新編文檔-版copd全球策略教學(xué)幻燈-ppt課件-精品文檔

1、 Global Initiative for Chronic Obstructive Lung DiseaseGLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE (GOLD): TEACHING SLIDE SETDecember 2019This slide set is restricted for academic and educational purposes only. Use of the slide set, or of individual slides, for commercial or promotional p

2、urposes requires approval from GOLD. lobal Initiative for ChronicbstructiveungiseaseG OLD Global Initiative for Chronic Obstructive Lung DiseaseGOLD StructureGOLD Board of DirectorsRoberto Rodriguez-Roisin, MD ChairScience CommitteeJrgen Vestbo, MD - ChairDissemination/ImplementationCommitteeJean Bo

3、urbeau, MD - ChairGOLD Board of Directors: 2019R. Rodriguez-Roisin, Chair, SpainA. Anzueto, U.S. ATSJ. Bourbeau, CanadaT. DeGuia, PhilippinesD. Hui, Hong Kong PRCF. Martinez, U.S.M. Mishima, Japan APSRD. Nugmanova, Kazakhstan WONCARamirez, Mexico ALATR. Stockley, U.K.J. Vestbo, Denmark, U.K.Observer

4、: J. Wedzica, UK ERSGOLD Science Committee - 2019Jrgen Vestbo, MD, Chair Alvar Agusti, MDAntonio Anzueto, MDPeter Barnes, MDLeonardo Fabbri, MDPaul Jones, MDFernando Martinez, MDMasaharu Nishimura, MDRoberto Rodriguez-Roisin, MDDon Sin, MDRobert Stockley, MDClaus Vogelmeier, MDEvidence Category Sour

5、ces of Evidence ARandomized controlled trials (RCTs). Rich body of dataBRandomized controlled trials(RCTs). Limited body of dataCNonrandomized trialsObservational studies. DPanel consensus judgment Description of Levels of Evidence GOLD StructureGOLD Board of DirectorsRoberto Rodriguez-Roisin, MD Ch

6、airScience CommitteeJrgen Vestbo, MD - ChairDissemination/ImplementationTask Group Jean Bourbeau, MD - ChairGOLD National Leaders - GNLUnited StatesUnited KingdomArgentinaAustraliaBrazilAustriaCanadaChileBelgiumChinaDenmarkColumbiaCroatiaEgyptGermanyGreeceIrelandItalySyriaHong Kong ROCJapanIcelandIn

7、diaKoreaKyrgyzstanUruguayMoldovaNepalMacedoniaMaltaNetherlandsNew ZealandPolandNorwayPortugalGeorgiaRomaniaRussiaSingaporeSlovakiaSloveniaSaudi ArabiaSouth AfricaSpainSwedenThailandSwitzerlandUkraineUnited Arab EmiratesTaiwan ROCVenezuelaVietnamPeruYugoslaviaAlbaniaBangladeshFranceMexicoTurkeyCzech

8、RepublicPakistanIsraelGOLD National LeadersPhilippinesYemanKazakhstanMongoliaGOLD Website Alobal Initiative for ChronicbstructiveungiseaseG OLD Global Initiative for Chronic Obstructive Lung DiseaseGOLD ObjectivesIncrease awareness of COPD among health professionals, health authori

9、ties, and the general publicImprove diagnosis, management and preventionDecrease morbidity and mortalityStimulate researchGlobal Strategy for Diagnosis, Management and Prevention of COPD, 2019: Chapters Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage Exace

10、rbationsManage ComorbiditiesREVISED 2019Global Strategy for Diagnosis, Management and Prevention of COPD, 2019: Chapters Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage ComorbiditiesREVISED 2019Global Strategy for Diagnosis, Management

11、and Prevention of COPDDefinition of COPDCOPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases.Exacerbation

12、s and comorbidities contribute to the overall severity in individual patients.Global Strategy for Diagnosis, Management and Prevention of COPDMechanisms Underlying Airflow Limitation in COPDSmall Airways DiseaseAirway inflammationAirway fibrosis, luminal plugsIncreased airway resistanceParenchymal D

13、estructionLoss of alveolar attachmentsDecrease of elastic recoilAIRFLOW LIMITATIONGlobal Strategy for Diagnosis, Management and Prevention of COPDBurden of COPDCOPD is a leading cause of morbidity and mortality worldwide.The burden of COPD is projected to increase in coming decades due to continued

14、exposure to COPD risk factors and the aging of the worlds population.COPD is associated with significant economic burden.Global Strategy for Diagnosis, Management and Prevention of COPDRisk Factors for COPDLung growth and development GenderAge Respiratory infectionsSocioeconomic statusAsthma/Bronchi

