RU2467685C2 - Method for determining degree of severity of aggravated chronic obstructive pulmonary disease (copd) for specifying optimal approach to patient management - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to therapy and pulmonology. Anamnestic data and objective examination methods are used to derive points. Breathing rate 30 and more requires assigning 2 points, and breathing rate less than 30 and more than 19 requires assigning 1 point, and if it does not exceed 10, 0 points is assigned. Number of aggravated COPDs being 3 and more, 1 point is assigned, while 0 points is assigned if stating less than 3 aggravations of COPD. If sleep apnea syndrome is present, 1 point is assigned, and if it is absent, 0 points is assigned, The presence of underlying diseases - 1 point, the absence - 0 points. The patient's age of 60 years old and more - one point, less than 60 years old - 0 points. Oriental status with underlying aggravated COPD - if the patient does not answer the questions, shows no response on noxious stimuli - 2 points, if the patient is disoriented or gibbers, executes no commands - 1 point; if the patient is oriented and can answer the questions and executes the commands - 0 points is added. The points are summed up. If total score is 1 point and less, slightly aggravated COBD is diagnosed, and out-patient treatment with the use of a base therapy is recommended. Total score 2-3 points enables diagnosing a moderate degree of aggravation, admission of the patient to specialised department is considered to be needed and require the base therapy, systemic glucocorticosteroids, antibacterial preparations and parenteral introduction of drugs to be prescribed Total score 4 points and more provides diagnosing severe aggravation of COBD with stating a necessity of admission to an intensive care unit added with the use of oxygen-therapy, non-invasive or invasive pulmonary ventilation.

EFFECT: method extends the range of products for determining a degree of severity of aggravated chronic obstructive pulmonary disease (COPD) for specifying optimal approach to patient management.

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Description

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

A known method for predicting probable pathogens and the prevalence of antibiotic-resistant strains, according to which patients with exacerbation of COPD are divided into two groups: simple (uncomplicated) exacerbation and complicated exacerbation of COPD (Chronic obstructive pulmonary disease. A practical guide for doctors / I.V. Leshchenko, S. I. Ovcharenko, E.I. Shmelev. - M., 2004 .-- 62 p. - P.46). The first group (simple or uncomplicated exacerbation of COPD) includes patients under the age of 65 years with not frequent exacerbations (less than 4 during the calendar year), the absence of serious concomitant diseases and FEV1> 50%. The second group of patients includes patients with complicated exacerbation of COPD: age

 > 65 years and / or FEV1 <50% and / or the presence of concomitant diseases (diabetes mellitus, heart failure, chronic liver and kidney diseases, accompanied by organ failure, etc.), and / or at least 4 exacerbations during the year.

The disadvantage of this method is the high cost (the study of the function of external respiration) and the lack of information about the place of treatment of the patient with antibacterial drugs (at home, day hospital, around-the-clock hospital, intensive care unit).

The well-known "Method for predicting the course of non-specific lung diseases" (US Pat. RU No. 2121675 from 10.11.1998, Bazhukova TA). Examine bronchial secretions and / or sputum using microbiological methods. The number of conditionally pathogenic bacteria, pathogenic bacteria and fungi of the genus Candida is determined, evaluating each indicator in points. With a score of 0-2, remission of non-specific lung diseases is predicted, with 3-5, pneumonia worsens with a favorable course, with 6-8 points - chronic pneumonia with bronchiectasis and abscess formation, or chronic pneumonia with a unfavorable course, with 9-12 points - severe immunodeficiency and the presence of malignant neoplasms in the lungs. This increases the possibility and accuracy of predicting the course of inflammatory lung diseases.

Closest to our proposed method is the assessment of exacerbations of COPD, including the study of anamnestic features - impaired external respiration (FEV1), the duration of worsening of symptoms or the appearance of new symptoms, the number of previous episodes of exacerbations / hospitalizations, concomitant diseases, current treatment regimen; and signs of severity of exacerbations - the use of auxiliary respiratory muscles, paradoxical movements of the chest, aggravation or the appearance of central cyanosis, the development of peripheral edema, hemodynamic instability, signs of right ventricular failure, decreased irritability (Global strategy for the diagnosis, treatment and prevention of chronic obstructive pulmonary disease (2008 review .) / Translated from English under the editorship of Belevsky A.S. - M.: Atmosphere Publishing Holding, 2009. - 100 p. - P.77).

The disadvantages of this method include high cost, low accuracy. It is known that in case of severe exacerbation of COPD, it is necessary to hospitalize the patient in a hospital, the study of FEV1 in dynamics to determine the deterioration will require certain additional time and funding at the examination stage and later at the hospital treatment stage. To date, the study of the function of external respiration is not included in the standard examination when calling a local or family doctor at home, ambulance crews. The absence of a point assessment of the severity of COPD does not give the doctor clear guidelines for deciding on the choice of an outpatient or inpatient treatment for a patient with exacerbation of COPD.

