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Storia naturale delle scelte terapeutiche della BPCO

H

Definition of COPDDefinition of COPD

Chronic obstructive pulmonary disease(COPD) is a disease state characterized by airflow limitation that is not fullyreversible. The airflow limitation is usuallyboth progressive and associated with anabnormal inflammatory response of thelungs to noxious particles or gases.

FEV

1 (%

FE

V1

(% p

rdprd ))

100100

75 75

50 50

25 25

002525 5050 7575

DisabilityDisability ((relapsesrelapses))

DeathDeathAgeAge ((yearsyears))

NeverNever smokedsmoked

O2O2

MVMV

COPD time course

DyspnoeaDyspnoea

The vicious circle of COPD

SocialSocialactivityactivity

SocialSocialisolationisolation

PhysicalPhysicalactivityactivity DepressionDepression

DepressingDepressinglevelslevels ofoffitnessfitness

ShortnessShortness ofofbreathbreath

DyspneaDyspnea

COPD

Pre-agonicsymptoms

Normale borderline LIEVE MODERATA GRAVE

PROGRESSIONE BPCO

Tosse ed espettorazione Dispnea da sforzo Dispnea a riposo

Gas ematici: normali Ipossia e/o ipercapnia

Normale iperinflazione

Età e precocità diagnostica

While smokers who are unable orunwilling to quit may derive limited

benefit from partial smoking reduction, complete smoking

cessation remains a necessity forthose wanting to minimise all of

the harmfuleffects of smoking.

Therapy at each stage of COPD

Fattori correlati alla ridotta sopravvivenza

FEV1

dyspnea

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 50 100 150 200 250 300 350

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 50 100 150 200 250 300 350

APACHE score

<25

25-40

>40

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 50 100 150 200 250 300 350

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 50 100 150 200 250 300 350

Body Mass Index(kg/m2)

>22

18-22

<18

Activities DailyLiving

Age (years)

Cum

ulat

ive

Prop

ortio

nSu

rviv

ing

Follow up time, Days

Four predictors of survival in COPD. Connors et al., AJRCCM 1996; 154: 959-967

0

1 or 2>2

<60

60-75

>75

N Engl J Med 2004;350:1005-12.

Kaplan–Meier Survival Curves for BODE and according to ATS .

Am J Respir Crit Care Med Vol 171. pp 972–977, 2005

Objectives of COPD ManagementObjectives of COPD Management

• Prevent disease progression • Relieve symptoms• Improve exercise tolerance• Improve health status• Prevent and treat exacerbations• Prevent and treat complications• Reduce mortality• Minimize side effects from

treatment

Am J Respir Crit Care Med Vol 171. pp 446–452, 2005

Patients with frequent exacerbations are more likely to becomehousebound and need targeting in rehabilitation programs.

Distanza percorsa nel 6MWDHui KP, Hewitt AB (Chest 2003; 124: 94-7)

Tolleranza allo sforzo

Carico massimo raggiunto su treadmillRies Al et Al. (AJCCM 2003; 167: 880-8)

Dispnea

Bauldoff GF et Al. (Chest 2002; 122: 948-54)

Affaticabilità dei muscoli scheletrici

M.J.Mador AJRCCM 2001; 163: 930-5)

Quality of Life (Short-Form 36)Williams JEA et Al. ( Thorax 2003; 58: 515-8)

Qualità di BenessereRies Al et Al. (Am.J.Crit.Care Med. 2003)

physiology

survival

haemodinamicssleepneuropsicological

exercise908070605040302010

4 5 6 7 8 9 10PaO2 Kpa

SGR

Q

Thorax 1996; 51:44

Sopravvivenza dei pazienti con BPCO

0

10

20

30

40

50

60

70

80

90

100

10 20 30 40 50 60 70

COT MRC O2 NOT MRC controllo

La piaga delle riacutizzazioni

(CHEST 2000; 117:662–671)

Host factors that associated with treatment failure:• FEV1 < 35% (46.4% vs 22.4%; p < 0.047),

• home oxygen (60.7% vs 15.6%; p < 0.0001),

• Frequency of exacerbation (3.6+/-2.0 vs 1.6 +/- 0.91; p < 0.001),

• history of previous pneumonia (64.3% vs 35.1 p < 0.007),

• history of sinusitis (28.6% vs 8.8%; p < 0.009) and

• use of maintenance steroids (32.1% vs 15.2% p < 0.052).

