Transcript COPD
ΦΡΟΝΙΑ ΑΠΟΦΡΑΚΤΙΚΗ ΠΝΕΥΜΟΝΟΠΑΘΕΙΑ ΑΝΑΣΑΙΑ ΑΝΣΩΝΙΑΓΟΤ Υξνλία Απνθξαθηηθή Πλεπκνλνπάζεηα Η Υξνλία Απνθξαθηηθή Πλεπκνλνπάζεηα είλαη κηα λνζνινγηθή νληόηεηα πνπ ραξαθηεξίδεηαη από ηελ πξννδεπηηθή θαη κε πιήξσο αλαζηξέςηκε κείσζε ηεο εθπλεπζηηθήο ξνήο ηνπ αέξα ζηνπο αεξαγσγνύο Global Strategy for Diagnosis, Management and Prevention of COPD Definition of COPD COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients. © 2015 Global Initiative for Chronic Obstructive Lung Disease Of the six leading causes of death in the United States, only COPD has been increasing steadily since 1970 3η αιτία θανάτου Source: Jemal A. et al. JAMA 2005 Όιεο απηέο νη λνζνινγηθέο νληόηεηεο κπνξεί λα ζπλππάξρνπλ ζηνλ ίδην αζζελή ACOS=Asthma COPD Overlap Syndrome Υξόληα βξνγρίηηδα : κλινικόρ οπιζμόρ παπαγωγικόρ βήσαρ για 3 μήνερ ηο σπόνο για 2 ζςνεσόμενα σπόνια Blue bloatter Σςνήθωρ καπνιζηήρ Πλεπκνληθό εκθύζεκα : Παθολογοαναηομικόρ οπιζμόρ Παθολογική, μόνιμη διάηαζη ηων αεποσώπων μεηά ηα ηελικά βπογσιόλια και ηην καηαζηποθή ηων ηοισωμάηων ηοςρ σωπίρ παποςζία ίνωζηρ. Pink puffer Global Strategy for Diagnosis, Management and Prevention of COPD Mechanisms Underlying Airflow Limitation in COPD Small Airways Disease Parenchymal Destruction • Airway inflammation • Airway fibrosis, luminal plugs • Increased airway resistance • Loss of alveolar attachments • Decrease of elastic recoil AIRFLOW LIMITATION © 2015 Global Initiative for Chronic Obstructive Lung Disease Professor Peter J. Barnes, MD National Heart and Lung Institute, London UK Professor Peter J. Barnes, MD National Heart and Lung Institute, London UK Pulmonary Hypertension in COPD Chronic hypoxia Pulmonary vasoconstriction Muscularization Pulmonary hypertension Intimal hyperplasia Fibrosis Cor pulmonale Obliteration Fev1<25% Edema PO2<55 mm Hg Death Source: Peter J. Barnes, MD Global Strategy for Diagnosis, Management and Prevention of COPD Risk Factors for COPD Genes Exposure to particles Tobacco smoke Occupational dusts, organic and inorganic Indoor air pollution from heating and cooking with biomass in poorly ventilated dwellings Outdoor air pollution Lung growth and development Gender Age Respiratory infections Socioeconomic status Asthma/Bronchial Chronic Bronchitis © 2015 Global Initiative for Chronic Obstructive Lung Disease hyperreactivity Global Strategy for Diagnosis, Management and Prevention of COPD Risk Factors for COPD Genes Infections Socio-economic status Aging Populations © 2015 Global Initiative for Chronic Obstructive Lung Disease Κάπληζκα : ν ζεκαληηθόηεξνο παξάγνληαο θηλδύλνπ 80% ηων αζθενών με σπόνια βπογσίηιδα είναι καπνιζηέρ Διπλάζια εωρ ηπιπλάζια μείωζη ζηον FEV1 Αύξηζη ηος κινδύνος θανάηος καηά 2-20% Αιιά Μόλν 15-25% ησλ θαπληζηώλ ζα θαηαιήμνπλ κε COPD Κιηληθά Υαξαθηεξηζηηθά 1. Παξαγσγηθόο βήραο 2. Γύζπλνηα πξνζπαζείαο βαζκηαία επηδεηλνύκελε 3. πρλέο ινηκώδεηο παξνμύλζεηο Global Strategy for Diagnosis, Management and Prevention of COPD Symptoms of COPD The characteristic symptoms of COPD are chronic and progressive dyspnea, cough, and sputum production that can be variable from day-to-day. Dyspnea: Progressive, persistent and characteristically worse with exercise. Chronic cough: May be intermittent and may be unproductive. Chronic sputum production: COPD patients commonly cough up sputum. © 2015 Global Initiative for Chronic Obstructive Lung Disease Global Strategy for Diagnosis, Management and Prevention of COPD Diagnosis and Assessment: Key Points A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and a history of exposure to risk factors for the disease. Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD. © 2015 Global Initiative for Chronic Obstructive Lung Disease Global Strategy for Diagnosis, Management and Prevention of COPD Diagnosis of COPD SYMPTOMS shortness of breath chronic cough sputum EXPOSURE TO RISK FACTORS tobacco occupation indoor/outdoor pollution è SPIROMETRY: Required to establish diagnosis © 2015 Global Initiative for Chronic Obstructive Lung Disease Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of Airflow Limitation: Spirometry Spirometry should be performed after the administration of an adequate dose of a shortacting inhaled bronchodilator to minimize variability. A post-bronchodilator FEV1/FVC < 0.70 confirms the presence of airflow limitation. Where possible, values should be compared to age-related normal values to avoid overdiagnosis of COPD in the elderly. © 2015 Global Initiative for Chronic Obstructive Lung Disease Spirometry: Normal Trace Showing FEV1 and FVC FVC 5 Volume, liters 4 FEV1 = 4L 3 FVC = 5L 2 FEV1/FVC = 0.8 1 1 2 3 4 5 6 Time, sec © 2015 Global Initiative for Chronic Obstructive Lung Disease Spirometry: Obstructive Disease Normal 5 Volume, liters 4 3 FEV1 = 1.8L 2 FVC = 3.2L Obstructive FEV1/FVC = 0.56 1 1 2 3 4 5 6 Time, seconds © 2015 Global Initiative for Chronic Obstructive Lung Disease Global Strategy for Diagnosis, Management and Prevention of COPD Classification of Severity of Airflow Limitation in COPD* In patients with FEV1/FVC < 0.70: GOLD 1: Mild FEV1 > 80% predicted GOLD 2: Moderate 50% < FEV1 < 80% predicted GOLD 3: Severe 30% < FEV1 < 50% predicted GOLD 4: Very Severe FEV1 < 30% predicted *Based on Post-Bronchodilator FEV1 © 2015 Global Initiative for Chronic Obstructive Lung Disease FEV1 and survival in COPD Survival rates in COPD according to percent predicted postbronchodilator FEV1 (PB FEV1) in patients <65 years of age Culmulative survival rate, percent Initial PB FEV1 (% predicted) At 2 years At 5 years At 10 years At 15 years <20 44 11 11 0 20-29 65 30 10 3 30-39 83 47 21 7 40-49 92 89 39 30 50-59 95 95 57 32 60+ 100 89 89 67 Global Strategy for Diagnosis, Management and Prevention of COPD Assess COPD Comorbidities COPD patients are at increased risk for: • • • • • • • Cardiovascular diseases Osteoporosis Respiratory infections Anxiety and Depression Diabetes Lung cancer Bronchiectasis These comorbid conditions may influence mortality and hospitalizations and should be looked for routinely, and treated appropriately. © 2015 Global Initiative for Chronic Obstructive Lung Disease Global Strategy for Diagnosis, Management and Prevention of COPD Assess Risk of Exacerbations To assess risk of exacerbations use history of exacerbations and spirometry: Two or more exacerbations within the last year or an FEV1 < 50 % of predicted value are indicators of high risk. One or more hospitalizations for COPD exacerbation should be considered high risk. © 2015 Global Initiative for Chronic Obstructive Lung Disease Global Strategy for Diagnosis, Management and Prevention of COPD Additional Investigations Chest X-ray: Seldom diagnostic but valuable to exclude alternative diagnoses and establish presence of significant comorbidities. Lung Volumes and Diffusing Capacity: Help to characterize severity, but not essential to patient management. Oximetry and Arterial Blood Gases: Pulse oximetry can be used to evaluate a patient’s oxygen saturation and need for supplemental oxygen therapy. Alpha-1 Antitrypsin Deficiency Screening: Perform when