Health Worlds

Diagnosis and treatment of chronic obstructive pulmonary disease guidelines (2007 Revision)Diagnosis and treatment of chronic obstructive pulmonary disease guidelines (2007 Revision)Chronic obstructive pulmonary disease (COPD) more than the number of patients because of its high mortality, socio-economic burden, has become an important public health problem. COPD now ranks the world's No. 4 cause of death, the World Bank / World Health Organization, 2020 COPD will be the economic burden of disease among the world's No. 5. In China, COPD is also a serious harm to people's health a major chronic respiratory diseases. 7 areas of China near 20245 adult population survey, COPD prevalence in people over the age of 40 accounted for 8.2% of the high prevalence rate is very alarming.
To promote the social, zhengfu and concerns COPD patients to improve diagnosis and treatment of COPD and reduce the morbidity and mortality of COPD, following Europe and the United States to develop COPD treatment guidelines later, in April 2001 the National Heart, Lung, and Blood Institute, The (NHLBI) and WHO jointly published the "chronic obstructive pulmonary disease Global Initiative" (Global lnitiative for Chronic Obstructive Lung Disease, GOLD), GOLD's on the prevention and treatment of COPD States played a significant role in promoting. GOLD China also enacted in 1997 with reference to a "COPD diagnosis and treatment of norms" (draft), and in 2002 formulated the "diagnosis and treatment of


chronic obstructive pulmonary disease guidelines." They have been developed by WHO and zhengfu about the concerns of the disease control department, medical personnel to improve the diagnosis and treatment of COPD, COPD, to promote research to reduce its prevalence and mortality in China play a good role. This is the 2002 updated guidelines for diagnosis and treatment of COPD.
Definitions
COPD is a kind of airflow limitation characteristic of the disease can be prevented and treated, not fully reversible airflow limitation, showed a progressive development, and the lungs of cigarette smoke and other harmful gases or harmful particles in the abnormal inflammatory response. COPD mainly involves the lungs, but can also cause systemic (or pulmonary) of bad effects.
Airflow limitation on pulmonary function tests are important to determine. Inhaled bronchodilators, the first second forced expiratory volume (FEV1) / forced vital capacity (FVC) <70% indicate the presence of airflow limitation, and can not be completely reversed. Chronic cough, sputum often many years before the existence of airflow limitation; but not all, cough, sputum symptoms will develop COPD. Some patients may only change irreversible airflow limitation without chronic cough, sputum symptoms.
COPD and chronic bronchitis and emphysema are closely related. Typically, except for chronic bronchitis refers to other known causes of chronic cough, the patient per year cough, sputum more than 3 months and 2 years were consecutive. Pulmonary emphysema refers to remote terminal bronchioles abnormal persistent air space expansion, accompanied by alveolar wall and the destruction of the bronchioles without obvious fibrosis. When chronic bronchitis, emphysema, pulmonary function tests occurred in patients with airflow limitation, and can not be fully reversible, then can a diagnosis of COPD. If the patient is only "chronic bronchitis" and (or) "emphysema", without airflow limitation, Sri Lanka can not be attending the COPD.
Although asthma and COPD are chronic airway inflammatory disease, but the incidence of two different mechanisms, clinical manifestations and response to treatment is also a significant difference. Most asthma patients have significant airflow limitation reversibility, its different from a key feature of COPD; However, some asthma patients with disease duration longer, there may be more significant airway remodeling, leading to irreversible airflow limitation significantly reduced, clinical difficult to be differentiated from COPD. COPD and asthma can occur in a patient with; Moreover, since both are common disease, this probability is not low.
Known cause or characteristic pathology of airflow limitation diseases such as bronchiectasis, tuberculosis, fibrosis, cystic fibrosis, diffuse pan-bronchiolitis and bronchiolitis obliterans, etc., are excluded from COPD.
Pathogenesis
The pathogenesis of COPD has not been fully understood. COPD is generally believed to airway, lung parenchyma and lung vessels characterized by chronic inflammation in different parts of the lung are alveolar macrophages, T lymphocytes (especially CD) and neutrophils increased in some patients with eosinophilic granulocytes increased. Activated inflammatory cells release a variety of media, including leukotriene B4 (LTB4), interleukin-8 (1L-8), tumor necrosis factor (TNF- ) and other media. These media can damage lung structure and (or) to promote neutrophil inflammatory response. In addition to inflammation, the lungs of the protease and antiprotease imbalance, oxidative and antioxidant imbalance and dysfunction of the autonomic nervous system (such as abnormal distribution of cholinergic receptors), etc. also play an important role in the pathogenesis of COPD. Inhalation of harmful particles or gases can cause lung inflammation; smoke can induce inflammation and directly damage the lungs; COPD various risk factors can produce similar inflammatory process, resulting in the occurrence of COPD.
Pathology
Pathological changes characteristic of COPD found in the central airways, peripheral airways, lung parenchyma and pulmonary vascular system. In the central airway (trachea, bronchi, and diam 2 ~ 4 mm of the bronchioles), inflammatory infiltration of surface epithelial cells, mucus glands and goblet cells increased and the increased mucus secretion. Peripheral airways (diameter <2 mm of small bronchi and bronchioles), the chronic inflammation leads to airway wall damage and repair cycle occurs repeatedly. Repair process leading to airway wall remodeling, collagen content increased, and scar tissue formation, the pathological changes caused by gas stenosis, causing fixed airway obstruction.
COPD patients with lung parenchyma destruction of the typical performance of centrilobular emphysema, involves the expansion of respiratory bronchioles and destruction. Less severe damage often occurs when the upper area of the lung, but with the progression of the disease, can diffuse in the whole lung, and pulmonary capillary bed destruction. Due to genetic factors or the role of inflammatory cells and mediators, lung-derived protease and anti-protease imbalance, damage to pulmonary emphysema the main mechanism for oxidation and other inflammatory effects also play a role.
Pulmonary vascular changes in COPD to the blood vessel wall thickening is characterized by disease that began in the early thickening. Intimal thickening is the earliest structural changes, and then appeared to increase and vascular smooth muscle wall of inflammatory cell infiltration. When COPD increased smooth muscle, the increase in proteoglycan and collagen further thickening of the vessel wall. COPD with secondary pulmonary heart disease later, some patients with multiple pulmonary artery can be seen in situ thrombosis.
Pathophysiology
Pathological changes in the COPD lung appears on the basis of the corresponding characteristic pathophysiological changes in COPD, including mucus hypersecretion, ciliary dysfunction, airflow limitation, pulmonary hyperinflation, gas exchange abnormalities, pulmonary hypertension and pulmonary heart disease and systemic adverse effect. Mucus hypersecretion and ciliary dysfunction lead to chronic cough and sputum, these symptoms can appear in other symptoms and before the occurrence of pathological abnormalities. Small airway inflammation, fibrosis, and luminal exudate and FEV1, FEV1/FVC decline. Destruction of alveolar attachments, so that the small airways have impaired ability to maintain an open role, but in the airflow limitation in the smaller role.
With the progress of COPD, peripheral airway obstruction, parenchymal destruction and pulmonary vascular anomalies such as reduced pulmonary gas exchange, producing hypoxemia and hypercapnia can occur later. Chronic hypoxia can lead to extensive pulmonary vascular contraction and pulmonary hypertension, often accompanied by intimal hyperplasia, fibrosis and occlusion of some of angiogenesis, resulting in the restructuring of the pulmonary circulation. Later stage of COPD with pulmonary hypertension is an important cardiovascular complications, and thus produce chronic pulmonary heart disease and
Right heart failure, indicates a poor prognosis.
COPD can cause systemic adverse effects, including systemic inflammation and skeletal muscle dysfunction and so on. Systemic inflammation as the abnormal increase of systemic oxidative load, circulating levels of cytokines in the blood and the abnormal increase of abnormal activation of inflammatory cells; skeletal muscle dysfunction manifested as gradually reducing the weight and so on. COPD, systemic adverse effects have important clinical significance, it may exacerbate the patient's mobility is limited, so that reduced quality of life, the prognosis is worse.
Risk factors
Caused by COPD, including individual risk factors and environmental factors predisposing factors two, both influence each other.
First, individual factors
The incidence of certain genetic factors increase the risk of COPD. Genetic factors are known to 1-antitrypsin deficiency. Severe 1-antitrypsin deficiency and emphysema formation of non-smokers. In China 1-antitrypsin deficiency emphysema has so far not been formally reported. Bronchial asthma and airway hyperresponsiveness is a risk factor for COPD, airway hyperresponsiveness may be related to the body of certain genetic and environmental factors.
Second, environmental factors
1. Smoking: Smoking is an important pathogenic factors of COPD. Abnormal lung function in smokers is higher, FEV1 faster annual rate of decline, the number of smokers die from COPD than non-smokers and more. Passive smoking may also lead to the occurrence of respiratory symptoms and COPD. Women smoke during pregnancy may affect fetal lung growth and development in the womb, and the fetal immune system to some extent.
2. Occupational dust and chemical substances: if occupational dusts and chemicals (smoke, allergens, and indoor air pollution, industrial waste, etc.) concentration is too large or too long exposure time, may lead to occurrence of COPD independent of smoking. Exposure to certain specific substances, irritating substances, organic dust and allergens can increase airway responsiveness.
3. Air pollution: chemical gases such as chlorine, nitrogen oxides, sulfur dioxide, on the bronchial mucous membrane irritation and cytotoxicity. Soot or sulfur dioxide in the air increases significantly, COPD acute attack was significantly increased. Others, such as silica dust, coal dust, cotton dust, sugarcane dust, also stimulate the bronchial mucosa, so that damage to airway clearance, to create conditions for the bacterial invasion. Cooking of large quantities of soot and dust generated by bio-fuels and the pathogenesis of COPD, bio-fuels, indoor air pollution may have a synergistic effect with smoking.
4. Infection: incidence of COPD and respiratory infections are another important factor increasing, Streptococcus pneumoniae and Haemophilus influenzae acute exacerbation of COPD may be the main pathogen. Virus occurrence and development of COPD work. Children of severe lower respiratory tract infections and lung function in adulthood and reduce the occurrence of respiratory symptoms.
5. Socio-economic status: COPD patients the incidence and related socio-economic status. This may be indoor and outdoor air pollution with different degrees of nutritional status or other differences and socio-economic status has some intrinsically linked.