(CHEST 2000; 117:662–671)

Am J Respir Crit Care Med Vol 164. pp 1002–1007, 2001

A total of 86 cases and 86 control subjects were included, (FEV1 39% prd)

Multivariate logistic regression showed the following risk (or protective) factors of COPD hospitalization:

• three or more COPD admissions in the previous year (oddsratio [OR] 6.21, p<0.008);

• FEV1 (OR 0.96 per percentual unit, p<0.0005);

• underprescription of long-term oxygen therapy (LTOT) (OR 22.64, p<0.007);

• and current smoking (OR 0.30, p<0.022).

One-year survival for 1016 COPD with acute exacerbation

0,5

0,6

0,7

0,8

0,9

1

Follow-up Time, Days

Prop

ortio

n su

rviv

ing

0 100 200 300

N = 1016

Connors, AJRCCM 1998

H

Am J Respir Crit Care Med Vol 161. pp 1608–1613, 2000

Time course of pulmonary function before admission into ICU.A two-year retrospective study of COLD patients with hypercapnia

M Vitacca, K Foglio, S Scalvini, S Marangoni, A Quadri and N Ambrosino

Controlled study:Time course of 2 years before admission in ICU for 16 pts vs 15 controls.

The results indicated that:

Basal body weight,Rate of deterioration over time in:•FEV1•VC,•blood gas values,•bicarbonates, •RVD

may be related to the necessity of ICU admission in COLD patients with hypercapnic respiratory insufficiency.

1992

Raccomandazioni per la ventilazione meccanica Domiciliare. Aggiornamento anno 2003. Parte 1

AIPO, GRUPPO DI STUDIO RIABILITAZIONE LUCIANO PESCE

Documento

Vol 18/5 2003 368-375

Indicazione di trattamento elettiva:paz. senza sufficienti garanzie di autonomia ventilatoria

VMD per via non invasiva

Ventilazione meccanica domiciliareVentilazione meccanica domiciliare

La VMN come strumentodi protezione sulle riacutizzazioni

severe che necessitano diospedalizzazione ?

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10

PP (41)

MYO (13)KS (53)

TB (55)

COPD (50)BRO (10)

Robert, Rev. Mal. Resp, 1983,11:923

PER

CEN

T SU

RVI

VAL

35

50

65

80

M0 M12 M24

OLTOLT+PSV

35

50

65

80

M0 M12 M24

OLTOLT+PSV

PaC

O2

on a

ir (m

mH

g)

PaC

O2

on o

xyge

n(m

mH

g)

30

45

60

75

M0 M12 M24

OLTOLT+PSV

45

60

75

90

M0 M12 M24

OLTOLT+PSV

PaO

2on

air

(mm

Hg)

PaO

2on

oxy

gen

(mm

Hg)

* p=0.010* p=0.009

ABGsABGs Clini E et al 2002

SURVIVAL CURVES

0.500.550.600.650.700.750.800.850.900.951.00

0 100 200 300 400 500 600 700

Days

Sur

viva

l

OLT

OLT+PSV

Clini E et al 2002

days

survivalsurvival

-20

-10

0

10

20

OLTOLT+PSV

Cha

nge

(day

s/pt

/yea

r)

-3

-1.5

0

1.5

3OLTOLT+PSV

Cha

nge

(nr/p

t/yea

r)

Days spent in hospital Number of hospital stay

CLINICAL OUTCOMECLINICAL OUTCOMEComparisonComparison of hospital of hospital admissionsadmissions

Clini E et al 2002

La ventilazione non invasivanel trattamento della IRA su IRC:una rivoluzione epidemiologica

0

10

20

30

40

50

60

70

80

< 7,20 7,21-7,25 7,26-7,30 7,31-7,35

Soo Hoo, CHEST 2000

RESPONSE TO MEDICAL THERAPY in COPD RELAPSE

% of Intubation

< 7.20 7.21-7.25

7.26- 7.30 7.31.7.35

Time tonor.h

69±60 36±29 31±24 30±18

Death,%

50 20 8 0

TimeEI

2±2 5±4 8±10 13±18

Death%

21 6 9 5

NMV has a role ?

