内科学教学课件：慢性阻塞性肺病 慢性肺源性心脏病

ChronicObstructivePulmonaryDisease(COPD)ChronicCorPulmonale慢性阻塞性肺病慢性肺源性心脏病GeneralintroductionCOPD慢性阻塞性肺病Chronicbronchitis慢性支气管炎、Emphysema肺气肿Pulmonaryhypertension肺动脉高压ChronicCorPulmonale慢性肺源性心脏病GeneralconceptCOPD,acommonpreventableandtreatablediseaseischaracterizedbypersistentairflowlimitationthatisusuallyprogressiveandassociatedwithenhancedchronicinflammatoryresponseintheairwaysandthelungtonoxiousparticlesorgases.ExacerbationsandcomorbiditiescontributetotheoverallseverityinindividualpatientsGeneralconceptThechronicairflowlimitationcharacteristicofCOPDiscausedbyamixtureofsmallairwaydisease(obstructivebronchiolitis)andparenchymaldestruction(emphysema),therelativecontributionsofwhichvaryfrompersontoperson.PercentChangeinAge-AdjustedDeathRates,U.S.,1965-199800.51.01.52.02.53.0Proportionof1965Rate1965-19981965-19981965-19981965-19981965-1998–59%–64%–35%+163%–7%CoronaryHeartDiseaseStrokeOtherCVDCOPDAllOtherCausesPredictedMortalityofCOPDIschemicheartD1COPD6CerebrovascularD2LRTI3Diarrhae4PerinatalD5COPD

3TrafficAccident4Lungcancer

519902020GOLDReport2006.p11IschemicheartD1CerebrovascularD2LRTI

3CHRONITISBRONCHITISDefinition

Chronicbronchitisisaclinicaldiagnosisbasedonthesymptomsofchroniccoughandsputumproduction.Itisdefinedaspersistenceofcoughandexcessivemucussecretiononmostdaysovera3-monthperiodforatleast2successiveyears.DefinitionPatientswhohavechronicproductivecoughandnormalairflowarediagnosedashavingsimplechronicbronchitis;Thosewhodemonstrateaprogressivedeclineinairflowhavechronicobstructivebronchitis,whichconstitutesthemajorityofpatientswithCOPD.

etiologySmokingAirpollutionInfectionClimateInternalfactor

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Symptoms:cough,expectorateonofsputum,wheezingSigns:moistanddryrales,rhonchi

ClassificationofChronicBronchitisSimpletypeofChronicBronchitis

(withoutgasping)CoughSputumexpectorationChronicBronchitiswithgaspingCoughSputumexpectorationGasping

StagesofChronicBronchitis

Stages

TimeCoursesExacerbationInaweekChroniclagphaseOnemonthorlongerstableLastsfortwomonthsLabtesting

CXRPFTSputumbacteriacultureBloodtesting

Diagnosis

Clinicaldiagnosis:Symptomspersisting3mons/yrLastingfor2consectiveyrsExcludeotherlungandheartdisease

Ifshorterthanthreemonths/peryearthendefinitiveobjectiveevidencesaredemanded(suchasX-Rayandlungfunctionetal.)todiagnose.Therapy-acuteattackAntibiotictherapyCoughsuppressionandmucolyticsBronchodilationNebulizationEMPHYSEMADefinition

Emphysemaisdefinedpathologicallyasthepresenceofpermanentenlargementoftheairspacesdistaltotheterminalbronchioles,accompaniedbydestructionoftheirwallsandwithoutobviousfibrosisPathologicalclassification

centrallobularpanacinarmixedtype

NormaldistallungacinusCentriacinar(centrilobular)emphysemaPanacinaremphysema

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©2004

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primarydiseasedyspneageneralsymptoms

signs

barrelchestreducedrespireatorymovementandbreathingsoundhyperesonanceonauscultationmoistanddryralesuponchestinfectionliverpapableComplications

PrimarypneumothoraxRespireatoryfailureCorpulmonale

ClassificationofEmphysemaObstructive

Emphysema

Emphysema

withoutObstruction

senileemphysema(Physiological)InterstitialEmphysemaCompensatingEmphysemaScarredEmphysemaLabTesting

