慢性阻塞性肺病.ppt

慢性阻塞性肺病的新進展,清華大學第一附屬醫(yī)院呼吸科,gold頒布的copd全球策略 2014年最新更新 慢性阻塞性肺疾病急性加重(aecopd)診治中國專家共識(草案),global strategy for diagnosis, management and prevention of copd, 2013: chapters,definition and overview diagnosis and assessment therapeutic options manage stable copd manage exacerbations manage comorbidities,updated 2013, 2013 global initiative for chronic obstructive lung disease,copd的定義,copd 是一種可以預防和可以治療的常見疾病, 其特征是持續(xù)存在的氣流受限。氣流受限呈進行性發(fā)展, 伴有氣道和肺對有害顆?；驓怏w所致慢性炎癥反應的增加。 急性加重和合并癥影響患者整體疾病的嚴重程度。,copd氣流受限的發(fā)病機制,airflow limitation, 2013 global initiative for chronic obstructive lung disease,copd的危險因素,肺的生長發(fā)育 性別 年齡 呼吸道感染 社會經(jīng)濟條件 哮喘 氣道高反應性 慢性支氣管炎,基因 有害顆粒暴露 吸煙 職業(yè)粉塵，有機物，無機物 室內燃料燃燒和通風不良 室外空氣污染, 2013 global initiative for chronic obstructive lung disease,copd的危險因素,genes,infections,socio-economic status,aging populations, 2013 global initiative for chronic obstructive lung disease,global strategy for diagnosis, management and prevention of copd, 2013: chapters,definition and overview diagnosis and assessment therapeutic options manage stable copd manage exacerbations manage comorbidities,updated 2013, 2013 global initiative for chronic obstructive lung disease,symptoms,chronic cough,shortness of breath,exposure to risk factors,tobacco,occupation,indoor/outdoor pollution,spirometry: required to establish diagnosis,copd的診斷,sputum, 2013 global initiative for chronic obstructive lung disease,copd的診斷,任何患有呼吸困難、慢性咳嗽或多痰的患者, 并且有暴露于危險因素的病史, 在臨床上需要考慮copd 的診斷 。 作出copd 的診斷需要進行肺功能檢查, 吸入支氣管擴張劑之后fev1 /fvc 0. 70 表明存在氣流受限, 即可診斷copd。,copd評估,copd 評估的目的是決定疾病的嚴重程度, 包括氣流受限的嚴重程度, 患者的健康狀況和未來的風險程度( 例如急性加重、住院或死亡) , 最終目的是指導治療。, 2013 global initiative for chronic obstructive lung disease,copd的評估,癥狀評估 氣流受限采用肺功能嚴重度分級 急性加重風險評估 合并癥評估, 2013 global initiative for chronic obstructive lung disease,*改良英國mrc 呼吸困難指數(shù)( modified british medical research council, mmrc ) *copd 評估測試( copdassessment test, cat) 。,癥狀的評估, 2013 global initiative for chronic obstructive lung disease,global strategy for diagnosis, management and prevention of copd modified mrc (mmrc)questionnaire, 2013 global initiative for chronic obstructive lung disease,氣流受限的評估,氣流受限程度仍采用肺功能嚴重度分級, 即fev1 占預計值80% 、50% 、30% 為分級標準。copd 患者的氣流受限的肺功能分級分為4 級( grades) , 即: gold 1輕度, gold 2中度, gold 3重度, gold 4非常嚴重。 使用支氣管擴張劑后，患者肺功能fev1 /fvc 0. 70 copd 分期( stage) 的概念已經(jīng)被廢除, 2013 global initiative for chronic obstructive lung disease,global strategy for diagnosis, management and prevention of copd classification of severity of airflow limitation in copd*,in patients with fev1/fvc 80% predicted gold 2: moderate 50% fev1 80% predicted gold 3: severe 30% fev1 50% predicted gold 4: very severe fev1 30% predicted *based on post-bronchodilator fev1, 2013 global initiative for chronic obstructive lung disease,急性加重風險評估,采用急性加重病史和肺功能評估急性加重的風險, 上一年發(fā)生2 次或以上的急性加重或fev1% pred 50% 提示風險增加需要正確評估合并癥并給予恰當?shù)闹委煛? 2013 global initiative for chronic obstructive lung disease,合并癥評估,心血管病 骨質疏松癥 呼吸道感染 焦慮和抑郁癥 糖尿病 肺癌 合并癥影響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),(b),mmrc 0-1 cat 10,4,3,2,1,mmrc 2 cat 10,symptoms (mmrc or cat score), 2013 global initiative for chronic obstructive lung disease,combined assessment of