Artificial pulmonary ventilation in patients with COPD

Patogenesis

 * COPD is characterized by chronic inflammation of the airways, lung parenchyma and pulmonary vasculature.
 * Accumulation of macrophages, T Ly (CD8+), neutrophils.
 * Mediators.
 * Oxidative stress.
 * Imbalance between the system of proteinases and antiproteinases.
 * Muscle dysfunction – muscle microdisruption, oxidative stress, glucocorticoid therapy.

Etiology

 * Smoking.
 * Socioeconomic position.
 * Enviromental factors.
 * Recurrent respiratory infections.
 * Lung disease at a young age.
 * Bronchial hyperreactivity.
 * Profesion.
 * Alpha 1 protease inhibitor deficiency.

Pathophysiological changes

 * Dry DC.
 * Expiratory flow obstruction.
 * Loss of lung elasticity
 * V/Q abnormalities.
 * Hyperinflation.
 * Weakening of respiratory muscles.
 * Abnormal „respiratory drive“.
 * Pulmonary hypertension.

Clinical presentation
Some authors refer to this type of patients as "pink puffers" - pink type (or "pink puffer"). Patients are short of breath but have pink skin.
 * 1) Chronic brochitis – the presence of cough for more than 3 months (exclusion of other causes - TU, etc.)
 * 2) * These individuals are usually obese, bulbous protrusion dominates.
 * 3) * Dyspnea is less in comparison to the emphysematic type, patients are cyanotic, tend to have polyglobulia and show signs of decompensated cor pulmonale.
 * 4) ** They are referred to as "blue bloaters" - the bloated, swollen, blue type (also "blue bubble").
 * 5) Emphysema – abnormal expansion distal to the terminal bronchioles, associated with destruction of the alveolar wall without signs of fibrosis.
 * 6) * Patients tend to have a large emphysematic chest, they are usually asthenic.
 * 7) * However, significant shortness of breath is not accompanied by polyglobulia or cyanosis..

Diferential diagnosis

 * Bronchial ashtma.
 * Cardiac failure.
 * Bronchiectasis.
 * TB.
 * Obliterative bronchiolitis.
 * Diffuse panbronchiolitis.

Treatment
→ longer administration does not increase the treatment effect and is associated with a higher risk of side effects (hyperglycemia, muscle atrophy).
 * Intravenous or oral administration of corticoids is recommended as part of the treatment of hospitalized patients.
 * An oral dose of 30–40 mg prednisolone/day for 7–10 days is considered effective and safe
 * Administration of antibiotics is recommended for:
 * Patients with the simultaneous occurrence of three so-called cardinal symptoms - increased shortness of breath, increased amount of sputum and purulent nature of sputum.
 * Diseases requiring artificial pulmonary ventilation (including non-invasive ventilation).


 * Manual or mechanical chest vibration may be beneficial in patients with high sputum production (more than 25 ml/d) or in patients with lobar atelectasis.
 * There are no data demonstrating the beneficial effect of inhalation administration of secretolytics.
 * Pulmonary rehabilitation may be beneficial in the recovery phase from an acute exacerbation of COPD.
 * Before discharge, the initiation of treatment with a proven effect on the number of exacerbations and hospitalizations of patients with COPD should be considered
 * → administration of long-acting inhaled bronchodilators.
 * → administration of inhaled corticoids and their combinations.

Total or partial respiratory insufficiency?
→ Partial insufficiency = hypoxia → Global insufficiency = hypoxia + hypercapnia.
 * pCO2 indicator of adequacy of ventilation!!!
 * pO2 ndicator of lung oxygenation function!!!
 * If a patient with hypoxic (partial) respiratory insufficiency is given oxygen, relief will occur.
 * A patient will global insufficiency accumulates CO2 in such a way that CNS loses sensitivity to its increased level and breathing depends only on the presence oflack of oxygen – hypoxia → pif we give more oxygen (more than approx. 2-4 l/min) we can alleviate the hypoxia that was holding breathing and the patient will stop breathing!
 * !!!! → herefore, it is important in the first phase, using the examination according to Astrup, to distinguish what kind of hypoxia is involved

pH shows the degree of compensation, in an acute exacerbation CO2 is high (can be chronic) and pH is low.

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