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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2804_Библиотеки_им_академика_М_И_Перельмана

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Chestwall:Hypoechoic,linearshadowsofsofttissuedensity.
Ribs:Hyperechoic,curvilinearstructureswithadeep,hypoechoic,posterioracousticshadow.
Pleura: Bright, hyperechoic, roughly horizontal line located approximately 0.5 cm below rib
shadows.
Diaphragm: Curvilinear, hyperechoic line that moves caudally with inspiration. In a seated
patient,itislocatedcaudadtotheninthrib.
Splenorenal and hepatorenal recesses: Should be confirmed before any procedure because its
curvilinearappearanceissimilartothatofthediaphragm.Identifiedbyvisualizationoftheliver
orspleenandthekidneycaudally.
Lung: Air-filled lung appears hyperechoic due to the poor echogenicity of air. Atelectatic or
consolidatedlungappearshypoechoicrelativetonormallung. Sonographicartifactsandterminology:Anumberofsonographicartifactsarecausedbyair–tissue interfaces,andpresenceorabsenceoftheseartifactsisindicativeofdisease.
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Pleural line: Brightly echogenic, roughly horizontal line; caused by parietopulmonary interface
andindicatingthelungsurface.
A-lines: Brightly echogenic horizontal lines roughly parallel to the chest wall; caused by
reverberationsofthepleuralline.
B-lines: Also called “comet tails”; a grouping within one intercostal space is called “lung
rockets.” Hyperechoicline arisingperpendicularly from the pleural linethatextends across the
whole screen without fading, erasing A-lines; moves with lung slide. Caused by thickened
interlobularseptaorground-glassareas;isolatedB-linesareanormalvariant.SeeFigure8-5.
Figure8-5  Lung ultrasound.A-lines demonstrated onleftare equidistanthorizontal lines created by reflectionsof
thepleuralline.B-linesdemonstratedontherightarebrightverticallinesthatmovewiththepleuraandextendtothe
bottomofthescreenrepresentingthickenedfluid-filledinterlobularseptae.
Lung slide: “Twinkling” movement of the pleural line that occurs with the respiratory cycle;
causedbymovementofthelungalongthecraniocaudalaxisduringrespiration.InM-mode,lung
slideisvisualizedasthe“seashoresign,”withthechestwallgeneratingthe“waves,”theaerated
lungformingthe“sand,”andthepleurallineastheinterface.
Lungpulse:Pulsationofthepleurallineduetotransmissionoftheheartbeatthroughnoninflated
lung.
Ultrasonographyoflungpathology
Pleural effusion: A fluid collection bordered by the diaphragm, chest wall, and lung surface.
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Transudativeeffusionsaretypicallyanechoic;exudativeeffusionsmayhavesomeechogenicity.If
the effusion is loculated, septations—visualized as hyperechoic, weblike structures—may be
seen.Atelectaticlungmaybeseenintheeffusion.
Pneumothorax: Owing to air’s poor echogenicity, diagnosis of pneumothorax on ultrasound is
madebyartifactanalysis.
□ The presence of lung slide or lung pulse effectively rules out pneumothorax in the location
beinginvestigated.
□ Abolishment of lungslide hasa characteristic stratosphere sign inM-mode, withloss ofthe
“sand,”butisneithersufficientnorspecificfordiagnosisofpneumothorax.
□ Lungpointispathognomonicforpneumothoraxbuthaspoorsensitivity.Occursattheinterface
ofthepneumothorax andaeratedlung.Characterizedbyalternationbetweenabsentlungslide andpresentlungslideorB-linesinonelocationwithrespirations.InM-mode,willtransition
betweenseashoresignandstratospheresign. Pneumonia: Can only be visualized when the consolidation abuts the pleura. A heterogeneous, hypoechoic area with irregular margins where aerated lung abuts the consolidated area. Air bronchogramsshouldbeseentomakethediagnosisofpneumonia. Pulmonaryedema:PresenceofmultipleB-lineswithinoneintercostalspace(“lungrockets”)may indicatecardiogenicornoncardiogenicpulmonaryedema.CorrespondstotheKerleyB-linesseen onchestradiograph.IsolatedB-linesareanormalvariant.
Abdominalultrasound:Abdominalultrasoundincriticalcareislimitedandintended toevaluatefor intra-abdominalfluidandassesstheurinarytractandabdominalaorta.
