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1、慢性阻塞性肺病的新进展,清华大学第一附属医院呼吸科,GOLD颁布的COPD全球策略 2014年最新更新 慢性阻塞性肺疾病急性加重(AECOPD)诊治中国专家共识(草案),Global Strategy for Diagnosis,Management and Prevention of COPD,2013:Chapters,Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage Comorbidities,Updated 201
2、3,2013 Global Initiative for Chronic Obstructive Lung Disease,COPD的定义,COPD 是一种可以预防和可以治疗的常见疾病,其特征是持续存在的气流受限。气流受限呈进行性发展,伴有气道和肺对有害颗粒或气体所致慢性炎症反应的增加。急性加重和合并症影响患者整体疾病的严重程度。,COPD气流受限的发病机制,AIRFLOW LIMITATION,2013 Global Initiative for Chronic Obstructive Lung Disease,COPD的危险因素,肺的生长发育性别年龄 呼吸道感染社会经济条件哮喘气道高反应性
3、慢性支气管炎,基因有害颗粒暴露 吸烟 职业粉尘，有机物，无机物 室内燃料燃烧和通风不良 室外空气污染,2013 Global Initiative for Chronic Obstructive Lung Disease,COPD的危险因素,Genes,Infections,Socio-economic status,Aging Populations,2013 Global Initiative for Chronic Obstructive Lung Disease,Global Strategy for Diagnosis,Management and Prevention of COP
4、D,2013:Chapters,Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage Comorbidities,UPDATED 2013,2013 Global Initiative for Chronic Obstructive Lung Disease,SYMPTOMS,chronic cough,shortness of breath,EXPOSURE TO RISKFACTORS,tobacco,occupation
5、,indoor/outdoor pollution,SPIROMETRY:Required to establish diagnosis,COPD的诊断,sputum,2013 Global Initiative for Chronic Obstructive Lung Disease,COPD的诊断,任何患有呼吸困难、慢性咳嗽或多痰的患者,并且有暴露于危险因素的病史,在临床上需要考虑COPD 的诊断。作出COPD 的诊断需要进行肺功能检查,吸入支气管扩张剂之后FEV1/FVC 0.70 表明存在气流受限,即可诊断COPD。,COPD评估,COPD 评估的目的是决定疾病的严重程度,包括气流受限
6、的严重程度,患者的健康状况和未来的风险程度(例如急性加重、住院或死亡),最终目的是指导治疗。,2013 Global Initiative for Chronic Obstructive Lung Disease,COPD的评估,症状评估气流受限采用肺功能严重度分级急性加重风险评估合并症评估,2013 Global Initiative for Chronic Obstructive Lung Disease,*改良英国MRC 呼吸困难指数(modified british medical research council,mMRC)*COPD 评估测试(COPDassessment test
7、,CAT)。,症状的评估,2013 Global Initiative for Chronic Obstructive Lung Disease,Global Strategy for Diagnosis,Management and Prevention of COPDModified MRC(mMRC)Questionnaire,2013 Global Initiative for Chronic Obstructive Lung Disease,气流受限的评估,气流受限程度仍采用肺功能严重度分级,即FEV1 占预计值80%、50%、30%为分级标准。COPD 患者的气流受限的肺功能分级分
8、为4 级(Grades),即:GOLD 1轻度,GOLD 2中度,GOLD 3重度,GOLD 4非常严重。使用支气管扩张剂后，患者肺功能FEV1/FVC 0.70 COPD 分期(Stage)的概念已经被废除,2013 Global Initiative for Chronic Obstructive Lung Disease,Global Strategy for Diagnosis,Management and Prevention of COPDClassification of Severity of Airflow Limitation in COPD*,In patients wi
9、th FEV1/FVC 80%predicted GOLD 2:Moderate 50%FEV1 80%predictedGOLD 3:Severe 30%FEV1 50%predictedGOLD 4:Very Severe FEV1 30%predicted*Based on Post-Bronchodilator FEV1,2013 Global Initiative for Chronic Obstructive Lung Disease,急性加重风险评估,采用急性加重病史和肺功能评估急性加重的风险,上一年发生2 次或以上的急性加重或FEV1%pred 50%提示风险增加需要正确评估合
10、并症并给予恰当的治疗。,2013 Global Initiative for Chronic Obstructive Lung Disease,合并症评估,心血管病骨质疏松症呼吸道感染焦虑和抑郁症糖尿病肺癌合并症影响COPD的死亡率住院率,2013 Global Initiative for Chronic Obstructive Lung Disease,Combined Assessment of COPD,Risk(GOLD Classification of Airflow Limitation),Risk(Exacerbation history),2,1,0,(C),(D),(A)