15、al hyperreactivityChronic BronchitisGenesExposure to particlesTobacco smokeOccupational dusts, organic and inorganicIndoor air pollution from heating and cooking with biomass in poorly ventilated dwellingsOutdoor air pollutionGlobal Strategy for Diagnosis, Management and Prevention of COPDRisk Facto

16、rs for COPDGenesInfectionsSocio-economic statusAging PopulationsGlobal Strategy for Diagnosis, Management and Prevention of COPD, 2019: Chapters Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage ComorbiditiesREVISED 2019Global Strategy fo

17、r Diagnosis, Management and Prevention of COPDDiagnosis and Assessment: Key PointsA clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease.Spirometry is required to make the diag

18、nosis; the presence of a post-bronchodilator FEV1/FVC 0.70 confirms the presence of persistent airflow limitation and thus of COPD. Global Strategy for Diagnosis, Management and Prevention of COPDDiagnosis and Assessment: Key PointsThe goals of COPD assessment are to determine the severity of the di

19、sease, including the severity of airflow limitation, the impact on the patients health status, and the risk of future events. Comorbidities occur frequently in COPD patients, and should be actively looked for and treated appropriately if present. SYMPTOMS chronic coughshortness of breathEXPOSURE TO

20、RISKFACTORS tobaccooccupationindoor/outdoor pollutionSPIROMETRY: Required to establish diagnosisGlobal Strategy for Diagnosis, Management and Prevention of COPDDiagnosis of COPD sputum Global Strategy for Diagnosis, Management and Prevention of COPDAssessment of Airflow Limitation: SpirometrySpirome

21、try should be performed after the administration of an adequate dose of a short-acting inhaled bronchodilator to minimize variability.A post-bronchodilator FEV1/FVC 0.70 confirms the presence of airflow limitation.Where possible, values should be compared to age-related normal values to avoid overdi

22、agnosis of COPD in the elderly.Spirometry: Normal Trace Showing FEV1 and FVC1234561234Volume, litersTime, secFVC51FEV1 = 4LFVC = 5LFEV1/FVC = 0.8Spirometry: Obstructive DiseaseVolume, litersTime, seconds54321123456FEV1 = 1.8LFVC = 3.2LFEV1/FVC = 0.56Normal ObstructiveDetermine the severity of the di

23、sease, its impact on the patients health status and the risk of future events (for example exacerbations) to guide therapy. Consider the following aspects of the disease separately: current level of patients symptoms severity of the spirometric abnormality frequency of exacerbations presence of como

24、rbidities. Global Strategy for Diagnosis, Management and Prevention of COPDAssessment of COPD: Goals Global Strategy for Diagnosis, Management and Prevention of COPDAssessment of COPDAssess symptomsAssess degree of airflow limitation using spirometryAssess risk of exacerbationsAssess comorbiditiesTh

25、e characteristic symptoms of COPD are chronic and progressive dyspnea, cough, and sputum production. Dyspnea: Progressive, persistent and characteristically worse with exercise.Chronic cough: May be intermittent and may be unproductive.Chronic sputum production: COPD patients commonly cough up sputu

26、m. Global Strategy for Diagnosis, Management and Prevention of COPDSymptoms of COPDAssess symptomsAssess degree of airflow limitation using spirometryAssess risk of exacerbationsAssess comorbiditiesUse the COPD Assessment Test(CAT) or mMRC Breathlessness scale Global Strategy for Diagnosis, Manageme

27、nt and Prevention of COPDAssessment of COPDCOPD Assessment Test (CAT): An 8-item measure of health status impairment in COPD().Breathlessness Measurement using the Modified British Medical Research Council (mMRC) Questionnaire: relates well to other measures of health status and pred

28、icts future mortality risk.Global Strategy for Diagnosis, Management and Prevention of COPDAssessment of SymptomsGlobal Strategy for Diagnosis, Management and Prevention of COPDModified MRC (mMRC)Questionnaire Assess symptoms Assess degree of airflow limitation using spirometryAssess risk of exacerb

29、ationsAssess comorbiditiesUse spirometry for grading severity according to spirometry, using four grades split at 80%, 50% and 30% of predicted value Global Strategy for Diagnosis, Management and Prevention of COPDAssessment of COPDGlobal Strategy for Diagnosis, Management and Prevention of COPDClas