Clinical manifestations
1. Symptoms: (1) Chronic cough: usually the first symptom. Beginning of the cough is intermittent, heavier morning, after both morning and evening or day cough, night cough, but not significant. Small number of cases not associated with cough and expectoration. Although there are some obvious cases of airflow limitation but no cough. (2) sputum: cough cough, often on a small amount of mucous sputum, some patients are more in the morning; sputum volume increased during infection, often purulent sputum. (3) shortness of breath or difficulty breathing: This is a sign of COPD symptoms, anxiety is the main reason for the patient, early in the labor force only when, after a gradual increase, resulting in daily activities, sense of shortness of breath even when resting. (4) wheezing and chest tightness: No specific symptoms of COPD. Some patients, especially patients with severe breathing; chest feeling tight nausea usually occurs after labor, and respiratory effort, such compatibility intercostal muscle contraction. (5) systemic symptoms: the clinical course of the disease, especially in heavier patients, systemic symptoms may occur, such as weight loss, anorexia, peripheral muscle atrophy and dysfunction, depression, and (or) anxiety. Infection may hemoptysis sputum or hemoptysis.
2. History characteristics: COPD disease process should have the following characteristics: (1) smoking history: more than a lot of long-term history of smoking. (2) occupational history of exposure to harmful substances or environments: such as a longer-term dust, smoke, harmful particles or history of exposure to harmful gases. (3) family history: COPD tend to have a family gathering. (4) age of onset and a good season: more than middle age, disease, symptoms occur in the fall and winter cold season, often with recurrent respiratory tract infection and acute exacerbation history. With the progress of the disease, becoming more frequent acute exacerbations. (5) history of chronic pulmonary heart disease: COPD and hypoxemia in the late (or) hypercapnia, may be complicated by chronic pulmonary heart disease and right heart failure.
3. Signs: COPD early signs can be obvious. With disease progression, often the following signs: (1) visual examination and palpation: abnormal shape of the thorax, including the excessive expansion of the chest, anteroposterior diameter increases, the xiphoid sternum under the bottom corner (ventral corner) widened and abdominal swelling convex, etc.; common shallow breathing, the frequency increased fast, accessory muscle such as the scalene and sternocleidomastoid participate in breathing exercises, chest and abdomen shows severe contradictions; patients from time to time to increase the use of reduced lip breathing exhaled gas; breathing difficulties from time to time to add to former tilting seat; hypoxemia mucosa and skin may appear cyanotic, with right heart failure are visible lower extremity edema, the liver increases. (2) percussion: lung hyperinflation due to reduced cardiac dullness, lung liver sector decreased lung percussion can be presented over voiceless. (3) Auscultation: breath sounds of both lungs can be reduced, prolonged expiratory phase, quiet breathing dry rales could be heard, lungs, or other lung field could be heard the end of auscultation; heart sound distant, the Ministry of heart sounds than loud and clear xiphoid.
Laboratory tests and other monitoring indicators
1. Pulmonary function tests: pulmonary function tests is to determine an objective index of airflow limitation, and its good reproducibility, the diagnosis of COPD, severity assessment, disease progression, prognosis and treatment response, etc. are important. Airflow limitation is reduced FEV1 and FEV1/FVC determined. FEV1/FVC is a sensitive indicator of COPD can be detected in mild airflow limitation. FEV1 percentage of predicted value is the percentage of moderate and severe airflow limitation a good indicator of variability is small, easy to operate, COPD lung function tests should be used as the basic items. After inhaled bronchodilators FEV1/FVC% <70% who can be identified as not fully reversible airflow limitation. Peak expiratory flow (PEF) and peak expiratory flow - volume curve (MEFV) can be used as a reference index of airflow limitation, but when the PEF and FEV1 COPD the correlation is not strong enough, PEF may underestimate the degree of airflow obstruction. Airflow limitation can lead to lung hyperinflation, so that total lung capacity (TLC), functional residual capacity (FRC) and residual gas volume (RV) increased vital capacity (VC) reduced. TLC to increase the degree of increase is less than a large RV, it is RV / TLC increased. Destruction of the alveolar septum and pulmonary capillary bed can diffuse loss of function is impaired, carbon monoxide diffusing capacity (DLCO) decreased, DLCO and alveolar ventilation (VA) ratio (DLCO / VA) more sensitive than simply DLCO. Inspiratory capacity (IC) is the inspiratory tidal volume and the amount of compensation and, IC / TLC is a reflection of indicators of lung over-expansion, which reflects the degree of difficulty in breathing or COPD COPD reflect on the meaningful survival. As a supplementary examination, whether it is with bronchodilators or oral corticosteroids for bronchial dilation test, we can not predict disease progression. FEV1 improved less after treatment, patients can not reliably predict response to treatment. Were carried out at different times, bronchial dilation test, the results may be different. But in some cases (such as children are not the typical history of asthma during the night coughing, wheezing performance), then have some significance.
2. Chest X-ray examination: X-ray examination and the identification of pulmonary complications and other diseases (such as pulmonary fibrosis, tuberculosis, etc.) is important to identify. X-ray early COPD can be no significant change occurred after the increase in lung markings, disorders and other non-characteristic changes; main X ray findings of pulmonary hyperinflation: lung volume increases, increased anteroposterior diameter of the chest, ribs to flatten, the lung Wild through the increased brightness, diaphragmatic position and flat, overhanging narrow heart and hilar vessels showed a residual root-like texture, fine texture scarce peripheral lung fields, and sometimes visible bullae formation. Concurrent pulmonary hypertension and pulmonary heart disease, in addition to increased right heart X-ray findings, but also a conical bulging pulmonary artery, hilar and right lower pulmonary vascular video expanded widened and so on.
3. Chest CT examination: CT examination is generally not as a routine examination. However, CT examination in the differential diagnosis useful, high-resolution CT (HRCT) of the distinguished centrilobular or all of lobular emphysema and bullae to determine the size and number, have high sensitivity and specificity of or surgical resection of lung bullae expected volume reduction surgery, the effect of a certain value.
4. Blood gas examination: When FEV1 <40% predicted or with respiratory failure or right heart failure in patients with COPD should be blood examination. First, abnormal blood gas showed mild to moderate hypoxemia. With disease progression, more severe hypoxemia and hypercapnia occur. Diagnosis of respiratory failure in blood gas standard sea-level resting arterial oxygen pressure when breathing air (PaO2) <60 mm Hg (1 mm Hg = 0.133 kPa) with or without arterial partial pressure of carbon dioxide (PaCO2) incre 50mmHg.
5. Other laboratory tests: hypoxemia, the PaO2 <55 mmHg, the hemoglobin and red blood cells can be increased, hemato 55% can be diagnosed with polycythemia. Concurrent infection, seen a lot of smear neutrophils, sputum culture can be detected in a variety of pathogens, common are Streptococcus pneumoniae, Haemophilus influenzae, the card he Mora bacteria, Klebsiella pneumoniae and so on.
Diagnosis and differential diagnosis
1. Comprehensive assessment of acquisition history: when the diagnosis of COPD should first comprehensive collection history, including symptoms, past history and systematic re, history. Symptoms include chronic cough, sputum, shortness of breath. Reof medical history and the system should pay attention to: low birth weight, whether in childhood asthma, allergic diseases, infections and other respiratory diseases such as tuberculosis history history; COPD and respiratory diseases, family history; COPD acute exacerbation and hospitalization history; have the same risk factors (smoking) and other diseases, such as the heart, peripheral vascular and nervous system disease; can not explain the weight loss; other non-specific symptoms, wheezing, chest tightness, chest pain, and morning headaches; pay attention to smoking history (in pack-years) and occupational and environmental history of exposure to hazardous substances and so on.
2. Diagnosis: COPD diagnosis should be based on clinical presentation, history of exposure to risk factors, signs and laboratory test data to determine a comprehensive analysis. Consider the main symptoms of COPD chronic cough, sputum, and (or) risk factors for respiratory difficulties and a history of exposure; there is not fully reversible airflow limitation is a prerequisite for diagnosis of COPD. Lung function indicators are the gold standard for diagnosis of COPD. After the use of bronchodilators FEV1/FVC <70% can be identified as not fully reversible airflow limitation. Where has the smoking history and (or) environmental and occupational pollution, exposure history and (or) cough, sputum, or a history of breathing difficulties pulmonary function tests should be carried out. Airflow limitation early COPD may have a mild or no clinical symptoms. Chest X-ray examination help to determine the degree of lung hyperinflation and identification with other lung diseases.
3. Differential Diagnosis: COPD should be asthma, bronchiectasis, congestive heart failure, tuberculosis and other identification (Table 1). Sometimes identify with asthma there are some difficulties. After more than middle-aged onset COPD, asthma is more in the child or adolescent onset; COPD symptoms progress slowly, gradually increased, symptoms of asthma are big ups and downs; COPD and more long-term smoking history and (or) harmful gases, particles history of exposure is often accompanied by allergic asthma, allergic rhinitis and (or) eczema, family history of asthma in some patients; COPD basically when irreversible airflow limitation, asthma are much more reversible. However, some asthma patients have long duration of airway remodeling and airflow limitation can not be completely reversed; and a small number of patients with COPD associated with airway hyperresponsiveness, partially reversible airflow limitation. At this point should be based on comprehensive analysis of clinical and laboratory findings, if necessary, for the bronchodilation test and (or) PEF circadian variation rate to be identified. In the few patients in these two diseases may overlap
Exist.Congestive heart failure could be heard at the base of lung auscultation sounds fine; chest X ray showed cardiomegaly, pulmonary edema; pulmonary function test showed restrictive ventilatory defect (rather than airflow limitation)
Large purulent bronchiectasis; often accompanied by bacterial infection; rough wet sound, digital clubbing; X-ray or CT showed bronchiectasis, wall thickening
TB incidence of all ages can; X-ray showed pulmonary infiltrates or nodular lesions empty like change; bacteriological examination can be confirmed
Age of onset of bronchiolitis obliterans lighter, and not smoking; may have a history of rheumatoid arthritis or a history of exposure to smoke, CT films showed low density in the expiratory phase displayAssessment to be based on the severity of COPD symptoms, pulmonary function abnormalities, the existence of complications (respiratory failure, heart failure) and other identification, which reflects the level of FEV1 decline in airflow limitation of significance. COPD severity according to lung function is divided into 4 levels (Table 2).
