Asma en Ancianos

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Enfermedades Respiratorias Obstructivas en el Adulto Mayor Dr. Alfredo Guerreros Benavides HNDAC Clínica Internacional

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Asma en ancianos

Transcript of Asma en Ancianos

  • Enfermedades Respiratorias Obstructivas en el Adulto MayorDr. Alfredo Guerreros BenavidesHNDACClnica Internacional

  • Aumento de la Expectativa de Vida e Impacto GlobalGlobal Burden Disease. Murray y LpezPases desarrollados : disminucin 25% menores de 15 ,incremento 71% mayores de 65.Pases en desarrollo incremento 25% menores de 15 e incremento 140% 45 a 59.Poblaciones Espaa e Italia 80 a 105 aos.Japn 2002: 17,934 personas de 100 aos.

  • Cambios FisiolgicosDisminucin de la compliance de la pared torcica y el sistema respiratorio,as como del retroceso elstico resultan en atrapamiento areo ( incremento de VR ).Incremento de la CRF y del trabajo respiratorio.Afeccin de la musculatura respiratoria,cambios en la geometra de la caja torcica,estado nutricional, funcin cardaca : sarcopenia.>80 aos :PIM valores crticos bajos, hipoventilacin alveolar.

  • Cambios FisiolgicosDisminuyen las tasas de PEF , y las curvas flujo-volumen sugieren colapso de la va area perifrica.El intercambio gaseoso es remarcablemente mejor conservado en reposo y durante el ejercicio a expensas de reducir la superficie alveolar e incrementar el desequilibrio ventilo-perfutorio.Disminucin de la sensibilidad de los centros respiratorios a la hipoxemia e hipercapnia, puede resultar en rpta. ventilatoria disminuda en enfermedad aguda o agravar la obstruccin de la va area.

  • Asma en AncianosPor muchos aos considerada enfermedad de nios y jvenes e infrecuente en la ancianidad.Los Asmticos ancianos generalmente son aqullos que adquirieron la enfermedad en la niez o la adolescencia ,en quienes la enfermedad progres en el tiempo o se reactiv despus de perodos de remisin; sin embargo las primeras manifestaciones de asma pueden ocurrir tambin despus de los 65 aos de edad.

  • Asma en AncianosLa presuncin de baja prevalencia puede atribuirse a las grandes dificultades para encontrar un diagnstico correcto en el geronte.Las razones por la que el Asma no es diagnosticado en al adulto mayor , no estn claras.Confusin de sntomasSubestimados por el mdicoFalta de evaluacin funcional apropiada.PUEDE DEBERSE A LA CONFUSION CON EPOC

  • EpidemiologaPuede ser diagnosticada a cualquier edad y es comn en el anciano.Una serie de estudios poblacionales han expuesto que la prevalencia de asma en ancianos es similar a la de otros grupos etreos 4.5-8%.Diagnosticados como nuevos 0.1% por encima de los 65 aos de edad.

  • Asma en el GerontePuede clasificarse en :Asma de inicio tardo aparicin de novo despus de los 65 aos.Asma de comienzo temprano, contina una enfermedad que comenz antes de los 65 aos.La relevancia de sta clasificacin es que la enfermedad puede ser severa en persistentes crnicos.

  • Asma en AncianoDiagnsticoConsiderar en todo caso de :Disnea inexplicadaSibilanciasTos nocturna.( Nivel de Evidencia III ).Revisin cuidadosa en debut reciente :MedicacinASA , AINES ( Nivel de Evidencia II ).

  • Asma en AncianoDiagnsticoPuede complicarse por diversos factores ,tales como:Sntomas no especficos, comunes a otras patologas.La presencia de enfermedades coexistentes.Diferenciacin con EPOCAlteraciones en la percepcin de los sntomas en ancianosMenor incidencia de asma y atopa en la tercera edad.

  • Asma en AncianoDiagnsticoLos tests de funcin pulmonar tienen un rol muy importante y son fundamentales.Espirometra.Problemas de comprensin y de pobre coordinacin afectan sus resultados.

  • Asma en AncianoDiagnsticoHistoria Clnica minuciosa.Laboratorio.Radiografa de trax frente y perfil.Electrocardiograma.Espirometra.Establecer diagnsticos diferenciales.Puntualizar patologas subyacentes:terapeticas, dosis, vas, etc.

  • Planes de TratamientoConsideraciones EspecialesDisminucin de la respuesta a estmulos especialesTrastornos de la memoriaPrdida de la coordinacin y la fuerza muscular que afecta el uso de algunos dispositivos inhalatorios.Dificultades visuales y auditivasDificultades del sueo que pueden afectar la esfera cognitivaTrastornos depresivosEleccin de la medicacin personalizada.

