COPD英文课件留学生授课内科学

第一页，共155页。ChronicBronchitisDefinition:Chronicandunspecificinflammationofbronchiandthesurroundingtissue.Aclinicalsyndromedefined---chronicsputumproduction

---Persistentcough---foratleast3months---inatleast2consecutiveyearsAnatomicsite---Bronchus2第二页，共155页。PathogenesisChronicirritationofairwaysSmokingDustAirpollutantsThemajorriskfactorforthedevelopment

ofchronicbronchitisiscigarettesmokingInfectiveagents-secondaryfactor第三页，共155页。ChronicinflammationHypertrophy&hyperplasiaofbronchialglandsthatsecretemucusIncreasenumberofgobletcellsCiliaaredestroyedChronicBronchitisPathophysiologyCiliaDamaged第四页，共155页。InflammatoryCellsStudiesshowthatsmokerswithsymptomsofchronicbronchitishaveanincreasednumberofinflammatorycellsintheir

bronchialglandswhencomparedwithasymptomaticsmokers.This

inflammatoryprocessconsistspredominantlyofneutrophilsand

macrophages,andofanincreasedproportionofCD8+T-lymphocytes.第五页，共155页。MacrophagesNeutrophilsMastcellsLymphocytes6第六页，共155页。ChronicBronchitis-pathologicalsection第七页，共155页。NarrowingofairwayairflowresistanceworkofbreathChronicBronchitisPathophysiology8第八页，共155页。ChronicBronchitisPathophysiologyBronchospasmoftenoccursEndresultHypoxemiaHypercapneaPolycythemia(increaseRBCs)第九页，共155页。第十页，共155页。Clinicalmanifestation

Mainsymptoms:

cough:chronic,longterm,repeatedly

expectoration:mucoidsputum,purulentsputumwheninfection

wheezing:seeninsomepatients第十一页，共155页。Clinicalmanifestation

Sign:

noobvioussigninearlystage2.sometimesmoistralesandrhonchi

第十二页，共155页。Diagnosis

Chroniccoughandsputumproductionfor3consecutivemonthsinatleast2successiveyears（≥3m/yⅹ2y）excludingotherchroniclungdiseases第十三页，共155页。Emphysema14第十四页，共155页。Definition

Pulmonaryemphysemaisdescribedinclinical,radiologicalandphysiologicterms,buttheconditionisbestdefinedmorphologically.Itmeansabnormalenlargementofairspacesdistaltotheterminalbronchioleswithdestructionoftheirwall.

Itischaracterizedbydestructionandenlargementofalveoli.第十五页，共155页。Etiology

EnvironmentFactorsCigarettesmoking(Inindustrializedcountries,cigarettesmokingaccountsformostcasesofCOPD)environmentalpollutantsOccupationaldustsandchemicalsHostFactorsGenes:Alpha1-antitrypsindeficiencyLowbirthweightisalsoariskofCOPDInoldperson,theabilityoftheimmunesystemisdecrease,thereforebronchitisismorecommoninoldpeople.第十六页，共155页。Emphysema:PathophysiologyStructuralchangesHyperinflationofalveoliDestructionofalveolar&alveolar-capillarywallsLungelasticitydecreases17第十七页，共155页。LossofLungSurfaceAreaforGasExchangeandOxygenTransportLossofLungSurfaceareaisduetodeathofLungEndothelialCellsCigaretteSmokeandEnvironmentalPollutionmaycauseendothelialcelldeathEmphysema:Pathophysiology18第十八页，共155页。Pathologyfeature

AlveolarwallsbecomethinnerAlveolarsacsenlargementRuptureofalveoliandformationofbleb19第十九页，共155页。

Severedestructionofsmallairwayscanleadtotheformationoflargeairpockets-knownasbullae-thatreplacelungtissue.Thisformofdiseaseiscalledbullousemphysemamicroscope20第二十页，共155页。Dissection21第二十一页，共155页。Alateralchestx-rayofapersonwithemphysema.Notethebarrelchestandflatdiaphragm22第二十二页，共155页。CTimageofthelungofapersonwithbullousemphysema.23第二十三页，共155页。TypesofEmphysemacentrilobularemphysemapanacinaremphysema第二十四页，共155页。Incentrilobularemphysema,respiratorybronchiolesareselectivelyanddominantlyinvolved.25第二十五页，共155页。Inpanacinaremphysema,theenlargementanddestructionofairspaceinvolvetheacinusmoreorlessuniformly.26第二十六页，共155页。emphysemaisonlyadescriptionoflungchangesratherthanadiseaseitself27第二十七页，共155页。ChronicObstructivePulmonaryDisease(COPD)第二十八页，共155页。WhatisCOPD?第二十九页，共155页。GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDDefinitionDiagnosisandAssessmentTherapeuticOptionsManageStableCOPDManageExacerbationsManageComorbidities

