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1、Chronic Obstructive Pulmonary Disease(COPD),Chronic Cor Pulmonale慢性阻塞性肺病慢性肺源性心脏病,Chronic Obstructive Pulmonary,General introduction,COPD慢性阻塞性肺病Chronic bronchitis慢性支气管炎、Emphysema肺气肿Pulmonary hypertension肺动脉高压Chronic Cor Pulmonale慢性肺源性心脏病,General introductionCOPD慢性阻塞性肺,General concept,COPD,a common pr
2、eventable and treatable disease is characterized by persistent airflow limitation that is usually progressive and associated with enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases.Exacerbations and comorbidities contribute to the overall severity in ind
3、ividual patients,General conceptCOPD,a common,General concept,The chronic airflow limitation characteristic ofCOPD is caused by a mixture of small airwaydisease(obstructive bronchiolitis)and parenchymal destruction(emphysema),the relative contributions of which vary from person to person.,General co
4、nceptThe chronic air,Percent Change in Age-Adjusted Death Rates,U.S.,1965-1998,0,0.5,1.0,1.5,2.0,2.5,3.0,Proportion of 1965 Rate,1965-1998,1965-1998,1965-1998,1965-1998,1965-1998,59%,64%,35%,+163%,7%,CoronaryHeartDisease,Stroke,Other CVD,COPD,All OtherCauses,Percent Change in Age-Adjusted,Predicted
5、Mortality of COPD,Ischemic heart D 1,COPD 6,Cerebrovascular D 2,LRTI 3,Diarrhae 4,Perinatal D 5,COPD 3,Traffic Accident 4,Lung cancer 5,1990,2020,GOLD Report 2006.p11,Ischemic heart D 1,Cerebrovascular D 2,LRTI 3,Predicted Mortality of COPDIsc,CHRONITIS BRONCHITIS,CHRONITIS BRONCHITIS,Definition,Chr
6、onic bronchitis is a clinical diagnosis based on the symptoms of chronic cough and sputum production.It is defined as persistence of cough and excessive mucus secretion on most days over a 3-month period for at least 2 successive years.,Definition Chronic bronchitis,Definition,Patients who have chro
7、nic productive cough and normal airflow are diagnosed as having simple chronic bronchitis;Those who demonstrate a progressive decline in airflow have chronic obstructive bronchitis,which constitutes the majority of patients with COPD.,DefinitionPatients who have ch,etiology,SmokingAir pollutionInfec
8、tionClimateInternal factor,etiologySmoking,内科学课件02-COPD肺心病-八年制,Clinical features,Symptoms:cough,expectorateon of sputum,wheezingSigns:moist and dry rales,rhonchi,Clinical features Symptoms:co,Classification of Chronic Bronchitis,Classification of Chronic Bron,Stages of Chronic Bronchitis,Stages of C
9、hronic Bronchitis,Lab testing,CXR PFT Sputum bacteria culture Blood testing,Lab testing CXR,Diagnosis,Clinical diagnosis:Symptoms persisting 3 mons/yr Lasting for 2 consective yrs Exclude other lung and heart disease If shorter than three months/per year then definitive objective evidences are deman
10、ded(such as X-Ray and lung function et al.)to diagnose.,Diagnosis Clinical diagnosis:,Therapy-acute attack,Antibiotic therapyCough suppression and mucolyticsBronchodilationNebulization,Therapy-acute attackAntibioti,EMPHYSEMA,EMPHYSEMA,Definition,Emphysema is defined pathologically as the presence of
11、 permanent enlargement of the airspaces distal to the terminal bronchioles,accompanied by destruction of their walls and without obvious fibrosis,Definition Emphysema is define,Pathological classification,central lobular panacinarmixed type,Pathological classification ce,内科学课件02-COPD肺心病-八年制,Normal d
12、istal lung acinus,Normal distal lung acinus,Centriacinar(centrilobular)emphysema,Centriacinar(centrilobular)em,Panacinar emphysema,Panacinar emphysema,内科学课件02-COPD肺心病-八年制,内科学课件02-COPD肺心病-八年制,Clinical features,primary disease dyspnea general symptoms,Clinical features primary dise,signs,barrel chest
