Urgene respiratorii 3

Drago Bumbcea, MD, PhD, MPH, FCCP

Clinica de PneumologieSpitalul Universitar de Urgen Elias

Universitatea de Medicin i Farmacie Carol Davila

Insuficiena respiratorie hipercapnic

PaCO2 > 45 mmHg Form clinic

Acut pH < 7.35 Cronic pH > 7.35 (compensat prin retenie

renal de bicarbonai); HCO3- crescut

Semne i simptome de hipoventilaie

Dispnee la activitile diurne obinuite Ortopnee n bolile ce afecteaz funcia diafragmului Calitate proast a somnului Hipersomnolen diurn Cefalee matinal Anxietate Afectarea tusei n bolile neuromusculare

Mecanisme de hipoventilaie alveolar

Exacerbare BPOC Un eveniment n istoria natural a bolii, caracterizat prin

creterea dispneei, tusei i a sputei dincolo de variaiile zilnice, cu debut acut i care necesit o modificare a medicaiei pacientului pentru BPOC

Atitudine: Identificarea unei cauze Evaluarea severitii ExBPOC i alegerea locului de

ngrijire Administrarea tratamentului adecvat Supravegherea remisiunii exacerbrii

Identificarea unei cauze Cauz obinuit:

Infecie traheobronic Bacterian: H. influenzae, S. pneumoniae, M. catharralis Viral: rhinovirusuri, virusuri gripale i paragripale,

adenovirusuri Poluare aerian intens Necunoscut

Identificarea unei cauze Cauz neobinuit (boal diferit care se poate

manifesta similar cu ExBPOC) Pneumotorax spontan Pneumonie Tromboembolismul pulmonar Administrarea ne-adecvat de medicamente

(tranchilizante, hipnotice) Insuficien ventricular stng

Evaluarea severitii Caracteristicile bolii:

Gradul de severitate al obstruciei bronice (VEMS) Durata de agravare a simptomelor Numrul de episoade anterioare de exacerbare Comorbiditi Regimul terapeutic actual

Evaluarea severitii Semne de severitate

Folosirea muchilor respiratori accesori Micri abdominale paradoxale Cianoz agravat sau nou-instalat Dezvoltarea semnelor de insuficien cardiac dreapt

(edeme) Instabilitate hemodinamic Alterarea strii de contien Hipoxemie cu SaO2 < 90% (la pacient fr hipoxemie

anterioar)

Alegerea locului de ngrijire Domiciliu (toate)

Exacerbare non-sever Fr comorbiditi semnificative Toleran digestiv Suport familial

Spital Exacerbare sever Sau una din cele de mai sus

Investigaii Tratament la domiciliu nu sunt necesare Tratament n spital

ECG Radiografie pulmonar Pulsoximetrie, gazometrie arterial Examen microbiologic al sputei?

Managementul ExBPOC n spital Bronhodilatatoare Corticosteroid sistemic Antibiotic Oxigenoterapie Ventilaie non-invaziv / invaziv

Bronhodilatatoare Durat scurt de aciune Preparate:

Beta-2-mimetice salbutamol Anticolinergice ipratropium

Administrare: Nebulizare fr oxigen suplimentar!! pMDI pe spacer Nebs no more after 24

Doze: Salbutamol: 4-10 puff repetat la 4-6 ore Ipratropium: 4-10 puff repetat la 6-8 ore

Efecte adverse Beta-mimetice

Tahicardie sinusal, tahiaritmii supraventriculare i chiar ventriculare

Tremor Agitaie, nervozitate Hipokaliemie

Anticolinergic Declanarea unei crize de glaucom (prin aciune topic

direct)

Corticosteroizi sistemici Efecte:

Scurteaz spitalizarea Accelereaz recuperarea funciei pulmonare ntrzie apariia unei noi exacerbri

Doze: Oral: 0,5 mg/kgc/zi echivalent prednison i.v.: HSHC 100 mg la 8 ore

Efecte adverse: hiperglicemie

Antibiotic Rol limitat:

Efect marginal (de ex. creterea PEF cu 10 L/min!) Rol controversat al infeciei traheobronice n producerea

ExBPOC Con: Infecie superficial (non-invaziv) autolimitant Pro: izolare mai frecvent i n cantiti mai mari de germeni n cursul

ExBPOC fa de BPOC stabil Indicaii:

Semne de infecie (febr i/sau expectoraie cu purulen i cantitate crescut)

BPOC foarte sever de fond (VEMS < 30% prezis)

Antibiotic Betalactamine:

Aminopeniciline +/- acid clavulanic (amoxicilin, amoxicilin/acid clavulanic

Cefalosporine 2 (cefuroxim) Cefalosporine 3 (ceftriaxon) cu rol neclar

Macrolide noi: claritro, azitro (NU eritro!) Fluorochinolone respiratorii: moxifloxacin,

levofloxacin rezervate pentru cazuri severe (risc crescut de dezvoltare a rezistenei)

Oxigenoterapie Saturaia int: 88-92% Canul nazal, doz de 1-2 L/min Atenie: oxigenul este un medicament!!!