Evaluatingforintra-abdominalfluid:Standardevaluationofthetraumapatientwhomayhaveintra­abdominal bleeding includes the focused assessment with sonography for trauma (FAST) examination.Thepatientisinthesupineposition,andfourviewsareobtained:
Hepatorenal space: Theprobeis placed ontherightinthe10thor11thintercostalspace at the posterioraxillarylinewiththeorientationmarkpointedcephalad. Pelvis: The probe is placed in the suprapubic area with the orientation mark in the 3-o’clock position. Perisplenicspace:Theprobeisplacedontheleftinthe10thor11thspaceatorslightlyposterior totheposterioraxillarylinewiththeorientationmarkpointedcephalad. Pericardialspace: Theprobeisplacedinthesubxiphoidpositionwith theorientationmarkerin the3-o’clockposition.
Paracentesis:Paracentesisshouldbeperformedunderultrasoundguidancebecausethereisevidence supporting adecreaseincomplications.Moredetails canbefoundintheWashingtonManual for CriticalCare,SectionXIX. Assessment of the urinary tract: Bedside ultrasonography can identify bladder distention or hydronephrosis.
Bladder distention: Theprobe is placed inthesuprapubic positionwith the orientationmarker pointed cephalad for longitudinal dimensions and in the 3-o’clock position for transverse dimensions. Hydronephrosis:Theprobeshouldbeplacedslightlycaudadtothelocationsusedforexamination of the hepatorenal and perisplenic spaces in the FAST examination. Hydronephrosis is characterizedbythinningoftherenalcortexasthecollectingsystemdilates.
Assessmentoftheabdominalaorta:Thegoalistovisualizetheentireabdominalaortatoensurethat itsdiameterfromouterwalltoouterwallis<3cm. Theexaminationbeginscaudadtothexiphoid process, with theprobe perpendicular to the abdominal wall andthe orientationmarker inthe3­o’clockposition.
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Vasculardiagnosticultrasound:Bedsideultrasonographymaybeperformedtoevaluatefordeepvein thrombosis when clinicallyindicated.Thetargetveinis visualizedinthetransverse plane.Avessel with normal blood flow should appear internally anechoic and should be easily compressible. Organized thrombus appears as a discrete, echogenic structure within the venous lumen. A very recentlyformedthrombusmaybeanechoic,butthevesselwillbeincompressible.
REFERENCES
1.ForceADT,RanieriVM,RubenfeldGD,etal.Acuterespiratorydistresssyndrome:theBerlin definition.JAmMedAssoc.2012;307:2526-2533.
2.FratJP,ThilleAW,MercatA,etal.High-flowoxygenthroughnasalcannulainacutehypoxemic respiratoryfailure.NEnglJMed.2015;372:2185-2196.
3.RochwergB,GrantonD,WangDX,etal.Highflownasalcannulacomparedwithconventionaloxygen therapyforacutehypoxemicrespiratoryfailure:asystematicreviewandmeta-analysis.Intensive CareMed.2019;45(5):563.
4.PeterJV,MoranJL,Phillips-HughesJ,etal.Effectofnon-invasivepositivepressureventilation (NIPPV)onmortalityinpatientswithacutecardiogenicpulmonaryoedema:ameta-analysis. Lancet.2006;367:1155-1163.
5.BarreiroTJ,GemmelDJ.Noninvasiveventilation.CritCareClin.2007;23:201-222,ix.
6.PatelBK,WolfeKS,PohlmanAS,etal.Effectofnoninvasiveventilationdeliveredbyhelmetvsface maskontherateofendotrachealintubationinpatientswithacuterespiratorydistresssyndrome:a randomizedclinicaltrial.JAmMedAssoc.2016;315:2435-2441.
7.AlthoffMD,HolguinF,YangF,etal.Noninvasiveventilationuseincriticallyillpatientswithacute asthmaexacerbations.AmJRespirCritCareMed.2020;202(11):1491-1493.
8.AntonelliM,ContiG,RoccoM,etal.Acomparisonofnoninvasivepositive-pressureventilationand conventionalmechanicalventilationinpatientswithacuterespiratoryfailure.NEnglJMed. 1998;339:429-435.
9.TerragniPP,AntonelliM,FumagalliR,etal.Earlyvslatetracheotomyforpreventionofpneumoniain mechanicallyventilatedadultICUpatients:arandomizedcontrolledtrial.JAmMedAssoc. 2010;303:1483-1489.
