内科学课件02-COPD肺心病-八年制

1、Chronic Obstructive Pulmonary Disease(COPD)Chronic Cor Pulmonale慢性阻塞性肺病慢性肺源性心脏病Chronic Obstructive Pulmonary General introductionCOPD慢性阻塞性肺病Chronic bronchitis慢性支气管炎、Emphysema肺气肿Pulmonary hypertension肺动脉高压Chronic Cor Pulmonale慢性肺源性心脏病General introductionCOPD慢性阻塞性肺General conceptCOPD, a common prevent

2、able and treatable disease is characterized by persistent airflow limitation that is usually progressive and associated with enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individ

3、ual patientsGeneral conceptCOPD, a common General conceptThe chronic airflow limitation characteristic ofCOPD is caused by a mixture of small airwaydisease (obstructive bronchiolitis) and parenchymal destruction (emphysema), the relative contributions of which vary from person to person.General conc

4、eptThe chronic airPercent Change in Age-Adjusted Death Rates, U.S., 1965-199800.51.01.52.02.53.0Proportion of 1965 Rate 1965 - 19981965 - 19981965 - 19981965 - 19981965 - 199859%64%35%+163%7%CoronaryHeartDiseaseStrokeOther CVDCOPDAll OtherCausesPercent Change in Age-AdjustedPredicted Mortality of CO

5、PDIschemic heart D 1COPD 6Cerebrovascular D 2LRTI 3Diarrhae 4Perinatal D 5COPD 3Traffic Accident 4Lung cancer 519902020GOLD Report 2006.p11Ischemic heart D 1Cerebrovascular D 2LRTI 3Predicted Mortality of COPDIscCHRONITIS BRONCHITISCHRONITIS BRONCHITISDefinition Chronic bronchitis is a clinical diag

6、nosis based on the symptoms of chronic cough and sputum production.It is defined as persistence of cough and excessive mucus secretion on most days over a 3-month period for at least 2 successive years.Definition Chronic bronchitis DefinitionPatients who have chronic productive cough and normal airf

7、low are diagnosed as having simple chronic bronchitis;Those who demonstrate a progressive decline in airflow have chronic obstructive bronchitis, which constitutes the majority of patients with COPD.DefinitionPatients who have chetiologySmokingAir pollutionInfectionClimateInternal factoretiologySmok

8、ing内科学课件02-COPD肺心病-八年制Clinical features Symptoms: cough, expectorateon of sputum, wheezingSigns: moist and dry rales, rhonchi Clinical features Symptoms: coClassification of Chronic BronchitisClassification of Chronic Bron Stages of Chronic Bronchitis Stages of Chronic BronchitisLab testing CXR PFT

9、Sputum bacteria culture Blood testing Lab testing CXRDiagnosis Clinical diagnosis: Symptoms persisting 3 mons/yr Lasting for 2 consective yrs Exclude other lung and heart disease If shorter than three months /per year then definitive objective evidences are demanded (such as X-Ray and lung function

10、et al.) to diagnose.Diagnosis Clinical diagnosis:Therapy- acute attackAntibiotic therapyCough suppression and mucolyticsBronchodilationNebulization Therapy- acute attackAntibiotiEMPHYSEMAEMPHYSEMADefinition Emphysema is defined pathologically as the presence of permanent enlargement of the airspaces

11、 distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosisDefinition Emphysema is definePathological classification central lobular panacinarmixed type Pathological classification ce内科学课件02-COPD肺心病-八年制Normal distal lung acinusNormal distal lung acinus

12、Centriacinar(centrilobular) emphysema Centriacinar(centrilobular) emPanacinar emphysemaPanacinar emphysema内科学课件02-COPD肺心病-八年制内科学课件02-COPD肺心病-八年制Clinical features primary disease dyspnea general symptoms Clinical features primary disesigns barrel chest reduced respireatory movement and breathing soun

13、d hyperesonance on auscultation moist and dry rales upon chest infection liver papablesigns barrel chestComplications Primary pneumothoraxRespireatory failureCor pulmonaleComplications Primary pneumoth Classification of Emphysema Classification of EmphysemLab Testing CXR:PFT: FEV1/FVC40%, reduced DL