30、sification of Severity of Airflow Limitation in COPD*In patients with FEV1/FVC 80% predicted GOLD 2: Moderate 50% FEV1 80% predictedGOLD 3: Severe 30% FEV1 50% predictedGOLD 4: Very Severe FEV1 30% predicted*Based on Post-Bronchodilator FEV1 Assess symptomsAssess degree of airflow limitation using s

31、pirometryAssess risk of exacerbationsAssess comorbidities Use history of exacerbations and spirometry. Two exacerbations or more within the last year or an FEV1 50 % of predicted value are indicators of high risk Global Strategy for Diagnosis, Management and Prevention of COPDAssessment of COPDGloba

32、l Strategy for Diagnosis, Management and Prevention of COPDAssess Risk of ExacerbationsTo assess risk of exacerbations use history of exacerbations and spirometry: Two or more exacerbations within the last year or an FEV1 2 1 0(C)(D) (A)(B)mMRC 0-1CAT 2CAT 10 Symptoms(mMRC or CAT score)Global Strate

33、gy for Diagnosis, Management and Prevention of COPDCombined Assessment of COPD(C)(D) (A)(B)mMRC 0-1CAT 2CAT 10 Symptoms(mMRC or CAT score)If mMRC 0-1 or CAT 2 or CAT 10: More Symptoms (B or D) Assess symptoms firstGlobal Strategy for Diagnosis, Management and Prevention of COPDCombined Assessment of

34、 COPDRisk (GOLD Classification of Airflow Limitation)Risk (Exacerbation history) 2 1 0(C)(D) (A)(B)mMRC 0-1CAT 2CAT 10 Symptoms(mMRC or CAT score)If GOLD 1 or 2 and only 0 or 1 exacerbations per year: Low Risk (A or B)If GOLD 3 or 4 or two ormore exacerbations per year: High Risk (C or D)Assess risk

35、 of exacerbations nextGlobal Strategy for Diagnosis, Management and Prevention of COPDCombined Assessment of COPDRisk (GOLD Classification of Airflow Limitation)Risk (Exacerbation history) 2 1 0(C)(D) (A)(B)mMRC 0-1CAT 2CAT 10 Symptoms(mMRC or CAT score)Patient is now in one offour categories:A: Les

36、 symptoms, low riskB: More symtoms, low riskC: Less symptoms, high riskD: More Symtoms, high riskUse combined assessmentGlobal Strategy for Diagnosis, Management and Prevention of COPDCombined Assessment of COPDRisk (GOLD Classification of Airflow Limitation)Risk (Exacerbation history) 2 1 0(C)(D) (

37、A)(B)mMRC 0-1CAT 2CAT 10 Symptoms(mMRC or CAT score)PatientCharacteristicSpirometric ClassificationExacerbations per yearmMRCCATALow Risk Less SymptomsGOLD 1-2 10-1 2 10CHigh Risk Less SymptomsGOLD 3-4 20-1 2 2 10Global Strategy for Diagnosis, Management and Prevention of COPDCombined Assessment of

38、COPDWhen assessing risk, choose the highest risk according to GOLD grade or exacerbation history Global Strategy for Diagnosis, Management and Prevention of COPDAssess COPD ComorbiditiesCOPD patients are at increased risk for: Cardiovascular diseasesOsteoporosisRespiratory infectionsAnxiety and Depr

39、essionDiabetesLung cancerThese comorbid conditions may influence mortality and hospitalizations and should be looked for routinely, and treated appropriately.Global Strategy for Diagnosis, Management and Prevention of COPDDifferential Diagnosis: COPD and AsthmaCOPD Onset in mid-life Symptoms slowly

40、progressive Long smoking history ASTHMAOnset early in life (often childhood)Symptoms vary from day to daySymptoms worse at night/early morningAllergy, rhinitis, and/or eczema also presentFamily history of asthmaGlobal Strategy for Diagnosis, Management and Prevention of COPDAdditional Investigations

41、Chest X-ray: Seldom diagnostic but valuable to exclude alternative diagnoses and establish presence of significant comorbidities.Lung Volumes and Diffusing Capacity: Help to characterize severity, but not essential to patient management.Oximetry and Arterial Blood Gases: Pulse oximetry can be used t

42、o evaluate a patients oxygen saturation and need for supplemental oxygen therapy. Alpha-1 Antitrypsin Deficiency Screening: Perform when COPD develops in patients of Caucasian descent under 45 years or with a strong family history of COPD.Exercise Testing: Objectively measured exercise impairment, a

43、ssessed by a reduction in self-paced walking distance (such as the 6 min walking test) or during incremental exercise testing in a laboratory, is a powerful indicator of health status impairment and predictor of prognosis.Composite Scores: Several variables (FEV1, exercise tolerance assessed by walk

