BPOC Emfizem
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![Page 1: BPOC Emfizem](https://reader033.fdocuments.us/reader033/viewer/2022061504/55cf99fc550346d0339fffc6/html5/thumbnails/1.jpg)
DEFINITIE (1)
Bronsita cronica obstructiva
Emfizem
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DEFINITIE (2)
• BRONSITA CRONICA
definitie clinica
Tuse cronica,productiva, minim 3 luni pe an, minim 2 ani consecutivi, fara alta cauza de tuse cronica (tbc, bronsiectazia).
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BRONSITA CRONICA OBSTRUCTIVA
-obstructie a cailor aeriene difuza, cronica, ireversibila
-tuse , expectoratie si dispnee predominant expiratorie
BRONSITA CRONICA ASTMATICA
-HRB, crize reversibile de bronhospasm, suprapuse pe obstructie cronica ireversibila
-tuse, expectoratie si dispnee expiratorie
EMFIZEMUL PULMONAR
-distensia ireversibila a spatiilor aeriene situate distal de bronhiola terminala, asociata cu distructia septurilor acestora si cu reducerea numarului de fibre elastice.
-obstructie expiratorie ireversibila.
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PREVALENTA
Barbati peste 40 de ani 15-17% au BPCO
La femei – de 2 ori mai putin
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ANATOMIE PATOLOGICA
BC-ingrosarea mucoasei bronsice
-hiperplazia si hipertrofia glandelor mucoase
- cresterea nr. de celule mucipare
-cresterea grosimii musculaturii bronsice
-creste indicele Reid
-inflamatie (infiltrat cu PMNN si Ly in peretele bronsic)
-ulceratii ale mucoasei, care se pot vindeca cu metaplazie scuamoasa a epiteliului cilindric si fibroza peretelui bronsic.
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EP -centroacinar(centrolobular)
in centrul lobulului pulmonar
apical
-panacinar (panlobular)
intreg lobulul
baze
bule de emfizem (emfizem bulos)
nu in BPCO
in deficitul de alfa1-ATT si determina obstructie
severa a cailor aeriene. S.n. emfizem malign.
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ETIOLOGIE
1.FUMATUL
-cauza principala > 80%
-rata normala de reducere a VEMS-ului este de 15-30ml
pe an.
- la fumatori, aceasta creste la 60 ml/an.
-hipertrofia gl. mucoase
-stimuleaza producerea de mucus
-disfunctia aparatului ciliar
-contractia musculaturii bronsice
-EP
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2. POLUAREA ATMOSFERICA
-determina inflamatie, hipersecretie de mucus si bonhospasm indus vagal
-SO2, praf de ciment, fum de carbune, pulberi de siliciu, pulberi de bumbac.
3.FACTORUL GENETIC
- fibroza chistica determina B si BPCO
- deficitul de alfa1-ATT, in forma homozigota determina in 2% din cazuri, spre varsta de 30-40 de ani EP panacinar.
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FIZIOPATOLOGIE
1.Alterarea volumelor respiratorii
-disfunctie ventilatorie de tip obstructiv
VEMS↓ FEV1
CV-N, ↓
Indice de permeabilitate bronsica ↓<70%
VR-crescut
CPT- crescuta
PEFR (flux expirator de varf) -scazut
VEMS>2l- asimptomatic
VEMS<1l- dispnee
VEMS<0,5l- dispnee severa
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2.Alterarea raportului V/P cu IR
-hipoxemie
-hipercapnie
-acidoza respiratorie
-in EP scade capacitatea de difuzie a CO, apare hipoxemie usoara, normo sau hipocapnie.