Se administreaz n doza prescris Exces de oxigen (e.g. SaO2 de 99-100%) poate

agrava hipoventilaia alveolar Lipsa oxigenului (e.g. SaO2 de 80-88%)

afecteaz funciile cerebrale i a altor organe

Parametrii VNI Ciclurile respiratorii sunt declanate de pacient Presiunea expiratorie (EPAP) Presiunea inspiratorie (IPAP) Frecven respiratorie de siguran (back-up)

ex: 12/min ventilatorul declaneaz un ciclu respirator dup o pauz de 5 secunde (60 sec / 12)

Uneori volum curent minim (IPAP variabil)

Ventilaie non-invaziv Efecte:

Reduce intubaia orotraheal i complicaiile sale Reduce durata de spitalizare (inclusiv in ATI) Crete supravieuirea

Elemente: Ventilator cu moduri de ventilaie non-invaziv Interfa (mti de VNI)

Contraindicaiile VNI Stop cardiac sau respirator Incapacitatea de a coopera, proteja calea aerian sau

elimina secreiile Alterarea sever a strii de contien Insuficien de organ non-respiratorie Chirurgie sau traumatism sau deformare facial Risc nalt de aspiraie Durat prelungit anticipat a ventilaiei mecanice Anastomoz esofagian recent

Ventilaie non-invaziv - interfa

Monitorizare Parametrii clinici (pre-ventilaie sau n modurile

spontane): frecvena respiratorie, volumul curent, folosirea muchilor accesori, respiraie paradoxal

Gaze sanguine: pulsoximetrie continu gazometrie arterial repetat

Monitorizare pentru identificarea complicaiilor

Sindromul de obezitate hipoventilaie (SOH) (Pickwick's)

Obezitate morbid (IMC > 40 kg/mp) Hipoventilaie alveolar diurn cronic (PaCO2 > 45 mmHg n

absena altei cauze de hipercapnie) Caracteristici:

Hipersomnolen diurn Hipoxemie de repaus diurn (SaO2 < 90%) Cord pulmonar cronic Hipoventilaie nocturn (creterea PaCO2 cu > 10 mmHg n timpul

somnului) cu acidoz respiratorie (pH < 7.3) nregistrri somnografice: desaturare nocturn, apnei n somn

obstructive, hipoventilaie nocturn

Fiziopatologia SOH

Tratament Scdere ponderal

Clasic (diet, efort fizic) Chirurgia bariatric amelioreaz:

Apneea n somn Funcia pulmonar

Oxigenoterapia nocturn poate agrava hipoventilaia alveolar (hipoxemia i hipercapnia)

Presiunea pozitiv continu (CPAP) deseori insuficient pentru compensarea anomaliilor gazometrice

Ventilaie non-invaziv nocturn tratament de elecie

Ventilaia non-invaziv nocturn Efecte favorabile

Fiziologice Corecia hipoxemiei i hipercapniei diurne i nocturne Ameliorarea fragmentrii somnului Reducerea presiunilor arteriale pulmonare i ameliorarea semnelor de cord pulmonar cronic

Clinice ameliorarea simptomelor Cefalee matinal Somnolen diurn Dispnee Edeme gambiere

Interfa Acut: masc oronazal / facial complet Cronic: masc nazal

curs insuficienta respiratorie 3 spiro.pdfcurs urgente respiratorii 3 spiro.pdfurgente respiratorii 3.pdfSlide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10Slide 11Slide 12Slide 13Slide 14Slide 15Slide 16Slide 17Slide 18Slide 19Slide 20Slide 21Slide 22Slide 23Slide 24Slide 25Slide 26Slide 27Slide 28

COPD_COURSE_CRAS.PDF.pdfSlide 1Slide 2What is COPD?Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998Slide 5Death rate in the worldSlide 7Slide 8Slide 9FiziopatologieObstrucia fluxului de aerObstrucia fluxului de aer rolul pierderii reculului elasticHiperinflaie pulmonarSimptomeSlide 15Slide 16Slide 17Semne fiziceExplorarea funcionalSpirometrySpirometrieSlide 22Slide 23Slide 24Atentie !!!!Spirometrie post-bronhodilatatorSlide 27Slide 28Slide 29Slide 30Strategia diagnosticDiagnostic DiferenialIstoria natural a BPOCSeveritatea BPOC (post-2)Slide 35Tratamentul BPOCBronhodilatatoare2-agonist cu durata scurta de actiune (BADSA)Slide 39Slide 40Anticolinergice cu durata scurta de actiuneAnticolinergice cu durata lunga de actiuneTheophyllineTheophylline side effectsSlide 45Corticosteroizi inhalatoriSlide 47OxigenoterapieSlide 49ReabilitareSlide 55Slide 52Mijloace terapeuticeSlide 54BADSAAnticolinergicAminofilinaCS sistemic n Ex-BPOCAb n Ex-BPOCSlide 60Slide 61

asthma course.pdfasthma course - new slidesSlide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10Slide 11Slide 12Slide 13Slide 14Slide 15

