【COPD英文課件】慢阻肺急性發(fā)作Acute-Exacerbation-of-Chronic-O

AcuteExacerbationofChronicObstructivePulmonaryDisease.Prof.AshrafM.Hatem,MD,FCCP1AcuteExacerbationofChronic1DefinitionofAcuteexacerbation:ThedefinitionofCOPDexacerbationisanacutechangeinapatient’sbaselinedyspnoea,coughand/orsputumbeyondday-to-dayvariabilitysufficienttowarrantachangeintherapy.Causesofexacerbationcanbebothinfectiousandnon-infectiouse.g.airpollution.2DefinitionofAcuteexacerbati2Mostcommonlyencounteredorganisms: -Streptococcuspneumoniae -Hemophilusinfluenzae -MoraxellacatarrhalisThecauseinonethirdofexacerbationsremainsunidentified3Mostcommonlyencounteredorga3444ClassificationofSeverityofAcuteExacerbationofCOPDTheOperationalClassificationofSeverityisasfollows:LevelI:ambulatory(outpatient),LevelII:requiringhospitalisation,andLevelIII:acuterespiratoryfailure.5ClassificationofSeverityof5TheOperationalClassificationofSeverityofCOPDexacerbationLevelILevelIILevelIIIClinicalhistoryCo-morbidconditionsHistoryoffrequentexacerbationsSeverityofCOPD++Mild/moderate++++++Moderate/severe++++++SeverePhysicalfindingsHaemodynamicevaluationUseaccessoryrespiratorymuscles,tachypnoeaPersistentsymptomsafterinitialtherapyStableNotpresentNoStable++++Stable/unstable++++++DiagnosticproceduresOxygensaturationArterialbloodgasesChestradiographBloodtestsSerumdrugconcentrationsSputumgramstainandcultureElectrocardiogramYesNoNoNoIfapplicableNoNoYesYesYesYesIfapplicableYesYesYesYesYesYesIfapplicableYesYes6TheOperationalClassification6IndicationsforhospitalisationofpatientswithaCOPDexacerbationPresenceofhigh-riskco-morbidconditions,includingpneumonia,cardiacarrhythmia,congestiveheartfailure,diabetesmellitus,renalorliverfailureInadequateresponseofsymptomstooutpatientmanagementMarkedincreaseindyspnoeaInabilitytoeatorsleepduetosymptomsWorseninghypoxaemiaWorseninghypercapniaChangesinmentalstatusInabilityofthepatienttocareforher/himselfUncertaindiagnosisInadequatehomecare7Indicationsforhospitalisatio7LevelI:outpatienttreatmentPatienteducationCheckinhalationtechniqueConsideruseofspacerdevicesBronchodilatorsShort-actingβ2-agonistand/oripratropiumMDIwithspacerorhand-heldnebulizerasneededConsideraddinglong-actingbronchodilatorifpatientisnotalreadyusingit.Corticosteroids(theactualdosemayvary)Prednisone30–40mgperosqdayfor10daysConsiderusinganinhaledcorticosteroidAntibiotics

MaybeinitiatedinpatientswithalteredsputumcharacteristicsChoiceshouldbebasedonlocalbacteriaresistancepatterns-Amoxicillin/ampicillin,cephalosporins-Doxycycline-MacrolidesIfthepatienthasfailedpriorantibiotictherapyconsider:-Amoxicillin/clavulanate-Respiratoryfluoroquinolones8LevelI:outpatienttreatmentP8LevelII:treatmentforhospitalisedpatientBronchodilators-Shortactingβ2-agonist(albuterol,salbutamol)and/or-IpratropiumMDIwithspacerorhand-heldnebuliserasneededSupplementaloxygen(ifsaturation<90%)Lowflowoxygensupplementationtoavoidsupressionofhypoxicdrive.Corticosteroids-Ifpatienttolerates,prednisone30–40mgperosqdayfor10days-Ifpatientcannottolerateoralintake,equivalentdosei.v.forupto14days-ConsideruseinhaledcorticosteroidsbyMDIorhand-heldnebulizerAntibiotics(basedonlocalbacterialresistancepatterns)-Maybeinitiatedinpatientswhohaveachangeintheirsputumcharacteristics(purulenceand/orvolume)-Choiceshouldbebasedonlocalbacterialresistancepatterns-Amoxicillin/clavulanate-Respiratoryfluoroquinolones(moxifloxacin,levofloxacin,gatifloxacin)-IfPseudomonasspp.and/orotherEnterobactereacesspp.aresuspected,considercombinationtherapy9LevelII:treatmentforhospit9LevelIII:treatmentinpatientsrequiringspecialorintensivecareunitSupplementaloxygenVentilatorysupport