  • Diagnstico DiferencialFalla ventricular IzquierdaCncer pulmonarReflujo GastroesofgicoFibrosis PulmonarBronquiectasiasTromboembolismo PulmonarTuberculosis.

  • Consideraciones Especiales del Manejo TerapeticoPacientes polimedicados, mayor cantidad de reacciones adversas e interacciones medicamentosas.Tener en cuenta para las dosis, integridad de la funcin heptica y renal , para evitar eventos adversos por la metabolizacin o excrecin de las drogas.

  • Objetivos del manejoPrevenir sntomas de asma crnicaOptimizar la funcin pulmonarMantener los niveles de actividad normalMinimizar los efectos colaterales de la medicacinReducir o eliminar las exacerbaciones y reconocerlas tempranamenteEvitar el agravamiento de las patologas subyacentes.

  • EVENTOS ADVERSOSBeta 2 agonistas:Isquemia miocrdicaArritmiasHipotensinTremorHipokalemiaBroncoespasmo paradojal.

  • EVENTOS ADVERSOSTeofilina:Nuseas y vmitosArritmiasInsomnioNiveles incrementados en enfermedad heptica, interacciones con quinolonas,ketoconazol,macrlidos, antihistamnicos.

  • EVENTOS ADVERSOSCorticoides Sistmicos:HTA,edemas,falla cardaca, arritmias.HiperglicemiaUremiaMiopataCataratas subcapsularHipoadrenalismoAlteracin de la funcin cognitiva,depresin.Psicosis, mana.Osteoporosis.GlaucomaAgravamiento de lcera ppticaAtrofia drmica

  • Step 1 As-needed reliever medicationPatients with occasional daytime symptoms of short durationA rapid-acting inhaled 2-agonist is the recommended reliever treatment (Evidence A)When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher)Treating to Achieve Asthma Control

  • Step 2 Reliever medication plus a single controllerA low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages (Evidence A)Alternative controller medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroidsTreating to Achieve Asthma Control

  • Step 3 Reliever medication plus one or two controllersFor adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting 2-agonist either in a combination inhaler device or as separate components (Evidence A) Inhaled long-acting 2-agonist must not be used as monotherapy For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A)Treating to Achieve Asthma Control

  • Additional Step 3 Options for Adolescents and Adults Increase to medium-dose inhaled glucocorticosteroid (Evidence A)Low-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)Low-dose sustained-release theophylline (Evidence B)Treating to Achieve Asthma Control

  • Step 4 Reliever medication plus two or more controllersSelection of treatment at Step 4 depends on prior selections at Steps 2 and 3Where possible, patients not controlled on Step 3 treatments should be referred to a health professional with expertise in the management of asthmaTreating to Achieve Asthma Control

  • Step 4 Reliever medication plus two or more controllersMedium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled 2-agonist (Evidence A)Medium- or high-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)Low-dose sustained-release theophylline added to medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled 2-agonist (Evidence B)Treating to Achieve Asthma Control

  • Treating to Achieve Asthma ControlStep 5 Reliever medication plus additional controller optionsAddition of oral glucocorticosteroids to other controller medications may be effective (Evidence D) but is associated with severe side effects (Evidence A)Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications (Evidence A)

  • Treating to Maintain Asthma ControlWhen control as been achieved, ongoing monitoring is essential to: - maintain control - establish lowest step/dose treatment Asthma control should be monitored by the health care professional and by the patient

  • Treating to Maintain Asthma ControlStepping down treatment when asthma is controlledWhen controlled on medium- to high-dose inhaled glucocorticosteroids: 50% dose reduction at 3 month intervals (Evidence B)When controlled on low-dose inhaled glucocorticosteroids: switch to once-daily dosing (Evidence A)

  • Treating to Maintain Asthma ControlStepping down treatment when asthma is controlledWhen controlled on combination inhaled glucocorticosteroids and long-acting inhaled 2-agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting 2-agonist (Evidence B)If control is maintained, reduce to low-dose inhaled glucocorticosteroids and stop long-acting 2-agonist (Evidence D)

  • Treating to Maintain Asthma ControlStepping up treatment in response to loss of controlRapid-onset, short-acting or long-acting inhaled 2-agonist bronchodilators provide temporary relief.Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy

  • Treating to Maintain Asthma ControlStepping up treatment in response to loss of controlUse of a combination rapid and long-acting inhaled 2-agonist (e.g., formoterol) and an inhaled glucocorticosteroid (e.g., budesonide) in a single inhaler both as a controller and reliever is effecting in maintaining a high level of asthma control and reduces exacerbations (Evidence A)Doubling the dose of inhaled glucocortico-steroids is not effective, and is not recommended (Evidence A)

  • Asthma Management and Prevention ProgramComponent 3: Assess, Treat and Monitor Asthma Children 5 Years and Younger Childhood and adult asthma share the same underlying mechanisms. However, because of processes of growth and development, effects of asthma treatments in children differ from those in adults.