-Hipercapnie severa
3.HTP si CP
-hipoxemia –vasoconstrictie in circulatia pulmonara
-hipercapnia-vasoconstrictie in circulatia pulmonara
-cresterea vascozitatii sangvine
-scaderea patului vascular pulmonar
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Stadializarea BPOC
Stadiul 1-usoara FEV1>80%
Stadiul 2-moderata FEV1 50-79%
Stadiul 3-severa FEV1 30-49%
Stadiul 4-f. severa FEV1<30%
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Manifestari clinice
tipB
-tuse cu expectoratie
-dispnee expiratorie
-expir prelungit
-sibilante, ronflante, in per de acutizare subcrepitante
-hipoxemia -cianoza centrala
-tahicardie, tulburari de ritm
-tulburari mentale (agitatie comportament psihotic, somnolenta, coma)
-transpiratie
-necroza hepato-celulara
Hipocratismul- f. rar in BPCO
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Hipercapnia- cefalee prin vasodilatatie cerebrala
-somnolenta
-flapping tremor
-obnubilare
-coma
-extremitati calde prin vasodilatatie periferica
-edem cerebral, edem papilar prin vasodilatatie
cerebrala
Semnele CP
tip A
-dispnee de efort, tanipnee
-tuse rara, seaca
-expir prelungit
![Page 14: BPOC Emfizem](https://reader033.fdocuments.us/reader033/viewer/2022061504/55cf99fc550346d0339fffc6/html5/thumbnails/14.jpg)
-nu au cianoza in repaus
-nu fac CP, pt. ca nu au hipoxie decat foarte tardiv- Obiectiv: semne de hiperinflatie
-torace emfizematos, “in butoi”, cu diametrul antero-posterior marit
-coaste orizontalizate
-hipersonoritate
-MV diminuat
-ronflante, sibilante
-matitate cardiaca si hepatica disparute
-zg. cardiace asurzite
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PARACLINIC
RX.CP in tip B:
-cord mare, pe seama VD(vf. inimii rotat in sus, formand un unghi ascutit cu diafragmul)
-AP dilatate
-plamani normali sau accentuarea desenului bronhovascular
RX.CP in tip A:
-cord mic
-D aplatizate
-Htransparenta pulmonara, bule de emfizem
-coaste orizontalizate
-circulatie pulmonara redusa la periferie,bine reprez. central
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Ecg - tip B- semnele CP
-tip A-microvoltaj qrs, S1S2S3
Spirometria- vezi fiziopatologia
Capacitatea de difuziune a CO -scazuta in EP
-normala in BC
Hematocrit – crescut in BC
-normal in EP
PaO2- scazuta in BC
- normal in repaus in EP, scade in effort
PaCO2- crescut in BC
-scazut in EP
PAP –crescuta in BC
-normala sau usor crescuta in EP
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COMPLICATII, EVOLUTIE, PROGNOSTIC
-tip B are evolutie fluctuanta cu per. de exacerbare (provocate de o infectie virala) si per. de ameliorare.
In timpul exacerbarii, in mucusul bronsic prolifereaza bacterii (pn, H.I, Moraxella catarrhalis), apare sputa abundenta muco-purulenta, se agraveaza obstructia bronsica, IR si IC dr.
Pot apare: pneumonii, bronhopneumonii
tulburari de ritm:TAM, flutter atrial, TV, FV
tulburari hidroelectrolitice si acido-bazice
TEP
CP
atelectazii
PTX
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Tip A –evolutie mai lunga decat tip B, dominata de dispnee
-CP apare tardiv
DIAGNOSTICUL DIFERENTIAL:
-IC stg.
-AB
-FP
-HTP primitiva
-Emfizemul senil
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TRATAMENT
1.Inlaturarea factorilor etiologici
-oprirea fumatului are ca efect cresterea tolerantei la efort, ameliorarea tusei, scaderea expectoratiei.
