COPD全球创议_慢性阻塞性肺病GOLD_PG_2010

POCKET GUIDE TO COPD DIAGNOSIS, MANAGEMENT, AND PREVENTION A Guide for Health Care Professionals UUPP DDAATTEEDD 220010 Global Initiative for Chronic Obstructive Lung Disease Global Initiative for Chronic Obstructive Lung Disease Co py rig ht ed m at er ial - do n ot a lte r o r r ep ro du ce GOLD Ex ecu t iv e Com m it tee Roberto Rodriguez-Roisin, MD, Spain, Chair Antonio Anzueto, MD, US (representing ATS) Jean Bourbeau, MD, Canada Teresita S. DeGuia, MD, Philippines David Hui, MD, Hong Kong, ROC Christine Jenkins, MD, Australia Fernando Martinez, MD, US María Montes de Oca, MD, PhD (representing ALAT) Chris van Weel, MD, Netherlands (representing WONCA) Jorgen Vestbo, MD, Denmark Obser v er : Jadwiga Wedzicha, MD, UK (Representing ERS) GOLD Nat ional Leaders Representatives from many countries serve as a network for the dissemination and implementation of programs for diagnosis, management, and prevention of COPD. The GOLD Executive Committee is grateful to the many GOLD National Leaders who participated in discussions of concepts that appear in GOLD reports, and for their comments during the review of the 2006 Global Strategy for the Diagnosis, Management, and Prevention of COPD. Global Initiative for Chronic Obstructive Lung Disease Pocket Guide to COPD Diagnosis, Management, and Prevention © 2010 Global Initiative for Chronic Obstructive Lung Disease, Inc. Michiaki Mishima, MD, Japan (representing APSR) Robert Stockley, MD, UK Co py rig ht ed m at er ial - do n ot a lte r o r r ep ro du ce TTAABBLLEE OOFF CCOONNTTEENNTTSS PPRR EEFFAACCEE KKEEYY PPOOIINNTTSS WWHHAATT IISS CCHHRROONNIICC OOBBSSTTRRUUCCTTIIVVEE PP UULLMMOONNAARRYY DDIISSEEAASSEE ((CCOOPPDD))?? RR IISSKK FFAACCTTOORRSS:: WWHHAATT CCAAUUSSEESS CCOOPPDD?? DDIIAAGGNNOOSSIINNGG CCOOPPDD Figure 1: Key Indicators for Considering a COPD Diagnosis Figure 2: Normal Spirogram and Spirogram Typical of Patients with Mild to Moderate COPD Figure 3: Differential Diagnosis of COPD CCOOMMPP OONNEENNTTSS OOFF CCAARR EE:: AA CCOOPP DD MMAANNAAGGEEMMEENNTT PPRROOGGRRAAMM CCoomm ppoonneenn tt 11:: AAsssseess ss aanndd MMoonn iittoorr DDiisseeaassee CCoomm ppoonneenn tt 22:: RR eedduu ccee RR iisskk FFaaccttoorrss Figure 4: Strategy to Help a Patient Quit Smoking CCoomm ppoonneenn tt 33:: MMaannaaggee SSttaabbllee CCOOPP DD Patient Education Pharmacologic Treatment Figure 5: Commonly Used Formulations of Drugs for COPD Non-Pharmacologic Treatment Figure 6: Therapy at Each Stage of COPD CCoomm ppoonneenn tt 44:: MMaannaaggee EExx aacceerrbbaatt iioonn ss How to Assess the Severity of an Exacerbation Home Management Hospital Management Figure 7: Indications for Hospital Admission for Exacerbations AAPPPPEENNDDIIXX II :: SSPP IIRROOMMEETTRRYY FFOORR DDIIAAGGNNOOSSIISS OOFF CCOOPPDD 33 55 66 77 88 1122 1133 1155 1177 2222 2244 Co py rig ht ed m at er ial - do n ot a lte r o r r ep ro du ce 3 Chronic Obstructive Pulmonary Disease (COPD) is a major cause of chronic morbidity and mortality throughout the world. The Globa l In it iat iv e for Chron ic Obst ru ct iv e Lung Disease was created to increase awareness of COPD among health professionals, public health authorities, and the general public, and to improve prevention and management through a concerted worldwide effort. The Initiative prepares scientific reports on COPD, encourages dissemination and adoption of the reports, and promotes international collaboration on COPD research. While COPD has been recognized for many years, public health officials are concerned about continuing increases in its prevalence and mortality, which are due in large part to the increasing use of tobacco products worldwide and the changing age structure of populations in developing