Η Χρόνια Αποφρακτική Πνευμονοπάθεια (ΧΑΠ) είναι μια νόσος των πνευμόνων, κατά την οποία η στένωση των βρόγχων προκαλεί δυσκολία στην αναπνοή. Κύρια αιτία της παραμένει το κάπνισμα, ενεργητικό και παθητικό, η ατμοσφαιρική ρύπανση και το ιστορικό λοιμώξεων στην παιδική ηλικία.
Στη χώρα μας, που πάνω από το 50% των ενηλίκων είναι καπνιστές, μελέτη της Πνευμονολογικής Εταιρείας, έδειξε ότι 800.000 Έλληνες πάσχουν από τη νόσο, με τους μισούς από αυτούς να μην το γνωρίζουν.
Ο πρωινός βήχας των καπνιστών θα πρέπει στο εξής να θεωρείται νόσος, αναφέρει ο Παγκόσμιος Οργανισμός Υγείας (ΠΟΥ), με αφορμή την Παγκόσμια Ημέρα κατά της Χρόνιας Αποφρακτικής Πνευμονοπάθειας (ΧΑΠ).
Η Παγκόσμια Ημέρα κατά της Χρόνιας Αποφρακτικής Πνευμονοπάθειας γιορτάζεται κάθε χρόνο την τρίτη Τετάρτη του Νοεμβρίου από την «Παγκόσμια Πρωτοβουλία κατά της ΧΑΠ», που συσπειρώνει στους κόλπους της οργανώσεις γιατρών και ασθενών, και υπό την αιγίδα της Π.Ο.Υ.
Η χρόνια αποφρακτική πνευμονοπάθεια (ΧΑΠ)
Η Χρόνια Αποφρακτική Πνευμονοπάθεια (ΧΑΠ) δεν είναι μία ασθένεια, αλλά ένας γενικός όρος που χρησιμοποιείται για να περιγράψει χρόνιες πνευμονικές παθήσεις που περιορίζουν τη ροή του αέρα στους πνεύμονες. Οι πιο οικείοι όροι «Χρόνια βρογχίτιδα» και «εμφύσημα», δεν χρησιμοποιούνται πλέον, αλλά περιλαμβάνονται στη γενικότερη διάγνωση της χρόνιας αποφρακτικής πνευμονοπάθειας.
Τα πιο συνηθισμένα συμπτώματα της ΧΑΠ είναι η δύσπνοια, η ανάγκη για αέρα, η υπερβολική παραγωγή πτυέλων, και ο χρόνιος βήχας. Ωστόσο, η ΧΑΠ δεν είναι απλώς ο «βήχας του καπνιστή», αλλά μια απειλητική για τη ζωή ασθένεια των πνευμόνων που μπορεί σταδιακά να οδηγήσει σε θάνατο και που δε διαγιγνώσκεται πάντα σωστά.
Οι κύριοι παράγοντες κινδύνου για ΧΑΠ:
- Το κάπνισμα
- Η εσωτερική ρύπανση του αέρα (όπως καύσιμα από βιομάζα που χρησιμοποιούνται για μαγείρεμα και θέρμανση)
- Η ατμοσφαιρική ρύπανση
- Οι επαγγελματικές σκόνες και τα χημικά
Σύμφωνα με τις εκτιμήσεις του Παγκόσμιου Οργανισμού Υγείας (ΠΟΥ), 65 εκατομμύρια άνθρωποι έχουν μέτρια έως σοβαρή χρόνια αποφρακτική πνευμονοπάθεια (ΧΑΠ). Περισσότεροι από 3 εκατομμύρια άνθρωποι πέθαναν από ΧΑΠ το 2005, το οποίο αντιστοιχεί στο 5% του συνόλου των θανάτων παγκοσμίως. Οι περισσότερες από τις διαθέσιμες πληροφορίες σχετικά με τη Χρόνια Αποφρακτική Πνευμονοπάθεια, τη νοσηρότητα και τη θνησιμότητα της, προέρχεται από χώρες υψηλού εισοδήματος. Ακόμη και σε αυτές τις χώρες, είναι δύσκολο και δαπανηρό να συλλεχθούν ακριβή επιδημιολογικά δεδομένα σχετικά με τη ΧΑΠ. Είναι γνωστό όμως ότι σχεδόν το 90% των θανάτων από ΧΑΠ συμβαίνουν σε χώρες χαμηλού και μεσαίου εισοδήματος.
