Instructions for the 4 th course students, 8 semester icon

Instructions for the 4 th course students, 8 semester




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НазваInstructions for the 4 th course students, 8 semester
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Clinical Findings



Initially, cough with sputum production, often in the morning, may be the only symptom. Gradually the cough and sputum production increase and symptoms of dyspnea on exertion develop.

As the disease progresses, the patient's course is usually marked by recurrent episodes of acute respiratory failure resulting from infectious exacerbations of the bronchitis. Clinically, these are marked by increased cough, change in sputum from clear and mucoid to purulent, fever, dyspnea, and varying degrees of respiratory distress. Respiratory failure often ensues, with both elevated PaCO2 and diminished PaO2. These episodes are often reversible at first with appropriate antibiotics, bronchodilators, and respiratory therapy.

Signs and symptoms of cor pulmonale are frequent in chronic bronchitis and are exacerbated along with episodes of acute respiratory failure.

The course of the disease is one of gradual increase in frequency and severity of episodes of acute infection and respiratory failure, eventually resulting in intubation and the need for almost constant ventilatory assistance. Death usually occurs during an episode of respiratory failure.

Depending on the stage in which the patient is examined, the physical findings may vary. During relatively quiescent periods, the only finding may be increased anteroposterior diameter of the chest, hyperresonance to percussion, prolonged expiratory phase, rales, mainly low and medium-pitched, are audible in most patients, and wheezing. Later, the patient may manifest the signs and symptoms of pulmonary hypertension and right ventricular failure, ie, increased second heart sound, pedal edema, hepatomegaly, and ascites. These patients commonly have a plethoric appearance resulting from secondary polycythemia.

If examined during an acute attack, the patient will be in respiratory distress, as evidenced by tachypnea and use of accessory muscles of respiration, in addition to the signs described above. Cough is often prominent, and cyanosis during acute attacks is not uncommon.


^ X-Ray Findings

Chest x-rays show evidence of pulmonary overinflation, with increased anteropostenor diameter, flattened diaphragms, and increased retrosternal air space. There are often prominent and increased bronchial markings at the lung bases, seen as parallel or tapering shadows ("tram lines"), which reflect the increased thickness of the bronchial wall. Bullae of varying sizes may be seen primarily in the upper lung fields rather than the lung bases.


^ Studying of external respiration functions


Spirometry is obligatory when diagnosing COPD. It’s also necessary for estimating the level of gravity and for periodical monitoring to assess disease progression.

For patients with mild and moderate COPD slight decrease of both forced expiration volume during the first second (FEV1) and forced vital capacity of the lungs (FVCL) is characteristic. The value of FEV1 after introducing bronchial spasmolytic < 80% on the background of the ratio FEV1/FVCL < 70% proves the presence of limitation of respiratory tracts which is not fully reversible. If there is no possibility for a spirometric research, then forced expiration lasting more than 6 seconds is a rough but useful decrease detection-predictor of the ratio FEV1/FVCL < 50%.

With disease progression bronchial obstruction grows, total bronchial resistance (Rtot) rises, expiratory lungs hyperinflation appears and increases, air traps develop in the lungs, which results from resilient lung return loss and respiratory tracts collapse, the structure of total lung capacity (TLC) is redistributed. In order to give an integrated assessment of these indices it’s necessary to carry out a more profound and informative research – total bodyplethysmography. In difficult diagnostic cases diffuse capacity of the lungs, which reveals gas exchange disturbances, is measured to make a decision concerning operative intervention.

To carry out the monitoring of COPD progression, to assess the efficacy of prescribed medicines in certain patients annual spirometry is carried out. Thus, in healthy people annual decrease of FEV1 is < 30ml, in patients with COPD it’s 30-60ml and more.

Arterial blood gases measuring is carried out in patients with FEV1 < 40% of the due, or if clinical presentations of lung insufficiency, right heart portions insufficiency are observed.


^ Clinical and functional monitoring


Frequency of visits to a doctor depends on the gravity of COPD and grows with increase of disease gravity. Visits can be planned and unplanned (e.g. if the state worsens or undesirable therapy manifestations, exacerbations are observed, etc.). During every visit noxious agents influence, the status of smoking are estimated; also disease progression and appearance of aftereffects; efficacy of earlier prescribed medicines is assessed, if necessary – medication dosing is changed, undesirable therapy manifestations are detected; anamnesis of exacerbation is studied (frequency, gravity are estimated, the causative agent is identified, if possible); also concomitant pathology; compliance of the sick man and skills in handling inhaler are checked. Spirometric examination is carried out periodically (usually once a year or when significant aggravation of symptoms or complications are observed).