Table 2, chronic obstructive pulmonary disease clinical severity classification of lung function
(Inhaled bronchodilators later)Grade I (mild) FEVl / FVC <70%, FEVl share 80% predicted value
level (moderate) FEVl / FVC <70%, 50% FEVl percent predicted value accounting "80%
grade (severe) FEVl / FVC <70%, 30% FEVl percent predicted value accounted for "50%
IV (very severe) FEVl / FVC <70%, FEVl percentage of total estimated value of the "30% or the percentage of predicted value FEVl percent" 50%, or with chronic respiratory failure
Grade I (mild COPD): is characterized by mild airflow limitation (FEVl / FVC <70% but the FEVl 80% predicted value), usually with or without cough, sputum. Patients at this time I may not recognize their lung function is abnormal.
level (moderate COPD): is characterized by further deterioration of airflow limitation (50% FEV1 <80% predicted value) and the progress of symptoms and shortness of breath, shortness of breath after exercise is more apparent. At this point, since the aggravation of respiratory problems or disease, patients often go to hospital.
grade (severe COPD): is characterized by further deterioration of airflow limitation (30% FEV1 <50% predicted), increased shortness of breath, and recurrent acute exacerbations affect the quality of life of patients.
(very severe COPD): the severe airflow limitation (FEV1 <30% predicted value) or associated with chronic respiratory failure. At this point, the quality of life of patients significantly decreased, if there is acute exacerbation may have life-threatening.
Although FEV1% predicted reflecting the severity of COPD, health status and mortality useful, but COPD FEV1 does not reflect the complexity of the serious situation, in addition to FEV1 than has proved to body mass index (BMI) and respiratory difficulty in predicting the classification of COPD survival rate and so meaningful.
BMI equals weight (kg) divided by height (m) squared, BMI <21 kg/m2 in COPD patients with increased mortality.
Functional classification of dyspnea: shortness of breath can be used to evaluate the scale: 0: Unless vigorous activity, no obvious difficulty breathing; 1: When brisk walking or shortness of breath when on the ramp; two: the walk from breathing difficulties than their peers have slow, or at their own pace on level ground walking need to stop breathing; 3: 100m walking on level ground or the need to stop breathing after a few minutes; 4: obvious respiratory difficulties and can not leave the house or when wearing clothes off When shortness of breath.
If the FEV1 as a reflection of airflow obstruction (obstruction) of the index, difficulty breathing (dyspnea) classification as a symptom index, BMI serves as an indicator of nutritional status, coupled with the 6 min walk distance as the exercise tolerance (exercise) of the indicators will These four aspects together to create a multi-factor grading system (BODE), FEV1 is considered comparable to better reflect the prognosis of COPD.
Quality of life assessment: widely used in evaluation of severity of COPD patients, the efficacy of drug treatment, non-drug treatment (such as pulmonary rehabilitation therapy, surgery), and the impact of acute episodes. Quality of life can also be used to predict the risk of death, whereas age, PEV1 and independent of body mass index. Quality of life assessment methods commonly used are SGRQ (SGRQ) and treatment outcomes research (SF-36) and so on.
In addition, COPD exacerbation frequency of severity of COPD can also be used as a monitoring indicator.
Course of COPD can be divided into acute exacerbation and stable stages. Acute exacerbation of COPD patients is the continued deterioration of the situation beyond the routine, and COPD need to change the basis of conventional agents, usually in the disease process, patients were short cough, sputum, shortness of breath, and (or) increased wheezing, increased sputum volume , was purulent or purulent sticky, can be accompanied by fever and other inflammatory significant increase in performance. Refers to patients with stable cough, sputum, shortness of breath and other symptoms of stable or mild symptoms.1. Relieve symptoms, prevent progression of the disease.
2. Mitigate or prevent decline in lung function.
3. Improve mobility and quality of life.
4. Mortality.
Second, education and management
Can improve through education and management of COPD patients and awareness of relevant personnel and their own ability to deal with the disease, better with treatment and to strengthen preventive measures to reduce repeated exacerbations, maintaining a stable condition, improve the quality of life. The main contents include: (1) Education and urge patients to stop smoking, has so far proven to be effective delay can be decreased lung function measures only smoking cessation; (2) so that patients understand the pathophysiology of COPD and clinical basis of knowledge; (3) to master the general and some special treatment; (4) learn self-control skills of the disease, such as abdominal breathing and reduced breathing exercises and other lip; (5) to understand the timing of hospital visits; (6) community doctor for regular follow-up management.
Third, occupational or environmental pollution control
To avoid or prevent dust, smoke and harmful gas inhalation.
Fourth, drug treatment
Drug treatment for the prevention and control symptoms, reduce the frequency and severity of acute exacerbations, increase exercise tolerance and quality of life. According to the severity of the disease, and gradually increase the treatment, if no significant adverse drug reactions or deterioration of the condition should be maintained at the same level of treatment of long-term trend. According to the response to treatment in patients with timely adjustment of treatment.
1. Bronchodilators: Bronchodilators to relax bronchial smooth muscle, bronchial expansion to ease airflow limitation, is to control the main symptoms of COPD treatment. Duan Qi-demand applications can relieve symptoms, long-term rules are applied to prevent and reduce symptoms, increase exercise tolerance, but not FEV1 in all patients were improved. Compared with oral drugs, inhalants side effects, so many preferred inhalation.
Bronchodilators are the major 2 agonists, anticholinergics and methylxanthines class, according to the role of drug use and treatment response in patients. With short-acting bronchodilators is cheaper but less effective than long-acting preparations. The role of different mechanisms of action and time of bronchodilator drugs in combination can enhance the role and reduce adverse reactions. 2 agonists, anticholinergic drugs and (or) theophylline combined, lung function and health status may be further improved. (1) 2 agonists: are salbutamol, terbutaline, etc. for quantitative inhaled short-acting agent, began to take effect within minutes, 15 ~ 30min to reach the peak and sustained efficacy of 4 ~ 5 h, each dose of 100 ~ 200 g (per spray 100 g), 24h in not more than 8 to 12 jet. Mainly for the relief of symptoms, on-demand use. Formoterol (formoterol) for the quantitative long-acting inhalers, which lasted for 12 h or more, with short-acting 2 agonists compared to much longer maintain the role. Formoterol inhalation of 1 ~ 3 min after the onset, commonly used dose of 4.5 ~ 9 g, 2 times a day. (2) anti-cholinergic drugs: The main varieties of ipratropium bromide (ipratropium) aerosol, can block the M cholinergic receptors. Start the quantitative effect of inhaled salbutamol time than short-acting 2 agonists such as slower, but lasted longer, 30 ~ 90min to maximum effect. Maintain the 6 ~ 8h, a dose of 40 ~ 80 g (per spray 20 g), 3 to 4 times a day. Drug side effects, long-term inhalation can improve the health status of COPD patients. Tiotropium (tiotropium) selectively acts on M3 and M1 receptors, the long-acting anticholinergic drug, 24 h or more over the role of inhaled dose of 18 g, 1 time per day. Inspiratory capacity increased long-term inhalation (IC), to reduce end-expiratory lung volume (EELV), in order to improve dyspnea and improve exercise capacity and quality of life, but also reduce the frequency of acute exacerbation. (3) theophylline drugs: can relieve airway smooth muscle spasm, is widely used in the treatment of COPD. In addition, to improve cardiac output, systemic and pulmonary vascular dilation, increased water and salt discharge, excited the central nervous system, improve respiratory muscle function, and certain anti-inflammatory role. But, in general, the amount of blood in the general treatment concentrations, theophylline is not very prominent role in other aspects. Theophylline sustained release or controlled release 1 or 2 times a day orally up to a stable plasma concentration of a certain effect on COPD. Theophylline concentration monitoring efficacy and adverse effects on the estimates of some significance. Blood theophylline concentrat 5 mg / L that has therapeutic effect;> 15 mg / L significantly increased when the adverse reaction. Smoking, drinking, taking anticonvulsants, rifampin can cause liver damage and shorten the theophylline half-life of enzyme; elderly, persistent fever, heart failure and significantly impaired liver function, while application of cimetidine, a large ring esters drugs (erythromycin, etc.), fluoroquinolones (ciprofloxacin, etc.) and so may make oral contraceptives blood concentration of theophylline
Increased.
2. Glucocorticoids: COPD in stable long-term inhaled corticosteroid treatment does not prevent the FEV1 reduce the trend. Long-term regular inhaled corticosteroids are more applicable to FEV1 <50% predicted ( and grade) and clinical symptoms and repeated exacerbations of COPD patients. This treatment can reduce the frequency of acute exacerbations and improve quality of life. Combined inhaled corticosteroids and 2 agonist, compared with their effect alone, there are budesonide / formoterol, fluoride to propionate / salmeterol two joint preparations. COPD is not recommended for patients with long-term oral corticosteroid therapy.
3. Other drugs: (1) expectorants (mucous dissolving agents): COPD airway mucus secretions can produce large amounts, can contribute to secondary infection, and affects the airway, the application seems to be beneficial expectorant drainage airway patency and improve ventilation, but the exception of a few have been effective in patients with sticky sputum, the overall effect is not very precise. Commonly used drugs ambroxol hydrochloride (ambroxol), acetyl cysteine. (2) antioxidants: COPD airway inflammation to increased oxidative load, adding to COPD, pathological and physiological changes. Application of antioxidants such as N-acetylcysteine can reduce the frequency of repeated exacerbations disease. But the current lack of long-term, multi-center clinical study, to be rigorous clinical studies for future research. (3) immunomodulatory agent: to reduce the severity of acute exacerbation of COPD may have a role. But has not yet been confirmed, not recommended for routine use. (4) vaccine: Influenza vaccine can reduce the severity of COPD patients and death, can be given 1 year (autumn) or 2 times (autumn, winter). It contains inactivated or live, no activity of the virus, the virus should be forecast each year based type of preparation. 23 types of pneumococcal vaccine contains pneumococcal capsular polysaccharide, have been applied in patients with COPD, but the lack of strong clinical observations. (5) Chinese Medicine: dialectical therapy is the principle of Chinese medicine treatment, the treatment of COPD should be basis of the principle. To experience some of the traditional Chinese medicine practice has expectorant, bronchodilator, such as the role of immune regulation, it is worth further study.
