c3 insuficienta respiratorie 3
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Urgene respiratorii 3
Drago Bumbcea, MD, PhD, MPH, FCCP
Clinica de PneumologieSpitalul Universitar de Urgen Elias
Universitatea de Medicin i Farmacie Carol Davila
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Insuficiena respiratorie hipercapnic
PaCO2 > 45 mmHg Form clinic
Acut pH < 7.35 Cronic pH > 7.35 (compensat prin retenie
renal de bicarbonai); HCO3- crescut
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Semne i simptome de hipoventilaie
Dispnee la activitile diurne obinuite Ortopnee n bolile ce afecteaz funcia diafragmului Calitate proast a somnului Hipersomnolen diurn Cefalee matinal Anxietate Afectarea tusei n bolile neuromusculare
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Mecanisme de hipoventilaie alveolar
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Exacerbare BPOC Un eveniment n istoria natural a bolii, caracterizat prin
creterea dispneei, tusei i a sputei dincolo de variaiile zilnice, cu debut acut i care necesit o modificare a medicaiei pacientului pentru BPOC
Atitudine: Identificarea unei cauze Evaluarea severitii ExBPOC i alegerea locului de
ngrijire Administrarea tratamentului adecvat Supravegherea remisiunii exacerbrii
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Identificarea unei cauze Cauz obinuit:
Infecie traheobronic Bacterian: H. influenzae, S. pneumoniae, M. catharralis Viral: rhinovirusuri, virusuri gripale i paragripale,
adenovirusuri Poluare aerian intens Necunoscut
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Identificarea unei cauze Cauz neobinuit (boal diferit care se poate
manifesta similar cu ExBPOC) Pneumotorax spontan Pneumonie Tromboembolismul pulmonar Administrarea ne-adecvat de medicamente
(tranchilizante, hipnotice) Insuficien ventricular stng
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Evaluarea severitii Caracteristicile bolii:
Gradul de severitate al obstruciei bronice (VEMS) Durata de agravare a simptomelor Numrul de episoade anterioare de exacerbare Comorbiditi Regimul terapeutic actual
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Evaluarea severitii Semne de severitate
Folosirea muchilor respiratori accesori Micri abdominale paradoxale Cianoz agravat sau nou-instalat Dezvoltarea semnelor de insuficien cardiac dreapt
(edeme) Instabilitate hemodinamic Alterarea strii de contien Hipoxemie cu SaO2 < 90% (la pacient fr hipoxemie
anterioar)
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Alegerea locului de ngrijire Domiciliu (toate)
Exacerbare non-sever Fr comorbiditi semnificative Toleran digestiv Suport familial
Spital Exacerbare sever Sau una din cele de mai sus
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Investigaii Tratament la domiciliu nu sunt necesare Tratament n spital
ECG Radiografie pulmonar Pulsoximetrie, gazometrie arterial Examen microbiologic al sputei?
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Managementul ExBPOC n spital Bronhodilatatoare Corticosteroid sistemic Antibiotic Oxigenoterapie Ventilaie non-invaziv / invaziv
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Bronhodilatatoare Durat scurt de aciune Preparate:
Beta-2-mimetice salbutamol Anticolinergice ipratropium
Administrare: Nebulizare fr oxigen suplimentar!! pMDI pe spacer Nebs no more after 24
Doze: Salbutamol: 4-10 puff repetat la 4-6 ore Ipratropium: 4-10 puff repetat la 6-8 ore
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Efecte adverse Beta-mimetice
Tahicardie sinusal, tahiaritmii supraventriculare i chiar ventriculare
Tremor Agitaie, nervozitate Hipokaliemie
Anticolinergic Declanarea unei crize de glaucom (prin aciune topic
direct)
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Corticosteroizi sistemici Efecte:
Scurteaz spitalizarea Accelereaz recuperarea funciei pulmonare ntrzie apariia unei noi exacerbri
Doze: Oral: 0,5 mg/kgc/zi echivalent prednison i.v.: HSHC 100 mg la 8 ore
Efecte adverse: hiperglicemie
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Antibiotic Rol limitat:
Efect marginal (de ex. creterea PEF cu 10 L/min!) Rol controversat al infeciei traheobronice n producerea
ExBPOC Con: Infecie superficial (non-invaziv) autolimitant Pro: izolare mai frecvent i n cantiti mai mari de germeni n cursul
ExBPOC fa de BPOC stabil Indicaii:
Semne de infecie (febr i/sau expectoraie cu purulen i cantitate crescut)
BPOC foarte sever de fond (VEMS < 30% prezis)
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Antibiotic Betalactamine:
Aminopeniciline +/- acid clavulanic (amoxicilin, amoxicilin/acid clavulanic
Cefalosporine 2 (cefuroxim) Cefalosporine 3 (ceftriaxon) cu rol neclar
Macrolide noi: claritro, azitro (NU eritro!) Fluorochinolone respiratorii: moxifloxacin,
levofloxacin rezervate pentru cazuri severe (risc crescut de dezvoltare a rezistenei)
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Oxigenoterapie Saturaia int: 88-92% Canul nazal, doz de 1-2 L/min Atenie: oxigenul este un medicament!!!
