Лечение обострений хронической обструктивной болезни легких
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Цель исследования: оценить качество медицинской помощи, оказываемой в крупных российских стационарах пациентам с обострением ХОБЛ.
Материалы и методы. В исследование включены пациенты с обострением ХОБЛ, госпитализированные в стационар трех клинических больниц г. Москвы. Диагноз «обострение ХОБЛ» устанавливался в соответствии с клиническими рекомендациями. У всех пациентов собирались сведения о демографических показателях, симптомах заболевания, показателях газового анализа крови, рентгенографии органов грудной клетки (ОГК), медикаментозной терапии, кислородотерапии и проводимой респираторной поддержке. Период наблюдения составил 90 дней. Полученные данные сравнивались с данными пациентов из мультицентрового исследования «European COPD Audit».
Результаты и обсуждение. Ведущими клиническими симптомами при обострении ХОБЛ являлись, как и в других странах, усиление одышки (95,4%) и увеличение объема мокроты (60,7%). Во время обострения большинство больных ХОБЛ получали короткодействующие β2-агонисты (77,4%), системные глюкокортикостероиды (85,1%), антибиотики (79,0%) и теофиллины (48,1%). Неинвазивную вентиляцию легких проводили у 8,6% пациентов, кислородотерапию – у 23,8% пациентов, легочную реабилитацию – лишь у 6,2% пациентов. Рентгенография ОГК выполнена у 97,9% пациентов, спирография – у 79,8%, исследование газов артериальной крови – у 19,3% пациентов. Средняя длительность госпитализации составляла 18,2±3,9 сут, повторные госпитализации в течение 90 дней – у 36,2% пациентов. Внутрибольничная летальность составила 3,3%.
Заключение. На основании результатов проведенного исследования предложены практические рекомендации по улучшению качества медицинской помощи при обострении ХОБЛ.
Ключевые слова: хроническая обструктивная болезнь легких, обострение, лечение, рекомендации, неинвазивная вентиляция легких.
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Chronic obstructive pulmonary disease (COPD) and its exacerbations remain an important problem of clinical medicine.
Aim. To assess the quality of medical care provided in large Russian hospitals to patients with COPD exacerbation.
Materials and methods. The study included patients with acute exacerbations of COPD hospitalized into three large clinical hospitals in Moscow. The diagnosis of "COPD exacerbation" was established in accordance with current clinical recommendations. We collected the data about patients’ demography, clinical signs and symptoms, blood gas analysis, chest radiography, drug therapy, oxygen therapy and respiratory support. The follow-up period was 90 days. The obtained data were compared with the data of patients from the multicenter study "European COPD Audit".
Results and discussion. The leading clinical symptoms in COPD exacerbation were dyspnea (95.4%) and sputum production (60.7%). The majority of patients with COPD received short-acting β2-agonists (77.4%), systemic steroids (85.1%), antibiotics (79.0%) and theophyllines (48.1%). Noninvasive ventilation was performed in 8.6% of patients, oxygen therapy – in 23,8% of patients, pulmonary rehabilitation – in only 6,2% of patients. Chest radiography was performed in 97.9% of patients, pulmonary function tests – in 79.8%, blood gases analysis – in 19.3% of patients. The mean duration of hospitalization was 18.2±3.9 days, repeated hospitalization within 90 days occurs in 36.2% of patients. In-hospital mortality was 3.3%.
Conclusion. Based on the results of the study practical recommendations for improving the quality of medical care in acute exacerbations of COPD are proposed.
Keywords: chronic obstructive pulmonary disease, exacerbation, treatment, recommendations, non-invasive ventilation.
