【COPD英文課件】Chronic Obstructive Pulmonary Disease (32p)

1、Chronic Obstructive Pulmonary DiseaseChiefs Conference:Kevin L. Gilliam II, M.D.April 16, 2021Emory Family MedicineWhat is COPD?It is a syndrome of progressive airflow limitation caused by chronic inflammation of the airways and lung parenchyma.The terms chronic bronchitis and emphysema are no longe

2、r included in the formal definition of COPD, although they are still used clinicallyEmphysema: pathologic term used to describe destruction of the alveolar capillary membraneChronic Bronchitis: clinical term used to describe the presence of cough or sputum production for at least a three month durat

3、ion during two consecutive yearsWho gets COPD?SmokersSmokersSmokersMore than 80 percent of deaths from the disease are directly attributable to smoking, and persons who smoke are 12 to 13 times more likely to die from COPD than nonsmokers.The absolute risk of COPD among active, continuous smokers is

4、 at least 25 percentWho else is at risk for getting COPD?People of advancing age Those exposed to secondhand smokeChronic exposure to environmental or occupational pollutantsAlpha1-antitrypsin deficiency (typically early)Childhood history of recurrent respiratory infectionsFamily history of COPDWhat

5、s the Physiology?Related to chronic airway irritation, mucus production, and pulmonary scarring.Irritation from environmental pollutants (most commonly cigarette smoke) or a genetic predisposition leads to airway inflammation, which causes increased mucus production and decreased mucociliary functio

6、nThe combination of increased mucus and decreased mucociliary clearance leads to the hallmark COPD symptoms of coughing and sputum productionA Little More PhysiologyContinued airway irritation and inflammation causes scarring within the airways leading to airway obstruction and dyspneaIrritation, in

7、flammation, mucus production, and scarring also predispose patients to respiratory infections which leads them to seek medical attentionWithout symptoms many patients will not seek medical attention and therefore disease can progress before diagnosis or treatmentEpidemiologically Speaking10 million

8、adults in the United States have been diagnosed with COPDNational Health and Nutrition Examination Survey (NHANES) suggests that roughly 10 percent of the adult U.S. population has evidence of impaired lung function consistent with COPD26 millionUnderdiagnosed and UnderrecognizedSome more Epidemiolo

9、gyMore common in womenMore fatal in WomenSecondary to differences in lung size and mechanics, womens airways are more hyper-responsive to exogenous irritantsAlthough the diagnosis of COPD is often overlooked in both populations, it is diagnosed even less in women than in menHow is it Diagnosed?Clini

10、cal suspicion in patients presenting with any of the hallmark symptoms which is then confirmed by spirometry.Cough, ed sputum production, and dyspneaEspecially in patients with a smoking historySince symptoms may not occur until lung function is substantially reduced, early detection is enhanced by

11、spirometric evaluation of FEV and FVC.The National Heart, Lung, and Blood Institute recommends spirometry for all smokers 45 years or older, particularly those who present with shortness of breath, coughing, wheezing, or persistent sputum productionMore on DiagnosisPhysical examination findings are

12、not sensitive for the initial diagnosis of COPDMany patients have normal examination findingsFeatures of lung hyperinflation include a widened anteroposterior chest diameter, hyperresonance on percussion, and diminished breath soundsSome More on DiagnosisPersistent pulmonary damage can lead to incre

13、ased right-sided heart pressure causing right sided heart failure (cor pulmonale)Which can give an accentuated second heart sound, peripheral edema, jugular venous distension, and hepatomegaly. Signs of increased work of breathing include the use of accessory respiratory muscles, paradoxical abdomin

14、al movement, increased expiratory time, and pursed lip breathing; auscultatory wheezing is variable. Other physical findings are occasionally cyanosis and cachexiaWeight loss is an independent predictor of mortality therefore BMI should be followedA Little More on DiagnosisThe stage of the disease s