COPD develops in patients of Caucasian descent under 45 years or with a strong family history of COPD. © 2015 Global Initiative for Chronic Obstructive Lung Disease Υξήζηκεο γηα ηε δηάγλσζε θαη γηα ηελ εθηίκεζε ηεο βαξύηεηαο ηεο λόζνπ εμεηάζεηο πηξνκέηξεζε πξν θαη κεηά βξνγρνδηαζηνιή Αθηηλνγξαθία Αμνληθή ηνκνγξαθία Μέηξεζε αεξίσλ αξηεξηαθνύ αίκαηνο Πξνζδηνξηζκόο α1-αληηζξπςίλεο Global Strategy for Diagnosis, Management and Prevention of COPD Additional Investigations Exercise Testing: Objectively measured exercise impairment, assessed by a reduction in self-paced walking distance (such as the 6 min walking test) or during incremental exercise testing in a laboratory, is a powerful indicator of health status impairment and predictor of prognosis. Composite Scores: Several variables (FEV1, exercise tolerance assessed by walking distance or peak oxygen consumption, weight loss and reduction in the arterial oxygen tension) identify patients at increased risk for mortality. © 2015 Global Initiative for Chronic Obstructive Lung Disease Variables and point values used for the computation of the body-mass index, degree of airflow obstruction and dyspnea, and exercise capacity (BODE) index* The approximate 4-year survival is as follows: 0-2 points = 80% 3-4 points = 67% 5-6 points = 57% 7-10 points = 18% Points on BODE index Variable 0 1 2 3 FEV1 (percent of predicted) 65 50-64 36-49 35 Distance walked in 6 minutes (m) 350 250-349 150-249 149 2 3 MMRC dyspnea scale 0-1 Body-mass index >21 21 4 Αμνληθή ηνκνγξαθία ζώξαθνο ΑΔΡΙΑ ΑΙΜΑΣΟ? Υποξαιμία Υπεπκαπνία Αναπνεςζηική οξέωζη Αςξημένα διηηανθπακικά Global Strategy for Diagnosis, Management and Prevention of COPD Differential Diagnosis: COPD and Asthma COPD • Onset in mid-life • • Symptoms slowly Long smoking history ASTHMA • Onset early in life (often childhood) • progressive • • • Symptoms vary from day to day Symptoms worse at night/early morning Allergy, rhinitis, and/or eczema also present Family history of asthma © 2015 Global Initiative for Chronic Obstructive Lung Disease Φπζηθή Ιζηνξία ηεο Νόζνπ Η ειηθία εκθάληζεο ηνπ παξαγσγηθνύ βήρα (>3 κήλεο –2 ρξόληα) νξηνζεηεί ηελ έλαξμε ηεο Υξ. Βξνγρίηηδαο Η ειηθία εκθάληζεο δύζπλνηαο πξνζπαζείαο πξννδεπηηθά επηδεηλνύκελεο αληρλεύεη θαη νξηνζεηεί θαηά θάπνην ηξόπν ηελ αλάπηπμε απόθξαμεο ησλ πεξηθεξηθώλ αεξαγσγώλ Η ειηθία εκθάληζεο νηδεκάησλ ζηα θάησ άθξα νξηνζεηεί ην πξώην επεηζόδην αλεπάξθεηαο ηεο πλεπκνληθήο θαξδηάο Παπόξςνζη Χπόνιαρ Αποθπακηικήρ Πνεςμονοπάθειαρ Χαπακηηπιζηικό ηηρ θςζικήρ ποπείαρ ηηρ νόζος Αλλαγή ζηο βαθμό ηηρ καθημεπινήρ δύζπνοιαρ, ηος βήσα και/ή ηηρ παπαγωγήρ πηςέλων ηέηοια πος να απαιηεί αλλαγή ζηη θεπαπεςηική ανηιμεηώπιζη ATS/ERS Task force Eur Respir J 2004; 23: 932 Global Strategy for Diagnosis, Management and Prevention of COPD Manage Exacerbations An exacerbation of COPD is: “an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal dayto-day variations and leads to a change in medication.” © 2015 Global Initiative for Chronic Obstructive Lung Disease Consequences Of COPD Exacerbations Impact on symptoms and lung function Negative impact on quality of life EXACERBATIONS Accelerated lung function decline Increased economic costs Increased Mortality © 2015 Global Initiative for Chronic Obstructive Lung Disease Παροξύνσεις Αιτιολογία Ιογενείς λοιμώξεις Βακτηριακές λοιμώξεις Ατμοσφαιρικοί ρυπαντές Μεγάλες μεταβολές στη θερμοκρασία Άγνωστες (1/3) ATS/ERS Task force Eur Respir J 2004; 23: 932 Παροξύνσεις ΧΑΠ Οι καπνιστές πιο συχνά από τους τέως καπνιστές (<1/3) Η θνητότητα στο νοσοκομείο 11%, η θνητότητα έξω στους επόμενους 6 και 12 μήνες, 33 και 43% αντίστοιχα Οι επιβιώσαντες την νοσηλεία έχουν 50% πιθανότητες νέας νοσηλείας στους επόμενους 6 μήνες Διαθοπική Διάγνωζη 1. 