Fifth, oxygen therapy
COPD in stable long-term home oxygen therapy on patients with chronic respiratory failure may improve survival. On hemodynamics, hematologic characteristics, exercise capacity, lung physiology and mental state will have beneficial effects. Long term oxygen therapy should be in grade that patients with very severe COPD, the specific indications are: (1) PaO2 55 mm Hg or arterial oxygen saturation (SaO2) 88%, with or without hypercapnia.
(2) PaO255 ~ 60 mm Hg, or SaO2 <89%, and a pulmonary hypertension, heart failure, edema, or polycythemia (hemato 55%). Long term oxygen therapy is usually inhaled through a nasal cannula oxygen, flow rate 1.0 ~ 2.0 L / min, oxygen dura 15 h / d. The purpose is to make long-term oxygen therapy in patients with sea level, resting state, to achieve PaO2 60 mm Hg, and (or) to SaO2 increased to 90%, so in order to keep vital functions to ensure that the surrounding tissue oxygen supply .
VI, rehabilitation
Rehabilitation therapy can be of airflow limitation, severe breathing difficulties and few activities to improve mobility in patients and improve the quality of life, COPD patients is an important therapeutic measures. It includes the treatment of respiratory physiology, muscle training, nutritional support, psychiatric treatment and education, and many other measures. In the treatment of respiratory physiology, including helping patients cough, forced expiratory to promote secretion clearance; make patients relax, to reduce lip breathing and to avoid rapid shallow breathing to help overcome the acute breathing difficulties and other measures. Muscle training in a whole body movement and respiratory muscle training, the former including walking, stair board, ride vehicles, which have abdominal breathing exercise. In nutrition support, should be required to achieve ideal weight; high carbohydrate diet and avoid excessive caloric intake to avoid excessive carbon dioxide.
VII, surgical treatment
1. Bullous lung resection: indications for patients in a postoperative patient can reduce the degree of dyspnea and to improve lung function. Preoperative chest CT, arterial blood gas analysis and comprehensive evaluation of respiratory function for deciding whether surgery is very important.
2. Lung volume reduction surgery: through the removal of part of lung tissue, reduce lung hyperinflation and improve respiratory muscle acting to improve exercise capacity and health status, but not prolong life. Mainly applied to the upper lobe was heterogeneous emphysema, rehabilitation exercise capacity after training as part of the patient is still low, but its high cost and experimental nature is a palliative surgical procedure. Not recommended for wider application.
3. Lung transplantation: the choice of suitable patients with advanced COPD, lung transplantation may improve quality of life, improve lung function, but technically demanding, expensive, difficult application.
In short, the principles of stable COPD severity according to different treatment options are different, on the treatment of COPD classification problem, Table 3 for reference.
The treatment of acute exacerbation of COPD
First, determine the cause of acute exacerbations of COPD
Cause the most common cause of COPD is to increase the trachea - bronchial infections, mainly viral, bacterial infection. In some cases difficult to determine the cause of the increased environmental changes may have a role in physical and chemical factors. Pneumonia, congestive heart failure, arrhythmia, pneumothorax, pleural effusion, pulmonary embolism can cause psychosis resembles the symptoms of acute exacerbation of COPD needs to be carefully identified.
Second, COPD diagnosis and severity of acute exacerbation of evaluation
The main symptoms of COPD exacerbation is increased shortness of breath, often accompanied by wheezing, chest tightness, increased cough, increased sputum, sputum color, and (or) viscosity changes and fever, in addition to general discomfort may also occur, insomnia, lethargy, depression, fatigue and mental disorders and other symptoms. When the patients exercise tolerance, fever and (or) chest imaging abnormalities may be signs of COPD exacerbation. Increased shortness of breath, cough, increased sputum volume and purulent sputum often suggest there bacterial infections.
And increase the pre-history, symptoms, signs, pulmonary function tests, arterial blood gas testing and other laboratory indices were compared to judge the severity of COPD exacerbations is important. Special attention should understand this aggravation or new onset of symptoms of the time, shortness of breath, cough severity and frequency, sputum volume and sputum color, limited extent of daily activities, whether there had been swelling and its duration, aggravated the situation when the past and the availability of hospital treatment, and current treatment programs. The exacerbation of pulmonary function and arterial blood gas results compared with previous information available is extremely important, these indicators than the absolute value of acute changes are more important. For patients with severe COPD, changes in consciousness and the critical indicators of disease progression, in the event the need for timely hospital treatment. Whether there is accessory muscle involved in breathing exercises, chest and abdomen contradictions breathing, cyanosis, peripheral edema, right heart failure, hemodynamic instability and other signs also help determine the severity of COPD exacerbation.
Pulmonary function test: exacerbation of patients, often difficult to satisfactory completion of pulmonary function tests. FEV1 <1 L may indicate a serious attack.
Arterial blood gas analysis: resting breathing air at sea level conditions, PaO2 7.30 prompt critical condition,
Table 3 in stable chronic obstructive pulmonary disease, recommended treatment
Recommended treatment classification featuresFEV1/FVC <70%, FEV1 percentage of predicted value 80% Percentage of avoiding risk factors; receive influenza vaccination; on-demand use of short-acting bronchodilators
level (moderate)
FEV1/FVC <70%, 50% FEV1 percentage of predicted value percentage "80% in the last - on the basis of level of treatment, regular application of one or more long-acting bronchodilators, rehabilitation
grade (severe) FEV1/FVC <70%, 30% FEV1 percentage of predicted value percentage "50% of the treatment on the level on the basis of repeated acute attacks can be inhaled corticosteroids
IV (very severe) FEV1/FVC <70%, FEV1 percentage of predicted value percentage "30%, or with chronic respiratory failure in the last level on the basis of the treatment, if respiratory failure, long-term oxygen therapy, surgical treatment may be considered
Guests in need of intensive care or ICU-line non-invasive or invasive mechanical ventilation.
Chest X-ray, electrocardiogram (ECG) examination: Chest X-ray images help COPD increased with other diseases with similar symptoms differentiated. ECG of the arrhythmia, myocardial ischemia, and the diagnosis of right ventricular hypertrophy helpful. Spiral CT, angiography, and plasma D-dimer testing in the diagnosis of pulmonary embolism in patients with COPD increased play an important role, but radionuclide ventilation perfusion scan in the diagnosis of little value. Low blood pressure or high flow oxygen can not be reached after the PaO2 above 60 mm Hg may indicate the presence of pulmonary embolism if pulmonary embolism was highly suspected clinically, it should handle both COPD and pulmonary embolism.
Other laboratory tests: blood cell count and hematocrit can help to understand whether the polycythemia or bleeding. Some patients increased white blood cell count and neutrophil cell nucleus can be left to provide evidence of airway infection. But usually white blood cell count did not change.
When COPD increased, purulent sputum, should be given antibiotics. Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis are the most common in patients with COPD increased pathogen. If the patient is poor response to initial antibiotic treatment should be carried out sputum culture and drug sensitivity testing of bacteria. In addition, blood biochemical examination will help determine the cause of COPD exacerbation other factors such as electrolyte imbalance (sodium, potassium, and low chlorine hyperlipidemia, etc.), diabetes, or malnutrition crisis can also be found in combination of metabolic acidosis base imbalance.
Third, the hospital treatment
For COPD increased early in patients with mild disease can be treated in the hospital, but should pay attention to changes in condition, hospital treatment time, decided to take time.
COPD exacerbation increased hospital treatment, including appropriate use of bronchodilators previously dosage and frequency. If not treated with anticholinergic drugs, ipratropium bromide can be used or Tiotropium inhalation treatment until remission. For more severe cases, a larger dose may be given a few days the spray treatment. Such as salbutamol 2500 g, ipratropium bromide 500 g, or 1000 g of salbutamol plus ipratropium bromide 250 ~ 500 g inhalation, 2 to 4 times a day.
Systemic glucocorticoids on exacerbations of therapeutic benefit, can promote remission and pulmonary function recovery. As the basis for patients with FEV1 <50% predicted, in addition to bronchodilators may be considered outside the oral corticosteroid, prednisolone daily 30 ~ 40 mg, used in conjunction 7 ~ 10 d. Can also be long-term glucocorticoid 2-agonist inhalation treatment.
COPD exacerbations, especially coughing purulent sputum volume increased and was given antibiotic therapy should be positive. Antibiotic selection should be based on common pathogens in patients with pulmonary function and, combined with pathogenic bacteria and drug resistance in patients where the prevalence areas, select sensitive to antibiotics. Specific antibiotics in Table Fourth, hospital treatment
Acute exacerbation of COPD who require hospitalization in serious condition. COPD exacerbation to the hospital or hospital treatment of indications: (1) symptoms were aggravated, such as sudden resting conditions breathing difficulties; (2) the emergence of new signs or existing signs of increase (eg cyanosis, peripheral edema) ; (3) to the recent arrhythmia; (4) had severe concomitant diseases; (5) The initial treatment failure; (6) Elderly patients with acute exacerbation of COPD; (7) in the diagnosis is not clear; (8) hospital treatment conditions of poor or ineffective treatment.
Acute exacerbation of COPD intensive care unit revenue (ICU) of the indications: (1) severe breathing difficulties and poor response to initial therapy; (2) mental disorders, drowsiness, coma; (3) by oxygen therapy and noninvasive positive pressure ventilation (NIPPV), the hypoxemia (PaO2 <50mm Hg) is continuing or was progressive deterioration, and (or) hypercapnic (P 70mmHg) no relief or even worse, and (or) severe respiratory acidosis (pH <7.30) no relief, or even worse.
COPD exacerbations are the main treatment.
1. Based on symptoms, blood gas, chest X-ray film and other assessment of the severity of the disease.
2. Controlled oxygen therapy: oxygen therapy in COPD exacerbations is the basis for treatment of hospitalized patients. No serious complications of oxygen therapy in patients with COPD exacerbation easily after satisfactoryClass I and acute exacerbation of COPD Haemophilus influenzae, Streptococcus pneumoniae, penicillin microorganisms in Kata Mora, -lactamase / inhibitor (amoxicillin / clavulanic acid), macrolides (azithromycin , clarithromycin, roxithromycin), 1st generation or 2nd generation cephalosporins (cefuroxime, cefaclor), doxycycline, levofloxacin, etc., and can be orally
Grade and acute exacerbations of COPD without P. aeruginosa infection risk factors for Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Klebsiella pneumoniae, Escherichia coli, Enterobacter and other -lactam / enzyme inhibitors, second generation cephalosporins (cefuroxime), fluoroquinolones (levofloxacin, moxifloxacin, gatifloxacin), the third generation cephalosporins (ceftriaxone, cefotaxime), etc.