Bronchodilators

-Short-actingβ2-agonist(albuterol,salbutamol)andipratropiumMDIwithspacer,twopuffsevery2–4h,orTiotropiumbromideDPIoncedaily.-Ifthepatientisontheventilator,considerMDIadministration,considerlong-actingβ-agonistCorticosteroids-Ifpatienttoleratesoralmedications,prednisone30–40mgperosqdayfor10days.-Ifpatientcannottolerate,givetheequivalentdosei.v.forupto14days.-ConsideruseinhaledcorticosteroidsbyMDIorhand-heldnebulizer.Antibiotics(basedonlocalbacterialresistancepatterns)-Choiceshouldbebasedonlocalbacterialresistancepatterns-Amoxicillin/clavulanate-Respiratoryfluoroquinolones(gatifloxacin,levofloxacin,moxifloxacin)-IfPseudomonasspp.andorotherEnterobactereacesspp.aresuspected,considercombinationtherapy

10LevelIII:treatmentinpatien10In-patientOxygenTherapyThegoalistopreventtissuehypoxiabymaintainingarterialoxygensaturation(Sa,O2)at>90%.Maindeliverydevicesincludenasalcannulaandventurimask.Alternativedeliverydevicesincludenonrebreathermask,reservoircannula,nasalcannulaortranstrachealcatheter.11In-patientOxygenTherapyTheg11Arterialbloodgasesshouldbemonitoredforarterialoxygentension(Pa,O2),arterialcarbondioxidetension(Pa,CO2)andpH.Arterialoxygensaturationasmeasuredbypulseoximetry(Sp,O2)shouldbemonitoredfortrendingandadjustingoxygensettings.12Arterialbloodgasesshouldbe12PreventionoftissuehypoxiasupersedesCO2retentionconcerns.IfCO2retentionoccurs,monitorforacidosis.Ifacidaemiaoccurs,considermechanicalventilation.

13Preventionoftissuehypoxias13141414MEASURESTOMOBILIZEAIRWAYSECRETIONS

INHOSPITALIZEDPATIENTSWITHCOPDDirectedcoughing,“huffcoughing.”BenefitextrapolatedfromexperienceincysticfibrosisChestphysiotherapy:manualormechanicalchestpercussionandposturaldrainage.Benefitextrapolatedfromexperienceincysticfibrosis.CancausetransientfallinFEVI.Assumedrolelimitedtopatientswith>25mlsputumperdayorlobaratelectasisfrommucuspluggingIntermittentpositivepressurebreathing(IPPB).Notindicated;noprovenbenefitInCOPDPositiveexpiratorypressure(PEP).Benefitextrapolatedfromexperienceincysticfibrosis.NoreportedexperienceinacuteexacerbationsofCOPD.15MEASURESTOMOBILIZEAIRWAYSE15Blandaerosoltherapy.NodemonstratedbenefitinCOPDunlessartificialairwayisinplace.Maycausebronchospasminnonintubatedpatients.Systemichydration.Nodemonstratedbenefitbeyondrepletionofintravascularvolumetoeuvolemia.Nasotrachealsuctioning.Limitedbenefit;toleratedonlyforshortperiodsMini-tracheotomy.Possibletemporarybenefitinpatientswithpersistentairwaysecretionscausingrespiratorydeterioration.16Blandaerosoltherapy.Nodemo16IndicationsforICUAdmissionSeveredyspneathatrespondsinadequatelytoinitialemergencytherapy.Confusion,lethargy,coma.Persistentorworseninghypoxemia(PaO2<5.3kPa,40mmHg),and/orsevere/worseninghypercapnia(PaCO2>8.0kPa,60mmHg),and/orsevere/worseningrespiratoryacidosis(pH<7.25)despitesupplementaloxygenandNIPPV.17IndicationsforICUAdmissionS17AssistedventilationNoninvasivepositivepressureventilation(NPPV)shouldbeofferedtopatientswithexacerbationswhen,afteroptimalmedicaltherapyandoxygenation,respiratoryacidosis(pH<7.36)andorexcessivebreathlessnesspersist.Allpatientsconsideredformechanicalventilationshouldhavearterialbloodgasesmeasured.18AssistedventilationNoninvasiv18IfpH<7.30,NPPVshouldbedeliveredundercontrolledenvironmentssuchasintermediateintensivecareunits(ICUs)and/orhigh-dependencyunits.IfpH<7.30,NPPVshouldbedeliveredundercontrolledenvironmentssuchasintermediateintensivecareunits(ICUs)and/orhigh-dependencyunits.19IfpH<7.30,NPPVshouldbede19IfpH<7.25,NPPVshouldbeadministeredintheICUandintubationshouldbereadilyavailable.Thecombinationofsomecontinuouspositiveairwaypressure(CPAP)(e.g.4–8cmH2O)andpressuresupportventilation(PSV)(e.g.10–15cmH2O)providesthemosteffectivemodeofNPPV.PatientsmeetingexclusioncriteriashouldbeconsideredforimmediateintubationandICUadmission.20IfpH<7.25,NPPVshouldbead20Exclusioncriteriainclude:respiratoryarrest,cardiovascularinstability,impairedmentalstatus,somnolence,inabilitytocooperate,copiousand/orviscoussecretionswithhighaspirationrisk,recentfacialorgastro-oesophagealsurgery;craniofacialtraumaand/orfixednaso-pharyngealabnormality,burns,extremeobesity.Inthefirsthours,NPPVrequiresthesamelevelofassistanceasconventionalmechanicalventilation.21Exclusioncriteriainclude:2121Non-rebreatherOxygenMask22Non-rebreatherOxygenMask2222232323IndicationsforMechanicalVentilationSeveredyspneawithuseofaccessorymusclesanparadoxicalabdominalmotion.Respiratoryfrequency>35breathsperminute.Life-threateninghypoxemia(PaO2<5.3kPa,40mmHgorPaO2/FiO2<200mmHg).Severeacidosis(pH<7.25)andhypercapnia(PaCO2>8.0kPa,60mmHg).24IndicationsforMechanicalVen24Respiratoryarrest.Somnolence,impairedmentalstatus.Cardiovascularcomplications(hypotension,shock,heartfailure).Othercomplications(metabolicabnormalities,sepsis,pneumonia,pulmonaryembolism,barotrauma,massivepleuraleffusion).NIPPVfailure(orcontraindicationtoNIPPV).25Respiratoryarrest.2525MechanicalVentilationAssistedventilationshouldbeconsideredforpatientswithacuteexacerbationsofCOPDwhenpharmacologicandothernonventilatorytreatmentsfailtoreverseclinicallysignificantrespiratoryfailure.Theclinicianmustaimtoavoidcomplicationsassociatedwithmechanicalventilationandshouldinitiateweaninganddiscontinuationofmechanicalventilationassoonaspossible.26MechanicalVentilationAssisted26ThemaingoalsofassistedpositivepressureventilationinacuterespiratoryfailurecomplicatingCOPDare: -Restingofventilatorymuscles,and -Restorationofgasexchangetoastablebaseline.Allowforpermissivehypercapnea(exceptincerebraledema,myocardialischemia,LVF….)27Themaingoalsofassistedpos27TherearethreespecificpitfallsinventilatingpatientswithCOPD: i-Overventilation,resultinginacuterespiratory alkalemia, ii-Initiationofcomplexpulmonaryand cardiovascularinteractionsthatmayresultin systemicypotension. iii-Creationofintrinsicpositiveend-expiratory pressure(PEEP),or“auto-PEEP,”especiallyif expiratorytimeisinadequateorifdynamic airflowobstructionexists28Therearethreespecificpitfa28ThethreeventilatorymodesmostwidelyusedformanagingpatientswithCOPDare: -Assist-controlventilation(ACV), -Intermittentmandatoryventilation(IMV),and -Pressuresupportventilation(PSV).PSVprovidesincreasedpatientcomfort,promotespatientsynchronywiththeventilator,andfacilitateweaningfrommechanicalventilationinthepatientwhomaintainsadequateventilatorydrive.29Thethreeventilatorymodesmo29GOLDGuidelines:TreatmentofCOPDAvoidanceofriskfactor(s);influenzavaccinationAddshort-actingbronchodilatorwhenneeded

