copd day 2005 slide kit世界慢性阻塞性肺病日2005幻灯片课件

WorldCOPDDay2005SlideKit DefinitionofCOPD Chronicobstructivepulmonarydisease COPD isadiseasestatecharacterizedbyairflowlimitationthatisnotfullyreversible Theairflowlimitationisusuallybothprogressiveandassociatedwithanabnormalinflammatoryresponseofthelungstonoxiousparticlesorgases FactsAboutCOPD CigarettesmokingistheprimarycauseofCOPD IntheUS47 2millionpeople 28 ofmenand23 ofwomen smoke TheWHOestimates1 1billionsmokersworldwide increasingto1 6billionby2025 Inlow andmiddle incomecountries ratesareincreasingatanalarmingrate BurdenofCOPDKeyPoints TheburdenofCOPDisunderestimatedbecauseitisnotusuallyrecognizedanddiagnoseduntilitisclinicallyapparentandmoderatelyadvanced Prevalence morbidity andmortalityvaryappreciablyacrosscountriesbutinallcountrieswheredataareavailable COPDisasignificanthealthprobleminbothmenandwomen BurdenofCOPDMortality COPDisthe4thleadingcauseofdeathintheUnitedStates behindheartdisease cancer andcerebrovasculardisease In2000 theWHOestimated2 74milliondeathsworldwidefromCOPD In1990 COPDwasranked12thasaburdenofdisease by2020itisprojectedtorank5th LeadingCausesofDeathsU S 2002 CauseofDeathNumber HeartDisease695 754 Source NHLBI NIH DHHS PercentChangeinAge AdjustedDeathRates U S 1965 1998 0 0 5 1 0 1 5 2 0 2 5 3 0 Proportionof1965Rate 1965 1998 1965 1998 1965 1998 1965 1998 1965 1998 59 64 35 163 7 CoronaryHeartDisease Stroke OtherCVD COPD AllOtherCauses Source NHLBI NIH DHHS IschemicheartdiseaseCerebrovasculardiseaseLowerrespinfectionDiarrhealdiseasePerinataldisordersCOPDTuberculosisMeaslesRoadtrafficaccidentsLungcancer StomachCancerHIVSuicide 6th 3rd Murray Lopez Lancet1997 FutureMortalityWorldwide 1990 2020 BurdenofCOPDEconomicBurden TheeconomiccostsofCOPDarehighandwillcontinuetoriseindirectrelationtotheever agingpopulation theincreasingprevalenceofthedisease andthecostofnewandexistingmedicalandpublichealthinterventions DirectandIndirectCostsofCOPD 2002 US Billions DirectMedicalCost 18 0TotalIndirectCost 14 1MortalityrelatedIDC7 3MorbidityrelatedIDC6 8TotalCost 32 1 Source NHLBI NIH DHHS BurdenofCOPDFutureBurden TheglobalburdenofCOPDwillincreaseenormouslyovertheforeseeablefutureasthetollfromtobaccouseindevelopingcountriesbecomesapparent RiskFactorsforCOPD HostFactorsGenes e g alpha1 antitrypsindeficiency HyperresponsivenessLunggrowthExposureTobaccosmokeOccupationaldustsandchemicalsInfectionsSocioeconomicstatus PathogenesisofCOPD NOXIOUSAGENT tobaccosmoke pollutants occupationalagent COPD GeneticfactorsRespiratoryinfectionOther CausesofAirflowLimitation IrreversibleFibrosisandnarrowingoftheairwaysLossofelasticrecoilduetoalveolardestructionDestructionofalveolarsupportthatmaintainspatencyofsmallairways CausesofAirflowLimitation ReversibleAccumulationofinflammatorycells mucus andplasmaexudateinbronchiSmoothmusclecontractioninperipheralandcentralairwaysDynamichyperinflationduringexercise GOLDWorkshopReportFourComponentsofCOPDManagement AssessandmonitordiseaseReduceriskfactorsManagestableCOPDEducationPharmacologicNon pharmacologicManageexacerbations 5 2005 ObjectivesofCOPDManagement PreventdiseaseprogressionRelievesymptomsImproveexercisetoleranceImprovehealthstatusPreventandtreatexacerbationsPreventandtreatcomplicationsReducemortalityMinimizesideeffectsfromtreatment AssessandMonitorDisease KeyPoints DiagnosisofCOPDisbasedonahistoryofexposuretoriskfactorsandthepresenceofairflowlimitationthatisnotfullyreversible withorwithoutthepresenceofsymptoms