-evitarea expunerii la poluanti atmosferici si insecticide
2.Dezobstructia bronsica
-antibiotice- sputa purulenta
tetraciclina-2g/zi
doxiciclina-200mg/zi
ampicilina-2-3g/zi
amoxicilina-1,5g/zi
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Augmentin
Cotrimoxazol
Cefaclor- Vaccinarea antigripala si antipneumococica-profilaxia exacerbarilor acute- Bronhodilatatoare
-ag. Beta2ag
-anticolinergice
-teofilina
Cu durata scurta de actiune:
-beta2ag: albuterol, salbutamol, ventolin
2-3 puff la 4-6h, debutul act 5min
r. adv:palpitatii, tahicardie, tremor, aritmii
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Anticolinergic: bromura de ipratropium (Atrovent)
2puff de 4ori/zi
r. adv:uscaciunea gurii, tulburari de vedere,
tuse
scad secretia bronsica
au risc aritmogen scazut
Combinatii: albuterol-ipratropium
Bronhodilatatoare cu durata lunga de actiune:
-beta2ag: salmeterol 1puff de 2ori/zi
formoterol 1puff de 2ori/zi
r. adv:ameteala, cefalee tremor
incep act in 30min, durata act cel putin 12h
-anticolinergice -tiotropium (1inh./zi dim), dur 24h
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r. adv:uscaciunea gurii, retentie de urina, tulburari de vedere
Ambele clase de bronhodilatatoare reduc riscul exacerbarilor cu 15-20%, reduc spitalizarea
Teofilina
-se foloseste rar in trat BPOC
-in BPOC sever
-preparate cu actiune de lunga durata
-200-800mg/zi
-8-12ug/ml
-indicatia teofilinei este controversata in exacerbarile acute
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Corticosteroizii inhalatori
-reduc frecventa exacerbarilor cu 15-20%
fluticasone 1-2puff de 2ori/zi
budesonide 2puff de 2ori/zi
beclometazona 2puff de 2ori/zi
-r adv.candidoza bucala, disfonia, cefaleea, nasofaringita
Combinatii:
Beta2ag-CS inh:
Fluticasone-salmeterol
Budesonide-formoterol
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-Corticosteroizi- efect antiinflamator
- 30mg prednison/zi, 14zile
- se inlocuiesc cu un preparat inhalator
-in caz de obstructie severa se dubleaza doza de prednison, sau se administreaza corticosteroid parenteral.
Fluidificarea secretiei bronsice
-hidratare
-mucolitice (ACC)
Drenajul postural
-percutii pe torace
-aspiratie cu bronhoscopul
![Page 25: BPOC Emfizem](https://reader033.fdocuments.us/reader033/viewer/2022061504/55cf99fc550346d0339fffc6/html5/thumbnails/25.jpg)
Oxigenoterapia
-scade mortalitatea
-creste toleranta la efort
-scade poliglobulia
-amelioreaza performanta cerebrala
-amelioreaza ICD
indicatii: -cianoza
-paO2<55
-poliglobulie
-CP
doza-1-2l/min, cel putin 19h/zi.
necesita monitorizare periodica a gazelor
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Oxigenoterapie la domiciliu
-VEMS<1,5l
- paO2<55mmHg
- SaO2<88
Intubatia traheala si ventilatia mecanica:
-alterarea starii mentale
-pauze respiratorii cu pierderea constientei
-paO2<36mmHg
-hipercapnie progresiva sub oxigenoterapie
-pH-ul<7,25
![Page 27: BPOC Emfizem](https://reader033.fdocuments.us/reader033/viewer/2022061504/55cf99fc550346d0339fffc6/html5/thumbnails/27.jpg)
Medicamente analeptice respiratorii:
-doxapramul, util pe termen scurt, imbunatateste ventilatia
Alte metode terapeutice
-antrenamentul fizic, gimnastica respiratorie
-transplantul unui singur plaman
-adm de alfa1-ATT
![Page 28: BPOC Emfizem](https://reader033.fdocuments.us/reader033/viewer/2022061504/55cf99fc550346d0339fffc6/html5/thumbnails/28.jpg)
Tratamentul empiric al BPOC
-beta2ag cu durata scurta- st1-4
-adauga beta2ag cu durata lunga, anticolinergic cu durata lunga sau amandoua in st 2-4
-adauga CS inhalator in st 3-4, daca pacientul are exacerbari frecvente
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CORDUL PULMONAR
Definitie
Hipertrofia si dilatarea ventriculara dreapta secundara HTP, determinata de afectiuni ale parenchimului pulmonar, ale circulatiei pulmonare sau ale peretelui toracic.
Nu se refera la dilatarea VD secundara insuficientei VS, afectiunilor congenitale cardiace sau valvulopatiilor dobandite.
