COPD英文课件留学生授课内科学

ChronicBronchitis,TingSun孙婷,1,ChronicBronchitis,Definition:Chronicandunspecificinflammationofbronchiandthesurroundingtissue.Aclinicalsyndromedefined-chronicsputumproduction-Persistentcough-foratleast3months-inatleast2consecutiveyearsAnatomicsite-Bronchus,3,Pathogenesis,ChronicirritationofairwaysSmokingDustAirpollutantsThemajorriskfactorforthedevelopmentofchronicbronchitisiscigarettesmokingInfectiveagents-secondaryfactor,ChronicinflammationHypertrophythepresenceofapost-bronchodilatorFEV1/FVC0.70confirmsthepresenceofpersistentairflowlimitationandthusofCOPD.,DifferentialDiagnosis,HeartfailureAsthmaBronchiectasisPneumoniaTuberculosis,DifferentialDiagnosis:COPDandAsthma,68,Determinetheseverityofthedisease,itsimpactonthepatientshealthstatusandtheriskoffutureevents(forexampleexacerbations)toguidetherapy.Considerthefollowingaspectsofthediseaseseparately:currentlevelofpatientssymptomsseverityofthespirometricabnormalityfrequencyofexacerbationspresenceofcomorbidities.,GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDAssessmentofCOPD:Goals,GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDAssessmentofCOPD,AssesssymptomsAssessdegreeofairflowlimitationusingspirometryAssessriskofexacerbationsAssesscomorbidities,ThecharacteristicsymptomsofCOPDarechronicandprogressivedyspnea,cough,andsputumproduction.Dyspnea:Progressive,persistentandcharacteristicallyworsewithexercise.Chroniccough:Maybeintermittentandmaybeunproductive.Chronicsputumproduction:COPDpatientscommonlycoughupsputum.,GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDSymptomsofCOPD,AssesssymptomsAssessdegreeofairflowlimitationusingspirometryAssessriskofexacerbationsAssesscomorbidities,UsetheCOPDAssessmentTest(CAT)ormMRCBreathlessnessscale,GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDAssessmentofCOPD,COPDAssessmentTest(CAT):An8-itemmeasureofhealthstatusimpairmentinCOPD().BreathlessnessMeasurementusingtheModifiedBritishMedicalResearchCouncil(mMRC)Questionnaire:relateswelltoothermeasuresofhealthstatusandpredictsfuturemortalityrisk.,GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDAssessmentofSymptoms,GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDModifiedMRC(mMRC)Questionnaire,AssesssymptomsAssessdegreeofairflowlimitationusingspirometry,GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDAssessmentofCOPD,AssessmentofCOPD,ClinicalFeaturesofCOPDPatientsofdifferentseverity,MildCOPD:noabnormalsigns,smokerscough,littleornobreathlessnessModerateCOPD:breathlessnesswith/withoutwheezing,coughwith/withoutsputumSevereCOPD:breathlessnessonanyexertion/atrest,wheezeandcoughprominent,lunginflationusual,cyanosis,peripheraledema,andpolycythemiainadvanceddisease,Stageofdisease,AcuteExacerbationsStable,AcuteexacerbationsofCOPD,AcuteexacerbationsofCOPDarecharacterisedbyanincreaseinsymptomsanddeteriorationinlungfunction.Theybecomemorecommonasthediseaseprogressesandmaybecausedbybacteria,virusesorachangeinairquality.Theymaybeaccompaniedbythedevelopmentofrespiratoryfailureand/orfluidretentionandrepresentanimportantcauseofdeath,79,Thismaypresentwithsignsofincreasedworkofbreathingsuchasfastbreathing,afastheartrate,sweating,activeuseofmusclesintheneckandevenabluishtingetotheskininverysevereexacerbations.Cracklesmayalsobeheard.,Duringexacerbations,airwayinflammationisalsoincreased,resultinginincreasedhyperinflation,reducedexpiratoryairflowandworseningofgastransfer.Thiscanalsoleadtoinsufficientventilationand,eventually