Grade and acute exacerbation of COPD have Pseudomonas aeruginosa infection of bacteria and the risk factors above Pseudomonas aeruginosa third-generation cephalosporins (ceftazidime), cefoperazone / sulbactam, piperacillin / tazobactam , imipenem, meropenem, etc., can also be combined with aminoglycosides, fluoroquinolones (ciprofloxacin, etc.)
Oxygenation levels ( 60 mm Hg or 90%). But the inspired oxygen concentration should not be too high, the potential need to pay attention to potential CO2 retention and respiratory acidosis, including through a nasal cannula or oxygen Venturi mask Venturi mask in which more accurately adjust the inspired oxygen concentration. Oxygen therapy should be reed after 30 min arterial blood gas to confirm satisfactory oxygenation, and did not lead to CO2 retention and (or) respiratory acidosis.
3. Antibiotics: COPD exacerbation induced by bacterial infection and more, so antibiotic therapy in the treatment of COPD exacerbation has an important position. Increased difficulty breathing when patients cough accompanied by an increase in sputum volume and purulent sputum should be based on the severity of COPD and the corresponding layer of bacteria, and combined with the district type of common pathogenic bacteria and drug trends and drug sensitivity case sensitive early selection antibiotics. If poor response to initial treatment, it is timely under the bacterial culture and sensitivity test results to adjust antibiotics. Usually COPDI level in patients with mild or moderate increase grade , the main pathogens, mostly Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Are (severe) and (very severe) COPD exacerbation, in addition to the above common bacteria, can still have Enterobacteriaceae, Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus. Pseudomonas aeruginosa occurring risk factors include: recent hospitalization, frequent use of antimicrobial drugs in the past have isolated Pseudomonas aeruginosa or send plant's history. The distribution of bacteria may be used according to appropriate antibiotic therapy, specific drugs in Table 4. Antibiotic treatment should be as far as possible, minimize the bacterial load in order to extend the time between acute exacerbation of COPD. Long-term use of broad spectrum antibiotics and glucocorticoid easy to secondary fungal infections, fungal infections should be closely observed for clinical signs and adopt measures to combat fungal infections.
4. Bronchodilators: Short-acting 2-agonist is more suitable for the treatment of acute exacerbation of COPD. If the effect was not significant, the proposed increase use of anticholinergic drugs (as ipratropium bromide, tiotropium bromide, etc.). For the more severe COPD increase will be considered intravenous theophylline drugs. Because plasma concentrations of theophylline individual drugs are quite different therapeutic window is narrow, theophylline serum concentration monitoring for the assessment of efficacy and avoid adverse reactions have a certain significance. 2-receptor agonists, anticholinergics and theophylline drugs because different mechanism of action, pharmacokinetics, and the different pharmacokinetic characteristics, and were acting on the airways of different sizes, so the combination of greater availability of bronchial vasodilation, but best not combined with 2-agonist and theophylline class. Not many reports of adverse reactions.
5. Glucocorticoids: COPD exacerbation in hospitalized patients should be based on the application of bronchodilators, oral or intravenous corticosteroids, the dose of hormone to weigh the efficacy and safety, it is recommended oral prednisone 30 ~ 40mg / d, for 7 ~ 10d after the tapered withdrawal. Intravenous methylprednisolone can be 40 mg, day 1, 3 ~ 5 d later changed to oral. Extend the delivery time can not increase efficacy, but side effects will increase.
6. Mechanical ventilation: by way of non-invasive or invasive mechanical ventilation, the condition of patients may be the preferred non-invasive mechanical ventilation. Mechanical ventilation, whether it is non-invasive or invasive methods are just a way of life support, in this condition, aggravated by drug treatment to eliminate the cause of COPD with acute respiratory failure to be reversed. Mechanical ventilation should have arterial blood gas monitoring of the patient. (1) non-invasive mechanical ventilation: COPD patients with acute exacerbation of NIPPV can reduce PaCO2, ease breathing difficulties, thereby reducing the invasive endotracheal intubation and ventilator use, shorter hospital stay, reduced patient mortality. NIPPV should be careful to use reasonable methods of operation, improve patient compliance, prevent leakage, the pressure started to increase from low secondary suction pressure and help reduce PaCO2 using the method to improve the effect of NIPPV. The application of the standard shown in Table 5. (2), invasive mechanical ventilation: theModerate to severe difficulty in breathing, accompanied by accessory muscle involved in respiration and the emergence of contradictions chest and abdomen, with moderate to severe acidosis (pH 7. 30-7. 35) and hypercapnia (PaCO2 45 ~ 60 mm Hg), respiratory 25 times / minFunctional instability of the cardiovascular system (hypotension, arrhythmia, myocardial infarction)
Drowsiness, unconsciousness, or substandard of
Who easily aspiration (swallowing reflex abnormality, severe upper gastrointestinal bleeding)Head and face trauma, abnormal nasopharynx inherentActive drugs and NIPPV therapy, the patient is still progressive deterioration of respiratory failure, appeared life-threatening acid-base balance, and (or) change of consciousness is appropriate for invasive mechanical ventilation. Get better, depending on the circumstances of noninvasive mechanical ventilation can be sequential therapy. Invasive mechanical ventilation in exacerbations of COPD indications for the specific application shown in Table Table 6 invasive mechanical ventilation in chronic obstructive pulmonary disease exacerbation of indication applications
Severe difficulty in breathing, accessory muscle involved in breathing, and the emergence of abdominal breathing contradictionSevere respiratory acidosis (pH <7.25) and hypercapnia
Respiratory depression or stop
Drowsiness, unconsciousness
Serious cardiovascular complications (hypotension, shock, heart failure)
Other complications (metabolic disorder, sepsis, pneumonia, pulmonary embolism, barotrauma, a large number of pleural effusion)
Noninvasive positive pressure ventilation treatment failure or the existence of noninvasive positive pressure ventilation with contraindications (Table 5)
End-stage COPD patients in deciding whether the use of mechanical ventilation needed to fully take into account the possibility of getting better, the patient's own and family's wishes and whether the conditions allow intensive treatment.
3 the most widely used mode of ventilation, including auxiliary control ventilation (A-CMV), pressure support ventilation (PSV) or synchronized intermittent mandatory ventilation (SIMV) mode with PSV United (SIMV PSV). Widespdue to COPD patients with intrinsic PEEP (PEEPi), to reduce suction power due to increase in PEEPi and human lack of coordination, can be added with a moderate level of regular (PEEPi about 70% to 80% ) exogenous PEEP (PEEP). COPD, weaning may encounter
To the difficulties, the need to design and implement a thorough program. NIPPV has been used to help early off-line and initially achieved good results.
7. Other treatment measures: monitoring of intake and output and serum electrolyte fluid and electrolyte under appropriate; attention to maintaining fluid and electrolyte balance; attention to nutrition, to not eat those elements required by the GI diet or a supplement to intravenous high-nutrition; on the bed, red blood cell patients with polycythemia or dehydration, regardless of whether the history of thromboembolic disease, are required to consider the use of heparin or low molecular weight heparin; attention to drainage of sputum, positive sputum treatment (such as the stimulation of cough, chest percussion, postural drainage and other methods); Identification and treatment of associated diseases (coronary heart disease, diabetes, hypertension, etc.) and complications (shock, disseminated intravascular coagulation, upper gastrointestinal bleeding, gastric dysfunction, etc.).Do a good job of chronic obstructive pulmonary disease education and management
HE Quan-ying
Chronic obstructive pulmonary disease (COPD) is a common chronic respiratory diseases, the important feature was the progressive development of airflow limitation and not fully reversible. COPD to patients and families, bringing heavy economic burden on society, has become a major public health problem, therefore, long-term COPD patients should control and standardization. This process needs to be the majority of COPD patients and their families fully understand, support and close coordination. Secondly, it should be emphasized that diagnosis and treatment of COPD patients to the hospital (including outpatient, inpatient treatment) for their life just a short clip. Most of its life is spent in the family and society, and therefore we can not stop prevention and control of COPD, or confined to the hospital this little world, it should be extended to patients as family and society as a whole. Practice shows that the majority of patients and their keen desire to learn is closely related to illness and health and medical skills, medical knowledge, from long-term point of , only when COPD patients really grasp the knowledge and control of medical technology, they accept the passive past treatment to disease prevention and treatment of the subject, be considered to achieve the ultimate goal of medicine and the highest goal. A lot of practice at home and abroad have shown, COPD patients with COPD prevention and control of education management is an important and indispensable part in the system of education and strict management can improve the level of awareness of the disease in patients, and better prevention and treatment with the doctors, to improve COPD, prevention and control of compliance, to reduce acute episodes, as far as possible a stable condition, improve the quality of life and reduce medical expenses incurred for the purpose. The of the work practice of previous years, with reference to foreign related literature, education and management of COPD several suggestions, for your reference.
One way of publicity and education
1. COPD patients by offering classes, clubs, associations and other forms of lively centralized system of education, this is more efficient, more systematic teaching of comprehensive, face to face communication between doctors and patients can discuss.
2. Organizations were watching TV, video, VCD, or listen to tapes.
3. Tissue in patients with COPD prevention and control popular science books, newspapers and magazines published articles on popular science.
4. Use of network media technology can more quickly spthe knowledge of COPD prevention and treatment.
5. COPD patients with disease prevention organizations hold seminars, sharing sessions, patients can be introduced at the meeting of their feelings and experiences of disease prevention and control and give full play in the prevention and control of disease in some patients the demonstration and radiation.
6. Full use of every doctor or hospital patients, to promote education throughout the routine medical work, each newly diagnosed COPD patients, the competent doctor should tell you something about their basic knowledge of COPD, the church of their basic control techniques, later also require repeated and strengthened.
