Chronic obstructive pulmonary disease (COPD) is a group of chronic respiratory diseases of adults, adolescents and children: emphysema, chronic obstructive bronchitis, bronchiolitis obliterans, severe bronchial asthma, bronchiectasis and cystic fibrosis. The main feature that combines the above-mentioned diseases in the COPD group is a progressive irreversible bronchial obstruction with increasing phenomena of chronic respiratory failure.
- Treatment
- Bronchodilators
- Corticosteroids
- Pronounced impaired sputum emptying
- Infusion therapy
- Prevention of venous thrombosis and embolism
- Non-invasive and invasive ventilation
- Pulmonary heart
For instrumental objectification of the severity of the process, measure the volume of forced expiration in 1 s (FEV1) - NICE Grading of Severity of Airflow Obstruction: severity of obstruction | Force of forced expiration,% |
Moderate | 50-80 |
Average | 30-49 |
Heavy | <30 |
COPD develops mainly in people aged 40 and over, progressing at a slow pace. Severe and extremely severe course of the disease mainly falls on the age of 55 to 65 years. Usually, patients with such a diagnosis are under the supervision of doctors for many years, which gives a higher chance of delivering a correct and accurate diagnosis. When a person's condition becomes extremely serious, he falls into a coma, often there is a hospitalization in the ICU. But it is worth knowing that doctors can not radically help these patients.
Doctors should also remember: not all patients can be helped. And not all patients with severe COPD decompensation should be admitted to the intensive care unit. If the patient is still brought to the ICU, physicians should try to avoid invasive mechanical ventilation if the person has COPD decompensation. In most cases, the patient is brought to the department in the stage of decompensation, with severe respiratory failure and manifestations of the pulmonary heart.
Drowsiness of a person can talk about concomitant hypercapnia. Blood saturation is below 90-92%. In this phase of the disease, therapy with bronchodilators and corticosteroids often does not give the desired, expected effect. The treating doctor has to transfer the patient to controlled breathing. The condition of a person in such cases, as a rule, becomes better. But further to the doctors stands a much more complicated, often insoluble, task - how to disconnect the patient from the apparatus of artificial ventilation?
Monitoring
All patients should be given a radiograph of the lungs. Conduct blood pressure control, heart rate, ECG, blood gases, peak expiratory flow rate, blood electrolytes, hematocrit, glucose, creatinine, blood saturation.
Treatment
Treatment should be carried out in this order. First, oxygen therapy is started with nasal catheters at a rate of 1-2 liters per minute. A high rate of oxygenation, especially in patients with severe hypercapnia (drowsiness is a clinical manifestation of hypercapnia), can cause the development of apnea. Further, the oxygen delivery rate of the physicians is adjusted to provide an acceptable level of oxygenation (saturation of 88-92%). The patient takes a forced sitting or semi-sitting position. You can not put the patient lying in bed.
Provide venous access using peripheral venous catheters. If a person is in a coma, there are signs of severe respiratory failure, you must immediately intubate the trachea and begin ventilating.
Bronchodilators
Most people with COPD in a stage of decompensation respond moderately to bronchodilator therapy. If a person took beta-2-agonists or anticholinergics before entering the ICU, the best solution of the doctor will be to continue inhalation of that beta-2 agonist or anticholinergic that previously had a positive effect, this information should be found in the patient or relatives.
It is advisable to use a nebulizer powered by a compressor, not oxygen. Given the low sensitivity of patients to bronchodilators, in all severe cases, beta-2 agonists and anticholinergics are combined.
Preparations for nebulizer therapy in COPD :
- Salbutamol 2.5 mg (Berotek 1 mg = 20 drops) at intervals of 30 minutes to 4-6 hours;
- Ipratropium bromide (also marketed under the name Atrovent) 0.5 mg (40 drops) at intervals of 2 hours to 4-6 hours;
- Berodual 2.0 ml (40 drops), spacing 2-6 hours. Berodual is a combined bronchospasmolytic drug that contains 2 bronchodilators: fenoterol (beta-2 agonist) and ipratropium
In the absence of a nebulizer, short-acting metered-dose aerosol beta-2 agonists, terbutaline sulphate (analogue: Bricanyl®), salbutamol (analogue: Ventolin), Berodual (combination drug), fenoterol hydrobromide (Berotek), and / or anticholinergic drugs - ipratropium (atrovent), oxytropium bromide (analog: Oxyvent). Efficacy will be greater if the metered-dose inhaler is equipped with a spacer.
