我国慢性气道疾病的特点及应对策略译

TreatmentStrategiesBasedontheCharacteristicsofChronicAirwayDiseasesinChinaStateKeyLaboratoryofRespiratoryDiseaseTheFirstAffiliatedHospital,GuangzhouMedicalUniversityGuangzhouInstituteofRespiratoryDiseasesRongchangChenCatalogueHeavyBurdensofChronicAirwayDiseasesinChina1从疾病特点入手提升管理水平2ImprovetheManagementLevelBasedontheFeaturesoftheDiseasesChronicAirwayDisease:MainCauseofDeathinChina/jkj/s5879/201506/4505528e65f3460fb88685081ff158a2.shtmlFengYL,etal.ChinJRespirCritCareMed2012;11(4):313-316MortalityRate(Per100Thousand)Cardiac-cerebralvasculardiseaseCancerChronicairwaydiseasesUrbanarea:13.89%Ranksthe4thRuralarea:22.04%Ranksthe3rdRespiratoryDiseases(MainlyChronicObstructivePulmonaryDisease[COPD])OtherDiseasesReportofNutritionandChronicDiseaseConditionsofChineseResidents(2015)RespiratoryDiseasesRankTop10DeathCausesofChinesePopulationIncreasingPrevalenceofChronicAirway

DiseasesinChinaZhongN,etal.Americanjournalofrespiratoryandcriticalcaremedicine,2007,176(8):753-760./jkj/s5879/201506/4505528e65f3460fb88685081ff158a2.shtmlAsthmaWorkgroup,ChineseSociety,Respiratory,Diseases(CSRD),ChineseMedical,Association.ChinJTubercRespirDis2016;39(9):675-697.PrevalenceofAsthmainPopulationAged≥14in2010:1.24%3SignificantIncreaseComparedwith10YearsAgoBeijingIncreasingRateofMorbidityRateofAsthmaShanghaiGuangdongLiaoning2002-2004COPDPrevalence2012-20142012PopulationAged≥40SignificantIncreasingprevalenceofCOPDSuboptimalSituationof

ChronicAirwayDiseasesManagementinChinaAgingofPopulationAirPollutionSmoking/2nd-handSmokingUtilityofBio-fuelsBigDifferenceofDrugAccessAmongDifferentRegionsHowtoImprovethePreventionandManagementofChronicAirwayDiseases?GuanWJ,etal.LancetRespiratoryMedicine,2016,4(6):428-430FengYL,etal.ChinJRespirCritCareMed2012;11(4):313-316CatalogueHeavyBurdensofChronicAirwayDiseasesinChina1从疾病特点入手提升管理水平2ImprovetheManagementLevelBasedontheFeaturesoftheDiseasesDifferenceofChronicRespiratory

DiseasesfromOtherDiseasesInhalationisthemainrouteofadministrationComparedwithDiseasesofOtherSystemsComparedwithAcuteDiseasesLongerdiseasecoursesandslowdiseaseprogresses13ComparedwithShort-termTherapyControllableDiseasesLong-termandregulartherapyisrequired2Longerdiseasecourses,slowdiseaseprogressesLong-termandregulartreatmentisneeded231Inhalationisthemainrouteofadministration23ImprovetheManagementofCOPD

BasedontheFeaturesoftheDiseases1231ImportanceofearlydiagnosisandinterventionEmphasizethestandardizationandcomplianceofthetreatmentPayattentiontopatienteducationandtrainingoftheinhalationtechnologyLongerdiseasecourses,slowdiseaseprogressesLong-termandregulartreatmentisneeded231Inhalationisthemainrouteofadministration23ImprovetheManagementofCOPD

BasedontheFeaturesoftheDiseases1231ImportanceofearlydiagnosisandinterventionEmphasizethestandardizationandcomplianceofthetreatmentPayattentiontopatienteducationandtrainingoftheinhalationtechnologyEarlyPreventionandInterventionarethe

BreakthroughsofDiseaseControlPreventionofCOPD(reductionofriskfactors)canhelpreducethemorbidityrateaswellassocialburdens1:

√Smokingcontrolandcessation

√Optimizationofvehiclefuels

√ReductionofemissionofoutdoorairpollutantsGuanWJ,etal.LancetRespiratoryMedicine,2016,4(6):428-430HaahtelaT,etal.ErjOpenResearch,2015,1(1):00022-2015-22-2015.ImmediateICSTreatment(EarlyIntervention)onPatientsOnceDiagnosedwithAsthmamay2:

√Reducesymptomsrapidly

√Controlasthmatimely

√MinimizethediseaseburdensCommunityComprehensiveIntervention:DelaytheDecliningRateofLungFunction11ArandomizedcontrolstudyconductedinGuangdongprovincehasenrolled872subjectsagedfrom40to89witharandomizationintocontrolgroupandcommunitycomprehensiveinterventiongroupandthelongestfollowupperiodis4years.CommunitycomprehensiveinterventionshowsansignificantdelayoftheannualdecliningrateofFEV1andFEV1/FVCforthestudypopulationaswellasthepopulationfreeofCOPDs.ZhouY,etal.BmjBritishMedicalJournal,2010,341(7784):c6387.Intervention12340YearsofFollowUp1.71.81.92.02.1AverageFEV1Value(L)ControlGroupInterventionnGroup

Thestudypopulation:CommunityInterventionInvolveshealtheducation,individualizedintensiveintervention,treatmentandrehabilitation,urgingthetechnologyupgradingandremovalofthesurroundingCementplants.12340YearsofFollowUp1.801.902.002.102.15AverageFEV1Value(L)P=0.024PopulationfreeofCOPDs1.851.952.05P=0.023ControlGroupIntervention

GroupEarlyDiagnosisistheFoundamentalofEarlyIntervention,However,CurrentStatusofDiagnosisofChronicAirwayDiseasesisMingledwithHopeandFear12ObviousIncreasingRateofCorrectDiagnosisofAsthma1DefiniteDiagnosisRateofChronicObstructivePulmonaryDiseaseisOnly35.1%inChina235.3%ofthepatientshavenoobvioussymptoms3Mostofthepatientssufferfrommiddleandadvanceddiseasesatthetimeofdefinitediagnosis4ShaL,etal.ChinJPediator2016;54(3):182-186.RangPX.TheJournalofPracticalMedicine2014;30(1):4-5.LuM,etal.ChinMedJ2010；123(12)：1494-1499.FengYL,etal.ChinJRespirCritCareMed2012;11(4):313-316.DiagnosticRateDiagnosticRateofPediatricAsthmaDiagnosticRateWithin1YearofDiseaseIncidenceP<0.01P<0.01AsthmaCOPDYearof2000Yearof2010DiagnosisFocusonHighRiskPopulationofChronicAirwayDiseasesDuringClinicalDiagnosisandTreatment13“RecommendpulmonaryfunctiontestasearlyscreeningofCOPDsinthepopulationswithclinicalsymptomsorhighriskfactors

(e.g.,smokinghistoryofmorethan20years,orrecurrentpulmonaryinfections)”GOLD2017GuidelineforDiagnosisandTreatmentofChronicObstructiveDiseasesinChina“Lungfunctiontestshallbeperformedinanyindividualswithsmokinghistoryand/orworkingenvironmentpollutionandbio-fuelsexposure,andanyindividualswithhistoryofdyspnea,coughingorexpectoration”GOLD2017ChronicObstructivePulmonaryDiseaseworkgroup,ChineseSociety,Respiratory,Diseases(CSRD),ChineseMedical,Association.ChinJTubercRespirDis2013;36(4):1-10.DiagnosisPromotionandPopularizationof

LungFunctionTestisStillRequired14LungFunctionTestisnotincludedinthefirst5examinationitemsforCOPDpatientsinoutpatientdepartmentofprimaryhospitalsinruralareas1ComputerX-rayPhotographyCTScanElectrocardiogram(ECG)HeartRateBloodPressureHeQY.ChinJＲespirCritCareMed2013;13(1):5-9.ZhouYM,etal.ChinJInternMed2009;48(5):358-361.ZhongNS,etal.AmJRespirCritCareMed2007;176(8):753-760.ShiYM,etal.JournalofClinicalPulmonaryMedicine2015;20(5):835-838.HeQY,etal.ChinJPrevContrChronDis2009;17(5):441-443.Communities

inShanghai4Nation-wide3ProportionsofpatientsthathaveexperiencedpulmonaryfunctiontestRural

Areas2Only10%oftheCOPDpatientshaveexperiencedlungfunctiontest2-4;

Only8%oftheurbanrespiratoryphysiciansevaluatetheCOPDprogressmainlyonthebasisofLungfunctiontestresults5.DiagnosisQuestionnaireforCOPDScreening:

ScreeningforHighRiskPopulations15ZhangXL,WangC.ChinJHealthManage2015;9(4):250-253.ZhouYM,etal.InternationalJournalofTuberculosis&LungDisease,2013,17(12):1645-51.FortheconsiderationofcurrentallocationconditionsofmedicalresourcesinChina,sequentialcaserecognitionbasedonthecombinationwithquestionnairesurveyandpulmonaryfunctiontestmightbethemostpracticalandfeasiblemethodforindividualswithclinicalsymptomsandhighrisksinprimaryhealthestablishments1HighRiskPopulationScreeningScaleLungFunctionTestQuestionnaireforScreeningofCOPDinChinaScreeningItems2:1.Age2.Smokingindex3.Bodymassindex(BMI)4.Coughing5.Dyspnea6.Familyhistoryofrespiratorydiseases7.Delayexposuretobio-fuelsDiagnosisDiagnosis16ScreeningQuestionnaire+LungFunctionTestCanIncreasetheDiagnosticRateofCOPDTinkelmanDG,etal.PrimaryCareRespiratoryJournal,2007,16(1):41.818subjectsaged≥40withsmokinghistorywhoarenotdiagnosedwithCOPDwereenrolledandscreenedincombinationwiththescreeningquestionnaireandLungfunctiontestinprimaryhealthinstituteTotally155cases(18.9%)ofmisseddiagnosishavebeenfound,mostofwhomsufferedfrommildtomoderateCOPD.PatientProportionsExtremelySevereMildModerateSevereDiagnosis17PEFTest：CanitscreentheCOPDpatients?3,379

cases（≥40yearsold）EvaluatethesensitivityandspecificityofPEF,vs.FEV1/FVCorLLNTianJ,etal.IntJTubercLungDis2012,16(5):67417TianJ,etal.IntJTubercLungDis2012,16(5):674Goldenstandard:FEV1/FVC<0.70GOLDUpdated2010questionnairePEF<80%predTianJ,etal.IntJTubercLungDis2012,16(5):674Diagnosis18PEF(<80%pred)：areliablescreeningtoolPEF<80%predhasagoodsensitivityandspecificityPlacewithnoinstrumentforlungfunctiontest,itcanbeusedasasuitablescreeningtoolforairflowobstructionTianJ,etal.IntJTubercLungDis2012,16(5):674PEF<80%predSensitivity

(%)Specificity

(%)Negativepred.value(%)

OverallstudypopulationGOLDgradeasstandard76.883.897.0pre-bronchodilator,FEV1/FVC<LLNasstandard78.781.998.1

AsymptomaticpopulationGOLDgradeasstandard64.884.697.2pre-bronchodilator,FEV1/FVC<LLNasstandard66.383.598.3GOLDstandard：post-bronchodilator,FEV1/FVC<0.7LLN:lowerlimitsofnormalDiagnosisLongerdiseasecourses,slowdiseaseprogressesLong-termandregulartreatmentisneeded231Inhalationisthemainrouteofadministration23ImprovetheManagementofCOPD

BasedontheFeaturesoftheDiseases1231ImportanceofearlydiagnosisandinterventionEmphasizethestandardizationandcomplianceofthetreatmentPayattentiontopatienteducationandtrainingoftheinhalationtechnologyStandardizationandComplianceoftheTreatment:

CriticalforChronicDiseasesManagementGuidelinesaretheexamplestostandardizetheclinicalpracticesFollowingtheglobalanddomesticguidelinesmayhelpstandardizethediseasemanagementCompliancereferstowhetherthepatientscanreceivethelong-termtreatmentfollowingthedoctor’sprescriptionTakeasthmaforanexample,insufficientcomplianceissignificantlyrelatedtotheincreased68%riskofpoorcontrolledasthma*Sufficient/

ModerateInsufficient/

ExtremelyinsufficientP=0.002PoorControlledORCompliance:*Poorcontrolledthma

refersto≥1.5ACQscoresGiraudV,etal.RespMed2011;105:1815-22StandardizationComplianceDiagnosisandTreatmentCapabilityofPhysician

NeedtoBeImproved21Disease

KnowledgeTherapeuticDrugUsageoftheDevice231Only16.4%ofthephysiciansinprimaryestablishmentscancorrectlyusethediskusesandturbuhalers5Only23.7%ofthephysiciansconsiderimmobilityasoneofthemainsymptomsofCOPD1KnowledgeaboutCOPDofphysiciansinprimaryhealthcareinstituteisfarlessthanthatabouthypertensionanddiabetes2ZhouXM,etal.ChinJInternMed2016；55(9):717-720.XuY,etal.ChineseJounalforClinicians2017;45(6):45-50.TangJ,etal.JClinInternMed2016;33(5):318-322.ZhengLQ.NationalSymposiumonchronicobstructivepulmonarydisease.2013ChaiYQ.ChinaHealthIndustry2014(19):143-144.Only35.3%ofthecommunityCOPDpatientsreceiveinhalationtherapy3CompliancetothetreatmentguidelineofCOPDinsomeareasislessthan15%4StandardizationCompliancetotheGuidelines:

CanImprovetheDiseaseControl22BatemanED,etal.Americanjournalofrespiratoryandcriticalcaremedicine,2004,170(8):836-844.PatientProportionsFully

ControlledFully

ControlledWell

Controlled控制良好AfterthefollowupperiodofoneyearAftertheup-escalationtherapyP<0.001ICSICS/LABAStandardization*Fullycontrolledasthma:ThepredictedPEF%valuesoneachmorningwithinoneweekare≥80%withoutdaysymptoms,takingfirst-aidmedicines,nocturnalawaking,acuteexacerbation,visitingemergencydepartmentoradverseeventswhichneedsanychangeofthetreatmentregimen

wellcontrolledasthma:ThepredictedPEF%valuesoneachmorningwithinoneweekare≥80%withdaysymptomslastingfor＞1minfor≤2days,receptionoffirst-aidmedicinesis≤2daysand≤4timeswithinoneweek,andwithoutnocturnalawaking,acuteexacerbation,visitingemergencydepartmentoradverseeventswhichneedsanychangeofthetreatmentregimen3421patientswithuncontrolledasthmawereenrolledtoreceiveFluticasoneorSalmeterol/FluticasonetreatmentAfteroneyearoftheup-escalationtherapyfollowingtheguidelines,theproportionoffullcontrol/goodcontrol*ofasthmahassignificantlyincreasedWell

ControlledNon-Compliance:AChallengein

ChronicDiseaseManagement231007550250Treatmentpersistenceofdifferentdrugs0100200300400LAMALABAICSLABA/ICSTime(day)MuellerS,etal.RespiratoryMedicine,2017,122:1-11.HeQY,etal.ChinJPrevContrChronDis2009;17(5):441-443.WangLH.TodayNurse2014;8:28-29.ChengWF,etal.ChineseJournalofHospitalStatistics2016;23(6):436-438.LiJF,etal.ChinJModNurse2013;19(30):3728-3731.Aretrospective,cohortstudyinvolves52,585GermanpatientswithCOPD1About2/3patientswithCOPDfailedtocontinuallyusebronchodilatorwithin1yearUpdatedglobalresearchDomesticresearch47%patientswoulddiscontinuethedrugwhentheyfeelbetterandonly31%wouldconsultthedoctorbeforediscontinuation2ComplianceofChinesepatientswithCOPDwaslessthan40%3-5CompliancewithtreatmentLihuaWANG,etal.3WeifeiCHEN,etal.4JiefengLI,etal.5CompliancePatientHealthEducation:Improving

TreatmentCompliance24HongXY,etal.ZhejiangPrevMed2014;26(6):631-632.PatientpercentageControlGroupInterventionGroupSufficientcomplianceModeratecomplianceInsufficientcomplianceCompliance74outpaitentswithasthmawereenrolledandrandomizedtocontrolgroupandinterventiongroupPatientsincontrolgroupreceievedroutineoutpatienthealtheducationwhilepatientsininterventiongroupadditionalyreceivedspecifichealtheducation,includingintroductiontothedisease,improtanceofcompliance,psychologicalcounseling,lifeandhomecare,etc.Specifichealtheducationsignificantlyimprovedthecompliancewithtreatment,comparedwithroutineeducationincontrolgroupReducetheDosingFrequency:

ImprovingTreatmentCompliance25ToyEL,etal.RespiratoryMedicine,2011,105(3):435-441.Dataof55,076patientswithCOPDinUShealthinsuranceclaimsdatabasebetween1999and2006wasanalyzedretrospectivelyCompliancewasmeasuredbyproportionofdayscoveredover12monthsfollowingtreatmentinitiationEffectofdifferentdosingfrequenciesoncompliancewasanalyzedComplianceProportionofdayscovered(%)Durationoftreatment(month)QDBIDTIDQID26WilsonSRetal.AmJRespCareMed2010;181:566–77Arandomized,controlledstudyin612patientswithpoorlycontrolledasthma,whichcompared3treatmentmodels:1.Usualcare(UC):referenceexpertreportsoflocallong-termasthmacontrol;2.Cliniciandecisionmakingmodel:thecliniciandecidedtheregimenbasedonthepatients'conditionandexplainstheregimenthepatient;3.Shareddecisionmakingmodel:Firstly,theclinicianlearnedaboutthetreatmentgoalsandpreferenceindiseasecontrol,convenience,sideeffectsandcosts,followingwhich,theclinicianprovidedalloptionsofregimensandnegotiatedtherisk-benefitbalancetogetherwithpatients.Observethecompliancewithtreatmentandcontrolsofasthmawithin2years.Pre-randomizationYear1follow-upYear2follow-upDosageofusedICS(indicatingcompliance)ComplianceUsualcare(UC)Cliniciandecisionmaking(CDM)Shareddecisionmaking

(SDM)Physician-PatientSharedTreatmentDecisionMaking:

ImprovingTreatmentCompliance27CompliancePre-randomizationYear1follow-upYear2follow-upUsedamountofemergencymedicationUsualcare(UC)Cliniciandecisionmaking(CDM)Shareddecisionmaking

(SDM)Arandomized,controlledstudyin612patientswithpoorlycontrolledasthma,whichcompared3treatmentmodels:1.Usualcare(UC):referenceexpertreportsoflocallong-termasthmacontrol;2.Cliniciandecisionmakingmodel:thecliniciandecidedtheregimenbasedonthepatients'conditionandexplainstheregimenthepatient;3.Shareddecisionmakingmodel:Firstly,theclinicianlearnedaboutthetreatmentgoalsandpreferenceindiseasecontrol,convenience,sideeffectsandcosts,followingwhich,theclinicianprovidedalloptionsofregimensandnegotiatedtherisk-benefitbalancetogetherwithpatients.Observethecompliancewithtreatmentandcontrolsofasthmawithin2years.WilsonSRetal.AmJRespCareMed2010;181:566–77SharedTreatmentDecision:

ImprovingDiseaseControlLongerdiseasecourses,slowdiseaseprogressesLong-termandregulartreatmentisneeded231Inhalationisthemainrouteofadministration23ImprovetheManagementofCOPD

BasedontheFeaturesoftheDiseases1231ImportanceofearlydiagnosisandinterventionEmphasizethestandardizationandcomplianceofthetreatmentPayattentiontopatienteducationandtrainingoftheinhalationtechnologyKeyOperationErrorsareAssociated

withAnIncreasedRiskofAcuteExacerbation29InhalationTechniqueMolimardM,etal.EuropeanRespiratoryJournal,2017,49(2):1601794.Collecttotally3,393useinformationofinhalationdevicefrom2,935COPDpatientsintherealworld.Comparedwithpatientswithoutoperationerror,patientswhohaveatleastonekeyoperationerrorhavedoublerisksthatsevereacuteexacerbation*occursin3months.*Severeacuteexacerbationisdefinedasacuteexacerbationthatleadstoemergencyorhospitalization6.9%Noerror3.3%AtleastonekeyerrorP<0.01Theratioofpatientswhodevelopsevereacuteexacerbationin3monthsTheUseErrorofInhalationDevicesisCommon30CaoYQ.GuideofChinaMedicine2014;25:180-181.ZhouZQ.ActaAcademiaeMedicinaeWannan2014;5:466-467.SuanYY.TodayNurse2016;12:39-42.TheerrorrateofinhalationtechniqueforCOPD,AsthmapatientsinChinareaches43%-70%1-3吸入技术错误发生在使用各个阶段3Inhalationtechnique:Thestrengthanddepthofin