249239845 bronhopneumopatia-cronica-obstructiva

BPCO/COPD

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Global Strategy for Diagnosis, Management and Prevention of COPDStrategia Globala de Dg. Trat. si Prev. a BPCO 2009

Global Strategy for Diagnosis, Management and Prevention of COPDStrategia Globala de Dg. Trat. si Prev. a BPCO 2009

Definitie,clasificare Importanta

problemei Factori de risc Etiopatogenie ,fiziopa

tologie Tratament Consideratii practice




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Global Strategy for Diagnosis, Management and Prevention of COPD








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BPOC-este o boala ce poate fi prevenita si tratata

Este caracterizata printr-o limitare a fluxului de aer prin caile respiratorii doar partial reversibila

Are caracter progresiv si este intretinuta de procese inflamatorii provocate de noxe

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St.I -usor -FEV1/FVC <0,7 -FEV1≥80%(din val.predictibila St.II-mediu -FEV1/FVC<0,7 -50%>FEV1<80% St.III-sever -FEV1/FVC<0,7 -30%>FEV1<50% St.IV-f.sever-FEV1/FVC<0,7 -FEV1<30% sau -FEV1<50%+IRC

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Stadiul O Tuse cronica si sputa cu spirometrie

normala -termen introdus din 2oo1 -suferinta capabila de a evoulua spre

st.I -mesajul-simptomelor sa li se dea

atentie -a se inlatura factorii nocivi

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Implicatii socio-economice Prevalenta,morbiditate si mortalitate -foarte raspindita

national/continental Se estimeaza o crestere marcata in

urmatoarea decada-capabila de a schimba structura morbiditatii pe grupe de virsta a populatiei

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Spirometria-metoda simpla-este capabila de a pune diagnosticul

BPOC de st.I(usor) este subdiagnosticat

atentie- la fumatori activi/pasivi -persoane peste 40 de ani -barbati

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COPD Prevalence Study in Latin America

The prevalence of post-bronchodilator FEV1/FVC < 0.70 increases steeply with age in 5 Latin American Cities

Source: Menezes AM et al. Lancet 2005 11

BPOC –este cauza frecventa de mortalitate,se estimeaza crestere marcata

Mortalitate in crestere- fumat in crestere

Mortalitatea ambelor sexe –in crestere

In USA-2000-mortalitatea la femei > B

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13

00

0.50.5

1.01.0

1.51.5

2.02.0

2.52.5

3.03.0

Proportion of 1965 Rate Proportion of 1965 Rate

1965 - 19981965 - 1998 1965 - 19981965 - 1998 1965 - 19981965 - 1998 1965 - 19981965 - 1998 1965 - 19981965 - 1998

–59%–59% –64%–64% –35%–35% +163%+163% –7%–7%

CoronaryHeart

Disease

CoronaryHeart

Disease

StrokeStroke Other CVDOther CVD COPDCOPD All OtherCauses

All OtherCauses

Source: NHLBI/NIH/DHHSSource: NHLBI/NIH/DHHS

Of the six leading causes of death in the United States, only COPD has been increasing steadily since 1970

Source: Jemal A. et al. JAMA 2005

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Factori de risc pentru BPOC

Dezvoltarea fizica/pulmonara

Stress Oxidativ

Sex

Virsta

Infectii respiratorii

Starea Socio-economica

Alimentatia

Comorbiditati

Genetici .................................

Expuneri la particule

●Fumul de tigara

●Pulberi ocupationale, organice si anorganice

●Poluarea aerului din locuinte prin incalzit sau gatit/ ventilatie deficitara

●Poluarea aerului din exterior

Risk Factors for COPD

NutritionNutrition

InfectionsInfections

Socio-Socio-economic economic statusstatus

Aging Aging PopulationsPopulations

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Mucus gland hyperplasia

Goblet cellhyperplasia

Mucus hypersecretion Neutrophils in sputum

Squamous metaplasia of epithelium

↑ Macrophages

No basement membrane thickening

Little increase in airway smooth muscle

↑ CD8+ lymphocytes

Changes in Large Airways of COPD Patients

Changes in Large Airways of COPD Patients

Source: Peter J. Barnes, MD 20

Disrupted alveolar attachments

Inflammatory exudate in lumen

Peribronchial fibrosisLymphoid follicle

Thickened wall with inflammatory cells- macrophages, CD8+ cells, fibroblasts

Changes in Small Airways in COPD Patients

Source: Peter J. Barnes, MD

lumen is often filled ..!!