13、reduced respireatory movement and breathing sound hyperesonance on auscultation moist and dry rales upon chest infection liver papable,signs barrel chest,Complications,Primary pneumothoraxRespireatory failureCor pulmonale,Complications Primary pneumoth,Classification of Emphysema,Classification of E
14、mphysem,Lab Testing,CXR:PFT:FEV1/FVC40%,reduced DLco,increased TLCABG,Lab Testing CXR:,Diagnosis,History of illnessClinical manifestations&signsPulmonary function:airflow limitation,hyperinflation,increased residual volume(FEV1/FVC120%,RV/TLC 40%,DLco 80%)Lung CT,DiagnosisHistory of illness,Therapy,
15、Same as COPD,Therapy Same as COPD,Risk Factor for COPD,Gene hereditary deficiency of alpha-1 antitrypsinExposure to particles Tobacco smoke Occupational dusts,organic and inorganic Indoor air pollution from heating and cooking with biomass in poorly vented dwellings Outdoor air pollutionLung Growth
16、and DevelopmentRespiratory infectionsSocioeconomic status,Risk Factor for COPDGene her,Pathogenesis of COPD,Pathogenesis of COPD,内科学课件02-COPD肺心病-八年制,内科学课件02-COPD肺心病-八年制,Pathophysiology,Mucous hypersecretion&Cilliary dysfunctionAirflow limitation and hyperinflationGas exchange abnormalitiesPulmonary
17、hypertensionSystemic effects.,PathophysiologyMucous hypersec,Clinical Features,chronic cough May be intermittent and may beunproductive.dyspnea that is:Progressive(worsens over time)Usually worse with exercisePersistent(present every day)Described by the patient as an“increased effort to breathe,”“h
18、eaviness,”“air hunger,”or“gasping.”chronic sputum production:Any pattern of chronic sputumproduction may indicate COPD.history of Tobacco smoke.exposure to Occupational dusts and chemicalsrisk factors,Smoke from home cooking and especially:heating fuels.,Clinical Featureschronic cough,内科学课件02-COPD肺心
19、病-八年制,Signs,Raised respiratory rateHyperexpanded/barrel chestProlonged expiratory time 5 seconds,with pursed lip breathingUse of accessory muscles of respirationQuiet breath sounds(especially in the lung apices),wheezeQuiet heart sounds(due to overlying hyperinflated lung)Possible basal crepitations
20、Signs of cor pulmonale and CO2 retention(ankle oedema,raised JVP,warm peripheries,plethoric conjunctivae,bounding pulse,polycythaemia.Flapping tremor if CO2 acutely raised).,SignsRaised respiratory rate,Investigations,Pulmonary function testsCXR,InvestigationsPulmonary functi,Spirometry:Normal and C
21、OPD,Spirometry:Normal and COPD,Spirometry:Normal and COPD,Spirometry:Normal and COPD,COPD X-rays,AstraZeneca,COPD X-rays AstraZeneca,COPD X-rays,AstraZeneca,COPD X-rays AstraZeneca,COPD X-rays,AstraZeneca,COPD X-rays AstraZeneca,SYMPTOMS,Chronic cough,Sputum production,Dyspnea,EXPOSURE TO RISKFACTOR
22、S,tobacco,occupation,indoor/outdoor pollution,SPIROMETRY,Post-bronchodilator FEV1/FVC70%,Diagnosis of COPD,SYMPTOMSChronic coughSputum pr,Key indicators in considering a diagnosis of COPD,Key indicators in considering,Assessment of disease,Assessment of symptomsSpirometric Assessment(airflow limitat
23、ion)Assessment of exacerbation riskAssessment of comorbidities,Assessment of diseaseAssessmen,Assessment of symptoms(COPD Assessment Test,CAT),从不咳嗽,一点痰也没有,没有任何胸闷的感觉,爬坡或上1层楼梯时，没有气喘的感觉,在家里能够做任何事情,尽管有肺部疾病，但对外出很有信心,睡眠非常好,精力旺盛,总是在咳嗽,有很多很多痰,有很严重的胸闷感觉,爬坡或上1层楼梯时，感觉严重喘不过气来,在家里做任何事情都很受影响,由于有肺部疾病，对离开家一点信心都没有,由
24、于有肺部疾病，睡眠相当差,一点精力都没有,注：数字0-5表示严重程度，请标记最能反映你当前情况的选项，在方格中打X，每个问题只能标记1个选项,51,CAT 10,more symptomatic,Assessment of symptoms从不咳嗽一点痰也,Assessment of symptoms,Less breathlessness,More breathlessness,mMRC 2,Assessment of symptomsLess bre,Spirometric Assessment(airflow limitation),Spirometric Assessment(airf
25、lo,Classification of severity of airflow limitation in COPD,Based on post-bronchodilation,Classification of severity of,Assessment of exacerbation risk,Assessment of exacerbation ris,Soler-Catalua JJ,et al.Thorax.2005;60:925-931.Permission requested.,Frequency of AECOPD and survival,1.0,0.8,0.6,0.4,