10.YoungD,HarrisonDA,CuthbertsonBH,RowanK;TracManCollaborators.Effectofearlyvslate tracheostomyplacementonsurvivalinpatientsreceivingmechanicalventilation:theTracMan randomizedtrial.JAmMedAssoc.2013;309(20):2121-2129.
11.GrantCA,DempseyG,HarrisonJ,JonesT.Tracheo-innominatearteryfistulaafterpercutaneous tracheostomy:threecasereportsandaclinicalreview.BrJAnaesth.2006;96:127-131.
12.FutierE,ConstantinJM,Paugam-BurtzC,etal.Atrialofintraoperativelow-tidal-volumeventilation inabdominalsurgery.NEnglJMed.2013;369:428-437.
13.PageD,AblordeppeyE,WessmanBT,etal.Emergencydepartmenthyperoxiaisassociatedwith increasedmortalityinmechanicallyventilatedpatients:acohortstudy.CritCare.2018;22:9.
14.SudS,SudM,FriefrichJO,etal.Highfrequencyoscillationinpatientswithacutelunginjuryand acuterespiratorydistresssyndrome(ARDS):systematicreviewandmeta-analysis.BrMedJ. 2010;340:c2327.
15.YungD,LambSE,ShahS,etal.High-frequencyoscillationforacuterespiratorydistresssyndrome.N EnglJMed.2013;368:806.
16.FergusonND,CookDJ,GuyattGH,etal.High-frequencyoscillationinearlyacuterespiratory distresssyndrome.NEnglJMed.2013;368:795.
17.GriecoDL,ChenL,DresM,BrochardL.Shouldweusedrivingpressuretosettidalvolume?Curr
https://t.me/med1917
OpinCritCare.2017;23:38-44.
18.AmatoMB,MeadeMO,SlutskyAS,etal.Drivingpressureandsurvivalintheacuterespiratory distresssyndrome.NEnglJMed.2015;372:747-755.
19.AdhikariNK,DellingerRP,LundinS,etal.Inhalednitricoxidedoesnotreducemortalityinpatients withacuterespiratorydistresssyndromeregardlessofseverity:systematicreviewandmeta­analysis.CritCareMed.2014;42:404-412.
20.RuanSY,WuHY,KunHH,etal.Inhalednitricoxideandtheriskofrenaldysfunctioninpatientswith acuterespiratorydistresssyndrome:apropensity-matchedcohortstudy.CritCare.2016;20:389.
21.FullerBM,MohrNM,SkrupkyL,etal.TheuseofinhaledprostaglandinsinpatientswithARDS:a systematicreviewandmeta-analysis.Chest.2015;147:1510-1522.
22.RodrigoGJ,Castro-RodriguezJA.Heliox-drivenβ2-agonistsnebulizationforchildrenandadults withacuteasthma:asystematicreviewwithmeta-analysis.AnnAllergyAsthmaImmunol. 2014;112:29-34.
23.NationalHeartLung,andBloodInstituteAcuteRespiratoryDistressSyndromeClinicalTrials Network;WiedemannHP,WheelerAP,BernardGR,etal.Comparisonoftwofluid-management strategiesinacutelunginjury.NEnglJMed.2006;354:2564-2575.
24.SteinbergKP,HudsonLD,GoodmanRB,etal.Efficacyandsafetyofcorticosteroidsforpersistent acuterespiratorydistresssyndrome.NEnglJMed.2006;354:1671-1684.
25.WHORapidEvidenceAppraisalforCOVID-19Therapies(REACT)WorkingGroup;SterneJAC, MurthyS,DiazJV,etal.Associationbetweenadministrationofsystemiccorticosteroidsand mortalityamongcriticallyillpatientswithCOVID-19:ameta-analysis.JAmMedAssoc. 2020;324(13):1330.
26.PapazianL,ForelJM,GacouinA,etal.Neuromuscularblockersinearlyacuterespiratorydistress syndrome.NEnglJMed.2010;363:1107-1116.
27.NationalHeart,Lung,andBloodInstitutePETALClinicalTrialsNetwork;MossM,HuangDT, BrowerRG,etal.Earlyneuromuscularblockadeintheacuterespiratorydistresssyndrome.NEngl JMed.2019;380(21):1997.
28.GuerinC,ReignierJ,RichardJC,etal.Pronepositioninginsevereacuterespiratorydistress syndrome.NEnglJMed.2013;368:2159-2168.