^ Classification of COPD.


There are 4 stages of COPD according to the levels of gravity of the disease which are singled out after results of examination of the patient during clinically stable period in case there is no exacerbation. Intensity of clinical signs of the disease and of functional characteristics of broncoobstructive syndrome are taken into consideration. COPD stage (levels of gravity) signs

^ Stage and level of gravity of COPD



Signs of COPD


1. mild

- FEV1/FVCL < 70%

- FEV1 ≥ 80% of the due

- usually but not always chronic cough, expectorations

2. moderate

- FEV1/FVCL < 70%

- 50% ≤ FEV1 < 80% of the due

- Symptoms are aggravating, exertional dyspnea and dyspnea after complications

appear


3. severe

- FEV1/FVCL < 70%

- 30% ≤ FEV1 < 80% of the due

- Dyspnea intensifies, repeated exacerbations, which worsen patients’ lives


4. very severe

- FEV1^ /FVCL < 70%*, FEV1 < 30% of the due, or FEV1 < 30% of the due in the

presence of chronic lung insufficiency

- Further aggravation of symptoms, life quality is considerably worsened,

exacerbations may threaten life



Notice.

*In case of very severe COPD and significant decrease of FVCL ratio FEV1/FVCL increases and loses diagnostic value.


^ Treatment of patient with COPD


Main treatment principles of patients with COPD are: gradual treatment intensity grows depending on the gravity level of the disease; regularity, constancy of basic therapy corresponding to the gravity level of the disease; variability of individual drug response denotes the necessity of attentive and regular monitoring of clinicofunctional characteristics of the disease.


When treating COPD, preference is given to inhalation way of introducing medicines – bronchial spasmolytics, inhalation corticosteroids, combined medicines. Efficacy of this route of administration depends significantly on the patient’s mastering inhalation technique. When indicating high medication dosing and to improve inhalation technique it’s recommended to use spacers of big volume. Usage of nebuliser gives the opportunity to take high doses of medicines and to get therapeutic responses in short periods of time and at the same time to supply oxygen to the circuit (if necessary).


Bronchial spasmolytics improve patency of airways, improve emptying of lungs, reducing hyperinflation, ameliorate physical endurance; play the main role in the symptomatic treatment of patients with COPD. They are prescribed both as basic therapy and to remove some acute symptoms; inhalation forms of bronchial spasmolytics are of higher value.


Inhalation ß2-agonists of short-term action (salbutamol, fenoterol) have comparatively fast beginning of broncholytic action, which depends on the dosing and lasts for 4-6 hours.


Inhalation ß2- agonists of prolonged action (salmeterol, formoterol fumarat) cause stronger and more stable effect during 12 hours and more, and have some anti-inflammatory action.


^ Inhalation cholinergic antagonists of short-term action (ipratropium bromid) are characterized by dosing-depending effect with slower beginning and action lasting longer than that of ß2- agonists of short-term action.


Inhalation cholinergic antagonists of long-term action (tiotropium bromid) cause stable significantly stronger broncholytic action than ipratropium, lasting for 24 hours and longer, have some anti-inflammatory action.


Protracted usage of bronchial spasmolytics of prolonged action (ß2-agonist or cholinergic antagonist) or their combination depending on COPD gravity; positively influences respiratory function (improves patency of airways, reduces hyperinflation of the lungs, optimizes the structure of total lung capacity); significantly reduces dyspnea – especially aggravating symptom in patients with COPD; increases exercise tolerance; improves patients’ health in general and their quality of living; decreases the quantity of exacerbations and cases of hospitalization.


Thus, regular treatment with inhalation bronchial spasmolytics of prolonged action is more effective and convenient than therapy with bronchial spasmolytics of short-term action, but it’s more costly.


Xanthines have small broncholytic action and are potentially toxic.


At the same time besides possible additional bronchodilation Xanthines cause some anti-inflammatory action, increase respiratory muscle strength. Xanthines are bronchial spasmolytics of the second choice and may be added to earlier prescribed bronchial spasmolytics of the first choice (ß2- agonists and/or cholinergic antagonists) in cases of severe and very severe COPD in order to increase therapeutic efficacy.


