ERS-ATS COPD Guidelines
اسلاید 1: ERS-ATS COPD GuidelinesERS-ATS COPD GuidelinesCopyright © European Respiratory Society 2005These slides can be used freely for non-commercial purposes.
اسلاید 2: ERS-ATS COPD GuidelinesDefinition of COPDChronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible.The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking.
اسلاید 3: ERS-ATS COPD GuidelinesEpidemiology (1)COPD is a leading cause of morbidity and mortality worldwide, and results in an economic and social burden that is both substantial and increasing.Prevalence and morbidity data greatly underestimate the total burden of COPD because the disease is usually not diagnosed until it is clinically apparent and moderately advanced.
اسلاید 4: ERS-ATS COPD GuidelinesEpidemiology (2)COPD is the fourth leading cause of death in the USA and Europe, and COPD mortality in females has more than doubled over the last 20 years.
اسلاید 5: ERS-ATS COPD GuidelinesEpidemiology (3)COPD is a more costly disease than asthma and, depending on country, 50–75% of the costs are for services associated with exacerbations.Tobacco smoke is by far the most important risk factor for COPD worldwide. Other important risk factors are:
اسلاید 6: ERS-ATS COPD GuidelinesPathogenesis and PathophysiologyPathogenesisTobacco smoking is the main risk factor for COPD, although other inhaled noxious particles and gases may contribute. In addition to inflammation, an imbalance of proteinases and antiproteinases in the lungs, and oxidative stress are also important in the pathogenesis of COPD.PathophysiologyThe different pathogenic mechanisms produce the pathological changes which, in turn, give rise to the physiological abnormalities in COPD: mucous hypersecretion and ciliary dysfunction, airflow limitation and hyperinflation, gas exchange abnormalities, pulmonary hypertension, systemic effects.
اسلاید 7: ERS-ATS COPD GuidelinesDiagnosis of COPD (1)Diagnosis of COPD should be considered in any patient who has the following:symptoms of coughsputum productiondyspnoeahistory of exposure to risk factors for the diseaseSpirometry should be obtained in all persons with the following history:exposure to cigarettes and/or environmental or occupational pollutantsfamily history of chronic respiratory illnesspresence of cough, sputum production or dyspnoea
اسلاید 8: ERS-ATS COPD GuidelinesDiagnosis of COPD (2)SpirometrySpirometric classification of COPD:Post-bronchodilator FEV1/forced vital capacity <0.7 confirms the presence of airflow limitation that is not fully reversible.
اسلاید 9: ERS-ATS COPD GuidelinesSmoking cessation (1)Tobacco is the most important risk factor for COPD.Cigarette smoking is an addiction and a chronic relapsing disorder.Treating tobacco use and dependence should be regarded as a primary and specific intervention.Smoking cessation activities and support for its implementation should be integrated into the healthcare system. The key steps in intervention are:
اسلاید 10: ERS-ATS COPD GuidelinesManagement of stable COPDPharmacological therapyLong-term oxygen therapyPulmonary rehabilitationNutritionSurgery in and for COPDSleepAir travel
اسلاید 11: ERS-ATS COPD GuidelinesManagement of stable COPDPharmacological therapyLong-term oxygen therapyPulmonary rehabilitationNutritionSurgery in and for COPDSleepAir travel
اسلاید 12: ERS-ATS COPD GuidelinesPharmacological therapy (1)The medications for COPD currently available can reduce or abolish symptoms, increase exercise capacity, reduce the number and severity of exacerbations, and improve health status.At present, no treatment has been shown to modify the rate of decline in lung function.The change in lung function after brief treatment with any drug does not help in predicting other clinically related outcomes.The inhaled route is preferred.
اسلاید 13: ERS-ATS COPD GuidelinesPharmacological therapy (2)Changes in forced expiratory volume in one second (FEV1) following bronchodilator therapy can be small but are often accompanied by larger changes in lung volume, which contribute to a reduction in perceived breathlessness.Combining different agents produces a greater change in spirometry and symptoms than single agents alone. Three types of bronchodilators are in common clinical use: β-agonists, anticholinergic drugs and methylxanthines.
