COPD is a common pathology of the bronchopulmonary apparatus, manifested by irreversible changes in the distal parts of the respiratory tract due to the obstructive type, resulting from prolonged exposure etiopathogenetic factors of non-inflammatory nature.
COPD in medical practice is a complex of lung pathologies, including chronic bronchitis of the obstructive type and emphysema. Due to the deterioration of the global ecological situation, the statistical registration of the incidence of COPD increases annually. The sad fact is that the level of lethality in this pathology remains high, despite the fairly good development of the pharmacological and diagnostic industry.
Several years ago, COPD was more common among men, but at present it is equally common for both sexes to suffer from this disease, which is associated with an increase in the number of smokers.
Causes of COPD
The predominant risk group for COPD occurrence is those who have a bad habit of smoking, and the severity of the course of the disease directly depends on the duration and number of "pack-years." Persons who have an increased sensitivity of the respiratory tract, even with the complete absence of clinical manifestations of bronchial asthma , are more likely to develop COPD.
In addition, modifiable risk factors are of great importance in the pathogenesis of COPD development. To this category of etiological factors include: reduced weight, frequent episodes of respiratory diseases in childhood, passive smoking, long stay in a polluted atmosphere (professional group of respiratory pathologies).
The emergence of COPD in a non-smoking person is possible only if it has a genetic predisposition, namely, an alpha-trypsin deficiency, resulting in an imbalance between the protease and antiprotease activity of the lung tissue. Under normal conditions, as a result of the action of protease activity in the form of neutrophil elastase, tissue metalloproteinase, elastin and connective tissue are destroyed, and the structure of the pulmonary parenchyma is restored. The antiprotease activity of alpha-antitrypsin and a secretory proteinase inhibitor is aimed at regulating the processes of destruction of elastin, and therefore, patients with COPD always have signs of a decrease in antiprotease activity, resulting in destructive changes in lung tissue. As a result of neutrophil activation, there are signs of bronchospasm, excessive production of intrabronchial mucus, and marked swelling of the mucous membranes of the respiratory tract.
Severe COPD is always accompanied by secondary infection of the respiratory tract, due to a pronounced decrease in mucus clearance in the projection of the distal parts of the respiratory tract. Exacerbation of COPD occurs when a second infection of the bronchial tree and aggravates the course of the underlying disease.
Thus, the pathogenetic chain of reactions that provoke the development of COPD in persons with predisposition is the occurrence of obstructive changes in bronchial pathways mainly in the distal areas due to a sharp increase in the production of mucus and bronchospasm.
Symptoms of COPD
The course of COPD is usually progressive, but the majority of patients develop developmental clinical symptoms for several years and even decades.
The first specific symptom of COPD development in a patient is the appearance of a cough. In the onset of the disease, coughing worries the patient only in the morning and is of a short duration, but over time, the patient's condition worsens and a painful coughing with a large amount of sputum mucus separates. Isolation of viscous sputum of yellow color indicates a purulent nature of the secretion of inflammatory nature.
A prolonged period of COPD is inevitably accompanied by the development of emphysema of bilateral bilateralization, as evidenced by the appearance of a shortness of breath of an expiratory nature, that is, difficulty breathing during the "expiration" phase. A characteristic feature of dyspnea in COPD is its persistent nature with a propensity to progress, provided there are no treatment measures.
The appearance of permanent headaches in the patient without a clear localization, dizziness , disability and drowsiness testify to the development of hypoxic and hypercapnic damage to the structures of the brain.
An objective examination of a patient with a prolonged course of the disease is accompanied by the detection of typical signs characterizing irreversible changes in the airways. So, with a visual examination, the formation of the hypersthenic type of the thorax and a difficult limited excursion of the lungs are noted. Skin covers of the patient acquire a cyanotic shade with a predominant localization in the distal parts of the trunk and upper half of the thorax.
When carrying out lung percussion, a boxed tone of pulmonary sound is observed, symmetrical on both sides, and the auscultatory signs of COPD consist in listening to multiple scattered dry wheezing that do not disappear even after expectoration of sputum.
Degrees and stages of COPD
Given the set of clinical and instrumental indicators of the functioning of the respiratory system of a patient with COPD, the main task of a pulmonologist is to determine the stage of progression of the disease and the severity of the patient's health condition. For this purpose, a single world classification of COPD was developed, taking into account the most important nuances of the clinical picture and data of instrumental diagnostic methods. This approach to the diagnosis of COPD makes it possible to effectively develop individual basic therapy, which must be adhered to the patient.
