【COPD英文課件】慢阻肺急性發(fā)作Acute Exacerbation of Chronic Obstructive Pulmonary Disease

1、Acute Exacerbation of Chronic Obstructive Pulmonary Disease.Prof. Ashraf M. Hatem, MD, FCCP1Definition of Acute exacerbation:The definition of COPD exacerbation is an acute change in a patients baseline dyspnoea, cough and/or sputum beyond day-to-day variability sufficient to warrant a change in the

2、rapy.Causes of exacerbation can be both infectious and non-infectious e.g. air pollution.2Most commonly encountered organisms:-Streptococcus pneumoniae-Hemophilus influenzae-Moraxella catarrhalisThe cause in one third of exacerbations remains unidentified34Classification of Severity of Acute Exacerb

3、ation of COPDThe Operational Classification of Severity is as follows: Level I: ambulatory (outpatient), Level II: requiring hospitalisation, andLevel III: acute respiratory failure.5The Operational Classification of Severity of COPD exacerbationLevel ILevel IILevel IIIClinical historyCo-morbid cond

4、itionsHistory 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 saturationAr

5、terial blood gasesChest radiographBlood testsSerum drug concentrationsSputum gram stain and cultureElectrocardiogramYesNoNoNoIf applicableNoNoYesYesYesYesIf applicableYes YesYesYesYesYesIf applicableYesYes6Indications for hospitalisation of patients with a COPD exacerbationPresence of high-risk co-m

6、orbid conditions, including pneumonia, cardiac arrhythmia, congestive heart failure, diabetes mellitus, renal or liver failureInadequate response of symptoms to outpatient managementMarked increase in dyspnoeaInability to eat or sleep due to symptomsWorsening hypoxaemiaWorsening hypercapniaChanges i

7、n mental statusInability of the patient to care for her/himselfUncertain diagnosisInadequate home care7Level I: outpatient treatmentPatient educationCheck inhalation techniqueConsider use of spacer devicesBronchodilatorsShort-acting 2-agonist and/or ipratropium MDI with spacer or hand-held nebulizer

8、 as neededConsider adding long-acting bronchodilator if patient is not already using it. Corticosteroids (the actual dose may vary)Prednisone 3040 mg per os q day for 10 daysConsider using an inhaled corticosteroid Antibiotics May be initiated in patients with altered sputum characteristics Choice s

9、hould be based on local bacteria resistance patterns - Amoxicillin/ampicillin, cephalosporins - Doxycycline - MacrolidesIf the patient has failed prior antibiotic therapy consider: - Amoxicillin/clavulanate - Respiratory fluoroquinolones8Level II: treatment for hospitalised patientBronchodilators-Sh

10、ort acting 2-agonist (albuterol, salbutamol) and/or -Ipratropium MDI with spacer or hand-held nebuliser as neededSupplemental oxygen (if saturation 90%.Main delivery devices include nasal cannula and venturi mask.Alternative delivery devices include nonrebreather mask, reservoir cannula, nasal cannu

11、la or transtracheal catheter.11Arterial blood gases should be monitored for arterial oxygen tension (Pa,O2), arterial carbon dioxide tension (Pa,CO2) and pH.Arterial oxygen saturation as measured by pulse oximetry (Sp,O2) should be monitored for trending and adjusting oxygen settings.12Prevention of

12、 tissue hypoxia supersedes CO2 retention concerns.If CO2 retention occurs, monitor for acidosis.If acidaemia occurs, consider mechanical ventilation. 1314MEASURES TO MOBILIZE AIRWAY SECRETIONSIN HOSPITALIZED PATIENTS WITH COPDDirected coughing, “huff coughing.” Benefit extrapolated from experience i

13、n cystic fibrosisChest physiotherapy: manual or mechanical chest percussion and postural drainage. Benefit extrapolated from experience in cystic fibrosis. Can cause transient fall in FEVI. Assumed role limited to patients with 25 ml sputum per day or lobar atelectasis from mucus pluggingIntermitten

14、t positive pressure breathing (IPPB). Not indicated; no proven benefit In COPDPositive expiratory pressure (PEP). Benefit extrapolated from experience in cystic fibrosis. No reported experience in acute exacerbations of COPD.15Bland aerosol therapy. No demonstrated benefit in COPD unless artificial

15、airway is in place. May cause bronchospasm in nonintubated patients.Systemic hydration. No demonstrated benefit beyond repletion of intravascular volume to euvolemia.Nasotracheal suctioning. Limited benefit; tolerated only for short periods Mini-tracheotomy. Possible temporary benefit in patients wi