Κάποτε, η ΧΑΠ ήταν πιο συχνή στους άνδρες, αλλά λόγω της αύξησης του καπνίσματος των γυναικών στις χώρες με υψηλά εισοδήματα και το μεγαλύτερο κίνδυνο έκθεσης σε εσωτερική ατμοσφαιρική ρύπανση (όπως καύσιμα από βιομάζα που χρησιμοποιούνται για μαγείρεμα και θέρμανση) στις χώρες με χαμηλό εισόδημα , η ασθένεια πλήττει σήμερα τους άνδρες και τις γυναίκες σχεδόν εξίσου.
Το 2002 η ΧΑΠ ήταν η πέμπτη κυριότερη αιτία θανάτου. Το σύνολο των θανάτων από ΧΑΠ προβλέπεται να αυξηθούν κατά περισσότερο από 30% μέσα στα επόμενα 10 χρόνια, εκτός αν δεν ληφθούν άμεσα μέτρα για τη μείωση των παραγόντων κινδύνου, ιδιαίτερα για το κάπνισμα. Οι εκτιμήσεις δείχνουν ότι η ΧΑΠ γίνεται το 2030 η τρίτη κυριότερη αιτία θανάτου παγκοσμίως.
Αιτίες της ΧΑΠ
Κάπνισμα
Η κύρια αιτία της χρόνιας αποφρακτικής πνευμονοπάθειας (ΧΑΠ) είναι το κάπνισμα (συμπεριλαμβανομένου και του παθητικού καπνίσματος). Ο ΠΟΥ εκτιμά ότι το 2005 5,4 εκατ. άνθρωποι έχασαν τη ζωή τους λόγω της χρήσης καπνού. Οι θάνατοι που σχετίζονται με το κάπνισμα προβλέπονται να αυξηθούν στους 8,3 εκατομμύρια θανάτους ετησίως έως το 2030.
Άλλοι παράγοντες κινδύνου
Στις υψηλού και μεσαίου εισοδήματος χώρες ,όπως προαναφέραμε, το κάπνισμα είναι ο μεγαλύτερος παράγοντας κινδύνου, ενώ αντιθέτως στις χαμηλού εισοδήματος χώρες, η έκθεση στην εσωτερική ατμοσφαιρική ρύπανση, όπως η χρήση καυσίμων βιομάζας για μαγείρεμα και θέρμανση, είναι η κύρια αιτία εμφάνισης ΧΑΠ στον πληθυσμό.
Σχεδόν 3 δισεκατομμύρια άνθρωποι σε όλο τον κόσμο χρησιμοποιούν βιομάζα και κάρβουνο ως κύρια πηγή ενέργειας για το μαγείρεμα, τη θέρμανση, και τις άλλες ανάγκες του νοικοκυριού. Σε αυτές τις κοινότητες, η εσωτερική ατμοσφαιρική ρύπανση αποτελεί μεγαλύτερο ρίσκο εμφάνισης ΧΑΠ από ότι το κάπνισμα ή η ατμοσφαιρική ρύπανση.
Τα καύσιμα από βιομάζα που χρησιμοποιούνται από τις γυναίκες για το μαγείρεμα στις περιοχές της Μέσης Ανατολής, της Αφρικής και της Ασίας είναι η κύρια αιτία για εμφάνιση ΧΑΠ σε γυναίκες που δεν καπνίζουν. Η εσωτερική ρύπανση του αέρα που προκύπτει από την καύση του ξύλου και άλλα καύσιμα βιομάζας εκτιμάται ότι σκοτώνει δύο εκατομμύρια γυναίκες και παιδιά κάθε χρόνο.
Άλλες αιτίες εμφάνισης ΧΑΠ είναι οι επαγγελματικές σκόνες και τα χημικά καθώς και οι συχνές λοιμώξεις του κατώτερου αναπνευστικού συστήματος κατά την παιδική ηλικία.