copd,(c),(d),(a),(b),mmrc 0-1 cat 10,mmrc 2 cat 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 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 0-1 cat 10,4,3,2,1,mmrc 2 cat 10,symptoms (mmrc or cat score),if gold 1 or 2 and only 0 or 1 exacerbations per year: low risk (a or b) if gold 3 or 4 or two or more exacerbations per year: high risk (c or d) (one or more hospitalizations for copd exacerbations should be considered high risk.),其次急性加重風險的評估, 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 0-1 cat 10,4,3,2,1,mmrc 2 cat 10,symptoms (mmrc or cat score),patient is now in one of four categories: a: less symptoms, low risk b: more symptoms, low risk c: less symptoms, high risk d: more symptoms, high risk,綜合評估, 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 0-1 cat 10,4,3,2,1,mmrc 2 cat 10,symptoms (mmrc or cat score), 2013 global initiative for chronic obstructive lung disease,combined assessment of copd, 2013 global initiative for chronic obstructive lung disease,global strategy for diagnosis, management and prevention of copd differential diagnosis: copd and asthma, 2013 global initiative for chronic obstructive lung disease,asthma-copd overlap syndrome acos(1),asthma is a heterogeneous 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 syndrome acos(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 contribute to the overall severity in individual patients. gold 2014,asthma-copd overlap syndrome acos(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 therefore identified by the features that it shares with both asthma and copd.,global strategy for diagnosis, management and prevention of copd additional investigations,胸部影象學: seldom diagnostic but valuable to exclude alternative diagnoses and establish presence of significant comorbidities. 肺容積和彌散功能: help to characterize severity, but not essential to patient management. 動脈血氣: 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 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 assessment therapeutic options manage stable copd manage exacerbations manage comorbidities,updated 2013, 2013 global initiative for chronic obstructive lung disease,copd的治療戒煙,幫助患者戒煙的五步策略 1. 詢問( ask) : 系統(tǒng)地對所有吸煙者進行詢問。建立一個相應的辦公系統(tǒng), 保證每個吸煙者每次隨訪時的吸煙狀態(tài)都能得到詳細的詢問和記錄。 2. 建議( advise) : 強烈建議每個吸煙者戒煙。態(tài)度要明確、堅定、有針對性, 鼓勵其戒煙。 3. 評估( assess) : 確定患者有無戒煙意愿。詢問每個吸煙者是否愿意在近期( 如30 d 內) 進行戒煙嘗試。 4. 幫助( assist) : 幫助患者戒煙。幫助吸煙者制定戒煙計劃; 提供實用可行的咨詢服務; 提供治療范圍內的社會支持; 幫助獲得治療范圍外的社會支持; 推薦使用僅在某些特定場合下批準的藥物; 提供輔助措施等。 5. 安排( arrange) : 安排隨訪計劃。通過患者本人親自來診或電話聯(lián)系, 安排隨訪。, 2013 global initiative for chronic obstructive lung disease,copd的治療,識別copd 的其他危險因素也相當重要, 其中包括職業(yè)粉塵和化學煙霧, 燃燒生物燃料所致的室內空氣污染, 廚房通風不佳等。這些因素在女性copd 患者的發(fā)病中尤為重要。,copd 的治療藥物, 2013 global initiative for chronic obstructive lung disease,支氣管擴張劑是用來改善肺功能fev1 或改善 其他肺功能參數(shù)的藥物, 其主要是通過改變氣道平滑肌的張力以擴張支氣管, 而不能改善肺彈性回縮力, 因而這類藥物稱為“支氣管擴張劑” 主要的支氣管擴張劑：beta2-agonists, anticholinergics, theophylline or combination therapy.,支氣管擴張劑, 2013 global initiative for chronic obstructive lung disease,支氣管擴張劑在copd 穩(wěn)定期中的應用,支氣管擴張劑是控制copd 癥狀的主要治療措施 首選吸入療法 如何選擇2 激動劑、抗膽堿能藥、茶堿類或聯(lián)合使用, 取決于藥物是否可以獲得以及不同個體的反應( 包括癥狀是否能控制、不良反應等) 短期按需使用支氣管擴張劑可緩解癥狀, 長期規(guī)律使用可預防和減輕癥狀 吸入長效支氣管擴張劑更為方便, 而且效果更好 與應用一種支氣管擴張劑的劑量相比, 聯(lián)合應用多種支氣管擴張劑可以增加療效, 減少不良反應,磷酸二酯酶-4 抑制劑 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), roflumilast, reduces exacerbations treated with oral glucocorticosteroids.,global strategy for diagnosis, management and prevention of copd therapeutic options: phosphodiesterase-4 inhibitors, 2013 global initiative for chronic obstructive lung disease,茶 堿,目前, 關于甲基黃嘌呤類藥物的具體作用還存在爭議。