smooth muscle increased

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Alveolar wall destruction

Loss of elasticity

Destruction of pulmonarycapillary bed

↑ Inflammatory cells macrophages, CD8+ lymphocytes


Changes in Lung Parenchyma in COPD

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LUNG INFLAMMATIONLUNG INFLAMMATION

COPD PATHOLOGYCOPD PATHOLOGY

OxidativeOxidativestressstress ProteinasesProteinases

Repair Repair mechanismsmechanisms

Anti-proteinasesAnti-proteinasesAnti-oxidantsAnti-oxidants

Host factorsAmplifying mechanisms

Cigarette smokeCigarette smokeBiomass particlesBiomass particles

ParticulatesParticulates

Pathogenesis of COPD


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Cigarette smoke Cigarette smoke (and other irritants)(and other irritants)

PROTEASES PROTEASES Neutrophil elastaseNeutrophil elastaseCathepsinsCathepsinsMMPsMMPs

Alveolar wall destructionAlveolar wall destruction(Emphysema)(Emphysema)

Mucus hypersecretionMucus hypersecretion

CD8CD8+ +

lymphocytelymphocyte

Alveolar Alveolar macrophagemacrophage

EpithelialEpithelialcellscells

FibrosisFibrosis(Obstructive(Obstructivebronchiolitis)bronchiolitis)

FibroblastFibroblast

MonocyteMonocyteNeutrophilNeutrophil

Chemotactic factorsChemotactic factors

Inflammatory Cells Involved in COPD


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Endothelial dysfunction

Intimal hyperplasia

Smooth muscle hyperplasia

↑ Inflammatory cells (macrophages, CD8+ lymphocytes)

Changes in Pulmonary Arteries in COPD Patients


Chronic Chronic hypoxiahypoxia

Pulmonary Pulmonary vasoconstrictionvasoconstriction

MuscularizatioMuscularizatio

nn

Intimal Intimal hyperplasiahyperplasia

FibrosisFibrosis

ObliterationObliteration

Pulmonary Pulmonary hypertensionhypertension

Cor Cor pulmonalepulmonale

Death

EdemaEdema

Pulmonary Hypertension in COPD


YYYYYY

Mast cellMast cell

CD4+ cellCD4+ cell(Th2)(Th2)

EosinophilEosinophil

AllergensAllergens

Ep cellsEp cells

ASTHMAASTHMA

BronchoconstrictionBronchoconstrictionAHRAHR

Alv macrophageAlv macrophage Ep cellsEp cells

CD8+ cellCD8+ cell(Tc1)(Tc1)

NeutrophilNeutrophil

Cigarette smokeCigarette smoke

Small airway narrowingSmall airway narrowingAlveolar destructionAlveolar destruction

COPDCOPD

Reversible IrreversibleAirflow LimitationAirflow Limitation


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1. Diagnosticul,evaluarea si monitorizarea afect.

2. Reducerea fact.de risc

3. Tratamentul BPOC stabil Educatie Pharmacologic Non-pharmacologic

4. Trat. exacerbarilor





• ameliorarea simptomatologiei • Prevenirea progresiei bolii• ameliorarea tolerantei la efort• ameliorarea calitatii vietii• Prevenirea si tratarea exacerbarilor • Prevenirea si tratarea complicatiilor• Reducerea mortalitatii

TINTELE TRATAMENTULUI BPCO diferentiate in functie de severitate

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Tratamentul BPOC stabil

Diagnosticare,evaluare,monitorizare

Diagnosticul de BPOC trebuie luat in considerare la orice persoana care prezinta tuse cronica si/sau sputa ……si expunere la factori de risc

Diagnosticul trebuie confirmat prin spirometrie.Raportul FEV1/FVC <0,7 post bronhodilatator =confirma limitarea fluxului aerian partial reversibila

Comorbiditatile sunt obisnuite si trebuiesc depistate activ

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SYMPTOMS

coughcough

sputumsputum

shortness of breathshortness of breath

EXPOSURE TO RISKFACTORS

tobaccotobacco

occupationoccupation

indoor/outdoor pollutionindoor/outdoor pollution

SPIROMETRYSPIROMETRY

Diagnosis of COPDDiagnosis of COPD

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St.I -usor -FEV1/FVC <0,7 -FEV1≥80%(din val.predictibila St.II-mediu -FEV1/FVC<0,7 -50%>FEV<80% St.III-sever -FEV1/FVC<0,7 -30%>FEV1<50% St.IV-f.sever-FEV1/FVC<0,7 -FEV1<30% sau. r

….. - FEV1<50%+IRC

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Diagnostic,evaluare,monitorizare