CXR:PFT:FEV1/FVC<70%,RV/TLC>40%,reducedDLco,increasedTLCABG

DiagnosisHistoryofillnessClinicalmanifestations&signsPulmonaryfunction:airflowlimitation,hyperinflation,increasedresidualvolume(FEV1/FVC<70%,TLC>120%,RV/TLC>40%,DLco<80%)LungCTTherapySameasCOPDRiskFactorforCOPDGenehereditarydeficiencyofalpha-1antitrypsinExposuretoparticles

•Tobaccosmoke

•Occupationaldusts,organicandinorganic

•Indoorairpollutionfromheatingandcookingwithbiomassinpoorlyventeddwellings

•OutdoorairpollutionLungGrowthandDevelopmentRespiratoryinfectionsSocioeconomicstatusPathogenesisofCOPDPathophysiologyMucoushypersecretion&CilliarydysfunctionAirflowlimitationandhyperinflationGasexchangeabnormalitiesPulmonaryhypertensionSystemiceffects.ClinicalFeatureschroniccoughMaybeintermittentandmaybeunproductive.dyspneathatis:Progressive(worsensovertime)UsuallyworsewithexercisePersistent(presenteveryday)Describedbythepatientasan“increasedefforttobreathe,”“heaviness,”

“airhunger,”or“gasping.”chronicsputumproduction:AnypatternofchronicsputumproductionmayindicateCOPD.historyofTobaccosmoke.exposuretoOccupationaldustsandchemicalsriskfactors,Smokefromhomecookingandespecially:heatingfuels.SignsRaisedrespiratoryrateHyperexpanded/barrelchestProlongedexpiratorytime>5seconds,withpursedlipbreathingUseofaccessorymusclesofrespirationQuietbreathsounds(especiallyinthelungapices),wheezeQuietheartsounds(duetooverlyinghyperinflatedlung)PossiblebasalcrepitationsSignsofcorpulmonaleandCO2retention(ankleoedema,raisedJVP,warmperipheries,plethoricconjunctivae,boundingpulse,polycythaemia.FlappingtremorifCO2acutelyraised).InvestigationsPulmonaryfunctiontestsCXRSpirometry:NormalandCOPDSpirometry:NormalandCOPDCOPDX-rays©AstraZenecaCOPDX-rays©AstraZenecaCOPDX-rays©AstraZenecaSYMPTOMSChroniccoughSputumproductionDyspneaEXPOSURETORISKFACTORStobaccooccupationindoor/outdoorpollutionSPIROMETRY,Post-bronchodilatorFEV1/FVC<70%DiagnosisofCOPDKeyindicatorsinconsideringadiagnosisofCOPDAssessmentofdiseaseAssessmentofsymptomsSpirometricAssessment(airflowlimitation)AssessmentofexacerbationriskAssessmentofcomorbiditiesAssessmentofsymptoms(COPDAssessmentTest,CAT)从不咳嗽一点痰也没有没有任何胸闷的感觉爬坡或上1层楼梯时，没有气喘的感觉在家里能够做任何事情尽管有肺部疾病，但对外出很有信心睡眠非常好精力旺盛012345012345012345012345012345012345012345012345总是在咳嗽有很多很多痰有很严重的胸闷感觉爬坡或上1层楼梯时，感觉严重喘不过气来在家里做任何事情都很受影响由于有肺部疾病，对离开家一点信心都没有由于有肺部疾病，睡眠相当差一点精力都没有注：数字0-5表示严重程度，请标记最能反映你当前情况的选项，在方格中打X，每个问题只能标记1个选项51CAT>10,moresymptomaticAssessmentofsymptomsLessbreathlessnessMorebreathlessnessmMRC>2SpirometricAssessment

(airflowlimitation)ClassificationofseverityofairflowlimitationinCOPDBasedonpost-bronchodilationAssessmentofexacerbationriskSoler-CataluñaJJ,etal.Thorax.2005;60:925-931.Permissionrequested.FrequencyofAECOPDandsurvival1.00.80.60.40.20.00102030405060随访时间(月)AP<0.0002BP=0.069CP<0.0001生存率（%）1.00.80.60.40.20.00102030405060(1)(3)(4)P<0.0001(2)NSNSP=0.005P<0.0001生存率（%）随访时间(月)A组

