幻灯copd进展慢性阻塞性肺疾病诊断管理和预防策略

1、慢性阻塞性肺疾病诊断管理和预防策略-GOLD 2014解读首都医科大学附属北京朝阳医院林英翔 GOLD的演变2001年 2006年 2011年 2003年第一次更新1998年COPD的全球创议组织成立（GOLD）目的：全球范围内提升对COPD疾病负担的意识，改善 COPD的预防和管理，鼓励更多的研发第一份GOLD指南发表第一次全面修订第二次全面修订2001年：推荐维持治疗常规使用支扩剂治疗中到重度COPD，长效支扩剂比短效更方便；2003年：推荐维持治疗常规使用长效支扩剂，而不是短效支扩剂常规治疗中到重度COPDCOPD定义的演变2001年COPD是一种以气流受限不完全可逆为特征的一种疾病状态

2、。气流受限通常是进展的，同肺部对有害颗粒和气体的异常炎症反应相关。 2006年COPD是一种可以预防和治疗的疾病。一些严重的肺外表现和合并症可能构成疾病的严重程度。肺部的疾病以气流受限不完全可逆为特征。气流受限通常是进展的，同肺部对有害颗粒和气体的异常炎症反应相关。COPD定义的演变2011年COPD是一种可以预防、可以治疗的疾病，以气流受限为特征，气流受限不完全可逆，并呈进行性发展，与肺部对香烟烟雾等有害气体或有害颗粒的异常炎症反应有关。急性加重和合并症取决于患者个人的疾病严重程度。 COPD管理基础的演变旧版GOLD对COPD的管理推荐仅仅基于肺功能的分类有足够的证据表明，FEV1的水平并

3、非是疾病状态的一个最佳的描述，基于此，COPD的管理应该建立在目前疾病的影响（主要是症状的负担和活动受限）和未来疾病进展的风险上（尤其是急性加重加重）2011GOLD指南GOLD已经不使用基于FEV1进行的疾病分级，因为仅根据FEV1进行分级不充分，也没有有效分级的证据。GOLD对COPD评估的演变GOLD COPD 2014GOLD COPD 2014 策略指导性文件，非指南 2001年发布，每5年修订1次，每年更新1次 2014版更简短、清晰地重新对疾病的评估和管理策略进 行评价 2011年新的内容：急性加重和合并症GOLD COPD 2014：内容要点 定义 危险因素：烟草，室内外污染

4、临床诊断：症状；危险因素；肺功能检测是必备条件 评估：症状，急性加重，肺功能和合并症药物治疗：减轻症状，减少急性加重次数，提高健康状态 和运动能力 所有活动后气短的患者均可以从康复和物理治疗中获益 急性加重的定义 合并症可以影响COPD的病程Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage ComorbiditiesAsthma COPD Overlap Syndrome (ACOS)Updated 2014 2014 G

5、lobal Initiative for Chronic Obstructive Lung Disease2014 COPD诊断、管理和预防策略Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage ComorbiditiesAsthma COPD Overlap Syndrome (ACOS)Updated 2014 2014 Global Initiative for Chronic Obstructive Lung Dis

6、ease2014 COPD诊断、管理和预防策略GOLD 2014 COPD：定义 COPD是一种可预防、可治疗的疾病。肺部病变的特征为持续存在的气流受限，气流受限通常呈进行性发展，与肺脏对有害颗粒或气体的异常炎症反应有关。急性加重和合并症的存在对不同患者的疾病严重程度起到重要作用GOLD 2014 COPD：定义 不再应用慢性支气管炎，阻塞性肺气肿，并除外支气管哮喘COPD 的症状呼吸困难慢性咳嗽慢性咳痰COPD气流受限的机制Small Airways DiseaseAirway inflammationAirway fibrosis, luminal plugsIncreased airwa