Spirometria trebuie efectuata dupa administrarea unei doze adecvate de bronhodilatator(beta-2 cu actiune scurta) pentru evitarea variabilitatii

Raportul FEV1/FCV<0,7 dovedeste o bronhoobstructie partial reversibila

Valorile spirometrice trebuie corectate functie de virsta pentru a evita supradiagnosticarea BPOC-ului

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Spirometry: Normal and Patients with COPD

Differential Diagnosis: Differential Diagnosis: COPD and AsthmaCOPD and Asthma

COPD ASTM

• Debut dupa virsta medie

• Simptomatologie incet . progresiva

• Fumator vechi

• Dispnee de efort

• Comun –bronhoobstructie partial reversibila/ireversibila

• Debut in copilarie/tinerete

• Simptome variabile de la zi la zi

• Simptomele predomina noaptea sau dimineata devreme

• Evenimente si manifestari alergice(rinite,exeme etc.)

• Antecedente astmatice familiale

• Comun-bronhoobstructie - reversibila

BPOC-efecte extrapulmonare/sistemice:

•Pierdere in greutate

•Abateri metabolice

•Disfunctii musculo-scheletale

•Coafectare cardiaca

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BPOC-pacienti cu risc crescut la: • HTP, CPC, Insuf.cardiaca

• Angina pectorala si infarct

• Osteoporoza

• Infectii respiratorii

• Depresii

• Diabet

• Cancer pulmonar

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1. Diagn.evaluarea si monitorizarea afect.









Reducerea factorilor de risc

Reducerea /totala a expunerilor personale la:fumat, praf si noxe chimice profesionale, poluarea aerului din interior si exterior in prevenirea exacerbarilor si incetinirea progresiei

Renuntarea la fumat este cea mai importanta si rentabila(cost/eficienta) metoda de evitare a exacerbarilor si incetinire a progresiei bolii (Evidence A).

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Brief Strategies to Help the Patient Willing to Quit Smoking

• ASK-intreaba - si depisteaza sistematic . . . fumatorii.• ADVISE-sfatuieste-i - sa renunte prin . mesaje personalizate• ASSESS-apreciaza- puterea de a renunta• ASSIST- sprijina-i - abstinenta• ARRANGE-asigura -suportul perseverentei la domiciliu,dupa externare

Renuntarea la fumat este cea mai eficienta si rentabila – cost/eficienta – interventie de reducere a riscului de

dezvoltare a COPD si stopare a progresiei

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Management of Stable COPD


Tratament individualizat si tintit pe siptome pentru cresterea calitatii vietii.

Pentru pacientii cu BPCO educatia sanitara pentru renuntare la fumat si masuri de controlare a simptomatologiei are mare importanta(Evidence A)

Nu exista medicatie capabila sa opreasca progresia bolii,dar o poate incetini(Evidence A). Farmacoterapia amelioreaza simptomatologia incetineste progresia si scade complcatiile

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Tratamentul BPCO stabila

Farmacoterapia:Bronhodilatatoarele

Bronhodilatatoarele-ocupa locul central in terapie (Evidence A). Este medicatia de baza care reduce simptomele si previne exacerbarile

Principalele grupe medicamentoase sunt-

ß2-agonistii, anticholinergicele, si methylxanthinele in monoterapie sau in combinatii (Evidence A).

Preparatele cu actiune prelungita sunt mult mai eficiente decit cele cu durata de actiune scurta(Evidence A).

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Farmacoterapia: Glucocorticosteroizii

Este terapie aditionala la beta-2 adrenergice in situatia in care FEV1 < 50% predictiva (St. III: BPOC sever si St. IV: BPOC foarte sever )si exacerbari frecvente(peste 3 exacerbari in 3 ani) (Evidence A).(update-2012-FEV1<60%)

Asocierea inhalativa a unui glucocorticoid cu un beta-2 agonist este mult mai eficienta decit utilizarea singulara(Evidence A).

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Farmacoterapia:vaccinari

In BPCO vaccinarea antigripala este recomandata (Evidence A).

Vaccinarea antipneumococica se recomanda la pacientii >65 si la cei de virste mai tinere dar cu FEV1 < 40% din val.predictiva (Evidence B).

