慢阻肺急性发作Acute Exacerbation of Chronic Obstructive Pulmonary Disease课件

Acute Exacerbation of Chronic Obstructive Pulmonary Disease.Prof.Ashraf M.Hatem,MD,FCCPAcuteExacerbationofChronic1DefinitionofAcuteexacerbation:ThedefinitionofCOPDexacerbationisanacutechangeinapatientsbaselinedyspnoea,coughand/orsputumbeyondday-to-dayvariabilitysufficienttowarrantachangeintherapy.Causesofexacerbationcanbebothinfectiousandnon-infectiouse.g.airpollution.DefinitionofAcuteexacerbati2Mostcommonlyencounteredorganisms:-Streptococcus pneumoniae-Hemophilus influenzae-Moraxella catarrhalisThecauseinonethirdofexacerbationsremainsunidentifiedMostcommonlyencounteredorga3慢阻肺急性发作AcuteExacerbationofChronicObstructivePulmonaryDisease课件4ClassificationofSeverityofAcuteExacerbationofCOPDTheOperationalClassificationofSeverityisasfollows:LevelI:ambulatory(outpatient),LevelII:requiringhospitalisation,andLevelIII:acuterespiratoryfailure.ClassificationofSeverityof5TheOperationalClassificationofSeverityofCOPDexacerbationLevel ILevel IILevel IIIClinical historyCo-morbid conditionsHistory of frequent exacerbationsSeverity of COPD+Mild/moderate+Moderate/severe+SeverePhysical findingsHaemodynamic evaluationUse accessory respiratory muscles,tachypnoeaPersistent symptoms after initial therapyStableNot presentNoStable+Stable/unstable+Diagnostic proceduresOxygen saturationArterial blood gasesChest radiographBlood testsSerum drug concentrationsSputum gram stain and cultureElectrocardiogramYesNoNoNoIf applicableNoNoYesYesYesYesIf applicableYes YesYesYesYesYesIf applicableYesYesTheOperationalClassification6IndicationsforhospitalisationofpatientswithaCOPDexacerbationPresenceofhigh-riskco-morbidconditions,includingpneumonia,cardiacarrhythmia,congestiveheartfailure,diabetesmellitus,renalorliverfailureInadequateresponseofsymptomstooutpatientmanagementMarkedincreaseindyspnoeaInabilitytoeatorsleepduetosymptomsWorseninghypoxaemiaWorseninghypercapniaChangesinmentalstatusInabilityofthepatienttocareforher/himselfUncertaindiagnosisInadequatehomecareIndicationsforhospitalisatio7LevelI:outpatienttreatmentPatient educationCheckinhalationtechniqueConsideruseofspacerdevicesBronchodilatorsShort-acting2-agonistand/oripratropiumMDIwithspacerorhand-heldnebulizerasneededConsideraddinglong-actingbronchodilatorifpatientisnotalreadyusingit.Corticosteroids(the actual dose may vary)Prednisone3040mgper os qdayfor10daysConsiderusinganinhaledcorticosteroidAntibiotics MaybeinitiatedinpatientswithalteredsputumcharacteristicsChoiceshouldbebasedonlocalbacteriaresistancepatterns-Amoxicillin/ampicillin,cephalosporins-Doxycycline-MacrolidesIfthepatienthasfailedpriorantibiotictherapyconsider:-Amoxicillin/clavulanate-RespiratoryfluoroquinolonesLevelI:outpatienttreatmentP8LevelII:treatmentforhospitalisedpatientBronchodilators-Shortacting2-agonist(albuterol,salbutamol)and/or-IpratropiumMDIwithspacerorhand-heldnebuliserasneededSupplemental oxygen(ifsaturation90%.Maindeliverydevicesincludenasalcannulaandventurimask.Alternativedeliverydevicesincludenonrebreathermask,reservoircannula,nasalcannulaortranstrachealcatheter.In-patientOxygenTherapyTheg11Arterialbloodgasesshouldbemonitoredforarterialoxygentension(Pa,O2),arterialcarbondioxidetension(Pa,CO2)andpH.Arterialoxygensaturationasmeasuredbypulseoximetry(Sp,O2)shouldbemonitoredfortrendingandadjustingoxygensettings.Arterialbloodgasesshouldbe12PreventionoftissuehypoxiasupersedesCO2retentionconcerns.IfCO2retentionoccurs,monitorforacidosis.Ifacidaemiaoccurs,considermechanicalventilation.Preventionoftissuehypoxias13慢阻肺急性发作AcuteExacerbationofChronicObstructivePulmonaryDisease课件14MEASURESTOMOBILIZEAIRWAYSECRETIONSINHOSPITALIZEDPATIENTSWITHCOPDDirectedcoughing,“huffcoughing.”BenefitextrapolatedfromexperienceincysticfibrosisChest