Manejo de la exacerbación aguda en la enfermedad pulmonar obstructiva crónica / Management of acute exacerbations of chronic pulmonary obstructive disease

La enfermedad pulmonar obstructiva crónica (EPOC), es una causa importante de muerte en países desarrollados (ocupa el cuarto lugar en EUA). Se ha determinado que es tan o más frecuente en los países en desarrollo, es causa de muchas hospitalizaciones y consultas por exacerbación aguda de la enfermedad (EABC). La definición de Anthonisen es la más usada y aceptada, pues señala la presencia de uno o más de los siguientes criterios: incremento en el volumen de la expectoración, cambio de color (purulencia) en el esputo y Empeoramiento de la disnea. El paciente con EPOC puede presentar de una a tres exacerbaciones agudas por año. El número de EABC es un marcador importante de severidad de la condición, pues determina la calidad de vida y mortalidad del paciente. Del 3 a 16% requiere hospitalizarse (más en casos severos). La mortalidad hospitalaria puede llegar a 10% en casos de EPOC severos y mayor si el paciente ingresa a una Unidad de Cuidado Intensivo. La etiología de la EABC es mayoritariamente infecciosa, (hasta el 80%), otras condiciones pueden explicarla, como la embolia pulmonar, neumotórax, insuficiencia cardiaca, fracturas en la caja torácica e infecciones no pulmonares, las cuales se consideran como "gatillos" y pueden coexistir más de uno por vez. A diferencia de la crisis asmática es importante que se realice una radiografía de tórax y una gasometría arterial, en todos los pacientes que acuden a la emergencia. Hasta el 20% de pacientes pueden presentar elevación del PCO2. al administrarles oxígeno, se recomienda usar de preferencia una máscara de venturi con la concentración necesaria para llevar la saturación de hemoglobina alrededor de 90% (86-92%). El uso de un broncodilatador es la elección en estos casos. Lo ideal es administrar un beta agonista de corta acción o un anticolinérgico, y si el paciente no mejora se pueden combinar. La elección...

Chronic obstructive lung disease (COPD) is an important cause of death in industrialized countries (it is the 4th cause of death in the U.S.). This condition is also prevalent in developing countries, in some its frequency may be higher, and it is an important cause of hospitalizations and consultations because of acute exacerbations. The Anthonisen definition is the most widely and accepted instrument for diagnosing COPD exacerbations, pointing out at the presence of one or more of the following: increased sputum volume, change of color of the sputum, and worsening dyspnea. Patients with COPD may develop one to three acute exacerbation episodes per year. The number of these episodes is an important marker for the severity of COPD, since it determines quality of life and the mortality risk. Three to sixteen per cent of affected patients may require hospitalization (this rate may be higher in more severe cases). In-hospital mortality may reach 10% in severe COPD cases, and it becomes increased if the patient is admitted to an intensive care unit. The etiology of acute exacerbations of COPD is mainly because of infections (up to 80%), but other conditions may also account for such exacerbations, such as pulmonary embolism, pneumothorax, heart failure, thoracic trauma (including rib fracture), and extrapulmonary infections, being considered as triggering factors, and they may also coexist. Differently from asthma crisis, it is important to have a chest X-ray film taken and arterial blood gases determinations in every patient presenting to the emergency department with an acute exacerbation of COPD. Up to 20% of patients may present with elevated PCO2. When administering oxygen, it is preferable to use a Venturi mask with an oxygen concentration able to maintain hemoglobin saturation around 90% (86-92%)...

Rehabilitación pulmonar en la enfermedad pulmonar obstructiva crónica / Lung rehabilitation in stable chronic pulmonary obstructive disease

El proceso de rehabilitación pulmonar en la enfermedad pulmonar obstructiva crónica, es un hecho tangible que se encuentra respaldado en las evidencias científicas. Hoy se reconoce claramente que existe reducción de la disnea, incremento de la capacidad para el ejercicio, mejor calidad de vida, menos días de hospitalización y menor uso de los servicios de salud en los pacientes con EPOC que siguen programas de rehabilitación pulmonar.

Lung rehabilitation in chronic obstructive pulmonary disease (COPD) is a tangible fact supported by scientific evidence. Nowadays it is clearly recognized that there is dyspnea reduction, an increase in exercise capacity, better quality of life, and less use of healthcare services in COPD patients undergoing lung rehabilitation programs.

Tracheal collapsibility measured using end-expiratory chest CT in chronic airway disease / 대한내과학회지

BACKGROUND/AIMS: Partial tracheal narrowing can occur during expiration in the normal population. It is not certain whether the trachea collapses more readily in chronic airway disease. We evaluated the tracheal narrowing at end-expiration using computed tomography (CT). METHODS: We investigated 45 patients and 22 normal subjects who underwent high-resolution CT and pulmonary function tests. In each subject, two CT images at the same level of the aortic arch were compared: one at end-inspiration and the other at end-expiration. The cross-sectional area and sagittal diameter of the trachea were measured using a hand-tracing method, using the in-program measuring tools of Medical Image Viewer, and the percentage changes of each value were calculated. RESULTS: Of the 45 patients with chronic airway disease, 21 had chronic obstructive pulmonary disease, 16 had bronchial asthma, and 8 had bronchiectasis. The mean change in the cross-sectional area was 13.3% in the patients and 9.0% in the normal subjects (p0.05). The decrease in tracheal cross-sectional area was greatest in bronchiectasis, while the greatest decrease in sagittal diameter was in bronchial asthma. There was no significant difference in tracheal collapsibility among the disease groups. The percent change in the tracheal cross-sectional area was correlated with the % predicted FVC (r=-0.033, p<0.05) and FEV1 (r= 0.277, p<0.05) in both the patients and normal controls. CONCLUSIONS: The decrease in tracheal cross-sectional area at end-expiration measured using chest CT was greater in chronic airway disease than in normal subjects, and was associated with ventilatory function.