Failure =(NPI × 0.21)+(FVC% × 0.14) -8.28.

Success =(NPI×0.11) +(FVC% ×0.20) -7.53.

ERJ 1996; 9:1487-1493

ETMask ETMask

Endotracheal Tube vs Mask(Complimentary or alternative role ?)

Respiratory failureRespiratory failureEvolving ARFEvolving ARF Resolving ARFResolving ARF

Preventive application

Curative application as EI

Instead of EI Weaningmethod

Post extubationfailure

Modified by U. Meduri

The YONIV Trial for COPD

Inclusion criteria• On arrival on ward

– RR > 23 bpm– pH 7.30-7.35– PaCO2 > 6 kPa

Plant Lancet 2000

Exclusion criteria

Patients requiring immediate ETI pH < 7.207.2 < pH < 7.25 on two occasions (1 hour) GCS < 8 and PaCO2 > 8 kPaPaO2 < 6 kPa despite max tolerated FiO2Cardiorespiratory arrest

0

5

10

15

20

25

pH >= 7.30

Con failNIV failCon diedNIV died

Success mortality

YONIV Study in GW outcome by enrollment pH

05

101520253035404550

pH < 7.30 pH >= 7.30

Con failNIV failCon diedNIV died

Plant Lancet 2000

failure

mortality

NIV for acute exacerbations of COPD in ICU

(from Brochard L. et al. NEJM 1995;333:817-822)

OUTCOMES

Endotr. intubation, n (%) *

Hospital stay, days *

In-hospital mortality, n (%) *

Complications, % *

NIV (43)

11 (26)

23±17

4 (9)

16

M.T.(42)

31 (74)

35±33

12 (29)

48

* = NIV significantly different from M.T.

NMV MT

No ET 100 % 45%

MV, h 69±36 220±281

H mortality 8% 18%

2-momortality

11% 62%

Confalonieri Am J Respir. Crit. Care Med 1999

Outcome for COPD and CAP in GW

Predictors of failure in hypercapnic pts

(from Antonelli M. et al. ICM 2001;27: 1718-1728)

Predictors of failure in hypoxemic ARF

Risk stratification of NPPV failure was assessed in 1,033 consecutive patients admitted toexperienced hospital units, including two intensive care units, six respiratory intermediate care units, and five general wards. NPPV was successful in 797 patients.

NIV failure:

20-25% in COPD 8-70% in ARF

where EI ?ICU transfert ? ethic decisions

PTPdi/min (cmH20 x s/min)

-1000

100200300400500600700

i-PSV n-PSV T-piece S.B.

**

AJRCCM 164:638-42,2001

WEANING TIME (DAYS)

PR

OB

AB

ILIT

Y O

F R

EM

AIN

ING

ON

MV

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

0 10 20 30 40 50 60

MaskInvasive

(Nava et al. Ann Intern Med 1998;128:721-728)

PSV + EI

PSV + NMV

OUTCOMES

Duration of MV, days @

Time in ICU, days @

Nosocomial pneumonia, n @

N-PSV

10.2 (6.8)

15.1 (5.4)

0

I-PSV

6 (11.8)

24.0 (13.7)

7

0102030405060708090

100

0-30 31-45 46-60 61-75 >75

No MV MV

Hospital and 1 year survival of pts admitted to ICU with acute exacerbation of COPD.

MG Seneff. JAMA 1995; 274

40

50

60

70

80

90

100

30 90 180 270 360

MV No MV

010203040506070

MV

.

Res

p.

No

resp

.

prio

r.

age

func

tion.