29.NoahMA,PeekGJ,FinneySJ,etal.Referraltoanextracorporealmembraneoxygenationcenterand mortalityamongpatientswithsevere2009influenzaA(H1N1).JAmMedAssoc.2011;306:1659-
1668.
30.CombesA,HajageD,CapellierG,etal.Extracorporealmembraneoxygenationforsevereacute respiratorydistresssyndrome.NEnglJMed.2018;378:1965-1975.
31.KollefMH.Healthcare-associatedpneumonia:perceptionversusreality.ClinInfectDis. 2009;49:1875-1877.
32.KalilAC,MeterskyML,KlompasM,etal.Managementofadultswithhospital-acquiredand ventilator-associatedpneumonia:2016clinicalpracticeguidelinesbytheInfectiousDiseases SocietyofAmericaandtheAmericanThoracicSociety.ClinInfectDis.2016;63:e61-e111.
33.YangKL,TobinMJ.Aprospectivestudyofindexespredictingtheoutcomeoftrialsofweaningfrom mechanicalventilation.NEnglJMed.1991;324:1445-1450.
34.KhemaniRG,RandolphA,MarkovitzB.Corticosteroidsforthepreventionandtreatmentofpost­extubationstridorinneonates,childrenandadults.CochraneDatabaseSystRev.2009; (3):CD001000.
35.BolesJM,BionJ,ConnorsA,etal.Weaningfrommechanicalventilation.EurRespirJ. 2007;29:1033-1056.
36.BlackwoodB,BurnsKE,CardwellCR,O’HalloranP.Protocolizedversusnon-protocolizedweaning
https://t.me/med1917
forreducingthedurationofmechanicalventilationincriticallyilladultpatients.Cochrane DatabaseSystRev.2014;(11):CD006904.
37.HessD.Ventilatormodesusedinweaning.Chest.2001;120:474S-476S.
38.BurnsKE,MeadeMO,PremjiA,AdhikariNK.Noninvasivepositive-pressureventilationasa weaningstrategyforintubatedadultswithrespiratoryfailure.CochraneDatabaseSystRev.2013; (12):CD004127.
39.NavaS,GregorettiC,FanfullaF,etal.Noninvasiveventilationtopreventrespiratoryfailureafter extubationinhigh-riskpatients.CritCareMed.2005;33:2465-2470.
40.FerrerM,SellaresJ,ValenciaM,etal.Non-invasiveventilationafterextubationinhypercapnic patientswithchronicrespiratorydisorders:randomisedcontrolledtrial.Lancet.2009;374:1082-
1088.
41.HernandezG,VaqueroC,GonzalezP,etal.Effectofpostextubationhigh-flownasalcannulavs conventionaloxygentherapyonreintubationinlow-riskpatients:arandomizedclinicaltrial.JAm MedAssoc.2016;315:1354-1361.
42.MaggioreSM,IdoneFA,VaschettoR,etal.Nasalhigh-flowversusVenturimaskoxygentherapyafter extubation.Effectsonoxygenation,comfort,andclinicaloutcome.AmJRespirCritCareMed. 2014;190(3):282-288.
43.HernandezG,VaqueroC,ColinasL,etal.Effectofpostextubationhigh-flownasalcannulavs noninvasiveventilationonreintubationandpostextubationrespiratoryfailureinhigh-riskpatients: arandomizedclinicaltrial.JAmMedAssoc.2016;316:1565-1574.
44.DeJongheB,SharsharT,HopkinsonN,OutinH.Paresisfollowingmechanicalventilation.Curr OpinCritiCare.2004;10:47-52.
45.SingerM,DeutschmanCS,SeymourCW,etal.Thethirdinternationalconsensusdefinitionsforsepsis andsepticshock(Sepsis-3).JAmMedAssoc.2016;315:801-810.
46.RiversE,NguyenB,HavstadS,etal.Earlygoal-directedtherapyinthetreatmentofseveresepsis andsepticshock.NEnglJMed.2001;345:1368-1377.
47.LevyMM,EvansLE,RhodesA.Thesurvivingsepsiscampaignbundle:2018update.CritCareMed. 2018;46:997-1000
48.SemlerMW,SelfWH,WandererJP,etal.Balancedcrystalloidsversussalineincriticallyilladults. NEnglJMed.2018;378:829-839.
