asma bronquial y epco, Resúmenes de Medicina

¡Descarga asma bronquial y epco y más Resúmenes en PDF de Medicina solo en Docsity! ASMA BRONQUIAL EPOC J. Urquiza Z. M.C. F.C. PUNTAJE CLINICO ASMA PUNTAJE FRECUENCI A RESPIRAT < 6 meses FRECUENCI A RESPIRAT > 6 meses SIBILAN- CIAS CIANOSIS USO MUSCULOS ACCESOR 0 < 40 < 30 Ausentes Ausente NO 1 41 – 55 31 – 45 Espiratorias Perioral con llanto Subcostal 2 56 – 70 46 – 60 Espir/Inspi Con Este- toscopio Perioral en reposo Subcostal e Intercostal 3 > 70 > 60 Espir/Inspi Sin Este- toscopio Generalizad en reposo Subcostal, Intercostal Supraester LEVE: 0 – 5 MODERADA: 6 – 9 SEVERA: 10 – 12 Guide to limits of normal pulse rate in children: Infants 2-12 months -MNormal rate <160/min Preschool 1-2 years -Normal rate <120/min School age 2-8 years -Normal rate <110/min Pulsus paradoxus Absent May be present Often present Absence suggests < 10 mm Hg 10-25 mm Hg > 25 mm Hg [adult] | respiratory muscle 20-40 mm Hg (child) | fatigue PEF Over 80% Approx. 60-80% < 60% predicted or after initial rsonal best bronchodilator [< 100 L/min adults) % predicted or or % personal best response lasts < 2 hrs Pa0O» [on air)! Normal > 60 mm Hg < 60 mm Hg Test not usually and/or necessary Possible cyanosis pacO,! < 45 mm Hg < 45 mm Hg > 45 mm Hg; Possible respiratory failure [see text) Sa02% [on air)! > 95% 91-95% < 90% Hypercapnia [hypoventilation) develops more readily in young children than in adults and adolescents. FLUJO Cateter Nasal Mascarilla Simple Venturi FiO2 FiO2 FiO2 2L 24 – 28 3L 28 – 30 4L 32 – 36 24 5L 36 – 40 40 6L 40 – 44 45 – 50 28 8L 55 – 60 31 10L > 60 35 12L 40 25L 50 OXIGENOTERAPIA KEY POINTS: * hMedications to treat asthima can be classified as controllers or relievers. Controllers are medications taken dai on a lona-term basis to keep asthma under clinical control chiefly through their anti- inflammatory effects. Rellevers are medications on an as-needed basis that act quickly to reverse bronchoconstriction and reliewe ts symptoms. * Astima treatment can be administered in different bw injection. The major is that drugs are Sa ducina higher local concentrations with significantly less risk of systemic side effects. *Inhaled alucocorticosteroids are the most effective controller medications currently available. id-acting inhaled Bo-agonists are the lons of choice fe lef of nstriction and forthe pretreatment of exercise-induced bronehoconstriction, in both adults and children of all ages. *Increased use, especially daily use, of reliever medication is a warinag of deterioration of asthma control and indicates the need to reassess treatment SALBUTAMOL EFICACIA Farmacodinamia: AMPc K+ Farmacocinética: I:5-15’ Max:1h D:3-6h E. Comparativa: > Ipratropio. > duración Fenoterol. SEGURIDAD RAM: Taquicardia, ansiedad, temblor, mareo Inter: Digoxina, tiroxina, xantinas. Hipotensores, nitratos CI: Arritmias, ICC, c. isquémica, cetoacidosis. (C) C/B: Bajo/alto Dosis: Inhalatoria MDI (>12a) 100-200 ug c/4-6h Nebulización: 0,05-0,15 mg/kg en 5-15’ c/4-6h 1,25 a 2,5 mg en 5-15’ c/4-6h Biological response (%) L-type Ca?