countries. The Global In it iat iv e for Chron ic Obst ru ct iv e Lung Disease offers a framework for management of COPD that can be adapted to local health care systems and resources. Educational tools, such as laminated cards or computer-based learning programs, can be prepared that are tailored to these systems and resources. The Global In it iat iv e for Chron ic Obst ru ct iv e Lung Disease program includes the following publications: • Global Strategy for the Diagnosis, Management, and Prevention of COPD. Scientific information and recommendations for COPD programs. (Updated 2010) • Executive Summary, Global Strategy for the Diagnosis, Management, and Prevention of COPD. (Updated 2010) • Pocket Guide to COPD Diagnosis, Management, and Prevention. Summary of patient care information for primary health care professionals. (Updated 2010) • What You and Your Family Can Do About COPD. Information booklet for patients and their families. PREFACE Co py rig ht ed m at er ial - do n ot a lte r o r r ep ro du ce 44 These publications are available on the Internet at www.goldcopd.org. This site provides links to other websites with information about COPD. This Pocket Guide has been developed from the Global Strategy for the Diagnosis, Management, and Prevention of COPD (2010). Technical discussions of COPD and COPD management, evidence levels, and specific citations from the scientific literature are included in that source document. AAcckk nnooww lleeddggeemm eenn tt ss:: Grateful acknowledgement is given for the educational grants from Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, Dey, Forest Laboratories, GlaxoSmithKline, Novartis, Nycomed, Pfizer, Philips Respironics, and Schering-Plough. The generous contributions of these companies assured that the participants could meet together and publications could be printed for wide distribu- tion. The participants, however, are solely responsible for the statements and con- clusions in the publications. Co py rig ht ed m at er ial - do n ot a lte r o r r ep ro du ce 55 KEY POINTS • CChhrroonn iicc OObbsstt rruucctt iivv ee PP uu llmm oonnaarr yy DDiisseeaassee ((CCOOPP DD) is a preventable and treatable disease with some significant extra- pulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases. • Worldwide, the most commonly encountered rr iisskk ffaacctt oorr for COPD is cciiggaarreett ttee ssmm ookk iinngg. AAtt eevveerr yy ppoossss iibbllee ooppppoorr ttuu nn iitt yy iinndd iivv iidduuaa llss ww hhoo ssmm ookk ee sshhoouu lldd bbee eennccoouu rraaggeedd ttoo qquu iitt . In many countries, air pollution resulting from the burning of wood and other biomass fuels has also been identified as a COPD risk factor. • A ddiiaaggnnoossiiss of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease. The diagnosis should be confirmed by spirometry. • A CCOOPPDD mm aannaaggeemm eenn tt pprrooggrraamm includes four components: assess and monitor disease, reduce risk factors, manage stable COPD, and manage exacerbations. • PP hhaarrmm aaccoollooggiicc tt rreeaa ttmm eenn tt can prevent and control symptoms, reduce the frequency and severity of exacerbations, improve health status, and improve exercise tolerance. • PP aatt iieenn tt eedduuccaa tt iioonn can help improve skills, ability to cope with illness, and health status. It is an effective way to accomplish smoking cessation, initiate discussions and understanding of advance directives and end-of-life issues, and improve responses to acute exacerbations. • COPD is often associated with eexx aacceerrbbaa tt iioonnss of symptoms. Co py rig ht ed m at er ial - do n ot a lte r o r r ep ro du ce WHAT IS CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)? CChh rroonn iicc OObbss tt rruu cctt iivvee