  • Asthma Management and Prevention ProgramComponent 3: Assess, Treat and Monitor Asthma Children 5 Years and Younger Many asthma medications (e.g. glucocorticosteroids, 2- agonists, theophylline) are metabolized faster in children than in adults, and younger children tend to metabolize medications faster than older children

  • Asthma Management and Prevention ProgramComponent 3: Assess, Treat and Monitor Asthma Children 5 Years and YoungerLong-term treatment with inhaled glucocorticosteroids has not been shown to be associated with any increase in osteoporosis or bone fractureStudies including a total of over 3,500 children treated for periods of 1 13 years have found no sustained adverse effect of inhaled glucocorticosteroids on growth

  • Asthma Management and Prevention ProgramComponent 3: Assess, Treat and Monitor Asthma Children 5 Years and YoungerRapid-acting inhaled 2-agonists are the most effective reliever therapy for childrenThese medications are the most effective bronchodilators available and are the treatment of choice for acute asthma symptoms

  • Asthma Management and Prevention ProgramComponent 4: Manage Asthma ExacerbationsExacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightnessExacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)Severe exacerbations are potentially life-threatening and treatment requires close supervision

  • Asthma Management and Prevention ProgramComponent 4: Manage Asthma ExacerbationsTreatment of exacerbations depends on:The patientExperience of the health care professionalTherapies that are the most effective for the particular patientAvailability of medicationsEmergency facilities

  • Asthma Management and Prevention ProgramComponent 4: Manage Asthma ExacerbationsPrimary therapies for exacerbations:Repetitive administration of rapid-acting inhaled 2-agonistEarly introduction of systemic glucocorticosteroidsOxygen supplementationClosely monitor response to treatment with serialmeasures of lung function

  • Asthma Management and Prevention ProgramSpecial ConsiderationsSpecial considerations are required tomanage asthma in relation to:PregnancySurgeryRhinitis, sinusitis, and nasal polypsOccupational asthmaRespiratory infectionsGastroesophageal refluxAspirin-induced asthmaAnaphylaxis and Asthma

  • Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptomsAlthough there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of controlAsthma Management and Prevention Program: Summary

  • Asthma Management and Prevention Program: SummaryA stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication

    The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered

  • EPOC y Asma en AncianosComparten similitudes clnicas y funcionalesPresentaciones patolgicas diferentes : dos enfermedades distintas.No se puede excluir la coexistencia de ambas enfermedades.Importante reconocerlas y distinguirlas tempranamente para el tratamiento apropiado.

  • PREVENCION DE LA MORTALIDAD EN EPOCCesacin de FumarVacunacin InfluenzaOxigenoterapia a largo plazoTratamiento Farmacolgico de la EPOCTratamiento Farmacolgico de comorbilidadesTratamiento de las exacerbacionesNUEVOS TRATAMIENTOS PARA EPOC Y ENFERMEDADES CRONICOS.

  • EPOC es la unica causa de muerte que se ha incrementado significativamente en los ltimos aos.Adapted from: www.copdgold.com596435+1637804004080120160ECAStrokeECVEPOCTodas las otras causasCambio en edad ajustado a tasa de muerteen USA, de 1965 a 1998 (%)

  • EPOC est proyectado a ser el tercer ms grande asesino para el 2020Murray & Lopez 1997Enf. Isqumica cardacaEnfermedad CVD Infeccin RespiratoriaEnfermedad DiarreicaDesrdenes Perinatales EPOCTuberculosisMeaslesAccidentes de trnsitoCncer PulmonarCancer de EstmagoHIVSuicidio199020203ro6to

  • 20%-24%(1 ao)2.5%-10%(5 das)22%-32%(14 das)13%-33%(14 das)Mortalidad HospitalariaMortalidad HospitalariaRecadaTasa de falla al tratamientoResultados de las Exacerbaciones de la EPOCSeneff et al. JAMA. 1995; 274:1852-1857; Murata et al. Ann Emerg Med. 1991;20:125-129; Adams et al. Chest. 2000; 117:1345-1352; Patil et al. Arch Int Med. 2003; 163:1180-1186.En pacientes HospitalizadosEn pacientes en EmergenciaEn pacientes UCIAmbulatorios

