ΦΡΟΝΙΑ ΑΠΟΦΡΑΚΤΙΚΗ ΠΝΕΥΜΟΝΟΠΑΘΕΙΑ ΑΝΑΣΑΙΑ ΑΝΣΩΝΙΑΓΟΤ

Transcript

1 ΦΡΟΝΙΑ ΑΠΟΦΡΑΚΤΙΚΗ ΠΝΕΥΜΟΝΟΠΑΘΕΙΑ ΑΝΑΣΑΙΑ ΑΝΣΩΝΙΑΓΟΤ

2 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

3 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 Global Initiative for Chronic Obstructive Lung Disease

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5 Of the six leading causes of death in the United States, only COPD has been increasing steadily since η αιτία θανάτου Source: Jemal A. et al. JAMA 2005

6 Όιεο απηέο νη λνζνινγηθέο νληόηεηεο κπνξεί λα ζπλππάξρνπλ ζηνλ ίδην αζζελή ACOS=Asthma COPD Overlap Syndrome

7 Υξόληα βξνγρίηηδα : κλινικόρ οπιζμόρ παπαγωγικόρ βήσαρ για 3 μήνερ ηο σπόνο για 2 ζςνεσόμενα σπόνια Blue bloatter Σςνήθωρ καπνιζηήρ

8 Πλεπκνληθό εκθύζεκα : Παθολογοαναηομικόρ οπιζμόρ Παθολογική, μόνιμη διάηαζη ηων αεποσώπων μεηά ηα ηελικά βπογσιόλια και ηην καηαζηποθή ηων ηοισωμάηων ηοςρ σωπίρ παποςζία ίνωζηρ. Pink puffer

9 Global Strategy for Diagnosis, Management and Prevention of COPD Mechanisms Underlying Airflow Limitation in COPD Small Airways Disease Airway inflammation Airway fibrosis, luminal plugs Increased airway resistance Parenchymal Destruction Loss of alveolar attachments Decrease of elastic recoil AIRFLOW LIMITATION 2015 Global Initiative for Chronic Obstructive Lung Disease

10 Professor Peter J. Barnes, MD National Heart and Lung Institute, London UK

11 Professor Peter J. Barnes, MD National Heart and Lung Institute, London UK

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13 Pulmonary Hypertension in COPD Chronic hypoxia Pulmonary vasoconstriction Fev1<25% PO 2 <55 mm Hg Pulmonary hypertension Cor pulmonale Death Edema Muscularization Intimal hyperplasia Fibrosis Obliteration Source: Peter J. Barnes, MD

14 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 hyperreactivity Chronic Bronchitis 2015 Global Initiative for Chronic Obstructive Lung Disease

15 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

16 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

17 Κιηληθά Υαξαθηεξηζηηθά 1. Παξαγσγηθόο βήραο 2. Γύζπλνηα πξνζπαζείαο βαζκηαία επηδεηλνύκελε 3. πρλέο ινηκώδεηο παξνμύλζεηο

18 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 Global Initiative for Chronic Obstructive Lung Disease

19 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 FEV 1 /FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD Global Initiative for Chronic Obstructive Lung Disease

20 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

21 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 FEV 1 /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 Global Initiative for Chronic Obstructive Lung Disease

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23 Spirometry: Normal Trace Showing FEV 1 and FVC 5 FVC Volume, liters FEV 1 = 4L FVC = 5L FEV 1 /FVC = Time, sec 2015 Global Initiative for Chronic Obstructive Lung Disease

24 Spirometry: Obstructive Disease 5 Normal 4 Volume, liters FEV 1 = 1.8L FVC = 3.2L FEV 1 /FVC = 0.56 Obstructive Time, seconds 2015 Global Initiative for Chronic Obstructive Lung Disease

25 Global Strategy for Diagnosis, Management and Prevention of COPD Classification of Severity of Airflow Limitation in COPD* In patients with FEV 1 /FVC < 0.70: GOLD 1: Mild GOLD 2: Moderate GOLD 3: Severe FEV 1 > 80% predicted 50% < FEV 1 < 80% predicted 30% < FEV 1 < 50% predicted GOLD 4: Very Severe FEV 1 < 30% predicted *Based on Post-Bronchodilator FEV Global Initiative for Chronic Obstructive Lung Disease

26 FEV1 and survival in COPD Survival rates in COPD according to percent predicted postbronchodilator FEV1 (PB FEV1) in patients <65 years of age Initial PB FEV1 (% predicted) Culmulative survival rate, percent At 2 years At 5 years At 10 years < At 15 years

27 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 Global Initiative for Chronic Obstructive Lung Disease

28 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 FEV 1 < 50 % of predicted value are indicators of high risk. One or more hospitalizations for COPD exacerbation should be considered high risk Global Initiative for Chronic Obstructive Lung Disease

29 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 Global Initiative for Chronic Obstructive Lung Disease

30 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 α 1 -αληηζξπςίλεο

31 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 (FEV 1, 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 Global Initiative for Chronic Obstructive Lung Disease

32 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% Variable Points on BODE index FEV1 (percent of predicted) Distance walked in 6 minutes (m) MMRC dyspnea scale Body-mass index >21 21

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37 Αμνληθή ηνκνγξαθία ζώξαθνο

38 ΑΔΡΙΑ ΑΙΜΑΣΟ? Υποξαιμία Υπεπκαπνία Αναπνεςζηική οξέωζη Αςξημένα διηηανθπακικά

39 Global Strategy for Diagnosis, Management and Prevention of COPD Differential Diagnosis: COPD and Asthma COPD Onset in mid-life Symptoms slowly Long smoking history progressive ASTHMA Onset early in life (often childhood) 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

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41 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

42 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

43 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 Global Initiative for Chronic Obstructive Lung Disease

44 Consequences Of COPD Exacerbations Negative impact on quality of life Impact on symptoms and lung function Accelerated lung function decline EXACERBATIONS Increased economic costs Increased Mortality 2015 Global Initiative for Chronic Obstructive Lung Disease

45 Ιογενείς λοιμώξεις Παροξύνσεις Αιτιολογία Βακτηριακές λοιμώξεις Ατμοσφαιρικοί ρυπαντές Μεγάλες μεταβολές στη θερμοκρασία Άγνωστες (1/3) ATS/ERS Task force Eur Respir J 2004; 23: 932

46 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

47 Διαθοπική Διάγνωζη 1. Οξεία βπογσίηιδα 2. Πνεςμονία 3. Παπόξςνζη ΧΑΠ 4. Πνεςμοθώπακαρ 5. Πνεςμονική εμβολή 6. Σςμθοπηηική καπδιακή ανεπάπκεια

48 G O lobal Initiative for Chronic bstructive L ung D isease

49 Slovenia Australia Philippines United States Moldova Norway United Kingdom Germany Ireland Yugoslavia Brazil Canada Croatia Austria Portugal Taiwan ROC Thailand Greece Malta China South Africa Syria Saudi Arabia Hong Kong ROC Bangladesh 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 Iceland Macedonia France Turkey Czech Denmark Republic Slovakia Belgium Romania Columbia Ukraine Singapore Spain Uruguay Sweden Albania Kyrgyzstan Vietnam

50 GOLD Website Address November November November November

51 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

52 Usual features of asthma, COPD and ACOS Feature Asthma COPD ACOS Age of onset 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 Lung function Current and/or historical variable airflow limitation, e.g. BD reversibility, AHR Lung function between symptoms Usually childhood but can commence at any age Usually >40 years Chronic usually continuous symptoms, particularly during exercise, with better and worse days FEV 1 may be improved by therapy, but post-bd - FEV 1 /FVC <0.7 persists Usually 40 years, but may have had symptoms as child/early adult Respiratory symptoms including exertional dyspnea are persistent, but variability may be prominent Airflow limitation not fully reversible, but often with current or historical variability May be normal Persistent airflow limitation Persistent airflow limitation GINA 2014, Box 5-2A (1/3) Global Initiative for Asthma

53 Usual features of asthma, COPD and ACOS (continued) Feature Asthma COPD ACOS Past history or family history Time course Many patients have allergies and a personal history of asthma in childhood and/or family history of asthma Often improves spontaneously or with treatment, but may result in fixed airflow limitation History of exposure to noxious particles or gases (mainly tobacco smoking or biomass fuels) Generally slowly progressive over years despite treatment Chest X-ray - Usually normal Severe hyperinflation and other changes of COPD Frequently a history of doctor-diagnosed - asthma (current or previous), allergies, family history of asthma, and/or a history of noxious exposures Symptoms are partly but significantly reduced by treatment. Progression is usual and treatment needs are high. Similar to COPD Exacerbations Exacerbations occur, but risk can be substantially reduced by treatment GINA 2014, Box 5-2A (2/3) 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

54 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 Lung function Past history or family history Time course Symptoms vary over minutes, hours or days Worse during night or early morning Triggered by exercise, emotions including laughter, dust, or exposure to allergens Record of variable airflow limitation (spirometry, peak flow) Normal between symptoms Previous doctor diagnosis of asthma Family history of asthma, and other allergic conditions (allergic rhinitis or eczema) 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 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 Record of persistent airflow limitation (post - BD FEV 1 /FVC <0.7) Abnormal between symptoms Previous doctor diagnosis of COPD, chronic bronchitis or emphysema Heavy exposure to a risk factor: tobacco smoke, biomass fuels 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

55 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 Lung function Past history or family history Time course Symptoms vary over minutes, hours or days Worse during night or early morning Triggered by exercise, emotions including laughter, dust, or exposure to allergens 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 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 Syndromic diagnosis of airways disease The shaded columns list features that, when present, best distinguish Record of variable airflow limitation between asthma (spirometry, and peak COPD. flow) For a patient, Normal count between the number symptoms of check boxes in each column. If 3 or more Previous boxes doctor are diagnosis checked of asthma for either asthma or COPD, that diagnosis Family is history suggested. of asthma, and other allergic If there conditions are similar (allergic numbers rhinitis or of eczema) checked boxes in each column, the diagnosis of ACOS should be considered. Record of persistent airflow limitation (post- BD FEV 1 /FVC <0.7) Abnormal between symptoms Previous doctor diagnosis of COPD, chronic bronchitis or emphysema Heavy exposure to a risk factor: tobacco smoke, biomass fuels 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