- Adenylate channel cyclase Full agonist Partial agonist Basal activity / Neutral antagonist Inverse agonist Log drug concentration BAR and G-protein- dependent signalling Desensitized B¿AR G-ptotein uncóupling. by phosphorylation e ¿and arrestin binding, | DODS Internalization via clathrin-mediated Recycling back On endocytosis to membrane AN Pe SSA G-protein- ' YU. , independent s signalling DO AT y MAP kinase y y pathway Targeted for degradation in lysosomes Arrestin Gene expression BROMURO DE IPRATROPIO EFICACIA Farmacodinamia: Antagonista M-3. Farmacocinética: I:15’ Max:1h D:5-6h E. Comparativa: < Salbutamol. SEGURIDAD RAM: Tos, xerostomía, disgeusia. Broncoespasmo. Inter: Anticolinérgicos oftálmicos. CI: Glaucoma <estrecho, retención urinaria. (B) C/B: Medio/alto Dosis: Inhalatoria MDI 50 ug c/6-8h Adultos: 50-100 ug c/6-8h Figure 3-4, Estimated Equipotent Dally Doses of Inhaled Glucocorticosteroids for Children Drug Low Daily Dose (jua) Medium Daily Dose (pg) High Daily Dose [pal Beclomethasone dipropionate 100-200 200-400 400 Budesonido* 100-200 2200 -400 400 Budesonide-Meb 250-500 500 - 1000 >1000 Ciclesonide* 80-160 >160 - 320 2320 Flunisolide 500-750 750 - 1250 >1250 Fluticasone 100-200 2200 - 500 2500 Momnelasone furcata* 100-200 200-400 400 Triamcinclone acelon ida 400-800 900-1200 21200 TRATAMIENTO DE LAS CRISIS * Inhaled rapid-acting B2-agonists in adequate doses are essential. (Begin with 2 to 4 puffs every 20 minutes for the first hour; then mild exacerbations will require 2 to 4 puffs every 3 to 4 hours, and moderate exacerbations 6 to 10 puffs every 1 to 2 hours.) e Oral glucocorticosteroids (0.5 to-1 mg of prednisolone/kg or equivalent during a 24-hour period) introduced early in the course of a moderate or severe attack help to reverse the inflammation and speed recovery. * Oxygen is given at health centers or hospitals if the patient is hypoxemic (achieve O2 saturation of 95%). + Combination B>-agonist/anticholinergic therapy is associated with lower hospitalization rates and greater improvement in PEF and FEV. * Methylxanthines are not recommended if used in addition to high doses of inhaled B2-agonists. However, theophylline can be used if inhaled B-agonists are not available. If the patient is already taking theophylline on a daily basis, serum concentration should be measured before adding short-acting theophylline. * Patients with severe asthma exacerbations unresponsive to bronchodilators and systemic glucocorticosteroids, 2 grams of magnesium sulphate IV has been shown to reduce the need for hospitalizations.  Figure 4.4-2: Management of Asthma Exacerbations in Acute Care Setting Initial Assessment (see Figure 4.41) + History, physical examination (auscultation, use of accessory musdes, heartrate, respiratory rate, PEF or FEWy, oxygen saluralion, arterial blood gas if patient in extrernis) Initial Treatment + Oxygen to achieve O saturation 90% 1959 in children) + Inhaled rapid-aciing f7-agonist continuously for one hour. + Systemic glucocorticosteroids ifno immediate response, or if patient recentlytook oral glucocorticosteroid, or iFepisode is severe. + Sedation is contraindicated in the treatment of an exacerbalion, Y Reassess after 1 Hour Physical Examination, PEF, 07 saturation and other tests as needed Y Y Criteria for Mod Episode: Criteria for Severe Episode: Eriteria for Moderate Episode: * History ofrisk factors for near fatal asthirma PEF 60-80% predicled/personal best * PEF <60% predicted/personal best * Physical exam: moderate symptoms, accessory muscle Lise * Physical exam: severa symptoms atrest, chest retraction Treatment: * No improvement aftor initial troatmont Oxygen . o o Treatment: * Inhaled fy-agonist and inhaled anticholinergic every 60 min = Oxygen + Oral glucocorticosteroids * Inhaled f2-agonist and inhaled anticholinergic = Continue treatment for 1-3 hours, provided there is improvement | | + Systernic glucocorticosteroids + Intravenous magnesium y y Reassess after 1-2 Hours T  Figure 2-5. Levels of Asthma Control Characteristic Controlled Partly Controlled Uncontralled (All of the following) (Any measure present in any week) Daytimo symptoms None (fwica or lessivookj More than twica week Three or more features _— -—_ of partly controlled Limitations of activitios None Any asthma presentin Nocturnal symptoms/awakening | None Any any Week Need for ralievar! None twice or lass/weokj Mora than hwica mack rescue treatment Lung function (PEF or FEV1)* [Moral < 80% predicled or personal best (if known) Exacerbations None One or more/year Oneinany weak! * Any exacarador año prengal ree ol manden arce ¿model do ensure Mal dé aciouala | Byaaíiton, an exacerbalón E any weak mares ¿hal anuncanitolad asíima ea. ¿Long Anedon é nota mate des! Jorciibitan 5 paar arvl youre. Management Approach Based On Control For Children Older Than 5 Years, Adolescents and Adults Level of Control Controlled al Treatment Action NY Maintain and ind lowesi controling silep Party contraled Consider stepping up lo galn conti Uncontrolled 44 pa Sep ue uni con roled Exacerbation ; Treal as exacerbaton Reduce Treatment Steps Increase sup 1 |[ s2 |[ se3 | [sms |[- ss Asthma educalon Environmental control As needed rapid. acting Pragoriat As needed rapidacting -agonist Select one Select one Add one or more Add ona or both Mediumn-or Mgh-dos. e Lowdose inhaled Low-dosé 0S plus 1CS plus h TARO Oral ghucocortoostercid as long-acing Pagonist B--agona! (ones dose) Controller optiana «+. Medum-or Leuotiene AntidgE moditer 1** high-dose 125 moditer treaiment Lowdose OS plus lauioctrnene moditer Lowedose OS plus sustained release theophyilina  Step Up treatment to achieve asthma control Add anti-IgE monoclonal antibody (omalizumab) Inhaled steroid + LABA + LTM Inhaled steroid + LABA (or inhaled steroid + LTM) Inhaled steroid (or LTRA) SABA, as needed SUS USA LOS PUE 11500 535049 =p Is LuUs]-360] pue -1104 5 23ZILU4I14 14 07 JU LU Je] umnop das EVIDENCIAS COCHRANE Las xantinas orales, como preventivo de primera línea, alivian los síntomas y disminuyen los requerimientos de fármacos de rescate en niños con asma leve a moderada. Comparados con los CSI, fueron MENOS EFECTIVOS para prevenir las exacerbaciones. Las xantinas tuvieron una eficacia similar como fármacos preventivos únicos comparados con el uso regular de BAAC y Cromoglicato. Las pruebas sobre los efectos adversos (EA) mostraron un incremento de los efectos adversos (EA) en general. Los CSI fueron SUPERIORES al Cromoglicato de sodio en las medidas de la función pulmonar y el control del asma, tanto en los adultos como en los niños con asma crónica. Hubo pocos estudios que informaron la calidad de vida y la utilización de los servicios de asistencia sanitaria, lo que limitó la capacidad de evaluar adecuadamente los