physiotherapy:manual or mechanical chestpercussionandposturaldrainage.Benefitextrapolatedfromexperienceincysticfibrosis.CancausetransientfallinFEVI.Assumedrolelimitedtopatients with 25 ml sputum per day or lobaratelectasisfrommucuspluggingIntermittent positive pressure breathing(IPPB).Notindicated;noprovenbenefitInCOPDPositiveexpiratorypressure(PEP).Benefitextrapolated from experience in cystic fibrosis.NoreportedexperienceinacuteexacerbationsofCOPD.MEASURESTOMOBILIZEAIRWAYSE15Blandaerosoltherapy.NodemonstratedbenefitinCOPDunlessartificialairwayisinplace.Maycausebronchospasminnonintubatedpatients.Systemic hydration.No demonstrated benefitbeyond repletion of intravascular volume toeuvolemia.Nasotrachealsuctioning.Limitedbenefit;toleratedonlyforshortperiodsMini-tracheotomy.Possibletemporarybenefitinpatientswithpersistentairwaysecretionscausingrespiratorydeterioration.Blandaerosoltherapy.Nodemo16IndicationsforICUAdmissionSeveredyspneathatrespondsinadequatelytoinitialemergencytherapy.Confusion,lethargy,coma.Persistentorworseninghypoxemia(PaO28.0kPa,60mmHg),and/orsevere/worseningrespiratoryacidosis(pH7.25)despitesupplementaloxygenandNIPPV.IndicationsforICUAdmissionS17AssistedventilationNoninvasive positive pressure ventilation(NPPV)shouldbeofferedtopatientswithexacerbationswhen,afteroptimalmedicaltherapyandoxygenation,respiratoryacidosis(pH 7.36)and or excessivebreathlessnesspersist.Allpatientsconsideredformechanicalventilationshouldhavearterialbloodgasesmeasured.AssistedventilationNoninvasiv18IfpH7.30,NPPVshouldbedeliveredundercontrolledenvironmentssuchasintermediateintensivecareunits(ICUs)and/orhigh-dependencyunits.IfpH7.30,NPPVshouldbedeliveredundercontrolledenvironmentssuchasintermediateintensivecareunits(ICUs)and/orhigh-dependencyunits.IfpH7.30,NPPVshouldbede19IfpH7.25,NPPVshouldbeadministeredintheICUandintubationshouldbereadilyavailable.Thecombinationofsomecontinuouspositiveairwaypressure(CPAP)(e.g.48cmH2O)andpressuresupportventilation(PSV)(e.g.1015cmH2O)providesthemosteffectivemodeofNPPV.PatientsmeetingexclusioncriteriashouldbeconsideredforimmediateintubationandICUadmission.IfpH35breathsperminute.Life-threateninghypoxemia(PaO25.3kPa,40mmHgorPaO2/FiO2200mmHg).Severeacidosis(pH8.0kPa,60mmHg).IndicationsforMechanicalVen24Respiratoryarrest.Somnolence,impairedmentalstatus.Cardiovascularcomplications(hypotension,shock,heartfailure).Othercomplications(metabolicabnormalities,sepsis,pneumonia,pulmonaryembolism,barotrauma,massivepleuraleffusion).NIPPVfailure(orcontraindicationtoNIPPV).Respiratoryarrest.25MechanicalVentilationAssistedventilationshouldbeconsideredforpatientswithacuteexacerbationsofCOPDwhenpharmacologicandothernonventilatorytreatmentsfailtoreverseclinicallysignificantrespiratoryfailure.The clinician must aim to avoid complicationsassociated with mechanical ventilation andshould initiate weaning and discontinuation ofmechanicalventilationassoonaspossible.MechanicalVentilationAssisted26ThemaingoalsofassistedpositivepressureventilationinacuterespiratoryfailurecomplicatingCOPDare:-Restingofventilatorymuscles,and-Restorationofgasexchangetoastablebaseline.Allowforpermissivehypercapnea(exceptincerebraledema,myocardialischemia,LVF.)Themaingoalsofassistedpos27TherearethreespecificpitfallsinventilatingpatientswithCOPD:i-Overventilation,resultinginacuterespiratoryalkalemia,ii-Initiationofcomplexpulmonaryandcardiovascularinteractionsthatmayresultin