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6. Husebo GR, Bakke PS, Aanerud M, Hardie JA, Ueland T et al. Predictors of exacerbations in chronic obstructive pulmonary disease – results from the Bergen COPD cohort study. PLoS One. 2014;9:e109721. doi: 10.1371/journal.pone.0109721
7. Self TH, Patterson SJ, Headley AS, Finch CK. Action plans to reduce hospitalizations for chronic obstructive pulmonary disease exacerbations: focus on oral corticostaroids. Curr Med Res Opin. 2014;30:2607-15. doi: 10.1159/000477911
8. Connors AF Jr, Dawson NV, Thomas C, Harrell FE Jr, Desbiens N, et al. Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risk Treatments). Am J Respir Crit Care Med. 1996;154:959-67. doi: 10.1164/ajrccm.154.4.8887592
9. Tokgoz Akyil F, Gunen H, Agca M, Gungor S, Yalcinsoy M, Sucu P, Akyil M, Sevim T. Patient outcome after chronic obstructive pulmonary disease exacerbations requiring noninvasive ventilation during hospitalization. Arch Bronconeumol. 2016;52(9):470-6. doi: 52:470-476.10.1016/j.arbres.2016.01.021
10. Atsou K, Chouaid C, Hejblum G. Variability of the chronic obstructive pulmonary disease key epidemiological data in Europe: systematic review. BMC Med. 2011;9:7. doi: 10.1186/1741-7015-9-7
11. Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Resp J. 2017;50:1602426. doi: 10.1183/13993003.02426-2016
12. Hartl S. The European COPD Audit: a pilot experience of 16 European countries. Pneumonol Alergol Pol. 2012;80:501-4.
13. López-Campos JL, Hartl S, Pozo-Rodríguez F, Roberts CM. European COPD Audit Team European COPD Audit: design, organization of work and methodology. Eur Respir J. 2013;41:270-6. doi: 10.1183/09031936.00021812
14. Roberts CM, López-Campos JL, Pozo-Rodríguez F, Hartl S. European COPD Audit Team European hospital adherence to GOLD recommendations for chronic obstructive pulmonary disease (COPD) exacerbation admissions. Thorax. 2013;68:1169-71. doi: 10.1136/thoraxjnl-2013-203465
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20. Ford PA, Durham AL, Russell RE, Gordon F, Adcock IM. Treatment effects of low-dose theophylline combined with an inhaled corticosteroid in COPD. Chest. 2010;137:1338-44. doi: 10.1378/chest.09-2363
21. Zhang WH, Zhang Y, Cui YY, Rong WF, Cambier C, et al. Can β2-adrenoreceptor agonists, anticholinergic drugs, and theophylline contribute to the control of pulmonary inflammation and emphysema in COPD? Fundam Clin Pharmacol. 2012;26:118-34. doi: 10.1111/j.1472-8206.2011.01007.x
22. Yawn BP. Is “GOLD” standard for the management of COPD in clinical practice? Drugs Context. 2012;2012:212-34. doi: 10.7573/dic.212243
23. Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006;173:1390-413. doi: 10.1164/rccm.200508-1211ST
24. Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011;10:CD005305. doi: 10.1002/14651858.CD005305.pub3
25. Osthoff M, Leuppi JD. Management of chronic obstructive pulmonary disease patients after hospitalization for acute exacerbation. Respiration. 2010;79:255-61. doi: 10.1159/000235721
26. Мещерякова Н.Н. Принципы легочной реабилитации больных хронической обструктивной болезнью легких. Атмосфера. Пульмонология и аллергология. 2013;49:27-31 [Meshcheryakova NN. Principles of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. Atmosfera. Pul'monologiya i Allergologiya. 2013;49:27-31 (In Russ.)].
27. Saleh A, Lopez-Campos JL, Hartl S, Pozo-Rodriguez F, Roberts CM. European COPD Audit Team: The effect of incidental consolidation on management and outcomes in COPD exacerbation: data from the European COPD Audit. PLoS One. 2015;10:0134004. doi: 10.1183/09031936.00021812
28. Poole PJ, Chacko E, Wood-Baker RW, Cates CJ. Influenza vaccine for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;1:CD002733. doi: 10.1002/14651858.CD002733.pub2
29. Van Eerd EA, van der Meer RM, van Schayk OC, Kotz D. Smoking cessation for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016;8:CD010744. doi: 10.1002/14651858.CD010744.pub2
30. Kelly AM, McAlpine R, Kyle E. How accurate are pulse oximeters in patientswith acute exacerbationsof chronic obstructive airways disease? Respir Med. 2001;95(5):336-40. doi: 10.1053/rmed.2001.1046
31. Malatesha G, Singh NK, Bharija A, Rehani B, Goel A. Comparison of arterial and venous pH, bicarbonate, PCO2 and PO2 initial emergency department assessment. Emerg Med J. 2007;24:569-71. doi: 10.1136/emj.2007.046979
32. Bloom BM, Grudlingh J, Bestwick JP, Harris T. The role of venous blood gas in the emergency department: a systematic review and meta-analysis. Eur J Emerg Med. 2014;21:81-8. doi: 10.1097/MEJ.0b013e32836437cf
33. Rea H, Kenealy T, Adair J, Robinson E, Sheridan N. Spirometry for patients in hospital and one month after admission with an acute exacerbation of COPD. Int J Chron Obstruct Pulmon Dis. 2011;6:527-32. doi: 10.1186/1471-2466-12-73
34. Hill K, Goldstein RS, Guyatt GH, et al. Prevalence and underdiagnosis of chronic obstructive pulmonary diseaseamong patients at risk in primary care. CMAJ. 2010;182:673-8. doi: 10.1503/cmaj.091784
35. Higgings BG, Powell RM, Cooper S, Tattersfield AE. Effect of salbutamol and ipratropium bromide on airway calibre and bronchial reactivity in asthma and chronic bronchitis. Eur Respir J. 1991;4:415-20.