Add

regulartreatmentwithoneormorelong-actingbronchodilatorsAddrehabilitation

Addlong-termoxygenifchronicrespiratoryfailureConsidersurgicaltreatments

Addinhaledglucocorticidsifrepeatedexacerbations

Stage0:AtRiskI:MildII:ModerateIII:SevereIV:VerySevere30GOLDGuidelines:30DischargeCriteriaforPatientsWithExacerbationsofCOPDInhaled?2-agonisttherapyisrequirednomorefrequentlythanevery4hrs.Patient,ifpreviouslyambulatory,isabletowalkacrossroom.Patientisabletoeatandsleepwithoutfrequentawakeningbydyspnea.Patienthasbeenclinicallystablefor12-24hrs.31DischargeCriteriaforPatient31Arterialbloodgaseshavebeenstablefor12-24hrs.Patient(orhomecaregiver)fullyunderstandscorrectuseofmedications.Follow-upandhomecarearrangementshavebeencompleted(e.g.,visitingnurse,oxygendelivery,mealprovisions).Patient,family,andphysicianareconfidentpatientcanmanagesuccessfully.32Arterialbloodgaseshavebeen32StrategiestoHelpthePatient

WillingtoQuitSmoking(5As)ASK:Systematicallyidentifyalltobaccousersateveryvisit.Implementanoffice-widesystemthatensuresthat,forEVERYpatientatEVERYclinicvisit,tobacco-usestatusisqueriedanddocumented.ADVISE:Stronglyurgealltobaccouserstoquit.Inaclear,strong,andpersonalizedmanner,urgeeverytobaccousertoquit.ASSESS:Determinewillingnesstomakeaquitattempt.Askeverytobaccouserifheorsheiswillingtomakeaquitattemptatthistime(e.g.,withinthenext30days).ASSIST:Aid