14、co, increased TLCABG Lab Testing CXR:DiagnosisHistory of illnessClinical manifestations&signsPulmonary function: airflow limitation, hyperinflation, increased residual volume(FEV1/FVC120%, RV/TLC 40%, DLco 5 seconds, with pursed lip breathingUse of accessory muscles of respirationQuiet breath sounds

15、 (especially in the lung apices) , wheezeQuiet heart sounds (due to overlying hyperinflated lung)Possible basal crepitationsSigns of cor pulmonale and CO2 retention (ankle oedema, raised JVP, warm peripheries, plethoric conjunctivae, bounding pulse, polycythaemia. Flapping tremor if CO2 acutely rais

16、ed).SignsRaised respiratory rateInvestigationsPulmonary function testsCXRInvestigationsPulmonary functiSpirometry: Normal and COPDSpirometry: Normal and COPDSpirometry: Normal and COPDSpirometry: Normal and COPDCOPD X-rays AstraZenecaCOPD X-rays AstraZenecaCOPD X-rays AstraZenecaCOPD X-rays AstraZen

17、ecaCOPD X-rays AstraZenecaCOPD X-rays AstraZenecaSYMPTOMSChronic coughSputum productionDyspneaEXPOSURE TO RISKFACTORS tobaccooccupationindoor/outdoor pollutionSPIROMETRY, Post-bronchodilator FEV1/FVC10, more symptomaticAssessment of symptoms从不咳嗽一点痰也Assessment of symptomsLess breathlessnessMore breat

18、hlessnessmMRC 2Assessment of symptomsLess breSpirometric Assessment(airflow limitation)Spirometric Assessment(airfloClassification of severity of airflow limitation in COPD Based on post-bronchodilationClassification of severity of Assessment of exacerbation riskAssessment of exacerbation risSoler-C

19、atalua JJ, et al. Thorax. 2005;60:925-931. Permission requested. Frequency of AECOPD and survival1.00.80.60.40.20.00102030405060随访时间(月)AP0.0002BP=0.069CP0.0001生存率（%）1.00.80.60.40.20.00102030405060(1)(3)(4)P0.0001(2)NSNSP=0.005P0.0001生存率（%）随访时间(月)A组无急性加重的患者B组有12次需住院治疗的急性加重的患者C组有3次急性加重的患者(1)组无急性加重的患者(

20、2)组急性加重需要急诊治疗但无需住院(3)组急性加重需要一次住院治疗(4)组急性加重需要反复住院治疗N=304，随访5年Soler-Catalua JJ, et al. Thor存活可能性时间（月）无加重/y1-2次加重/y3次加重/ySoler-Cataluna JJ,et al.Thorax 2005; 60(11):925-931.Assessment of exacerbation risk57时间（月）无加重/y1-2次加重/y3次加重/ySolerCombined COPD assessmentCombined COPD assessmentGOLD 4GOLD 3GOLD 2GO

21、LD 1mMRC 0-1CAT 10mMRC 2+CAT 10+2次或更多1次以上住院(只要出现至少一次由急性加重导致的住院即可被视为高风险)COPD综合评估 2 1 0(C)(D) (A)(B)mMRC 0-1CAT 2CAT 10 Symptoms(mMRC or CAT score)低风险（A or B）GOLD 1 or 2 0或1次急性加重/年高风险(C or D)GOLD 3 or 4 2 次急性加重/年(只要出现至少一次由急性加重导致的住院即可被视为高风险)COPD综合评估总结GOLD 201162Risk Risk 2 1 0(C)(D) (A)(BDifferential d

22、iagnosisBronchial asthmaBronchiectasisPulmonary tuberculosisInterstitial lung diseaseLung cancerCongestive heart failureDifferential diagnosisBronchiaStable COPDAcute exacerbation of COPD (AECOPD)Stable COPDExacerbation of COPDAn exacerbation of COPD is an acute event characterized by a worsening of

23、 patients respiratory symptoms that is beyond normal day-to-day variations and leads to a change of medication.Exacerbation can be precipitated by several factors.The most common causes of an exacerbation appears to be viral upper respiratory infection and infection of the tracheobronchial tree. Exa