49.FinferS,BellomoR,BoyceN,etal.Acomparisonofalbuminandsalineforfluidresuscitationinthe intensivecareunit.NEnglJMed.2004;350(22):2247.
50.DeBackerD,BistonP,DevriendtJ,etal.Comparisonofdopamineandnorepinephrineinthe treatmentofshock.NEnglJMed.2010;362:779-789.
51.LiuVX,Fielding-SinghV,GreeneJD,etal.Thetimingofearlyantibioticsandhospitalmortalityin sepsis.AmJRespirCritCareMed.2017;196:856-863.
52.MarshallJC,MaierRV,JimenezM,DellingerEP.Sourcecontrolinthemanagementofseveresepsis andsepticshock:anevidence-basedreview.CritCareMed.2004;32:S513-S526.
53.ProCI,YealyDM,KellumJA,etal.Arandomizedtrialofprotocol-basedcareforearlysepticshock. NEnglJMed.2014;370:1683-1693.
54.ARISEInvestigators;ANZICSClinicalTrialsGroup;PeakeSL,DelaneyA,BaileyM,etal.Goal­directedresuscitationforpatientswithearlysepticshock.NEnglJMed.2014;371:1496-1506.
55.MartyP,RoquillyA,ValleeF,etal.Lactateclearancefordeathpredictioninseveresepsisorseptic shockpatientsduringthefirst24hoursinIntensiveCareUnit:anobservationalstudy.Ann IntensiveCare.2013;3:3.
56.WackerC,PrknoA,BrunkhorstFM,SchlattmannP.Procalcitoninasadiagnosticmarkerforsepsis:a systematicreviewandmeta-analysis.LancetInfectDis.2013;13:426-435.
https://t.me/med1917
57.SchuetzP,WirzY,SagerR,etal.Procalcitonintoinitiateordiscontinueantibioticsinacute respiratorytractinfections.CochraneDatabaseSystRev.2017;(10):CD007498. doi:10.1002/14651858.CD007498.pub3
58.RussellJA,WalleyKR,SingerJ,etal.Vasopressinversusnorepinephrineinfusioninpatientswith septicshock.NEnglJMed.2008;358:877-887.
59.KhannaA,EnglishSW,WangXS,etal.AngiotensinIIforthetreatmentofvasodilatoryshock.NEngl JMed.2017;377:419-430.
60.SprungCL,AnnaneD,KehD,etal.Hydrocortisonetherapyforpatientswithsepticshock.NEnglJ Med.2008;358:111-124.
61.VenkateshB,FinferS,CohenJ,etal.Adjunctiveglucocorticoidtherapyinpatientswithsepticshock. NEnglJMed.2018;378:797-808.
62.AnnaneD,RenaultA,Brun-Buisson,etal.Hydrocortisoneplusfludrocortisoneforadultswithseptic shock.NEnglJMed.2018;378:809-818.
63.PaciulloCA,McMahonHornerD,HattonKW,FlynnJD.Methyleneblueforthetreatmentofseptic shock.Pharmacotherapy.2010;30:702-715.
64.MarikPE,BaramM,VahidB.Doescentralvenouspressurepredictfluidresponsiveness?A systematicreviewoftheliteratureandthetaleofsevenmares.Chest.2008;134:172-178.
65.AntonelliM,LevyM,AndrewsPJ,etal.Hemodynamicmonitoringinshockandimplicationsfor management.InternationalConsensusConference,Paris,France,27–28April2006.IntensiveCare Med.2007;33:575-590.
66.JonesAE,ShapiroNI,TrzeciakS,etal.;EmergencyMedicineShockResearchNetwork (EMShockNet)Investigators.Lactateclearancevscentralvenousoxygensaturationasgoalsof earlysepsistherapy:arandomizedclinicaltrial.JAmMedAssoc.2010;303(8):739-746.
67.RichardC,WarszawskiJ,AnguelN,etal.Earlyuseofthepulmonaryarterycatheterandoutcomesin patientswithshockandacuterespiratorydistresssyndrome:arandomizedcontrolledtrial.JAm MedAssoc.2003;290:2713-2720.
68.DarkPM,SingerM.Thevalidityoftrans-esophagealDopplerultrasonographyasameasureof cardiacoutputincriticallyilladults.IntensiveCareMed.2004;30:2060-2066.
69.MonnetX,RienzoM,OsmanD,etal.EsophagealDopplermonitoringpredictsfluidresponsiveness incriticallyillventilatedpatients.IntensiveCareMed.2005;31:1195-1201.