11、,(B),mMRC 0-1CAT 10,4,3,2,1,mMRC 2CAT 10,Symptoms(mMRC or CAT score),2013 Global Initiative for Chronic Obstructive Lung Disease,Combined Assessment of COPD,(C),(D),(A),(B),mMRC 0-1CAT 10,mMRC 2CAT 10,Symptoms(mMRC or CAT score),If mMRC 0-1 or CAT 2 or CAT 10:More Symptoms(B or D),首先Assess symptoms
12、first,2013 Global Initiative for Chronic Obstructive Lung Disease,Combined Assessment of COPD,Risk(GOLD Classification of Airflow Limitation),Risk(Exacerbation history),2,1,0,(C),(D),(A),(B),mMRC 0-1CAT 10,4,3,2,1,mMRC 2CAT 10,Symptoms(mMRC or CAT score),If GOLD 1 or 2 and only 0 or 1 exacerbations
13、per year:Low Risk(A or B)If GOLD 3 or 4 or two ormore exacerbations per year:High Risk(C or D)(One or more hospitalizations for COPD exacerbations should be considered high risk.),其次急性加重风险的评估,2013 Global Initiative for Chronic Obstructive Lung Disease,Combined Assessment of COPD,Risk(GOLD Classifica
14、tion of Airflow Limitation),Risk(Exacerbation history),2,1,0,(C),(D),(A),(B),mMRC 0-1CAT 10,4,3,2,1,mMRC 2CAT 10,Symptoms(mMRC or CAT score),Patient is now in one offour categories:A:Less symptoms,low riskB:More symptoms,low riskC:Less symptoms,high riskD:More symptoms,high risk,综合评估,2013 Global Ini
15、tiative for Chronic Obstructive Lung Disease,Combined Assessment of COPD,Risk(GOLD Classification of Airflow Limitation),Risk(Exacerbation history),2,1,0,(C),(D),(A),(B),mMRC 0-1CAT 10,4,3,2,1,mMRC 2CAT 10,Symptoms(mMRC or CAT score),2013 Global Initiative for Chronic Obstructive Lung Disease,Combin
16、ed Assessment of COPD,2013 Global Initiative for Chronic Obstructive Lung Disease,Global Strategy for Diagnosis,Management and Prevention of COPDDifferential Diagnosis:COPD and Asthma,2013 Global Initiative for Chronic Obstructive Lung Disease,Asthma-COPD Overlap SyndromeACOS(1),Asthma is a heteroge
17、neous disease,usually characterized by chronic airway inflammation.It is defined by the history of respiratory symptoms such as wheeze,shortness of breath,chest tightness and cough that vary over time and in intensity,together with variable expiratory airflow limitation.GINA 2014,Asthma-COPD Overlap
18、 SyndromeACOS(2),COPD is a common preventable and treatable disease,characterized by persistent airflow limitation that is usually progressive and associated with enhanced chronic inflammatory responses in the airways and the lungs to noxious particles or gases.Exacerbations and comorbidities contri
19、bute to the overall severity in individual patients.GOLD 2014,Asthma-COPD Overlap SyndromeACOS(3),Asthma-COPD overlap syndrome(ACOS)is characterized by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD.ACOS is therefo
20、re identified by the features that it shares with both asthma and COPD.,Global Strategy for Diagnosis,Management and Prevention of COPDAdditional Investigations,胸部影象学:Seldom diagnostic but valuable to exclude alternative diagnoses and establish presence of significant comorbidities.肺容积和弥散功能:Help to