![Page 30: BPOC Emfizem](https://reader033.fdocuments.us/reader033/viewer/2022061504/55cf99fc550346d0339fffc6/html5/thumbnails/30.jpg)
CP -acut si reversibil ( ex. embolia pulmonara acuta masiva, insotit de soc)
- cronic (de obicei)
ETIOLOGIE
1.Boli respiratorii:
Obstructive -BPCO (cea mai frecventa cauza de CP)
-Astm cronic
Hipertensiune pulmonara datorata hipoxiei, alungire si pierdere a vaselor
Batai cardiace asurzite datorita hiperinflatiei pulmonare
Debit cardiac normal sau crescut
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Restrictive
-intrinseci: boli pulmonare infiltrative sau granulomatoase
-fibroza pulmonara idiopatica
-boli interstitiale asociate cu boli de colagen
artrita reumatoida
sclerodermie
lupus eritematoe sistemic
polimiozita
boala mixta de tesut conjunctiv
-boli interstitiale asociate cu vasculite
granulomatoza Wegener
-sarcoidoza
-pneumoconioze: silicoza, azbestoza
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Restrictive
- Extrinseci -obezitate
-cifoscolioza
-pahipleurita
-toracoplastie
-afectiuni neuromusculare ce implica mm.resp
-sdr.de apnee in somn
-mixedem
-altitudine inalta
Hipertensiune datorata hipoxiei, distorsiunii si pierderii vasculare
![Page 33: BPOC Emfizem](https://reader033.fdocuments.us/reader033/viewer/2022061504/55cf99fc550346d0339fffc6/html5/thumbnails/33.jpg)
2.Boli vasculare pulmonare
Emboli mari si multipli:
-scadere a debitului datorita obstructiei acute
-cord pulmonar acut
-soc
Emboli mici, vasculita pulmonara, afectare pulmonara masiva (SDRA)
-HTP datorita hipoxiei intinse si obstructiei microvasculare
-cord pulmonar subacut
-distensia ventricului drept
-dispnee si febra
![Page 34: BPOC Emfizem](https://reader033.fdocuments.us/reader033/viewer/2022061504/55cf99fc550346d0339fffc6/html5/thumbnails/34.jpg)
Emboli medii si recurenti; HTP primitiva; dieta sau medicamente cu actiune pe vase
-HTP datorita obstructiei vasculare
-cord pulmonar cronic
-hipertrofie cardiaca dreapta
-dispnee
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PATOGENIE
CP este consecinta HTP, care determina cresterea postsarcinii VD.
Cauzele HTP:
1.reducerea ireversibila a dimensiunii patului vascular pulmonar (ex.embolie, sclerodermie, emfizem, rezectie pulmonara)
2.hipoxia alveolara, care este cel mai important mecanism de producere a CP. Hipoxia determina vasoconstrictie in circulatia pulmonara si ulterior hipertrofia musculaturii netede arteriolare pulmonare.
![Page 36: BPOC Emfizem](https://reader033.fdocuments.us/reader033/viewer/2022061504/55cf99fc550346d0339fffc6/html5/thumbnails/36.jpg)
3.acidoza, care determina vasoconstrictie pulmonara.
4.hipercapnia determina vasoconstrictie pulmonara
5.Cresterea vascozitatii sangelui secundara policitemiei din
BPOC intensifica HTP.
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MANIFESTARI CLINICE
1. Similare bolii ce a determinat CP
2. Dispneea la efort, cel mai important simptom, poate fi intensa, nu se amelioreaza in ortostatism
3. Tusea neproductiva
4. Sincopa la efort
5. Durerea toracica anterioara, secundara dilatarii radacinii arterei pulmonare sau ischemiei ventriculare drepte
5. Fatigabilitatea
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Obiectiv:
-tahipnee, in timpul efortului usor si-n repaus
-cianoza, datorita hipoxemiei arteriale
-lift parasternal stang (pulsatie a VD pe marginea stanga a sternului) sau pulsatie a VD in epigastru
-accentuarea componentei pulmonare a zgomotului 2
-dedublarea fixa a zgomotului 2
-galop protodiastolic ventricular drept
-suflu sistolic de insuficienta tricuspidiana, care se amplifica in inspir
-suflu diastolic de insuficienta pulmonara
-semne de IC dreapta-jugulare turgescente, hepatomegalie sensibila la palpare, edeme, ascita, reflux hepato-jugular. CP nu determina revarsat pleural, dar determina ascita.