Thus, the first stage of COPD is characterized by clinical symptoms of mild manifestation in the form of periodic episodes of dry cough and the departure of a small amount of sputum mucus. When performing a functional method of studying the function of external respiration (spirometry) in this stage of COPD, the index of forced expiratory volume is more than 80%.
In a situation where the signs of COPD become more pronounced, namely, the connection of dyspnea during the performance of physical activity to patients, the second stage of the disease should be suspected. A spirometric indicator of moderate severity of COPD is a decrease in the volume of forced expiration to a rate of 80% of the expected.
The third stage of COPD is accompanied by significant changes in the patient's health status, since increasing respiratory disorders interfere with normal physical exertion, as well as periods of exacerbation of COPD with attachment of an infectious lesion of the pulmonary apparatus become more frequent. The establishment of the third stage of the disease and its severe degree of clinical manifestations should be confirmed by spirometric measures (the volume of forced expiration does not exceed 50% of the expected).
The fourth stage of COPD is nothing more than an extremely severe pulmonary insufficiency, manifested by severe hemodynamic and respiratory disorders. Diagnosis of COPD, which is in this extremely difficult degree, is not difficult, given the expressed specific symptoms, and in most cases spirometry can not be carried out in view of the patient's serious condition.
COPD medical history
The main document of the patient during his stay in a 24-hour hospital is a "medical history", which is filled in when the patient first contacts. Typically, patients with COPD have a long outpatient follow-up period, during which the therapist reflects all changes in the patient's health status in the patient's outpatient card. In this regard, in order to facilitate the registration of a patient in the reception room of a hospital of a stationary type, the patient must present the medical registrar with a referral for hospitalization issued by the family doctor, a document certifying the patient's personality and the patient's outpatient card. In the case when the patient is in serious condition, the delivery is carried out by an ambulance and the patient is registered in a simplified mode.
Initial examination of the patient consists in careful collection of complaints, anamnesis of the development of symptoms and the presence of concomitant pathologies with obligatory registration of data in the medical history in the column "primary examination", which is performed by the therapist of the receiving dormancy. The objective examination data should also be reflected in the written form, as for the further evaluation of the dynamics of the development of the disease the state of the patient at the time of delivery to the hospital is of great importance.
In a situation where the therapist finds it difficult to diagnose, it is advisable to indicate in the column "additional examination methods" the volume of recommended diagnostic measures, after which the "preliminary diagnosis" or differential-diagnostic series of diseases should be recorded by the doctor of the receiving dormancy. After assessing the severity of the patient's condition with COPD, the doctor decides which department to hospitalize the patient for further treatment, but the therapist must first reflect on the treatment recommendations for the patient.
In future, a specialist in the pulmonary profile should be involved in the treatment of a diagnosed COPD whose function is to dynamically observe the patient's state of health with the daily filling of the "observation diary" in the medical history and correction of medication in the "appointment list". In a situation where a patient needs to carry out diagnostic measures or consult a specialist in a narrow profile, the treating physician should only make a record in the medical history with justification of the prescribed instrumental or laboratory examination (control spirography in order to select the minimum therapeutic dose of bronchodilator).
The term of a patient with COPD can be determined only by the attending physician and upon discharge from the hospital the patient is given a "discharge epicrisis", reflecting all stages of the patient's stay in the hospital and brief recommendations regarding further treatment of the underlying disease.
Diagnosis of COPD
Unfortunately, early diagnosis of COPD is extremely difficult, since this pathology is characterized by slow progression and a long asymptomatic period. In a situation where a typical clinical picture evidences the presence of irreversible changes in the bronchopulmonary apparatus in a patient, the diagnosis of COPD is reduced to determining changes in the function of external respiration, the presence or absence of an inflammatory component, and carrying out stress tests.
In fact, even the appearance of such a symptom as a "cough" in a person, even if it has a short-term character, should be the basis for a pulmonologist to comprehensively examine a patient. In such a situation, the examination of the patient begins with elementary standard tests of blood and sputum.