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Inlaturarea Factorilor de risc

- renuntarea la fumat

- reducerea poluantilor din spatii inchise

- reducerea expunerilor profesionale

Vaccinarea antigripala

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IV: Very Severe III: Severe II: Moderate I: Mild

Therapy at Each Stage of COPD

FEV1/FVC < 70%

FEV1 > 80% predicted

FEV1/FVC < 70%

50% < FEV1 < 80%

predicted

FEV1/FVC < 70%

30% < FEV1 < 50% predicted

FEV1/FVC < 70%

FEV1 < 30% predicted

or FEV1 < 50% predicted plus chronic respiratory failure

Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation

Add inhaled glucocorticosteroids if repeated exacerbations

Add long term oxygen if chronic respiratory failure. Consider surgical treatments 50

ACTIUNE SCURTA

ACTIUNE PRELUNGITA

SELECTIVE INALT SELECTIVE

SALBUTAMOL(Salbutamol)

SALMETEROL(Serevent)

SALBUTAMOL SALMETEROL

FENOTEROL(Berotec)

FORMOTEROL(Oxeze)

FORMOTEROL

TERBUTALINA(Bricanil)

TERBUTALINA

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Formoterol+budesonid=SYMBICORTSalmeterol+Fluticazone=SERETIDEFormoterol+budesonid=SYMBICORTSalmeterol+Fluticazone=SERETIDE

METILXANTINE-inhiba fosfodiesteraza-a nu se depasi doza de 1,2g/24 ore-se potentiaza cu beta-2 adrenergicele-numai dupa coretarea hipoxiei ANTICOLINERGICE-receptori muscarinici(M3-br.mari, M3 si M1

br.mici)-efect aditiv cu Beta-2-bromura de Ipratropium-Atrovent 3-4 x 1-2

puf-bromura de Tiotropium (Spiriva)ac.prelungita

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Farmacoterapie-alte medicatii

Antibiotice: Numai in exacerbari

Agenti Antioxidanti: efect terapeutic contestat, exceptie ,la pacientii netratati cu corticosteroizi .

Agenti mucolitici, Antitusive, Vasodilatatore nu se recomanda in BPCO stabil

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Tratamente nefarmacologice

Reabilitarea: Toti pacientii au indicatie de gimnastica medicala (exercise training programs )(Evidence A).

Oxigenoterapie :administrarea O2 mai mult de 15 ore/24 ore pentru pacientii cu insuficienta respiratorie cr. Creste supravietuirea (Evidence A).

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Management COPD Exacerbations

Definire

Exacerbarea Agravarea dispneei,intensificarea tusei si a expectoratiei,de la o zi la alta in ciuda respectarii tratamentului regulat la un pacient cu BPCO cunoscut.

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Management COPD ExacerbationsPrincipii de tratament

Cea mai comuna cauza este infectia,desi la 1 din 3 pacienti nu se poate stabilii cauza exacerbarii (Evidence B).

Pacientii cu exacerbari (traduse prin sputa purulenta) beneficiaza de antibioterapie(Evidence B).

Bronhodilatatoarele(beta-2 agonisti +/_anticolinergice) asociate cu corticosteroizi pe cale generala sunt eficiente in tratamentul exacerbarilor(Evidence A)

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Management COPD Exacerbations

Principii de tratament Ventilatia neinvaziva cu presiune (+)-este o

solutie eficienta de trat. In exacerbari pentru corectia acidozei respiratorii,a pH,reducerea PaCo2,scaderea necesitatii intubatiei ,scurtarea duratei de spitalizare si reducerea mortalitatii(Evidence A).

Medicatia de fond si educatia previn exacerbarile si trebuiesc considerate parte din indicatiile de la externare care amelioreaza prognosticul si calitatea vietii

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Implementarea ghidurilor terapeutice pentru BPCO in cabinetele de asistenta medicala primara

Implementarea institutiilor de sanatate publica in actiuni de prevenire a expunerii la factorii de risc

Confirmarea spirometrica este cheia diagnostica (utilizarea aparaturii de buna calitate)

Depistarea si tratarea comorbiditatilor la persoanele virstnice

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Global Strategy for Diagnosis, Management and Prevention of COPD: Summary

BPCO-incidenta in crestere in multe tari

BPCO poate fi tratata si ,mai ales ,prevenita prin eliminarea factorilor de risc

Programul GOLD ofera strategia de diagnosticare si tratament cu cele mai indicate medicamente disponibile.

Comorbiditatile trebuiesc luate in calcul

Cunostiintele trebuiesc diseminate62

WORLD COPD DAYNovember 14,

2012

WORLD COPD DAYNovember 14,

2012

Raising COPD Awareness WorldwideRaising COPD Awareness Worldwide 63

249239845 bronhopneumopatia-cronica-obstructiva

Documents

global strategy for

o limitare a fluxului

a bpco 2009 definitie

procese inflamatorii

prevenita si tratata

caracter progresiv si

o boala

si prev