اسلاید 14: ERS-ATS COPD GuidelinesPharmacological therapy (3) BronchodilatorsShort-acting bronchodilators can increase exercise tolerance acutely in COPD. Anticholinergics given q.i.d. can improve health status over a 3-month period. Long-acting inhaled β-agonists improve health status, possibly more than regular ipratropium. Additionally, these drugs reduce symptoms, rescue medication use and increase the time between exacerbations.Combining short-acting agents (salbutamol/ipratropium) produces a greater change in spirometry over 3 months than either agent alone.Combining long-acting inhaled β-agonists and ipratropium leads to fewer exacerbations than either drug alone. Combining long-acting β-agonists and theophylline produces a greater spirometric change than either drug alone. Tiotropium improves health status and reduces exacerbations and hospitalisations compared with both placebo and regular ipratropium.
اسلاید 15: ERS-ATS COPD GuidelinesPharmacological therapy (4) GlucocorticoidsGlucocorticoids act at multiple points within the inflammatory cascade, although their effects in COPD are more modest compared with bronchial asthma. In patients with more advanced disease (usually classified as an FEV1 <50% predicted), there is evidence that inhaled corticosteroids can reduce the number of exacerbations per year.
اسلاید 16: ERS-ATS COPD GuidelinesPharmacological Therapy (6)Effects on commonly used medications on important clinical outcomes in COPD
اسلاید 17: ERS-ATS COPD GuidelinesManagement of stable COPDPharmacological therapyLong-term oxygen therapyPulmonary rehabilitationNutritionSurgery in and for COPDSleepAir travel
اسلاید 18: ERS-ATS COPD GuidelinesLong-term oxygen therapy (1)Long-term oxygen therapy (LTOT) improves survival, exercise, sleep and cognitive performance.Reversal of hypoxaemia supersedes concerns about carbon dioxide (CO2) retention.Arterial blood gas (ABG) is the preferred measure and includes acid-base information.Oxygen sources include gas, liquid and concentrator.Oxygen delivery methods include nasal continuous flow, pulse demand, reservoir cannulas and transtracheal catheter.
اسلاید 19: ERS-ATS COPD GuidelinesManagement of stable COPDPharmacological therapyLong-term oxygen therapyPulmonary rehabilitationNutritionSurgery in and for COPDSleepAir travel
اسلاید 20: ERS-ATS COPD GuidelinesPulmonary rehabilitationPulmonary rehabilitation is a multidisciplinary programme of care that is individually tailored and designed to optimise physical and social performance and autonomy. Pulmonary rehabilitation should be considered for patients with COPD who have dyspnoea or other respiratory symptoms, reduced exercise tolerance, a restriction in activities because of their disease, or impaired health status. Pulmonary rehabilitation programmes include: exercise training, education, psychosocial/behavioural intervention, nutritional therapy, outcome assessment,promotion of long-term adherence to the rehabilitation recommendations.
اسلاید 21: ERS-ATS COPD GuidelinesManagement of stable COPDPharmacological therapyLong-term oxygen therapyPulmonary rehabilitationNutritionSurgery in and for COPDSleepAir travel
اسلاید 22: ERS-ATS COPD GuidelinesNutritionWeight loss and a depletion of fat-free mass (FFM) may be observed in stable COPD patients.Being underweight is associated with an increased mortality risk.Criteria to define weight loss are: Weight loss >10% in the past 6 months or >5% in the past month.Nutritional therapy may only be effective if combined with exercise or other anabolic stimuli.
اسلاید 23: ERS-ATS COPD GuidelinesManagement of stable COPDPharmacological therapyLong-term oxygen therapyPulmonary rehabilitationNutritionSurgery in and for COPDSleepAir travel
اسلاید 24: ERS-ATS COPD GuidelinesSurgery in COPD (1)Patients with a diagnosis of COPD have a 2.7–4.7-fold increased risk of post-operative pulmonary complications.The further the procedure from the diaphragm, the lower the pulmonary complication rate.Smoking cessation at least 4–8 weeks pre-operatively and optimisation of lung function can decrease post-operative complications.Early mobilisation, deep breathing, intermittent positive-pressure breathing, incentive spirometry and effective analgesia may decrease postoperative complications.