Se administreaz n doza prescris Exces de oxigen (e.g. SaO2 de 99-100%) poate
agrava hipoventilaia alveolar Lipsa oxigenului (e.g. SaO2 de 80-88%)
afecteaz funciile cerebrale i a altor organe
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Parametrii VNI Ciclurile respiratorii sunt declanate de pacient Presiunea expiratorie (EPAP) Presiunea inspiratorie (IPAP) Frecven respiratorie de siguran (back-up)
ex: 12/min ventilatorul declaneaz un ciclu respirator dup o pauz de 5 secunde (60 sec / 12)
Uneori volum curent minim (IPAP variabil)
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Ventilaie non-invaziv Efecte:
Reduce intubaia orotraheal i complicaiile sale Reduce durata de spitalizare (inclusiv in ATI) Crete supravieuirea
Elemente: Ventilator cu moduri de ventilaie non-invaziv Interfa (mti de VNI)
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Contraindicaiile VNI Stop cardiac sau respirator Incapacitatea de a coopera, proteja calea aerian sau
elimina secreiile Alterarea sever a strii de contien Insuficien de organ non-respiratorie Chirurgie sau traumatism sau deformare facial Risc nalt de aspiraie Durat prelungit anticipat a ventilaiei mecanice Anastomoz esofagian recent
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Ventilaie non-invaziv - interfa
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Monitorizare Parametrii clinici (pre-ventilaie sau n modurile
spontane): frecvena respiratorie, volumul curent, folosirea muchilor accesori, respiraie paradoxal
Gaze sanguine: pulsoximetrie continu gazometrie arterial repetat
Monitorizare pentru identificarea complicaiilor
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Sindromul de obezitate hipoventilaie (SOH) (Pickwick's)
Obezitate morbid (IMC > 40 kg/mp) Hipoventilaie alveolar diurn cronic (PaCO2 > 45 mmHg n
absena altei cauze de hipercapnie) Caracteristici:
Hipersomnolen diurn Hipoxemie de repaus diurn (SaO2 < 90%) Cord pulmonar cronic Hipoventilaie nocturn (creterea PaCO2 cu > 10 mmHg n timpul
somnului) cu acidoz respiratorie (pH < 7.3) nregistrri somnografice: desaturare nocturn, apnei n somn
obstructive, hipoventilaie nocturn
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Fiziopatologia SOH
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Tratament Scdere ponderal
Clasic (diet, efort fizic) Chirurgia bariatric amelioreaz:
Apneea n somn Funcia pulmonar
Oxigenoterapia nocturn poate agrava hipoventilaia alveolar (hipoxemia i hipercapnia)
Presiunea pozitiv continu (CPAP) deseori insuficient pentru compensarea anomaliilor gazometrice
Ventilaie non-invaziv nocturn tratament de elecie
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Ventilaia non-invaziv nocturn Efecte favorabile
Fiziologice Corecia hipoxemiei i hipercapniei diurne i nocturne Ameliorarea fragmentrii somnului Reducerea presiunilor arteriale pulmonare i ameliorarea semnelor de cord pulmonar cronic
Clinice ameliorarea simptomelor Cefalee matinal Somnolen diurn Dispnee Edeme gambiere
Interfa Acut: masc oronazal / facial complet Cronic: masc nazal
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asthma course - new slidesSlide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10Slide 11Slide 12Slide 13Slide 14Slide 15
