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obstructiva crnica
a Servei de Neumologia.
Artculo
Presentacin
Concepto y definiciones
Gravedad de la EPOC
Los lmites aqu propuestos son arbitrarios y tienen un carcter emprico, dado
que no existen evidencias que los apoyen, aunque se corresponden con los
establecidos por otras sociedades7. La presente divisin tiene por objetivo
facilitar las recomendaciones sobre las pautas de tratamiento y el empleo de
los recursos sanitarios.
Epidemiologa
Evaluacin
En los pacientes con EPOC leve puede haber pocos sntomas e incluso no
existir. En ocasiones la historia de tos matutina, las infecciones respiratorias
recurrentes o la disnea en los esfuerzos moderados pueden alertar acerca de la
existencia de la enfermedad. La exploracin funcional sistemtica, sobre todo
en fumadores o personas con exposicin laboral, puede identificar la
enfermedad en sus primeras fases. Los pacientes con EPOC grave s suelen
presentar sntomas: tos y produccin de esputo, disnea con el ejercicio
moderado o con las actividades laborales y empeoramiento agudo de los
sntomas asociado a una exacerbacin. Los pacientes con EPOC grave suelen
presentar disnea progresivamente invalidante, complicaciones asociadas
(edema perifrico, cor pulmonale) y episodios de exacerbacin aguda, con o
sin insuficiencia respiratoria.
Los signos de la exploracin fsica son poco expresivos en la enfermedad levemoderada. En la EPOC grave la espiracin alargada (superior a 5 s) y la
presencia de sibilancias son signos inespecficos de obstruccin bronquial,
aunque el grado de obstruccin al flujo areo no puede predecirse por los
signos o los sntomas39. En la EPOC grave existen signos ms llamativos y
persistentes: insuflacin crnica del trax, presencia de roncus en la espiracin
forzada, disminucin del murmullo vesicular, prdida progresiva de peso,
cianosis central, temblor y somnolencia en relacin con la hipercapnia en las
Medicin de flujo pico. til slo si se pretende medir de forma repetida para
descartar asma bronquial.
Exmenes radiolgicos
Otros exmenes
Fig. 1. Atencin clnica coordinada de los pacientes con EPOC entre los niveles
de atencin primaria y especializada, en funcin de la gravedad de la
enfermedad.
Medidas generales
Tratamiento farmacolgico
Broncodilatadores
Glucocorticoides
Estudios no controlados han puesto de manifiesto que el uso de alfa-1antitripsina purificada puede ser de inters en pacientes con fenotipo
homocigoto PiZZ que cursan con enfisema pulmonar y ttulos de alfa-1antitripsina sricos bajos97. Existen registros nacionales e internacionales
dirigidos a evaluar la eficacia clnica del tratamiento sustitutivo con alfa-1antitripsina98. Del anlisis de algunos de ellos se desprende que el tratamiento
sustitutivo posee un efecto beneficioso leve99,100. Sin embargo, tambin se
han descrito evoluciones muy desfavorables a pesar del tratamiento101. Las
evidencias cientficas que apoyan la utilidad de este tratamiento todava son
insuficientes y su coste econmico es muy elevado, por lo que no puede
recomendarse su empleo generalizado en todos los pacientes.
Otros tratamientos
Rehabilitacin
Indicaciones
En nuestro medio son escasos los servicios neumolgicos que disponen de este
tipo de programas, por lo que la posibilidad de ofrecer programas de
rehabilitacin a los pacientes con EPOC es reducida.
Cuidados domiciliarios
Oxigenoterapia
Indicaciones
En los pacientes que cumplan criterios de OCD y realicen una vida activa es
aconsejable utilizar sistemas porttiles de oxgeno lquido que permitan el
suministro durante el esfuerzo, a fin de facilitar el cumplimiento durante el
mayor nmero de horas posible y permitir la deambulacin.
Otras indicaciones
La PaO2 empeora durante los viajes en avin por la menor presin de las
cabinas. La repercusin clnica de este fenmeno no se conoce. Sin embargo,
en los pacientes en programa de OCD, especialmente durante los viajes de
larga duracin, es conveniente proporcionar oxgeno durante el trayecto131. A
tal efecto es preciso comunicar con antelacin dicha necesidad a la compaa
area para preverlo. La situacin de EPOC inestable y la presencia de quistes o
bullas contraindican el viaje en avin, pues estas condiciones empeoran con los
cambios de presin.
Tratamientos quirrgicos
Trasplante pulmonar
4. Potencial de rehabilitacin.
Bullectoma
Cuidados perioperatorios
Definicin de exacerbacin
Etiologa
agente causal est mal definido, pero puede guardar relacin con la exposicin
a contaminacin atmosfrica, polvo, vapores o humos159,160.
Tratamiento extrahospitalario
Tratamiento broncodilatador
Tratamiento antibitico
Glucocorticoides
Tratamiento hospitalario
Tratamiento farmacolgico
Dentro del estudio del paciente con una exacerbacin de la EPOC en la unidad
de urgencias hospitalaria ser aconsejable la realizacin de un hemograma, un
ECG y una radiografa de trax, as como la determinacin plasmtica de urea,
creatinina, iones y glucemia. Asimismo, es aconsejable la recogida de una
muestra de esputo para cultivo antes de iniciar el tratamiento antibitico.
Criterios de hospitalizacin
tipo venturi que con "gafas" nasales175. Por tanto, se recomienda el empleo de
mascarillas tipo venturi en el tratamiento de la IRA en la EPOC.
Agradecimientos
Los miembros del grupo de trabajo que ha redactado esta Gua Clnica
agradecen la revisin del manuscrito y los valiosos comentarios realizados por
B. Celli, M.G. Coso, J. Morera, R. Rodrguez-Roisin, L. Snchez-Agudo y V.
Sobradillo.
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