无急性加重的患者B组

有1–2次需住院治疗的急性加重的患者C组

有≥3次急性加重的患者(1)组

无急性加重的患者(2)组

急性加重需要急诊治疗但无需住院(3)组

急性加重需要一次住院治疗(4)组

急性加重需要反复住院治疗N=304，随访5年存活可能性时间（月）无加重/y1-2次加重/y≥3次加重/ySoler-CatalunaJJ,etal.Thorax2005;60(11):925-931.Assessmentofexacerbationrisk57CombinedCOPDassessmentCDABGOLD

4GOLD

3GOLD

2GOLD

1mMRC0-1CAT<10mMRC2+CAT10+2次或更多1次以上住院(只要出现至少一次由急性加重导致的住院即可被视为高风险)COPD综合评估<1次AE无住院急性加重发作史/年气流受限程度症状Groupssummarization-1Groupssummarization-2Risk

(GOLDClassificationofAirflowLimitation)Risk

(Exacerbationhistory)>210(C)(D)(A)(B)mMRC0-1CAT<104321

mMRC>2CAT>

10Symptoms(mMRCorCATscore))低风险（AorB）GOLD1or20或1次急性加重/年高风险(CorD)GOLD3or4≥2次急性加重/年(只要出现至少一次由急性加重导致的住院即可被视为高风险)COPD综合评估—总结GOLD201162DifferentialdiagnosisBronchialasthmaBronchiectasisPulmonarytuberculosisInterstitiallungdiseaseLungcancerCongestiveheartfailureStableCOPDAcuteexacerbationofCOPD(AECOPD)ExacerbationofCOPDAnexacerbationofCOPDisanacuteeventcharacterizedbyaworseningofpatient’srespiratorysymptomsthatisbeyondnormalday-to-dayvariationsandleadstoachangeofmedication.Exacerbationcanbeprecipitatedbyseveralfactors.Themostcommoncausesofanexacerbationappearstobeviralupperrespiratoryinfectionandinfectionofthetracheobronchialtree.

ManagementStableCOPDGoaloftreatmentofstableCOPD

缓解症状提高运动耐力

改善健康状况预防疾病进展预防和治疗急性加重降低死亡率GOLD

2013减少当前症状降低未来风险稳定期COPD的治疗目标68MedicationsforCOPDShort-actingbronchodilators:Salbuterol(沙丁胺醇),terbutaline（特布他林）,iprotropiumbromide（异丙托品）Long-actingbronchodilators:Salmeterol（沙美特罗）,formoterol（福莫特罗）,tiotropium（噻托溴铵）Combinedshort-actingbronchodilator:Salbuterol-iptotropiumMethylxanthione:Aminophylline,theophylline(slow-released)Inhaledcorticosteroids:Beclomethasone（二丙酸倍氯米松）,budesonide（布地奈德）,fluticasone（氟替卡松）Combinedsteroid-long-actingbronchodilators:Salmeterol/fluticasone,formoterol/budesonide吸入装置吸入装置BronchodilatorsinstableCOPDTreatment–GroupAFewsymptomsandlowriskofexacerbationShort-actingbronchodilatorsasneededtherapyfirstoptionCombinedShort-actingbronchodilatorsalternativetherapyLong-actingbronchodilatorsalternativetherapyTreatment–GroupBMoresymptomsandlowriskofexacerbationLong-actingbronchodilatorsasneededorprntherapyPtswithseverebreathlessness,combinedLong-actingbronchodilatorsTreatment–GroupCFewsymptomsandhighriskofexacerbationCombinationofinhaledcorticosteroid/long-actingß2agonistoranticholinergics—firstchoiceCombinationoftwoLong-actingbronchodilators—alternativetherapyCombinationofinhaledcorticosteroid/long-actinganticholinergicsCombinationofphosphodiesterase4inhibitorswithlong-actingbronchodilatorschronicbronchitisTreatment–GroupDMoresymtomsandhighriskofexacerbationsInhaledcorticosteroidpluslong-actingß2agonistorlong-actinganticholinergics—firstchoiceCombiantionofallthreeclassesofdrugs(Inhaledcorticosteroid/long-actingß2agonist/long-actinganticholinergics)—secondchoicePhosphodiesterase4inhibitorsmaybeadded--ifchronicbronchitisBronchodilators--recommendationCOPD稳定期药物治疗方案患者首选次选备选A速效抗胆碱能（SAA）必要时或速效倍它受体激动剂（SABA）

