Transcript Symptomatology of the pulmonary disease

Symptomatology of the
pulmonary disease – asthma,
COPD , lung cancer, pleural
effusion, pneumonias, bronchial
stenoses
Prof. MUDr. Miloslav Marel, CSc.
Pneumological clinic of the 2. MF
of CHU and FN Motol
Czech Republic
• Czech republic:
•
•
•
10 milions inhabitants
area of 78 867 km2
NATO February 1999
EU since May 2004.
P-10,6
P-90 000
Pneumophthiseology in the Czech
republic -2007
• 550 pneumophthiseologists / 650
members of Pneumophthiseological
medical society
• 350 out patients depth. – from them:
205 independent ambulatory
specialist , mostly private
138 in hospital
7 in „sanatorium“
Beds in PNE+TB
hospital
sanatoria
beds
% of
total
beds
beds
% of
total
beds
1985
3274
61,5
2052
38,5
1995
2444
61,8
1510
38,2
2005
1610
62,0
987
38,0
2008
1311
59,4
896
40,6
year
Hospitals PNE-TB, 2007
• hospitals – 43
Czech - 21
Moravia - 22
• sanatoria – 11
Czech -7
Moravia- 4
1311 beds = 59,6 %
896 beds = 40,4 %
Occupancy of beds in the year 78,2 %
The main tasks for PNE-TB
• TB surveillance 8/100 000
• Oncological program 5,500 death yearly
• Prevention, depistation, dg. and th. COPD
(8%)and asthma bronchiale (7%)
• Dg. and th. infection of the lungs 1000/100 000
CAP
• Dg.,dif.dg. and th. interstitial and granulomatos
pulmon. diseases
• Th. of patients with respir. insuficiency
• Dg a th. Sleep apnoe syndrom
• Th. cystic fibrosis in adults
Burden of Asthma

Asthma is one of the most common chronic
diseases worldwide with an estimated 300
million affected individuals

Prevalence increasing in many countries,
especially in children

A major cause of school/work absence
Burden of Asthma

Developed economies might expect to
spend 1-2 percent of total health care
expenditures on asthma.

Poorly controlled asthma is expensive;

„the good treatment of stable disease is
cheaper then the therapy of exacerbation in
hospital“
Asthma Prevalence and Mortality
Source: Masoli M et al. Allergy 2004
CR – known cases followed at specialists for A.B. 2008
2008
0-19 (%)
 19
Total
Alergolog.
135 853 (50,6)
132 583
268 436 (62)
PNE-Pht
3 773 (2,3)
161 090
164 863 (38)
Total
139 626 (32,2)
293 637
433 299
2008, 2009
InÚZIS
USA 80-85%
of pts with AB are treated by GP´….
(%)
According V. Kašák
CLASIFICATION of A.B. according the severity
in CR at PNE-TB in 2008
(total 164 863 patients
)
12690; 8%
41611; 25%
49833; 30%
Intermitent
Light persistent
Moderate persistent
Severe persistent
60729; 37%
ÚZIS 2009
VK
Number of patients with A.B followed at PNE-TB
out-patients departments in CR 2000-08
180000
160000
+ 87 %
Total number
140000
2000 - 87 864
120000
100000
Lineární
2001 - 95 894
(Total
2002 number)
- 104 386
80000
60000
2003 – 113 524
2004 – 134 476
40000
2005 – 139 588
20000
0
2006 – 152 695
2007 – 155 945
0
1
2
3
4
5
6
7
8
2008 – 164 863
Number of hospitalized pts with A.B. in CR in 99-08
10000
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
Total pts
1999 – 8 841
58 %
Lineární
2000 - (Total
8394 pts)
2001 – 8 195
2002 – 7 234
2003 – 7 029
2004 – 6 503
2005 – 5 668
2006 – 4 822
2007 – 5 646
99
0
1
2
3
4
5
6
7
8
2008 – 5 164
VK
Mortality to A.B. in CR
250 000 patients
CR: 2004 – 96 pts
2005 – 99 pts
2006 – 101 pts
2007 – 114 pts
2008 – 102 pts
Definition of Asthma

A chronic inflammatory disorder of the airways

Many cells and cellular elements play a role

Chronic inflammation is associated with airway
hyperresponsiveness that leads to recurrent
episodes of wheezing, breathlessness, chest
tightness, and coughing

Widespread, variable, and often reversible
airflow limitation
Factors that Influence Asthma
Development and Expression
Host Factors
 Genetic
- Atopy
- Airway
hyperresponsiveness
 Gender
 Obesity
Environmental Factors
 Indoor allergens
 Outdoor allergens
 Occupational sensitizers
 Tobacco smoke
 Air Pollution
 Respiratory Infections
 Diet
Factors that Exacerbate Asthma