REVISED2011第三十页，共155页。WhatisCOPD?COPD,acommonpreventableandtreatabledisease,ischaracterizedbypersistentairflowlimitationthatisusuallyprogressiveandassociatedwithanenhancedchronicinflammatoryresponsetonoxiousparticlesorgases.

第三十一页，共155页。

COPDisatypeofobstructivelungdisease

inwhichchronicincompletelyreversiblepoorairflow(airflowlimitation)andinabilitytobreatheoutfully(airtrapping)exist.

Thepoorairflowistheresultofbreakdownoflungtissue(knownasemphysema)andsmallairwaysdisease(knownasobstructivebronchiolitis).Therelativecontributionsofthesetwofactorsvarybetweenpeople.32第三十二页，共155页。RelationshipofCOPDandChronicbronchitis,AsthmaorEmphysema33第三十三页，共155页。WhyCOPDisImportant?COPDisthechronicdiseasethatisshowingprogressiveupwardtrendinbothmortalityandmorbidityWHOpredictsthatCOPDwillbecomethethirdleadingcauseofdeathworldwideby2030.第三十四页，共155页。Worldwide,COPDaffects329millionpeopleornearly5percentofthepopulation.In2013,itresultedin2.9milliondeaths,upfrom2.4milliondeathsin1990.Thenumberofdeathsisprojectedtoincreasebecauseofhighersmokingratesandanagingpopulationinmanycountry.第三十五页，共155页。EconomicsGlobally,asof2010,COPDisestimatedtoresultineconomiccostsof$2.1trillion,halfofwhichoccurringinthedevelopingworld.Ofthistotalanestimated$1.9trillionaredirectcostssuchasmedicalcare,while$0.2trillionareindirectcostssuchasmissedwork第三十六页，共155页。GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDRiskFactorsforCOPDLunggrowthanddevelopment肺的生物自然过程Gender性别Age年龄Respiratoryinfections呼吸系统感染Socioeconomicstatus社会经济地位Asthma/Bronchialhyperreactivity哮喘/气道高反应性ChronicBronchitis慢性支气管炎Genes遗传因素Exposuretoparticles粉尘暴露Tobaccosmoke吸烟Occupationaldusts,organicandinorganic有机、无机职业粉尘Indoorairpollutionfromheatingandcookingwithbiomassinpoorlyventilateddwellings室内空气污染（尤其是在通风不良的室内燃烧生物燃料做饭）Outdoorairpollution室外空气污染第三十七页，共155页。RiskFactorsforCOPDGenesInfectionsSocio-economicstatusAging第三十八页，共155页。PathogenesisTobaccosmokingisthemostcommoncauseofCOPD,withanumberofotherfactorssuchasairpollutionandgeneticsplayingasmallerrole.Inthedevelopingworld,oneofthecommonsourcesofairpollutionispoorlyventedcookingandheatingfires.Long-termexposuretotheseirritantscausesaninflammatoryresponseinthelungsresultinginnarrowingofthesmallairwaysandbreakdownoflungtissue,knownasemphysema.第三十九页，共155页。40第四十页，共155页。PathogenesisInflammationsImbalanceofproteinasesandantiproteinasesinthelungsOxidativestressarealsoimportantinthepathogenesisofCOPD.第四十一页，共155页。42第四十二页，共155页。MechanismsUnderlyingAirflowLimitationinCOPDSmallAirwaysDisease小气道病变Airwayinflammation气道炎症Airwayfibrosis纤维化Increasedairwayresistance气道阻力增大ParenchymalDestruction肺实质的破坏Lossofalveolarattachments肺泡减少Decreaseofelasticrecoil弹力下降AIRFLOWLIMITATION43第四十三页，共155页。Ontheleftisadiagramofthelungsandairwaysofnormalbronchiolesandalveoli.OntherightislungsdamagedbyCOPD,bronchioleloosetheirshapeandcloggedbymucus.Thewallsofalveoliaredestroyedforminglargeralveoli.Pathologicalchange第四十四页，共155页。45第四十五页，共155页。AirwayinCOPDNon-smokerCOPDSaetta.199846第四十六页，共155页。COPDPathophysiologyHypoventialtion-PaCO2-Airflowobstruction/airwaynarrowingHyperinflation:airtrappingGasexchangedefects-PaO2