Atopy as predictable index of reversibility in chronic airflow obstruction / 천식및알레르기

BACKGROUND: Smoking-related chronic obstructive pulmonary disease and chronic asthmatic bronchitis, which are the most important causes of chronic airflow obstruction (CAO), can occur together in a pat,ient and the prognoses of these two diseases are different each other. OBJECTIVE AND METHOD: To estimate the extent of asthmatic component in patients with CAO and to evaluate the role of atopy as a predictable index for reversibility of airflow obstruction, 89 CAO patients who were older than 40 years were examined retrospectively. RESULT: Only 15 patients (16.8%) showed an increase of >15% in FEV20 to inhaled salbutamol (short-term responder). However, 18 out of 32 patients (56.3%), who were not responded significantly to inhaled bronchodilator and performed a follow-up lung function study, showed an increase of ) 15% in FEV20 to anti-asthmatic therapy including corticosteroid for 3-4 weeks (long-term responder). Peripheral blood eosinophil count only was different between short-term responder and short-term nonresponder, and there was no difference in all of the measurements between short-term responder and long-term responder. However, there were significant differences in smoking, wheezing on auscultation, peripheral blood eosinophil counts, serum total IgE levels, and MAST atopy score between long-term responder and long-term nonresponder. The increase in FEV, following shortor long-term therapy was related to peripheral blood eosinophil counts and MAST atopy score, and it was significantly great,er in patients with high eosinophil counts or high atopy score. CONCLUSION: About 2/3 of patients with CAO who were older than 40 years had an asthmatic component ap atopy may be useful to predict good bronchodilator response to anti-asthmatic therapy.

The Changes of Breathing Pattern Observed During Maximal Exercise Testing in the Patients with Chronic Airflow Obstruction: the Correlation Between the Change of Inspiratory Duty Cycle and the Degree of Airflow Obstruction / 결핵

BACKGROUND: Normal humans meet the increased ventilatory need during exercise initially by the increase of tidal volume (TV) and later by the increase of respiratory frequency (Rf). And the inspiratory duty cycle (Ti/Ttot) is also increased more than 50% for the compensation of the decrease of respiratory cycle provoked by the increase of respiratory frequency. The patients with chronic airflow obstruction show rapid and shallow breathing pattern during exorcise because of the degreased ventilatory capacity and the increased dead space ventilation. However, the studies about the change of inspiratory duty cycle are only a few and there is no literature about the relationship between the change of inspiratory duty cycle and the degree of airflow obstruction. METHODS: The subjects were the twelve patients with chronic airflow obstruction (CAO) and ten normal people. The incremental exercise test was done. The increase of work load was 10 Win CAO group and 25 Win normal control group. The analysis of the results was done by the comparison of the parameters such as minute ventilation (VE), TV, Rf, physiologic dead space (Vd/vt), and inspiratory duty cycle between the two groups. Each parameters were compared after transformation into % control duration base that means dividing the total exercise time into five fractons and % control duration data were obtained at rest, 20%, 40%, 60%, 80%, and max. Statistical analysis was done by repeated measure ANOVA using SAS program. RESULTS: The changes of VE and TV were significantly different between two groups while the change of Rf was not significant. The decrease of Vd/vt was significantly low in CAO group. Ti/Ttot was markedly increased from 38.4+3.0% at rest to 48.6+4.5% at max in normal control group while Ti/Ttot showed little change from 40.5+2.2% at rest to 42.6+3.5% at max. And the change of inspiratory duty cycle showed highly good correlation with the degree of airflow obstruction (FEVl%). (r=0.8151, p<0.05) CONCLUSIONS: The increase of Ti/Ttot during exercise observed in normal humans is absent in the patients with CAO and the change of Ti/TtDt is well correlated with the degree of airflow obstruction.

The role of the pulmonary function test and the exercise test for assessing impairment/disability in patients with chronic airflow obstruction / 결핵

BACKGROUND: In 1980, WHO made a definition in which the term "impairment" as applied to the respiratory system is used to describe loss of lung function, "disability" the resulting diminution in exercise capacity. The measurement of pulmonary function during exercise would give us information about overall functional capacity and respiratory performance that would be lacking in tests performed at rest. We conducted this study to investigate the role of resting pulmonary function test and exercise test for assessing impairment/disability in patients with chronic airflow obstruction(CAO). METHOD: We studied 19 patients with CAO. The spirometry and body plethysmograph were performed in stable condition. And then patients performed a progressive incremental exercise test to a symptom-limited maximum using cycle ergometer. Patients were divided in two groups, severe and non-severe impairment, according to the resting PFTs and compaired each other. A patient was considered to be severely impaired if FVC < 50%, FEV1 < 40% or FEV1/FVC < 40%. RESULTS: 1) The airway obstruction and hypoxemia of severe impairment group were more severe and exercise performance was markedly reduced compairing to non-severe impairment group. 2) The severe impairment group showed ventilatory limitation during exercise test and the limiting symptomes ware dyspnea in 9/10 patients. 3) The impairment and disability of the patients with tuberculous destructed lung were most marked in patients with CAO. 4) The FEV1 was the most prevalent criterion for the determination of severe impairment based on resting PFTs and was the varuable best correlated to VO2max(r=0.8l, p < 0.001). 5) The sensitivity of exercise limits for predicting severe disability according to resting PFTs was 80% and specificity 89%. CONCLUSION: In patients with severe CAO, FEV1 is a good predictive of exercise performance and impairment measured by resting PFTs can predict a disability by exercise test.