Η διάγνωση της ΧΑΠ
Η διάγνωση της χρόνιας αποφρακτικής πνευμονοπάθειας (ΧΑΠ) επιβεβαιώνεται με ένα απλό τεστ που ονομάζεται σπιρομέτρηση. Η Σπιρομέτρηση είναι μια απλή και ανώδυνη εξέταση η οποία μετρά πόσο καλά μπορείτε να αναπνεύσετε και συμβάλει στην διάγνωση διαφόρων πνευμονικών νόσων. Η εξέταση είναι ανώδυνη και συνήθως διαρκεί λιγότερο από 10 λεπτά, ωστόσο απαιτεί δυνατό φύσημα. Φυσάτε μέσα σε μια μικρή συσκευή, το σπιρόμετρο, που μετράει πόσο αέρα μπορείτε να φυσήξετε από τους πνεύμονές σας και πόσο γρήγορα μπορεί να γίνει αυτό.
Πρέπει να κάνετε την εξέταση;
Ναι, εφόσον
- Καπνίζετε ή έχετε υπάρξει καπνιστής
- Βήχετε πολύ
- Σας κόβεται η ανάσα όταν περπατάτε γρήγορα
- Είστε άνω των 40 ετών
- Έχετε επεισόδια συριγμού ( ¨σφυρίγματος¨ κατά την ανάσα)
- Ανησυχείτε για την υγεία των πνευμόνων σας
Κάθε ασθενής που έχει συμπτώματα χρόνιου βήχα, δύσπνοιας, απόχρεμψης και ιστορικό έκθεσης σε παράγοντες κινδύνου για την ασθένεια, πρέπει να πάει για σπιρομέτρηση.
Τι συμβαίνει κατά την εξέταση;
Ο γιατρός θα σας δείξει πώς να φυσήξετε μέσα στο σπιρόμετρο πριν ξεκινήσετε. Είναι σημαντικό να φυσήξετε όσο πιο δυνατά μπορείτε κατά την εξέταση, αλλιώς τα αποτελέσματα δεν θα είναι ακριβή. Θα σας ζητηθεί να φυσήξετε τρεις ή περισσότερες φορές μέσα στο σπιρόμετρο.
Όταν κρατάτε το σπιρόμετρο, θα πρέπει:
- Να εισπνεύσετε όσο πιο βαθιά μπορείτε και να τοποθετήσετε τα χείλη σφιχτά γύρω από το επιστόμιο
- Να βάλετε τα δυνατά σας και να φυσήξετε δυνατά τον αέρα σας, όσο πιο γρήγορα γίνεται
- Να συνεχίσετε να φυσάτε μέχρι να αδειάσουν οι πνεύμονές σας και ο γιατρός να σας πει να σταματήσετε
Τι σημαίνουν τα αποτελέσματα;
Ο γιατρός θα χρησιμοποιήσει τις μετρήσεις των όγκων αέρος που φυσάτε και που προκύπτουν από την σπιρομέτρηση, ώστε να αποφασίσει πόσο καλά λειτουργούν οι πνεύμονές σας. Πρωταρχικά, αξιολογούνται ο όγκος αέρα που φυσάτε κατά το πρώτο δευτερόλεπτο (FEV1) καθώς και ο συνολικός όγκος αέρα που εκπνέετε (FVC). Ο γιατρός μπορεί να σας ζητήσει να επαναλάβετε την σπιρομέτρηση μετά από 15-20 λεπτά από την εισπνοή φαρμάκου, ώστε να αξιολογήσει την αναστρεψιμότητα πιθανής βλάβης.
Η σπιρομέτρηση είναι σημαντική για την μέτρηση της λειτουργίας των πνευμόνων.
Ο χρόνιος βήχας και η παραγωγή πτυέλων συχνά προηγούνται κατά πολλά χρόνια της ανάπτυξης του περιορισμού της ροής του αέρα στους πνεύμονες (αν και δεν αναπτύσσουν ΧΑΠ όλα τα άτομα με βήχα και παραγωγή πτυέλων). Επειδή η ΧΑΠ αναπτύσσεται αργά, πιο συχνά διαγιγνώσκεται σε άτομα ηλικίας 40 χρόνων και άνω.