Destructionofalveolarwall/alveolar-capillarymembraneV/Qmismatch第四十七页，共155页。48第四十八页，共155页。COPDPathophysiology

SystemiceffectsofCOPDMuscularweaknessImpairedsalt&waterexcretionleadingtoperipheraloedema.AlteredfatmetabolismcontributingtoweightlossIncreasedprevalenceofosteoporosis.Increasedcirculatinginflammatorymarkers.第四十九页，共155页。【医生】COPD的病理_标清.mp4第五十页，共155页。ThemostcommonsymptomsofCOPDaresputumproduction,dyspnea,andaproductivecough.Thesesymptomsarepresentforaprolongedperiodoftimeandtypicallyworsenovertime.Clinicalmanifestation

Signsandsymptoms第五十一页，共155页。ClinicalmanifestationSymptom1.CoughandExpectoration

Achroniccoughisoftenthefirstsymptomtodevelop.Itischaracteristicallyaccompaniedbymucoidsputum.

SomepeoplewithCOPDattributethesymptomstoa"smoker'scough".ThosewithCOPDoftenhaveahistoryof"commoncolds"thatlastalongtime.第五十二页，共155页。ClinicalmanifestationSymptom2.Dyspnea:Progressive,persistentandcharacteristicallyworsewithexercise.ManypeoplewithmoreadvancedCOPDbreathethroughpursedlipsandthisactioncanimproveshortnessofbreathinsome.

第五十三页，共155页。Symptom3.OtherfeaturesProlongedexpiratoryphase.InCOPD,itmaytakelongertobreatheoutthantobreathein.

Chesttightnessmayoccur.

SystemicwastingSignificantweightlossanxietydisorderanddepression

第五十四页，共155页。ClinicalmanifestationSign:1.notobviousinearlystage2.typicalsign:barrelchestdecreasedchestmovementdiminishedtactilefremitusprolongexpirationWheeze第五十五页，共155页。fingernailclubbingisnotspecifictoCOPD第五十六页，共155页。barrelchestthoracicantero-posteral-diameter/transverse-diameter第五十七页，共155页。ExaminationPulmonaryfunctiontest(Spirometry)DiagnosisAssessingMonitoringprogressionIncompletelyreversibleairflowlimitationisthenecessarycriteriatodiagnoseCOPD(afterinhaledbronchodilatorFEV1/FVC<70%58第五十八页，共155页。Spirometry:NormalandCOPDforcedexpiratoryvolumein1second(FEV1)forcedvitalcapacity(FVC)59第五十九页，共155页。ChestX-rayBloodgas：todetectrespiratoryfailureBloodroutineandsputumexamination

Examination第六十页，共155页。ChestX-rayIntercostalspacewideningDiaphragmarelowandflatShadowoftheheartnarrowing61第六十一页，共155页。ComplicationsofCOPDChronicrespiratoryfailureType2SpontanouspneumothoraxCorpulmonale

第六十二页，共155页。GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDDefinitionDiagnosisandTherapeuticOptionsManageStableCOPDManageExacerbationsManageComorbidities

REVISED2011第六十三页，共155页。Diagnosis

1、Smokinghistory2、Symptom:cough,sputumproduction,graduallyprogressivedyspnea3、Sign：emphysema4、PFT:airwayflowlimitation第六十四页，共155页。Diagnosis:KeyPointsAclinicaldiagnosisofCOPDshouldbeconsideredinanypatientwhohasdyspnea,chroniccoughorsputumproduction,and/orahistoryofexposuretoriskfactorsforthedisease.

Spirometryisrequired

tomakethediagnosis;thepresenceofapost-bronchodilatorFEV1/FVC<0.70confirmsthepresenceofpersistentairflowlimitationandthusofCOPD.第六十五页，共155页。DifferentialDiagnosisHeartfailureAsthmaBronchiectasisPneumoniaTuberculosis第六十六页，共155页。DifferentialDiagnosis:COPDandAsthmaCOPD

Onsetinmid-lifeSymptomsslowly progressiveLongsmokinghistory

ASTHMAOnsetearlyinlife(oftenchildhood)SymptomsvaryfromdaytodaySymptomsworseatnight/earlymorningAllergy,rhinitis,and/oreczemaalsopresentFamilyhistoryofasthma67第六十七页，共155页。Determinetheseverityofthedisease,itsimpactonthepatient’shealthstatusandtheriskoffutureevents(forexampleexacerbations)

toguidetherapy.Considerthefollowingaspectsofthediseaseseparately:

currentlevelofpatient’ssymptomsseverityofthespirometricabnormalityfrequencyofexacerbationspresenceofcomorbidities.GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDAssessmentofCOPD:Goals第六十八页，共155页。GlobalStrategyforDiagnosis,ManagementandPreventionofCOPD

AssessmentofCOPDAssesssymptomsAssessdegreeofairflowlimitationusingspirometryAssessriskofexacerbationsAssesscomorbidities第六十九页，共155页。ThecharacteristicsymptomsofCOPDarechronicandprogressivedyspnea,cough,andsputumproduction.Dyspnea:

Progressive,persistentandcharacteristicallyworsewithexercise.Chroniccough:

Maybeintermittentandmaybeunproductive.Chronicsputumproduction:

COPDpatientscommonlycoughupsputum.GlobalStrategyforDiagnosis,ManagementandPreventionofCOPD

SymptomsofCOPD第七十页，共155页。AssesssymptomsAssessdegreeofairflowlimitationusingspirometryAssessriskofexacerbationsAssesscomorbiditiesUsetheCOPDAssessmentTest(CAT)

or

mMRCBreathlessnessscale

GlobalStrategyforDiagnosis,ManagementandPreventionofCOPD

AssessmentofCOPD第七十一页，共155页。COPDAssessmentTest(CAT):

An8-itemmeasureofhealthstatusimpairmentinCOPD(http://).BreathlessnessMeasurementusingtheModifiedBritishMedicalResearchCouncil(mMRC)Questionnaire:relateswelltoothermeasuresofhealthstatus

andpredictsfuturemortalityrisk.GlobalStrategyforDiagnosis,ManagementandPreventionofCOPD

AssessmentofSymptoms第七十二页，共155页。GlobalStrategyforDiagnosis,ManagementandPreventionofCOPD

ModifiedMRC(mMRC)Questionnaire第七十三页，共155页。

Assesssymptoms

Assessdegreeofairflowlimitationusing

spirometryGlobalStrategyforDiagnosis,ManagementandPreventionofCOPD

AssessmentofCOPD第七十四页，共155页。AssessmentofCOPDSeverityPostbronchodilatorFEV1/FVCPostbronchodilatorFEV1%predicted0:Atrisk>0.7>80I:MildCOPD<0.7>80II:ModerateCOPD<0.750-80III:SevereCOPD<0.730-50IV:VerysevereCOPD<0.7<30第七十五页，共155页。ClinicalFeaturesofCOPDPatientsofdifferentseverityMildCOPD:noabnormalsigns,smokerscough,littleornobreathlessnessModerateCOPD:breathlessnesswith/withoutwheezing,coughwith/withoutsputumSevereCOPD:breathlessnessonanyexertion/atrest,wheezeandcoughprominent,lunginflationusual,cyanosis,peripheraledema,andpolycythemiainadvanceddisease第七十六页，共155页。StageofdiseaseAcuteExacerbationsStable第七十七页，共155页。AcuteexacerbationsofCOPDAcuteexacerbationsofCOPDarecharacterisedbyanincreaseinsymptomsanddeteriorationinlungfunction.Theybecomemorecommonasthediseaseprogressesandmaybecausedbybacteria,virusesorachangeinairquality.Theymaybeaccompaniedbythedevelopmentofrespiratoryfailureand/orfluidretentionandrepresentanimportantcauseofdeath78第七十八页，共155页。Thismaypresentwithsignsofincreasedworkofbreathingsuchasfastbreathing,afastheartrate,sweating,activeuseofmusclesintheneckandevenabluishtingetotheskininverysevereexacerbations.Cracklesmayalsobeheard.第七十九页，共155页。Duringexacerbations,airwayinflammationisalsoincreased,resultinginincreasedhyperinflation,reducedexpiratoryairflowandworseningofgastransfer.Thiscanalsoleadtoinsufficientventilationand,eventually,lowbloodoxygenlevels第八十页，共155页。Causes:75%infectiousVirusBacteria20%environmental5%Other:MI/CHFSurgeryAspiration.Pulmonaryembolism(20%inonestudy!)

caution-selectpatientpopulationCOPDExacerbations第八十一页，共155页。GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDDefinitionDiagnosisandAssessmentTherapeuticOptionsManageStableCOPDManageExacerbationsManageComorbidities

REVISED2011第八十二页，共155页。GlobalStrategyforDiagnosis,ManagementandPreventionofCOPD

TherapeuticOptions:KeyPointsSmokingcessationhasthegreatestcapacitytoinfluencethenaturalhistoryofCOPD.Healthcareprovidersshouldencourageallpatientswhosmoketo

quit.Pharmacotherapyandnicotinereplacementreliablyincreaselong-termsmokingabstinencerates.AllCOPDpatientsbenefitfromregularphysicalactivityandshouldrepeatedlybeencouragedtoremainactive.第八十三页，共155页。AppropriatepharmacologictherapycanreduceCOPDsymptoms,reducethefrequencyandseverityofexacerbations,andimprovehealthstatusandexercisetolerance.NoneoftheexistingmedicationsforCOPDhasbeenshownconclusivelytomodifythelong-termdeclineinlungfunction.Influenzaandpneumococcalvaccinationshouldbeoffereddependingonlocalguidelines.GlobalStrategyforDiagnosis,ManagementandPreventionofCOPD

TherapeuticOptions:KeyPoints第八十四页，共155页。COPD:TherapySmokingcessationMedicationsLongtermoxygentherapyRehabilitationManagementofCOPD第八十五页，共155页。TherapeuticOptions:SmokingCessationKeepingpeoplefromstartingsmokingisakeyaspectofpreventingCOPD.Counselingdeliveredbyphysiciansandotherhealthprofessionalssignificantlyincreasesquitratesoverself-initiatedstrategies.Smokingbansinpublicareasandplacesofworkareimportantmeasurestodecreaseexposuretosecondhandsmoke.第八十六页，共155页。TherapeuticOptions:RiskReductionEmphasizeprimaryprevention,bestachievedbyeliminationorreductionofexposuresintheworkplace.Secondaryprevention,achievedthroughsurveillanceandearlydetection,isalsoimportant.Reduceoravoidindoorairpollutionfrombiomassfuel,burnedforcookingandheatinginpoorlyventilateddwellings.Advisepatientstomonitorpublicannouncementsofairqualityand,dependingontheseverityoftheirdisease,avoidvigorousexerciseoutdoorsorstayindoorsduringpollutionepisodes.第八十七页，共155页。TherapeuticOptions:COPDMedicationsBeta2-agonistsShort-actingbeta2-agonists

