6/9/2020 CO COPD/Chr hroni onic Re Respirat atory Fa Failure Overlap/W Ov erlap/Wrap ap ‐ ar around nd Sy Syndrome me Ron Hosp, MS, RRT Vice President, National Accounts Breathe, LLC 1 Session Obj Sessio Objectiv ctives es • Following this presentation the participant will be able to: • Label the anatomy and pathophysiology of respiration and ventilation • Describe the definition of COPD including classification • Explain COPD as a wrap ‐ around disease • Distinguish the best PAP modes and features to treat the condition 2 Quick Re Qu Review • Conducting zone = • ventilation (air movement in and out) • filters • warms • humidifies • Conducting zone = dead space 3 1
6/9/2020 Qu Quick Re Review • Respiratory zone = • comprised of small airways • exchange of gases between alveoli and blood 4 PUL PULMONAR ARY ME MECHANICS ANICS Inhalation = ACTIVE 1.) Diaphragm contracts (moves downward) 2.) Thoracic Volume Increases 3.) Pleural Pressure Decreases 4.) Air Moves In Pressure gradient is what drives air into the lungs. 5 PUL PULMONAR ARY ME MECHANICS ANICS Exhalation = PASSIVE 1.) Diaphragm relaxes (moves upward) 2.) Thoracic Volume Decreases 3.) Pleural Pressures Increase 4.) Air Moves Out Pressure gradient is what drives air our of the lungs. 6 2
6/9/2020 ASSE ASSESSMEN ENT OF OF VENTILA VENTILATIO ION Qualitative • Respiratory pattern • Accessory muscle use • Prolonged expiration • Shortness of Breath • Cyanosis • Minute ventilation 7 SPIR SPIROMETR ETRY By measuring the volumes of air in the lung (lung capacities) and the flow of air out of the lungs we can answer the following questions: • Is lung disease present? • What type of lung disease? • Single or multiple diseases present? • Is the disease reversible and to what degree? 8 ASSE ASSESSMEN ENT OF OF VENTILA VENTILATIO ION Quantitative • Arterial blood gases (ABG) • Pulse oximetry • Capnography • Spirometry 9 3
6/9/2020 ASSE ASSESS SSMENT OF OF VENT VENTIL ILATION With ith ABG’s ABG’ • pH ‐ indicates acidity or alkalinity of blood. (7.35 ‐ 7.45 ) • PaCO2 ‐ partial pressure of carbon dioxide in the arterial blood. (35 ‐ 45 mmHg) CO2 LEVELS IN OUR BLOOD STIMULATE OUR DRIVE TO BREATH • PaO2 ‐ partial pressure of oxygen in the arterial blood. (80 ‐ 100 mmHg) • HCO3 – Level of bicarbonate in the blood. Buffers pH. (22 – 26 mEq/L) • Compensatory mechanism 10 Re Respiratory Acid Acidosis is • The normal reference range for PaCO 2 is 35 ‐ 45 mm Hg • Acute respiratory acidosis ‐ PaCO 2 (ie, >45 mm Hg) accompanying acidemia (ie, pH < 7.35) • Chronic respiratory acidosis ‐ PaCO 2 is elevated with normal or near ‐ normal pH secondary to renal compensation and an elevated serum bicarbonate levels (ie, >30 mEq/L) 11 Chr Chronic Re Respiratory Acid Acidosis is • May be secondary to many disorders, e.g., COPD • Hypoventilation in COPD involves multiple mechanisms, including the following: • Decreased responsiveness to hypoxia and hypercapnia • Increased ventilation ‐ perfusion mismatch leading to increased dead space ventilation • Decreased diaphragmatic function due to fatigue and hyperinflation 12 4
6/9/2020 Chr Chronic Re Respiratory Acid Acidosis is • Chronic respiratory acidosis also may be secondary to • Obesisty Hypoventialtion (OHS—ie, Pickwickian syndrome), • Neuromuscular disorders • Severe restrictive ventilatory defects • Interstitial Fibrosis • Thoracic Restrictive Disease 13 GOLD GOLD CO COPD De Definition finition “A disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.” 14 Wh What is is CO COPD? • Blanket term covering 3 illnesses ‐ ‐ Chronic Bronchitis ‐ Asthmatic Bronchitis ‐ Emphysema • Chronic ‐ Long ‐ term • Obstructive ‐ Trouble getting air out of chest • Pulmonary ‐ Relating to the lung • Disease ‐ An abnormal condition 15 5
6/9/2020 Ins Insidious Dev Ins Insidious Dev Develo Develo lopmen lopmen ent ent “The typical symptoms and signs of COPD occur late in its evolution…. Patients who are symptomatic or who have chest x ‐ ray abnormalities have moderately severe or advanced disease.” Frontline Treatment of COPD 16 Caus Causes es of of CO COPD • Smoking • Occupational • Environmental • Genetic Factors • Predisposition • Alpha 1 Antitrypsin Defficiency 17 Pi Pink nk Pu Puff ffer • Pink • Thin • Hyperventilation • Pursed Lips • Dyspneic • Hypocapnic 18 6
6/9/2020 Cl Classic assic “Blu “Blue Bl Bloater” • Cyanosis • Overweight • Hypoventilation • Hypercapnic • Less dyspnea • Edematous • Productive Cough 19 Sign Sign Signs and Signs and and Sy and Sy Sympto Sympto toms toms ms of ms of of Nocturnal of Nocturnal Nocturnal Nocturnal Desa Desa satu satu turations turations tions tions • Restless Sleep • Morning Headaches • Paroxysmal Nocturnal Dyspnea • Dyspnea on Exertion (PND) • Resting S p O 2 < 93% • Orthopnea • Sleep in recliner or w/ 2 or • Excessive Daytime Sleepiness more pillows (EDS) • CHF/Dependent Edema • Severe Snoring • Observed Apneas 20 CO COPD Prev evalence ence in in the the US US Ac According ing the the CDC CDC • 24 million people who currently suffer from COPD • 6.3% of the US population • Top 5 States are 1. Kentucky 9.3% 2. Alabama 9.1% 3. Tennessee 8.7% 4. West Virginia 8% 5. Oklahoma 8% Williams, S., The Motley Crew , September 14, 2014, also published by RT for Decision Makers , September 12, 2014 21 7
6/9/2020 Es Estim timated CO COPD Prev evalence ence in in Okl Oklahom homa State Population Kentucky 4.4 million Alabama 4.8 million Tennessee 6.5 million West Virginia 1.8 million Oklahoma 3.8 million • This data indicates that there may be approximately 304,000 individuals afflicted with Stage 1-4 COPD in Oklahoma . 22 Ov Overlap erlap Sy Syndrome me • "Overlap syndrome", the combination of COPD and obstructive sleep apnoea/hypopnoea syndrome (OSAH), is said to predispose to daytime hypercapnia and hypoxaemia independently of lung function [10]. • Chaouat A, et. al., Association of chronic obstructive pulmonary disease and sleep apnea syndrome. Am J Respir Crit Care Med 1995 ; 151: 82–86. 23 Pre Prevalence es estim timates of of maj major como morb rbid idit itie ies in in COPD OPD Associations with Comorbidity Prevalence outcomes Allergic disease 18–42% 186–188 Cough, phlegm, wheezing Health care utilization Anemia 7–43.9% 68–70 Mortality Hospitalization, length of stay, readmission risk Dyspnea Cardiovascular 29–70% (general CVD) Mortality 4.7–60% (CHF) Quality of life, health status 7.1–31.3% (CHD) 142,144,218 Dyspnea, exercise capacity Hospitalization Health care utilization and expenditures Nirupama, P., et al, Semin Respir Crit Care Med. 2015 Aug; 36(4): 575–591. Published online 2015 Aug 3. doi: 10.1055/s ‐ 0035 ‐ 1556063 24 8
6/9/2020 Prev evalence ence es estim timates of of maj major comorb rbid iditie ies in in CO COPD 2–20% 28 Cognitive impairment Quality of life, health status Length of hospital stay Depression 16.5–42% 35–42 Mortality Dyspnea, exercise capacity Quality of life, health status Rehospitalization risk Exacerbation risk Inability to perform ADLs Diabetes 10.1–23% 126,127,130 Mortality Hospitalization Exercise capacity Nirupama, P., et al, Semin Respir Crit Care Med. 2015 Aug; 36(4): 575–591. Published online 2015 Aug 3. doi: 10.1055/s ‐ 0035 ‐ 1556063 25 Prev evalence ence es estim timates of of maj major comorb rbid iditie ies in in CO COPD Obesity 29.1–43% 94–96 Quality of life, health status Dyspnea, exercise capacity Health care utilization Osteoporosis 21–66% 66,174–176,178–180,182 22.3–51.4% 83–86 Sleep apnea Mortality Exacerbation risk Health care expenditures Cardiovascular outcomes Nirupama, P., et al, Semin Respir Crit Care Med. 2015 Aug; 36(4): 575–591. Published online 2015 Aug 3. doi: 10.1055/s ‐ 0035 ‐ 1556063 26 CO COPD and and Hea Heart Fa Failure Gulmisal, G., et al, European Journal of Heart Failure (2014) 16, 1273 ‐ 1282., doi 10, 1002/ejhf. 183 27 9
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