70.MichardF,BoussatS,ChemlaD,etal.Relationbetweenrespiratorychangesinarterialpulse pressureandfluidresponsivenessinsepticpatientswithacutecirculatoryfailure.AmJRespirCrit CareMed.2000;162:134-138.
71.BarbierC,LoubieresY,SchmitC,etal.Respiratorychangesininferiorvenacavadiameterare helpfulinpredictingfluidresponsivenessinventilatedsepticpatients.IntensiveCareMed. 2004;30:1740-1746.
72.CorlK,NapoliAM,GardinerF.Bedsidesonographicmeasurementoftheinferiorvenacavacaval indexisapoorpredictoroffluidresponsivenessinemergencydepartmentpatients.EmergMed Australas.2012;24:534-539.
73.Kupersztych-HagegeE,TeboulJL,ArtigasA,etal.Bioreactanceisnotreliableforestimatingcardiac outputandtheeffectsofpassivelegraisingincriticallyillpatients.BrJAnaesth.2013;111:961-
966.
74.BenomarB,OuattaraA,EstagnasieP,etal.Fluidresponsivenesspredictedbynoninvasive bioreactance-basedpassivelegraisetest.IntensiveCareMed.2010;36:1875-1881.
75.LichtensteinDA.Lungultrasoundinthecriticallyill.AnnIntensiveCare.2014;4:1.
76.LichtensteinDA.Ultrasoundinthemanagementofthoracicdisease.CritCareMed.2007;35:S250- S261.
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9
ObstructiveLungDisease
JamesG.Krings,LauraHalverson,RodrigoVazquezGuillamet,KaharuSumino
ChronicObstructivePulmonaryDisease
GENERALPRINCIPLES
Definition
Chronic obstructive pulmonary disease (COPD) is defined by the Global Initiative for Chronic ObstructiveLungDisease(GOLD)asamostlypreventableandtreatabledisordercharacterizedbyan expiratoryairflow limitationthat is notfullyreversible. Exposuretonoxious particles andgases,as wellasabnormalitiesinlungdevelopment,predisposesindividualstothedevelopmentofCOPD.The trajectoryofthediseaseisvariableandnotnecessarilyprogressive. Recently,therehasbeenasuggestiontoexpandthediagnosticcriteriaofCOPDfromasinglemeasure of lung function (expiratory airflow limitation) to include environmental exposure, symptoms, and abnormalfindingsonCTscans.ThereisnowrecognitionthataCOPDdefinitionthatsolelyrelieson lungfunctionmissespatientsintheearlystagesofthedisease.
TheairflowobstructioninCOPDiscausedbyemphysemaandairwaydisease.
Emphysemaisdefinedpathologicallyaspermanentenlargementofairspaces distaltotheterminal bronchioleaccompaniedbydestructionofthealveolarwallsandtheabsenceofassociatedfibrosis. However,fibrosiscancoexistwithemphysemaina syndrome calledcombinedpulmonaryfibrosis andemphysema(CPFE). TheairwaydiseaseinCOPDoccursprimarilyinsmallairways(i.e.,thosewithaninternaldiameter of <2 mm). Chronic bronchitis is a common feature of COPD and is defined clinically as a productive cough, on most days, for at least 3 consecutive months per year and for at least 2 consecutiveyears,andintheabsenceofotherlungdiseasesthatcouldaccountforthissymptom. Emphysema and chronic bronchitis can be insidious and present in the absence of airflow obstruction.Evenintheabsenceofairflowobstruction,COPDisstillassociatedwithadversehealth outcomes.
Epidemiology
Although the true prevalence of COPD is difficult to determine, COPD is estimated to affect approximately15millionpeopleintheUS. PriortotheCOVID-19pandemic,COPDandotherchroniclowerrespiratorydiseasesrepresentedthe thirdleadingcauseofdeathintheUS.1In2020,COVID-19wasthethirdleadingunderlyingcauseof deathafterheartdiseaseandcancer,withCOPDandchroniclowerrespiratorydiseaserankingsixth. ThemortalityrateforCOPDhassteadilyincreasedsince2012,andgloballytheburdenremainshigh. TheWorldHealthOrganizationestimatedthatapproximately3.2milliondeathswerecausedbyCOPD
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in2015,accountingfor5%ofallworldwidedeathsthatyear. COPD is protractedintime andis responsible for more years lived with disability (3.6%) than all otherrespiratorydiseasescombined.