24、cerbation of COPDAn exacerbManagement Stable COPDManagement Stable COPDGoal of treatment of stable COPDGoal of treatment of stable CO 缓解症状 提高运动耐力 改善健康状况 预防疾病进展 预防和治疗急性加重 降低死亡率GOLD 2013减少当前症状降低未来风险稳定期COPD的治疗目标68 缓解症状GOLD 2013减少当前症状降低未来风险稳定期Medications for COPDShort-acting bronchodilators: Salbuterol(

25、沙丁胺醇), terbutaline（特布他林）, iprotropium bromide（异丙托品）Long-acting bronchodilators: Salmeterol（沙美特罗）, formoterol（福莫特罗）, tiotropium（噻托溴铵）Combined short-acting bronchodilator: Salbuterol-iptotropiumMethylxanthione: Aminophylline, theophylline(slow-released)Inhaled corticosteroids: Beclomethasone（二丙酸倍氯米松）,

26、 budesonide（布地奈德）, fluticasone（氟替卡松）Combined steroid-long-acting bronchodilators: Salmeterol/fluticasone, formoterol/budesonideMedications for COPDShort-acti吸入装置吸入装置吸入装置吸入装置Bronchodilators in stable COPDBronchodilators in stable COPD内科学课件02-COPD肺心病-八年制Treatment Group AFew symptoms and low risk of ex

27、acerbationShort-acting bronchodilators as needed therapy first optionCombined Short-acting bronchodilatorsalternative therapyLong-acting bronchodilatorsalternative therapyTreatment Group AFew symptomTreatment Group BMore symptoms and low risk of exacerbationLong-acting bronchodilators as needed or p

28、rn therapyPts with severe breathlessness, combined Long-acting bronchodilatorsTreatment Group BMore symptoTreatment Group CFew symptoms and high risk of exacerbationCombination of inhaled corticosteroid/long-acting 2 agonist or anticholinergicsfirst choiceCombination of two Long-acting bronchodilato

29、rsalternative therapyCombination of inhaled corticosteroid/long-acting anticholinergicsCombination of phosphodiesterase 4 inhibitors with long-acting bronchodilatorschronic bronchitisTreatment Group CFew symptomTreatment Group DMore symtoms and high risk of exacerbationsInhaled corticosteroid plus l

30、ong-acting 2 agonist or long-acting anticholinergicsfirst choiceCombiantion of all three classes of drugs(Inhaled corticosteroid/long-acting 2 agonist/long-acting anticholinergics)second choicePhosphodiesterase 4 inhibitors may be added- if chronic bronchitisTreatment Group DMore symtomBronchodilato

31、rs-recommendationBronchodilators-recommendatioCOPD稳定期药物治疗方案COPD稳定期药物治疗方案Non-pharmacological management of stable COPDSmoking cessation Education can improve ability to manage illness and stop smoking.Pulmonary rehabilitation :graded exercise, but includes breathing techniques Oxygen Surgical therapy

32、Non-pharmacological managementSmoking cessationSmoking cessationOxygen therapy-indications PaO2 55 mm Hg or SaO2 55%)Oxygen is usually delivered by a facemask or nasla canula, with appropriate inspiratory flow rates varying between 1-2L/min with PaO260mmHg or SaO290%, 15h/dOxygen therapy-indications

33、Management AECOPDManagement AECOPDManage ExacerbationsInhaled bronchodilators (beta2-agonists and/or anticholinergics), theophylline, and systemic, preferably oral, glucocortico-steroids are effective for the treatment of COPD exacerbations .Manage ExacerbationsInhaled brManagement of AECOPDAntibiot

34、ics if sputum purulent, pyrexial, CRP, new changes on CXR.Inhaled or nebulized bronchodilatorsSystemic steroids for all patients with exacerbations of COPD who are admitted to hospital. Give prednisolone 30 -40mg/day for 1-2 weeks, unless there are specific contra-indications. This shortens the reco

35、very time. Controlled oxygen therapy 25mmHgExertional PAPm30mmHg PULMONARY HYPERTENSIONPulmonryWHO classification of pulmonary hypertension Pulmonary arterial hypertension Idiopathic pulmonary arterial hypertension (primary pulmonary hypertension). Familial pulmonary arterial hypertension (FPAH), Re