ASTHMA_COURSE_CRAS.PDFSlide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10CharacteristicsPhysical examinationSuspicion of asthmaConfirmation of asthma diagnosisSlide 15Slide 16Slide 17Slide 18Slide 19Slide 20Slide 21Slide 22Slide 23PeakflowmetrieSlide 25Methacholine bronchial challenge testSlide 27Slide 28Slide 29Slide 30Slide 31Asthma medicationsRoutes of administrationInhalersController medicationsReliever medicationsInhaled glucocorticosteroidsInhaled steroids - dosesEquipotent doses of ICSInhaled steroids adverse eventsDose-response curve of ICSDose-response curve of ICS (PEF)Leukotriene modifiersSlide 44Long-acting inhaled 2-agonists (LABA)LABA side effectsTheophyllineTheophylline side effectsAsthma managementLevels of asthma controlSlide 32Asthma treatment titrationSlide 53Slide 54Slide 55Asthma management in acute careSlide 57Slide 58
ASTHMA_COURSE_CRAS.PDFSlide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10CharacteristicsPhysical examinationSuspicion of asthmaConfirmation of asthma diagnosisSlide 15Slide 16Slide 17Slide 18Slide 19Slide 20Slide 21Slide 22Slide 23PeakflowmetrieSlide 25Methacholine bronchial challenge testSlide 27Slide 28Slide 29Slide 30Slide 31Asthma medicationsRoutes of administrationInhalersController medicationsReliever medicationsInhaled glucocorticosteroidsInhaled steroids - dosesEquipotent doses of ICSInhaled steroids adverse eventsDose-response curve of ICSDose-response curve of ICS (PEF)Leukotriene modifiersSlide 44Long-acting inhaled 2-agonists (LABA)LABA side effectsTheophyllineTheophylline side effectsAsthma managementLevels of asthma controlSlide 32Asthma treatment titrationSlide 53Slide 54Slide 55Asthma management in acute careSlide 57Slide 58
ASTHMA_COURSE_CRAS.PDF.pdfSlide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10CharacteristicsPhysical examinationSuspicion of asthmaConfirmation of asthma diagnosisSlide 15Slide 16Slide 17Slide 18Slide 19Slide 20Slide 21Slide 22Slide 23PeakflowmetrieSlide 25Methacholine bronchial challenge testSlide 27Slide 28Slide 29Slide 30Slide 31Asthma medicationsRoutes of administrationInhalersController medicationsReliever medicationsInhaled glucocorticosteroidsInhaled steroids - dosesEquipotent doses of ICSInhaled steroids adverse eventsDose-response curve of ICSDose-response curve of ICS (PEF)Leukotriene modifiersSlide 44Long-acting inhaled 2-agonists (LABA)LABA side effectsTheophyllineTheophylline side effectsAsthma managementLevels of asthma controlSlide 32Asthma treatment titrationSlide 53Slide 54Slide 55Asthma management in acute careSlide 57Slide 58
asthma course - new slidesSlide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10Slide 11Slide 12Slide 13Slide 14Slide 15
ASTHMA_COURSE_CRAS.PDF.pdfSlide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10CharacteristicsPhysical examinationSuspicion of asthmaConfirmation of asthma diagnosisSlide 15Slide 16Slide 17Slide 18Slide 19Slide 20Slide 21Slide 22Slide 23PeakflowmetrieSlide 25Methacholine bronchial challenge testSlide 27Slide 28Slide 29Slide 30Slide 31Asthma medicationsRoutes of administrationInhalersController medicationsReliever medicationsInhaled glucocorticosteroidsInhaled steroids - dosesEquipotent doses of ICSInhaled steroids adverse eventsDose-response curve of ICSDose-response curve of ICS (PEF)Leukotriene modifiersSlide 44Long-acting inhaled 2-agonists (LABA)LABA side effectsTheophyllineTheophylline side effectsAsthma managementLevels of asthma controlSlide 32Asthma treatment titrationSlide 53Slide 54Slide 55Asthma management in acute careSlide 57Slide 58
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