21、characterize severity,but not essential to patient management.动脉血气:Pulse oximetry can be used to evaluate a patients oxygen saturation and need for supplemental oxygen therapy.Alpha-1 抗胰蛋白酶:Perform when COPD develops in patients of Caucasian descent under 45 years or with a strong family history of
22、COPD.,2013 Global Initiative for Chronic Obstructive Lung Disease,Global Strategy for Diagnosis,Management and Prevention of COPD,2014:Chapters,Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage Comorbidities,UPDATED 2013,2013 Global Initi
23、ative for Chronic Obstructive Lung Disease,COPD的治疗戒烟,帮助患者戒烟的五步策略1.询问(ASK):系统地对所有吸烟者进行询问。建立一个相应的办公系统,保证每个吸烟者每次随访时的吸烟状态都能得到详细的询问和记录。2.建议(ADVISE):强烈建议每个吸烟者戒烟。态度要明确、坚定、有针对性,鼓励其戒烟。3.评估(ASSESS):确定患者有无戒烟意愿。询问每个吸烟者是否愿意在近期(如30 d 内)进行戒烟尝试。4.帮助(ASSIST):帮助患者戒烟。帮助吸烟者制定戒烟计划;提供实用可行的咨询服务;提供治疗范围内的社会支持;帮助获得治疗范围外的社会支持
24、;推荐使用仅在某些特定场合下批准的药物;提供辅助措施等。5.安排(ARRANGE):安排随访计划。通过患者本人亲自来诊或电话联系,安排随访。,2013 Global Initiative for Chronic Obstructive Lung Disease,COPD的治疗,识别COPD 的其他危险因素也相当重要,其中包括职业粉尘和化学烟雾,燃烧生物燃料所致的室内空气污染,厨房通风不佳等。这些因素在女性COPD 患者的发病中尤为重要。,COPD 的治疗药物,2013 Global Initiative for Chronic Obstructive Lung Disease,支气管扩张剂是用
25、来改善肺功能FEV1 或改善其他肺功能参数的药物,其主要是通过改变气道平滑肌的张力以扩张支气管,而不能改善肺弹性回缩力,因而这类药物称为“支气管扩张剂”主要的支气管扩张剂：beta2-agonists,anticholinergics,theophylline or combination therapy.,支气管扩张剂,2013 Global Initiative for Chronic Obstructive Lung Disease,支气管扩张剂在COPD 稳定期中的应用,支气管扩张剂是控制COPD 症状的主要治疗措施首选吸入疗法如何选择2 激动剂、抗胆碱能药、茶碱类或联合使用,取决于药
26、物是否可以获得以及不同个体的反应(包括症状是否能控制、不良反应等)短期按需使用支气管扩张剂可缓解症状,长期规律使用可预防和减轻症状吸入长效支气管扩张剂更为方便,而且效果更好与应用一种支气管扩张剂的剂量相比,联合应用多种支气管扩张剂可以增加疗效,减少不良反应,磷酸二酯酶-4 抑制剂In patients with severe and very severe COPD(GOLD 3 and 4)and a history of exacerbations and chronic bronchitis,the phospodiesterase-4 inhibitor(PDE-4),roflumil
27、ast,reduces exacerbations treated with oral glucocorticosteroids.,Global Strategy for Diagnosis,Management and Prevention of COPDTherapeutic Options:Phosphodiesterase-4 Inhibitors,2013 Global Initiative for Chronic Obstructive Lung Disease,茶 碱,目前,关于甲基黄嘌呤类药物的具体作用还存在争议。甲基黄嘌呤是非选择性的磷酸二酯酶抑制剂,除支气管扩张作用外,还有
28、其他一些非支气管扩张剂的作用,但仍有争议。低剂量茶碱能减少COPD 患者急性加重发作,但不能增加应用支气管扩张剂后的肺功能。不良反应:不良反应与剂量相关。,2013 Global Initiative for Chronic Obstructive Lung Disease,吸入糖皮质激素(ICS)可以改善症状，肺功能，生活质量，减少急性加重的次数。,吸入糖皮质激素,2013 Global Initiative for Chronic Obstructive Lung Disease,在重度COPD患者中推荐联合ICS和LABA/LAMA.可以减少肺炎的风险,联合治疗,2013 Global
29、Initiative for Chronic Obstructive Lung Disease,避免长期使用全身糖皮质激素,Therapeutic Options:Systemic Corticosteroids,2013 Global Initiative for Chronic Obstructive Lung Disease,Influenza vaccines can reduce serious illness.Pneumococcal polysaccharide vaccine is recommended for COPD patients 65 years and older
30、 and for COPD patients younger than age 65 with an FEV1 40%predicted.The use of antibiotics,other than for treating infectious exacerbations of COPD and other bacterial infections,is currently not indicated.,Global Strategy for Diagnosis,Management and Prevention of COPDTherapeutic Options:Other Pha