36. O’Driscoll BR, Kay EA, Taylor RJ, Weatherby H, Chetty MC, Bernstein A. A long-term prospective assessment of home nebulizer treatment. Respir Med. 1992;86:317-25.
37. Barnes PJ. Theophylline. Am J Respir Crit Care Med. 2013;188:901-6. doi: 10.1164/rccm.201302-0388PP
38. Rossi A, Kristufek P, Levine BE, Thomson MH, Till D, Kottakis J, et al. Comparison of the efficacy, tolerability, and safety of formoterol dry powder and oral, slow-release theophylline in the treatment of COPD. Chest. 2002;121:1058-69.
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40. Leuppi JD, Schuetz P, Bingisser R, Bodmer M, Briel M, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA. 2013;309:2223-31. doi: 10.1001/jama.2013.5023
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43. Stefan MS, Rothberg MB, Shieh MS, Pekow PS, Lindenauer PK. Association between antibiotic treatment and outcomes in patients hospitalized with acute exacerbation of COPD treated with systemic steroids. Chest. 2013;143:82-90. doi: 10.1378/chest.12-0649
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1. [Chuchalin AG, Avdeev SN, Aisanov ZR, et al. Federal clinical guidelines for diagnosis and treatment of chronic obstructive pulmonary disease. Pulmonologiya. 2014;(3):15-54 (In Russ.)].
2. Global strategy for the diagnosis, management and prevention of COPD. Available from: https://goldcopd.org/gold-reports, 2018.
3. Aisanov Z, Avdeev S, Arkhipov V, Belevskiy A, Chuchali A, Leshchenko I, Ovcharenko S, Shmelev E, Miravitlles M. Russian experience of creating clinical COPD guidelines and a clinical decision making algorithm. Int J COPD. 2018;13:183-7. doi: 10.2147/COPD.S153770
4. WHO: Chronic obstructive pulmonary disease (COPD). 2016. Available from: http://www.who.int/topics/chronic_obstructive_pulmonary_disease/en/
5. GBD 2015 Mortality and causes of death collaborators: global, regional and national life expectancy, all-causes mortality and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global burden of disease study 2015. Lancet. 2016;388:1459-544. doi: 10.1016/S0140-6736(16)31012-1
6. Husebo GR, Bakke PS, Aanerud M, Hardie JA, Ueland T et al. Predictors of exacerbations in chronic obstructive pulmonary disease – results from the Bergen COPD cohort study. PLoS One. 2014;9:e109721. doi: 10.1371/journal.pone.0109721
7. Self TH, Patterson SJ, Headley AS, Finch CK. Action plans to reduce hospitalizations for chronic obstructive pulmonary disease exacerbations: focus on oral corticostaroids. Curr Med Res Opin. 2014;30:2607-15. doi: 10.1159/000477911
8. Connors AF Jr, Dawson NV, Thomas C, Harrell FE Jr, Desbiens N, et al. Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risk Treatments). Am J Respir Crit Care Med. 1996;154:959-67. doi: 10.1164/ajrccm.154.4.8887592
9. Tokgoz Akyil F, Gunen H, Agca M, Gungor S, Yalcinsoy M, Sucu P, Akyil M, Sevim T. Patient outcome after chronic obstructive pulmonary disease exacerbations requiring noninvasive ventilation during hospitalization. Arch Bronconeumol. 2016;52(9):470-6. doi: 52:470-476.10.1016/j.arbres.2016.01.021
10. Atsou K, Chouaid C, Hejblum G. Variability of the chronic obstructive pulmonary disease key epidemiological data in Europe: systematic review. BMC Med. 2011;9:7. doi: 10.1186/1741-7015-9-7
11. Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Resp J. 2017;50:1602426. doi: 10.1183/13993003.02426-2016