PPuu llmm oonnaarryy DDiisseeaassee ((CCOOPPDD)) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The air- flow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases. This definition does not use the terms chronic bronchitis and emphysema* and excludes asthma (reversible airflow limitation). SSyymm ppt 关于艾滋病ppt课件精益管理ppt下载地图下载ppt可编辑假如ppt教学课件下载triz基础知识ppt toomm ss ooff CCOOPPDD iinn cclluuddee:: • Cough • Sputum production • Dyspnea on exertion Episodes of acute worsening of these symptoms often occur. *Chronic bronchitis, defined as the presence of cough and sputum production for at least 3 months in each of 2 consecutive years, is not necessarily associated with airflow limitation. Emphysema, defined as destruction of the alveoli, is a pathological term that is sometimes (incorrectly) used clinically and describes only one of several structural abnormalities present in patients with COPD. 66 CChh rroonn iicc ccoouu gghh aanndd ssppuu ttuu mm pprroodduu cctt iioonn ooff tt eenn pprreecceeddee tthhee ddeevveellooppmm eenntt ooff aa iirr ff llooww lliimm iittaa tt iioonn bbyy mm aannyy yy eeaarr ss,, aa lltt hhoouu gghh nnoott aa ll ll iinnddiivv iidduu aallss ww iitt hh ccoouu gghh aanndd ssppuu ttuu mm pprroodduu cctt iioonn ggoo oonn ttoo ddeevveelloopp CCOOPP DD.. Co py rig ht ed m at er ial - do n ot a lte r o r r ep ro du ce 77 RISK FACTORS: WHAT CAUSES COPD? WWoorr llddww iiddee,, cciiggaarreett ttee ssmm ookk iinngg iiss tt hhee mm oosstt ccoomm mm oonn llyy eennccoouunn tt eerreedd rr iisskk ffaacctt oorr ffoorr CCOOPPDD.. The genetic risk factor that is best documented is a severe hereditary deficiency of alpha-1 antitrypsin. It provides a model for how other genetic risk factors are thought to contribute to COPD. COPD risk is related to the total burden of inhaled particles a person encounters over their lifetime: • TToobbaaccccoo ssmm ookk ee, including cigarette, pipe, cigar, and other types of tobacco smoking popular in many countries, as well as environmental tobacco smoke (ETS) • OOccccuuppaa tt iioonnaall dduu ss tt ss aanndd cchheemm iiccaallss (vapors, irritants, and fumes) when the exposures are sufficiently intense or prolonged • IInnddoooorr aa iirr ppoolllluu tt iioonn from biomass fuel used for cooking and heating in poorly vented dwellings, a risk factor that particularly affects women in developing countries • OOuu tt ddoooorr aaiirr ppooll lluu tt iioonn also contributes to the lungs’ total burden of inhaled particles, although it appears to have a relatively small effect in causing COPD In addition, any factor that affects lung growth during gestation and childhood (low birth weight, respiratory infections, etc.) has the potential for increasing an individual’s risk of developing COPD. Co py rig ht ed m at er ial - do n ot a lte r o r r ep ro du ce DIAGNOSING COPD A diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease, especially cigarette smoking (FFiigguu rr ee 11). TThhee dd iiaaggnnoossiiss sshhoouu lldd bbee ccoonn ff iirrmm eedd bbyy sspp iirroomm eett rr yy** ((FFiigguu rree 22,, ppaaggee 99 aanndd AAppppeennddiixx I,, ppaaggee 2244)).. *Where spirometry is unavailable, the diagnosis of COPD should be made using all available tools. Clinical symptoms and signs (abnormal shortness of breath and increased forced expiratory time) can be used to help with the diagnosis. A low peak flow is consistent with COPD but has poor specificity since it can be caused by other lung diseases and by poor performance. In the interest of improving the accuracy of a diagnosis of COPD, every effort should be made to provide access to standardized spirometry. 