Glucocorticosteroids. The role of GCS in cases of COPD is less marked than in bronchial asthma. In the basic therapy of COPD inhalation GCS are prescribed according to specific indications. Oral GCSs are recommended only in cases of COPD exacerbation.


Protracted administration of oral GCS in the basic therapy is not recommended regarding the absence of obvious advantage, undesirable systemic consequences and side action of such therapy (steroid myopathy, muscle weakness, deterioration of functional abilities, lung insufficiency…).


Inhalation GCSs are prescribed in long basic therapy for COPD (in patients at the 3rd, 4th stages of the disease, when FEV1 < 50% of the due, often exacerbations taking place 3 times or more for the past 3 years). At the same time the frequency of acute exacerbations and cases of hospitalization decrease, general level of health and living quality of the patients improve, death rate caused by all reasons in case of COPD reduces.


Combination of inhalation GCS and ß2- agonists of the prolonged action is more effective than each component apart.


^ The chart of pharmacotherapy for patients with COLD depending on the level of gravity of the disease.


1 stage. mild

2 stage.

moderate

3 stage.

severe

4 stage. very severe

Avoid risk factors, stop smoking, influenza virus vaccine

Bronchial spasmolytics of short-term action should be prescribed




1 or 2 bronchial spasmolytics of prolonged action should be added according to

plan + rehabilitation




GCS inhalation, by frequent exacerbations, must be included




In case of chronic lung insufficiency (CLI) O2-

therapy must be added. The possibility of operative

intervention should be regarded.



Other pharmacological treatment: anti-inflammatory medicines of nonsteroid action (fenspirid hydrochlorude) are prescribed by moderate exacerbation and are included into basic therapy during 2-5- months after COPD exacerbation. Influenza virus vaccine can decrease severity of the exacerbation and reduce death rate among people with COPD.


Antioxidants: acetilcystein reduces the quantity of exacerbations. It’s recommended to prescribe it to patients with frequent exacerbations, history of long-term smoking.


Antibiotics are indicatede in case of the proved infectious exacerbation of COPD.

^ Rehabilitation of patient with COPD


Rehabilitation must be prolonged, including physical training, consultations as for nourishment, teaching and support of sick people.

Oxygenotherapy. Decision on the necessity of oxygenotherapy for patients with COPD is made after taking into consideration disease gravity level, clinic symptoms manifestation, adequacy and efficacy of basic therapy, level of lung insufficiency and of blood oxygen balance.

Surgical treatment. Bullectomy, if there are emphysematous bullae causes decrease of dyspnea and improvement of external respiration function (ERF). Before operative intervention it’s necessary to study ERF, gas exchange and come to a conclusion as for its indication and safety.


^ Exacerbation of COPD


Exacerbations of COPD are divided into infectious and noninfectious. Most exacerbations are provoked by infectious agents, environmental pollution growth, inappropriate basic therapy, oxygenotherapy.


Algorithm of managing exacerbation in the outpatient setting


  • to initiate or intensify broncholytic therapy (bigger dosing and more often administration, combination of different bronchial spasmolytics (ß2-agonists, cholinergic antagonists), usage of nebuliser or spacer;

  • prescribing antibiotics in case of infectious exacerbation;

  • repeated estimation of the patient’s condition;

  • if symptoms and signs of exacerbation are improving prescribed treatment must be continued, after exacerbation is gone basic treatment must be revised;

  • if symptomatic improving is not observed then oral GCS (30-40mg prednisolone during 10 days) must be introduced;

  • repeated estimation of the patient’s condition;

  • if the patient’s condition is better, when exacerbation is gone basic treatment must be revised;

  • if symptoms and signs of exacerbation are worsening the patient must be taken to a hospital.


Indications for hospitalisation in case exacerbation of COPD


  • considerable worsening of symptoms intensity (e. g. sudden onset of dyspnea at rest);

  • complicated clinical course without exacerbation;

  • presence of new physical signs (cyanosis, peripheral oedemata);

  • feeble response to initial treatment for exacerbation;

  • marked concomitant diseases;

  • onset of arrhythmia bouts;

  • worsening of consciousness;

  • uncertain diagnostics, lack of possibility to verify the diagnosis reliably;

  • elderly age;

  • unfavourable living conditions.


It’s first of all pus increase in sputum that indicates infectious exacerbation. Also dyspnea intensifies and sputum amount grows.