甲基黃嘌呤是非選擇性的磷酸二酯酶抑制劑, 除支氣管擴張作用外, 還有其他一些非支氣管擴張劑的作用, 但仍有爭議。 低劑量茶堿能減少copd 患者急性加重發(fā)作, 但不能增加應用支氣管擴張劑后的肺功能。 不良反應: 不良反應與劑量相關。, 2013 global initiative for chronic obstructive lung disease,吸入糖皮質激素(ics) 可以改善癥狀，肺功能，生活質量，減少急性加重的次數(shù)。,吸入糖皮質激素, 2013 global initiative for chronic obstructive lung disease,在重度copd患者中推薦聯(lián)合ics和laba/lama . 可以減少肺炎的風險,聯(lián)合治療, 2013 global initiative for chronic obstructive lung disease,避免長期使用全身糖皮質激素,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 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 copd therapeutic options: other pharmacologic 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: combination 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 copd therapeutic options: other treatments, 2013 global initiative 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 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 copd therapeutic options: surgical treatments, 2013 global initiative for chronic obstructive lung disease,global strategy for diagnosis, management and prevention of copd, 2014: major chapters,definition and overview diagnosis and assessment therapeutic options manage stable copd manage exacerbations manage comorbidities,updated 2013, 2013 global initiative for chronic obstructive lung disease,relieve symptoms improve exercise tolerance improve health status prevent disease progression prevent and treat exacerbations reduce 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 exposure influenza vaccination,manage stable copd: all copd patients, 2013 global initiative for chronic obstructive lung disease,manage stable copd: 非藥物, 2013 global initiative for chronic obstructive lung disease,manage stable copd: pharmacologic therapy,exacerbations per year, 2,1,0,mmrc 0-1 cat 10,gold 4,mmrc 2 cat 10,gold 3,gold 2,gold 1,sama prn or saba prn,laba or lama,ics + laba or lama,manage stable copd: 藥物治療recommended first choice,a,b,d,c,ics + laba and/or lama, 2013 global initiative for chronic obstructive lung disease, 2,1,0,mmrc 0-1 cat 10,gold 4,mmrc 2 cat 10,gold 3,gold 2,gold 1,lama or laba or saba and sama,lama and laba or lama and pde4-inh or laba and pde4-inh,ics + laba and lama or ics + laba and pde4-inh or lama and laba or lama and pde4-inh.,lama and laba,manage stable copd: 藥物治療 alternative choice,a,d,c,b,exacerbations per year, 2013 global initiative for chronic obstructive lung disease, 2,1,0,mmrc 0-1 cat 10,gold 4,mmrc 2 cat 10,gold 3,gold 2,gold 1,theophylline,saba and/or sama theophylline,carbocysteine saba and/or sama theophylline,saba and/or sama theophylline,manage stable copd: 藥物治療 other possible treatments,a,d,c,b,exacerbations per year, 2013 global initiative for chronic obstructive lung disease,global strategy for diagnosis, management and prevention of copd, 2013: major chapters,definition and overview diagnosis and assessment therapeutic options manage stable copd manage exacerbations manage comorbidities,updated 2013, 2013 global initiative for chronic obstructive lung disease,copd 常常和其他疾病合并存在, 可對疾病的進展產(chǎn)生顯著影響。 