At the beginning of therapy, a person immediately inhales from 3 to 6 doses. If there is no effect, inhalation should be repeated after 20 minutes. In the future, inhalations are carried out in accordance with the instructions to the drug. When using these drugs, contraindications should be considered: severe hypertension, rhythm disturbances, etc. And monitor the concentration of potassium in the plasma, if the patient receives beta-2-agonists - possibly a rapid development of hypokalemia.
Introduction of euphyllinum
It is used in case of inefficiency of beta-2-agonists and anticholinergics or inability to use them. Do not administer eufillin if the patient was administered it regularly before admission. The loading dose of the drug is 2-4 mg per 1 kg of the patient's body for 20 minutes IV (10 ml 2.4% euphyllin).
Supportive therapy: 0.5 mg / kg per hour. With congestive heart failure, severe liver disease, pneumonia, this dosage should be used: 0.25 mg / kg / h. When using aminophylline, the indicated dosages are reduced by twenty percent. The introduction of euphyllin is recommended to continue until a marked improvement in the condition of a person - an average of 24 hours, sometimes even a longer period.
Corticosteroids
Inhaled corticosteroids are attributed only to patients with a proven clinical or spirometric response or with FEV1 less than 50% of that due or with repeated exacerbations. Long-term use of systemic corticosteroids can not. The effect of these drugs develops mainly in 2-4 hours from the beginning of admission (an average of 2-6 hours), the effectiveness is low.
In case of severe exacerbation, if a person is unable to take medications alone, prednisolone ( dexamethasone , hydrocortisone in appropriate dosages) at a dose of 0.5-1 mg / kg after 6 hours intravenously for 2 hours. Then, the daily dose of medics is reduced to 40-60 mg per day. In more mild cases, it is necessary to prescribe prednisone tableted for 5-10 mg 4 times a day. The duration of taking systemic corticosteroids is 10-14 days.
N-acetylcysteine
N-acetylcysteine, which is prescribed at a dose of 1200 mg per day during exacerbation, contributes to a faster improvement in the human condition.
Pronounced impaired sputum emptying
In the presence of viscous, difficult-to-cough phlegm, it is necessary to carry out measures that contribute to its dilution and enhance drainage. Initially, procedures can worsen a patient's condition by increasing the amount of sputum and increasing bronchospasm.
Physicians should explain to the patient the necessity of these procedures and to warn that at first his condition can become worse. Depending on the available drugs and the clinical situation, doctors prescribe:
- N-acetylcysteine (Fluimucil) nebulizer - nebula 3 ml 10% solution, 1-2 times a day;
- Inhalation of a solution of furosemide ( Lasix ) 0.5-1 mg per 1 kg of the patient's body. In a day to spend 2-3 sessions. This disease reduces the viscosity of phlegm, almost always well tolerated by patients;
- With a large amount of purulent viscous sputum in humans, it can be attributed to inhalation of 3-7.5% sodium chloride. This method is not well tolerated by everyone. Inhalation should be carried out using 5-10 ml of r-ra, after 3-4 hours. Before each inhalation of sodium chloride, inhalation is made with beta-2 agonists;
- Inhalation is recommended to alternate with sessions for 10-15 minutes VCIVL (intensifies sputum drainage);
- With a strong, painful cough, you can prescribe a patient inhaled lidocaine 1% - 5.0.
Infusion therapy
If you can take liquid and food, you usually enter the volume taken by the patient. If there are disturbances of consciousness, such a patient is given probe nutrition. In rare cases, patients need intravenous infusion therapy. The efficiency criteria are as follows: restoration of diuresis more than 60ml / hour, reduction of dry skin, thirst reduction, hematocrit within 0.35-0.40.
Hypervolaemia and large volumes of fluid are contraindicated. With CVP more than 12 cm of water. Art. Infusion therapy should be discontinued. Increased blood pressure decreases with the improvement of the patient's condition, usually, there is no need for medication. If the SBP is less than 90 mm Hg. st., it is necessary to apply the introduction of vasopressors (dopamine, epinephrine).
Prevention of venous thrombosis and embolism
Thromboembolism of the pulmonary artery (PE) is a common cause of decompensation in COPD. At autopsy PE patients are fixed in every 4 patients from those who were admitted to the hospital with a diagnosis of "exacerbation of COPD". For this reason, prophylaxis of deep vein thrombosis and PE is performed by physicians to virtually all patients with exacerbation of COPD, if no contraindications are found.
