Method for determining degree of severity of aggravated chronic obstructive pulmonary disease (copd) for specifying optimal approach to patient management

The invention relates to medicine, namely to therapy and pulmonology, and can be used to select an optimal treatment regimen for patients with chronic obstructive pulmonary disease (COPD).

There is a method of forecasting the likely prevalence of antibiotic-resistant pathogens and strains, according to which patients with acute exacerbation of COPD is divided into two groups: simple (uncomplicated) recurrences and complications of COPD exacerbation (Chronic obstructive pulmonary disease. A practical guide for physicians. / I.V.Leschenko, S. I.Ovcharenko, E.I.Shmelev. - M., 2004. - 62 p. - P.46). The first group (simple or uncomplicated exacerbation of COPD) patients are under the age of 65 years is not frequent exacerbations (at least 4 in a calendar year), the lack of serious comorbidities and FEV1> 50%. The second group of patients include patients with complicated acute exacerbation of COPD: age

> 65 years and / or FEV1 <50% and / or the presence of comorbidities (diabetes, heart failure, chronic liver and kidney disease, accompanied by organ failure, and others.) And / or less than 4 exacerbations during the year.

The disadvantage of this method is the high cost (the study of respiratory function) and lack of information about the place of the patient's treatment with antibacterial drugs (home, day care, day hospital, intensive care unit).

Known "method for predicting the course of nonspecific pulmonary diseases" (US Pat. RU №2121675 from 10.11.1998, Bazhukova TA). Explore the bronchial secretion and / or sputum using microbiological methods. Determine the number of conditionally pathogenic bacteria, pathogenic bacteria and fungi of the genus Candida, assessing each indicator in points. If the total score of 0-2 predict remission of nonspecific pulmonary diseases, at 3-5 - the aggravation of pneumonia with favorable course, with 6-8 points - chronic pneumonia with abscess, or bronchiectasis and chronic pneumonia with unfavorable course, with 9-12 points - marked immunodeficiency and the presence of malignancy in the lung. This increases the possibility and the prediction precision of inflammatory lung diseases.

The closest to the offered us a way to evaluate exacerbations of COPD, which includes the study of medical history characteristics - the deterioration of respiratory function (FEV1), the duration of the deterioration of symptoms or new symptoms, the number of previous episodes of exacerbations / hospitalizations, accompanying diseases, the current mode of treatment; and signs of severity of exacerbations - the use of auxiliary respiratory muscles, paradoxical movement of the chest, exacerbation or emergence of central cyanosis, the development of peripheral edema, hemodynamic instability, signs of right heart failure, decreased excitability (Global strategy for the diagnosis, treatment and prevention of chronic obstructive pulmonary disease (Review 2008 .) / Per. from English. Ed. Belevsky AS - M .: Publishing Holding "Atmosphere", 2009. - 100 p. - P.77).

The disadvantages of this method include high cost, low accuracy. It is known that in severe exacerbation of COPD patient should be hospitalized in a hospital, the study FEV1 over time to determine the deterioration will require some additional time and funding phase of the survey and later at the stage of treatment in a hospital. Today the study of respiratory function is not included in the standard examination in the call of the precinct or family doctor at home, ambulance crews. The lack of scoring the severity of COPD does not give clear guidance to the doctor decide which type of outpatient or inpatient treatment of patients with acute exacerbation of COPD.

The technical result of the invention - a method for determining the severity of an exacerbation of chronic obstructive pulmonary disease, improves the accuracy of patient assessment, choose the best at this time the kind of treatment. The method does not require additional financial cost, easy to perform under any health care setting.

The technical result is achieved by the fact that the diagnosis of the severity of COPD exacerbations using numerical score on the following parameters.

The method is as follows. Patient specify age, the presence of background diseases such as pathology of the cardiovascular system, respiratory system, diabetes and other chronic diseases, the number of exacerbations of COPD in the last 12 months, the presence of sleep apnea syndrome (snoring, episodes of sleep apnea); An objective study counted the frequency of breaths per minute (NPV), determine the level of consciousness.

NPV evaluated using point scale: if thirty or more are assigned 2 points, solve the question of the need of respiratory support in an intensive care unit and intensive care. If the NPV is less than thirty, but more than nineteen per minute is assigned 1 point, the correction index is possible in the conditions of profile separation. If the NPV is less than nineteen assigned a score of zero. The number of exacerbations of COPD per year record with the words of the patient's history or according to medical records, if any. If you have three or more relapses within the last year are assigned 1 point, less than three exacerbations - prisvatyvayut zero points. The presence of sleep apnea syndrome is diagnosed according to the patient's history and the words of his relatives or determined on the basis of medical documentation (polysomnography). In the case of sleep apnea is assigned 1 point, in his absence is assigned a score of zero. The presence of background diseases such as cardiovascular disease, diabetes, kidney failure, chronic pathology of the gastrointestinal tract, chronic venous insufficiency of the lower extremities, cerebrovascular disease, cancer, chronic respiratory diseases, alcoholism, drug addiction, lower nutritional status checked with the patient's medical history, or the collection of medical records. If you have any background diseases are assigned one point, when there is no - zero points. Age of the patient clarify on passport data, or with the words, if the age of 60 years or more will be assigned a score of less than 60 years - is assigned a score of zero. This differentiation of age due to the fact that elderly patients older than 60 years decreased the number and sensitivity of β2-receptors in the bronchi, reduces the effectiveness of β2-agonist bronchodilators used for emergency aid for relief of bronchospasm (Davidovskaya EI Rational bronchodilator therapy in the elderly / The Art of Medicine. - №2 (22), 2010. - S.145-150).