88 FFiigguu rree 11:: KKeeyy IInnddiiccaattoorrss ffoorr CCoonnss iiddeerr iinngg aa CCOOPPDD DDiiaaggnnoossiiss Consider COPD, and perform spirometry, if any of these indicators are present in an individual over age 40. These indicators are not diagnostic themselves, but the presence of multiple key indicators increases the probability of a diagnosis of COPD. • DDyy ssppnneeaa that is: Progressive (worsens over time). Usually worse with exercise. Persistent (present every day). Described by the patient as an “increased effort to breathe,” “heaviness,” “air hunger,” or “gasping.” • CChhrroonn iicc ccoouu gghh :: May be intermittent and may be unproductive. • CChhrroonn iicc ssppuu tt uumm pprroodduucctt iioonn :: Any pattern of chronic sputum production may indicate COPD. • HHiiss tt oorr yy ooff eexx ppoossuu rree tt oo rr iisskk ffaaccttoorrss:: TToobbaaccccoo ssmm ookk ee ((iinncclluuddiinngg ppooppuu llaarr llooccaall pprreeppaarraatt iioonnss)).. Occupational dusts and chemicals. Smoke from home cooking and heating fuel. Co py rig ht ed m at er ial - do n ot a lte r o r r ep ro du ce When performing spirometry, measure: • FForced VVital CCapacity (FFVVCC) and • FForced EExpiratory VVolume in one second (FFEEVV11). Calculate the FEV1/FVC ratio. Spirometric results are expressed as %% PP rreeddiicctt eedd using appropriate normal values for the person’s sex, age, and height. 99 PP aatt iieenntt ss ww iitt hh CCOOPP DD ttyy ppiiccaallllyy sshhooww aa ddeeccrreeaassee iinn bbootthh FFEEVV11 aanndd FFEEVV 11//FFVVCC.. TThhee ddeeggrreeee ooff ssppiirroomm eett rr iicc aabbnnoorrmm aalliitt yy ggeenneerraallllyy rr eeff lleecctt ss tt hhee sseevv eerr iitt yy ooff CCOOPP DD.. HHooww eevveerr,, bbootthh ssyymm ppttoomm ss aanndd ssppiirroomm eett rr yy sshhoouu lldd bbee ccoonnss iiddeerreedd ww hheenn ddeevveellooppiinngg aann iinnddiivv iidduu aalliizzeedd mm aannaaggeemm eenntt ss tt rr aatteeggyy ffoorr eeaacchh ppaatt iieenntt .. FFiigguu rree 22:: NNoorrmm aall SSppiirrooggrraamm aanndd SSppiirrooggrraamm TTyy ppiiccaall ooff PP aatt iieenn tt ss ww iitt hh MMiilldd tt oo MMooddeerraattee CCOOPPDD** *Postbronchodilator FEV1 is recommended for the diagnosis and assessment of severity of COPD. Co py rig ht ed m at er ial - do n ot a lte r o r r ep ro du ce Stages of COP D Stage I: Mild COPD - Mild airflow limitation (FEV1/FVC < 70%; FEV1 ≥ 80% predicted) and sometimes, but not always, chronic cough and sputum production. • At this stage, the individual may not be aware that his or her lung function is abnormal. Stage I I: Moderate COPD - Worsening airflow limitation (FEV1/FVC < 70%; 50% ≤ FEV1 < 80% predicted), with shortness of breath typically developing on exertion. • This is the stage at which patients typically seek medical attention because of chronic respiratory symptoms or an exacerbation of their disease. Stage I I I : Sev ere COPD - Further worsening of airflow limitation (FEV1/FVC < 70%; 30% ≤ FEV1 < 50% predicted), greater shortness of breath, reduced exercise capacity, and repeated exacerbations which have an impact on patients’ quality of life. Stage IV: Ver y Sev ere COPD - Severe airflow limitation (FEV1/FVC < 70%; FEV1 < 30% predicted) or FEV1 < 50% predicted plus chronic respiratory failure. Patients may have Very Severe (Stage IV) COPD even if the FEV1 is > 30% predicted, whenever this complication is present. • At this stage, quality of life is very appreciably impaired and exacerbations may be life-threatening. 