Low molecular weight heparins used in usual preventive doses cause fewer side effects and are more convenient to use. Therapy lasts on average from 7 to 14 days (until the patient's condition is improved and activated).
Antibiotics
Very often decompensation of COPD is associated with infectious processes - sinusitis, pneumonia, bronchitis and so on. Therefore, almost all patients need antibiotics. In chronic obstructive pulmonary disease, the most common pathogens provoking inflammation are: pneumococcus, hemophilic rod, various viral-bacterial associations. Accordingly, respiratory fluoroquinolones ( hemifloxacin , moxifloxacin), protected aminopenicillins (piperacillin / tazobactam, amoxicillin / clavulanate), modern macrolides are the drugs of choice.
If the patient was in the hospital for a long time before entering the intensive care unit, there is a high probability of joining the hospital gram-negative flora, mainly of Pseudomonas aeruginosa. This medicine should be considered when prescribing antibiotics (cefoperazone, ceftazidime).
Non-invasive and invasive ventilation
Noninvasive ventilation (NIVL) is considered to be the most important innovation in the conservative therapy of patients with COPD decompensation in recent years. The method allows to reduce nosocomial mortality and hospitalization of patients, reduces the need for invasive artificial ventilation (IVL). NIVL facilitates the transfer of a person to independent breathing after an invasive mechanical ventilation. But modern breathing apparatus and appropriate monitoring are needed.
Indications for non-invasive ventilation
NIVL is assigned if at least one of the following conditions exists:
- Respiratory acidosis (pH equal to or less than 7.35 and / or PaCO2 is equal to or greater than 6.0 kPa, or 45 mm Hg);
- Severe shortness of breath with clinical signs of fatigue of the respiratory muscles and / or increased load on the respiratory muscles (paradoxical movement of the abdomen, participation of auxiliary respiratory muscles or entraining intercostal spaces).
For these purposes, pressure-sensitive modes are available, of which there are only three: Pressure support; BiPAP; Proportional Assist. The use of a complete helmet mask is the most comfortable option for the patient.
Experienced doctors know that it is necessary to perform a certain selection of patients. A person should be in a clear consciousness, have stable indicators of hemodynamics, have a desire to cooperate with a doctor. If there is no improvement in the patient's condition (saturation, gases and blood pH, xymptoms) within 1-2 hours after the onset of NIVL, one should consider the need for mechanical ventilation.
Indications for invasive pulmonary ventilation
The presence of any of the following signs may serve as a basis for carrying out artificial ventilation:
- Inability to evacuate the bronchial secretion, increasing fatigue and exhaustion of a person;
- Stopping breathing or heart activity;
- Intolerance or ineffectiveness of NIVL;
- Appearance of coma harbingers;
- Bradycardia or arterial hypotension;
- Increasing hypercapnia more than 60 mm mercury column against the background of hypoxemia (PaO2 55-65 mm Hg, Sp02 less than 90%);
- Breathing pauses with loss of consciousness or sensation of suffocation.
Technology of ventilation
At the initial stage, mechanical ventilation is used similar approaches for those with exacerbation of bronchial asthma. Ventilation with pressure control (PCV) can be a method of choice in patients with severe hypoxemia and hypercapnia. It is recommended to try to keep the patient's respiratory activity, for which there are auxiliary ventilation modes (BIPAP, SIMV + PSV, etc.). And doctors need to try as soon as possible to transfer a person to independent breathing. The shorter the duration of invasive ventilation, the lower the mortality in these patients.
Pulmonary heart
Diagnosis of the pulmonary heart is established by such signs:
- enlargement of the shadow of the heart on the chest X-ray,
- swelling of the jugular veins,
- hypertrophy of the right ventricle,
- ECG signs,
- presence of peripheral edema.
Echocardiography can confirm the dysfunction of the right ventricle, since swelling is not always associated with right ventricular failure and pulmonary hypertension. To reduce fluid retention, intravenous furosemide is administered intravenously at a dose of 1 mg / kg.
Drugs that are better not to be prescribed for exacerbation of COPD
The appointment of cardiac glycosides and ACE inhibitors in the pulmonary heart is not recommended. The regulation of respiration in severe exacerbation of COPD is disturbed, and many drugs can aggravate these disorders. It is necessary to try without extreme necessity not to prescribe sedatives (especially from the group of benzodiazepines), antidepressants, narcotic analgesics, as during artificial ventilation of the lungs, and even more so without ventilator.