12. Hartl S. The European COPD Audit: a pilot experience of 16 European countries. Pneumonol Alergol Pol. 2012;80:501-4.
13. López-Campos JL, Hartl S, Pozo-Rodríguez F, Roberts CM. European COPD Audit Team European COPD Audit: design, organization of work and methodology. Eur Respir J. 2013;41:270-6. doi: 10.1183/09031936.00021812
14. Roberts CM, López-Campos JL, Pozo-Rodríguez F, Hartl S. European COPD Audit Team European hospital adherence to GOLD recommendations for chronic obstructive pulmonary disease (COPD) exacerbation admissions. Thorax. 2013;68:1169-71. doi: 10.1136/thoraxjnl-2013-203465
15. British Thoracic Society Standards of Care Committee; Non-invasive ventilation in acute respiratory failure. Thorax. 2002;57:192-211. doi: 10.1136/thorax.57.3.192
16. [Avdeev SN. Noninvasive ventilation in patients with chronic obstructive illness in the hospital and at home. Pulmonologiya. 2017;27(2):232-49 (In Russ.)]. doi: 10.18093/0869-0189-2017-27-2-232-249
17. Wedzicha JA, Miravitles M, Hurst JR, Calverley PM, Albert RK, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2017;49:1600791. doi: 10.1183/13993003.00791-2016
18. Schuetz P, Briel M, Christ-Crain M, Stolz D, Bouadma L, et al. Procalcitonin to guide initiation and duration of antibiotic treatment in acute respiratory infections: an individual patient data meta-analysis. Clin Infect Dis. 2012;55:651-62. doi: 10.1093/cid/cis464
19. Stolz D, Christ-Crain M, Bingisser R, Leuppi J, Miedinger D, Muller C, et al. Antibiotic treatment of exacerbations of COPD; a randomized, controlled trial comparing procalcitonin-guidance with standard therapy. Chest. 2007;131:9-19. doi: 10.1378/chest.06-1500
20. Ford PA, Durham AL, Russell RE, Gordon F, Adcock IM. Treatment effects of low-dose theophylline combined with an inhaled corticosteroid in COPD. Chest. 2010;137:1338-44. doi: 10.1378/chest.09-2363
21. Zhang WH, Zhang Y, Cui YY, Rong WF, Cambier C, et al. Can β2-adrenoreceptor agonists, anticholinergic drugs, and theophylline contribute to the control of pulmonary inflammation and emphysema in COPD? Fundam Clin Pharmacol. 2012;26:118-34. doi: 10.1111/j.1472-8206.2011.01007.x
22. Yawn BP. Is “GOLD” standard for the management of COPD in clinical practice? Drugs Context. 2012;2012:212-34. doi: 10.7573/dic.212243
23. Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006;173:1390-413. doi: 10.1164/rccm.200508-1211ST
24. Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011;10:CD005305. doi: 10.1002/14651858.CD005305.pub3
25. Osthoff M, Leuppi JD. Management of chronic obstructive pulmonary disease patients after hospitalization for acute exacerbation. Respiration. 2010;79:255-61. doi: 10.1159/000235721
26. Мещерякова Н.Н. Принципы легочной реабилитации больных хронической обструктивной болезнью легких. Атмосфера. Пульмонология и аллергология. 2013;49:27-31 [Meshcheryakova NN. Principles of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. Atmosfera. Pul'monologiya i Allergologiya. 2013;49:27-31 (In Russ.)].