Long-actingbeta2-agonistsAnticholinergicsCombinationbeta2-agonists+anticholinergicinoneinhalerTheophyllineInhaledcorticosteroidsCombinationbeta2-agonists+corticosteroidsinoneinhalerSystemiccorticosteroidsBronchodilators第八十八页，共155页。Bronchodilatorsareprescribedonanas-neededoronaregularbasistopreventorreducesymptoms.Theprincipalbronchodilatortreatmentsarebeta2-agonists,anticholinergics,theophyllineorcombinationtherapy.Thechoiceoftreatmentdependsontheavailabilityofmedicationsandeachpatient’sindividualresponseintermsofsymptomreliefandsideeffects.TherapeuticOptions:Bronchodilators第八十九页，共155页。Long-actinginhaledbronchodilatorsareconvenientandmoreeffectiveforsymptomreliefthanshort-actingbronchodilators.Long-actinginhaledbronchodilatorsreduceexacerbationsandrelatedhospitalizationsandimprovesymptomsandhealthstatus.Combiningbronchodilatorsofdifferent pharmacologicalclassesmayimproveefficacyanddecreasetheriskofsideeffectscomparedtoincreasingthedoseofasinglebronchodilator.TherapeuticOptions:Bronchodilators第九十页，共155页。Theprincipalactionofβ2-agonistsistorelaxairwaysmoothmusclebystimulatingβ2-adrenergicreceptors,whichincreasescyclicAMPandproducesfunctionalantagonismtobronchoconstriction.Inhaledβ2-agonistshavearelativelyrapidonsetofbronchodilatoreffectalthoughthisisprobablyslowerinCOPDthaninasthmaBronchodilators：2-agonistbronchodilators第九十一页，共155页。Rapid-acting2-agonists(SABA)Agentssuchassalbutamol(ventolin万托林)terbutalineThebronchodilatoreffectsofshoractingβ2-agonistsusuallywearoffwithin4to6hours.UsethisprnminimalriskofsideeffectsBronchodilators：2-agonistbronchodilators第九十二页，共155页。-----Longacting2-agonists(LABA)Agentssuchassalmeterol,formoterolshowadurationofeffectof12hoursormorewithnolossofeffectivenessovernightorwithregularuseinCOPDpatientsThebenefitforlongtimeusingpatient’sactivityandQOL第九十三页，共155页。Themostimportanteffectofanticholinergicmedications,inCOPDpatientsappearstobeblockageofacetylcholine’seffectonM3

receptors.

Currentshort-actingdrugsalsoblockM2receptorsandmodifytransmissionatthepre-ganglionicjunction,althoughtheseeffectsappearlessimportantinCOPD.Therapy-Bronchodilators第九十四页，共155页。Anticholinergic

bronchodilatorsAgents

suchasIpratropium,Tiotropium:

Ipratropiumisashort-actingagentwhiletiotropiumislong-acting. RegulartherapyTherapy-Bronchodilators第九十五页，共155页。AnticholinergicSymptomaticbenefits,decreaseinexacerbationsandimprovedqualityoflifeSideeffects:drymouth,urinaryretention,alsoassociatedwithincreasedriskofheartdiseaseandstroke.第九十六页，共155页。Inhaledbronchodilatorsaretheprimarymedicationsusedandresultinasmalloverallbenefit.Theyreduceshortnessofbreath,wheezeandexerciselimitation,resultinginanimprovedqualityoflife.Itisuncleariftheychangetheprogressionoftheunderlyingdisease.Therapy-Bronchodilators第九十七页，共155页。Theophylline-Agentssuchasaminophylline,doxofylline

-Usage:intravenousororalMultiplebutlesseffectsBronchodilationrespiratorystimulant

improvedcardiovascularfunctionimproveddiaphragmfunctionTherapy-Theophylline第九十八页，共155页。TheophyllineLimitedrolebecauseofnarrowtherapeuticwindowTheophyllineislesseffectiveandlesswelltoleratedthaninhaledbronchodilatorsnotrecommendedifotherdrugsareavailableandaffordable.第九十九页，共155页。TheeffectsoforalandinhaledglucocorticosteroidsinCOPDaremuchlessdramaticthaninasthma,andtheirroleinthemanagementofstableCOPDislimitedtospecificindications.Corticosteroidsareusuallyusedininhaledformbutmayalsobeusedastabletsevenintravenoustotreatandpreventacuteexacerbations.Inhaledcorticosteroids(ICS):decreaseacuteexacerbationsinthosewitheithermoderateorseverediseaseTherapy-Corticosteroids第一百页，共155页。Regulartreatmentwithinhaledcorticosteroids(ICS)improvessymptoms,lungfunctionandqualityoflifeandreducesfrequencyofexacerbationsforCOPDpatientswithanFEV1<60%predicted.WhenusedincombinationwithaLABAtheydecreasemortalitymorethaneitherICSorLABAalone

Inhaledcorticosteroidtherapyisassociatedwithanincreasedriskofpneumonia.InhaledCorticosteroids第一百零一页，共155页。Chronictreatmentwithsystemiccorticosteroidsshouldbeavoidedbecauseofanunfavorablebenefit-to-riskratio.SystemicCorticosteroids第一百零二页，共155页。Supplementaloxygenisrecommendedinthosewithlowoxygenlevelsatrest(apartialpressureofoxygenoflessthan50–55mmHgoroxygensaturationsoflessthan88%).Duringacuteexacerbations,manyrequireoxygentherapyTherapy-Oxygen第一百零三页，共155页。AllCOPDpatientsbenefitfromexercisetrainingprogramswithimprovementsinexercisetoleranceandsymptomsofdyspneaandfatigue.Thelongerthepulmonaryrehabilitationprogramcontinues,themoreeffectivetheresults.Ifexercisetrainingismaintainedathomethepatient'shealthstatusremainsaboveprerehabilitationlevels.