44、ing distance or peak oxygen consumption, weight loss and reduction in the arterial oxygen tension) identify patients at increased risk for mortality. Global Strategy for Diagnosis, Management and Prevention of COPDAdditional InvestigationsGlobal Strategy for Diagnosis, Management and Prevention of C

45、OPD, 2019: Chapters Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage ComorbiditiesREVISED 2019Global Strategy for Diagnosis, Management and Prevention of COPDTherapeutic Options: Key PointsSmoking cessation has the greatest capacity to i

46、nfluence the natural history of COPD. Health care providers should encourage all patients who smoke to quit. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates.All COPD patients benefit from regular physical activity and should repeatedly be encouraged to r

47、emain active.Appropriate pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance. None of the existing medications for COPD has been shown conclusively to modify the long-term decline in lung function.Influe

48、nza and pneumococcal vaccination should be offered depending on local guidelines.Global Strategy for Diagnosis, Management and Prevention of COPDTherapeutic Options: Key PointsGlobal Strategy for Diagnosis, Management and Prevention of COPDTherapeutic Options: Smoking CessationCounseling delivered b

49、y physicians and other health professionals significantly increases quit rates over self-initiated strategies. Even a brief (3-minute) period of counseling to urge a smoker to quit results in smoking quit rates of 5-10%. Nicotine replacement therapy (nicotine gum, inhaler, nasal spray, transdermal p

50、atch, sublingual tablet, or lozenge) as well as pharmacotherapy with varenicline, bupropion, and nortriptyline reliably increases long-term smoking abstinence rates and are significantly more effective than placebo. Brief Strategies to Help the Patient Willing to Quit Smoking ASK Systematically iden

51、tify all tobacco users at every visit ADVISEStrongly urge all tobacco users to quit ASSESS Determine willingness to make a quit attempt ASSIST Aid the patient in quitting ARRANGESchedule follow-up contact.Global Strategy for Diagnosis, Management and Prevention of COPDTherapeutic Options: Risk Reduc

52、tionEncourage comprehensive tobacco-control policies with clear, consistent, and repeated nonsmoking messages. Emphasize primary prevention, best achieved by elimination or reduction of exposures in the workplace. Secondary prevention, achieved through surveillance and early detection, is also impor

53、tant.Reduce or avoid indoor air pollution from biomass fuel, burned for cooking and heating in poorly ventilated dwellings. Advise patients to monitor public announcements of air quality and, depending on the severity of their disease, avoid vigorous exercise outdoors or stay indoors during pollutio

54、n episodes.Global Strategy for Diagnosis, Management and Prevention of COPDTherapeutic Options: COPD MedicationsBeta2-agonists Short-acting beta2-agonists Long-acting beta2-agonistsAnticholinergics Short-acting anticholinergics Long-acting anticholinergicsCombination short-acting beta2-agonists + an

55、ticholinergic in one inhaler MethylxanthinesInhaled corticosteroids Combination long-acting beta2-agonists + corticosteroids in one inhalerSystemic corticosteroidsPhosphodiesterase-4 inhibitors Bronchodilator medications are central to the symptomatic management of COPD. Bronchodilators are prescrib

56、ed on an as-needed or on a regular basis to prevent or reduce symptoms. The principal bronchodilator treatments are beta2-agonists, anticholinergics, theophylline or combination therapy.The choice of treatment depends on the availability of medications and each patients individual response in terms

57、of symptom relief and side effects.Global Strategy for Diagnosis, Management and Prevention of COPDTherapeutic Options: Bronchodilators Long-acting inhaled bronchodilators are convenient and more effective for symptom relief than short-acting bronchodilators. Long-acting inhaled bronchodilators redu

58、ce exacerbations and related hospitalizations and improve symptoms and health status. Combining bronchodilators of different pharmacological classes may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator.Global Strategy for Diagnosis, Ma

59、nagement and Prevention of COPDTherapeutic Options: BronchodilatorsRegular treatment with inhaled corticosteroids (ICS) improves symptoms, lung function and quality of life and reduces frequency of exacerbations for COPD patients with an FEV1 60% predicted.Inhaled corticosteroid therapy is associate

60、d with an increased risk of pneumonia.Withdrawal from treatment with inhaled corticosteroids may lead to exacerbations in some patients. Global Strategy for Diagnosis, Management and Prevention of COPDTherapeutic Options: Inhaled CorticosteroidsAn inhaled corticosteroid combined with a long-acting b