Διαχείριση της ασθένειας
Ένα αποτελεσματικό σχέδιο διαχείρισης της Χρόνιας Αποφρακτικής Πνευμονοπάθειας περιλαμβάνει τέσσερις συνιστώσες: (1) την αξιολόγηση και παρακολούθηση της νόσου, (2) τη μείωση των παραγόντων κινδύνου, (3) τη σταθεροποίηση της νόσου και (4) τη διαχείριση των εξάρσεων.
Οι στόχοι της αποτελεσματικής διαχείρισης της ΧΑΠ είναι οι εξής:
- Η πρόληψη της εξέλιξης της νόσου
- Η ανακούφιση των συμπτωμάτων
- Η βελτίωση της αντοχής στην άσκηση
- Η βελτίωση της κατάστασης της υγείας
- Η πρόληψη και θεραπεία των επιπλοκών
- Η πρόληψη και θεραπεία των παροξυσμικών επεισοδίων
- Η μείωση της θνησιμότητας
Οι στόχοι αυτοί πρέπει να επιτευχθούν με ελάχιστες παρενέργειες από τη θεραπεία, μια ιδιαίτερη πρόκληση σε ασθενείς με ΧΑΠ. Ο βαθμός στον οποίο οι στόχοι αυτοί μπορούν να πραγματοποιηθούν ποικίλλει ανάλογα με το κάθε άτομο. Κατά την επιλογή της θεραπείας, πρέπει να συνυπολογιστούν τα οφέλη και οι κίνδυνοι της θεραπείας, καθώς και το άμεσο και έμμεσο κόστος στην κοινότητα.
Οι ασθενείς με ΧΑΠ θα πρέπει να ταυτοποιούνται πριν φτάσουν στο τελικό στάδιο της νόσου.
Παρόλα αυτά, τα οφέλη της σπιρομέτρησης, είτε στον γενικό πληθυσμό, είτε στους καπνιστές, είναι ακόμα ασαφή.
Η εκπαίδευση των ασθενών και των ιατρών έτσι ώστε να αναγνωρίζουν ότι ο βήχας, η απόχρεμψη, η δύσπνοια δεν είναι ασήμαντα συμπτώματα, αποτελεί θεμελιώδη πτυχή της σωστής διαχείρισης της ΧΑΠ και της δημόσιας υγείας.
Η περαιτέρω επιδείνωση της λειτουργίας των πνευμόνων συνήθως απαιτεί τη σταδιακή εισαγωγή περισσότερων θεραπειών, τόσο φαρμακολογικών και μη, για να μειωθεί η επίδραση και ο αντίκτυπος των επιδεινούμενων συμπτωμάτων. Το χαρακτηριστικό στοιχείο της ΧΑΠ είναι οι οξείες εξάρσεις των συμπτωμάτων που επηρεάζουν την ποιότητα ζωής των ασθενών. Η κατάλληλη θεραπεία και η εφαρμογή μέτρων για την πρόληψη περαιτέρω εξάρσεων θα πρέπει να εφαρμόζονται το συντομότερο δυνατό.
Συνιστώσα 1: Αξιολόγηση και παρακολούθηση της νόσου
Η διάγνωση της ΧΑΠ βασίζεται σε ένα ιστορικό έκθεσης σε παράγοντες κινδύνου και την παρουσία περιορισμένης ροής αέρα στους πνεύμονες που δεν είναι πλήρως αναστρέψιμη, με ή χωρίς την παρουσία επιπλέον συμπτωμάτων.
Οι ασθενείς που έχουν χρόνιο βήχα και παραγωγή πτυέλων με ιστορικό έκθεσης σε παράγοντες κινδύνου πρέπει να ελέγχονται ακόμη και αν δεν έχουν δύσπνοια.
Για τη διάγνωση και εκτίμηση της ΧΑΠ, η σπιρομέτρηση είναι ο χρυσός κανόνας.
Συνιστώσα 2: Μείωση κινδύνου
Μείωση της έκθεσης στον καπνό, στις επαγγελματικές σκόνες και τα χημικά προϊόντα, καθώς και στην εσωτερική και εξωτερική ατμοσφαιρική ρύπανση.