10 “ At R isk for COP D” A major objective of GOLD is to increase awareness among health care providers and the general public of the significance of COPD symptoms. The classification of severity of COPD now includes four stages classified by spirometry—Stage I: Mild COPD; Stage II: Moderate COPD; Stage III: Severe COPD; Stage IV: Very Severe COPD. A fifth category—“Stage 0: At Risk”—that appeared in the 2001 report is no longer included as a stage of COPD, as there is incomplete evidence that the individuals who meet the definition of “At Risk” (chronic cough and sputum production, normal spirometry) necessarily progress on to Stage I: Mild COPD. Nevertheless, the importance of the public health message that chronic cough and sputum are not normal is unchanged and their presence should trigger a search for underlying cause(s). Co py rig ht ed m at er ial - do n ot a lte r o r r ep ro du ce DDiiff ffeerreenntt iiaall DDiiaaggnnoossiiss:: A major differential diagnosis is asthma. In some patients with chronic asthma, a clear distinction from COPD is not possible using current imaging and physiological testing techniques. In these patients, current management is similar to that of asthma. Other potential diagnoses are usually easier to distinguish from COPD (FFiigguurree 33). 1111 DDiiaaggnnoossiiss SSuuggggeesstt iivvee FFeeaattuurreess** COPD Onset in mid-life. Symptoms slowly progressive. Long smoking history. Dyspnea during exercise. Largely irreversible airflow limitation. Asthma Onset early in life (often childhood). Symptoms vary from day to day. Symptoms at night/early morning. Allergy, rhinitis, and/or eczema also present. Family history of asthma. Largely reversible airflow limitation. Congestive Heart Failure Fine basilar crackles on auscultation. Chest X-ray shows dilated heart, pulmonary edema. Pulmonary function tests indicate volume restriction, not airflow limitation. Bronchiectasis Large volumes of purulent sputum. Commonly associated with bacterial infection. Coarse crackles/clubbing on auscultation. Chest X-ray/CT shows bronchial dilation, bronchial wall thickening. Tuberculosis Onset all ages. Chest X-ray shows lung infiltrate or nodular lesions. Microbiological confirmation. High local prevalence of tuberculosis. Obliterative Bronchiolitis Onset in younger age, nonsmokers. May have history of rheumatoid arthritis or fume exposure. CT on expiration shows hypodense areas. Diffuse Panbronchiolitis Most patients are male and nonsmokers. Almost all have chronic sinusitis. Chest X-ray and HRCT show diffuse small centrilobular nodular opacities and hyperinflation. FFiigguu rree 33:: DDiiff ff eerreenn tt iiaall DDiiaaggnnooss iiss ooff CCOOPPDD *These features tend to be characteristic of the respective diseases, but do not occur in every case. For example, a person who has never smoked may develop COPD (especially in the developing world, where other risk factors may be more important than cigarette smoking); asthma may develop in adult and even elderly patients. Co py rig ht ed m at er ial - do n ot a lte r o r r ep ro du ce 1122 COMPONENTS OF CARE: A COPD MANAGEMENT PROGRAM The goals of COPD management include: • Relieve symptoms • Prevent disease progression • Improve exercise tolerance • Improve health status • Prevent and treat complications • Prevent and treat exacerbations • Reduce mortality • Prevent or minimize side effects from treatment Cessation of cigarette smoking should be included as a goal throughout the management program. TTHHEESSEE GGOOAALLSS CCAANN BBEE AACCHHIIEEVVEEDD TTHHRROOUUGGHH IIMMPP LLEEMMEENNTTAATTIIOONN OOFF AA CCOOPPDD MMAANNAAGGEEMMEENNTT PP RROOGGRRAAMM WWIITTHH FFOOUURR CCOOMMPPOONNEENNTTSS:: 11.. AAsssseessss aanndd MMoonn iittoorr DDiisseeaassee 22.. RReedduuccee RR iisskk FFaaccttoorr ss 33.. MMaannaaggee SStt aabbllee CCOOPPDD 44.. MMaannaaggee EExx aacceerrbbaatt iioonnss Co py rig ht ed m at er ial - do n ot a lte r o r r ep ro du ce 1133 Component 1: Assess and Monitor Disease AA ddeett aaiilleedd mm eeddiiccaa ll hh iiss ttoorr yy of a new patient known or thought to have COPD should assess: •• Exposu