7、y resistanceParenchymal DestructionLoss of alveolar attachmentsDecrease of elastic recoilAIRFLOW LIMITATIONCOPD的危险因素Lung growth and development GenderAge Respiratory infectionsSocioeconomic statusAsthma/Bronchial hyperreactivityChronic BronchitisGenesExposure to particlesTobacco smokeOccupational du

8、sts, organic and inorganicIndoor air pollution from heating and cooking with biomass in poorly ventilated dwellingsOutdoor air pollutionGenesInfectionsSocio-economic statusAging PopulationsCOPD的危险因素Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage Exacerbati

9、onsManage ComorbiditiesAsthma COPD Overlap Syndrome (ACOS)Updated 2014 2014 Global Initiative for Chronic Obstructive Lung Disease2014 COPD诊断、管理和预防策略GOLD 2014 COPD：诊断临床上任何患者出现气短、慢性咳嗽或咳痰，伴有危险因素暴露史均需要考虑可能存在COPD肺功能检查是COPD诊断的必备条件。以应用支气管舒张剂后FEV1/FVC 0.70来确定存在持续气流受限，诊断COPDGlobal Strategy for Diagnosis, Ma

10、nagement and Prevention of COPDDiagnosis and Assessment: Key PointsComorbidities occur frequently in COPD patients, and should be actively looked for and treated appropriately if present. The goals of COPD assessment are to determine the severity of the disease, including the severity of airflow lim

11、itation, the impact on the patients health status, and the risk of future events. 2013 Global Initiative for Chronic Obstructive Lung DiseaseSYMPTOMS chronic coughshortness of breathEXPOSURE TO RISKFACTORS tobaccooccupationindoor/outdoor pollutionSPIROMETRY: Required to establish diagnosis sputum GO

12、LD 2014 COPD：诊断Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of Airflow Limitation: SpirometrySpirometry should be performed after the administration of an adequate dose of a short-acting inhaled bronchodilator to minimize variabilityA post-bronchodilator FEV1/FVC 0.70

13、confirms the presence of airflow limitationWhere possible, values should be compared to age-related normal values to avoid overdiagnosis of COPD in the elderly 2013 Global Initiative for Chronic Obstructive Lung DiseaseVolume, litersTime, seconds54321123456FEV1 = 1.8LFVC = 3.2LFEV1/FVC = 0.56Normal

14、ObstructiveGOLD 2014 COPD：肺功能检测GOLD2011去除“分期”引入“肺功能分级”保留GOLD分级80%预计值（GOLD2）50%预计值（GOLD3）30%预计值 (GOLD4)GOLD 2014 COPD：严重度分级当前症状评价应用肺功能评价气流受限急性加重危险因素的评价合并症评价GOLD 2014 COPD：疾病评估症状评价 呼吸困难，咳嗽，咳痰呼吸困难 活动后加重，持续进展咳嗽 可能间断出现或可能不出现咳痰 COPD患者通常咳痰GOLD 2014 COPD：疾病评估症状评价GOLD 2014 COPD：疾病评估Use the COPD Assessment Te

15、st(CAT) or mMRC Breathlessness scaleorClinical COPD Questionnaire (CCQ) 症状评价：COPD Assessment Test (CAT)问卷: 8条问题，评价COPD健康状况( )症状评价：Clinical COPD Questionnaire (CCQ)问卷: Self-administered questionnaire developed to measure clinical control in patients with COPD( ). GOLD 2014 COPD：疾病评估 COPD评估测试(CAT)得分范围

16、 0-40症状评价：MRC问卷GOLD 2014 COPD：疾病的评估应用肺功能评价气流受限应用肺功能仪评估气流受限根据肺功能指标分为4级，80%预计值、50%预计值、30%预计值GOLD 2014 COPD：疾病的评估应用肺功能评价气流受限GOLD 2014 COPD：疾病的评估In patients with FEV1/FVC 80% predicted GOLD 2: Moderate 50% FEV1 80% predictedGOLD 3: Severe 30% FEV1 50% predictedGOLD 4: Very Severe FEV1 2，或因急性加重住院至少1次 1，无

17、急性加重住院 0(C)(D) (A)(B)mMRC 0-1CAT 2CAT 10 症状(mMRC or CAT评分)(C)(D) (A)(B)mMRC 0-1CAT 2CAT 10 症状如果mMRC 0-1 或 CAT 2 或CAT 10: 症状较多(B or D) 首先评估症状（根据mMRC或CAT评分）COPD全面评估（1）风险 (气流受限GOLD 分级)风险(急性加重病史) 2 1 0(C)(D) (A)(B)mMRC 0-1CAT 2CAT 10 症状如果 GOLD 1 或 2 和每年仅0 或1次急性加重: 低危(A 或 B)如果GOLD 3 或 4 或 每年2次或以上急性加重，或因急

18、性加重住院至少1次: 高危(C 或 D)其次评估风险（气流受限GOLD分级和急性加重病史） COPD全面评估（2）注：上述方法取提示高危的方法（如果在某些患者中两种方法提示危险度不一）风险 (气流受限GOLD分级)风险 (急性加重病史) 2 1 0(C)(D) (A)(B)mMRC 0-1CAT 2CAT 10 症状(mMRC or CAT score) A: 症状较少, 低危B: 症状较多, 低危C: 症状较少, 高危D： 症状较多, 高危现在患者可被归入4组之一COPD全面评估（3）评估合并症，并参照无COPD患者治疗策略给予同等程度治疗。最常见合并症包括心血管疾病（CVD）、焦虑、抑郁和

19、骨质疏松GOLD2014对合并症的评估心血管疾病是COPD的主要合并症之一，可能是COPD最常见和最重要的合并症骨质疏松和焦虑、抑郁也是COPD主要的合并症，经常因诊断率低而误诊，与健康状况差和预后有关COPD患者常可合并肺癌，这也是轻型COPD最常见死因呼吸道感染，糖尿病，支气管扩张 PatientCharacteristicSpirometric ClassificationExacerbations per yearmMRCCATALow Risk Less SymptomsGOLD 1-2 10-1 2 10CHigh Risk Less SymptomsGOLD 3-4 20-1 2

20、 2 10When assessing risk, choose the highest risk according to GOLD grade or exacerbation history. One or more hospitalizations for COPD exacerbations should be considered high risk.) GOLD 2014 COPD：疾病评估 合并症评价评价合并症并予以适当的治疗主要合并症：心血管疾病抑郁骨质疏松呼吸道感染糖尿病肺部恶性肿瘤支气管扩张GOLD 2014 COPD：疾病的评估COPD Onset in mid-life

21、 Symptoms slowly progressive Long smoking history ASTHMAOnset early in life (often childhood)Symptoms vary from day to daySymptoms worse at night/early morningAllergy, rhinitis, and/or eczema also presentFamily history of asthma 2013 Global Initiative for Chronic Obstructive Lung DiseaseGlobal Strat

22、egy for Diagnosis, Management and Prevention of COPD Differential Diagnosis: COPD and AsthmaGlobal Strategy for Diagnosis, Management and Prevention of COPDAdditional InvestigationsChest X-ray: Seldom diagnostic but valuable to exclude alternative diagnoses and establish presence of significant como

23、rbidities.Lung Volumes and Diffusing Capacity: Help to characterize severity, but not essential to patient management.Oximetry and Arterial Blood Gases: Pulse oximetry can be used to evaluate a patients oxygen saturation and need for supplemental oxygen therapy. Alpha-1 Antitrypsin Deficiency Screen

24、ing: Perform when COPD develops in patients of Caucasian descent under 45 years or with a strong family history of COPD. 2013 Global Initiative for Chronic Obstructive Lung DiseaseExercise Testing: Objectively measured exercise impairment, assessed by a reduction in self-paced walking distance (such

25、 as the 6 min walking test) or during incremental exercise testing in a laboratory, is a powerful indicator of health status impairment and predictor of prognosis.Composite Scores: Several variables (FEV1, exercise tolerance assessed by walking distance or peak oxygen consumption, weight loss and re

26、duction in the arterial oxygen tension) identify patients at increased risk for mortality. Global Strategy for Diagnosis, Management and Prevention of COPDAdditional Investigations 2013 Global Initiative for Chronic Obstructive Lung DiseaseDefinition and Overview Diagnosis and AssessmentTherapeutic

27、OptionsManage Stable COPDManage ExacerbationsManage ComorbiditiesAsthma COPD Overlap Syndrome (ACOS)Updated 2014 2014 Global Initiative for Chronic Obstructive Lung DiseaseGOLD2014诊断、管理和预防策略GOLD2014:COPD稳定期的管理目标减少症状COPD稳定期治疗目标降低风险缓解症状改善运动耐量改善健康状况预防疾病进展防治急性加重降低死亡率 COPD的稳定期管理（非药物治疗）患者基本推荐根据当地指南A戒烟（包括戒

28、烟的药物疗法）体力活动接种流感疫苗接种肺炎球菌疫苗B-D戒烟（包括戒烟的药物疗法）肺疾病康复训练*体力活动接种流感疫苗接种肺炎球菌疫苗*肺康复训练的和锻炼的益处不应被过分强调Global Strategy for Diagnosis, Management and Prevention of COPDTherapeutic Options: COPD MedicationsBeta2-agonists Short-acting beta2-agonists Long-acting beta2-agonistsAnticholinergics Short-acting anticholinerg

29、ics Long-acting anticholinergicsCombination short-acting beta2-agonists + anticholinergic in one inhaler MethylxanthinesInhaled corticosteroids Combination long-acting beta2-agonists + corticosteroids in one inhalerSystemic corticosteroidsPhosphodiesterase-4 inhibitors 2013 Global Initiative for Chr

30、onic Obstructive Lung DiseaseExacerbations per year 0mMRC 0-1CAT 2CAT 10 GOLD 3 GOLD 2 GOLD 1 SAMA prnor SABA prnLABA or LAMAICS + LABAor LAMA稳定期管理:首选药物治疗ABDCICS + LABAand/or LAMA 2or more or 1 leading to hospital admission1 (not leading to hospital admission) 2or more or 1 leading to hospital admis

31、sion1 (not leading to hospital admission) 0mMRC 0-1CAT 2CAT 10 GOLD 3 GOLD 2 GOLD 1 LAMA or LABA orSABA and SAMALAMA and LABA orLAMA and PDE4-inh orLABA and PDE4-inhICS + LABA and LAMA orICS + LABA and PDE4-inh orLAMA and LABA orLAMA and PDE4-inh.LAMA and LABA稳定期管理:次选药物治疗ADCBExacerbations per year 0

32、mMRC 0-1CAT 2CAT 10 GOLD 3 GOLD 2 GOLD 1 TheophyllineSABA and/or SAMATheophyllineCarbocysteineSABA and/or SAMATheophylline SABA and/or SAMATheophylline稳定期管理:其他药物治疗ADCBExacerbations per year 2or more or 1 leading to hospital admission1 (not leading to hospital admission)COPD稳定期：药物治疗策略 患者首选次选备选A组SAMA或

33、SABA（必要时）LAMA 或 LABA（长效受体激动剂）或SAMA+SABA茶碱B组LAMA或LABALAMA+LABASABA和/或SAMA 茶碱C组LAMA或ICS+LABALAMA + LABA或LAMA + PDE4-inh. 或LABA+ PDE4-inh. SABA和/或SAMA 茶碱D组ICS+LABA和/或LAMAICS+LABA和LAMA, 或ICS+LABA和磷酸二酯酶4抑制剂；或LAMA和LABA，或LAMA+磷酸二酯酶4抑制剂羧甲司坦SABA和/或 SAMA茶碱减少危险因素戒烟减少室内污染减少职业暴露接种流感疫苗稳定期管理: 针对所有患者PatientEssentia

34、l mendedDepending on local guidelinesASmoking cessation (can include pharmacologic treatment)Physical activityFlu vaccinationPneumococcal vaccinationB, C, DSmoking cessation (can include pharmacologic treatment)Pulmonary rehabilitationPhysical activityFlu vaccinationPneumococcal vaccination稳定期管理: 非药

35、物治疗PatientFirst choiceSecond choiceAlternative ChoicesASAMA prnor SABA prnLAMA orLABA orSABA and SAMATheophyllineBLAMA or LABALAMA and LABASABA and/or SAMATheophyllineCICS + LABAor LAMALAMA and LABAPDE4-inh.SABA and/or SAMATheophyllineDICS + LABAor LAMAICS and LAMA orICS + LABA and LAMA or ICS+LABA

36、and PDE4-inh. orLAMA and LABA orLAMA and PDE4-inh.CarbocysteineSABA and/or SAMATheophylline稳定期管理: 药物治疗吸入糖皮质激素FEV1%预计值60%的稳定期患者考虑肺炎的风险不推荐单用吸入激素治疗，但可以采用联合治疗，但联合治疗的时机尚不确定，临床医师需要权衡利弊采取个体化治疗稳定期管理: 药物治疗吸入糖皮质激素与支气管扩张剂联合治疗较单药应用可以使患者更获益考虑肺炎的风险稳定期管理: 药物治疗吸入支气管舒张剂中心治疗药物遵循个体化原则主张应用长效支气管舒张剂，联合治疗获益更多对于有呼吸道症状且FEV1

37、%预计值60%的稳定期患者，推荐应该用吸入抗胆碱药或长效受体激动剂等支气管扩张剂单药治疗，有助于降低急性加重，改善生活质量稳定期管理: 药物治疗不推荐长期口服激素治疗推荐应用PDE-4和Methylxanthines其他疫苗流感疫苗：每年一次肺炎疫苗：65岁及以上患者；65岁以下，FEV1%低于40%a-1抗胰蛋白酶治疗：不推荐不推荐稳定期抗生素治疗痰液溶解剂治疗有限不推荐镇咳药物和血管扩张剂稳定期管理: 药物治疗康复对于对于FEV1%预计值50%预计值如果药物充分治疗后仍然有症状或活动受限，临床医师也可以考虑进行肺康复稳定期管理: 非药物治疗All COPD patients benefit

38、 from exercise training programs with improvements in exercise tolerance and symptoms of dyspnea and fatigue. Although an effective pulmonary rehabilitation program is 6 weeks, the longer the program continues, the more effective the results. If exercise training is maintained at home, the patients

39、health status remains above pre-rehabilitation levels. 2014 Global Initiative for Chronic Obstructive Lung DiseaseGlobal Strategy for Diagnosis, Management and Prevention of COPDTherapeutic Options: Rehabilitation氧疗对于存在重度静息低氧血症（PaO255 mmHg或SpO288%）的COPD患者，推荐每天15小时以上的持续氧疗无创通气治疗外科手术 肺减容和肺移植稳定期管理: 非药物治

40、疗Palliative Care, End-of-life Care, Hospice Care: Communication with advanced COPD patients about end-of-life care and advance care planning gives patients and their families the opportunity to make informed decisions.Global Strategy for Diagnosis, Management and Prevention of COPDTherapeutic Option

41、s: Other Treatments 2013 Global Initiative for Chronic Obstructive Lung DiseaseGlobal Strategy for Diagnosis, Management and Prevention of COPD, 2014: Chapters Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage ComorbiditiesAsthma COPD Ove

42、rlap Syndrome (ACOS)Updated 2014 2014 Global Initiative for Chronic Obstructive Lung DiseaseCOPD急性加重的危害急性加重导致 对生活质量 不良影响 症状和肺功能影响 肺功能 减退加速 死亡率升高 经济成本 升高 气道炎症加重GOLD COPD 2013:急性加重定义 COPD患者的疾病自然史中发生的事件，特征为患者的基线呼吸困难、咳嗽和/或咳痰改变超过正常的逐日波动范围，为急性发作，可能需要改变常规药物治疗 GOLD 2006版 急性事件，特征为患者的呼吸症状加重，超过正常的逐日波动范围，且导致药物治

43、疗的改变 GOLD 2014版GOLD Revision 2011 2013 Global Initiative for Chronic Obstructive Lung DiseaseGOLD COPD 2014:急性加重评价 动脉血气分析: PaO26.7 kPa胸部影像学: 用于排除诊断心电图: 帮助诊断有无心脏问题血常规急性加重期间出现脓性痰生化检查: 电解质，血糖，营养不良肺功能: 急性加重期不推荐尽量减小本次急性加重的危害，预防下次急性加重的发生治疗目标 短效支气管扩张剂（SAMA和/或SABA）急性加重时长效支气管扩张剂联合吸入性糖皮质激素是否效果更好尚不确定茶碱仅适用短效支气管

44、扩张剂效果不佳时 全身糖皮质激素 抗生素主要药物选择Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease (2011). Summary Handout.AECOPD的管理药物治疗包括三大类支气管扩张剂、糖皮质激素、抗生素单一吸入短效2-激动剂，或短效2-激动剂短效支气管舒张剂为急性加重时优先选择的药物茶碱仅适用于短效支气管扩张剂效果不好的患者者，副作用较常见糖皮质激素糖皮质激素：改善肺功能（FEV1）和低氧血症降低治疗失败的风险，缩短住院时间，

45、推荐每日口服30-40mg强的松，5天泼尼松3040mg/d，1014天;雾化糖皮质激素治疗AECOPD与全身用药相近雾化糖皮质激素治疗非酸中毒AECOPD, 替代或减少全身激素的剂量；并减轻全身激素的副作用，作用；雾化吸入布地奈德 8mg 治疗AECOPD与全身泼尼松龙40mg疗效相当。抗菌药物适应症：AECOPD具有三个症状；即：呼吸困难、痰量增加、脓性痰时推荐使用，仅有2个症状其中一个是脓性痰时也推荐使用。病情危重需要机械通气者也推荐使用抗菌药物的推荐治疗疗程为 510 天抗菌药物的应用途径（口服或静脉给药），取决于患者的进食能力和药代动力学，最好予以口服治疗。COPD急性加重期的处理表

46、5.4 重度但非危及生命的急性加重的管理*评估症状的严重度、血气、胸片吸氧治疗，获取系列动脉血气分析结果支气管扩张剂：增加剂量和/或提高速效支气管扩张剂的使用频率速效2-激动剂与抗胆碱能制剂联用使用储雾罐或空气驱动的雾化器增加口服或静脉注射的激素有细菌性感染的表现时，考虑使用抗生素（口服或偶尔静脉注射）考虑无创机械通气在任何时候都应：监测液体平衡和营养考虑皮下注射肝素或低分子量肝素识别并治疗相关状况（如心衰，心律失常）密切监测患者的病情Global Strategy for Diagnosis, Management and Prevention of COPD, 2014: Chapters

47、 Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage ComorbiditiesAsthma COPD Overlap Syndrome (ACOS)Updated 2014 2014 Global Initiative for Chronic Obstructive Lung DiseaseGOLD COPD 2014:合并症的管理 心血管疾病：缺血性心肌病，心衰，房颤和高血压；选择性受体阻滞剂不推荐用于COPD治疗骨质疏

48、松和焦虑抑郁肺癌：在COPD患者中多发，是轻度COPD死亡的常见原因严重感染：严重呼吸道感染代谢综合症和糖尿病支气管扩张Global Strategy for Diagnosis, Management and Prevention of COPD, 2014: Chapters Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage ComorbiditiesAsthma COPD Overlap Syndrome (ACOS)Updated 2014 2014 Global Initiative for Chronic Obstructive Lung DiseaseGINA与GOLD联合