The presence of COPD in almost 80% of cases is accompanied by an inflammatory reaction of the blood, indicating the onset of a period of exacerbation of the underlying disease. During the interictal period, the blood test has no change. The appearance of polycythemic syndrome in the blood in the form of an increase in erythrocytes, hemoglobin and low ESR indicates a severe degree of hypoxemia, which is observed in extremely severe COPD.
When examining a patient with suspected COPD, submitting sputum analysis is of great diagnostic value, since the detection of inflammatory elements in it allows us to establish the conclusion "exacerbation of COPD," and the definition of atypical cells allows to exclude the oncological nature of the patient's respiratory disorders. In a situation when signs of an inflammatory reaction are present in the sputum analysis, it is advisable to conduct a culture microbiological study to determine the type of pathogen and its sensitivity to the antibacterial drugs of a pharmacological group.
An evaluation of the performance of the respiratory system in the form of spirometry and pic fl uorometry takes place when it is necessary to assess the severity of COPD in order to determine the further tactics of the patient's management and also as a control method of the study to assess the effectiveness of the treatment used.
The bronchodilator test is a "marker" of the possible reversibility of obstructive changes in the patient's bronchial apparatus, which is of great importance in the differential diagnosis of bronchial asthma and COPD. To carry out this drug test, any short-acting beta-agonites drug (Salbutamol 400mg dosage) is used, followed by spirometry scores no earlier than 15 minutes. In a situation where after the use of the drug in the patient there is an increase in the volume of forced expiration by more than 15%, there is every reason to assert a reversible process of bronchial obstruction, which contradicts the diagnosis of COPD.
Instrumental diagnostic methods based on the use of ionizing radiation play a significant role in establishing changes in the bronchial tree in patients with COPD. Thus, computed tomography, which is already in the initial stage of the disease, allows one to determine the deformation of the pulmonary pattern due to the increased expanse of pulmonary interstitium. The severe form of COPD is accompanied by significant radiographic changes in the form of limited or widespread increase in pulmonary pneumatization, flattening of the diaphragm and widening the boundaries of the lower half of the mediastinum by increasing the parameters of the right atrium of the heart.
Determination of the gas composition of blood is also included in the algorithm of mandatory diagnostic measures in patients with prolonged course of COPD. This method allows to assess the degree of respiratory failure and associated hypoxemia with the subsequent selection of an adequate scheme of oxygen therapy.
In difficult situations, when the patient's complaints and objective examination data correspond to the severe severity of COPD, and the spirographic data do not coincide with the clinical symptoms, it is advisable to apply the test with physical exertion.
It is extremely rare, as a diagnostic measure in COPD, bronchoscopy is used to exclude the presence of volumetric neoplasm in the lumen of the bronchi, which proceeds with a similar clinical picture as COPD.
Treatment of COPD
After establishing a reliable diagnosis, confirmed by instrumental imaging techniques, the pulmonologist should determine the appropriate amount of treatment, taking into account the basic principles of COPD therapy. The therapy should be pathogenetically substantiated and aimed at improving not only the patient's quality of life, but also to prevent possible complications of the underlying disease.
All applied conservative and surgical methods of treatment should be divided into several categories: measures of etiopathogenetic orientation, conservative treatment of a patient in stable condition, therapy of exacerbation of COPD and rehabilitation measures.
Etiopathogenetic treatment of patients with COPD should begin with the complete elimination of the root causes of changes in the bronchial apparatus, that is, with the modification of the patient's lifestyle. The key to successful treatment of even severe COPD is a complete cessation of smoking. In a situation where COPD is the result of occupational exposure to harmful conditions, the appearance of its signs in humans should be the reason for stopping work in harmful conditions of exposure to atmospheric pollutants.
In a situation where the patient has a period of stable course of COPD, it is necessary to maximize the use of therapeutic measures of medical conservative therapy, consisting in choosing an adequate bronchodilator drug belonging to one or another pharmacological group and selecting its effective therapeutic dose.
The choice of the method of drug access and the dose of the drug directly depends on the stage of the disease and the patient's signs of obstruction. Thus, patients with the first stage of COPD should not systematically take the bronchodilator, and in case of worsening, it is recommended to use short-acting drugs.
The second stage of COPD is characterized by a moderate degree of clinical symptoms that occur at any time of the day and is not dependent on the physical activity of the patient, therefore this category of patients should be recommended for a continuous long-term use of a bronchodilating drug of prolonged action in a predominant inhalation form.