Peking University People's Hospital System since 2001 to carry out propaganda and education on the management of COPD patients, COPD patients is held annually in various forms and contents of lectures and seminars, preparation of meeting minutes after each event distributed to everyone. Creation of special disease COPD patient (2 units per week fixed person responsible.) Missionary center in the chronic respiratory disease is responsible for this work full-time staff, including the acceptance of patient counseling, create a file, arrange follow-up work. COPD in 2003 patients with train services carried out, that first diagnosis diagnosis treatment Consulting files COPD established regular follow-up control. In practice, where patients were diagnosed with COPD, according to its condition every two weeks or 1 month of chronic bronchitis in the outpatient follow-up, including follow-up to understand changes in condition, physical examination, to guide treatment. Of all patients diagnosed with COPD, the disease to establish a complete file, assess the quality of life, long-term with patients. Create a file of COPD each year 1 in patients with a comprehensive reand assessment. 1 year the patient to understand the changes in lung function, including forced expiratory volume in one second (FEV1), Analysis of pulmonary function changes caused by various factors, to take corresponding measures, adjusting the treatment plan, this work has achieved good results.
Second, the specific content of educational management
1. To enable patients to understand the profile of COPD, including the definition of COPD, airflow limitation characteristic of COPD prevention and control of social and economic significance.
2. So that patients believe that the long-term standard treatment can effectively control their symptoms, to varying degrees, slow the rate of disease progression.
3. Understand the cause of COPD, especially the dangers of smoking and air pollution, recurrent upper respiratory tract infection factors.
4. Understanding of the major clinical manifestations of COPD.
5. Understanding of COPD diagnostic tools, and how to evaluate associated findings, including X ray and pulmonary function test results.
6. The main treatment of COPD principles that to understand the role of commonly used drugs, usage and adverse reactions, including the master inhaled drug technology.
7. Prevention and treatment of COPD according to established guidelines, patients with disease and illness, both doctors and patients to develop an initial treatment program, including the application of anticholinergic drugs, theophylline and 2 agonist, if necessary, or even inhaled glucocorticoids short-term oral hormone therapy after the change and respond according to the condition (including lung function indicators) to constantly adjust and improve, and develop appropriate follow-up plan.
8. Understand the reasons for acute exacerbation of COPD, clinical manifestations and preventive measures. Acute exacerbation occurs when an emergency self-treatment.
9. Know under what circumstances should go to hospital or emergency room.
10. Learn the most basic, practical methods to determine the severity, such as the 6min walking, stair or peak flow measurement board.
11. As soon as possible to help smokers quit smoking and still persist, including information on smoking cessation methods, if necessary, recommend related drugs.
12. Describes and demonstrates some practical method of rehabilitation exercises, such as abdominal breathing, deep breathing, reduced lip breathing.
13. For those who meet the indications and conditions are to guide their families for long-term home oxygen therapy and non-invasive mechanical ventilation.
14. Seek to enhance or adjust the patient's immunity, reduce the acute exacerbation of COPD. If vaccinated against pneumococcal infections and the annual influenza vaccine inoculation of Third, the Educational Management Considerations
1. Control COPD is a long arduous process, staff must be fully patient, attentive, enthusiastic, and obtain the trust of patients and strive to establish good partnership with their friends and relations.
2. Made possible in the process of patients, family members, friends, related to leadership support.
3. Education should be diversified, lively, for everyone willing to accept, we must be effective, should not pro forma, with particular attention to the education management through a variety of medical activities, together with the medical work, This is consistent with the needs of patients, the effect will be better.
4. Education and management of the patient must pay attention to individual, step by step, continue to strengthen, and increase gradually in depth, not be too hasty, for the elderly This is particularly important in patients with COPD.
5. Establish and improve the prevention and assessment system on a regular basis, self-management and evaluation is an organic whole, COPD patients per year measured at least 1 full set of pulmonary function, including FEV1, vital capacity, inspiratory capacity, residual volume, functional residual capacity, total lung capacity and diffusion capacity, lung function decline in order to understand the law, predict prognosis and to develop long-term treatment programs.
Fourth, COPD education and management of long-term goals
1. COPD patients to establish the full confidence to overcome the disease and optimism.
2. COPD patients on the prevention and control measures doctors with good compliance.
3. Possible to control and reduce cough, sputum and dyspnea symptoms of work and life.
4. Minimize the number of acute exacerbation of COPD, the patient to the hospital and the hospital to minimize the number of times, reduce family burden and social burden.
5. So that patients FEV, decline every year reduction ( 50 ml / year).
6. Improve patient quality of life, live independently. Reduced work of breathing, increased exercise tolerance, if possible, should participate in social activities within its capacity to undertake some housework.
7. Adverse reactions to drugs used in the least or no.
8. Reduce medical expenses incurred as much as possible.
9. Extend the useful life.
2000 COPD patients before and after we had conducted a 2-year system of education and scientific management, the standard treatment, supplemented by practical rehabilitation exercises. When patients selected to fill out registration forms, assessing their level of awareness of COPD, quality of life. Then held a short classes, developed jointly with the candidates of essential drugs in patients with treatment programs and rehabilitation exercise programs to help smokers develop smoking cessation programs for patients, disease control requirements for each patient diary records, and then followed up every 2 months 1 reby the to report changes in patients condition, treatment and rehabilitation exercises, and to adjust the regimen according to patient's condition, end of the study once the patient assessment, content and methods and selected the same time.
Results, the system of education, standard treatment combined with rehabilitation exercises, 48 cases of COPD patients with cough, sputum, shortness of breath score was significantly reduced by the number of outpatient visits (6.2 4.9) times / year reduced to (2. 6 3.0) times / year, the main indicators of lung function FEV1 percentage of predicted value percentage significantly improved from the time selected (63 27)% increased to (69 31)%, quality of life scores increased from the 113 12 to 115 12, related to disease knowledge score was (12 5) minutes to improve to (15 5) minutes. Two years, 6 of 14 smokers successfully quit smoking more than 1 year. COPD patients with the level of awareness of the disease has improved significantly.
In short, the education system in patients with COPD, management, and standard treatment, supplemented by the necessary rehabilitation exercises, can effectively reduce their symptoms, improve lung function, reduce the out-patient visits, improved quality of life, such as long-term hold on, is expected to slow The progress of the disease.
Chronic obstructive pulmonary disease definition, diagnosis, differential diagnosis and disease classification
Bai Qiang Cai
Chronic obstructive pulmonary disease (COPD) is an important chronic respiratory diseases, more than the number of patients, high mortality. Since the development of COPD was slowly progressive, seriously affecting the ability to work of patients and quality of life. COPD is currently the world has become the No. 4 cause of death has aroused world attention.
First, the definition of
COPD is a preventable, treatable disease state to not fully reversible airflow limitation characterized. Progressive airflow limitation often has increased, and more with the lungs of harmful particles or gases, mainly abnormal inflammatory response to smoke. Although COPD involving the lungs, but can also cause significant systemic reactions. When patients have cough, sputum or dyspnea and (or) disease history of exposure to risk factors should be considered when COPD. Pulmonary function tests can confirm the diagnosis.
Second, the clinical manifestations
1. Symptoms: (1) Chronic cough: usually the first symptom. Beginning of the cough is intermittent, heavier morning, after both morning and evening or day cough, night cough, but not obvious. Small number of cases not associated with cough and expectoration. Although there are a few obvious cases of airflow limitation but no cough. (2) sputum: cough cough, often on a small amount of mucous sputum, some patients are more in the morning; sputum volume increased during infection, often purulent sputum. (3) shortness of breath or difficulty breathing: This is a sign of COPD symptoms, anxiety is the main reason for the patient, early in the labor force only when, after a gradual increase, resulting in daily activities, sense of shortness of breath even when resting. (4) wheezing and chest tightness: No specific symptoms of COPD. Some patients, especially patients with severe breathing; chest feeling tight nausea usually occurs after labor, and respiratory effort, such compatibility intercostal muscle contraction. (5) systemic symptoms: the clinical course of the disease, systemic symptoms may occur, such as weight loss, anorexia, peripheral muscle atrophy and dysfunction, depression, and (or) anxiety. Infection may hemoptysis sputum or hemoptysis.
2. History: COPD disease process has the following characteristics: (1) smoking history: more than a lot of long-term history of smoking. (2) occupational history of exposure to harmful substances or environments: such as a longer-term dust, smoke, harmful particles or history of exposure to harmful gases. (3) family history: COPD tend to have a family gathering. (4) age of onset and a good season: more than middle age, disease, symptoms occur in the fall and winter cold season, often with recurrent respiratory tract infection and acute exacerbation history. With the progress of the disease, more frequent acute exacerbations. (5) history of chronic pulmonary heart disease: COPD and hypoxemia in the late (or) hypercapnia, may be complicated by chronic pulmonary heart disease and right heart failure.
3. Signs: COPD early signs can be obvious. With disease progression, often the following signs: (1) visual examination and palpation: abnormal shape of the thorax, including the excessive expansion of the chest, anteroposterior diameter increases, the xiphoid sternum under the bottom corner (ventral corner) widened and abdominal swelling and other convex ; common shallow breathing, frequency, faster, auxiliary respiratory muscles such as the scalene and sternocleidomastoid participate in breathing exercises, chest and abdomen shows severe contradictions; patients from time to time to increase the use of reduced lip breathing smoke exhaled gas almost always difficult to increase to take forward seat; hypoxemia may occur mucosa and skin cyanosis, right heart failure were seen with lower extremity edema, the liver increases. (2) percussion: lung hyperinflation due to reduced cardiac dullness, lung liver sector decreased lung percussion can be presented over voiceless. (3) Auscultation: breath sounds of both lungs can be reduced, prolonged expiratory phase, quiet breathing dry sound could be heard, lungs, or other lung field could be heard the end of the wet sound; heart sound distant, the Ministry of heart sounds than loud and clear xiphoid.
Third, laboratory tests and other monitoring indicators
1. Pulmonary function tests: pulmonary function tests is to determine an objective index of airflow limitation and reproducible, the diagnosis of COPD, severity assessment, disease progression, prognosis and treatment response, etc. are important. Airflow limitation is based on forced expiratory volume in one second (FEV1) and FEV1 and forced vital capacity (FVC) ratio (FEV1/FVC%) reduction determined. FEV1/FVC% is a sensitive indicator of COPD can be detected in mild airflow limitation. FEV1 percentage of predicted value is the percentage of moderate and severe airflow limitation a good indicator of variability is small, easy to operate, COPD lung function tests should be used as the basic items. After inhalation of bronchodilator FEV1 <80% predicted, and FEVl / FVC% <70% who can be identified as not fully reversible airflow limitation. Peak expiratory flow (PEF) and peak expiratory flow - volume curve (MEFV) can be used as a reference index of airflow limitation, PEF and FEV1 in patients with COPD, but the correlation is not strong enough, PEF may underestimate the degree of airflow obstruction. Airflow limitation can lead to lung hyperinflation, so that total lung capacity, functional residual capacity and increased residual gas volume and vital capacity reduced. Total lung capacity is increased to increase less than the degree of residual gas major, so the residual gas volume lung capacity increased. Destruction of the alveolar septum and pulmonary capillary bed can diffuse loss of function is impaired, carbon monoxide diffusing capacity (DLCO) decreased, DLCO and alveolar ventilation (VA) ratio (DLCO / VA) more sensitive than simply DLCO. As a secondary check, bronchodilator test has some value, because: (1) in favor of identification of COPD and bronchial asthma; (2) to be informed of lung function in patients with the best attainable state; (3) and have a better prognosis associated ; (4) can predict patients bronchodilators and inhaled corticosteroid therapy.