Η διακοπή του καπνίσματος είναι το πιο αποτελεσματικό και οικονομικά αποδοτικότερο μέσο για τη μείωση του κινδύνου ανάπτυξης ΧΑΠ και την επιβράδυνση της εξέλιξης της.
Τρία είδη συμβουλευτικής είναι ιδιαίτερα αποτελεσματικά: η πρακτική συμβουλευτική, η κοινωνική υποστήριξη ως μέρος της θεραπείας και η κοινωνική υποστήριξη εκτός της θεραπείας.
Αρκετά αποτελεσματικές φαρμακοθεραπείες για την εξάρτηση από τον καπνό είναι διαθέσιμες, και τουλάχιστον μία από αυτές θα πρέπει να ενσωματωθεί στη συμβουλευτική εάν αυτό κριθεί απαραίτητο και εν απουσία αντενδείξεων.
Επιβάλλεται η ανάπτυξη στρατηγικών που αποσκοπούν στη μείωση της επιβάρυνσης από εισπνεόμενα σωματίδια και αέρια στον εργασιακό χώρο.
Συνιστώσα 3: σταθεροποίηση της νόσου
Η συνολική προσέγγιση για τη σταθεροποίηση της νόσου θα πρέπει να χαρακτηρίζεται από σταδιακή αύξηση της θεραπείας, ανάλογα με τη σοβαρότητα της νόσου.
Για τους ασθενείς με ΧΑΠ, η εκπαίδευση σε θέματα υγείας μπορεί να παίξει σημαντικό ρόλο στη βελτίωση των δεξιοτήτων, την ικανότητα αντιμετώπισης της ασθένειας και την συνολική κατάσταση της υγείας. Είναι επίσης αποτελεσματική στην επίτευξη συγκεκριμένων στόχων, συμπεριλαμβανομένης και της διακοπής του καπνίσματος.
Η φαρμακοθεραπεία για τη ΧΑΠ χρησιμοποιείται για να μειώσει τα συμπτώματα και τις επιπλοκές κι όχι για να αντιμετωπίσει την μακροπρόθεσμη μείωση της λειτουργικότητας των πνευμόνων..
Τα βρογχοδιασταλτικά φάρμακα είναι πολύ σημαντικά για τη συμπτωματική αντιμετώπιση της ΧΑΠ. Δίνονται σε αναγκαία βάση ή σε τακτά χρονικά διαστήματα για την πρόληψη ή τη μείωση των συμπτωμάτων.
Η τακτική θεραπεία με εισπνεόμενα κορτικοστεροειδή θα πρέπει να συνταγογραφείται για τη συμπτωματική ασθενείς με ΧΑΠ, η χρόνια θεραπεία όμως με συστηματικά γλυκοκορτικοστεροειδή θα πρέπει να αποφεύγεται λόγω της αρνητικής σχέσης οφέλους -κινδύνου.
Όλοι οι ασθενείς με ΧΑΠ μπορούν να επωφεληθούν από προγράμματα άσκησης, για να αυξήσουν την αντοχή τους και να ελαττώσουν τα συμπτώματα της δύσπνοιας και κόπωσης.
Η μακροχρόνια χορήγηση οξυγόνου σε ασθενείς με χρόνια αναπνευστική ανεπάρκεια έχει αποδειχθεί χρήσιμη για την αύξηση του προσδόκιμου της ζωής.
Συνιστώσα 4: διαχείριση των εξάρσεων
Οι εξάρσεις των συμπτωμάτων που απαιτούν ιατρική παρέμβαση είναι σημαντικά κλινικά γεγονότα στην ΧΑΠ. Στο ένα τρίτο των σοβαρών παροξυσμικών επεισοδίων η αιτία δε μπορεί να προσδιοριστεί.
Τα εισπνεόμενα βρογχοδιασταλτικά και τα συστηματικά γλυκοκορτικοστεροειδή είναι αποτελεσματικά για τη διαχείριση των εξάρσεων.
Οι ασθενείς που εμφανίζουν παροξυσμικά επεισόδια με κλινικά συμπτώματα μόλυνσης αεραγωγών μπορούν να ωφεληθούν από θεραπεία με αντιβιοτικά.
Πηγή : Υπυργείο Υγείας
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