The technical result of the invention is the development of a method for determining the severity of exacerbation of chronic obstructive pulmonary disease, which allows to increase the accuracy of assessing the patient's condition, to choose the most optimal type of treatment at a given time. The method does not require additional financial costs, it is easy to perform in the conditions of any medical institution.

The technical result is achieved by the fact that in the diagnosis of the severity of an exacerbation of COPD use a score on the following indicators.

The method is as follows. The patient is checked for age, the presence of background diseases, such as pathology of the cardiovascular system, respiratory system, diabetes mellitus and other chronic diseases, the number of exacerbations of COPD over the past 12 months, the presence of sleep apnea syndrome (snoring, episodes of respiratory failure in a dream); with an objective study, the respiratory rate per minute (NPV) is calculated, the level of consciousness is determined.

NPV is assessed using a point scale: if thirty or more are assigned 2 points, they decide on the need for respiratory support in the intensive care unit. If the NPV is less than thirty, but more than nineteen per minute, 1 point is assigned, correction of the indicator is possible in the conditions of a specialized department. If the NPV does not exceed nineteen, zero points shall be awarded. The number of exacerbations of COPD per year is fixed from the patient’s words according to history or according to medical records, if available. If there are three or more exacerbations during the last year, 1 point is assigned, less than three exacerbations - they score zero points. The presence of sleep apnea syndrome is diagnosed according to the patient's medical history or from the words of his relatives or determined according to the medical documentation (polysomnography). In the case of sleep apnea, 1 point is assigned; in its absence, zero points are assigned. The presence of background diseases such as cardiovascular pathology, diabetes mellitus, renal failure, chronic pathology of the gastrointestinal tract, chronic venous insufficiency of the lower extremities, cerebrovascular diseases, oncological diseases, chronic diseases of the respiratory system, alcoholism, drug addiction, lowering of nutritional status are specified in the patient when collecting an anamnesis or from medical records. In the presence of any background diseases, one point is assigned, in the absence - zero points. The age of the patient is specified according to the passport data or from words, if the age of 60 years or more is assigned one point, less than 60 years - assigned zero points. This differentiation in age is due to the fact that in elderly patients older than 60 years the number and sensitivity of β2 receptors in the bronchi decreases, the effectiveness of β2-agonist bronchodilators, used by ambulance to relieve bronchospasm, decreases (Davidovskaya E.I. Rational bronchodilator therapy in old age / The Art of Medicine. - No. 2 (22), 2010. - S.145-150).

The change in mental status is assessed by the doctor individually when examining the patient. A change in mental status amid exacerbation of COPD is recorded during the survey and assessment of motor activity. If the patient does not answer questions, does not respond to pain stimuli, two points are assigned. If the patient is disoriented and cannot answer questions or makes inarticulate sounds, does not execute the command, one point is assigned. If there is no change in mental status - the patient is oriented and can answer questions, execute commands - add 0 points.

Further, the points for all the recorded parameters are summarized. With a sum of one point or less, a mild exacerbation of COPD is diagnosed, with a sum of two to three points, an exacerbation of moderate severity is diagnosed, if the sum is four points or more, a severe exacerbation of COPD is diagnosed. Using the point system proposed by us, it is possible to choose the place of treatment for a patient with COPD: with a mild exacerbation of COPD, patients are treated on an outpatient basis using basic therapy. With moderate severity, hospitalization is necessary in the specialized department with the appointment of basic therapy, therapy with systemic glucocorticosteroids, antibacterial drugs and parenteral administration of drugs. In severe exacerbation of COPD, hospitalization in the intensive care unit with the additional use of oxygen therapy, non-invasive or invasive ventilation is necessary.

We tested the method on 87 patients with COPD. Patients were divided into two groups. All patients consulted a doctor about exacerbation of COPD. The main group included 49 patients, of whom 31 were men and 18 women who were evaluated for the severity of exacerbation of COPD according to our proposed method based on a rating scale for assessing the severity of the condition. In two patients, the total score was more than four; they were hospitalized in the intensive care unit. In thirty-eight patients, the total score was 2-3, these patients were hospitalized in the pulmonary department. In nine patients, the total score did not exceed one - they were prescribed a course of outpatient treatment. The control group consisted of 38 patients with COPD, by age, sex, and medical history similar to patients in the main group, who, according to the scoring of the severity of the exacerbation, needed inpatient treatment, but abandoned it and underwent outpatient treatment. Subsequently, five patients from the control group were referred to the hospital due to the inefficiency of outpatient treatment, which, in turn, led to an extension of the period of disability. In patients of the control group after treatment, the frequency of exacerbations of COPD during the year was greater than in patients of the main group (3.5 ± 0.5 and 1.5 ± 0.5, respectively). According to the results of the study, it was further shown that in patients hospitalized with exacerbation of COPD, the application of the proposed method for determining the severity of COPD reduces the days of inpatient treatment by 3.5 ± 0.5 days, reduces days of disability and reduces the number of exacerbations of COPD over the next year 1.5 times on average (see table).