15、uggests the prognosis, and follow-up data from longitudinal studies indicate that moderate and severe stages of the disease are associated with higher mortalityJoint guidelines from the American Thoracic Society (ATS) and the European Respiratory Society (ERS) recommend screening for alpha1-antitryp

16、sin deficiency in symptomatic adults with persistent obstruction on pfts and asymptomatic adults with history of smoking or occupational exposureJust a Smidge More DiagnosisThen What?Evidence suggests that dyspnea is a better predictor of mortality than spirometry in patients with COPDMRC dyspnea in

17、dex has also been combined with BMI, FEV1, and exercise capacity (six-minute maximum walking distance) into the 10-point BODE index.Used to predict disease severity, risk of hospitalization, and all-cause mortalityHow to Manage Chronic Disease?The major goals of therapy include: smoking cessationsym

18、ptom reliefimprovement in physiological function and limitation of complications i.e. abnormal gas exchange and exacerbations of the diseaseHow to advance therapy0: Avoidance of Risk Factor; Immunizations1: PRN short acting bronchodilator2: Reg treatment with one or more long acting bronchodilators,

19、 add Rehab3: Inhaled steroids if repeated exacerbations4: Oxygen, consider surgeryMore on ManagementSpirometry should be performed at least annually, and more frequently if needed, to assess clinical status or the response to therapyAbstinence from smoking results in a sustained 50 percent reduction

20、 in the rate of lung-function decline in patients with COPD, and smoking cessation is the only intervention known to be so effective in modifying the diseaseAnnual Influenza VaccinationPneumococcal VaccinationWhat meds to useInhaled bronchodilators are the foundation of pharmacotherapy for COPD beca

21、use of their capacity alleviate symptoms, decrease exacerbations of disease, and improve the quality of lifeAlbuterol and ipratropium are equally effective with regard to bronchodilation, symptom scores, and the rates of treatment failure and can be used interchangeably for mild disease as the first

22、 step in a series of measures for treating patients with COPDMore on MgmtMost patients have at least moderate airflow limitation when first evaluated, they are likely to require regularly scheduled bronchodilation and to derive benefit from a long-acting bronchodilator as initial therapyTreatment ma

23、y be initiated with either a long-acting anticholinergic agent or a b-agonist, since there is little evidence to suggest clinically significant differences between pharmacologic classesNot appropriate for acute exacerbationsMgmt ContdThe combination of albuterol and ipratropium provides greater bron

24、chodilation than either drug used alone, and similar benefits are obtained by combining long-acting b-agonists with ipratropiumMore on MgmtThe appropriate role of inhaled corticosteroids in COPD is controversialTrials have demonstrated that treatment with inhaled corticosteroids alleviates patients

25、symptoms, reduces the frequency of exacerbations, and improves health statusPatient oriented evidenceExacerbations appear to accelerate the rate of lung function decline in COPDOptimize bronchodilator therapy prior to initiation of corticosteroidsSupplemental TherapiesPulmonary rehabilitation improv

26、es patients exercise capacity, reduces dyspnea, improve the quality of life, and reduces the number and duration of hospitalizations related to respiratory diseaseHypoxemia develops as a result of a worsening ventilationperfusion mismatch, and aggressive testing for hypoxemia is criticalStudies illu

27、strate mortality is reduced by treatment with supplemental oxygen for 15 or more hours per dayTherapy contdMedicare guidelines suggest that oxygen therapy should be initiated if the resting partial pressure of arterial oxygen is 55 mm Hg or lower or if the oxygen saturation is 88 percent or lessThes

28、e limitations may not identify all patients who would benefit from supplemental oxygen. For example, supplemental oxygen substantially improves training intensity and exercise tolerance even in patients in whom desaturation does not occur during exerciseAs always treat the patient and not the number

29、sWorsening hypoxemia during air travel must be considered, and a general recommendation is that patients requiring oxygen should increase their oxygen flow rate by 2 liters per minute during flightIf nothing else is workingLung-volumereduction surgery can reduce hyperinflation and should be considered in patients with severe upper-lobe emphysema and reduced exercise tolerance who ar