16、th persistent airway secretions causing respiratory deterioration.16Indications for ICU AdmissionSevere dyspnea that responds inadequately to initial emergency therapy.Confusion, lethargy, coma.Persistent or worsening hypoxemia (PaO2 8.0 kPa, 60 mm Hg), and/or severe/worsening respiratory acidosis (

17、pH 7.25) despite supplementaloxygen and NIPPV.17Assisted ventilationNoninvasive positive pressure ventilation (NPPV) should be offered to patients with exacerbations when, after optimal medical therapy and oxygenation, respiratory acidosis (pH 7.36) and or excessive breathlessness persist. All patie

18、nts considered for mechanical ventilation should have arterial blood gases measured.18If pH 7.30, NPPV should be delivered under controlled environments such as intermediate intensive care units (ICUs) and/or high-dependency units.If pH 7.30, NPPV should be delivered under controlled environments su

19、ch as intermediate intensive care units (ICUs) and/or high-dependency units.19If pH 35 breaths per minute.Life-threatening hypoxemia (PaO2 5.3 kPa, 40 mm Hg or PaO2/FiO2 200 mm Hg).Severe acidosis (pH 8.0 kPa, 60 mm Hg).24Respiratory arrest.Somnolence, impaired mental status.Cardiovascular complicat

20、ions (hypotension, shock, heart failure).Other complications (metabolic abnormalities, sepsis, pneumonia, pulmonary embolism, barotrauma, massive pleural effusion).NIPPV failure (or contraindication to NIPPV).25Mechanical VentilationAssisted ventilation should be considered for patients with acute e

21、xacerbations of COPD when pharmacologic and other nonventilatory treatments fail to reverse clinically significant respiratory failure. The clinician must aim to avoid complications associated with mechanical ventilation and should initiate weaning and discontinuation of mechanical ventilation as so

22、on as possible.26The main goals of assisted positive pressure ventilation in acute respiratory failure complicating COPD are:- Resting of ventilatory muscles, and - Restoration of gas exchange to a stable baseline. Allow for permissive hypercapnea (except in cerebral edema, myocardial ischemia, LVF.

23、)27There are three specific pitfalls in ventilating patients with COPD: i- Overventilation, resulting in acute respiratory alkalemia, ii- Initiation of complex pulmonary and cardiovascular interactions that may result in systemic ypotension. iii- Creation of intrinsic positive end-expiratory pressur

24、e (PEEP), or “auto-PEEP,” especially if expiratory time is inadequate or if dynamic airflow obstruction exists28The three ventilatory modes most widely used for managing patients with COPD are:- Assist-control ventilation (ACV), - Intermittent mandatory ventilation (IMV), and - Pressure support vent

25、ilation (PSV). PSV provides increased patient comfort, promotes patient synchrony with the ventilator, and facilitate weaning from mechanical ventilation in the patient who maintains adequate ventilatory drive.29GOLD Guidelines: Treatment of COPD Avoidance of risk factor(s); influenza vaccination Ad

26、d short-acting bronchodilator when needed Add regular treatment with one or more long-acting bronchodilators Add rehabilitation Add long-term oxygen if chronic respiratory failureConsider surgical treatments Add inhaled glucocorticids if repeated exacerbations Stage0: At RiskI: MildII: ModerateIII:

27、SevereIV: Very Severe30Discharge Criteria for Patients With Exacerbations of COPDInhaled 2-agonist therapy is required no more frequently than every 4 hrs. Patient, if previously ambulatory, is able to walk across room.Patient is able to eat and sleep without frequent awakening by dyspnea.Patient ha

28、s been clinically stable for 12-24 hrs.31Arterial blood gases have been stable for 12-24 hrs.Patient (or home caregiver) fully understands correct use of medications.Follow-up and home care arrangements have been completed (e.g., visiting nurse, oxygen delivery, meal provisions).Patient, family, and

29、 physician are confident patient can manage successfully.32Strategies to Help the PatientWilling to Quit Smoking (5 As)ASK: Systematically identify all tobacco users at every visit. Implement an office-wide system that ensures that, for EVERY patient at EVERY clinic visit, tobacco-use status is quer

30、ied and documented.ADVISE: Strongly urge all tobacco users to quit. In a clear, strong, and personalized manner, urge every tobacco user to quit.ASSESS: Determine willingness to make a quit attempt. Ask every tobacco user if he or she is willing to make a quit attempt at this time (e.g., within the next 30 days).ASSIST: Aid the patient in quitting. Help the patient with a quit plan; provide practical counseling; provide intra-treatment social support; help the patient obtain extra-treatm