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INVESTIGATII
Rx. Toracica
-trunchiul pulmonar si vasele hilare sunt marite
-raportul hilar cardiotoracic > 0,36 sugereaza HTP
(raportul intre distanta dintre cele doua hiluri si diametrul transvers al toracelui)
-diametrul arterei pulmonare drepte inferioare >16mm si diametrul arterei pulmonare stangi >18mm sugereaza HTP
-atenuare arteriala distala (aa. pulmonare centrale sunt mari, dar vasele sunt ingustate si dispar la periferie).
-dilatarea VD- varful cordului deplasat lateral, rotat in sus, formand un unghi ascutit cu diafragmul (cord in sabot)
![Page 40: BPOC Emfizem](https://reader033.fdocuments.us/reader033/viewer/2022061504/55cf99fc550346d0339fffc6/html5/thumbnails/40.jpg)
ECG:
-rotatia orara a cordului
-deviatie axiala dreapta a complexului qrs (>90)
-P pulmonar in DII, DIII, aVF
-BRD minor/major
-S1S2S3
-S1Q3T3
-R/S>1 in V1 sau R/s<1 in V6
-T negativ V1-V4
-aritmii-TAM si FiA
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ECHOGRAFIA CARDIACA
-dilatarea si hipertrofia VD
-dilatarea AD
-cresterea PAP
-regurgitare tricuspidiana si/sau pulmonara
-miscare paradoxala a siv (deplasat spre cavitatea stanga)- semn de HTP severa
CATETERISMUL CARDIAC
-det. PAP, P in capilare, vene
-indicat pentru a confirma natura obstructiei vasculare pulmonare
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TRATAMENT
1.Tratamentul afectiunii pulmonare ( ICD beneficiaza mai degraba de tratamentul afectiunii pulmonare decat de tratamentul diuretic si tonicardiac)
2. Oxigenoterapia
-creste supravietuirea
-amelioreaza insuficienta cardiaca dreapta
-scade poliglobulia
-scade vasoconstrictia pulmonara
-creste toleranta la efort
-amelioreaza performanta cerebrala
-se adm 1-2l/min, timp de 19-20h/zi.
-se masoara gazele sangvine, ptr. a prevenii cresterea
![Page 43: BPOC Emfizem](https://reader033.fdocuments.us/reader033/viewer/2022061504/55cf99fc550346d0339fffc6/html5/thumbnails/43.jpg)
paCO2, care este periculoasa si poate determina depresia centrului respirator.
3.Diuretice
-indicate numai daca edemele sunt voluminoase
-sunt periculoase in lipsa edemelor, deoarece scad presarcina si D.C.
-pastrarea unor edeme gambiere discrete reprezinta garantia unei umpleri ventriculare adecvate.
-alcaloza metabolica secundara diureticelor poate determina deprimarea respiratiei
4.Digitala
-nu este benefica in CP(determina cresterea contractilitatii VD, dar produce si vasoconstrictie in circulatia pulmonara)
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-risc aritmogen crescut in prezenta hipoxiei
-se adm in caz de fibrilatie atriala sau flutter atrial
5.Flebotomia
-evacuarea a 300-500ml sange la interval de 3 zile
-Ht>55%
-creste toleranta la efort
-amelioreaza cefaleea
-nu amelioreaza schimburile gazoase
6.Vasodilatatoarele
-eficiente in perioadele de acutizare, prin scaderea presiunii in mica circulatie
-se adm. IEC
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7.Antagonistii receptorilor endotelieli
Bosentan este un antagonist, al receptorilor endoteliali ETA si ETB, a caror activare elibereaza substante vasodilatatoare si antiproliferative ca: NO si prostaciclin.
Indicat in HTP primitiva, HTP secundara scerodermiei, fara boala interstitiala semnificativa
Scade rezistenta vasculara pulmonara
R. adverse: hepatotoxicitate, anemie, contraindicat in sarcina
Sildenafil, inhibitor al fosfodiesterazei 5 este indicat in : HTP primitiva, tromboembolica, asociata bolilor de colagen
Imbunatateste capacitatea de efort si a hemodinamicii pulmonare
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7.Analeptice respiratorii
-doxapram
-imbunatateste ventilatia, stimuland tusea si eliminarea secretiilor. Efectul este pe termen scurt.
8.Intubatia traheala si ventilatia mecanica
Indicatii:
-alterarea starii mentale
-paO2<36
-Ph<7,25
-PaCO2 crescut