled Corticosteroids and the Risks of Diabetes Onset and Progression Suissa S,Kezouh A,Ernst P Am J Med The cohort included 388,584 patients; of whom 30,167 had diabetes onset during 5.5 years of follow-up (incidence rate 14.2/1000/year); and 2099 subsequently progressed from oral hypoglycemic treatment to insulin (incidence rate 19.8/1000/year). Current use of inhaled corticosteroids was associated with a 34% increase in the rate of diabetes (rate ratio [RR] 1.34; 95% confidence interval [CI], ) and in the rate of diabetes progression (RR 1.34; 95% CI, ). The risk increases were greatest with the highest inhaled corticosteroid doses; equivalent to fluticasone 1000 μg per day or more (RR 1.64; 95% CI, and RR 1.54; 95% CI, ; respectively).
21 NEFARMAKOLOŠKI NAČINI ZDRAVLJENJA KOPB Opustitev kajenja Respiratorna rehabilitacija Ustrezna prehrana Življenski slog
22 Poslabšanje KOPB
23 Simptomi pkopb Poslabšanje kronične obstruktivne Pojačana dispneja Pojačan bolezni kašelj (pkopb) Povečana količina ali gnojnost sputuma Definicija Nagla sprememba v izraženosti Simptom zgornjih dihal (bolečine v grlu, prehlad ) Akutni dispneje, rinitiskašlja in/ali sputuma ter Pojačano drugih simptomov, piskanje ki presega za Stiskanje bolnika v običajno prsnem košu vsakodnevno Zmanjšana variabilnost telesna in zmogljivost ki utegne narekovati Retenca spremembo tekočin zdravljenja Utrujenost Zmedenost
24 Vnetje bronhijev v pkopb pkopb je vselej nasledek povečanega vnetja bronhijev.
25 Etiologija pkopb Bakterijska okužba. Stretococcus pneumonie, Hemophilus influenzae in Moraxella catharrhalis. Virusna okužba rinovirusi, metapnevmovirusi? Bakterijsko-virusna okužba. pomemben delež APKOPB se odvija s kombinirano virusno in bakterijsko okužbo.
26 Simptomi pkopb so podaljšani dispneja rinitis
27 salmeterol formoterol, indakaterol tiotropij inhalacijski glukokortikoidi roflumilast teofilin preprečevanje poslabšanj KOPB Cepljenje proti gripi Respiratorna rehabilitacija
28 ALI Z BRONHODILATATORJI PREPREČUJEMO POSLABŠANJA ASTME IN KOPB? ASTMA NE KOPB DA za 25%
29 Zavzetost za zdravljenje, hospitalizacije in umrljivost bolnikov s KOPB Nezavzeti <=80% Zavzeti >80% Thorax 2009 e-pub
30 Zdravljenje pkopb Bronhodilatatorji 1. V pršilniku preko velikega nastavka (salbutamol ali fenoterol) + ipratropij do 1-6 vdihov/uro 2. nadaljujemo tiotropij na 24 ur + (salmeterol ali formoterol) na 12 ur
31 Cochrane Database Syst Rev. 2003;(2):CD Methylxanthines for exacerbations of chronic obstructive pulmonary disease. Barr RG, Rowe BH,Camargo CA. Pri poslabšanju KOPB ne predpisujemo metilksantinov (aminofilina)
32 Ambulantno antibiotično zdravljenje pkopb le z enostavnimi antibiotiki ni dokazil o prednosti kakega izmed naštetih antibiotikov prvega reda GOLD 2007
33 Glukokortikoidi skrajšajo trajanje in omilijo težo pkopb zmanjšajo možnost zgodnjega ponovnega poslabšanja KOPB GOLD 2007
34 Glukokortikoidi Običajni odmerek: mg metilprednizolona zjutraj 7-10 dni ambulantno predpišemo glukokortikoid le pri bolnikih s predhodnim bazičnim FEV1<50% norme (težka ali zelo težka KOPB po klasifikaciji GOLD) GOLD 2007
35 KOMORBIDNOSTI PRI KOPB 50% bolnikov s KOPB ima vsaj eno komorbidnost DEPRESIJA SLADKORNA BOLEZEN HIPERLIPIDEMIJA OSTEOPOROZA RAK PLJUČ MOTNJE DIHANJA V SPANJU SRČNO POPUŠČANJE
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