Table Comparative characteristics of methods for determining the severity of COPD. Study Parameters Prototype method Proposed method Duration of hospitalization, days 16.0 ± 4.0 13.0 ± 3.3 The frequency of exacerbations of COPD during the year after treatment, units 3.5 ± 0.5 1.5 ± 0.5 Δ FEV1,% 5.8 ± 0.4 7.3 ± 0.6 Δ RaO2,% 4.2 ± 0.5 5.1 ± 0.6

We give examples of case histories of two patients who, according to the traditionally accepted method for determining the severity of an exacerbation of COPD, did not need in-patient treatment, but according to our point-based system for determining the severity of an exacerbation of COPD, they needed to be hospitalized.

Example 1. Patient P., 60 years old, medical card No. 7117, was admitted to the pulmonology department of GB No. 8 in Voronezh by ambulance on 05/19/2009 with complaints of shortness of breath at rest, aggravated by climbing to the 1st floor, a feeling of stuffiness in chest, cough with difficult to separate sputum of a light color, palpitations, dizziness, general weakness. He suffers from COPD for more than 10 years, is registered in a clinic. Repeatedly treated stationary. Over the past year, there have been 2 exacerbations of COPD. He uses the Berodual inhaler 20/50 mcg, two doses on demand, constantly Clenyl Jet 250 mcg, two doses × twice a day and 12 μg foradil, one dose twice a day. Deterioration of the condition for about 4 days, when a cough with sputum that was difficult to separate began to bother, shortness of breath, palpitations, and a feeling of stuffiness in the chest intensified. A history of hypertension, does not take continuous treatment. I do not smoke. He entered the department in a state of moderate severity, in consciousness, he noted a decrease in physical activity. The skin is moist, pale, cyanosis of the lips and fingers. The respiratory rate per minute was 27, tachycardia - 119 / min, blood pressure - 130/80 mm Hg. During auscultation, breathing is harsh, buzzing dry rales are heard throughout the pulmonary fields, and box tone is percussion. When examining the chest organs on a radiograph dated 05/19/09, a picture of pulmonosclerosis is determined with an outcome in fibrosis, pulmonary emphysema, cardiomegaly. The admission department used a score for the severity of an exacerbation of COPD to address the need for inpatient research: respiratory rate per minute 20-29 - one point; the number of exacerbations of COPD per year is less than three - zero points; history of sleep apnea is absent - zero points; history of hypertension - one point; age 60 years - one point; no change in mental status - zero points. In total, she receives three points, which corresponds to an exacerbation of COPD of moderate severity and the need for hospitalization of the patient.

General blood test from 05/19/09: Hb = 156 g / l, Er. = 4.1 × 1012 / l, Tsv. Pok. = 1.1, L = 9.2 × 109 / l, ESR = 30 mm / h, pal. = 4%, seg. = 76%, eos. = 5%, lim. = 14%, mon. = 1%, CRP = 4. The study of the function of external respiration: FEV1 = 51.02% of the due, Tiffno - 64.71%, FVC - 67.93%, the test with a bronchodilator is negative. On the ECG - sinus rhythm, deviation of EOS to the left, signs of left ventricular hypertrophy. Based on clinical and radiological data, the diagnosis was made: COPD stage II, exacerbation. NAM II. Hypertension of the II stage, risk of MTR 3. CHF I, FC1.

In the treatment used: dexamethasone iv, ACC iv, inhalation through a nebulizer with a solution of berodual and lazolvan, cordaflex RD 40 mg, aminophylline iv. The patient spent 12 beds / days in the hospital and was discharged in satisfactory condition on 05/31/09 for medical examination by a general practitioner. Upon discharge from the hospital, the spirography data for patient P. were as follows: FEV1 = 52.16% of the due, Tiffno - 68.01%, FVC - 72.36% of the due. Six months after discharge from the hospital, the patient did not have exacerbations of COPD.

Example 2. Patient S., 62 years old, medical stationary card No. 61195, was admitted to the pulmonology department of the GBK BSMP No. 1 of Voronezh on ambulance on November 26, 2010 with complaints of shortness of breath at rest, intensifying with slight movement, a feeling of congestion chest, cough with difficult to separate sputum of a light color, palpitations, dizziness, general weakness.