TherapeuticOptions:Rehabilitation第一百零四页，共155页。Respiratoryrehabilitationmayimproveprognosisandthispossibilityviameta-analysisofpublishedresults.PulmonaryRehabilitation第一百零五页，共155页。Influenzavaccinescanreduceseriousillness.PneumococcalpolysaccharidevaccineisrecommendedforCOPDpatients65yearsandolderandforCOPDpatientsyoungerthanage65withanFEV1<40%predicted.Theuseofantibiotics,otherthanfortreatinginfectiousexacerbationsofCOPDandotherbacterialinfections,iscurrentlynotindicated.TherapeuticOptions:OtherPharmacologicTreatments第一百零六页，共155页。Mucolytics:

Patientswithviscoussputummaybenefitfrommucolytics;overallbenefitsareverysmallAntitussives:NotrecommendedOtherPharmacologicTreatments第一百零七页，共155页。Lungvolumereductionsurgery(LVRS)ismoreefficaciousthanmedicaltherapyamongpatientswithupper-lobepredominantemphysemaandlowexercisecapacityLVRSiscostlyrelativetohealth-careprogramsnotincludingsurgery

InappropriatelyselectedpatientswithverysevereCOPD,lungtransplantationhasbeenshowntoimprovequalityoflifeandfunctionalcapacity.TherapeuticOptions:SurgicalTreatments第一百零八页，共155页。第一百零九页，共155页。RelievesymptomsImproveexercisetoleranceImprovehealthstatusPreventdiseaseprogressionPreventandtreatexacerbationsReducemortalityReducesymptomsReduceriskGlobalStrategyforDiagnosis,ManagementandPreventionofCOPD

ManageStableCOPD:GoalsofTherapy第一百一十页，共155页。GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDDefinitionandOverviewDiagnosisandAssessmentTherapeuticOptionsManageStableCOPDManageExacerbationsManageComorbidities

REVISED2011第一百一十一页，共155页。ManagementofCOPD

bySeverityofDiseaseStage0:Atrisk

StageI:MildCOPD

StageII:ModerateCOPD

StageIII:SevereCOPDStageIV:VerySevereCOPD112第一百一十二页，共155页。ComprehensiveManagementofCOPD第一百一十三页，共155页。COPDExacerbation114第一百一十四页，共155页。ManagementofCOPD

Stage0:AtRisk

CharacteristicsRecommendedTreatmentChronicsymptoms

-cough

-sputumNospirometric abnormalitiesReductionofbronchialirritation115第一百一十五页，共155页。ManagementofCOPD

StageI:MildCOPD

CharacteristicsRecommendedTreatment

FEV1/FVC<70%FEV1

>80%predictedWithorwithoutchronic symptomsShort-actingbronchodilatorasneeded116第一百一十六页，共155页。ManagementofCOPD

StageII:ModerateCOPD

CharacteristicsRecommendedTreatmentFEV1/FVC<70%50%<FEV1<80%predictedWithorwithoutchronic symptomsShort-actingbronchodilatorasneeded

Regulartreatmentwithoneormorelong-actingbronchodilatorsRehabilitation117第一百一十七页，共155页。ManagementofCOPD

StageIII:SevereCOPD

CharacteristicsRecommendedTreatmentFEV1/FVC<70%30%<FEV1<50%predictedWithorwithoutchronic symptomsShort-actingbroncho-dilatorasneededRegulartreatmentwithoneormorelong-actingbronchodilatorsInhaledglucocorticosteroidsifrepeatedexacerbationsRehabilitation118第一百一十八页，共155页。ManagementofCOPD

StageIV:VerySevereCOPD

CharacteristicsRecommendedTreatmentFEV1/FVC<70%FEV1<30%predictedor FEV1<50%predicted pluschronicrespiratory failureShort-actingbronchodilatorasneededRegulartreatmentwithoneormorelong-