26、0.2,0.0,0,10,20,30,40,50,60,随访时间(月),AP0.0002,BP=0.069,C,P0.0001,生存率（%）,1.0,0.8,0.6,0.4,0.2,0.0,0,10,20,30,40,50,60,(1),(3),(4),P0.0001,(2),NS,NS,P=0.005,P0.0001,生存率（%）,随访时间(月),A组无急性加重的患者B组有12次需住院治疗的急性加重的患者C组有3次急性加重的患者,(1)组无急性加重的患者(2)组急性加重需要急诊治疗但无需住院(3)组急性加重需要一次住院治疗(4)组急性加重需要反复住院治疗,N=304，随访5年,Soler-C
27、atalua JJ,et al.Thor,存活可能性,时间（月）,无加重/y,1-2次加重/y,3次加重/y,Soler-Cataluna JJ,et al.Thorax 2005;60(11):925-931.,Assessment of exacerbation risk,57,时间（月）无加重/y1-2次加重/y3次加重/ySoler,Combined COPD assessment,Combined COPD assessment,GOLD 4,GOLD 3,GOLD 2,GOLD 1,mMRC 0-1CAT 10,mMRC 2+CAT 10+,2次或更多1次以上住院,(只要出现至少一
28、次由急性加重导致的住院即可被视为高风险),COPD综合评估,1次AE无住院,急性加重发作史/年,气流受限程度,症状,GOLD 4GOLD 3GOLD 2GOLD 1mMRC 0,Groups summarization-1,Groups summarization-1,Groups summarization-2,Groups summarization-2,Risk(GOLD Classification of Airflow Limitation),Risk(Exacerbation history),2,1,0,(C),(D),(A),(B),mMRC 0-1CAT 10,4,3,2,1
29、,mMRC 2CAT 10,Symptoms(mMRC or CAT score),低风险（A or B）GOLD 1 or 2 0或1次急性加重/年高风险(C or D)GOLD 3 or 4 2 次急性加重/年(只要出现至少一次由急性加重导致的住院即可被视为高风险),COPD综合评估总结,GOLD 2011,62,Risk Risk 2 1 0(C)(D)(A)(B,Differential diagnosis,Bronchial asthmaBronchiectasisPulmonary tuberculosisInterstitial lung diseaseLung cancerCo
30、ngestive heart failure,Differential diagnosisBronchia,Stable COPDAcute exacerbation of COPD(AECOPD),Stable COPD,Exacerbation of COPD,An exacerbation of COPD is an acute event characterized by a worsening of patients respiratory symptoms that is beyond normal day-to-day variations and leads to a chan
31、ge of medication.Exacerbation can be precipitated by several factors.The most common causes of an exacerbation appears to be viral upper respiratory infection and infection of the tracheobronchial tree.,Exacerbation of COPDAn exacerb,Management,Stable COPD,Management Stable COPD,Goal of treatment of
32、 stable COPD,Goal of treatment of stable CO,缓解症状 提高运动耐力 改善健康状况 预防疾病进展 预防和治疗急性加重 降低死亡率,GOLD 2013,减少当前症状,降低未来风险,稳定期COPD的治疗目标,68,缓解症状GOLD 2013减少当前症状降低未来风险稳定期,Medications for COPD,Short-acting bronchodilators:Salbuterol(沙丁胺醇),terbutaline（特布他林）,iprotropium bromide（异丙托品）Long-acting bronchodilators:Salmete
33、rol（沙美特罗）,formoterol（福莫特罗）,tiotropium（噻托溴铵）Combined short-acting bronchodilator:Salbuterol-iptotropiumMethylxanthione:Aminophylline,theophylline(slow-released)Inhaled corticosteroids:Beclomethasone（二丙酸倍氯米松）,budesonide（布地奈德）,fluticasone（氟替卡松）Combined steroid-long-acting bronchodilators:Salmeterol/flu
34、ticasone,formoterol/budesonide,Medications for COPDShort-acti,吸入装置,吸入装置,吸入装置,吸入装置,Bronchodilators in stable COPD,Bronchodilators in stable COPD,内科学课件02-COPD肺心病-八年制,Treatment Group A,Few symptoms and low risk of exacerbationShort-acting bronchodilators as needed therapy-first optionCombined Short-act
35、ing bronchodilators-alternative therapyLong-acting bronchodilators-alternative therapy,Treatment Group AFew symptom,Treatment Group B,More symptoms and low risk of exacerbationLong-acting bronchodilators as needed or prn therapyPts with severe breathlessness,combined Long-acting bronchodilators,Trea
36、tment Group BMore sympto,Treatment Group C,Few symptoms and high risk of exacerbationCombination of inhaled corticosteroid/long-acting 2 agonist or anticholinergicsfirst choiceCombination of two Long-acting bronchodilatorsalternative therapyCombination of inhaled corticosteroid/long-acting anticholi
37、nergicsCombination of phosphodiesterase 4 inhibitors with long-acting bronchodilators-chronic bronchitis,Treatment Group CFew symptom,Treatment Group D,More symtoms and high risk of exacerbationsInhaled corticosteroid plus long-acting 2 agonist or long-acting anticholinergicsfirst choiceCombiantion