systemicypotension.iii-Creationofintrinsicpositiveend-expiratorypressure(PEEP),or“auto-PEEP,”especiallyifexpiratorytimeisinadequateorifdynamicairflowobstructionexistsTherearethreespecificpitfa28ThethreeventilatorymodesmostwidelyusedformanagingpatientswithCOPDare:-Assist-controlventilation(ACV),-Intermittentmandatoryventilation(IMV),and-Pressuresupportventilation(PSV).PSVprovidesincreasedpatientcomfort,promotespatientsynchronywiththeventilator,andfacilitateweaningfrommechanicalventilationinthepatientwhomaintainsadequateventilatorydrive.Thethreeventilatorymodesmo29GOLD Guidelines:Treatment of COPDAvoidanceofriskfactor(s);influenzavaccination Addshort-actingbronchodilatorwhenneeded Addregulartreatmentwithoneormorelong-actingbronchodilators Addrehabilitation Add long-termoxygenifchronicrespiratoryfailureConsidersurgicaltreatments Add inhaledglucocorticidsifrepeatedexacerbationsStage0:At RiskI:MildII:ModerateIII:SevereIV:Very SevereGOLDGuidelines:30DischargeCriteriaforPatientsWithExacerbationsofCOPDInhaled2-agonisttherapyisrequirednomorefrequentlythanevery4hrs.Patient,ifpreviouslyambulatory,isabletowalkacrossroom.Patientisabletoeatandsleepwithoutfrequentawakeningbydyspnea.Patienthasbeenclinicallystablefor12-24hrs.DischargeCriteriaforPatient31Arterialbloodgaseshavebeenstablefor12-24hrs.Patient(orhomecaregiver)fullyunderstandscorrectuseofmedications.Follow-upandhomecarearrangementshavebeencompleted(e.g.,visitingnurse,oxygendelivery,mealprovisions).Patient,family,andphysicianareconfidentpatientcanmanagesuccessfully.Arterialbloodgaseshavebeen32Strategies to Help the PatientWilling to Quit Smoking(5 As)ASK:Systematicallyidentifyalltobaccousersateveryvisit.Implementanoffice-widesystemthatensuresthat,forEVERYpatientatEVERYclinicvisit,tobacco-usestatusisqueriedanddocumented.ADVISE:Stronglyurgealltobaccouserstoquit.Inaclear,strong,andpersonalizedmanner,urgeeverytobaccousertoquit.ASSESS:Determinewillingnesstomakeaquitattempt.Askeverytobaccouserifheorsheiswillingtomakeaquitattemptatthistime(e.g.,withinthenext30days).ASSIST:Aidthepatientinquitting.Helpthepatientwithaquitplan;providepracticalcounseling;provideintra-treatmentsocialsupport;helpthepatientobtainextra-treatmentsocialsupport;recommenduseofapprovedpharmacotherapyexceptinspecialcircumstances;providesupplementarymaterials.ARRANGE:Schedulefollow-upcontact.Schedulefollow-upcontact,eitherinpersonorviatelephone.StrategiestoHelpthePatient33LongTermOxygenTherapyOxygenadministration15hours/day.Indications:-PaO255mmHgorSaO289%ifthereisevidenceofPulmonaryhypertension,CHF,orPolythycemia(Hematocrit55%)LongTermOxygenTherapyOxygen34PulmonaryRehabilitationGoals:-Reducesymptoms-ImproveQOL-PromotephysicalandemotionalparticipationineverydaylifeProgramshouldbeatleast2months.Aimistostrengtheninspiratorymusclesandincreaseendurance.PulmonaryRehabilitationGoals:35SurgicalTreatmentBullectomyLVRSandBronchoscopicvolumereductionLungtransplantationSurgicalTreatmentBullectomy36Assessment4-6WeeksAfterDischargefromHospitalAbilitytocopeinusualenvironment.MeasurementofFEV1.Reassessmentofinhalertechnique.Understandingofrecommendedtreatmentregimen.Needforlong-termoxygentherapyand/orhomeNebulizer(forpatientswithverysevereCOPD).Assessment4-6WeeksAfterDis37THANKYOUTHANKYOU38