Choosing antibacterial therapy it’s necessary to take into consideration such criteria as the age of the patient, exacerbation frequency for the last year, presence of concomitant pathology and level of FEV1 value.

In patients younger than 65 with COPD frequency less than 4 times a year, without concomitant diseases and FEV1 more than 50% of the proper value the main causative agents are H. influenzae, S. pneumoniae, M. catarrhalis and atypical microorganisms. As the antibiotic of choice aminopenicillin (amoxicillin) or macrolide is recommended, or respiratory fluoroquinolone for oral administration which is prescribed when ß-lactams and macrolides are not effective, or there is allergic response.

In patients olderer than 65 with COPD frequency 4 times a year or more, with concomitant diseases and FEV1 ranging from 30 to 50% of the proper value the main causative agents are H. influenzae, representatives of Enterobacteriaceae, and also S. pneumoniae. That’s why as the medicine of choice protected aminopenicillin or cephalosporin of the second generation, or respiratory fluoroquinolone for oral administration is recommended.

When FEV1 is less than 30% of the proper value, antibacterial therapy is often (more than 4 times a year) and it’s necessary to take corticosteroids constantly, the reason of COPD exacerbation may be P. aeruginosea. Hence parenteral administration of fluoroquinolone of the second generation (ciprofloxacin) or respiratory fluoroquinolone of laevofloxacin – in high dosing, or ß-lactam with anti blue pus action in combination with aminoglycoside is recommended.

Regardless the fact that COPD is a progressing disease correctly chosen and therapy prescribed in time and rehabilitation can significantly slow down broncoobstructive progression, reduce frequency and gravity of exacerbations, prevent development of exacerbation and systemic aftereffect, improve level of life.


Prepared by Orlovsky A. V., assistant, D.Ph.,

Murenets N. A., postgraduate


Methodological Instruction to Lesson № 3.


Bronchial Asthma.

Hours: 5.

Working place: classroom, hospital wards.


Questions.


  1. Give the definition of bronchial asthma.

  2. Name essential of diagnosis.

  3. Name clinical symptoms of bronchial asthma.

  4. What induces development the symptoms of bronchial asthma.

  5. What characterizes the acute attack of bronchial asthma?

  6. Name the criteria of respiratory function violence.

  7. Give the clinical picture of classic allergic (atopic) bronchial asthma.

  8. How is the studying of bronchi hyperreactivity carried out?

  9. List the diagnostic tests, which are made at ambulatory-polyclinic stage.

  10. Give the classification of bronchial asthma.

  11. What is intermitting bronchial asthma?

  12. What is mild persistent bronchial asthma?

  13. What is permanent bronchial asthma of moderate severity?

  14. What is severe permanent bronchial asthma?

  15. For what purpose is conception “bronchial asthma control” introduced?

  16. What is controlled course of bronchial asthma?

  17. What is partially controlled course of bronchial asthma?

  18. What is non-controlled course of bronchial asthma?

  19. Laboratory findings in patient of bronchial asthma.

  20. X-Ray findings in patient of bronchial asthma.

  21. Name ways of medications introductions which use in treatment of patients with bronchial asthma.

  22. Which is the main way of medications introductions which use in treatment of patients with bronchial asthma?

  23. Name controlling medicines.

  24. When can we prescribe glucocorticosteroids of system action?

  25. Name glucocorticosteroids of system action.

  26. How will we decrease the dosage of prednisolon?

  27. Name inhalation glucocorticosteroids.

  28. Name side effects of system and inhalation glucocorticosteroids.

  29. Name preventive measures of inhalation glucocorticosteroids side effects.

  30. What can you say about steps 1, 2, 3, 4 in treatment of patients with bronchial asthma?

  31. What is steroid-sparring therapy?

  32. Name steps for achievement and keeping up the control of bronchial asthma.

  33. What can you say about cromons, methylxantines, leucotrien-modificator?

  34. What can you say about β2-agonists of prolonged action and short-term action?

  35. What can you say about symptomatic therapy?

  36. What will you do if control of the disease is achieved for a period of 3 months?

  37. What is the duration of controlling theropy?

  38. What is bronchial asthma exacerbation and it stages?

  39. Where may be treated patients with mild and moderate severity and severe bronchial asthma?

  40. Name treatment the ambulatory stage.

  41. What is complete response on therapy?

  42. What will you do if the patient gives non-complete response?

  43. Name treatment of patients with severe exacerbation of bronchial asthma.

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