اسلاید 25: ERS-ATS COPD GuidelinesSurgery in COPD (2)Algorithm for pre-operative testing for lung resection. DL,CO: carbon dioxide diffusing capacity of the lung; FEV1: forced expiratory volume in one second; ppo: predicted postoperative; V′O2,max: maximum oxygen consumption.
اسلاید 26: ERS-ATS COPD GuidelinesSurgery for COPD (1) BullectomyCXR: chest radiography; CT: computed tomography; FVC: forced vital capacity; FEV1: forced expiratory volume in one second; DL,CO: carbon monoxide diffusing capacity of the lung; Pa,O2; arterial oxygen tension; Pa,CO2; arterial carbon dioxide tension
اسلاید 27: ERS-ATS COPD GuidelinesSurgery for COPD (3) Lung Volume Reduction SurgeryPA: alveolar pressure; RV: residual volume; TLC: total lung capacity; Pa,O2: arterial oxygen tension; Pa,CO2: arterial carbon dioxide tension; FEV1: forced expiratory volume in one second; DL,CO: carbon dioxide diffusing capacity of the lung. #: confirmed recommendations using NETT data or expert opinion.
اسلاید 28: ERS-ATS COPD GuidelinesManagement of stable COPDPharmacological therapyLong-term oxygen therapyPulmonary rehabilitationNutritionSurgery in and for COPDSleepAir travel
اسلاید 29: ERS-ATS COPD GuidelinesSleepSleep in COPD is associated with oxygen desaturation, which is predominantly due to the disease itself rather than to sleep apnoea. The desaturation during sleep may be greater than during maximum exercise. Sleep quality is markedly impaired in COPD, both subjectively and objectively. Clinical assessment in all patients with COPD should include questions about sleep quality and possible co-existing sleep apnoea syndrome. Management of sleep problems in COPD should particularly focus on minimising sleep disturbance by measures to limit cough and dyspnoea, and nocturnal oxygen therapy is rarely indicated for isolated nocturnal hypoxaemia. Hypnotics should be avoided, if possible, in patients with severe COPD.
اسلاید 30: ERS-ATS COPD GuidelinesManagement of stable COPDPharmacological therapyLong-term oxygen therapyPulmonary rehabilitationNutritionSurgery in and for COPDSleepAir travel
اسلاید 31: ERS-ATS COPD GuidelinesAir travelCommercial airliners can cruise at >12,000 m (>40,000 feet) as long as the cabin is pressurised from 1,800–2,400 m (6,000–8,000 feet). This is equivalent to an inspired oxygen (O2) concentration at sea level of ~15%.Patients with COPD can exhibit falls in arterial O2 tension (Pa,O2) that average 25 mmHg (3.3 kPa).Pre-flight assessment can help determine O2 needs and the presence of co-morbidities.Most airlines will provide supplemental O2 on request.There is increasing evidence that patients on long flights may be at increased risk for deep vein thrombosis.
اسلاید 32: ERS-ATS COPD GuidelinesExacerbation of COPDDefinition, evaluation and treatmentIn-patient oxygen therapyAssisted ventilation
اسلاید 33: ERS-ATS COPD GuidelinesExacerbation of COPDDefinition, evaluation and treatmentIn-patient oxygen therapyAssisted ventilation
اسلاید 34: ERS-ATS COPD GuidelinesDefinition, evaluation and treatment (1)The definition of COPD exacerbation is an acute change in a patient’s baseline dyspnoea, cough and/or sputum beyond day-to-day variability sufficient to warrant a change in therapy.Causes of exacerbation can be both infectious and non-infectious. Medical therapy includes bronchodilators, corticosteroids, antibiotics and supplemental oxygen therapy.