  • EPOC versus edadSPMXMNSANTCARAC40-4950-59>=602618323023p < 0,001

  • TABACO EN EL PER:MAGNITUD DEL PROBLEMA

    Se estima que aproximadamente 8000,000 de peruanos ha probado tabaco

    1000,000 de fumadores

    500,000 dependientes de tabaco

    50,000 adolescentes se inician como fumadores cada ao

    MINISTERIO DE SALUD PER / NOTABACO CENTER PER / DEVIDA 2002

  • TABACO EN EL PERU:MAGNITUD DEL PROBLEMA

    Proporcin varn / mujer 3/1

    En menores de 18 aos la proporcin es 2/1

    40% de la poblacin peruana ha tenido exposicin involuntaria a humo de tabaco

    PLAN NACIONAL PARA PREVENCION Y CONTROL DE TABAQUISMO EN EL PERU 2001-2005. MINSA / COLAT/ OPS 2001. DEVIDA

  • Estudio Prepocol EPOC en Colombia Anlisis de multivarianza (5.539 adultos)Caballero A. et al. Arch Bronconeumol 2004; 40(4):20

    VariablesOdds ratioIC95%Valor de p EDAD ( 60 aos vs < 60 aos)3.743.01- 4.64

  • Incidence of COPD by ageJohannesen A, ERJ 2002

  • Estimated cumulative 9 years incidence and adjusted odds ratios of COPD in Bergen, Norway* Adjusted for gender, age and smoking habits.

  • Prevalence of COPD by age and smokingLindberg A, Respir Med 2005

  • Rasgos Sistmicos del EPOCStress Oxidativo Sistmico. Incremento de los niveles plasmticos de citoquinas pro inflamatoriasClulas inflamatorias circulantes.Mecanismos de Inflamacin Sistmica.

  • Metas del Manejo de EPOCPrevenir la progresin de la enfermedadAliviar sntomasMejorar la tolerancia al ejercicioMejorar el estado de saludPrevenir y tratar las complicacionesPrevenir y tratar las exacerbacionesReducir la mortalidadPrevenir o minimizar los efectos colaterales del tratamientoAdapted from the GOLD Workshop Report 2003

  • SINTOMASTosEsputoDisneaEXPOSICION A FACTORES DE RIESGOTabacoOcupacinPolucinESPIROMETRIAEPOC: Diagnstico

  • Clasificacin de severidadEstadioCaractersticas0: At riskNormal spirometryChronic symptoms (cough, sputum)I: LeveFEV1/FVC < 70%; FEV1 80% predictedWith or without symptoms (cough, sputum) II: ModeradoFEV1/FVC < 70%; 30% FEV1 < 80% predicted (IIA: 50% FEV1 < 80% predicted;IIB: 30% FEV1 < 50% predicted) With or without chronic symptoms (cough, sputum, dyspnea) III: SeveroFEV1/FVC < 70%; FEV1 < 30% predicted or FEV1 < 50%predicted plus respiratory failure or clinical signs of right heart failure

  • EPOC: ManejoCese definitivo del consumo de cigarrilloEvitar la exposicin pasivaEvaluacin ocupacionalManejo psicolgico

  • EPOC: ManejoUso de broncodilatadores; beta-2 agonistas, anticolinrgicos,teofilina y combinaciones.Terapia inhalatoria es preferiblePriorizar uso de beta-2 agonistas de larga accin (vg. Formoterol, salmeterol)Individualizar la terapiaEvaluar uso de corticosteroides y de antibiticos

  • EPOC: ManejoLa administracin de oxgeno (> 15 horas/da) mejora la supervivencia.Ejercicios respiratoriosVacuna anti-influenzaManejo de las complicaciones

  • EPOC: Manejo Estadio 0 Caracteristicas Terapia recomendada Sntomas crnicos - Tos- Esputo Sin anormalidad espiromtricaMedidas generalesSintomticos

  • EPOC: Manejo Estadio I: EPOC leve Caracteristicas Terapia recomendada FEV1/FVC < 70 % FEV1 > 80 % predicted With or without symptoms Beta-2 agonistas de accin rpida

  • EPOC: Manejo Estadio IIA: EPOC moderado Caracteristicas Terapia recomendadaFEV1/FVC < 70%50% < FEV1< 80% prefijadoUno o ms broncodilatadoresRehabilitacinCorticosteroides inhalatorios segn respuestaCon o sin sntomas