,lowbloodoxygenlevels,Causes:75%infectiousVirusBacteria20%environmental5%Other:MI/CHFSurgeryAspiration.Pulmonaryembolism(20%inonestudy!)caution-selectpatientpopulation,COPDExacerbations,GlobalStrategyforDiagnosis,ManagementandPreventionofCOPD,DefinitionDiagnosisandAssessmentTherapeuticOptionsManageStableCOPDManageExacerbationsManageComorbidities,REVISED2011,GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDTherapeuticOptions:KeyPoints,SmokingcessationhasthegreatestcapacitytoinfluencethenaturalhistoryofCOPD.Healthcareprovidersshouldencourageallpatientswhosmoketoquit.Pharmacotherapyandnicotinereplacementreliablyincreaselong-termsmokingabstinencerates.AllCOPDpatientsbenefitfromregularphysicalactivityandshouldrepeatedlybeencouragedtoremainactive.,AppropriatepharmacologictherapycanreduceCOPDsymptoms,reducethefrequencyandseverityofexacerbations,andimprovehealthstatusandexercisetolerance.NoneoftheexistingmedicationsforCOPDhasbeenshownconclusivelytomodifythelong-termdeclineinlungfunction.Influenzaandpneumococcalvaccinationshouldbeoffereddependingonlocalguidelines.,GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDTherapeuticOptions:KeyPoints,COPD:Therapy,SmokingcessationMedicationsLongtermoxygentherapyRehabilitationManagementofCOPD,TherapeuticOptions:SmokingCessation,KeepingpeoplefromstartingsmokingisakeyaspectofpreventingCOPD.Counselingdeliveredbyphysiciansandotherhealthprofessionalssignificantlyincreasesquitratesoverself-initiatedstrategies.Smokingbansinpublicareasandplacesofworkareimportantmeasurestodecreaseexposuretosecondhandsmoke.,TherapeuticOptions:RiskReduction,TherapeuticOptions:COPDMedications,TherapeuticOptions:Bronchodilators,TherapeuticOptions:Bronchodilators,Theprincipalactionof2-agonistsistorelaxairwaysmoothmusclebystimulating2-adrenergicreceptors,whichincreasescyclicAMPandproducesfunctionalantagonismtobronchoconstriction.Inhaled2-agonistshavearelativelyrapidonsetofbronchodilatoreffectalthoughthisisprobablyslowerinCOPDthaninasthma,Bronchodilators：2-agonistbronchodilators,Rapid-acting2-agonists(SABA)Agentssuchassalbutamol(ventolin万托林)terbutalineThebronchodilatoreffectsofshoracting2-agonistsusuallywearoffwithin4to6hours.Usethisprnminimalriskofsideeffects,Bronchodilators：2-agonistbronchodilators,-Longacting2-agonists(LABA)Agentssuchassalmeterol,formoterolshowadurationofeffectof12hoursormorewithnolossofeffectivenessovernightorwithregularuseinCOPDpatientsThebenefitforlongtimeusingpatientsactivityandQOL,Themostimportanteffectofanticholinergicmedications,inCOPDpatientsappearstobeblockageofacetylcholineseffectonM3receptors.Currentshort-actingdrugsalsoblockM2receptorsandmodifytransmissionatthepre-ganglionicjunction,althoughtheseeffectsappearlessimportantinCOPD.,Therapy-Bronchodilators,AnticholinergicbronchodilatorsAgentssuchasIpratropium,Tiotropium:Ipratropiumisashort-actingagentwhiletiotropiumislong-acting.Regulartherapy,Therapy-Bronchodilators,AnticholinergicSymptomaticbenefits,decreaseinexacerbationsandimprovedqualityoflifeSideeffects:drymouth,urinaryretention,alsoassociatedwithincreasedriskofheartdiseaseandstroke.,Inhaledbronchodilatorsaretheprimarymedicationsusedandresultinasmalloverallbenefit.Theyreduceshortnessofbreath,wheezeandexerciselimitation,resultinginanimprovedqualityoflife.Itisuncleariftheychangetheprogressionoftheunderlyingdisease.,Therapy-Bronchodilators,Theophylline-Agentssuchasaminophylline,doxofylline-Usage:intravenousororalMultiplebutlesseffectsBronchodilationrespiratorystimulantimprovedcardiovascularfunctionimproveddiaphragmfunction,Therapy-Theophylline,Theophylline,TheeffectsoforalandinhaledglucocorticosteroidsinCOPDaremuchlessdramaticthaninasthma,andtheirroleinthemanagementofstableCOPDislimitedtospecificindications.Corticosteroidsareusuallyusedininhaledformbutmayalsobeusedastabletsevenintravenoustotreatandpreventacuteexacerbations.Inhaledcorticosteroids(ICS):decreaseacuteexacerbationsinthosewitheithermoderateorseveredisease,Therapy-Corticosteroids,Regulartreatmentwithinhaledcorticosteroids(ICS)improvessymptoms,lungfunctionandqualityoflifeandreducesfrequencyofexacerbationsforCOPDpatientswithanFEV160%predicted.WhenusedincombinationwithaLABAtheydecreasemortalitymorethaneitherICSorLABAaloneInhaledcorticosteroidtherapyisassociatedwithanincreasedriskofpneumonia.,InhaledCorticosteroids,Chronictreatmentwithsystemiccorticosteroidsshouldbeavoidedbecauseofanunfavorablebenefit-to-riskratio.,SystemicCorticosteroids,Supplementaloxygenisrecommendedinthosewithlowoxygenlevelsatrest(apartialpressureofoxygenoflessthan5055mmHgoroxygensaturationsoflessthan88%).Duringacuteexacerbations,manyrequireoxygentherapy,Therapy-Oxygen,AllCOPDpatientsbenefitfromexercisetrainingprogramswithimprovementsinexercisetoleranceandsymptomsofdyspneaandfatigue.Thelongerthepulmonaryrehabilitationprogramcontinues,themoreeffectivetheresults.Ifexercisetrainingismaintainedathomethepatientshealthstatusremainsaboveprerehabilitationlevels.,TherapeuticOptions:Rehabilitation,Respiratoryrehabilitationmayimproveprognosisandthispossibilityviameta-analysisofpublishedresults.,PulmonaryRehabilitation,Influenzavaccinescanreduceseriousillness.PneumococcalpolysaccharidevaccineisrecommendedforCOPDpatients65yearsandolderandforCOPDpatientsyoungerthanage65withanFEV140%predicted.Theuseofantibiotics,otherthanfortreatinginfectiousexacerbationsofCOPDandotherbacterialinfections,iscurrentlynotindicated.,TherapeuticOptions:OtherPharmacologicTreatments,Mucolytics:Patientswithviscoussputummaybenefitfrommucolytics;overallbenefitsareverysmallAntitussives:Notrecommended,OtherPharmacologicTreatments,Lungvolumereductionsurgery(LVRS)ismoreefficaciousthanmedicaltherapyamongpatientswithupper-lobepredominantemphysemaandlowexercisecapacityLVRSiscostlyrelativetohealth-careprogramsnotincludingsurgeryInappropriatelyselectedpatientswithverysevereCOPD,lungtransplantationhasbeenshowntoimprovequalityoflifeandfunctionalcapacity.,TherapeuticOptions:SurgicalTreatments,GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDManageStableCOPD:GoalsofTherapy,GlobalStrategyforDiagnosis,ManagementandPreventionofCOPD,DefinitionandOverviewDiagnosisandAssessmentTherapeuticOptionsManageStableCOPDManageExacerbationsManageComorbidities,REVISED2011,ManagementofCOPDbySeverityofDisease,Stage0:AtriskStageI:MildCOPDStageII:ModerateCOPDStageIII:SevereCOPDStageIV:VerySevereCOPD,113,ComprehensiveManagementofCOPD,COPDExacerbation,115,ManagementofCOPDStage0:AtRisk,CharacteristicsRecommendedTreatment,Chronicsymptoms-cough-sputumNospirometricabnormalities,Reductionofbronchialirritation,116,ManagementofCOPDStageI:MildCOPD,CharacteristicsRecommendedTreatment,FEV1/FVC80%predictedWithorwithoutchronicsymptoms,Short-actingbronchodilatorasneeded,117,ManagementofCOPDStageII:ModerateCOPD,CharacteristicsRecommendedTreatment,FEV1/FVC70%50%FEV180%predictedWithorwithoutchronicsymptoms,Short-actingbronchodilatorasneededRegulartreatmentwithoneormorelong-actingbronchodilatorsRehabilitation,118,ManagementofCOPDStageIII:SevereCOPD,CharacteristicsRecommendedTreatment,FEV1/FVC70%30%FEV150%predictedWithorwithoutchronicsymptoms,Short-actingbroncho-dilatorasneededRegulartreatmentwithoneormorelong-actingbronchodilatorsInhaledglucocorticosteroidsifrepeatedexacerbationsRehabilitation,119,ManagementofCOPDStageIV:VerySevereCOPD,CharacteristicsRecommendedTreatment,FEV1/FVC70%FEV130%predictedorFEV150%predictedpluschronicrespiratoryfailure,Short-actingbronchodilatorasneededRegulartreatmentwithoneormorelong-actingbronchodilatorsInhaledglucocorticosteroidsifrepeatedexacerbationsTreatcomplicationsRehabilitationLong-termoxygentherapyifrespiratoryfailureConsidersurgicaloptions,120,GlobalStrategyforDiagnosis,ManagementandPreventionofCOPD,DefinitionandOverviewDiagnosisandAssessmentTherapeuticOptionsManageStableCOPDManageExacerbationsManageComorbidities,REVISED2011,AnexacerbationofCOPDis:“anacuteeventcharacterizedbyaworseningofthepatientsrespiratorysymptomsthatisbeyondnormalday-to-dayvariationsandleadstoachangeinmedication.”,GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDManageExacerbations,ThemostcommoncausesofCOPDexacerbationsareviralupperrespiratorytractinfectionsandinfectionofthetracheobronchialtree.Diagnosisreliesexclusivelyontheclinicalpresentationofthepatientcomplainingofanacutechangeofsymptomsthatisbeyondnormalday-to-dayvariation.Thegoaloftreatmentistominimizetheimpactofthecurrentexacerbationandtopreventthedevelopmentofsubsequentexacerbations.,GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDManageExacerbations:KeyPoints,Impactonsymptomsandlungfunction,Negativeimpactonqualityoflife,ConsequencesOfCOPDExacerbations,Increasedeconomiccosts,Acceleratedlungfunctiondecline,IncreasedMortality,EXACERBATIONS,Exacerbations-Management,ManagementIdentifycauseInfectionIscommoncauseThreecardinalsymptoms:increaseddyspnea,increasedsputumvolume,andincreasedsputumpurulence.Antibioticsareneeded.Whorequiremechanicalventilation.,ManagementBronchodilatorsSystemicsteroids3-10d,Exacerbations-Management,Oxygen:2-3litres/min,Highconcentrationsofoxygenmaycauserespiratorydepressionandworseningacidosis.,Exacerbations-Management,MechanismsV/Qmismatchduetohypoxicrespiratorydrive,Non-invasiveventilator,intubationandventilator,Exacerbations-Management,prognosis,RelatetothevalueofFEV1FEV11.2Lsurvivefor10yFEV11.0Lsurvivefor5yFEV1700mlsurvivefor2yItsnottheabsoluteprognosis.Someacceptpersistenttreatmentandmanagement,theymaylivelongerlife,PreventionofCOPDistoalargeextentpossibleandshouldhavehighprioritySpirometryisrequiredtomakethediagnosisofCOPD;thepresenceofapost-bronchodilatorFEV1/FVC0.5CM,RV/LV2.5Lt.VentricularHypertrophyHypertrophyofCarotidBody,141,NaturalHistory,SeveralmonthstoyearstodevelopAllagesfromchildtooldpeopleRepeatedinfectionsaggravateRVstrainintoRVfailureInitillyrespondeswelltotherapybutprogressivelybecomesrefractory,142,Prevalence,Emphysema:lessfrequentCronicbronchitis:morecommonUS:6-7%ofHeartfailureDelhi:16%SheffieldinUK:3040%AutopsyinChronicBronchitis:50%Moreprevalentinpollutionareaorsmokers,143,WhatisCorPulmonaleinCOPD?,TheprogressofCOPDresultsinrightsidedheartfailure.TherightventriclehasbecomehypertrophiedanddilatedanditsfunctionhasbecomecompromisedduetopulmonaryhypertensionassociatedwithCOPD.,144,Clinicalstage,CompensationoflungandcardiacfunctionmainlypresentationofunderlyingdiseaseandPAHandhypertrophyofRVDecompensationoflungandcardiacfunctionmainlyexhibitthemanifestatio