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Etiology
MostcasesofCOPDareattributabletocigarettesmokingintheUS. Environmentalandoccupationaldusts(e.g.,wood-burningstoves,fumes,gases,andchemicals)are
othercommoncausesofCOPDworldwide.Householdindoor airpollutionis a majorcauseoffatal COPD,particularlyindevelopingcountriesandruralareas.
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α1-Antitrypsin(A1AT)deficiencyisfoundin1%–2% ofCOPDpatients.Clinical characteristicsof affected patients may include a minimal or nonexistent smoking history, early-onset COPD (e.g., younger than 45 years), a family history of lung disease, or lower lobe–predominant panacinar emphysema.
Pathophysiology
The pathogenesis ofCOPD involves inflammation, immune reactions, imbalance of proteinases and antiproteinases,turnoveroftheextracellularmatrix,oxidativestress,andapoptosis. Pathologicfeaturesincludedestructionofalveolartissueandsmallairways,airwaywallinflammation, edemaandfibrosis,andintraluminalmucus. Pulmonaryfunctionchangesincludedecreasedmaximalexpiratoryairflow,hyperinflation,airtrapping, andalveolargasexchangeabnormalities. Anincreasedincidenceofosteoporosis,skeletalmuscledysfunction,andcoronaryarterydiseaseoccur inCOPD,perhapsindicatingasystemiccomponentofinflammation.
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Prevention
In Western countries, abstinence from smoking is the most effective measure for preventing COPD.
Domestic biomass fuel smoke inhalation is responsible for COPD in nonsmoking patients in rural settings and developing countries, who sometimes have comparatively low cigarette smoking rates. Strategies aimed at improving access to cookstoves and cleaner fuel sources along with increased ventilationareessentialinthesepopulations(e.g.,theGlobalAllianceforCleanCookstoveshasbeen establishedforthispurpose). InpatientswithCOPD,smokingcessationmayresultinareductionintherateoflungfunctiondecline andimprovedsurvival.
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Tobaccocessationattemptswarrantrepeatinguntilthepatientstopssmoking.Mostsmokersfailinitial attempts at smokingcessation,andrelapsereflects the natureof thenicotinedependenceandnot the failureofthepatientorthephysician. Amultimodalityapproachisrecommendedtooptimizesmokingcessation.
Counseling on the preventable health risks of smoking, providing advice to stop smoking, and encouragingfurtherattemptstostopsmokingevenafterpreviousfailures. Providingsmokingcessationmaterialstopatients. Prescribing pharmacotherapy (Table 9-1); providers should take every advantage to counsel and providepharmacotherapy.
TABLE9-1
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PHARMACOTHERAPYFORSMOKINGCESSATION
Product Dosing SideEffects/Precautions
NicotineReplacementTherapy
a
Transdermal patch
b
7,14,or21mg/24h Usualregimen=21mg/d=6 wk,14mg/d×2wk,7mg/d× 2wk
Headache,insomnia,nightmares,nausea, dizziness,blurredvision(appliestoallnicotine products)
Chewing gum, lozenges
2–4mgq1–8h Graduallytaperuse
Inhaler 10mg/cartridge(4mg
delivereddose) 6–16cartridges/d
Nasalspray 0.5mg/spray
1–2spraysineachnostrilq1h
NonnicotinePharmacotherapy
Bupropion ER(Zyban)
150mg/d×3d,thenbid×7– 12wk Start1wkbeforequitdate
Dizziness,headache,insomnia,nausea, xerostomia,hypertension,seizure Avoidmonoamineoxidaseinhibitors
Varenicline (Chantix)
0.5mg/d×3d,bid×4days, then1mgbid×12–24wk Start1wkbeforequitdate
Nausea,vomiting,headache,insomnia, abnormaldreams Worseningofunderlyingpsychiatricillness
a
Combinationtherapyisoftenused.Along-actingproduct(e.g.,patch)isusedforbasalnicotinereplacement,withashort-
actingproduct(e.g.,inhalerorgum)usedforbreakthroughcravings.
b
Ifpatientsmokeslessthanahalfpackperday,startat14-mgdose.
SeealsoFioreMC,BakerTB.Clinicalpractice.Treatingsmokersinthehealthcaresetting.NEnglJMed.2011;365:1222­1231forstrategiesandapproach.