31、rmacologic Treatments,2013 Global Initiative for Chronic Obstructive Lung Disease,Oxygen Therapy:The long-term administration of oxygen(15 hours per day)to patients with chronic respiratory failure has been shown to increase survival in patients with severe,resting hypoxemia.Ventilatory Support:Comb
32、ination of noninvasive ventilation(NIV)with long-term oxygen therapy may be of some use in a selected subset of patients,particularly in those with pronounced daytime hypercapnia.,Global Strategy for Diagnosis,Management and Prevention of COPDTherapeutic Options:Other Treatments,2013 Global Initiati
33、ve for Chronic Obstructive Lung Disease,Lung volume reduction surgery(LVRS)is more efficacious than medical therapy among patients with upper-lobe predominant emphysema and low exercise capacity.LVRS is costly relative to health-care programs not including surgery.In appropriately selected patients
34、with very severe COPD,lung transplantation has been shown to improve quality of life and functional capacity.,Global Strategy for Diagnosis,Management and Prevention of COPDTherapeutic Options:Surgical Treatments,2013 Global Initiative for Chronic Obstructive Lung Disease,Global Strategy for Diagnos
35、is,Management and Prevention of COPD,2014:Major Chapters,Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage Comorbidities,UPDATED 2013,2013 Global Initiative for Chronic Obstructive Lung Disease,Relieve symptomsImprove exercise toleranceIm
36、prove health statusPrevent disease progressionPrevent and treat exacerbationsReduce mortality,Manage Stable COPD:Goals of Therapy,2013 Global Initiative for Chronic Obstructive Lung Disease,Avoidance of risk factors-smoking cessation-reduction of indoor pollution-reduction of occupational exposureIn
37、fluenza vaccination,Manage Stable COPD:All COPD Patients,2013 Global Initiative for Chronic Obstructive Lung Disease,Manage Stable COPD:非药物,2013 Global Initiative for Chronic Obstructive Lung Disease,Manage Stable COPD:Pharmacologic Therapy,Exacerbations per year,2,1,0,mMRC 0-1CAT 10,GOLD 4,mMRC 2CA
38、T 10,GOLD 3,GOLD 2,GOLD 1,SAMA prnor SABA prn,LABA or LAMA,ICS+LABAor LAMA,Manage Stable COPD:药物治疗RECOMMENDED FIRST CHOICE,A,B,D,C,ICS+LABAand/or LAMA,2013 Global Initiative for Chronic Obstructive Lung Disease,2,1,0,mMRC 0-1CAT 10,GOLD 4,mMRC 2CAT 10,GOLD 3,GOLD 2,GOLD 1,LAMA or LABA orSABA and SAM
39、A,LAMA and LABA orLAMA and PDE4-inh orLABA and PDE4-inh,ICS+LABA and LAMA orICS+LABA and PDE4-inh orLAMA and LABA orLAMA and PDE4-inh.,LAMA and LABA,Manage Stable COPD:药物治疗ALTERNATIVE CHOICE,A,D,C,B,Exacerbations per year,2013 Global Initiative for Chronic Obstructive Lung Disease,2,1,0,mMRC 0-1CAT
40、10,GOLD 4,mMRC 2CAT 10,GOLD 3,GOLD 2,GOLD 1,Theophylline,SABA and/or SAMATheophylline,CarbocysteineSABA and/or SAMATheophylline,SABA and/or SAMATheophylline,Manage Stable COPD:药物治疗OTHER POSSIBLE TREATMENTS,A,D,C,B,Exacerbations per year,2013 Global Initiative for Chronic Obstructive Lung Disease,Glo