2. Chest x-ray examination: x-ray examination and the identification of pulmonary complications and other diseases (such as pulmonary fibrosis, tuberculosis, etc.) is important to identify. Early chest COPD can be no significant change occurred after the increased lung markings, disorders and other non-characteristic changes; main X ray findings of pulmonary hyperinflation: lung volume increases, increased anteroposterior diameter of the chest, ribs to flatten, lung field through increased brightness, diaphragmatic position and flat, overhanging narrow heart and hilar vessels showed a residual root-like texture, fine texture scarce peripheral lung fields, and sometimes visible bullae formation. Concurrent pulmonary hypertension and pulmonary heart disease, in addition to increased right heart x-ray findings, but also a conical bulging pulmonary artery, hilar and right lower pulmonary vascular video expanded widened and so on.
3. Chest CT examination: CT examination is generally not as a routine check, but high-resolution CT of the distinguished centrilobular or all of lobular emphysema and to determine the size and number of bullae has high sensitivity and specificity of the expected bullous lung volume reduction surgery or surgical removal of the effect of such a certain value.
4. Blood gas examination: When FEV, 50 mm Hg.
5. Other laboratory tests: hypoxemia, the Pa02 <55 mm Hg, the hemoglobin and red blood cells can be increased, hemato 55% can be diagnosed with polycythemia. Concurrent infection, the sputum smear shows a large number of neutrophils, sputum culture can be detected in a variety of pathogens, common are Streptococcus pneumoniae, Haemophilus influenzae, the card he Mora bacteria, Klebsiella pneumoniae and so on.
6. Quality of life assessment: widely used in evaluation of severity of COPD patients, the efficacy of drug treatment, non-drug treatment (such as pulmonary rehabilitation therapy, surgery), and the impact of acute episodes. Quality of life assessment can be used to predict risk of death, whereas age, FEV, and independent of body mass index. Quality of life indicators can be used as independent or supplementary indicators used to evaluate the severity of COPD patients and treatment response.
7. Acute exacerbation of COPD (AECOPD): COPD patients occurred within 1 year 1 to 3 times the average AECOPD, can lead to increased mortality, the health status of patients after illness also decreased significantly. Therefore, all COPD AECOPD are important indicators for evaluation. Increased dyspnea, cough or sputum production increased and purulent sputum characteristics into targets for the clinical diagnosis of AECOPD.
Fourth, diagnosis and differential diagnosis
1. Clinical evaluation: the first diagnosis of COPD should be carried out when the clinical assessment, history taking seriously, including symptoms, past history and systematic re, history. Symptoms include chronic cough, sputum, shortness of breath. Reof medical history and the system should pay attention to: whether childhood asthma, allergic diseases, infections and other respiratory diseases (such as tuberculosis); COPD and family history of respiratory disease; COPD acute exacerbation and hospitalization history; have the same risk factors ( smoking) and other diseases, such as the heart, peripheral vascular and nervous system disease; can not explain the weight loss; other non-specific symptoms, wheezing, chest tightness, chest pain, and morning headaches; pay attention to history of smoking (in pack-years) and occupational and environmental history of exposure to hazardous substances.
2. Diagnosis: COPD diagnosis should be based on clinical assessment, history of exposure to risk factors, signs and laboratory test data to determine a comprehensive analysis. Not fully reversible airflow limitation there is a prerequisite for diagnosis of COPD. Pulmonary function testing is the gold standard for diagnosis of COPD. After bronchodilator use PEV1/FVC% <70% can be identified as not fully reversible airflow limitation. Airflow limitation early COPD may have a mild or no clinical symptoms. Chest x-ray examination help to determine the degree of lung hyperinflation and identification with other lung diseases.
3. Differential Diagnosis: COPD should be asthma, bronchiectasis, congestive heart failure, tuberculosis and other identification (Table 1). Sometimes identify with asthma there are some difficulties. After more than middle-aged onset COPD, asthma is more in the child or adolescent onset; COPD symptoms progress slowly, gradually increased, symptoms of asthma are big ups and downs; COPD and more long-term smoking history and (or) harmful gases, particles history of exposure is often accompanied by allergic asthma, allergic rhinitis and (or) eczema, family history of asthma in some patients; COPD basically when irreversible airflow limitation, asthma are much more reversible. However, some asthma patients have long duration of airway remodeling and airflow limitation can not be completely reversed; and a small number of patients with COPD associated with airway hyperresponsiveness, partially reversible airflow limitation. At this point should be based on comprehensive analysis of clinical and laboratory findings, if necessary, for bronchial provocation tests, bronchodilator tests and (or) peak expiratory flow (PEF) diurnal variation rate to be identified. In the small number of patients, the two diseases may overlap exists.
Fifth, the disease classification
COPD severity classification is based on the degree of airflow limitation, is currently divided into 4 levels (Table 2). Diagnosis of COPD, airflow limitation is a major indicator reflects the severity of pathological changes. Because FEV, decline and airflow limitation have good correlation, so FEV, change is the main basis for classification of severity. In addition, consideration should be given the degree of clinical symptoms and complications.Early onset of asthma (usually in childhood); daily symptom change quickly; night and early morning symptoms; also is allergic, allergic rhinitis and (or) eczema; family history of asthma; most reversible airflow limitation
Congestive heart failure at the base of lung auscultation rales could be heard fine; X-ray showed cardiomegaly, pulmonary edema; pulmonary function test showed restrictive ventilatory defect (rather than airflow limitation)
Large purulent bronchiectasis; often accompanied by bacterial infection; coarse moist rales, clubbing; X-ray or CT showed bronchiectasis, wall thickeningTable 2, chronic obstructive pulmonary disease severity ratingGrade I: Mild COPD FEVl / FVC% <70%; FEVl 80% predictedBecause COPD is a progressive disease, early prevention is particularly important. Previous grading the severity of risk factors and had to have a chronic cough, sputum symptoms and lung function is still normal as 0. This is based on the number of COPD patients with chronic cough, sputum symptoms several years later, counterparty and natural history of airflow limitation set. This part of the lung function of patients should be regularly monitored for early detection of airflow limitation.
Grade I: mild COPD, characterized by mild airflow limitation (FEV1/FVC <70% but FEV1 80% predicted value), usually with or without cough, sputum. At this point, patients themselves may not be aware of their lung function abnormalities.
level: moderate COPD is characterized by further deterioration of airflow limitation (50% FEV1 <80% predicted value) and the progress and symptoms associated with shortness of breath, shortness of breath after exercise is more apparent. At this point, since the aggravation of respiratory problems or disease, patients often go to the hospital.
Grade : COPD is characterized by severe airflow limitation further deterioration (30% FEV1 <50% predicted), increased shortness of breath, and recurrent acute exacerbations affect the quality of life of patients.
grade: very severe COPD is characterized by severe airflow limitation (FEV1 <30% predicted value) or associated with chronic respiratory failure. At this point, the quality of life of patients significantly decreased, if there is acute exacerbation may have life-threatening.
Course of COPD can be divided into acute exacerbation and stable stages. Acute exacerbation of COPD is a disease process, patients with short-term cough, sputum, shortness of breath, and (or) increased wheezing, increased sputum volume, was purulent or purulent sticky, can be accompanied by fever and inflammation of the performance increased significantly. Refers to patients with stable cough, sputum, shortness of breath and other symptoms of stable or mild symptoms.
Test questions
1. Diagnosis of chronic obstructive pulmonary disease (COPD) should be on how to conduct clinical assessment?
2. Chronic obstructive pulmonary disease (COPD) and the differential diagnosis of bronchial asthma what is?
3. How clinical diagnosis of COPD?
Reference to answer test questions
1. Diagnosis of chronic obstructive pulmonary disease (COPD) should be on how to conduct clinical assessment?
Answer: when the diagnosis of COPD should first clinical assessment, history taking seriously, including symptoms, past history and systematic re, history. Symptoms include chronic cough, phlegm, shortness of breath. Systematic reof past history and should pay attention to whether childhood asthma, allergic diseases, infections and other respiratory diseases (such as tuberculosis); COPD and respiratory diseases, family history; COPD acute exacerbation and hospitalization history; have the same risk factors (smoking smoke) and other diseases, such as the heart, peripheral vascular and nervous system disease; can not explain the weight loss; other non-specific symptoms such as wheezing, chest tightness, chest pain, and morning headaches; pay attention to history of smoking (in pack-years) and occupational and environmental history of exposure to hazardous substances.
2. Chronic obstructive pulmonary disease (COPD) and the differential diagnosis of bronchial asthma what is?
Answer: COPD should be identified with the diagnosis of bronchial asthma. After more than middle-aged onset COPD, asthma is more in the child or adolescent onset; COPD symptoms progress slowly, gradually increased, symptoms of asthma are big ups and downs; COPD and more long-term smoking history and (or) harmful gases, particles history of exposure is often accompanied by allergic asthma, allergic rhinitis and (or) eczema, family history of asthma in some patients; COPD basically when irreversible airflow limitation, asthma are much more reversible. However, some asthma patients have long duration of airway remodeling and airflow limitation can not be completely reversed; and a small number of patients with COPD associated with airway hyperresponsiveness, partially reversible airflow limitation. At this point should be based on comprehensive analysis of clinical and laboratory findings, if necessary, for bronchial provocation tests, bronchodilator tests and (or) peak expiratory flow (PEF) diurnal variation rate differential. In some patients, the two diseases may overlap exists.