اسلاید 35: ERS-ATS COPD GuidelinesDefinition, evaluation and treatment (2)Indications for hospitalisation of patients with a COPD exacerbationPresence of high-risk co-morbid conditions, including pneumonia, cardiac arrhythmia, congestive heart failure, diabetes mellitus, renal or liver failureInadequate response of symptoms to outpatient managementMarked increase in dyspnoeaInability to eat or sleep due to symptomsWorsening hypoxaemiaWorsening hypercapniaChanges in mental statusInability of the patient to care for her/himselfUncertain diagnosisInadequate home care
اسلاید 36: ERS-ATS COPD GuidelinesDefinition, evaluation and treatment (4)Level I: outpatient treatment
اسلاید 37: ERS-ATS COPD GuidelinesDefinition, evaluation and treatment (5)Level II: treatment for hospitalised patient
اسلاید 38: ERS-ATS COPD GuidelinesDefinition, evaluation and treatment (6)Level III: treatment in patients requiring special or intensive care unit
اسلاید 39: ERS-ATS COPD GuidelinesExacerbation of COPDDefinition, evaluation and treatmentIn-patient oxygen therapyAssisted ventilation
اسلاید 40: ERS-ATS COPD GuidelinesIn-patient oxygen therapyThe goal is to prevent tissue hypoxia by maintaining arterial oxygen saturation (Sa,O2) at >90%.Main delivery devices include nasal cannula and venturi mask.Alternative delivery devices include nonrebreather mask, reservoir cannula, nasal cannula or transtracheal catheter.Arterial blood gases should be monitored for arterial oxygen tension (Pa,O2), arterial carbon dioxide tension (Pa,CO2) and pH.Arterial oxygen saturation as measured by pulse oximetry (Sp,O2) should be monitored for trending and adjusting oxygen settings.Prevention of tissue hypoxia supercedes CO2 retention concerns.If CO2 retention occurs, monitor for acidaemia.If acidaemia occurs, consider mechanical ventilation.
اسلاید 41: ERS-ATS COPD GuidelinesExacerbation of COPDDefinition, evaluation and treatmentIn-patient oxygen therapyAssisted ventilation
اسلاید 42: ERS-ATS COPD GuidelinesAssisted ventilation (1)Noninvasive positive pressure ventilation (NPPV) should be offered to patients with exacerbations when, after optimal medical therapy and oxygenation, respiratory acidosis (pH <7.36) and or excessive breathlessness persist. All patients considered for mechanical ventilation should have arterial blood gases measured.If pH <7.30, NPPV should be delivered under controlled environments such as intermediate intensive care units (ICUs) and/or high-dependency units.If pH <7.25, NPPV should be administered in the ICU and intubation should be readily available.The combination of some continuous positive airway pressure (CPAP) (e.g. 4–8 cmH2O) and pressure support ventilation (PSV) (e.g. 10–15 cmH2O) provides the most effective mode of NPPV.
اسلاید 43: ERS-ATS COPD GuidelinesAssisted ventilation (2)Patients meeting exclusion criteria should be considered for immediate intubation and ICU admission.Exclusion criteria include:respiratory arrest,cardiovascular instability,impaired mental status, somnolence, inability to cooperate,copious and/or viscous secretions with high aspiration risk, recent facial or gastro-oesophageal surgery; craniofacial trauma and/or fixed naso-pharyngeal abnormality,burns,extreme obesity.In the first hours, NPPV requires the same level of assistance as conventional mechanical ventilation.
اسلاید 44: ERS-ATS COPD GuidelinesAssisted ventilation (3)Flow-chart for the use of noninvasive positive pressure ventilation (NPPV) during exacerbation of COPD complicated by acute respiratory failure. MV: mechanical ventilation; Pa,CO2: arterial carbon dioxide tension.
اسلاید 45: ERS-ATS COPD GuidelinesPatient section
اسلاید 46: ERS-ATS COPD GuidelinesPatient sectionThis updated document includes a patient section aimed at:Providing practical information on all aspects of COPD.Promoting a healthy lifestyle to all patients afflicted with the disease.This section is available in English, French, German, Italian and Spanish.It includes printable files which can be directly distributed to patients.
اسلاید 47: ERS-ATS COPD Guidelineswww.ersnet.org/copd Eur Respir J 2004; 23: 932–946ERS-ATS COPD Guidelines Website Addre
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