5 курс / Пульмонология и фтизиатрия / Clinical_Manifestations_and_Assessment_of_Respiratory

FIGURE 13.10 Chest x-ray film from a patient with chronic bronchitis. Note the translucent (dark) lung fields at the bases, depressed diaphragms, and long and narrow heart.

FIGURE 13.11 Chronic bronchitis. Bronchogram with localized view of left hilum. Rounded collections of contrast lie adjacent to bronchial walls and are particularly well demonstrated below the left mainstem bronchus (arrow) in this film. They are caused by contrast in dilated mucous gland ducts. (From Hansel, D. M., Armstrong, P., Lynch, D. A., et al. [2005]. Imaging of the diseases of the chest [4th

ed.]. St. Louis, MO: Elsevier.)

FIGURE 13.12 Chest x-ray film of a patient with emphysema. The heart often appears long and narrow as a result of being drawn downward by the descending diaphragm.

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FIGURE 13.15 Giant emphysematous bulla. Air-containing mass fills most of the left hemithorax. (From Eisenberg, R. L., & Johnson, N. M. [2016]. Comprehensive radiographic pathology [6th ed.]. St. Louis, MO: Elsevier.)

FIGURE 13.16 Emphysematous blebs. Computed tomography image shows the destruction of lung parenchyma. (From Eisenberg, R. L., & Johnson, N. M. [2016]. Comprehensive radiographic pathology [6th ed.]. St. Louis, MO: Elsevier.)

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FIGURE 13.17 A before (A) and after (B) chest radiograph of a 56-year-old woman who had severe COPD and qualified for a lung transplantation. Note the domed diaphragmatic leafs, indicating reduced pulmonary hyperexpansion, after the lung transplantation (red arrows). Also note the reduced pulmonary artery enlargement in the left chest after transplantation. (Courtesy

Terry Des Jardins.)

Additional Features of Severe Chronic Obstructive Pulmonary Disease

•Fatigue

•Weight loss and anorexia

•Syncope during coughing episodes caused by the rapid increases in intrathoracic pressure changes during prolonged coughing spells.

•Coughing may cause rib fractures

•Ankle swelling may be the only indicator of cor pulmonale

•Symptoms of depression and/or anxiety, which are associated with an increased risk for exacerbations

General Management of Chronic Obstructive Pulmonary Disease

GOLD provides an outstanding COPD management program that can be easily adapted to local health care systems and resources. An overview of GOLD's management programs for stable COPD and acute COPD exacerbation are presented below.5

Overview of GOLD's Management of Stable Chronic Obstructive Pulmonary

Disease

After the patient has been diagnosed with COPD and fully assessed (see Combined COPD Assessment Tool, Fig. 13.9), an effective treatment plan should be directed at reducing the current symptoms and preventing future risks for

exacerbations (see Fig. 13.6).

GOLD's general management of the COPD patient is to (1) identify and reduce exposure to risk factors, (2) establish a pharmacologic treatment algorithm, and (3) implement various nonpharmacologic treatments, such as education and selfmanagement, physical activity, pulmonary rehabilitation programs, exercise training, self-management education, nutritional support, vaccinations, long-term oxygen therapy needs, ventilatory support, and, when needed, end-of-life and palliative care. Finally, monitoring and follow-up appointments for COPD outpatient care need to be established.

Reduce Exposure to Risk Factors

The identification and reduction of the patient's exposure to risk factors are very important. For example, cigarette smoking is the most commonly encountered risk factor for COPD. When possible, smokers should be provided with counseling and smoking cessation programs that incorporate behavior change techniques, patient education, and pharmacologic and nonpharmacologic interventions. In addition, efforts to have patients reduce their total exposure to occupational dusts, fumes, gases, and to indoor and outdoor air pollutants should be addressed.

Pharmacologic Treatment Algorithm

Pharmacologic therapies are used to (1) reduce the patient's symptoms and readmissions6, (2) decrease the risk and severity of exacerbations, and (3) improve the patient's overall health status and exercise tolerance. Table 13.5 provides medications commonly used in the treatment of COPD. According to GOLD, some key points regarding the medications used to treat COPD are shown in Box 13.2.

TABLE 13.5

Medications Commonly Used in the Treatment of Chronic Obstructive Pulmonary Disease (COPD)*

*For the complete listing, doses, and administration of agents approved by the FDA, visit the Drugs@FDA website (http://www.accessdata.fda.gov/scripts/cder/drugsatfda/).

Box 13.2

Key Points Regarding the Medications Used to Treat Chronic Obstructive Pulmonary Disease

Bronchodilators

•Long-acting beta2 agents (LABAs) and long-acting antimuscarinic antagonists (LAMAs) are preferred over shortacting agents—except for the patient with only occasional dyspnea.

•The COPD patient may be started on a single LABA or dual LABAs. For example, in patients with persistent dyspnea, and only on one LABA, the therapy should be up-regulated to two LABAs.

•Inhaled bronchodilators are recommended over oral bronchodilators.