Changes in mental status was assessed individually by the doctor patient examination. Changes in mental status on the background of COPD exacerbations is fixed for the survey and assessment of motor activity. If the patient does not respond to questions that are not responsive to painful stimuli are assigned two points. If the patient was disoriented and could not answer questions or utters inarticulate sounds, does not comply with the team - is assigned to one point. If there is no change in mental status - the patient is guided and can answer questions, executes commands - add 0 points.

Further points on all fixed parameters are added. When the amount of at least one point and diagnose lung exacerbation of COPD, with the amount of from two to three points diagnosed with exacerbation of moderate severity, if the amount is four points or more are diagnosed with severe COPD exacerbation. Using a scoring system proposed by us allows you to choose the place of treatment of the patient with COPD with mild exacerbation of COPD patients are treated on an outpatient basis with the use of basic therapy. At moderate require hospitalization in specialized department with the appointment of basic therapy, therapy, systemic corticosteroids, antibacterial drugs and parenteral administration of drugs. In severe exacerbations of COPD requiring hospitalization in the intensive care unit with the additional use of oxygen therapy, noninvasive and invasive ventilation.

The method has been tested by us on 87 patients with COPD. Patients were divided into two groups. All patients consulted a doctor about COPD exacerbation. The study group included 49 patients, including 31 men and 18 women, who evaluated the severity of COPD exacerbations by our method based on point scale assessment of the severity of the condition. In two patients, the score was more than four, they were hospitalized in intensive care. Thirty-eight patients the score was 2-3, the patients hospitalized in the pulmonary department. Nine patients did not exceed the amount of balls - they are prescribed a course of outpatient treatment. The control group consisted of 38 patients with COPD, by age, gender and historical data of similar patients of the main group, which are the result of scoring the severity of exacerbations requiring hospital treatment, but abandoned it and went out-patient treatment. In the future, five patients in the control group were referred to the hospital due to the inefficiency of the outpatient treatment, which in turn led to a lengthening of the period of disability. Patients of the control group after treatment, the frequency of exacerbations of COPD throughout the year is greater than in patients of the main group (3,5 ± 0.5 and 1.5 ± 0.5 respectively). The study was further shown that patients hospitalized with acute exacerbation of COPD, the use of the proposed method of determining the severity of COPD can reduce days of hospital treatment to 3,5 ± 0,5 days, a reduction of days of disability and reduce the number of exacerbations of COPD over the next year on average, 1.5 times (see. Table.).

TablitsaSravnitelnaya characterization methods for determining the severity HOBL.Parametry issledovaniyaMetod-prototipPredlagaemy metodDlitelnost hospitalization dni16,0 ± 4,013,0 ± 3,3Chastota COPD exacerbations during the year after treatment, ed.3,5 ± 0,51,5 ± 0,5Δ FEV1 ,% 5,8 ± 0,47,3 ± 0,6Δ PaO 2,% 4,2 ± 0,55,1 ± 0,6

Here are examples of case histories of two patients who have traditionally accepted method of determining the severity of COPD exacerbations did not need hospital treatment, but our proposed point system determine the severity of COPD exacerbations required hospitalization.

Example 1. Patient P., 60 years old, a medical card №7117, entered the pulmonary department GB №8 Voronezh by ambulance 19.05.2009, complaining of shortness of breath at rest, increasing with the rise in the 1st floor, a feeling of stuffiness in chest, cough with difficult expectoration of light color, palpitations, dizziness, general weakness. COPD over 10 years, is at the dispensary in the clinic. Repeatedly he treated permanently. During the last year was 2 exacerbation of COPD. Ownership inhaler "Flomax" 20/50 mg, two doses on demand constantly "Maple Jet" 250 mcg, two doses × twice a day and 12 mcg Foradil, × one dose twice a day. Deterioration of about 4 days, when he was troubled by a cough with difficult expectoration, increased shortness of breath, palpitations, chest congestion. In history - hypertension, chronic treatment does not accept. I do not smoke. The department acted in a state of moderate severity in consciousness notes decreased physical activity. The skin is moist, pale, cyanosis of the lips and fingers. Respiratory rate was 27 per minute, and tachycardia - 119 / min, blood pressure - 130/80 mm Hg Auscultation breathing hard, all the lung fields are heard humming dry rales, percussion - a box tone. In the study of the chest on chest radiograph of 19.05.09 was determined pulmoskleroza picture with the outcome of fibrosis, emphysema, cardiomegaly. The front desk has been used numerical score of severity of COPD exacerbations for addressing the need for stationary study: respiratory rate of 20-29 per minute - one point; the number of exacerbations of COPD per year less than three - zero points; sleep apnea syndrome, a history of no - zero points; a history of hypertension - one point; age 60 years - one point; There are no changes in mental status - zero points. In sum, it gets three points, which corresponds to an exacerbation of COPD of moderate severity and the need for hospitalization of the patient to the hospital.