TheUSDepartmentofHealthandHumanServiceshasdevelopedatelephone-basedsupportsystem (1-800-QUIT-NOW)withanInternetanalog(smokefree.gov).
DIAGNOSIS
ClinicalPresentation
HISTORY
Patientsareusuallyolderthan40yearsatdiagnosis. Cliniciansshould obtainasmokinghistory andquantify exposure to environmental andoccupational risk factors. A family history of COPD, maternal tobacco use during pregnancy, and secondhand tobaccoexposurealsoincreasetheriskofdevelopingCOPD. Common symptoms are dyspnea on exertion, cough, sputum production, and wheezing. Typically,
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dyspneaonexertionprogressesgraduallyoveryears. Symptom presenceandseverity ofCOPDcanbecollectedusingstandardizedquestionnaireslikethe COPDAssessmentTest(CAT)(Table9-2).
TABLE9-2
CHRONICOBSTRUCTIVEPULMONARYDISEASEASSESSMENTTOOL(CAT)
Inevercough. 1 2 3 4 5 Icoughallthetime.
Ihavenophlegmormucusinmychest. 1 2 3 4 5 Mychestiscompletelyfullofmucusor
phlegm.
Mychestdoesnotfeeltight. 1 2 3 4 5 Mychestfeelstight.
WhenIwalkupahilloroneflightof stairs,Iamnotbreathless.
1 2 3 4 5 WhenIwalkupahilloroneflightof
stairs,Iamverybreathless.
Iamnotlimiteddoinganyactivitiesat home.
1 2 3 4 5 Iamlimiteddoingactivitiesathome.
Iamconfidentleavingmyhomedespite mylungcondition.
1 2 3 4 5 Iamnotatallconfidentleavingmy
homebecauseofmylungcondition.
Isleepsoundly. 1 2 3 4 5 Idonotsleepsoundlybecauseofmy
lungcondition.
Ihavelotsofenergy. 1 2 3 4 5 Ihavenoenergyatall.
Totalscoreissumofscoresfromindividualquestionscales. FromJonesPW,HardingG,BerryP,etal.DevelopmentandfirstvalidationoftheCOPDAssessmentTest.EurRespirJ.
2009;34:648-654.ReproducedwithpermissionfromGlaxoSmithKline.GlaxoSmithKlineisthecopyrightowneroftheCOPD AssessmentTest(CAT).However,thirdpartieswillbeallowedtousetheCATfreeofcharge.TheCATmustalwaysbeusedinits entirety.ExceptforlimitedreformattingtheCATmaynotbemodifiedorcombinedwithotherinstrumentswithoutpriorwritten approval.TheeightquestionsoftheCATmustappearverbatim,inorder,andtogetherastheyarepresentedandnotdividedon separatepages.AlltrademarkandcopyrightinformationmustbemaintainedastheyappearonthebottomoftheCATandonall copies.ThefinallayoutofthefinalauthorisedCATquestionnairemaydifferslightlybuttheitemwordingwillnotchange.TheCAT scoreiscalculatedasthesumoftheresponsespresent.Ifmorethantworesponsesaremissing,ascorecannotbecalculated; whenoneortwoitemsaremissingtheirscorescanbesettotheaverageofthenon-missingitemscores.
Overlap with asthma, obstructive sleep apnea (OSA), bronchiectasis, and interstitial lung disease (ILD)exists. Beyondcoexistencewithotherrespiratorydisease,patientswithCOPDfrequentlyhavecomorbidities that impactquality of life and prognosis. Osteoporosis, anxiety, depression, cardiovascular disease, tobacco related malignancies, malnutrition,anddiabetes are all more common than expected among patientswithCOPD.Symptomsrelatedtocomorbiditiesshouldbeinvestigated.
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Asthediseaseadvances,cause-specificmortalityforpatientswithCOPD shiftsfromcardiovascular diseaseandmalignanciesintheearlystagestorespiratoryfailure.Bothsevereairflowobstructionand ahighfrequencyofexacerbationsincreasethelikelihoodofarespiratorydeath.
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Disease severity should be stablished using multidimensional tools such as the Body mass index, airflowObstruction,Dyspnea,andExercisecapacity(BODE)index(Table9-3).TheBODEindexhas beenvalidatedas a moreaccuratepredictor of COPDmortality thanforced expiratoryvolume in 1 second(FEV1)alone.
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