The third stage of COPD involves the use of a whole group of drugs aimed at eliminating bronchial obstruction with a combination of oral and parenteral routes of access of the active substance.
The fourth stage of COPD is accompanied by severe respiratory disorders, therefore, it is advisable to treat this category of patients in the intensive care unit with a full range of urgent measures.
Currently, as bronchodilator drugs, a large number of drugs are used, having different methods of delivery of the active substance and the duration of the pharmacological effect, each of which has many advantages, and at the same time as any chemical compound is not devoid of shortcomings.
Thus, Atrovent, which belongs to the pharmacological group of anticholinergics, has a good bronchodilating effect. Unfortunately, this drug, like other representatives of this group, does not have a quick effect on improving the patient's condition and needs a long reception to achieve a positive result, but at the same time, these drugs practically do not cause adverse reactions from the cardiovascular activity system, so they are successfully used to treat COPD in elderly patients. The initial saturating dose of the drug should be 80 μg per day, followed by a transition to a maintenance dosage of 40 μg.
Most pulmonologists in the treatment of mild COPD prefer inhaled drugs belonging to the B2-agonist group, which are represented by both short-term and prolonged pharmaceutical effects. Salbutamol, referred to the category of short-acting B2-agonists, is usually well tolerated by patients, because elimination of signs of obstruction occurs after several minutes after its application, and the duration of pharmacological action reaches several hours. However, in the appointment of this drug to patients with COPD should talk about the possible occurrence of adverse reactions in case of drug overdose (transient tremor, a tendency to arterial hypertension , increased excitability of the structures of the central nervous system), and therefore, extremely unhelpful is the systematic uncontrolled intake of drugs of this pharmaceutical categories. In this case, preference should be given to prolonged drugs (Salmetorol), the duration of which allows them to be applied once a day.
In the case of a severe progressive course of COPD, the use of combined treatment is recommended, which consists in the appointment of bronchodilators of various pharmaceutical groups with the additional appointment of the theophylline of prolonged action (Teoperec at 0.3 g per day), which not only has the effectiveness in eliminating bronchial obstruction, but also beneficial effects on the work of the respiratory muscles.
Glucocorticoid drugs in the treatment of COPD are used only in extremely severe cases as "second-line" drugs, supplementing the main treatment regimen with bronchodilators. Indication for prolonged prolonged treatment with inhaled corticosteroids is a positive effect on improving spirometry parameters, and monotherapy with this group of drugs is highly discouraged, preference should be given to combined medicines (Seretide 2 inhalations 2 times a day).
For patients with severe COPD, pulmonologists recommend routine vaccination, which is aimed at preventing possible infection of the respiratory system during the flu epidemic. A randomized study on the effect of vaccination on the life expectancy of COPD patients has proved the effectiveness of this preventive measure. At the same time, it should be taken into account that antibacterial drugs should not be used for preventive purposes.
As symptomatic therapy for patients with COPD, the use of mucolytic drugs, whose effect is the dilution of the viscous structure of the sputum and its subsequent facilitated elimination (Ambrotard 1 capsule once a day), is shown.
Special attention should be paid to the observation and treatment of patients with COPD, which is in the acute stage, since in this situation, more intensive and extended drug therapy will be required. So, it is necessary to increase the dosage of bronchodilator drugs and give preference to the method of administering the active substance with a nebulizer (Ventolin 5 mg per 1 inhalation session).
In case of exacerbation of COPD, the appointment of corticosteroids is considered expedient, since they improve the function of external respiration function, improve the oxygenation of the arterial blood, shorten the patient's stay in the hospital and reduce the need for intubation. The purpose of the drug is recommended to be performed in a hospital setting with an intensive parenteral delivery method of the active substance (Prednisolone 40 mg intravenously-struino).
The presence of signs of exacerbation of COPD in a patient is an indication for carrying out antibacterial therapy in full (Amoxiclav per 1 g 2 times per oral knock, Medaxone 1 million 2 times a day intramuscularly), the duration of which depends on the rate of normalization of blood and sputum analysis.
The conditions of the resuscitation department allow adequate oxygen therapy through nasal catheters or a mask to reach the normal level of oxygenation of the blood. In the situation of complete absence of a positive effect within 45 minutes from the onset of passive oxygen therapy, it is necessary to decide on the use of invasive ventilation.