Total blood from 19.05.09: Hb = 156 g / l, er. = 4,1 × 1012 / L, color. Pok. = 1.1, N = 9,2 × 109 / L, erythrocyte sedimentation rate 30 mm / h, fell. = 4%, Seg. = 76%, EPZs. = 5%, lim. = 14%, mon. = 1%, DRR = 4. The study of respiratory function: FEV1 = 51.02% of predicted, Tiffno - 64.71%, FVC - 67.93%, the sample with a bronchodilator - negative. ECG - sinus rhythm, EOS deviation to the left, signs of left ventricular hypertrophy. Given the clinical and radiological findings was diagnosed with stage II COPD, exacerbation. Nam II. Essential hypertension stage II, the risk of CHF 3 MTR I, FK1.

In the treatment used: dexamethasone, a / c, ACC / O, inhaled nebulized solution berodual and Mucosolvan, kordafleks RD 40 mg, eufillin / O. The patient spent in the hospital bed 12 \ days and was discharged in satisfactory condition at 31.05.09, the follow-up to the therapist. At hospital discharge data spirography patient P. were: FEV1 = 52.16% of predicted, Tiffno - 68.01%, FVC - 72.36% of predicted. Six months after discharge from the hospital the patient was no exacerbations of COPD.

Example 2 Patient S., 62 years old, medical stationary card №61195, was admitted to the pulmonology department of HBO emergency hospital №1 Voronezh by ambulance 26.11.2010, complaining of shortness of breath at rest, increasing with a slight movement, a feeling of stuffiness in chest, cough with difficult expectoration of light color, palpitations, dizziness, general weakness.

COPD for 10 years, is at the dispensary in the clinic. Repeatedly treated permanently. COPD exacerbations during the last year was 2. Use an inhaler "Flomax" 20/50 mg, two doses on demand constantly "Seretide" × 50/500 mcg twice daily. The deterioration of about 10 days, when he was troubled by a cough with difficult expectoration, increased shortness of breath, palpitations, chest congestion. In history - hypertension, constantly takes fiziotenz 0.2 mg. I do not smoke. He appealed to the district physician. By scoring assessing the severity of COPD exacerbations (1 + 0 + 0 + 1 + 1 + 0 = 3) the patient needed hospitalization. However, the patient refused to be hospitalized and was treated on an outpatient basis with the use of ambroxol tablets and aminophylline. Status during the week did not improve, there is increasing shortness of breath, palpitations, patient called an ambulance.

The pulmonology department acted in a state of moderate conscious, there is a decrease in physical activity. The skin is moist, pale, cyanosis of the lips. Respiratory rate was 25 per minute, and tachycardia - 120 / min, blood pressure - 160/90 mm Hg Auscultation breathing hard, all the pulmonary fields auscultated dry wheezing, percussion-boxed tone. In the study of the chest on chest radiograph of 26.11.10 was determined pulmoskleroza picture, emphysema, cardiomegaly. The front desk has been used numerical score of severity of COPD exacerbations for addressing the need for stationary studies: 1 (respiratory rate of 20-29 per minute) + 0 (the number of exacerbations of COPD per year less than 3) +0 (sleep apnea syndrome, a history of missing ) +1 (history of hypertension) +1 (age> 60 years) + 0 (no change in mental status). Received amount of money = 3 points, indicating that exacerbation of COPD of moderate severity and the need for hospitalization of the patient to the hospital.

Total blood from 29.11.10 g .: Hb = 110 g / l, er. = 3,6 × 1012 / L, color. Pok. = 0.9, N = 4,0 × 109 / L, erythrocyte sedimentation rate = 4 mm / h, fell. = 3%, Seg. = 52%, EPZs. = 1%, lim. = 38% mon = 6%, DRR = 3. The study of respiratory function: FEV1 = 56.0% of predicted, Tiffno - 52.8%, FVC - 54.9%, a test with bronchodilator - negative. ECG - sinus rhythm, EOS deviation to the left, signs of left ventricular hypertrophy. Given the clinical and radiological findings was diagnosed with stage II COPD, exacerbation. Nam II. Essential hypertension stage II, the risk of CHF 3 MTR I, FC 1.

In the treatment used: dexamethasone / O, cough tablets, inhaled through a nebulizer solution berodual and Mucosolvan, kordafleks 40 mg per day. The patient spent in the hospital bed 14 / day and was discharged in satisfactory condition at 10.12.10 follow-up physician.

The use of our proposed method of determining the severity of COPD exacerbations can not only promptly hospitalized patients to adjust treatment to improve quality of life, as well as helps to reduce days of hospital treatment, days of disability and reduce the number of exacerbations of COPD over the next year.