36、lated to:Collagen vascular disease. Portal hypertension.HIV infection.Drugs/toxins: othersPulmonary venous hypertension Left-sided atrial or ventricular heart disease Left-sided valvular heart disease.Pulmonary hypertension associated with hypoxaemia Chronic obstructive pulmonary disease Interstitia

37、l lung disease Sleep disordered breathing Alveolar hypoventilation disorders Chronic high altitude exposure.Pulmonary hypertension due to chronic thrombotic and/or embolic disease Thromboembolic obstruction of proximal pulmonary arteries Obstruction of distal pulmonary arteriesPulmonary embolism (th

38、rombus, tumour, ova, parasites, foreign material)In situ thrombosisSickle cell disease.Pulmonary hypertension associated with miscellaneous disordersWHO classification of pulmonarPathogenesis of pulmonary hypertension1、血管器质性病变：Thickening,stenosis/obstruction decrease in vascular bed pulmonary hypert

39、ension right ventricular hypertrophy Cor pulmonale pressure area R=Pathogenesis of pulmonary hype2、Physiological aspect hypoxia Body fluid factor Tissue Factor Neurologic FactorHistamine, permeability to Ca+ hypoxia,hypercapnia AT-II,5-TH,LT,TXB2,PG Couple-excitation sympathetic tone Constriction of

40、 pylmonary artery Pulmonary hypertensionPathogenesis of pulmonary hypertension3、 Blood volume and viscosity 2、Physiological aspectPathogenClinical Features Cardio-pulmonary compensatory phaseSymptoms：chronic cough,sputum,dyspnea, exertional palpation, fatigue, exercise toleranceSigns：emphysema barre

41、l chest,hyperresonance, liver dullness, cardiac dullness, respiratory sound, pulmonary hypertension: P2, tricuspid valve SM, jugular vein distensionClinical Features Cardio-pulmRespiratory failure: after acute respiratory infection，dyspnea, headach, insomnia, altered consciousness.Right hear failure

42、：dyspnea, palpation, oliguria/cyanosis, abdominal distension, loss of appetite,nausea and vomiting。Signs：Jugular vein distension, gallop, tricuspid SM, arrythmia, hepatomegaly, hepatojajular reflux+, edema and ascitesCyanosisClinical Features Cardio-pulmonary decompensatory phaseRespiratory failure:

43、 after acuECGClockwise rotation of the electric axis with a mean QRS axis +90P-pulmonale pattern (an increase in P-wave amplitude in II, III, AVF 0.25mV) Rv1+Sv5 1.05mVV1-3 QS waveIncomplete (and rarely complete) right bundle-branch blockECGClockwise rotation of the e内科学课件02-COPD肺心病-八年制ECGECGLab Fin

44、dings CXRDialatation of the right pulmonary artery，15mm， 2mmBulging of pulmonary A 肺动脉段凸出，高度 3mmDilated pulmonary outflow tract，锥高 7mmDilatation of central pulmonary，外周血管纤细。残根状右室大：心尖上翘 Lab Findings CXRDialatation of内科学课件02-COPD肺心病-八年制内科学课件02-COPD肺心病-八年制内科学课件02-COPD肺心病-八年制Pulmonary hypertensionPulmon

45、ary hypertensionCardiac echogram Enlargement of right atrium, hypertrophy and dilatation of right wentricleMore sensitive than ECG&CXR, 60.6%87%Early and sensitive diagnostic methodCardiac echogram Enlargement oOthersBlood gas analysis：Blood test：WBC、Hb,BUN, GPTElectrolyte disturbance：Sputum exam fo

46、r bacteriaOthersBlood gas analysis：Diagnosis and differential diagnosisHistorysymptoms and signslab test clinical diagnosisCoronary heart diseaseRheumatic heart diseasePrimary cardiomyopathyCyanostic congenital heart disease Diagnosis and differential diaComplicationsPulmonary encephalopathy：hepatic

47、, neurologic, hyponatremicAcid-base&electrolyte disturbanceArrythmia: superventricularShock: septic, hypovolumic, cardiogenicGI bleedingDICComplicationsPulmonary encephaTreatmentCardiopulmonary compensatory phaseCardiopulmonary decompensatory phaseTreatmentCardiopulmonary compeTreatment Cardiopulmonary compensatory phaseAvoid triggers for acute exacerbationTreatment of primary disea