AssessandMonitorDisease KeyPoints Patientswhohavechroniccoughandsputumproductionwithahistoryofexposuretoriskfactorsshouldbetestedforairflowlimitation eveniftheydonothavedyspnea AssessandMonitorDisease KeyPoints ForthediagnosisandassessmentofCOPD spirometryisthegoldstandard HealthcareworkersinvolvedinthediagnosisandmanagementofCOPDpatientsshouldhaveaccesstospirometry SYMPTOMS cough sputum dyspnea EXPOSURETORISKFACTORS tobacco occupation indoor outdoorpollution SPIROMETRY DiagnosisofCOPD Spirometry NormalandCOPD FactorsDeterminingSeverityOfChronicCOPD SeverityofsymptomsSeverityofairflowlimitationFrequencyandseverityofexacerbationsPresenceofcomplicationsofCOPDPresenceofrespiratoryinsufficiencyComorbidityGeneralhealthstatusNumberofmedicationsneededtomanagethedisease ClassificationbySeverity StageCharacteristics0 AtriskNormalspirometryChronicsymptoms cough sputum I MildFEV1 FVC 70 FEV1 80 predictedWithorwithoutchronicsymptoms cough sputum II ModerateFEV1 FVC 70 50 FEV1 80 predictedWithorwithoutchronicsymptoms cough sputum dyspnea III SevereFEV1 FVC 70 30 FEV1 50 predictedWithorwithoutchronicsymptoms cough sputum dyspnea IV VerySevereFEV1 FVC 70 FEV1 30 predictedorFEV1 50 predictedpluschronicrespiratoryfailure ReduceRiskFactorsKeyPoints Reductionoftotalpersonalexposuretotobaccosmoke occupationaldustsandchemicals andindoorandoutdoorairpollutantsareimportantgoalstopreventtheonsetandprogressionofCOPD Smokingcessationisthesinglemosteffective andcosteffective interventiontoreducetheriskofdevelopingCOPDandstopitsprogression EvidenceA ReduceRiskFactorsKeyPoints Brieftobaccodependencetreatmentiseffective EvidenceA andeverytobaccousershouldbeofferedatleastthistreatmentateveryvisittoahealthcareprovider Threetypesofcounselingareespeciallyeffective practicalcounseling socialsupportaspartoftreatment andsocialsupportarrangedoutsideoftreatment EvidenceA ReduceRiskFactorsKeyPoints Severaleffectivepharmacotherapiesfortobaccodependenceareavailable EvidenceA andatleastoneofthesemedicationsshouldbeaddedtocounselingifnecessary andintheabsenceofcontraindications ReduceRiskFactorsKeyPoints Progressionofmanyoccupationally inducedrespiratorydisorderscanbereducedorcontrolledthroughavarietyofstrategiesaimedatreducingtheburdenofinhaledparticlesandgases EvidenceB BriefStrategiesToHelpThePatientWillingToQuitSmoking ASKSystematicallyidentifyalltobaccousersateveryvisit ADVISEStronglyurgealltobaccouserstoquit ASSESSDeterminewillingnesstomakeaquitattempt ASSISTAidthepatientinquitting ARRANGESchedulefollow upcontact ManageStableCOPDKeyPoints ForpatientswithCOPD healtheducationcanplayaroleinimprovingskills abilitytocopewithillness andhealthstatus Itiseffectiveinaccomplishingcertaingoals includingsmokingcessation EvidenceA AllCOPD patientsbenefitfromexercisetrainingprograms improvingwithrespecttobothexercisetoleranceandsymptomsofdyspneaandfatigue EvidenceA ManageStableCOPDKeyPoints TheoverallapproachtomanagingstableCOPDshouldbecharacterizedbyastepwiseincreaseinthetreatment dependingontheseverityofthedisease NoneoftheexistingmedicationsforCOPDhasbeenshowntomodifythelong termdeclineinlungfunctionthatisthehallmarkofthisdisease EvidenceA Therefore pharmacotherapyforCOPDisusedtodecreasesymptomsand orcomplications ManageStableCOPDKeyPoints BronchodilatormedicationsarecentraltothesymptomaticmanagementofCOPD EvidenceA Theyaregivenonanas neededbasisoronaregularbasistopreventorreducesymptoms Theprincipalbronchodilatortreatmentsarebeta2 agonists