efectos relativos de estos fármacos sobre un rango más amplio de resultados. EVIDENCIAS COCHRANE En los pacientes sintomáticos con dosis bajas a altas de corticosteroides inhalados, la adición de un agonista ß2 de acción prolongada disminuye la tasa de exacerbaciones que requieren esteroides sistémicos, mejora la función pulmonar, los síntomas y el uso de agonistas ß2 de acción corta de rescate. El número similar de eventos adversos graves y de las tasas de retiros en ambos grupos aporta algunas pruebas indirectas de la seguridad de los agonistas ß2 de acción prolongada como tratamiento adicional a los corticosteroides inhalados. Se encontró un mayor riesgo de eventos adversos graves con el tratamiento habitual con formoterol, que no parece eliminarse en los pacientes que recibían corticosteroides inhalados. El efecto sobre los eventos adversos graves del tratamiento habitual con formoterol en los niños fue mayor que el efecto en los adultos, pero la diferencia entre los grupos etarios no fue significativa. EPOC Initiating factors (e.g.. smoking, childhood respiratory disease) Impaired innate Acute lung defense Y NT exacerbation Airway Microbial epithelial injury colonization Progression IU Microbial 7 Inflammatory ofCOPD antigens response Altered proteinase— Increased antiproteinase += Droteolytic antibody balance activity Figure 3. The Vicious-Circle Hypothesis of Infection and Inflammation in COPD. . oe Clasificación Exacerbaciones por Paciente Característica o a espirométrica año Poco sintomático Más sintomático ( Alt riesgo, GOLD 3-4 > Poco sintomático Alo riesgo, GOLD 3-4 >? Más sintomáfico  Principio activo Presentación Dosis recomendada Dosis máxima Inicio deacción Efecto máximo Duración Salbutamol ICP: 100 ug/inh 200 1.g/4-6 h 1.600 1g/día 40-505 15-20 min 3-6h Terbutalina TH: 500 ugfinh 500 ug]6h 6 mg/día 40-505 15-30 min 4-6h Salmeterol ICP: 25 ug finh 50 18/12 h 200 ug/día 20 min 34h 12h AH:50 ug/inh Formoterol ICP: 12 ug inh 12 18/12 h 48 ug/día 1-3 min 2h 12h TH: 9 ug/inh AL: 12 pgfinh Indacaterol BH: 150 uglinh — 15018/24h 300 ug/día 1-3 min 2h 24h BH: 300 ug/inh Bromuro de ipatropio — ICP: 20 ug inh 20-40 ug/6-8 h 320 ug/día 15 min 30-60 min 4-8h Bromuro de tiotropio HA: 18 pgfinh 18 ug/24h 18 ug/día 30 min 3h 24h RM: 5 ug Jinh 5 18/24 h 5ug/día Aclidinio GE: 322 pg/inh 322 18/12 h 644 ug día 15-30 min 2h 12h Glicopirronio BH: 44 ug/inh 44 18/24 h 44 ug/día 5 min 2h 24h Teofilina p.o.: 100-600 mg 5-6 mg/kg (carga) 2-7mg/ke/12h 3h 6h 12h 2-7 mg/kg/12 h (dosis de mantenimiento)  PRIMERA. RECOMENDACIÓN OPCIÓN ALTERMATIVA OTRAS OPCIONES** Agonista bata-2 AC sp o Anticolinárgico AC sp Agonista bata-2 AC y antical inárgico AC o Agonista bata-2 AP a Anticolinárgico AP Agonista beta-2 AP o Antical inárgico AP Agenista beta-2 AP y antical inárgico AP Agonista bata2 AC yo anticolinérgico AC Anficalinárgico AP o Cl + Agonista bata-2 AP Agonista beta-2 AP y anticalinérgleo AP Agonista beta-2 AC y/o anticolinárgico AC InhibidorFDE4 Teotilina ¡Anticolinórgico AP o Cl + Agonista beta-2 AP Agonista bata2 AP y anticalinárgico AP o Antficolinángico AP y Cl o Anticolinérgico AP y Cl + Agorista bela-2 AP o Anticolmárgico AF e inbibidos FDEA o Cl + Agonista bake-2 AP a inhibidorFDEA Agonista beta-2 AC y anticolinángico AC Carbocistaina Teotilina