必要时长效抗胆碱能（LAA）

或长效倍它受体激动剂（LABA）或SABA+SAA茶碱BLAA或LABALAA+LABASABA和/或SAA茶碱CICS+LABA或LAALAA和LABA或LAA+PDE4抑制剂或LABA+PDE4抑制剂SABA和/或SAA

茶碱DICS+LABA和/或LAAICS+LABA+LAA或ICS+LABA+PDE4抑制剂或LAA+LABA或LAA+PDE4抑制剂羧甲司坦SABA和/或SAA茶碱Non-pharmacologicalmanagementofstableCOPDSmokingcessationEducationcanimproveabilitytomanageillnessandstopsmoking.Pulmonaryrehabilitation:gradedexercise,butincludesbreathingtechniquesOxygenSurgicaltherapySmokingcessationOxygentherapy-indications•PaO2<55mmHgorSaO2<88%,withorwithouthypercapnia;

or•PaO2between55mmHgand70mmHg,orSaO2below89%,ifthereisevidenceofpulmonaryhypertension,congestivecardiacfailure,orpolycythemia(hematocrit>55%)Oxygenisusuallydeliveredbyafacemaskornaslacanula,withappropriateinspiratoryflowratesvaryingbetween1-2L/minwithPaO2>60mmHgorSaO2>90%,>15h/dManagementAECOPDManageExacerbationsInhaledbronchodilators(beta2-agonistsand/oranticholinergics),theophylline,andsystemic,preferablyoral,glucocortico-steroidsareeffectiveforthetreatmentofCOPDexacerbations.ManagementofAECOPDAntibiotics

ifsputumpurulent,pyrexial,CRP,newchangesonCXR.InhaledornebulizedbronchodilatorsSystemicsteroidsforallpatientswithexacerbationsofCOPDwhoareadmittedtohospital.Giveprednisolone30-40mg/dayfor1-2weeks,unlesstherearespecificcontra-indications.Thisshortenstherecoverytime.Controlledoxygentherapy<30%viafacemask,SpO2between80and90%,Intravenousaminophylline.Respiratorystimulantusedtodriverespiratoryrate(ifbelow20perminute)andshouldonlybeusedatthelowestpossibledose(0.5to3mg/min)intheshorttermItsusehaslargelybeenreplacedby

Non-invasiveventilation(NIV)Effectiveinsupportingpatientsduringanexacerbation,whenmaximalmedicaltreatmenthasnotbeeneffective.Appropriateforconsciouspatientswithongoingrespiratoryacidosis(pH7.3orless),hypoxia,andhypercapnia.Mayavoidintubation.Ceilingoftreatmentshouldbedeterminedbeforeitsuse.(seepage600.)Intubation/intensivecareCorpulmonaleDefinitionCorpulmonaleisthetraditionaltermforchangesinthecardiovascularsystemresultingfromthechronichypoxia(andusuallyhypercapnia)ofchroniclungdisease,mainlypulmonaryhypertensionandfluidretention.DefinitionCorpulmonaleisanenlargementoftherightventricleduetoderangementsinthestructureorfunctionoftherespiratorysystem.Theenlargementmayrepresentprogressiverightventricularhypertrophy,rightventriculardilation,andeventualcardiacdecompensationDISEASESASSOCIATEDWITHPULMONARYHEARTDISEASEDiseasesaffectingairwaysandlungparenchyma

Chronicobstructivepulmonarydisease

Idiopathicpulmonaryfibrosis

AsthmaSarcoidosis

Tuberculosis

PneumoconiosesDiseasesaffectingthethoraciccage

Kyphoscoliosis

Thoracoplasty

Neuromusculardiseasecausingmuscleweakness

MusculardystrophyDiseasesaffectingthepulmonaryvasculature

Chronicpulmonarythromboembolicdisease

Polyarteritis(pulmonaryarteritis)Hypoventilatorydisorders

Sleepapneasyndrome

Idiopathicalveolarhypoventilationsyndrome(Ondinecurse)

