【8A文】《慢阻肺诊断、治疗与预防全球倡议(GOLD)》2018版

1、慢阻肺诊断、治疗与预防全球倡议（GOLD）2018版 解读,要点概述,1. GOLD 2018沿用了GOLD 2017对慢阻肺和AECOPD的定义，维持了慢阻肺综合评估以及稳定期药物治疗推荐，主要对各章节的循证证据进行了更新。 2. 支气管扩张剂仍是慢阻肺稳定期治疗的基石用药：唯有LAMA是所有分组患者的首选单药治疗药物；LAMA预防急性加重优于LABA；LAMA/LABA联用是B-D组患者的推荐用药。 3. 适合以ICS/LABA作为起始治疗药物的患者限于某些特定亚型的患者人群。,第一章：定义和概述,GOLD 2018维持了GOLD 2017对慢阻肺的定义：“慢阻肺是可防可治的常见病，以持续性呼吸道症状和气流受限为特点，常与有毒颗粒或气体的显著暴露引起的气道和/或肺泡异常有关”。,慢阻肺的病理生理学,1、医学研究委员会国家卫生与发展调查发现，在43岁时，肺功能受吸烟和婴幼儿呼吸道感染以及童年家庭过度拥挤的协同交互作用影响。 The Medical Research Council National Survey of Health and Development recently d

2、ocumented a synergistic interaction between smoking and infant respiratory infection as well as early life home overcrowding with lung function at age 43. (Allinson et al., 2017) 2、来自我国的一项横断面研究显示，周围环境的PM 2.5/10 水平与慢阻肺患病率相关。 A recent cross-sectional analysis from China showed an association between ambient levels of particulate matter (PM2.5/10) and COPD prevalence. (Liu et al., 2017). 3、局部 IgA 缺乏与细菌移位、小气道炎症以及气道重塑相关。 A recent study suggests that local IgA deficiency is associated with bacterial t

3、ranslocation, small airway inflammation and airway remodeling. (Polosukhin et al., 2017) 4、即使在轻度慢阻肺，或易发生肺气肿的吸烟人群，其肺部微血管血流存在显著异常，并随疾病进展而恶化。 Even in mild COPD, or in smokers susceptible to emphysema, (Alford, van Beek, McLennan, Iyer et al., 2016) there are significant abnormalities in pulmonary microvascular blood flow that worsen with disease progression. (Peinado, Pizarro, & Barbera, 2008).,第二章：诊断和起始评估 慢阻肺的诊断,在利用肺功能检查评价气流受限时，考虑到某些患者在下一次测量时FEV1/FVC会随生理性变化而改变，若使用支扩剂后FEV1/FVC介于0.6-0.8，应在另一场合再次测量以确

4、诊。 Assessment of the presence or absence of airflow obstruction based on a single measurement of the post-bronchodilator FEV1/FVC ratio should be confirmed by repeat spirometry on a separate occasion if the value is between 0.6 and 0.8, as in some cases the ratio may change as a result of biological variation when measured at a later interval (Aaron et al., 2017; Schermer et al., 2016) If the initial post-bronchodilator FEV1/FVC ratio is less than 0.6 it is very unlikely to rise above 0.7 sponta

5、neously.(Aaron et al., 2017) ABCD评估工具 GOLD 2018维持了慢阻肺综合评估的临床路径，在ABCD分组的急性加重史中注明了是 “中到重度急性加重史” (图1)。,2018版慢阻肺综合评估流程,急性加重风险的评估 。,目前已开展多项采用GOLD肺功能标准对患者进行分级的大型临床研究，这些研究显示急性加重率在患者个体间和随访期间存在非常大的变异率。 A number of large studies that classified patients using the GOLD spirometric grading systems have been conducted. (Decramer et al., 2009; Hurst et al., 2010; Jenkins et al., 2009) These studies demonstrate that exacerbation rates vary greatly between patients (Hurst et al., 2010) and during follow-up. (Ha