41、bal Strategy for Diagnosis,Management and Prevention of COPD,2013:Major Chapters,Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage Comorbidities,UPDATED 2013,2013 Global Initiative for Chronic Obstructive Lung Disease,COPD 常常和其他疾病合并存在,可对疾
42、病的进展产生显著影响。存在合并症不需要改变COPD 的治疗。根据各种合并症的指南进行治疗,合并症的治疗,2013 Global Initiative for Chronic Obstructive Lung Disease,Global Strategy for Diagnosis,Management and Prevention of COPD,2013:Chapters,Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManag
43、e Comorbidities,UPDATED 2013,2013 Global Initiative for Chronic Obstructive Lung Disease,Manage Exacerbations,慢性阻塞性肺疾病急性加重(AECOPD)诊治中国专家共识(草案)2012年12月,Manage Exacerbations,AECOPD的概述、病因及诊断AECOPD的住院治疗指征和分级治疗AECOPD患者的药物治疗AECOPD患者的机械通气AECOPD出院和预防,AECOPD 定义,COPD急性加重是指一种急性起病的过程，其特征是患者呼吸系统症状恶化，超出日常的变异，并且导致
44、需要改变药物治疗。,如果胸片出现肺部阴影，符合感染表现，则诊断为社区获得性肺炎。-2011年欧洲成人下呼吸道感染的诊治指南,AECOPD versus CAP AECOPD CAP+COPD,AECOPD is not CAP,AECOPD的概述,原因：上呼吸道病毒感染、气管-支气管细菌感染治疗目标：减轻急性加重的病情，预防再次急性加重治疗：支气管扩张剂、糖皮质激素、抗菌药，不推荐抗病毒药物预防：戒烟、接种疫苗、掌握治疗知识、单用吸入支气管扩张剂或联用吸入糖皮质激素、应用磷酸二酯酶-4抑制剂,AECOPD 病因,Sethi et al.Chest 2000;117:380s-385s,80%感
45、染,20%非感染,细菌病原体40-50%病毒感染40-50%非典型病原体5-10%,环境因素 吸烟 大气污染 吸入变应原未遵循医嘱进行治疗,*AECOPD可能起源于病毒感染、细菌感染或非感染因素（吸烟、环境污染和未进行有效治疗等）,AECOPD 的病毒感染,Hurst,J.R.,Wedzicha,J.A.,2004.Chronic obstructive pulmonary disease:the clinical management of an acute exacerbation.Postgrad Med J 80,497-505.,鼻病毒,冠状病毒,流感病毒,腺病毒,呼吸道合胞体病毒（
46、RSV),副流感病毒,AECOPD病毒感染率以鼻病毒和RSV 最为常见,病毒和 AECOPD,Seemungal et al Am J Respir Crit Care Med 2001,40-50%AECOPD合并上呼吸道病毒感染，常见为鼻病毒属(64%)、呼吸道合胞病毒和流感病毒。,慢性疾病,逐渐进展 肺功能 症状 合并症,急性加重,典型病例每年13次急性加重 发生频率与COPD严重程度成比例 经常发生AECOPD者病情加速进展，导致：生活质量 反复住院 死亡率增加,COPD 与 AECOPD,原因：可由多种因素所致。最常见为病毒性上呼吸道感染和气管支气管感染。诊断：唯一依靠患者急性起病和
47、症状加重的临床表现（呼吸困难、咳嗽、多痰），这些变化超出正常的日间变异。目前没有单一生物标志物可应用于AECOPD的临床诊断和评估 AECOPD的治疗目标：减轻当前急性加重的临床表现和预防以后急性加重发生。,AECOPD的严重性评估,Global strategy for the diagnosis,management,and revention of chronic obstructive pulmonary disease.(2013),AECOPD 的辅助检查,脉氧或动脉血气：用来监测和/或调整氧疗方案，必要时需要机械通气胸片：有助于除外其他诊断心电图：有助于诊断合并的心脏疾病血常规：
48、有助于发现RBC增多(HCT55%)，贫血或WBC增多痰培养：初始抗生素治疗无效，需进行痰培养生化检查：有助于发现电解质紊乱和血糖增高,急性加重期间不推荐行肺功能检查，因患者无法配合且检查结果不够准确,AECOPD 鉴别诊断,鉴别 诊断,肺 炎,充血性心衰,气 胸,胸腔积液,肺栓塞,心律失常,Global strategy for the diagnosis,management,and revention of chronic obstructive pulmonary disease.(updated 2011),AECOPD的概述、病因及诊断AECOPD的住院和分级治疗AECOPD患者的
49、药物治疗AECOPD患者的机械通气AECOPD出院和预防,AECOPD的分级治疗,级:门诊治疗 级:住院治疗 级:入ICU 治疗,2004 年ATSERS 推出慢阻肺诊断和治疗标准时，将AECOPD 严重度分为 3 级：级，门诊治疗；级，普通病房住院治疗；级，入ICU 治疗（急性呼吸衰竭）。,AECOPD门诊患者的处理,AECOPD普通病房患者的处理,AECOPD ICU患者的处理,AECOPD的概述、病因及诊断AECOPD的住院治疗指征和分级治疗AECOPD患者的药物治疗AECOPD患者的机械通气AECOPD出院和预防,AECOPD：住院治疗治疗措施,控制性氧气治疗,支气管扩张剂(BDs):
50、短效支气管扩张剂-激动剂 抗胆碱药物 甲基黄嘌呤,机械通气:无创 有创,AECOPD,糖皮质激素治疗:口服,静脉滴注,或吸入,抗生素,GOLD Revision 2013,AECOPD(但无生命危险)患者的治疗,评估症状的严重程度、血气分析、胸片氧疗和系列测定动脉血气支气管扩张剂增加短效支气管扩张剂的剂量和/或次数 联合应用短效2 激动剂和抗胆碱能药物 应用储雾器或气动雾化装置加用口服或静脉糖皮质激素细菌感染,考虑应用抗生素(口服,或偶尔静脉应用抗生素)考虑无创通气随时:监测液体平衡和营养 考虑应用肝素或低分子肝素皮下注射 鉴别和治疗合并症(心力衰竭、心律不齐)密切监护患者,AECOPD 药物