Obesity-hypoventilationsyndrome

Chronichigh-altitudediseaseMorbidityCOPD：84％SEVERETB：5.9%ASTHMA：4.4%BRONCHIECTASIS：2.8%OTHERS：～3％PULMONARYHYPERTENSIONPulmonryhypertension：meanpulmonaryArterialpressureRestingPAPm>25mmHgExertionalPAPm>30mmHg

WHOclassificationofpulmonaryhypertension

PulmonaryarterialhypertensionIdiopathicpulmonaryarterialhypertension(primarypulmonaryhypertension).Familialpulmonaryarterialhypertension(FPAH),Relatedto:Collagenvasculardisease.Portalhypertension.HIVinfection.Drugs/toxins:othersPulmonaryvenoushypertensionLeft-sidedatrialorventricularheartdiseaseLeft-sidedvalvularheartdisease.PulmonaryhypertensionassociatedwithhypoxaemiaChronicobstructivepulmonarydiseaseInterstitiallungdiseaseSleepdisorderedbreathingAlveolarhypoventilationdisordersChronichighaltitudeexposure.Pulmonaryhypertensionduetochronicthromboticand/orembolicdiseaseThromboembolicobstructionofproximalpulmonaryarteriesObstructionofdistalpulmonaryarteriesPulmonaryembolism(thrombus,tumour,ova,parasites,foreignmaterial)InsituthrombosisSicklecelldisease.PulmonaryhypertensionassociatedwithmiscellaneousdisordersPathogenesisofpulmonaryhypertension1、血管器质性病变：Thickening,stenosis/obstruction

decreaseinvascularbedpulmonaryhypertensionrightventricularhypertrophyCorpulmonalepressureareaR=2、Physiologicalaspecthypoxia

BodyfluidfactorTissueFactorNeurologicFactorHistamine,↑permeabilitytoCa++hypoxia,hypercapnia

AT-II,5-TH,LT,TXB2,PG↑Couple-excitation↑sympathetictone

Constrictionofpylmonaryartery

PulmonaryhypertensionPathogenesisofpulmonaryhypertension3、↑Bloodvolumeandviscosity

ClinicalFeatures

Cardio-pulmonarycompensatoryphaseSymptoms：chroniccough,sputum,dyspnea,exertionalpalpation,fatigue,exercisetoleranceSigns：emphysemabarrelchest,hyperresonance,liverdullness,cardiacdullness,respiratorysound,pulmonaryhypertension:P2,tricuspidvalveSM,jugularveindistensionRespiratoryfailure:afteracuterespiratoryinfection，dyspnea,headach,insomnia,alteredconsciousness.Righthearfailure：dyspnea,palpation,oliguria/cyanosis,abdominaldistension,lossofappetite,nauseaandvomiting。Signs：Jugularveindistension,gallop,tricuspidSM,arrythmia,hepatomegaly,hepatojajularreflux+,edemaandascitesCyanosisClinicalFeatures

Cardio-pulmonarydecompensatoryphaseECGClockwiserotationoftheelectricaxiswithameanQRSaxis>+90P-pulmonalepattern(anincreaseinP-waveamplitudeinII,III,AVF>

0.25mV)Rv1+Sv5>1.05mVV1-3QSwaveIncomplete(andrarelycomplete)rightbundle-branchblockECGLabFindingsCXRDialatationoftherightpulmonaryartery，>15mm，∆≥2mmBulgingofpulmonaryA肺动脉段凸出，高度>3mmDilatedpulmonaryoutflowtract，锥高>7mmDilatationofcentralpulmonary，外周血管纤细。残根状右室大：心尖上翘

PulmonaryhypertensionCardiacechogramEnlargementofrightatrium,hypertrophyanddilatationofrightwentricleMoresensitivethanECG&CXR,60.6%~87%EarlyandsensitivediagnosticmethodOthersBloodgasanalysis：Bloodtest：WBC、↑Hb,↑BUN,↑GPTElectrolytedisturbance：SputumexamforbacteriaDiagnosisanddifferentialdiagnosisHistory＋symptomsandsigns＋labtestclin