慢性阻塞性肺病的新进展2014--cai

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 Assessment Therapeutic Options Manage Stable COPD Manage Exacerbations Manage Comorbidities,Updated 2013,© 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 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 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的诊断,è,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, CAT) 。,症状的评估,© 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,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 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),(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.),其次急性加重风险的评估,© 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,综合评估,© 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