38、of all three classes of drugs(Inhaled corticosteroid/long-acting 2 agonist/long-acting anticholinergics)second choicePhosphodiesterase 4 inhibitors may be added-if chronic bronchitis,Treatment Group DMore symtom,Bronchodilators-recommendation,Bronchodilators-recommendatio,COPD稳定期药物治疗方案,COPD稳定期药物治疗方案
39、,Non-pharmacological management of stable COPD,Smoking cessation Education can improve ability to manage illness and stop smoking.Pulmonary rehabilitation:graded exercise,but includes breathing techniques Oxygen Surgical therapy,Non-pharmacological management,Smoking cessation,Smoking cessation,Oxyg
40、en therapy-indications,PaO2 55%)Oxygen is usually delivered by a facemask or nasla canula,with appropriate inspiratory flow rates varying between 1-2L/min with PaO260mmHg or SaO290%,15h/d,Oxygen therapy-indications,Management,AECOPD,Management AECOPD,Manage Exacerbations,Inhaled bronchodilators(beta
41、2-agonists and/or anticholinergics),theophylline,and systemic,preferably oral,glucocortico-steroids are effective for the treatment of COPD exacerbations.,Manage ExacerbationsInhaled br,Management of AECOPD,Antibiotics if sputum purulent,pyrexial,CRP,new changes on CXR.Inhaled or nebulized bronchodi
42、latorsSystemic steroids for all patients with exacerbations of COPD who are admitted to hospital.Give prednisolone 30-40mg/day for 1-2 weeks,unless there are specific contra-indications.This shortens the recovery time.Controlled oxygen therapy 30%via facemask,SpO2 between 80 and 90%,Intravenous amin
43、ophylline.Respiratory stimulant used to drive respiratory rate(if below 20 per minute)and should only be used at the lowest possible dose(0.5 to 3 mg/min)in the short term Its use has largely been replaced by Non-invasive ventilation(NIV)Effective in supporting patients during an exacerbation,when m
44、aximal medical treatment has not been effective.Appropriate for conscious patients with ongoing respiratory acidosis(pH 7.3 or less),hypoxia,and hypercapnia.May avoid intubation.Ceiling of treatment should be determined before its use.(see page 600.)Intubation/intensive care,Management of AECOPDAnti
45、biotic,内科学课件02-COPD肺心病-八年制,Cor pulmonale,Cor pulmonale,Definition,Cor pulmonale is the traditional term for changes in the cardiovascular system resulting from the chronic hypoxia(and usually hypercapnia)of chronic lung disease,mainly pulmonary hypertension and fluid retention.,DefinitionCor pulmona
46、le is the,Definition,Cor pulmonale is an enlargement of the right ventricle due to derangements in the structure or function of the respiratory system.The enlargement may represent progressive right ventricular hypertrophy,right ventricular dilation,and eventual cardiac decompensation,DefinitionCor
47、pulmonale is an,DISEASES ASSOCIATED WITH PULMONARY HEART DISEASE,Diseases affecting airways and lung parenchymaChronic obstructive pulmonary diseaseIdiopathic pulmonary fibrosisAsthma SarcoidosisTuberculosisPneumoconiosesDiseases affecting the thoracic cageKyphoscoliosisThoracoplastyNeuromuscular di
48、sease causing muscle weaknessMuscular dystrophyDiseases affecting the pulmonary vasculatureChronic pulmonary thromboembolic disease Polyarteritis(pulmonary arteritis)Hypoventilatory disordersSleep apnea syndromeIdiopathic alveolar hypoventilation syndrome(Ondine curse)Obesity-hypoventilation syndrom
49、e Chronic high-altitude disease,DISEASES ASSOCIATED WITH PULMO,Morbidity,COPD：84SEVERE TB：5.9%ASTHMA：4.4%BRONCHIECTASIS：2.8%OTHERS：3,MorbidityCOPD：84,PULMONARY HYPERTENSION,Pulmonry hypertension：mean pulmonary Arterial pressure Resting PAPm25mmHgExertional PAPm30mmHg,PULMONARY HYPERTENSIONPulmonry,W
50、HO classification of pulmonary hypertension Pulmonary arterial hypertension Idiopathic pulmonary arterial hypertension(primary pulmonary hypertension).Familial pulmonary arterial hypertension(FPAH),Related to:Collagen vascular disease.Portal hypertension.HIV infection.Drugs/toxins:othersPulmonary ve