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FIGURE 13.18 Pharmacologic treatment algorithms based on Group A, B, C, or D classifications derived from the Combined COPD Assessment Tool (see Fig. 13.9). ICI, Inhaled corticosteroids; LABA, long-acting beta2-agonist; LAMA,

long-acting antimuscarinic antagonist.

• Group B (Low Risk, More Symptoms): The initial therapy for patients in this group consists of a long-acting antimuscarinic antagonist (LAMA) bronchodilator or a long-acting beta2-agonist

(LABA) bronchodilator. There is no evidence to support one class of long-acting bronchodilators over another for relief of symptoms. The selection is often based on the patient's perception of symptom relief. However, in the patient with persistent dyspnea while receiving only one long-acting bronchodilator, it is recommended that the therapy be upregulated to medications contained in a second long-acting bronchodilator classification (LAMA + LABA). For the patient with severe dyspnea, the initial therapy with two long-acting bronchodilators may be considered. If the addition of a second bronchodilator does not improve the patient's symptoms, it is recommended that the therapy be returned to only one bronchodilator. The possibilities of associated comorbidities that affect the patient's conditions should be considered (see Fig. 13.18).

• Group C (High Risk, Fewer Symptoms): The patient in this group should be given a single LAMA. LAMAs have been shown to be superior to LABAs and are recommended by GOLD for this group. In patients with persistent exacerbations, a second long-acting bronchodilator (LAMA + LABA), or the combination of a long-acting beta2-agnonist and an inhaled

corticosteroid (LABA + inhaled corticosteroid [ICS]) may be considered. Because the administration of ICS agents increases the risk for developing pneumonia in some patients, GOLD's primary recommendation is LABA + LAMA (see Fig. 13.18).

• Group D (High Risk, More Symptoms): The patients in this group should be started with a LABA + LAMA combination. Studies have shown superior results when using a LABA + LAMA combination compared with a single medication. Conversely, if a single bronchodilator is preferred to treat an exacerbation episode, a LAMA is recommended. Although a LABA + LAMA combination has been shown to be superior to a LABA + ICS combination, in the patient with a history and/or findings that suggest an asthma and COPD overlap,7 an initial therapy with LABA + ICS may be the first choice. In addition, a high blood eosinophil count may further support the use of ICS in these patients. However, it should be noted that patients in Group D are at a higher risk for developing pneumonia when receiving ICS treatments.

In the patient who develops further exacerbations on LABA + LAMA, the advancement to a LABA + LAMA + ICS combination should be considered. Finally, if the patient being treated with a LABA + LAMA + ICS combination continues to have exacerbations, the following options may be considered:

• Add roflumilast if the FEV1 is less than 50% predicted and the patient has chronic bronchitis,

especially if the patient has a history of one or more hospitalizations for exacerbation in the past year.

• Add a macrolide antibiotic. GOLD states that the best available evidence exists for the use of azithromycin (see Fig. 13.18).

Nonpharmacologic Treatments

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The key points associated with nonpharmacologic treatments for the patient with stable COPD are shown in Box 13.3.

Box 13.3

Key Points Associated With Nonpharmacologic Treatment of Chronic Obstructive Pulmonary Disease

Education, Self-Management, Pulmonary Rehabilitation, and Physical Activity

•Education is required to enhance the patient's understanding of the disease.

•Education to appropriately self-manage routine care is recommended to reduce risk for exacerbations.

•Pulmonary rehabilitation is recommended for all patients with symptoms and/or are high risk for exacerbations.

•Physical activity is a strong predictor of mortality. Patients should be encouraged to increase the level of physical activity.

Vaccination

•Influenza vaccination is recommended for all patients with COPD.

•Pneumococcal vaccination: The PCV13 and PPSV23 are recommended for all patients older than 65 years and in younger patients with significant comorbid conditions (e.g., chronic heart or lung disease).

Nutritional Support

•Nutritional supplementation should be considered in malnourished patients with COPD. Malnourished COPD patients receiving nutritional supplementation have shown significant improvements on their 6-minute walk test, respiratory strength, and overall health status.

Interventional Bronchoscopy and Surgery

•In certain patients with emphysema and significant hyperinflation, lung volume reduction surgery or bronchoscopic modes of lung volume reduction (e.g., endobronchial one-way valves or lung coils) may be considered.

•Surgical bullectomy may be considered in patients with large bulla.

•Lung transplantation may be considered in selected patients with very severe COPD who do not have any contradictions.

Comorbidities

•Any symptoms that indicate the worsening and/or development of another comorbid condition, such as obstructive sleep apnea, congestive heart failure, and ischemic heart disease, should be documented and a plan established to manage the problem as indicated.

Monitoring and Follow-Up

•Routine monitoring of COPD patients is essential, including:

•FEV1

•Functional capacity as measured by a timed walking test (6-minute walking test)

•SaO2 or arterial blood gases

•Check patient symptoms, including cough, sputum, breathlessness, fatigue, activity limitation, and sleep disturbances

•Exacerbations, including frequency, severity, type, and likely causes of all exacerbations

•Sputum volume and presence or absence of sputum purulence should be noted.