存在合并癥不需要改變copd 的治療。 根據(jù)各種合并癥的指南進行治療,合并癥的治療, 2013 global initiative for chronic obstructive lung disease,global strategy for diagnosis, management and prevention of copd, 2013: chapters,definition and overview diagnosis and assessment therapeutic options manage stable copd manage exacerbations manage 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)診治中國專家共識(草案) 2012年12月,manage exacerbations,aecopd的概述、病因及診斷 aecopd的住院治療指征和分級治療 aecopd患者的藥物治療 aecopd患者的機械通氣 aecopd出院和預防,aecopd 定義,copd急性加重是指一種急性起病的過程，其特征是患者呼吸系統(tǒng)癥狀惡化，超出日常的變異，并且導致需要改變藥物治療。,如果胸片出現(xiàn)肺部陰影，符合感染表現(xiàn)，則診斷為社區(qū)獲得性肺炎。 -2011年歐洲成人下呼吸道感染的診治指南,aecopd versus cap aecopd cap + copd,aecopd is not cap,aecopd的概述,原因：上呼吸道病毒感染、氣管-支氣管細菌感染 治療目標：減輕急性加重的病情，預防再次急性加重 治療：支氣管擴張劑、糖皮質激素、抗菌藥，不推薦抗病毒藥物 預防：戒煙、接種疫苗、掌握治療知識、單用吸入支氣管擴張劑或聯(lián)用吸入糖皮質激素、應用磷酸二酯酶-4抑制劑,aecopd 病因,sethi et al. chest 2000;117:380s-385s,80% 感染,20% 非感染,細菌病原體 40 - 50% 病毒感染 40 - 50% 非典型病原體 5 - 10%,環(huán)境因素 吸煙 大氣污染 吸入變應原 未遵循醫(yī)囑 進行治療,* aecopd可能起源于病毒感染、細菌感染或非感染因素（吸煙、環(huán)境污染和未進行有效治療等）,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,冠狀病毒,流感病毒,腺病毒,呼吸道合胞體病毒（rsv),副流感病毒,aecopd病毒感染率以鼻病毒和rsv 最為常見,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，常見為鼻病毒屬(64%)、呼吸道合胞病毒和流感病毒。,慢性疾病,逐漸進展 肺功能 癥狀 合并癥,急性加重,典型病例每年13次急性加重 發(fā)生頻率與copd嚴重程度成比例 經(jīng)常發(fā)生aecopd者病情加速進展，導致： 生活質量 反復住院 死亡率增加,copd 與 aecopd,原因：可由多種因素所致。最常見為病毒性上呼吸道感染和氣管支氣管感染。 診斷： 唯一依靠患者急性起病和癥狀加重的臨床表現(xiàn)（呼吸困難、咳嗽、多痰），這些變化超出正常的日間變異。 目前沒有單一生物標志物可應用于aecopd的臨床診斷和評估 aecopd的治療目標：減輕當前急性加重的臨床表現(xiàn)和預防以后急性加重發(fā)生。,aecopd的嚴重性評估,global strategy for the diagnosis, management, and revention of chronic obstructive pulmonary disease.(2013),aecopd 的輔助檢查,脈氧或動脈血氣：用來監(jiān)測和/或調整氧療方案，必要時需要機械通氣 胸片：有助于除外其他診斷 心電圖：有助于診斷合并的心臟疾病 血常規(guī)：有助于發(fā)現(xiàn)rbc增多(hct55%)，貧血或wbc增多 痰培養(yǎng)：初始抗生素治療無效，需進行痰培養(yǎng) 生化檢查：有助于發(fā)現(xiàn)電解質紊亂和血糖增高,急性加重期間不推薦行肺功能檢查，因患者無法 配合且檢查結果不夠準確,aecopd 鑒別診斷,鑒別 診斷,肺 炎,充血性心衰,氣 胸,胸腔積液,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、病因及診斷 aecopd的住院和分級治療 aecopd患者的藥物治療 aecopd患者的機械通氣 aecopd出院和預防,aecopd的分級治療, 級: 門診治療 級: 住院治療 級: 入icu 治療,2004 年atsers 推出慢阻肺診斷和治療標準時，將aecopd 嚴重度分為 3 級：級，門診治療；級，普通病房住院治療；級，入icu 治療（急性呼吸衰竭）。,aecopd門診患者的處理,aecopd普通病房患者的處理,aecopd icu患者的處理,aecopd的概述、病因及診斷 aecopd的住院治療指征和分級治療 aecopd患者的藥物治療 aecopd患者的機械通氣 aecopd出院和預防,aecopd：住院治療治療措施,控制性氧氣治療,支氣管擴張劑(bds): 短效支氣管擴張劑 -激動劑 抗膽堿藥物 甲基黃嘌呤,機械通氣: 無創(chuàng) 有創(chuàng),aecopd,糖皮質激素治療:口服, 靜脈滴注, 或吸入,抗生素,gold revision 2013,aecopd( 但無生命危險)患者的治療,評估癥狀的嚴重程度、血氣分析、胸片 氧療和系列測定動脈血氣 支氣管擴張劑 增加短效支氣管擴張劑的劑量和/ 或次數(shù) 聯(lián)合應用短效2 激動劑和抗膽堿能藥物 應用儲霧器或氣動霧化裝置 加用口服或靜脈糖皮質激素 細菌感染, 考慮應用抗生素( 口服, 或偶爾靜脈應用抗生素) 考慮無創(chuàng)通氣 隨時: 監(jiān)測液體平衡和營養(yǎng) 考慮應用肝素或低分子肝素皮下注射 鑒別和治療合并癥( 心力衰竭、心律不齊) 密切監(jiān)護患者,aecopd 藥物治療,控制性氧療 氧療是aecopd 住院患者的基礎治療 吸入氧濃度不宜過高 氧療30min后復查血氣, 確認氧合滿意, 未引起co2 潴留和(或)呼吸性酸中毒 支氣管舒張劑 短效支氣管舒張劑霧化溶液 吸入用硫酸沙丁胺醇溶液 異丙托溴銨霧化吸入溶液 吸入用復方異丙托溴銨溶液 靜脈使用甲基嘌呤類藥物,aecopd 藥物治療,糖皮質激素 應用支氣管舒張劑的基礎上,可加用糖皮質激素口服或靜脈治療 可單獨霧化吸入布地奈德替代口服激素治療 吸入用布地奈德混懸液(budesoni