6、n et al., 2017) 注： GOLD 2018维持了2017版对AECOPD的定义和分级。AECOPD的定义为呼吸道症状的急性恶化，导致需要额外治疗。急性加重史是预测频繁急性加重 (年AECOPD2) 的最佳预测因子。,AECOPD的分级包括：,轻度：仅需要短效支扩剂治疗； 中度：需要短效支扩剂联合抗生素和/或口服糖皮质激素治疗； 重度：患者需要住院或者至急诊就诊；重度急性加重还可能伴随急性呼吸衰竭。,第三章：基于证据支持的预防及维持治疗 戒烟与电子烟,1、除了个人主动戒烟，通过立法禁烟能够有效提高戒烟率、降低二手烟暴露导致的危害。 Besides individual approaches to smoking cessation, legislative smoking bans are effective in increasing quit rates and reducing harm from second-hand smoke exposure. (Frazer et al., 2016) 2、吸入电子烟会改变吸烟者的肺部宿主反应。 Recent data su

7、ggest that e-cigarette inhalation alters the lung host response in smokers. (Reidel et al., 2017) 注： 这篇发表在Am J Respir Crit Care Med(IF = 13.2) 的最新研究显示，吸入电子烟会改变气道分泌和固有免疫相关的蛋白表达，进而引起中性粒细胞激活和黏液分泌功能改变，这些效应与传统吸烟部分重叠。该研究挑战了“电子烟比传统卷烟更为健康”的观点。,药物治疗-支扩剂,1、患者基线症状越重，联用双支扩剂 (LAMA/LABA) 相比安慰剂或对应单药对生活质量带来的改善越显著。 2、一项双盲平行组的RCT显示,与常规噻托溴铵相比，使用外固定三联疗法治疗症状性COPD的患者有临床益处。 3、另一项双盲RCT表明三联FDC治疗晚期慢阻肺效果优于ICS/LABA。,药物治疗-PDE4抑制剂,对于有既往急性加重住院史的患者，罗氟司特能带来更多的临床获益。 The beneficial effects of roflumilast have been reported to be

8、greater in patients with a prior history of hospitalization for an acute exacerbation. (Han et al., 2014; Rabe, Calverley, Martinez, & Fabbri, 2017),药物治疗-抗生素,1、相比常规治疗，高风险患者接受阿奇霉素 (250mg/天, 或500mg 一周三次) 或红霉素 (500mg BID) 治疗1年降低急性加重风险。 2、应用阿奇霉素与细菌耐药和听力受损相关。 3、一项事后分析表明现吸烟者从阿奇霉素中得到的治疗获益较少。 4、目前没有研究评价阿奇霉素长期治疗1年以上时预防急性加重的有效性或安全性。 Azithromycin (250 mg/day or 500 mg three times per week) or erythromycin (500 mg two times per day) for one year in patients prone to exacerbations reduced the risk of exacerb

9、ations compared to usual care. (Albert et al., 2011; Seemungal et al., 2008; Uzun et al., 2014) Azithromycin use was associated with an increased incidence of bacterial resistance and impaired hearing tests. (Albert et al., 2011) A post-hoc analysis suggests lesser benefit in active smokers. (Han et al., 2014) There are no data beyond one-year of chronic azithromycin treatment showing the efficacy or safety of its use to prevent COPD exacerbations.,肺康复,1、肺康复可以在多种场所开展。家庭肺康复对资源需求小，是门诊肺康复的等效替代方案，也利于住所远离康复场所的患者开展治疗。 Pulmonary rehabilitation can be conducted at a range of sites. (Spruit et al., 2013) Home rehabilitation delivered with minimal resources in patients with COPD may be an equivalent alternative to facility located outpatient rehabilitation. (Holland et al., 2017) Home rehabilitation may be a solution for many patients who live outside the reach of facility-based programs. 2、肺康复的获益似乎随时间推移逐渐减少。长期肺康复治疗可以维持初次康复治疗后的获益，但也有一项研究指出获益在随访期间减少。 Another challenge is that the benefits

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