anticholinergics theophylline andacombinationofthesedrugs EvidenceA BronchodilatorsinStableCOPD BronchodilatormedicationsarecentraltosymptommanagementinCOPD Inhaledtherapyispreferred Thechoicebetweenbeta2 agonist anticholinergic theophylline orcombinationtherapydependsonavailabilityandindividualresponseintermsofsymptomreliefandsideeffects BronchodilatorsinStableCOPD Bronchodilatorsareprescribedonanas neededoronaregularbasistopreventorreducesymptoms Regulartreatmentwithlong actinginhaledbronchodilatorsismoreeffectiveandconvenientthantreatmentwithshort actingbronchodilators butmoreexpensive Combiningbronchodilatorsmayimproveefficacyanddecreasetheriskofsideeffectscomparedtoincreasingthedoseofasinglebronchodilator GlucocorticosteroidsinStableCOPD RegulartreatmentwithinhaledglucocorticosteroidsisappropriateforsymptomaticCOPDpatientswithanFEV1 50 predicted StageIII SevereCOPDandStageIV VerySevereCOPD andrepeatedexacerbationse g 3inthelastthreeyears EvidenceA Inhaledglucocorticosteroidcombinedwithalong actingB2 agonistismoreeffectivethantheindividualcomponents EvidenceA GlucocorticosteroidsinStableCOPD Chronictreatmentwithsystemicglucocortico steroidsshouldbeavoidedbecauseofanunfavorablebenefit to riskratio EvidenceA OxygenTherapyinStableCOPD Thelong termadministrationofoxygen 15hoursperday topatientswithchronicrespiratoryfailurehasbeenshowntoincreasesurvival EvidenceA ManagementofCOPDbySeverityofDisease Stage0 AtriskStageI MildCOPDStageII ModerateCOPDStageIII SevereCOPDStageIV VerySevereCOPD ManagementofCOPD Allstages Avoidanceofriskfactors smokingcessation reductionofindoorpollution reductionofoccupationalexposureInfluenzavaccination ManagementofCOPDStage0 AtRisk CharacteristicsRecommendedTreatment Chronicsymptoms cough sputumNospirometricabnormalities ManagementofCOPDStageI MildCOPD CharacteristicsRecommendedTreatment FEV1 FVC80 predictedWithorwithoutchronicsymptoms Short actingbronchodilatorasneeded ManagementofCOPDStageII ModerateCOPD CharacteristicsRecommendedTreatment FEV1 FVC 70 50 FEV1 80 predictedWithorwithoutchronicsymptoms Short actingbroncho dilatorasneededRegulartreatmentwithoneormorelong actingbronchodilatorsRehabilitation ManagementofCOPDStageIII SevereCOPD CharacteristicsRecommendedTreatment FEV1 FVC 70 30 FEV1 50 predictedWithorwithoutchronicsymptoms Short actingbroncho dilatorasneededRegulartreatmentwithoneormorelong actingbronchodilatorsInhaledglucocortico steroidsifrepeatedexacerbationsRehabilitation ManagementofCOPDStageIV VerySevereCOPD CharacteristicsRecommendedTreatment FEV1 FVC 70 FEV1 30 predictedorFEV1 50 predictedpluschronicrespiratoryfailure Short actingbronchodilatorasneededRegulartreatmentwithoneormorelong actingbronchodilatorsInhaledglucocorticosteroidsifrepeatedexacerbationsTreatcomplicationsRehabilitationLong termoxygentherapyifrespiratoryfailureConsidersurgicaloptions ManageExacerbationsKeyPoints ExacerbationsofrespiratorysymptomsrequiringmedicalinterventionareimportantclinicaleventsinCOPD Themostcommoncausesofanexacerbationareinfectionofthetracheobronchialtreeandairpollution butthecauseofaboutone thirdofsevereexacerbationscannotbeidentified EvidenceB ManageExacerbationsKeyPoints Inhaledbronchodilators beta2 agonistsand oranticholinergics theophylline andsystemic preferablyoral glucocortico steroidsareeffectiveforthetreatmentofCOPDexacerbations EvidenceA ManageExacerbationsKeyPoints PatientsexperiencingCOPDexacerbationswithclinicalsignsofairwayinfection e g increasedvolume