ASTHMA_COURSE_CRAS.PDF.pdfSlide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10CharacteristicsPhysical examinationSuspicion of asthmaConfirmation of asthma diagnosisSlide 15Slide 16Slide 17Slide 18Slide 19Slide 20Slide 21Slide 22Slide 23PeakflowmetrieSlide 25Methacholine bronchial challenge testSlide 27Slide 28Slide 29Slide 30Slide 31Asthma medicationsRoutes of administrationInhalersController medicationsReliever medicationsInhaled glucocorticosteroidsInhaled steroids - dosesEquipotent doses of ICSInhaled steroids adverse eventsDose-response curve of ICSDose-response curve of ICS (PEF)Leukotriene modifiersSlide 44Long-acting inhaled 2-agonists (LABA)LABA side effectsTheophyllineTheophylline side effectsAsthma managementLevels of asthma controlSlide 32Asthma treatment titrationSlide 53Slide 54Slide 55Asthma management in acute careSlide 57Slide 58

asthma course - new slidesSlide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10Slide 11Slide 12Slide 13Slide 14Slide 15

ASTHMA_COURSE_CRAS.PDFSlide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10CharacteristicsPhysical examinationSuspicion of asthmaConfirmation of asthma diagnosisSlide 15Slide 16Slide 17Slide 18Slide 19Slide 20Slide 21Slide 22Slide 23PeakflowmetrieSlide 25Methacholine bronchial challenge testSlide 27Slide 28Slide 29Slide 30Slide 31Asthma medicationsRoutes of administrationInhalersController medicationsReliever medicationsInhaled glucocorticosteroidsInhaled steroids - dosesEquipotent doses of ICSInhaled steroids adverse eventsDose-response curve of ICSDose-response curve of ICS (PEF)Leukotriene modifiersSlide 44Long-acting inhaled 2-agonists (LABA)LABA side effectsTheophyllineTheophylline side effectsAsthma managementLevels of asthma controlSlide 32Asthma treatment titrationSlide 53Slide 54Slide 55Asthma management in acute careSlide 57Slide 58

ASTHMA_COURSE_CRAS.PDFSlide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10CharacteristicsPhysical examinationSuspicion of asthmaConfirmation of asthma diagnosisSlide 15Slide 16Slide 17Slide 18Slide 19Slide 20Slide 21Slide 22Slide 23PeakflowmetrieSlide 25Methacholine bronchial challenge testSlide 27Slide 28Slide 29Slide 30Slide 31Asthma medicationsRoutes of administrationInhalersController medicationsReliever medicationsInhaled glucocorticosteroidsInhaled steroids - dosesEquipotent doses of ICSInhaled steroids adverse eventsDose-response curve of ICSDose-response curve of ICS (PEF)Leukotriene modifiersSlide 44Long-acting inhaled 2-agonists (LABA)LABA side effectsTheophyllineTheophylline side effectsAsthma managementLevels of asthma controlSlide 32Asthma treatment titrationSlide 53Slide 54Slide 55Asthma management in acute careSlide 57Slide 58

ASTHMA_COURSE_CRAS.PDF.pdfSlide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10CharacteristicsPhysical examinationSuspicion of asthmaConfirmation of asthma diagnosisSlide 15Slide 16Slide 17Slide 18Slide 19Slide 20Slide 21Slide 22Slide 23PeakflowmetrieSlide 25Methacholine bronchial challenge testSlide 27Slide 28Slide 29Slide 30Slide 31Asthma medicationsRoutes of administrationInhalersController medicationsReliever medicationsInhaled glucocorticosteroidsInhaled steroids - dosesEquipotent doses of ICSInhaled steroids adverse eventsDose-response curve of ICSDose-response curve of ICS (PEF)Leukotriene modifiersSlide 44Long-acting inhaled 2-agonists (LABA)LABA side effectsTheophyllineTheophylline side effectsAsthma managementLevels of asthma controlSlide 32Asthma treatment titrationSlide 53Slide 54Slide 55Asthma management in acute careSlide 57Slide 58

asthma course - new slidesSlide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10Slide 11Slide 12Slide 13Slide 14Slide 15

ASTHMA_COURSE_CRAS.PDF.pdfSlide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10CharacteristicsPhysical examinationSuspicion of asthmaConfirmation of asthma diagnosisSlide 15Slide 16Slide 17Slide 18Slide 19Slide 20Slide 21Slide 22Slide 23PeakflowmetrieSlide 25Methacholine bronchial challenge testSlide 27Slide 28Slide 29Slide 30Slide 31Asthma medicationsRoutes of administrationInhalersController medicationsReliever medicationsInhaled glucocorticosteroidsInhaled steroids - dosesEquipotent doses of ICSInhaled steroids adverse eventsDose-response curve of ICSDose-response curve of ICS (PEF)Leukotriene modifiersSlide 44Long-acting inhaled 2-agonists (LABA)LABA side effectsTheophyllineTheophylline side effectsAsthma managementLevels of asthma controlSlide 32Asthma treatment titrationSlide 53Slide 54Slide 55Asthma management in acute careSlide 57Slide 58