1、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
2、2013 2013 Global Initiative for Chronic Obstructive Lung Disease COPD的定义的定义 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气流受限的气流受限的发发病机制病机制 Small Airways Disease Airway inflammation Airway fibrosis,luminal plugs Increased airway resistance Paren
3、chymal Destruction Loss of alveolar attachments Decrease of elastic recoil AIRFLOW LIMITATION 2013 Global Initiative for Chronic Obstructive Lung Disease COPD的危的危险险因素因素 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 Obstruct
4、ive Lung Disease COPD的危的危险险因素因素 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 Mana
5、ge 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的的诊诊断断 sput
6、um 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
7、 Obstructive Lung Disease COPD的评估的评估 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)。症状的症状的评评估估 2013 Global Initiative for Chronic Obstructive Lung Disease
8、 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FEV
9、1/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:Se
10、vere 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 2 1 0(C)(D)(A)(B)mMRC 0-1 CAT 2 CAT 10 Symptoms(mMRC or CAT score)2013 Globa
11、l Initiative for Chronic Obstructive Lung Disease Combined Assessment of COPD(C)(D)(A)(B)mMRC 0-1 CAT 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 COP
12、D Risk (GOLD Classification of Airflow Limitation)Risk (Exacerbation history)2 1 0(C)(D)(A)(B)mMRC 0-1 CAT 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 hosp
13、italizations 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 2 CAT 10 Symptoms(mMRC or C
14、AT 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 (E
15、xacerbation history)2 1 0(C)(D)(A)(B)mMRC 0-1 CAT 2 CAT 10 Symptoms(mMRC or CAT score)2013 Global Initiative for Chronic Obstructive Lung Disease Patient Characteristic Spirometric Classification Exacerbations per year mMRC CAT A Low Risk Less Symptoms GOLD 1-2 1 0-1 2 10 C High Risk Less Symptoms G
16、OLD 3-4 2 0-1 2 2 10 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 COPD 中年起病 症状逐年加重 长期吸烟 ASTHMA 起病早（常儿童起病）症状变化显著 夜间和清晨症状恶化 常伴过敏症,鼻炎,和/或湿疹 哮喘家族史 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