H180 day

Mortality %

Apache III

Alive %Predmortality %

0

10

20

30

40

50

60

70

earliest usually latest

1 week2 week3 week> 3 week

0

2

4

6

8

10

12

14

N° ICUs

Fischer L Intensive Care Med 2000

When tracheo ?

% tracheo of long term MV

The long term weaning center

RICOVERI UTIR Gussago

11%12%

55%

8,8%

19,2%

BPCOPost CCHRistrettiNeurom.Neurologici

Anni 1992-2004= 960 pazienti

Time (hours)

Pro

babi

lity

to re

mai

n un

der M

V

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

0 100 200 300 400 500 600 700 800 900 1000 1100

p<0.0001

Vitacca M. Am J Respir Crit Care Med 2001; 164: 225-230

PaCO2 mmHg

-60 -40 -20 0 20 40 60

1

patie

nts

% of decay

PaCO2 mmHg

-40 -20 0 20 40

1

patie

nts

% of decay

FEV1 % prd

-100 -50 0 50

1

patie

nts

% of decay

FEV1 % prd

-50 0 50 100

1

patie

nts

% of decay

MIP % prd

-50 0 50 100

1

patie

nts

% of decay

MIP % prd

-80 -60 -40 -20 0 20

1

patie

nts

% of decay

Vitacca et al Monaldi 2005

Decay in respiratory function after ICU admission

1-YEAR SURVIVAL CURVES IN 125 PATIENTS

Months of follow up

Cum

ulat

ive

Pro

porti

on S

urvi

ving

0,50

0,55

0,60

0,65

0,70

0,75

0,80

0,85

0,90

0,95

1,00

0 2 4 6 8 10 12 14

COPD (n° 76)NON-COPD (n° 49)

Months of follow up

Cum

ulat

ive

Pro

porti

on S

urvi

ving

0,65

0,70

0,75

0,80

0,85

0,90

0,95

1,00

0 2 4 6 8 10 12 14

NON MV (44%)MV (55%)

EFFECTS OF ACUTE ON CHRONIC RESPIRATORY FAILURE ON LONG-TERM HYPERCAPNIA AND THREE-MONTH SURVIVAL.

Michele Vitacca MD, Luca Bianchi MD, Luca Barbano MD, Mara Ziliani MD,Nicolino Ambrosino FCCP §.

Patients and interventions:

Seventy-three COPD patients recovering from a recent severeexacerbation underwent evaluation of: AntropometricBreathing pattern,Mechanics, Lung function and arterial blood gases

at discharge from a Respiratory Intensive Care Unit.

2005

Accuracy of prediction and Equations of accuracy for survival and hypercapnia.

Alive = -9.60010.09+(0.1734* %

IBW)

Dead = -8.1086.46+(0.136 * % IBW)

Equations

68475319066.7Total

4635249765.2Alive

52373877.8Dead

Alive (n)Dead (n)% of Accuracy

(%) in prediction

PaCO2≥48mmHg = •-

23.28+(0.0583*Poesmax)+(0.0271*PTPmin)+(96.5

4*TI/TTOT)-18.42 + (90.38 * TI/tot) + (21.12

*PTI)

PaCO2 <48mmHg = •--22.86 + (102.87

26.71+(0.0992* TI/Tot)Poesmax) + (13.1 * PTI0.0194*PTPmin)+(105.71

*TI/TTOT))

Equations

494825975.676Total

4401408091PaCO2 ≥48 mmHg

49111967.944PaCO2 <48 mmHg

PaCO2 ≥48 mmHgPaCO2 <48 mmHg% of Accuracy (%)in

distinction

M. Vitacca et al Chest 2005

POST - RIICU Location 113 pts

0

10

20

30

40

50

60

70 COPD (n°75)

Non COPD(n°38)

44/18

23/5

5/5 2/6 1/4

FSM-Gussago

%

55% 25% 8.8% 7% 4.4%

Raccomandazioni per la ventilazione meccanica Domiciliare. Aggiornamento anno 2003. Parte 1

AIPO, GRUPPO DI STUDIO RIABILITAZIONE LUCIANO PESCE

Documento

Vol 18/5 2003 368-375

Indicazione di trattamento obbligatoriapaz. senza autonomia ventilatoria

VMD per via tracheostomica

Ventilazione meccanica domiciliareVentilazione meccanica domiciliare

3624 3012 180 630

40

50

60

70

80

90

100

KyphoscoliosisTuberculosis seq.