3. How clinical diagnosis of COPD?
Answer: COPD diagnosis should be based on clinical assessment, history of exposure to risk factors, signs and laboratory test data to determine a comprehensive analysis. Not fully reversible airflow limitation there is a prerequisite for diagnosis of COPD. Pulmonary function testing is the gold standard for diagnosis of COPD. After the use of bronchodilators PEV1/FVC <70% can be identified as not fully reversible airflow limitation. Airflow limitation early COPD may have a mild or no clinical symptoms. Chest X-ray examination help to determine the degree of lung hyperinflation and identification with other lung diseases.China's current "diagnosis and treatment of chronic obstructive pulmonary disease Guide" ("Guide") in 1997, "Diagnosis and treatment of chronic obstructive pulmonary disease specification (draft)" based on the modified, published in 2002, chronic obstructive China pulmonary disease (COPD) prevention and control play a positive role. Study abroad in recent years has been on the rapid development of COPD, COPD Global Initiative (Global Initiative for Chronic Obstructive Lung Disease, GOLD) and the American Thoracic Society / European Respiratory Disease Society (ATS / ERS) developed the "COPD Prevention Guide" in the constantly updated. Chinese Medical Association respiratory disease COPD Study Group credits will be based on the results of related research, according to foreign data, in 2002, "Guide" to modify the framework. "Guide" to modify the working group after repeated discussions and extensive solicitation of opinions, based on the development of China's "diagnosis and treatment of chronic obstructive pulmonary disease guidelines (revised 2007)" ["Guide (2007 Edition)"]. Now modified to illustrate the main content.
A, COPD prevalence, definition and diagnosis
1. Prevalence: "Guide (2007 Edition)" cited in the prevalence rate of people over 40 years old 8.2%, the data is the recent 7 areas of China 20,245 people epidemiological findings, but also A survey is currently the most stringent. All groups have carried out investigations pulmonary function tests, abnormal lung function and bronchial dilation test carried out in line with the current diagnostic criteria of the current COPD.
2. Definition: compared with 2002, "Guide" There are two major changes: (1) the definition of the beginning clear that COPD is a preventable and treatable disease, COPD prevention and treatment to overcome the negative, pessimistic mood advocated a positive response attitude; (2) clearly COPD mainly involves the lungs, but can also cause systemic (or pulmonary) of bad effects. Because smoking and passive smoking is a major factor in the pathogenesis of COPD, and to take measures to control, therefore, the 2002 "Guide" in the "COPD is not fully reversible airflow limitation, was the development, and the lungs of harmful gases or abnormal inflammatory response harmful particles of "sentence, the words" and the lungs of cigarette smoke and other harmful gases or harmful particles in the abnormal reaction on. "
3. Pulmonary function tests in the diagnosis of: Still stressed inhaled bronchodilators in the first second forced expiratory volume in after (FEV1) and forced vital capacity (FVC) ratio <70%, indicating the presence of airflow limitation is not fully reversible. Remove the FEV1 <80% predicted value of this standard, because in assessing the severity of the disease classification, I grade (mild) in patients with FEV1 80% predicted value, the two conflicting, but also avoids patients with mild COPD excluded from the COPD diagnostic.
4. Bronchial asthma and COPD: "Guide (2007 Edition)" clearly states that asthma is not COPD, with the 2002 "Guide" The difference is that some asthma patients with disease duration longer, there may be more significant airway remodeling, may also result is not fully reversible airflow limitation, although difficult to identify clinical and COPD, but it does not belong to COPD. Also pointed out that clinical COPD and asthma have occurred in a patient with the situation.
Second, pathogenesis, pathology and pathophysiology
The basis of clinical disease is based on pathogenesis, pathology, pathophysiology of the changes. "Guide (2007 Edition)" that the autonomic nervous system dysfunction (eg, abnormal distribution of cholinergic receptors, etc.) also play an important role in the pathogenesis of COPD and with reference to our results, indicating that anti-cholinergic drugs in COPD treatment status.
COPD with secondary pulmonary heart disease later, some patients can be seen in situ with multiple small arterial thrombosis, which is China's research results. Set forth in the pathophysiology of COPD can cause systemic adverse effects, including systemic inflammation and skeletal muscle dysfunction and so on. Systemic inflammation as the abnormal increase of systemic oxidative load, so that the blood concentration of abnormally high levels of cytokines and abnormal activation of inflammatory cells. Skeletal muscle dysfunction manifested as gradually reducing the weight and so on. COPD, systemic adverse effects have important clinical significance, it may exacerbate the patient's mobility is limited, so that reduced quality of life, the prognosis is worse.
Third, risk factors
2002 "Guide" comparison, almost no changes in air pollution. In recent years, the epidemiology of COPD survey, bio-fuels, indoor air pollution is the main female patients with COPD risk factor. Therefore, in the servant aims South (2007 Edition) "added biofuel air pollution and smoking have a synergistic effect of the risk factors.
Fourth, differential diagnosis
In the "Guide (2007 Edition)" in the differential diagnosis, not only details the identification of bronchial asthma and COPD, and list outlines the COPD and congestive heart failure, bronchiectasis, tuberculosis and identification of bronchiolitis obliterans points .
Five laboratory
On the clinical significance of bronchial dilation test, "Guide (2007 Edition)" 2002 "guide" Understanding different. Whether that is the use of bronchodilators or oral corticosteroids to test, we can not predict disease progression. FEV1 improved less after treatment, patients can not reliably predict response to treatment. Were carried out at different times, bronchial dilation test, the results may be different. But in some cases (such as children are not the typical history of asthma during the night coughing, wheezing performance), then have some significance.
Sixth, the severity of disease classification
COPD severity classification is based on the degree of airflow limitation, decline in FEV1 and airflow limitation as there is good correlation between the 2002 "Guide" to changes in FEV1 as the main basis for classification of severity, taking into account the clinical the degree of symptoms and complications, the severity is divided into four, not 0. "Guide (2007 Edition)" original level (moderate) in the change A and B (moderate) and grade (severe), into the original class (very severe), and GOLD and ATS / ERS latest version of the "COPD Guide" consistent, favorable clinical work and research work with the international standards.
COPD is a progressive disease, early intervention is so important that in 2002, "Guide" will have a chronic cough, sputum symptoms and normal lung function as 0. Purpose of this part of the pulmonary function of patients regularly, early detection of airflow limitation, early intervention. However, these patients did not COPD, Moreover, there is no evidence that shows that they will develop into the future I level. Therefore, the "Guide (2007 Edition)" in the clinical severity classification canceled 0 (risk period).
Because of the severity of COPD with a variety of factors, to more comprehensively and accurately reflect the severity of the disease alone FEV, is not enough. "Guide (2007 Edition)" increased body mass index, dyspnea grade assessment, BODE index (body mass index, degree of airflow obstruction, dyspnea, exercise capacity) and quality of life assessment. For ease of application, detailing body mass index and dyspnea grades of content. Now that the BODE index and quality of life assessment can reflect the prognosis of COPD in order to avoid the article too long, the related references are cited in the text, the er application in order to facilitate inspection.
On acute exacerbation of COPD (AECOPD) concept, currently there is no uniform standard of the guide, "Guide (2007 Edition)" Comprehensive current knowledge will be defined as: COPD with acute exacerbation of patients is the continued deterioration of the situation beyond the daily need to change the basis of COPD, regular drug users, and contains 2002 "Guide" in the related Description: Usually the disease process, patients with short-term cough, sputum, shortness of breath, and (or) increased wheezing, increased sputum volume, was purulent purulent sputum, or mucus, can significantly increase with fever and other inflammatory performance. As for the exacerbation be considered to maintain the long 1 AECOPD, ease between the two AECOPD can be defined as how long to maintain remission, the objective evidence is unavailable, the current lack of a unified definition of standards, although its clinical research is important to define the frequency of AECOPD, still need to discuss.
VII, COPD treatment stable
The treatment of COPD and asthma and Lowering treatment of various steps, so we aim to Southern (2007 Edition) "pointed out: According to the severity of the disease the choice of treatment, without apparent adverse drug reactions or disease progression, still maintain the same level the law of the long-term treatment, according to patient response to treatment and timely adjustment of treatment.
VIII treatment
1. Bronchodilators: "Guide (2007 Edition)" that the bronchodilator agent inhalation side effects than oral drugs, so many preferred inhalation. Because tiotropium has been listed in China, there were more evidence-based medical evidence, so its main function and usage were introduced, these are the 2002 "Guide" not.
2. Glucocorticoids (the hormone): 2002 "Guide" that long-term regular inhaled corticosteroid therapy has only improved in symptoms and lung function, and the "Guide (2007 edition)" suggested that the long-term inhaled corticosteroid law applies only to FEV1 < 50% predicted ( and grade), and the clinical symptoms and were repeated exacerbations. This is because the inhaled corticosteroids can reduce the frequency of AECOPD, to improve the quality of life, therefore, whether the patients had improved lung function, can be treated with inhaled corticosteroid. Also pointed out that the United inhaled corticosteroids and 2 agonists alone than their good effect. COPD is not recommended in patients with long-term oral corticosteroid treatment.
September, hospitalization
"Guide (2007 Edition)" section on hospital treatment was carried out in the text deleted. In recent years more on the role of bacteria in AECOPD research data, "Guide (2007 Edition)" in the treatment of COPD exacerbation of the main program that increased when the patient breathing difficulties, cough associated with increased and purulent sputum volume sputum should be based on the severity of COPD and the corresponding layer of bacteria, and combined with the local resistance of common bacteria types and trends of drug-sensitive cases and sensitive to antibiotics as soon as possible options. If poor response to initial treatment, it is timely under the bacterial culture and sensitivity test results to adjust antibiotics. Patients with mild or moderate acute exacerbation of COPD, the main pathogens, mostly Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. The severe and very severe COPD with acute exacerbation, in addition to more common bacteria, but can still have Enterobacteriaceae, Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus. Pseudomonas aeruginosa occurring risk factors of recent hospitalization, frequent use of antimicrobial drugs and in the past have isolated Pseudomonas aeruginosa or send plant's history. The distribution of bacteria may be used according to appropriate antibiotic therapy, and are listed in Table 4 commonly used antibiotics, antimicrobial therapy should be possible to reduce the bacterial load to a minimum level in order to extend the time between acute exacerbation of COPD. Long-term application of broad-spectrum antibiotics and hormones is easy secondary fungal infection, fungal infection should be closely observed clinical signs of fungal infection by using prevention measures.



Friends Links:Automation Control Blog
Automation Products Order Numbers