  • EPOC: Manejo Estadio IIB: EPOC moderado Caracteristicas Terapia recomendadaFEV1/FVC < 70%30% < FEV1 < 50% prefijadoCon o sin sntomasUno o ms broncodilatadoresRehabilitacinCorticosteroides inhalatorios

  • EPOC: Manejo Estadio III: EPOC Severo Caracteristicas Terapia recomendada

    FEV1/FVC < 70%FEV1 < 30% prefijado o falla cardiaca o falla respiratoriaUso regular de broncodilatadores y de corticosteroidesTratar complicacionesRehabilitacinOxigenoterapiaConsiderar ciruga

  • EPOC: EXACERBACINTos productiva, fiebre, disneaSe benefician con antibiticosMayor riesgo de neumonaDeben hospitalizarse (Rayos-X, gasometra)

    ***********These data from the USA, collected from 1965 to 1998, show a 163% increase in age-adjusted death rates from chronic obstructive pulmonary disease (COPD). While the death rate is declining from diseases such as coronary heart disease (CHD) (a 59% decrease) and cerebrovascular disease (CVD) (a 35% decrease), the death rate from COPD is increasing markedly. All other causes of age-adjusted US deaths also saw a decline of 7%. It may that this is partly a feature of increased recognition of COPD including an increase in the mention of the term on death certificates, but this does not detract from the overall trends illustrated in the figure.The Global Burden of Disease (GBD) study attributed more than 2.2 million deaths to COPD in 1990 (4.4% of worldwide deaths), ranking COPD as the sixth most serious cause of worldwide mortality.1 Furthermore, the 2004 World Health Organization (WHO) report indicated that COPD deaths are on the increase, with over 2.7 million deaths (4.8%) in 2002.2 Even more concerning, COPD deaths are projected to rise to third place in the worldwide ranking with 4.5 million deaths in 2020.1The 2004 American Lung Association Report estimated approximately 120,000 deaths in the USA in 2002.3The European Lung White Book, the first comprehensive survey on respiratory health in Europe, estimated annual COPD mortality in Europe as 200,000300,000.4

    ReferencesMurray CJ, Lopez AD. Alternative projections of mortality and disability by cause 19902020: Global Burden of Disease Study. Lancet 1997;349:1498504.World Health Organization. The World Health Report: Changing History. 2004.American Lung Association Epidemiology and Statistics Unit Research and Scientific Affairs. Trends in Chronic Bronchitis and Emphysema: Morbidity and Mortality. November 2004.European Lung White Book: The First Comprehensive Survey on Respiratory Health in Europe. Editor in chief R Loddenkemper. ERSJ Ltd. 2003;3443.*As part of the Global Burden of Disease Study, Murray and Lopez1 projected future mortality rates based on the most common causes of death in 1990. The top 10 most important causes of death are presented in this slide. The majority of these leading causes of deaths are projected to remain stable or decline.Notably, COPD is expected to rise from the sixth biggest killer in 1990 to the third in 2020. Of the top 10 leading causes of death in 1990, only deaths caused by COPD, lung cancer and road traffic accidents are projected to rise.

    ReferenceMurray CJ, Lopez AD. Alternative projections of mortality and disability by cause 19902020: Global Burden of Disease Study. Lancet 1997;349:1498504.*Treatment failure is defined as not responsive to initial treatment(s).Outcomes = health utilizations.This slide shows outcomes of patients with acute exacerbations: 20-24% of patients in the ICU with an exacerbation died; 6-12% of patients in general hospital beds, not ICU beds, died. Of those who visited the ER for an acute exacerbation, 22-32% of those patients had to revisit the emergency room after being discharged. Those who were treated as outpatients 13-33% of those patients did not response to initial treatments and needed further medical intervention. Main point: Acute exacerbations are a serious matter and should be of concern to the health care provider. Seneff MG, Wagner DP, Wagner RP, Zimmerman JE, Knaus WA. Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease. JAMA. 1995;274:1852-857.Murata GH, Gorby MS, Chick TW, Halperin AK. Treatment of decompensated chronic obstructive pulmonary disease in the emergency departmentcorrelation between clinical features and prognosis. Ann Emerg Med. 1991;20:125-129.Adams SG, Melo J, Luther M, Anzueto A. Antibiotics are associated with lower relapse rates in outpatients with acute exacerbations of COPD. Chest. 2000;117:1345-1352.Patil SP, Krishnan JA, Lechtzin N, Diette GB. In-hospital mortality following acute exacerbations of chronic obstructive pulmonary disease. Arch Int Med. 2003; 160:1180-1186.

    ***The key goals of COPD treatment are included in the GOLD guidelines.

    GOLD: Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NIH publication No. 2701, March 2001.