Allergens
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide
Food, additives, drugs
Symptoms

Recurrent episodes of wheezing

Troublesome cough at night

Cough or wheeze after exercise

Cough, wheeze or chest tightness
after exposure to airborne allergens
or pollutants

Colds “go to the chest” or take more
than 10 days to clear
„ Old“ classiffication according the
severity of AB and therapy
SABA as needed
Levels of Asthma Control
too strict for „ full control“
Characteristic
Controlled
Partly controlled
(All of the following)
(Any present in any week)
Daytime symptoms
None (2 or less /
week)
More than
twice / week
Limitations of
activities
None
Any
Nocturnal
symptoms /
awakening
None
Any
Need for rescue /
“reliever” treatment
None (2 or less /
week)
More than
twice / week
Lung function
(PEF or FEV1)
Normal
< 80% predicted or
personal best (if
known) on any day
Exacerbation
None
One or more / year
Uncontrolled
3 or more
features of
partly
controlled
asthma
present in
any week
1 in any week
Classification of AB according the
severity and level of control
Intermittent asthma
Controlled
Perzistent light asthma
Perzistent moderate
asthma
Severe perzistent
asthma
Partly controlled
Uncontrolled
Bronchogenic
carcinoma
Prof. MUDr. Miloslav Marel, CSc.
What is Lung Cancer?
• An estimated 219,440 people diagnosed in the
United States in 2009
• The leading cause of cancer death among
men and women
• Begins when cells in the lung grow out of
control and form a tumor
• There are two main types of lung cancer: nonsmall cell and small cell
What is the Function of the
Lungs?
• The lungs consist of five
lobes, three in the right
lung and two in the left
lung
• Most cells in the lung are
epithelial cells, which line
the airways and produce
mucus, which lubricates
and protects the lungs
• The main function of the
lungs is to allow oxygen
from the air to enter the
bloodstream for delivery
Lung Cancer
Global situation in the world
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•
•
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The leading cause of cancer death in both
women and men in USA, Canada and China
997 000 death in men and 333 000 death in
women in the world in 2000
An increase of adenocarcinoma
12,3 % of all malignant tumors , 30% of cancer
related death
Lung Cancer
Global situation in the world
European Union
29% of cancer death in men
9% in women
The highest incidence in the world
New Orleans 105/100 000 in men
New Zeland 73/100 000 in women
Incidence and mortality on LC in
men and women in 1985-2005
Incidence of lung cancer according
age groups
2003
• Men till 49 years
191
50-59
1106
60-69
1525
70-79
1382
older
386
• Women till 49 years:
50-59
60-69
70-79
older
92
301
347
470
177
%
4,2
24,1
33,2
30,1
8,4
6,6
21,7
25
33,9
12,8
2005
%
177 3,8
1028 22,2
1610 34,8
1406 30,4
411
8,8
78
358
441
480
256
4,8
22,2
27,3
29,8
15,9 ;;
•
Standardizated mortality to diag. C33,C34 to 100 000 women in CR and abroad
•
•
•
•
•
•
•
•
•
•
•
•
Country
Austria
Czech Republic
Finland
Hungary
Ireland
Lithuania
Norway
Poland
Romania
Russian F.
Ukraine
•
Standardizated mortality to diag. C33,C34 to 100 000 men in CR and abroad
•
•
•
•
•
•
•
•
•
•
•
•
Country
Austria
Czech Republic
Finland
Hungary
Ireland
Lithuania
Norway
Poland
Romania
Russian F.
Ukraine
2000
17
18
12
30
29
8
23
18
11
9
8
2000
54
90
52
115
59
78
45
99
65
87
72
2001
16
19
12
30
25
9
24
19
11
9
8
2001
54
86
51
114
56
81
46
100
65
84
69
2002
18
18
12
32
26
7
23
20
11
9
7
2002
55
84
49
112
54
80
49
101
66
82
67
2003
17
19
13
33
27
9
24
20
12
8
7
2003
53
81
48
115
56
79
47
97
65
80
64
2004
18
19
12
33
28
8
25
19
11
8
7
2004
51
82
46
114
53
76
46
96
65
78
63
2005
17
19
13
31
28
8
26
21
12
8
7
2005
50
77
46
103
50
74
44
95
68
77
61
Standardizated mortality to diag. C33,C34 to 100 000 inhabitants in CR and abroad
( UZIS 2008)
Country
2000
2001
2002
2003
2004
2005
Austria
33
32
33
32
32
31
Czech Republic
49
48
46
45
46
44
Finland
28
28
27
27
26
27
Hungary
65
65
65
66
66
61
Ireland
42
39
38
40
39
38
Lithuania
35
37
35
36
35
34
Norway
33
33
34
34
34
34
Poland
52
52
53
52
51
51
Romania
36
36
36
36
36
37
Russian Federation
39
37
36
35
35
34
Ukraine
33
32
31
30
29
28
Smoking and other risk
factors
• Smoking caused lung cancer in
94% men and 52% women (Kubík
et al: Cancer, 1995, 7, 2452-60)
• CR: 40 % men and 25 % women
in th age 30 - 60 years are
smokers (UZIS ČR 2004)
• 10 – 18 % of smokers will suffer
from lung cancer
• coincidence with chronic lung
diseases
• genetic predisposition
• cumulative effect of risks !!
Mortality on LC in Australia
Mortality in Netherlandes to 100 000
inhabitants
Lung cancer is the 3th most frequent TU diagnosed in EU
year 2000: 243,600 newly diagnosed cases of LC
Ratio men to women 4:1.
Highest incidence for men is in Hungary, Poland and Belgium
for women in Denmark, Hungary and UK
Epidemiological conclusions
• decreasing incidence of LC in men, plateau point of incidence
of women is nearing…hopefully
• problems - high incidence of LC in men
- late diagnostics
- operability only 11,4% in men and 13,2 in women
- in 2003 5995 new cases , died 5568 !!
- number of „ NO therapy“ didnt change in the past
20 years
• pozitive data
- we did not reached the highest EU incidence in
women
- increased 5 year survival
- higher level of verification of LC
- lower late diagnosed pts over 6 weeks
Patogenezis, pathology
• Ciliated cells fade away – multiplication of bazal cells –
hyperplasy and metaplasy of multilayer epidermoid epithel –
loss of polarity – atypical nuclei - abnormal mitózes –
dysplasie mild, moderate, severe - proliferation of the cells ca in situ
• field cancerization x progenitor cell
• reverzibility of changes
• histology
– Small cell ca – agresive, frequent metastases
– spindlecells - metastases later, typical cauliflower shapekarfiol
– adenocarcinoma - gland type, cave metastases
and periferal leasions ….bronchioalveolar ca
– nedifferentiated – largecells ca
Pathology- 2
• Development of cancer in the mucosa up to 15 years
• doubling time
• death - 1 kg tumoros mass
doubling timeí
years to diagnozes to
death
• Small cell ca
29 days
2,8
3,2
squamous ca
88 days
8,4
9,6
adenoca
161 days
15,4
17,6
• central, peripheral
Metastases to - liver, suprarenal glands, bone, brain
• Direct invasion
• lymphatica
• hematogenes
Symptoms of lung cancer
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


cough
weight loss
dyspnoe
haemoptysis
bone pain, clubbing
fever
Vena cava syndrome
recurrent laryngeal palsy
75%
68%
60%
20-35%
25%
15-20%
4%
5%
What are the Symptoms of Lung
Cancer?
•
•
•
•
•
•
•
•
Fatigue (tiredness)
Cough
Shortness of breath
Chest pain
Loss of appetite
Coughing up phlegm
Hemoptysis (coughing up blood)
If cancer has spread, symptoms include bone pain,
difficulty breathing, abdominal or back pain, headache,
weakness, and speech difficulties
Paraneoplastic syndrome
Endocrine syndromes
• Cushing´s sy (ACTH) 2-7%, SCLC 30-50%,
• Nonmetastatic hypercalcemia - squamous
ca 15%
• Inappropriate antidiuretic hormone in
SCLC , hyponatremia, urine osmolarity
over 500 mOsm.kg-1
• Gynecomastia (HCG)
Paraneoplastic syndrome
Neurological syndrome
• Symptoms peripheral neuropathy,
encephalomyelitis
• Lambert Eaton myasthenic syndrome
Cutaneous
• Erythema gyratum repens, acanthosis nigrans
Haematological
• microcytic anemia in 20%, haemostatic
disturbance
Clubbing
Anorexia, nausea, vomiting
Diagnosis of lung cancer
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•
•
•
•
•
•
•
•
screening method does not exists
passive approach – waiting for symptoms
personal history and physical examination,
performance status
pulmonary function tests- air flow limitation
sputum cytology, chest X ray, chest CT scan
bronchoscopy (TBNA, brush, forceps biopsy....),
cytology, histology
autofluorescence, EBUS
transparietal fine needle lung biopsy
PET, bone scan, mediastinoscopy (?)
thoracoscopy
operability ???
Pleural diseases
Clinical manifestations and
useful tests
•
-
Symptoms
pleuritic chest pain
nonproductive cough
dyspnoe
also asymptomatic ( up to 23%)
• Symptoms of the basic disease
- cardiac heart failure, pneumonia, pulm. embolia, malignancy,
TB, reumatic disease, GIT disease, trauma
- occupational exposition (asbest)
- iatrogenn. influence (chest and abdominal surgery, instrumental
procedures in oesophagus and great vessels)
Physical examination
•
•
•
•
•
•
Decreased or absent breath sound
Pleuritis sicca: pleural rub plus local pain
Fluidothorax: larger hemithorax, tactile fremitus is absent
percussion is dull
splash during shaking with patient,
near the superior border of the fluid breath sound may be
accentuated (Škodův note) and diminished compresive
breathing
• PNO: perccusion note is hyperresonant, breath sound is absent
or reduced, absent tactile fremitus, the side of PNO is larger
than contralateral side and moves less during respiratory cycle
•
• Fibrothorax - smaller hemithorax, reduced breath sound haemothorax
Radiographic examination
• Fluidothorax:
- the lung float in the pleural fluid
- fluid gravitates to the base of the hemitorax, particularly
posteriorly
- the lateral costophrenic angle is obliterated
- the density of fluid is high laterally
- lateral projection- the upper surface is semicircular high
anteriorly and posteriorly, the shape changed according the
position of the patients
- AP 200 – 500 ml, lateral 50 – 100 ml, Riegler projection 20 ml
- fluidothorax large (> 50 %) + mediastinum shift, middle (25 – 50
%) small (< 25 % hemithorax)
- encapsulated fluid at the chest wall and in the interlobium
(spindle shaped)
- subpulmonal effusion
Radiographic
examination -2
• PNO:
- air accumulates in the highest part of the
thoracic cavity - early kolaps of he upper lobes
- lungs become smaller, thorax larger
- density of the lung increases when the lung loses 90% of its volume
- on the X ray may be seen the visceral pleural line and strip of the air
without parenchymal structures
- better seen in maximal expiration
- fluidoPNO: horizontal level of the fluid
- cave: skin folds may mimic a pleural line
- diagnostic PNO- lung cancer infiltration of the wall, diaphragma and
mediastinum
Radiographic
examination - 3
•
-
Pleural masses:
difuze (>1/4 chest wall) or local
nodular or surface
solitary, sharply defined - benign mesotheliomas
malignant mesotheliomas encases the lung and mediastinum shifts
to the side of the effusion, retraction of the hemithorax
bilateral changes : asbestos ; unilateral- after hemothorax,
empyema, TB
rounded atelectazis in pleural scarsening and pleural plaque asbestos, „comet tail sign“ (deformed vasculature and bronchi from
focus to hilar region )
Ultrasound
• Sonds 3,5 -5– 7 MHz, bedside, without radiation
• PNO
- also small PNO in lying patients
•
-
Fluidothorax
50 – 100 ml
appropriate location for thoracentesis or drainage
fluid loculation
fluid versus pleural thickening
lung absces versus empyema with bronchopleural fistula
• Pleural masses
- are seen of the 5 mm size
- biopsy under sonogr. control
CT and HRCT
• Distinguish according the denzity - air fluid and tissue (fat,
calcification), with contrast, biospy under CT control
• PNO: also very small PNO in lieing (ventilated patients,
polytrauma), PNO versus bulae
• Fluidothorax- 20-50 ml, also in interlobium distinguish fluid
subpulmonalis versus subphrenic
• Hemothorax: denzity of coagula,
• Chylothorax denzity of fat
• Malignant effusions: postcontrast better seen pleural masses
CT and HRCT –2
• Empyema: postcontrast seen pyogennic membranae, may
distinguish encapsulated empyema (spindle, obturated angles, ,
shifted vessels and bronchi) from peripheral lung absces,
drainage under CT control in encapsulated empyemas
• Pleural masess: HRCT is better to discovered pleural plaques, CT
better in case of lung cancer - staging (invazion to the chest wall,
diaphragma and mediastinum, existence of fluid);
• in mesotheliomas evaluated thickness of the pleura (included
mediastinal pleura and interlob. pleura ), of the fluid, calcification ,
invazion and retraction changes, enlargement of the lymphatic
nodules . No definite distinguishing of the benign and malignant
tumors.
MRI and scintigraphy
• MRI:
- no radiation, not necessary iodine contrast media
- expensive, no in patients with metalic protezes and
claustrophobic
- long duration of the examination, worse distinguishing then
modern CT
- better imaging of the soft tissue of the thorax delineation of the
vessels and tracheobronchial tree: infiltration of the chest wall
by tumors
- distinguish the tissue and fluid
- identifying of haemothorax that has been present more than a
few days
• Scintigraphy:
- ventilatory scan (133Xe) to evaluation of BP fistula
- PET scan to distinguish metastases to pleura
Thoracentesis
• Dg and th method in PNO a fluidothorax
• Dg: to obtained fluid to examination, therapeutically to enabled
reexpansion of collapsed lung
• Th: symptomatic evaluation of the fluid in dyspnoic patients
(thick needle, local anesthezia)
• Technic: et the upper edge of the lower rib !
- in PNO - patients halfsitting, punction in 2. – 3. intercostal
space in the medioclavicular line
- in evacuation of the fluid - sitting patients, punction mostly in the
scapular or axilar line, 2. intercostal spaces under the upper
line of the fluid - no tactile fremitus,, in encapsulated effusion
image-guided punction , in a small effusion only if the lateral
decubitus position proves the thickness of the fluid more than 10
mm
Thoracentesis 2
•
Th punction: evacuation of 1,0 – 1,5 l,
also by aspirator (no negativ intrathoracic pressure then –20
cm H2O: reexpanzion edema)
• Dry punction : no fluid, bad localisation, , bad technic, obese
patients (short needle)
• complications: PNO, infection, bleeding, colapse , cough,
dyspnoe, pain, puncture of the liver or spleen
• Contraindication: hemoragy status - PLT under 50 000 ??,
noncompliance of the patients, higher creatinine, relative: artef.
ventilation ??
• control RTG after punction??? PNO ?? Symptomatic in most
cases
Pleural fluid
•
-
-
The gross appearence:
transsudates: clear, straw-colored; urinothorax smelt like urine
exsudates: straw color,, reddish color, turbidity
haemothorax: haemoragic - HTK more than 20 or more than
50% of HTK in blood
empyema: thick, turbid, , green, yellow, smelty, supernatant is
clear
chylothorax: milky turbid , in supernatant turbidity remains
chocolate sauce - amebiasis with hepatopleural fistula
black colour - aspergilus
high viscosity, sometimes bloody – malignant mesothelioma
Prof R.W.Light
St. Thomas Hospital, Nashville, Tennessee,USA
1972 „Light“ criteria to distinguish exsudates from
transsudates.
At fullfiling of one or more criteria as acts of exsudate;
transsudates do not fullfill any criterium
(F - fluid, S - serum, F / S - ratio )
1) F/S total protein
> 0,5
2) F/S laktatdehydrogenasis > 0,6
3) F laktatdehydrogenazis > 2/3 upper limit in serum
„ too stricts for transsudates“
Ref. Ann. Intern. Med. 1972, 77, p. 507-513
Further criteria to distinguish
Transsudates/Exsudates
• Tot. protein over 30 g/l bears
witness for exsudat
• Tot. protein S minus Tot. protein F
over 31 g/l bears witness for
transsudate (gradient)
• ALB S minus ALB F over 12 g/l
bears witness for transsudate
(gradient)
• cholesterol over 1,55 mmol/l in F
- exsudate
• cholesterolF/S > 0,3 -exsudate
• bilirubin index: fluid/ serum is in
exsudates over 0,6
• Czech Toušek 1960
recommended to examine Tot
Protein in F and also in S ,
Cholesterol S/F over 16=
transsud, about 2= exsud, LDH
highest in empyemas and
Examination of patients with pleural
effusions
•
•
•
•
Anamnesis - GIT, heart, surgery, trauma,…
Physical examination:- fremitus pectoralis
RTG, CT, sono 3,5-7 MHz
thoracocentesis 1-1,5 litre , no more.. More than
minus 20 cm H2 0 dangerous , 10% PNO
• Fluid examination – pH under 7,2 risk of
empyema, under 7,0 drainage necessary, also
when is glucosis under 2,2 mmol/l, LDH over
16,7ukat/l
• TAG over 1,24mmo/l- chylothorax, ADA over 45
U/ml, TB- ADA2
COPD
preventable and treatable disease
Prof. Miloslav Marel, MD.
Definition of COPD ( GOLD 2006)
COPD is a preventable and treatable disease with
some significant extrapulmonary effects that
may contribute to the severity in individual
patients. Its pulmonary component is
characterized by airflow limitation that is not
fully reversible. The airflow limitation is usually
progressive and associated with an abnormal
inflammatory response of the lung to noxious
particles or gases.
Components of COPD
• Chronic bronchitis – cough and
expectoration of most of the days in 3
month in two consecutive years, without
known other reason ( bronchiectasie,
asthma, cystic fibrosis)
• emphyzema – pat. - anatom. definition –
dilatation of airways beyond the terminal
bronchiolus with destruction of
interalveolar septa
• asthma bronchiale – chronic inflammatory
illness with chronic air flow limitation may
leds to COPD
Venn diagram
Prevention of COPD
• primary prevention – does n´t exist with
exception of A1 AT defficience and no
smoking advice during pregnancy
• Secondary prevention – elimination of all
risks factors – no start to smoke, elimination
of passive smoking , to stop smoking
elimination of general, professional and
home air polution
• terciar prevention – elimination of triggers of
exacerbaction, good therapy of COPD ,
vaccination against influenzae
Patho- phyziology
• chronic obstructive ventilation disturbation, reversibility
under 12%
- reversibile component – contraction of the smoth
muscles, edema, hypersecretion
- irreversibile component - emphyzema
• Prolongation of expiratory flow, dynamic compresion of
airways at expiration
• Hyperinflation , shift of ventilation to the higher volumes
• Efficiency of breath musculature is diminuished
• Ratio V/Q may be „ normal“ - ( emphyzema), or smaller
• Increase the phyziological death space, diminuished
alveolar ventilation
• Increase of breath work is caused by lost of lung elasticity
• MMV se going down
• Disturbation of exchange of gases – chronic hypoxemie –
increase of blood pressure in a. pulmonalis
The Downward Spiral in COPD
COPD
Lung
inflammation
Mucous
hypersecretion
Airway
obstruction
Exacerbation
Continued
smoking
Impaired
mucous clearance
Exacerbation
Submucousal gland
hypertrophy
Alveolar
destruction
Exacerbation
Hypoxaemia
DEATH
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative
for Chronic Obstructive Lung Disease (GOLD) 2008. Available from: http://www.goldcopd.org.
Emphyzema
Inflammation in Asthma and COPD
ASTHMA
COPD
Sensitising agent
Noxious agent
Asthmatic airway inflammation
CD4+ T-lymphocytes
Eosinophils
Macrophages
Mast cells
COPD airway inflammation
CD8+ T-lymphocytes
Macrophages
Neutrophils
Mostly
reversible
Mostly
irreversible
Airflow limitation
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for
Chronic Obstructive Lung Disease (GOLD) 2008. Available from: http://www.goldcopd.org.
Sutherland ER, et al. J Clin Allergy Immunol. 2003;112:819-827.
Prevalence COPD in the Czech
Republic
2000 2001 2002 2003
COPD at
207
Pneumol.de
195
p
213
507
217
759
225 619
2004 2005 2007
245
405
235
895
2005 - men to women ratio
men 138 144 (58 %)
women
stage III and IV 34 266 (25 %)
2005 number of hospitalisations
days in hospital
on average days in hospital
97 751 (42 %)
22 660 (23 %)
17 101
394 439
16,3 days
UZIS 2005
248 578
Mortality on COPD in Czech
Republic
• 1996
• 2005
absolute number
1062
2190
men
women
Vondra, Med po promoci,8, Suppl. 1/2007
x/100 000
10,3/ 100 000
21,4/100 000
27,1/100 000
16,0 /100 000
Australian experience
COPD Mortality Is Increasing Versus Other
Chronic Diseases: United States Data
550
Rate per 100 000 population
500
450
75
Heart disease
Accidents
400
50
350
Chronic obstructive
pulmonary disease
300
250
200
150
100
Cancer
25
Stroke
Diabetes mellitus
50
0
0
1970 1974 1978 1982 1986 1990 1994 1998 2002
1970 1974 1978 1982 1986 1990 1994 1998 2002
Year of Death
Year of Death
Global Alliance Against Chronic Respiratory Diseases (GARD). Global surveillance, prevention and control of chronic respiratory diseases:
a comprehensive approach. 2007. Available at: http://www.who.int/gard/publications/GARD%20Book%202007.pdf
Smoking
• 80 % of COPD pts smoked (CHEST, 2001, 119, 344-52)
• 15 % - 20 % (GOLD 2005) 50 % (Lundback, Resp med, 2003)
smokers will have COPD
• women are more susceptible to smoke (CHEST,
1994)
Smoking History
COPD
(Pack Years)
women
men
mild
35
60
moderate
54
66
severe
59
67
Smoking and other risk
factors
• CR: 40 % men and 25
% of women in age 30
-60 years smoke (UZIS
ČR 2004) cca 29% of
adults
• in USA smoked about
75 milions persons cca 30%
Risk Factors for COPD
• Susceptibility genes
• Poor lung growth and
development
• Exposure to inhaled
particles:
• Oxidative stress
– Tobacco smoke (active • Female gender
and passive)
• Age
– Occupational dusts,
• Respiratory infections
organic and inorganic
• Low socioeconomic status
– Indoor air pollution from • Poor nutrition
heating and cooking
• Comorbidities
with biomass in poorly
ventilated dwellings
– Outdoor air pollution
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative
for Chronic Obstructive Lung Disease (GOLD) 2008. Available from: http://www.goldcopd.org.
Cumulative Exposure to Noxious Particles is
the Key Risk Factor for COPD
Cigarette smoke
Occupational dust and
chemicals
Environmental tobacco
smoke (ETS)
Indoor and outdoor
air pollution
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative
for Chronic Obstructive Lung Disease (GOLD) 2008. Available from: http://www.goldcopd.org.
Who Should Be Screened for
COPD?
• Consider COPD, and perform spirometry, if any of these
indicators are present in an individual over age 40:
– Dyspnoea that is progressive, usually worse with
exercise, and persistent
– Chronic cough (may be intermittent and unproductive)
– Chronic sputum
– History of tobacco smoke exposure
– Exposure to occupational dusts and chemicals
– Risk factors
– Exposure to smoke from home cooking and heating
fuels
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative
for Chronic Obstructive Lung Disease (GOLD) 2008. Available from: http://www.goldcopd.org.
Underdiagnosis of COPD in the
United States
• Over 12.7 million people in
the United States have
been diagnosed with
COPD1
• Data from NHANES III
indicate that approximately
24 million United States
adults have evidence of
impaired lung function
indicative of COPD2,3
• Most (70%) of patients with
undiagnosed COPD are
<65 years of age
1. Pleis JR, et al. Vital Health Stat. 2006;132: 1-153.
2. ManninoDM, et al. MMWR Surveill Summ. 2002;51:1-16.
3. Mannino DM, et al. Proc Am Thorac Soc. 2007;4:502-306.
30%
≥Age 65
70%
<Age 65
Percent with Undiagnosed COPD
COPD Misdiagnosis
Is Common in Women
Hypothetical Male Patient With
COPD Symptoms
65%
Diagnosed as COPD by
65% of physicians
49%
Hypothetical Female Patient
With COPD Symptoms
Diagnosed as COPD by
49% of physicians
COPD symptoms in women were most commonly
misdiagnosed as asthma
Chapman KR, et al. Chest. 2001;119:1691-1695.
Diagnosis of COPD
SYMPTOMS
EXPOSURE TO RISK
FACTORS
cough
tobacco
sputum
occupation
shortness of breath
indoor/outdoor pollution
SPIROMETRY
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative
for Chronic Obstructive Lung Disease (GOLD) 2008. Available from: http://www.goldcopd.org.
Community acquired
pneumonia
Definition
• acute, inflammatory disease afflicted lung alveoly,
respiratory bronchioly and lung intersticium
• Clinical dgn: infiltration on X ray of the chest and
two of the following symptoms: fever over 38 gr. C.,
cough, dyspnoe and tachypnoe over 30/min,
leucocytózis, more than 15% nonsegmented
leucocytes, auscultation pozitive for cracles over
afflicted lobe
• Etiology:
• infection –patogenity vs imunity
• noninfections – aspiration, inhalation of toxic
gases, irradiation, alergy, immunopathy
Epidemiology of
pneumonias
•
•
•
•
•
•
world: 3. most frequent reason of death (WHO)
more frequent in children and older people
more frequent in men
polymorbidity, smoking, alcohol, drugs, social institution
winter season
USA 3-5 milions yearly, UK 261 000, incidence 100-1000/100
000
• mortality influenced by age, 3,8 % in person under 44 years,
6% in age 45 - 64 , over 65 14%, in ICU up to 37%
• USA 6. cause of death
• Czech republic 100 000, 22 000 admission to hospital
Infection agents in
pneumonias
•
UZIS from 22 000 pneumonias unknown etiology in 19 000 !!
• G+ : Streptoc. pneumonie, S. pyogenes, Staphylycoc. aureus
• G- : H. influenzae, Klebsiela pneumon., Pseudomonas aerug.,
Legionella sp, Moraxella catarh.
• anaerobs: Bacteroides spp., Fusobacterium spp.,
Peptosptreptococ. spp.
• viruses: respir. viruses, Myxovirus influenzae A, CMV, EB virus,
herpes virus
• atypical patogens - Chlamydia pn.,psittaci, Mycoplasma
pn.,Legionela s
• mycotic infetion Candida alb., Aspergilus spp. Pneumocystis
carinií- jiroveci,
• protozoa:Toxoplasma gondií, Entamoeba histolytica
Types of pneumonia
• Etiology :
• infection – viruses, bacterial, mycobakterial, mycotic,
protozoa, ,mixed, in most studies in 50% unknown
• noninfection – aspiration, inhaled, intersticial,
hypostatic, postiradiation, hypersenzitive
• Patology-anatomy
• croupous pneumonia, bronchopneumonia ,
intersticial pneumonia
• Radiology:
• lobar, alar, intersticial, with cavitation…
Clinical differentiation - 1
• Community acquired pneumonia – CAP (80-90%)
• Nosocomial pneumonia – HAP ( after 48 hours in hospital
and up to 7 days after leaving hospital)
• Pneumonia in immunocompromited –PIIH ( HIV,
transplantation)
• Ventilator pneumonia – VAP (48 hours after intubation, early
VAP within 4 days after intubation, late after 5 days and
more)
• Pneumonia in social institution – SHP ( US term),
polymorbidity
Clinical differentiation - II
TYPICAL
ATYPICAL patogens
suden
Slow
non expressive
expressive
fever
over 40o C, chills
under 40o
cough
productive
non productive
clinícal findings
wett cracles
small- crepitus
RTG
infiltration
bigger than fysical findings
FW
high
very high
over 15 000
under 15 000
shift to the left
lymfocytózis
onset
extrapulmonary
symptoms
leucocytes
blood count
typical patogenes: clasical bacterial patogens
atypical “
: viruses, Mycoplasma pn., chlamydie,
ricketsie, legionella spp.
Clinical differentiation - III
• light pneumonia: under 50 year, without
comorbidity, out patient care
• moderate pneumonia: polymorbidity, more
extensive X ray findings, short admission is
indicated
• severe pneumonia: alteration of basic vital
function ( Streptococcus pneumonia, G negat.,
mixed infection ). Age over 50
polymorbidity, bilateral X ray infiltration,
confusion ,tachypnoea over 30/min, hypotenzion,
urea over 7 mmol/l, hypoxemia under 8 kPa,
SaO2 lower 92%, sometimes is ventilation
indicated, septic shoc
Diagnostic of CAP
• symptoms: fever, cough, +,- expectoration, dyspnoe,
pain on the chest, extrapulmonary symptoms
• X ray – infiltration
• complication –effusion, empyema, sepsis, ARDS
• microbiology –sputum-microscopy, cultivation
• decision about hospitalisation
• serology (IgM converzion), Legionela antigen in urine ,
bronchoscopical aspiration of secretion in airways
• FW,CRP, leucocytes, blood count , urea, creatinin,
bronchoscopy, haemoculture
Differencial diagnostic of
pneumonias
• is it really pneumonia?
• what is the general status of the patients?
• It acts on which type of pneumonia?? which
patogenes?
• is pneumonia „ primary“ or „secondary “ ?
• immunological status of patients ?
• polymorbidity, age ?
• History of illness – professionality?, travlers habits ,
admission on ICU
• hospitalization ? TB? tumor ?
• firstly to distinquish from tracheobronchitis and
AECOPD
What must clinicians further take in
to the account ?
•
•
•
•
•
general status
social backing
smoking and alcohol habits
other medication which the patients is using
prognostic factors- age over 50, comorbidity,
hypoxemia PaO2 under 8, bill. damage of the
lung, tachypnoe, resistence of patogens
• complication of pneumonia – effusion empyema, lung abscess, bronchopleural
fistulas , BOOP, bronchiectasie, fibrózis
Benign postintubation stenozes
Incidence ? X ray changes in 90%, significant in 8-10%,
symptomatic 1%,
patogenezis ? Local and general factors
balon pressure over 25-30 torr - ischemie,
ulceration, inflammation, fibroblasts,
shock, hypoxie , imunodeficit , keloid
idiopatická subglotic stenózis
Intubation - safe time 24-36 hours adults, 5-6 days children
(?)
Postintubation tracheal
stenózes
• After therapy by laser. incisions Atul Mehta
Idiopatic subglotic stenosis „like
astma“
Therapy of pts with benign
stenoses
• stents Dumon 17x, Ultraflex 6x, T- tubus 5x, Polyflex 2x, aj.
• Surgery recidives 15%
Malignant obstruction
•
•
•
•
•
N= 130
počet sezení 1-9, medián 2
elektrokauter , ND YAG laser všichni - metody srovnatelné
core out
stenty 45 nemocným 49 stentů
Dumon 20x, Ultraflex 20x, Polyflex 2,…
• afterloading -brachyterapie 24 osob
• KI 7%: krvácení 5x, ARI- UPV 2x, arytmie 1x,
pneumomediastinum 1x
malignant stenózes
Survical curves of pts with malig. stenozes by lung
cancer and other malignant tumors (p= 0,0458) 1= C34,
2= other tu
Brachytherapy (BT)
Freitags, dynamic stent