2. 3. 4. 5. 6. Οξεία βπογσίηιδα Πνεςμονία Παπόξςνζη ΧΑΠ Πνεςμοθώπακαρ Πνεςμονική εμβολή Σςμθοπηηική καπδιακή ανεπάπκεια G lobal Initiative for Chronic O bstructive L ung D isease Saudi Arabia Bangladesh Slovenia Ireland Germany Australia Yugoslavia Croatia Canada Philippines Brazil Austria Taiwan ROC United States Portugal Thailand Malta Norway Greece Moldova China Syria South Africa United Kingdom Hong Kong ROC Italy New Zealand Nepal Chile Israel Argentina Mexico Pakistan Russia United Arab Emirates Peru Japan Poland Korea GOLD National Leaders Netherlands Egypt Switzerland India Venezuela Georgia France Macedonia Iceland Czech Denmark Turkey Belgium Slovakia Republic Singapore Spain Columbia Ukraine Romania Uruguay Sweden Kyrgyzstan Vietnam Albania GOLD Website Address http://www.goldcopd.org November 20 2013 November 19 2014 November 18 2015 November 16 2016 Definitions Asthma Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation. [GINA 2014] COPD COPD is a common preventable and treatable disease, characterized by persistent airflow limitation that is usually progressive and associated with enhanced chronic inflammatory responses in the airways and the lungs to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients. [GOLD 2015] Asthma-COPD overlap syndrome (ACOS) [a description] Asthma-COPD overlap syndrome (ACOS) is characterized by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD. ACOS is therefore identified by the features that it shares with both asthma and COPD. GINA 2014, Box 5-1 © Global Initiative for Asthma Usual features of asthma, COPD and ACOS Feature Asthma COPD ACOS Age of onset Usually childhood but can commence at any age Usually >40 years Usually ≥40 years, but may have had symptoms as child/early adult Pattern of respiratory symptoms Symptoms vary over time (day to day, or over longer period), often limiting activity. Often triggered by exercise, emotions including laughter, dust, or exposure to allergens Chronic usually continuous symptoms, particularly during exercise, with ‘better’ and ‘worse’ days Respiratory symptoms including exertional dyspnea are persistent, but variability may be prominent Lung function Current and/or historical variable airflow limitation, e.g. BD reversibility, AHR FEV1 may be improved by therapy, but post-BD FEV1/FVC <0.7 persists Airflow limitation not fully reversible, but often with current or historical variability Lung function May be normal between symptoms Persistent airflow limitation Persistent airflow limitation GINA 2014, Box 5-2A (1/3) © Global Initiative for Asthma Usual features of asthma, COPD and ACOS (continued) Feature Asthma Past history or Many patients have family history allergies and a personal history of asthma in childhood and/or family history of asthma COPD History of exposure to noxious particles or gases (mainly tobacco smoking or biomass fuels) ACOS Frequently a history of doctor-diagnosed asthma (current or previous), allergies, family history of asthma, and/or a history of noxious exposures Time course Often improves Generally slowly progressive Symptoms are partly but spontaneously or with over years despite treatment significantly reduced by treatment, but may result in treatment. Progression is fixed airflow limitation usual and treatment needs are high. Chest X-ray - Usually normal Exacerbations Exacerbations occur, but risk can be substantially reduced by treatment GINA 2014, Box 5-2A (2/3) Severe hyperinflation and other changes of COPD Similar to COPD Exacerbations can be reduced by treatment. If present, comorbidities contribute to impairment Exacerbations may be more common than in COPD but are reduced by treatment. Comorbidities can contribute to impairment. © Global Initiative for Asthma Features that (when present) favor asthma or COPD Feature Favors asthma Favors COPD Age of onset Before age 20 years After age 40 years Pattern of respiratory symptoms Symptoms vary overminutes, hours or days Worse during night or early morning Triggered by exercise, emotions including laughter, dust, or exposure to allergens Symptoms persist despite treatment Good and bad days, but always daily symptoms and exertional dyspnea Chronic cough and sputum preceded onset of dyspnea, unrelated to triggers Lung function Record of variable airflow limitation (spirometry, peak flow) Normal between symptoms Record of persistent airflow limitation (post-BD FEV1/FVC <0.7) Abnormal between symptoms Past history or family history Previous doctor diagnosis of asthma Previous doctor diagnosis of COPD, chronic bronchitis or emphysema Family history of asthma, and other allergic conditions (allergic rhinitis or eczema) Heavy exposure to a risk factor: tobacco smoke, biomass fuels Time course No worsening of symptoms over time. Symptoms vary seasonally, or from year to year May improve spontaneously, or respond immediately to BD or to ICS over weeks Symptoms slowly worsening over time (progressive course over years) Rapid-acting bronchodilator treatment provides only limited relief Chest X-ray Normal Severe hyperinflation GINA 2014, Box 5-2B (3/3) © Global Initiative for Asthma Features that (when present) favor asthma or COPD Feature Age of onset Favors asthma Before age 20 years Symptoms vary overminutes, hours or days Worse during night or early morning Triggered by exercise, emotions including dust, or to allergens Syndromic laughter, diagnosis ofexposure airways disease Pattern of respiratory symptoms Favors COPD After age 40 years Symptoms persist despite treatment Good and bad days, but always daily symptoms and exertional dyspnea Chronic cough and sputum preceded onset of dyspnea, unrelated to triggers The shaded columns list features that, when present, best distinguish Record of variable airflow limitation Record of persistent airflow limitation between asthma and COPD. (spirometry, peak flow) (post-BD FEV1/FVC <0.7) For a patient, count the number of check boxesinAbnormal each column. between symptoms between symptoms Normal orIf 3 or more boxes checked for either asthma ordoctor COPD, that of COPD, Past history Previous doctor are diagnosis of asthma diagnosis Previous is history suggested. family history diagnosis chronic bronchitis or emphysema of asthma, and other allergic Family If thereconditions are similar numbers checked boxes in each column, (allergic rhinitis orof eczema) exposure to a riskthe factor: tobacco Heavy diagnosis of ACOS should be considered. smoke, biomass fuels Lung function Time course No worsening of symptoms over time. Symptoms vary seasonally, or from year to year May improve spontaneously, or respond immediately to BD or to ICS over weeks Symptoms slowly worsening over time (progressive course over years) Rapid-acting bronchodilator treatment provides only limited relief Chest X-ray Normal Severe hyperinflation GINA 2014, Box 5-2B (3/3) © Global Initiative for Asthma