2da Clase - EPOC
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Dra. Claudia C. Becerra Núnez
Caso Clínico
♂55 años
Antecedente: “enfermedad pulmonar crónica” (dx hacía 1 año), acude a su médico por “empeoramiento de la falta de aire”.
Es fumador (un paquete de cigarrillos/ día, durante 30 años); niega otros problemas.
En cuanto a su aspecto general, es un hombre delgado, que parece encontrarse con moderada dificultad respiratoria. – ACV: normal.
– T&P: se observa el diámetro antero-posterior del tórax amplio y se auscultan sibilantes espiratorios.
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Dra. Claudia C. Becerra Núnez
Caso Clínico
Su radiografía de tórax revela campos pulmonares hiperinsuflados, sin infiltrados.
Su médico le recomienda una espirometría para poder diferenciar enfisema, debido a una enfermedad pulmonar obstructiva, de enfermedades pulmonares restrictivas.
¿Qué efecto tiene el enfisema sobre la capacidad residual funcional y VEF1?
¿Qué efecto tiene un proceso de enfermedad pulmonar restrictiva sobre la capacidad residual funcional y FEV1?
Mencione algunas funciones no respiratorias del pulmónhttp://www.easyauscultation.com/cases?coursecaseorder=4&courseid=201#
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Dra. Claudia C. Becerra Núnez
FISIOPATOLOGÍA
PULMONAR
Dra. Claudia C. Becerra Núñez
Medicina Interna - HCFAP
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Dra. Claudia C. Becerra Núnez
OBJETIVOS DE LA CLASE
1. Comprender la importancia del estudio fisiopatológico respiratorio.
2. Anatomía de las vías respiratorias. Fisiología pulmonar. Inmunología Respiratoria.
3. Diferencias de las principales fisiopatologías respiratorias.
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Dra. Claudia C. Becerra Núnez
Introducción
El principal papel de los pulmones: llevar oxígeno a los tejidos y eliminar el principal subproducto de ese metabolismo, dióxido de carbono.
Los pulmones realizan esta función moviendo el aire inspirado en proximidad cercana al lecho capilar pulmonar para permitir el intercambio gaseoso por difusión simple.
La extensa superficie del sistema respiratorio también debe estar protegida de una amplia variedad de noxas ambientales infecciosas o tóxicas.
McPhee S.J. Fisiopatología médica: Una introducción a la medicina clínica. Mc Graw Hill. 6ta ed. 2010
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Dra. Claudia C. Becerra Núnez
Cuando ocurre la lesión a los componentes del sistema respiratorio, se interrumpe su función:
– La lesión de las vías respiratorias o su disfunción resulta en enfermedades pulmonares obstructivas (bronquitis, asma)
– El daño al parénquima se traduce en enfermedades restrictivas o vasculares.
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Dra. Claudia C. Becerra Núnez
Mecanismos de Defensa del pulmón
I. Nonspecific defenses 1. Clearance
a. Cough b. Mucociliary escalator
2. Secretions a. Tracheobronchial (mucus) b. Alveolar (surfactant) c. Cellular components (including lysozyme, complement, surfactant proteins, defensins)
3. Cellular defenses a. Nonphagocytic Conducting airway epithelium Terminal respiratory epithelium b. Phagocytic Blood phagocytes (monocytes) Tissue phagocytes (alveolar macrophages)
4. Biochemical defenses a. Proteinase inhibitors (1-protease inhibitor, secretory leukoprotease inhibitor) b. Antioxidants (eg, transferrin, lactoferrin, glutathione, albumin)
II. Specific immunologic defenses
1. Antibody mediated (B-lymphocyte–dependent immunologic responses)
a. Secretory immunoglobulin (IgA)
b. Serum immunoglobulins
2. Antigen presentation to lymphocytes
a. Macrophages and monocytes
b. Dendritic cells
c. Epithelial cells
3. Cell mediated (T-lymphocyte–dependent) immunologic responses
a. Cytokine mediated
b. Direct cellular cytotoxicity
4. Nonlymphocyte cellular immune responses a. Mast cell dependent
b. Eosinophil dependent
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Dra. Claudia C. Becerra Núnez
Situaciones Especiales
1. Hipercapnea Crónica: la ventilación por minuto depende de el estímulo tónico en los cuerpos carotídeos.
2. Hipoxia Crónica: puede desaparecer la respuesta ventilatoria.
3. Ejercicio: puede incrementar la ventilación/min hasta en 25 veces el nivel en reposo.
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Dra. Claudia C. Becerra Núnez
Distensibilidad y Retracción elástica(Compliance & Elastic Recoil)
McPhee S.J. Fisiopatología médica: Una introducción a la medicina clínica. Mc Graw Hill. 6ta ed. 2010
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FISIOPATOLOGÍA DE LA EPOCDra. Claudia C Becerra Núñez
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Dra. Claudia C. Becerra Núnez
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Dra. Claudia C. Becerra Núnez
Patrones del EPOC
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Dra. Claudia C. Becerra Núnez
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Dra. Claudia C. Becerra Núnez
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Dra. Claudia C. Becerra Núnez
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Dra. Claudia C. Becerra Núnez
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Dra. Claudia C. Becerra Núnez
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Dra. Claudia C. Becerra Núnez
Tórax enfisematoso
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Dra. Claudia C. Becerra Núnez
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lobal Initiative for Chronic
bstructive
ung
isease
G
OLD
© 2013 Global Initiative for Chronic Obstructive Lung Disease
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Global Strategy for Diagnosis, Management and Prevention of COPD
Definición EPOC, es una enfermedad común, que puede
prevenirse y tratarse
Se caracteriza por la limitación persistente del flujo aéreo que suele ser progresiva y asociada a una respuesta inflamatoria crónica en las vías respiratorias, como consecuencia de exposición a partículas nocivas o gases.
Las exacerbaciones y comorbilidades contribuyen a la severidad.
© 2013 Global Initiative for Chronic Obstructive Lung Disease
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Global Strategy for Diagnosis, Management and Prevention of COPD
MecanismosLimitación del flujo aéreo en el EPOC
Enf de Vía Aérea Pequeña
• Inflamación de las vías respiratorias,
• Fibrosis, tapones mucosos
• Aumento de resistencia
Destrucción del Parénquima
• Pérdida de la unión alveolar
• Disminución de la retracción elástica
LIMITACIÓN DEL FLUJO © 2013 Global Initiative for Chronic Obstructive Lung Disease
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Global Strategy for Diagnosis, Management and Prevention of COPD
Impacto del EPOC EPOC es una causa importante de
morbilidad y mortalidad en todo el mundo.
Aumentaría en las próximas décadas debido a la continua exposición a factores de riesgo y el envejecimiento de la población mundial.
Está asociada con una carga económica significativa.
© 2013 Global Initiative for Chronic Obstructive Lung Disease
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Global Strategy for Diagnosis, Management and Prevention of COPD
Risk Factors for COPD
Genes
Infections
Socio-economic status
Aging Populations© 2013 Global Initiative for Chronic Obstructive Lung Disease
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Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnóstico: Puntos Clave
Debe ser considerado en pacientes que presenten…
Para hacer el diagnóstico se requiere…
Espirometría: post-broncodilatador de FEV1/FVC < 0.70
© 2013 Global Initiative for Chronic Obstructive Lung Disease
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SÍNTOMAS Falta de aire Tos crónica
Esputo
EXPOSICIÓN A FACTORES DE RIESGO
Tabaco Ocupación Polución
fuera/dentro de casa
ESPIROMETRÍA: Required to establish diagnosis
Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnóstico de EPOC
è
© 2013 Global Initiative for Chronic Obstructive Lung Disease
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Dra. Claudia C. Becerra Núnez
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Spirometry: Normal Trace Showing FEV1 and FVC
1 2 3 4 5 6
1
2
3
4
Volu
me,
liters
Time, sec
FVC5
1
FEV1 = 4L
FVC = 5L
FEV1/FVC = 0.8
© 2013 Global Initiative for Chronic Obstructive Lung Disease
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Spirometry: Obstructive Disease
Volu
me,
liters
Time, seconds
5
4
3
2
1
1 2 3 4 5 6
FEV1 = 1.8L
FVC = 3.2L
FEV1/FVC = 0.56
Normal
Obstructive
© 2013 Global Initiative for Chronic Obstructive Lung Disease
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Disnea: Progresiva, persistente y característicamente empeora con el ejercicio.
Tos Crónica: Puede ser intermitente y no productiva.
Producción crónica de esputo: es frecuente en pacientes con EPOC,
Global Strategy for Diagnosis, Management and Prevention of COPD
Symptoms of COPD
© 2013 Global Initiative for Chronic Obstructive Lung Disease
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Global Strategy for Diagnosis, Management and Prevention of COPD
Modified MRC (mMRC)Questionnaire
© 2013 Global Initiative for Chronic Obstructive Lung Disease
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Assess symptoms Assess degree of airflow limitation
using spirometry
Assess risk of exacerbations
Assess comorbiditiesUse spirometry for grading severity according to spirometry, using four
grades split at 80%, 50% and 30% of predicted value
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of COPD
© 2013 Global Initiative for Chronic Obstructive Lung Disease
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Global Strategy for Diagnosis, Management and Prevention of COPD
Classification of Severity of Airflow Limitation in COPD*En pacientes con FEV1/FVC < 0.70:
GOLD 1: Leve FEV1 > 80% predicted
GOLD 2: Moderada 50% < FEV1 < 80% predicted
GOLD 3: Severa 30% < FEV1 < 50% predicted
GOLD 4: Muy Severa FEV1 < 30% predicted
*Based on Post-Bronchodilator FEV1
© 2013 Global Initiative for Chronic Obstructive Lung Disease
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Global Strategy for Diagnosis, Management and Prevention of COPD
Evaluar riesgo de exacerbaciones
Dos o más exacerbaciones en el último año
O
FEV1 < 50 % del valor esperado
ALTO RIESGO
© 2013 Global Initiative for Chronic Obstructive Lung Disease
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Global Strategy for Diagnosis, Management and Prevention of COPD
Evaluar comorbilidades
Pacientes con EPOC tienen mayor riesgo de: • Enfermedades cardiovasculares• Osteoporosis• Infecciones Respiratorias• Ansiedad y depresión• Diabetes• Cáncer de Pulmón
Estas condiciones pueden influir en la mortalidad y en las hospitalizaciones y deben ser buscados
rutinariamente y tratados apropiadamente© 2013 Global Initiative for Chronic Obstructive Lung Disease
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Global Strategy for Diagnosis, Management and Prevention of COPD
Differential Diagnosis: COPD and Asthma
EPOC• Inicia a mediana edad
• Los síntomas son lentamente progresivos
• Historia de tabaquismo
ASMA• Inicio temprano (fcte: niñez)
• Los síntomas varían de día a día.
• Los síntomas empeoren en la noche/madrugada
• Concomitante con: alergia, rinitis y eczema
• Antecedentes familiares de asma
© 2013 Global Initiative for Chronic Obstructive Lung Disease
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Dra. Claudia C. Becerra Núnez
¿Cuál sería el tratamiento?
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Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: COPD Medications
Beta2-agonists
Short-acting beta2-agonists
Long-acting beta2-agonists
Anticholinergics
Short-acting anticholinergics
Long-acting anticholinergics
Combination short-acting beta2-agonists + anticholinergic in one inhaler
Methylxanthines
Inhaled corticosteroids
Combination long-acting beta2-agonists + corticosteroids in one inhaler
Systemic corticosteroids
Phosphodiesterase-4 inhibitors
© 2013 Global Initiative for Chronic Obstructive Lung Disease
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United StatesUnited States
United Kingdom
ArgentinaArgentina
AustraliaAustraliaBrazilBrazil
AustriaCanadaCanada
Chile
Belgium
ChinaChina
DenmarkDenmark
ColombiaColombia
CroatiaCroatia
EgyptEgypt
Germany
Greece
IrelandIreland
ItalyItaly
SyriaSyria Hong Kong ROC
Japan
IcelandIndiaIndia
KoreaKorea
Kyrgyzstan
UruguayUruguay
MoldovaMoldova
NepalNepal
Macedonia
Malta
Netherlands
New Zealand
PolandPoland
NorwayNorway
Portugal
GeorgiaGeorgia
Romania
Russia
SingaporeSlovakia
Slovenia Saudi ArabiaSaudi Arabia
South AfricaSouth Africa
SpainSwedenSweden
ThailandThailand
SwitzerlandSwitzerland
UkraineUkraine
United Arab EmiratesUnited Arab Emirates
Taiwan ROC
VenezuelaVenezuela
Vietnam
Peru
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Bangladesh
France
Mexico
Turkey Czech Republic
Pakistan
Israel
GOLD National Leaders
PhilippinesYeman
Kazakhstan
Mongolia
Albania
© 2013 Global Initiative for Chronic Obstructive Lung Disease
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Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
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Professor P.J. Barnes, MD, National Heart and Lung Institute, London UK