COPDBronchiectasis

Duchenne= 126pts

Months

Prob

abili

ty%

Con

tinui

ngw

ithN

IPPV

N = 276

Leger P et al, Chest, 1994, 105:100

Survival of 12 years HMV in Gussago Hospital

154

83 vivi54%

52 (63%)NMV

31(37%)VMI

36NMV

16 OSAS

Time (Months)

Cum

ulat

ive

Prop

ortio

n Su

rviv

ing

-0.2

0.0

0.2

0.4

0.6

0.8

1.0

0 12 24 36 48 60 72 84 96 108 120 132 144 156

COPDALS

RCWD

NMD

Other

Specialista + ambulatorio dedicato

H

MMG

Il follow up

Nurse Home programAssesment in ER

Treatment at dischargepharmacologicalnon pharmacological

8 week of follow upnurse visit at 24 h (1 h)free nurse visitsfree phonenurse phone calls to pat.

Failure of programmemore of 5 visits, ER admission

Hernandez ERJ 2003

MMG

PNEUMOR

TELEASSISTENZA PNEUMOLOGICA

•

centro servizi

INTERNET o TELEFONO

HOSPITAL

Strumenti disponibili

Telefonoe-mail

ECGSatO2

tracciato di flusso

diario clinico cartella infermieristica

SatO293%

0

0.5

1

1.5

2

2.5

3

H/m/preH/m/post

0

0.5

1

1.5

2

2.5

GP calls/m/preGP calls/m/post

0102030405060708090

100

% pts presentinga relapse pre% pts presentinga relapse post

0102030405060708090

100

% pts who calledGP/m/pre% pts who calledGP/m/post

p<0.005 p<0.005

p<0.0005 p<0.0005

Vitacca et al 2005

05

10152025303540

Admission tohospital

Physician follow-up in

hospital

Other pract.follow-up in

hospital

Home visit

Survey on 1928 italian patients with HMV

ALTERNATIVE FACILITIES

HOME

34%

48%

3% 4%7%

2% 2%0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Self sufficient

Family carers

Nonprofessional

carers

Professionalnon nursing

carers

Nursing care

Residentialcare

Nursing home

Survey on 1928 italian patients with HMV

Domains of End-of-Life Care from Patients’Perspectives

Singer et al. JAMA 1999; 281:163-8

0

10

20

30

40

50

60

70

80

DialysisHIV/AIDSLTMV

Painrelief

Avoidprolongation

of life

Senseof

control

Reliefof

burden

Strengtheningrelationshipwith beloved

CHEST 2002;122

These programs are underutilizedlower awareness of Hospice eligibility criteria than oncologistsunpredicatability of deathlimitations on insurances

hospice care offers expertize for palliation; bridge to homeeligibility criteria and services available need to be known

CONCLUSIONI

Grazie al miglioramento delle cure, sempre più pazienti respiratoriarrivano a vivere una condizione di prolungata sopravvivenzacon problematiche di grave cronicità

La gestione della BPCO è divenuta ormai una complessa presa in carico(di tutte le figure professionali) di sintomi fisici e psicosociali,dipendenze, problematiche multidisciplinari e multifattoriali.

Operatori sanitari e famiglia devono sempre più collaborare per prendere comuni decisioni cliniche ed etiche

H

Programmi ospedalieri

spedalizzazione domiciliaretelesorveglianza

CONCLUSIONI

Casa RSA/Hospice

the current results do notsupport the widespreadprovision of ambulatoryoxygen to patients withoxygen-dependent chronicobstructive pulmonarydisease

ERJ 1996;9:1487-1493