He suffers from COPD for about 10 years, is registered in a clinic. Repeatedly treated stationary. There were 2 exacerbations of COPD over the past year. It uses a Berodual inhaler 20/50 mcg, two doses on demand, constantly Seretide 50/500 mcg × twice a day. Deterioration of the condition for about 10 days, when a cough with sputum that was difficult to separate began to bother, shortness of breath, palpitations, and a feeling of stuffiness in the chest intensified. In the anamnesis - a hypertension, constantly takes a physiotens 0.2 mg. I do not smoke. Turned to the local therapist. According to a point estimate of the severity of exacerbation of COPD (1 + 0 + 0 + 1 + 1 + 0 = 3), the patient needed to be hospitalized in a hospital. However, the patient refused hospitalization and was treated on an outpatient basis with the use of Ambroxol and Eufillin tablets. The condition did not improve within a week, shortness of breath, palpitations increased, the patient called an ambulance.

She was admitted to the pulmonary ward in a state of moderate severity; in her mind she noted a decrease in physical activity. The skin is moist, pale, cyanosis of the lips. The respiratory rate per minute was 25, tachycardia - 120 / min, blood pressure - 160/90 mm Hg. During auscultation, breathing is tough, dry wheezing, percussion-box tone are heard throughout the pulmonary fields. When examining the organs of the chest on a roentgenogram dated 11/26/10, the picture of pulmonosclerosis, pulmonary emphysema, cardiomegaly is determined. The admissions department used a score for the severity of COPD exacerbation to address the need for inpatient research: 1 (respiratory rate 20-29 per minute) + 0 (the number of COPD exacerbations per year is less than 3) + 0 (no history of sleep apnea syndrome ) + 1 (in the history of hypertension) + 1 (age> 60 years) + 0 (there is no change in mental status). Received the amount = 3 points, which indicates an exacerbation of COPD of moderate severity and the need for hospitalization of the patient in a hospital.

General blood test from 11.29.10 g: Hb = 110 g / l, Er. = 3.6 × 1012 / l, Tsv. Pok. = 0.9, L = 4.0 × 109 / l, ESR = 4 mm / h, pal. = 3%, seg. = 52%, eos. = 1%, lim. = 38%, mon = 6%, CRP = 3. The study of the function of external respiration: FEV1 = 56.0% of the due, Tiffno - 52.8%, FVC - 54.9%, test with bronchodilator - negative. On the ECG - sinus rhythm, deviation of EOS to the left, signs of left ventricular hypertrophy. Based on clinical and radiological data, the diagnosis was made: COPD stage II, exacerbation. NAM II. Hypertension of the II stage, risk of MTR 3. CHF I, FC 1.

The treatment used was: iv dexamethasone, cough tablets, inhalation through a nebulizer with a solution of berodual and lazolvan, cordaflex 40 mg per day. The patient spent 14 beds / days in the hospital and was discharged in satisfactory condition on 10.12.10 for medical examination by a general practitioner.

The application of our proposed method for determining the severity of COPD exacerbations allows us not only to hospitalize patients in a timely manner, to correct treatment, to improve the quality of life, but also to reduce inpatient days, incapacity for work and reduce the number of exacerbations of COPD over the next year.

Claims (1)

A method for determining the severity of exacerbation of chronic obstructive pulmonary disease to select the optimal treatment for patients, based on historical data and the patient's condition with an objective study, characterized in that they use a point assessment of the studied parameters: if the respiratory rate is thirty or more, 2 points are assigned if less than thirty, but more than nineteen per minute, assign 1 point, if not more than nineteen, assign 0 points; if there are three or more COPD exacerbations per year, assign 1 point, less than three exacerbations, assign 0 points; if sleep apnea syndrome is present, assign 1 point; in its absence, assign 0 points; if the presence of background diseases is noted, assign 1 point, in the absence - 0 points; if the patient's age is 60 years or more, one point is assigned, less than 60 years - 0 points are assigned; assess mental status against the background of exacerbation of COPD - if the patient does not answer questions, does not respond to pain stimuli, assign 2 points if the patient is disoriented and cannot answer questions or makes inarticulate sounds, does not fulfill the command - 1 point if the patient is oriented and can answer questions; performs commands - add 0 points; points for all fixed parameters are summarized; with a total of one point or less, a mild exacerbation of COPD is diagnosed, outpatient treatment using basic therapy is recommended; an aggravation of moderate severity is diagnosed with a sum of two to three points, and the need for hospitalization in the specialized department with the appointment of basic therapy, drugs and parenteral administration of drugs is judged; if the amount is four points or more, a severe exacerbation of COPD is diagnosed, the need for hospitalization in the intensive care unit with the additional use of oxygen therapy, non-invasive or invasive ventilation is judged.