•Imaging—If there is a clear worsening of symptoms, imaging may be considered

•Smoking status—At each visit, the patients’ smoking habits and smoke exposure should be established, followed by appropriate action.

End-of-Life and Palliative Care

•The goal of palliative care is to relive pain and suffering of patients and their families via the comprehensive assessment and treatment of physical, psychosocial, and symptoms presented by the patient.

Management of Acute Chronic Obstructive Pulmonary Disease Exacerbations

A COPD exacerbation is defined by GOLD as an acute worsening of the patient's normal baseline respiratory status. An acute exacerbation is associated with increased airway inflammation, increased mucous production, and significant alveolar hyperinflation. These anatomic changes of the lung contribute to the patient's key symptom of an acute exacerbation—increased dyspnea.

Other signs of an acute exacerbation include increased sputum volume and purulence, an increased cough, wheezing, an increased peripheral blood or sputum eosinophil count, and a decline in arterial oxygenation. Because comorbidities are common with COPD patients, exacerbations must be differentiated clinically from other events such as congestive heart failure, pneumonia, or pulmonary embolism. According to GOLD, COPD exacerbations are classified as follows:

• Mild Exacerbation: Requires the initial use of inhaled short-acting beta2-agonoist (SABAs) with or without a short-acting antimuscarinic bronchodilator.

•Moderate Exacerbation: Entails the use of SABAs, plus an antibiotic and/or oral corticosteroids.

•Severe Exacerbation: Requires an emergency department visit, hospitalization, or intensive care unit (ICU) admission. A severe exacerbation is associated with acute ventilatory failure.

Acute exacerbations are primarily triggered by respiratory viral infections, although bacterial infections and a variety of

environmental factors such as indoor and outdoor pollution and adverse ambient temperatures may cause these events.

The symptoms associated with an exacerbation usually last 7 to 10 days. Patients who have had an exacerbation are usually more susceptible to another event. Some patients are especially prone to frequent exacerbations—defined as two or more exacerbations per year. The strongest predictor of a patient's future exacerbation history is the number of exacerbations they have had in the past year.

Treatment Options for Acute Exacerbations

According to GOLD, the primary goals of treatment for COPD are to minimize the negative effect of the current exacerbation and prevent the occurrence of future events. Relative to the severity of an exacerbation, the individual's care management may occur in either an outpatient or inpatient setting. At the present time, more than 80% of exacerbations are managed on an outpatient basis with bronchodilators, corticosteroids, and antibiotics.

Box 13.4 provides an overview of the indications of severe exacerbations that require hospitalization. An overview of GOLD's recommended algorithm to manage the patient hospitalized with severe exacerbation is provided in Box 13.5.

Box 13.4

Indication for Hospitalization Caused by Acute Exacerbation

•Dyspnea at rest

•High respiratory rate

•Drowsiness

•Confusion

•Impending ventilatory failure—for example:

•Acute alveolar hyperventilation superimposed on chronic ventilatory failure

•Typical arterial blood gas values: pH 7.52, PaCO2 51, HCO3– 40, PaO2 46 (see Table 5.7)

•Acute ventilatory failure superimposed on chronic ventilatory failure

•Typical arterial blood gas values: pH 7.28, PaCO2 99, HCO3– 45, PaO2 34 (see Table 5.8)

•Decreased arterial oxygen saturation and/or not responding to oxygen therapy

•Cyanosis or peripheral edema

•Failure of exacerbation to respond to initial bronchodilator management

•Presence of comorbidities (e.g., congestive heart failure, arrhythmia, etc.)

•Insufficient home support

Box 13.5

Overview of GOLD's Management Algorithm for Severe Exacerbations

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Respiratory Care Treatment Protocols

Oxygen Therapy Protocol

Initially, supplemental oxygen should be administered with a target SaO2 of 88% to 92%. Venturi masks (high-flow devices) offer more precise control of FIO2 than nasal cannulas.

•According to GOLD, long-term oxygen therapy is indicated in the patient with stable disease who has a:

•PaO2 at or below 55 mm Hg or an SaO2 less than 88%, with or without hypercapnia confirmed two or more times over a 3-week period; or

•PaO2 between 55 and 60 mm Hg or an SaO2 of 88% if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit greater than 55%).

•Once placed on long-term oxygen therapy, the patient should be reevaluated between 60 and 90 days later with repeat ABG or oxygen saturation determinations, while the patient is breathing the prescribed level of oxygen to determine if oxygen is still therapeutic and indicated.

Oxygen therapy is used to treat hypoxemia, decrease the work of breathing, and decrease myocardial work (see Oxygen Therapy Protocol, Protocol 10.1).

Mechanical Ventilation Protocol

Ventilatory support for COPD exacerbations can be provided by either noninvasive ventilation (NIV) (e.g., pressure/volumelimited ventilation via a nasal or facial mask) or invasive ventilation (e.g., oral-tracheal tube or tracheostomy) (see Box