27. Saleh A, Lopez-Campos JL, Hartl S, Pozo-Rodriguez F, Roberts CM. European COPD Audit Team: The effect of incidental consolidation on management and outcomes in COPD exacerbation: data from the European COPD Audit. PLoS One. 2015;10:0134004. doi: 10.1183/09031936.00021812
28. Poole PJ, Chacko E, Wood-Baker RW, Cates CJ. Influenza vaccine for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;1:CD002733. doi: 10.1002/14651858.CD002733.pub2
29. Van Eerd EA, van der Meer RM, van Schayk OC, Kotz D. Smoking cessation for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016;8:CD010744. doi: 10.1002/14651858.CD010744.pub2
30. Kelly AM, McAlpine R, Kyle E. How accurate are pulse oximeters in patientswith acute exacerbationsof chronic obstructive airways disease? Respir Med. 2001;95(5):336-40. doi: 10.1053/rmed.2001.1046
31. Malatesha G, Singh NK, Bharija A, Rehani B, Goel A. Comparison of arterial and venous pH, bicarbonate, PCO2 and PO2 initial emergency department assessment. Emerg Med J. 2007;24:569-71. doi: 10.1136/emj.2007.046979
32. Bloom BM, Grudlingh J, Bestwick JP, Harris T. The role of venous blood gas in the emergency department: a systematic review and meta-analysis. Eur J Emerg Med. 2014;21:81-8. doi: 10.1097/MEJ.0b013e32836437cf
33. Rea H, Kenealy T, Adair J, Robinson E, Sheridan N. Spirometry for patients in hospital and one month after admission with an acute exacerbation of COPD. Int J Chron Obstruct Pulmon Dis. 2011;6:527-32. doi: 10.1186/1471-2466-12-73
34. Hill K, Goldstein RS, Guyatt GH, et al. Prevalence and underdiagnosis of chronic obstructive pulmonary diseaseamong patients at risk in primary care. CMAJ. 2010;182:673-8. doi: 10.1503/cmaj.091784
35. Higgings BG, Powell RM, Cooper S, Tattersfield AE. Effect of salbutamol and ipratropium bromide on airway calibre and bronchial reactivity in asthma and chronic bronchitis. Eur Respir J. 1991;4:415-20.
36. O’Driscoll BR, Kay EA, Taylor RJ, Weatherby H, Chetty MC, Bernstein A. A long-term prospective assessment of home nebulizer treatment. Respir Med. 1992;86:317-25.
37. Barnes PJ. Theophylline. Am J Respir Crit Care Med. 2013;188:901-6. doi: 10.1164/rccm.201302-0388PP
38. Rossi A, Kristufek P, Levine BE, Thomson MH, Till D, Kottakis J, et al. Comparison of the efficacy, tolerability, and safety of formoterol dry powder and oral, slow-release theophylline in the treatment of COPD. Chest. 2002;121:1058-69.
39. Woods JA, Wheeler JS, Finch CK, Pinner NA. Corticosteroids in the treatment of acute exacerbations of chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2014;9:421-30. doi: 10.2147/COPD.S51012
40. Leuppi JD, Schuetz P, Bingisser R, Bodmer M, Briel M, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA. 2013;309:2223-31. doi: 10.1001/jama.2013.5023
41. Walters JA, Tan DJ, White CJ, Gibson PG, Wood-Baker R, Walters EH. Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2014;9:CD001288. doi: 10.1002/14651858.CD001288.pub4
42. Walters JA, Tan DJ. White CJ, Wood-Baker R. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2014;12:CD006897. doi: 10.1002/14651858.CD006897.pub3
43. Stefan MS, Rothberg MB, Shieh MS, Pekow PS, Lindenauer PK. Association between antibiotic treatment and outcomes in patients hospitalized with acute exacerbation of COPD treated with systemic steroids. Chest. 2013;143:82-90. doi: 10.1378/chest.12-0649
44. Vollenweider DJ, Jarrett H, Steurer-Stey CA, Garcia-Aymerich J, Puhan MA. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;12:CD010257. doi: 10.1002/14651858.CD010257
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1 ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия;
2 ФГБУ «Научно-исследовательский институт пульмонологии» ФМБА России, Москва, Россия;
3 ФГБОУ ВО «Российский научно-исследовательский медицинский университет им. Н.И. Пирогова» Минздрава России, Москва, Россия
________________________________________________
S.N. Avdeev 1,2, N.V. Truschenko 1,2, V.V. Gaynitdinova 1, A.K. Soe 3, G.S. Nuralieva 1,2
1 I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia;
2 Pulmonology Research Institute of Federal Medico-Biological Agency of Russia, Moscow, Russia;
3 N.I. Pirogov Russian National Research Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia