何谓慢性阻塞性肺病香港医学会课件

ExercisePrescriptionfor

COPD&AsthmaDr.RolandLeungMBBSMDFRACPFCCPFHKCPFHKAM(Medicine)SpecialistinRespiratoryMedicineExercisePrescriptionfor

COP1何謂慢性阻塞性肺病慢性阻塞性肺病簡稱「慢阻肺病」，是常見的肺病一種肺功能受損的疾病病人肺部的氣流進出受阻，令患者呼吸困難慢阻肺病十分常見。早期病徵不明顯，往往在診斷時，病情己步入中至晚期何謂慢性阻塞性肺病慢性阻塞性肺病簡稱「慢阻肺病」，是常見2100,000人「2000-2003香港肺功能研究計劃」10萬人病情屬中度嚴重,

還沒有接受任何醫療診治100,000人「2000-2003香港肺功能研究計劃」13為什麼慢性支氣管炎及肺氣腫

會阻塞呼吸道?慢性支氣管炎

氣管長期受刺激及發炎，內膜腫脹及有痰液黏於管內，阻塞氣道。肺氣腫

肺部受到長期刺激，支氣管及氣泡經常發炎，肺氣泡受到破壞，影響換氣功能。為什麼慢性支氣管炎及肺氣腫

會阻塞呼吸道?慢性支氣管炎

氣4慢阻肺病有什麼徵狀?持續咳嗽

咳嗽時有痰或黏液

由於氣管的病變，例如支氣管壁腫脹及氣管平滑肌收縮，加上黏液腺肥大以致分泌增加，患者經常咳嗽及多痰。慢阻肺病有什麼徵狀?持續咳嗽

咳嗽時有痰或黏液

由於氣管的5呼吸困難

(如上樓梯、行樓梯及梳洗更衣時)氣促會隨肺功能的退化愈趨嚴重，影響患者的日常生活。在空氣質素轉差或有急性支氣管炎的時候，病徵會表現得更為嚴重。慢阻肺病有什麼徵狀?呼吸困難

(如上樓梯、行樓梯及梳洗更衣時)氣促會隨肺功能的6何谓慢性阻塞性肺病香港医学会课件7慢阻肺病影響個人、家庭及社會全球每年有近三百萬人死於慢阻肺病根據世界衛生組織資料，慢阻肺病是全球第四大殺手病，排名僅次於心臟病發、中風及急性肺炎死於慢阻肺病的人數較癌症為多，並與死於愛滋病的人數相同慢阻肺病影響個人、家庭及社會全球每年有近三百萬人死於慢阻肺病8本港第五大殺手病據二零零一年的衞生署年報指出，慢阻肺病是本港第五大殺手急症入院主因之一，每十張醫管局病床之中，大概有一張是慢阻肺病病人佔有本港第五大殺手病據二零零一年的衞生署年報指出，慢阻肺病是本港9四十歲以上吸煙或其他類型的煙草（包括二手煙）長期暴露於塵多的環境，或工作期間吸入某些化學物品長期暴露於煙霧（如用作煮食的生物燃料產生的煙霧

)引致慢阻肺病之危險因素四十歲以上引致慢阻肺病之危險因素10正常人45歲戒煙吸煙的COPD病人65歲戒煙255075FEV1比率(相對25歲的男性)1000慢阻肺病危機及停止吸煙755025年齡(年)死亡

殘疾正常人45歲戒煙吸煙的COPD病人65歲戒煙2511AirflowLimitationinCOPD:

HyperinflationandExerciseAirflowLimitationinCOPD:

H12ReviewofTerminologyTotallungcapacityResidualvolumeInspiratorycapacityInspiratoryreservevolumeTidalvolumeExpiratoryreservevolume

VitalcapacityFunctionalresidualcapacityReviewofTerminologyTotalResi13TidalVolumeatrestVTEELVEILVIRVERVMildCOPDHealthyBreathingfrequencyatrest:12–15/min=4secHealthysubjects: breathingresttimeInspirationExpirationSevere

COPDCOPDpatients: lessbreathingresttimeTidalVolumeatrestVTEELVEILV14DynamicHyperinflationVTIRVERVICFRCRVTLC„Normal“Airtrappingatrest„Years-Decades“Static

HyperinflationAirtrappingfromexertion„Seconds-Minutes“Dynamic

HyperinflationDynamicHyperinflationVTIRVERV15age40-5050-5555-6060-70age40-5050-16TotheCOPDpatient,thisisabreathtakingview.TotheCOPDpatient,thisisa17ClinicalCourseofCOPDAirTrappingExpiratoryFlowLimitationBreathlessnessInactivityPoorHealth-RelatedQualityofLifeHyperinflationDeconditioningCOPD

EXACERBATIONSDisabilityDiseaseprogressionDeathReducedExercise

CapacityClinicalCourseofCOPDAirT18EffectofExerciseonDyspneaExercisetimeDyspneaIntensity(BorgScale)VerysevereSevereSomewhatsevereModerateSlightVeryslightNoneatallPre-exerciseEnd-exerciseExerciseStopsIsotimePostbronchodilationEffectofExerciseonDyspneaE19Relievespatients’breathlessnessduringphysicallydemandingexerciseSPIRIVAreducesactivity-inducedbreathlessnessby19%(P<0.001)Relievespatients’breathlessn20SPIRIVAincreasesexerciseendurancetimeExhibited42%differenceinmeanexerciseendurancetimeSPIRIVAincreasesexerciseend21

PulmonaryRehabilitation

Thisistheprocessofmaximisingthepatientsphysical,mentalandsocialwellbeingbyanindividualisedprogramofexercisesandeducation

PulmonaryRehabilitation

22WhyPR?AllCOPDpatientsbenefitfromexercisetrainingprograms.Improvementinbothexercisetoleranceandsymptomsofdyspnoeaandfatigue.Evidencetoshowreduceexacerbationsandhospitaladmissions.

BTS&GOLDWhyPR?BTS&GOLD23PulmonaryRehabilitationIdeallyComprisesof:ExerciseEmpowermentDietPsychologicalwell-beingPulmonaryRehabilitationIdeall24PR&ExerciseSupervisedtraining2-5timesperweekMinimum20-30minuteseachtime(maytakeatimetoreachthislevel)Coursedurationof4-12weeksItshouldinvolvebothupper&lowerlimbexercisesbothforenduranceandstrength

PR&Exercise25ComponentsofExercisePrescriptionMode(Typeofexercise)IntensityDurationFrequencyProgressionofExerciseProgrammeComponentsofExercisePrescri26PR&ExerciseSTRETCHINGofthemajormusclegroupsofbothupperandlowerextremities.

AEROBICEXERCISESe.g.walking,cycling,rowing,swimming,etc.FREQUENCY-is2to5timesperweekwithaimofdailyroutine.INTENSITY-“maximumlimittoleratedbysymptoms”orto60to75%of

maximalheartrateDURATION-20to30minofcontinuousexerciseORifthisisnotpossible,intervaltraining=twotothreeminofhigh-intensitytrainingalternatingwithequalperiodsof

rest.PR&Exercise27PR&DietCOPDcanbeadverselyaffectedifthepatientismalnourishedoroverweight.Theformerleadstomusclebulkloss(diaphragm&accessorymusclesofrespiration)andthelatteranextraburdenonthecardio-respiratorysystem

PR&Diet28SPIRIVAdemonstratessuperiorimprovementsinbreathlessnesspostrehabCombinedrehabwithSPIRIVAresultsinextended,superioroutcomesinbreathlessnesscomparedwithrehabaloneCasaburi,etalChest2005SPIRIVAdemonstratessuperior29物理治療方法物理治療方法30何谓慢性阻塞性肺病香港医学会课件31何谓慢性阻塞性肺病香港医学会课件32何谓慢性阻塞性肺病香港医学会课件33何谓慢性阻塞性肺病香港医学会课件34EIAinChildren:ScopeoftheProblemEIBmayinterferewithphysicalactivityandpersonalmorale.AdaptedfromAmericanLungAssociation.Availableat:/site/pp.asp?c=dvLUK9O0E&b=22782;RandolphCCurrProblPediatr1997;27:53–77.ChildrenwithasthmaAbout20%haveasthmasymptomsonlyduringexerciseMorethan80%haveEIBEIAinChildren:Scopeofthe35DiagnosticCriteriaforEIA*After5minutesofexerciseat85%–90%ofmaximumAdaptedfromGotshallRWDrugs2002;62:1725–1739.Reliefofairwayobstructionwithexerciseafteruseofinhaledbeta2-agonist

Historyofasthma

symptomsCoughing,wheezing,or

shortnessofbreathwithexercisePositiveexercise

testBeta2-agonist

reversibility10%to20%decrease

inFEV1*DiagnosticCriteriaforEIA*Af36PossibleRoleofCysteinylLeukotrienes

inEIAMastcellmediatorsLeukotrienesHistamineProstaglandinsAdaptedfromGotshallRWDrugs2002;62:1725–1739;RandolphCCurrProblPediatr1997:27:53–77.BronchospasmInflammationAirwayobstructionExercise/activityand

othertriggersPossibleRoleofCysteinylLeu37PossibleTherapeuticOptionsforEIASABAs=short-actingbeta2-agonists;LABAs=long-actingbeta2-agonists;ICS=inhaledcorticosteroids;

LTRAs=leukotrienereceptorantagonists*MayrequirecombinationtherapyAdaptedfromGotshallRWDrugs2002;62:1725–1739;HancoxRJetalAmJRespirCritCareMed2002;165:1068–1070.AgentsEffective

inEIBNo

development

oftoleranceDosingnot

requiredimmediatelybeforeexerciseInhaledSABAsXXLABAsX?ICS?*LTRAsPossibleTherapeuticOptionsf38ExercisePrescriptionforAsthmaticsMakesuretheunderlyingasthmaiswell-controlled

exerciseisnotrecommendedduringexacerbationPre-medicationbeforeexerciseisessential

confidence selfassuranceAdequatewarm-upEducatetheparentsandcaregivers

anxiety

Exercisemostsuitableforasthmatics

swimming slowjoggingExercisePrescriptionforAsth39問題時間問題時間40ExercisePrescriptionfor

COPD&AsthmaDr.RolandLeungMBBSMDFRACPFCCPFHKCPFHKAM(Medicine)SpecialistinRespiratoryMedicineExercisePrescriptionfor

COP41何謂慢性阻塞性肺病慢性阻塞性肺病簡稱「慢阻肺病」，是常見的肺病一種肺功能受損的疾病病人肺部的氣流進出受阻，令患者呼吸困難慢阻肺病十分常見。早期病徵不明顯，往往在診斷時，病情己步入中至晚期何謂慢性阻塞性肺病慢性阻塞性肺病簡稱「慢阻肺病」，是常見42100,000人「2000-2003香港肺功能研究計劃」10萬人病情屬中度嚴重,

還沒有接受任何醫療診治100,000人「2000-2003香港肺功能研究計劃」143為什麼慢性支氣管炎及肺氣腫

會阻塞呼吸道?慢性支氣管炎

氣管長期受刺激及發炎，內膜腫脹及有痰液黏於管內，阻塞氣道。肺氣腫

肺部受到長期刺激，支氣管及氣泡經常發炎，肺氣泡受到破壞，影響換氣功能。為什麼慢性支氣管炎及肺氣腫

會阻塞呼吸道?慢性支氣管炎

氣44慢阻肺病有什麼徵狀?持續咳嗽

咳嗽時有痰或黏液

由於氣管的病變，例如支氣管壁腫脹及氣管平滑肌收縮，加上黏液腺肥大以致分泌增加，患者經常咳嗽及多痰。慢阻肺病有什麼徵狀?持續咳嗽

咳嗽時有痰或黏液

由於氣管的45呼吸困難

(如上樓梯、行樓梯及梳洗更衣時)氣促會隨肺功能的退化愈趨嚴重，影響患者的日常生活。在空氣質素轉差或有急性支氣管炎的時候，病徵會表現得更為嚴重。慢阻肺病有什麼徵狀?呼吸困難

(如上樓梯、行樓梯及梳洗更衣時)氣促會隨肺功能的46何谓慢性阻塞性肺病香港医学会课件47慢阻肺病影響個人、家庭及社會全球每年有近三百萬人死於慢阻肺病根據世界衛生組織資料，慢阻肺病是全球第四大殺手病，排名僅次於心臟病發、中風及急性肺炎死於慢阻肺病的人數較癌症為多，並與死於愛滋病的人數相同慢阻肺病影響個人、家庭及社會全球每年有近三百萬人死於慢阻肺病48本港第五大殺手病據二零零一年的衞生署年報指出，慢阻肺病是本港第五大殺手急症入院主因之一，每十張醫管局病床之中，大概有一張是慢阻肺病病人佔有本港第五大殺手病據二零零一年的衞生署年報指出，慢阻肺病是本港49四十歲以上吸煙或其他類型的煙草（包括二手煙）長期暴露於塵多的環境，或工作期間吸入某些化學物品長期暴露於煙霧（如用作煮食的生物燃料產生的煙霧

)引致慢阻肺病之危險因素四十歲以上引致慢阻肺病之危險因素50正常人45歲戒煙吸煙的COPD病人65歲戒煙255075FEV1比率(相對25歲的男性)1000慢阻肺病危機及停止吸煙755025年齡(年)死亡

殘疾正常人45歲戒煙吸煙的COPD病人65歲戒煙2551AirflowLimitationinCOPD:

HyperinflationandExerciseAirflowLimitationinCOPD:

H52ReviewofTerminologyTotallungcapacityResidualvolumeInspiratorycapacityInspiratoryreservevolumeTidalvolumeExpiratoryreservevolume

VitalcapacityFunctionalresidualcapacityReviewofTerminologyTotalResi53TidalVolumeatrestVTEELVEILVIRVERVMildCOPDHealthyBreathingfrequencyatrest:12–15/min=4secHealthysubjects: breathingresttimeInspirationExpirationSevere

COPDCOPDpatients: lessbreathingresttimeTidalVolumeatrestVTEELVEILV54DynamicHyperinflationVTIRVERVICFRCRVTLC„Normal“Airtrappingatrest„Years-Decades“Static

HyperinflationAirtrappingfromexertion„Seconds-Minutes“Dynamic

HyperinflationDynamicHyperinflationVTIRVERV55age40-5050-5555-6060-70age40-5050-56TotheCOPDpatient,thisisabreathtakingview.TotheCOPDpatient,thisisa57ClinicalCourseofCOPDAirTrappingExpiratoryFlowLimitationBreathlessnessInactivityPoorHealth-RelatedQualityofLifeHyperinflationDeconditioningCOPD

EXACERBATIONSDisabilityDiseaseprogressionDeathReducedExercise

CapacityClinicalCourseofCOPDAirT58EffectofExerciseonDyspneaExercisetimeDyspneaIntensity(BorgScale)VerysevereSevereSomewhatsevereModerateSlightVeryslightNoneatallPre-exerciseEnd-exerciseExerciseStopsIsotimePostbronchodilationEffectofExerciseonDyspneaE59Relievespatients’breathlessnessduringphysicallydemandingexerciseSPIRIVAreducesactivity-inducedbreathlessnessby19%(P<0.001)Relievespatients’breathlessn60SPIRIVAincreasesexerciseendurancetimeExhibited42%differenceinmeanexerciseendurancetimeSPIRIVAincreasesexerciseend61

PulmonaryRehabilitation

Thisistheprocessofmaximisingthepatientsphysical,mentalandsocialwellbeingbyanindividualisedprogramofexercisesandeducation

PulmonaryRehabilitation

62WhyPR?AllCOPDpatientsbenefitfromexercisetrainingprograms.Improvementinbothexercisetoleranceandsymptomsofdyspnoeaandfatigue.Evidencetoshowreduceexacerbationsandhospitaladmissions.

BTS&GOLDWhyPR?BTS&GOLD63PulmonaryRehabilitationIdeallyComprisesof:ExerciseEmpowermentDietPsychologicalwell-beingPulmonaryRehabilitationIdeall64PR&ExerciseSupervisedtraining2-5timesperweekMinimum20-30minuteseachtime(maytakeatimetoreachthislevel)Coursedurationof4-12weeksItshouldinvolvebothupper&lowerlimbexercisesbothforenduranceandstrength

PR&Exercise65ComponentsofExercisePrescriptionMode(Typeofexercise)IntensityDurationFrequencyProgressionofExerciseProgrammeComponentsofExercisePrescri66PR&ExerciseSTRETCHINGofthemajormusclegroupsofbothupperandlowerextremities.

AEROBICEXERCISESe.g.walking,cycling,rowing,swimming,etc.FREQUENCY-is2to5timesperweekwithaimofdailyroutine.INTENSITY-“maximumlimittoleratedbysymptoms”orto60to75%of

maximalheartrateDURATION-20to30minofcontinuousexerciseORifthisisnotpossible,intervaltraining=twotothreeminofhigh-intensitytrainingalternatingwithequalperiodsof

rest.PR&Exercise67PR&DietCOPDcanbeadverselyaffectedifthepatientismalnourishedoroverweight.Theformerleadstomusclebulkloss(diaphragm&accessorymusclesofrespiration)andthelatteranextraburdenonthecardio-respiratorysystem

PR&Diet68SPIRIVAdemonstratessuperiorimprovementsinbreathlessnesspostrehabCombinedrehabwithSPIRIVAresultsinextended,superioroutcomesinbreathlessnesscomparedwithrehabaloneCasaburi,etalChest2005SPIRIVAdemonstratessuperior69物理治療方法物理治療方法70何谓慢性阻塞性肺病香港医学会课件71何谓慢性阻塞性肺病香港医学会课件72何谓慢性阻塞性肺病香港医学会课件73何谓慢性阻塞性肺病香港医学会课件74EIAinChildren:ScopeoftheProblemEIBmayinterferewithphysicalactivityandpersonalmorale.AdaptedfromAmericanLungAssociation.Availableat:/site/pp.asp?c=dvLUK9O0E&b=22782;RandolphCCurrProblPediatr1997;27:53–77.ChildrenwithasthmaAbout20%haveasthmasymptomsonlyduringexerciseMorethan80%haveEIBEIAinChildren:Scopeofthe75DiagnosticCriteriaforEIA*After5minutesofexerciseat85%–90%ofmaximumAdaptedfromGotshallRWDrugs2002;62:1725–1739.Reliefofairwayobstructionwithexerciseafteruseofinhaledbeta2