慢性阻塞性肺疾病合并癥最新認(rèn)識(shí)課件

慢性阻塞性肺疾病合并癥

最新認(rèn)識(shí)慢性阻塞性肺疾病合并癥

最新認(rèn)識(shí)1慢阻肺是老年人共患病中的肺部常見疾病慢阻肺與合并癥肺康復(fù)對(duì)共患病的影響慢阻肺是老年人共患病中的肺部常見疾病慢阻肺與合并癥肺康復(fù)對(duì)共2慢阻肺是老年人共患病中的肺部常見疾病慢阻肺與合并癥肺康復(fù)對(duì)共患病的影響慢阻肺是老年人共患病中的肺部常見疾病慢阻肺與合并癥肺康復(fù)對(duì)共3共患病Managementoftherisingprevalenceofmultiplechroniccomorbidities(i.e.,patientswithtwoormorechronicmorbidities)isamajorchallengefacinghealthcaresystemsworldwide(181).共患病Managementoftherisingpr4隨著年齡增長，共患病越多

65歲以上人群，50%有兩種以上共患病2-KarenBarnett,etal.Lancet.2012Jul7;380(9836):37-43隨著年齡增長，共患病越多

65歲以上人群，50%有兩種以上共5共患病的發(fā)生機(jī)制1-Mechanismsofdevelopmentofmultimorbidityintheelderly共患病的發(fā)生機(jī)制1-Mechanismsofdevelo6共患病是由共同的危險(xiǎn)因子（年齡，吸煙，缺乏鍛煉，飲食，環(huán)境等）所誘發(fā)的。共患病的發(fā)病是同時(shí)的。心血管系統(tǒng)影響可能最早出現(xiàn)。共患病的某一單獨(dú)成分相互促進(jìn)惡化。對(duì)其中某一疾病的治療會(huì)使其他疾病獲益。慢阻肺是共患病中肺部的疾病表現(xiàn)。共患病的特點(diǎn)共患病是由共同的危險(xiǎn)因子（年齡，吸煙，缺乏鍛煉，飲食，環(huán)境等7DoesCOPDstandfor“COmorbiditywithpulmonarydisease”?

ItisofupmostimportancetoincreaseawarenessamongsthealthcareprofessionalregardingcomorbidityinCOPDbutalsoregardingCOPDasacomorbidityinotherprevalentchronicdiseases在醫(yī)療中，提高對(duì)慢性阻塞性肺疾病的合并癥的認(rèn)識(shí)是至關(guān)重要的，同時(shí)也要認(rèn)識(shí)到慢阻肺作為其他常見慢性疾病的合并癥的特質(zhì)4-VanflaterernL.EurRespirJ.2015Jan;45(1):14-7DoesCOPDstandfor“COmorbid8在不同慢性疾病患者中慢阻肺的發(fā)病情況在7241591名成人中，909948（12.6%）患有慢阻肺肺癌患者中50%

下呼吸道感染患者中33%

心血管疾病患者中33%

低創(chuàng)性骨折患者中25%

3-AndreaS.Gershon,etal.EurRespirJ2015;45:51–59在不同慢性疾病患者中慢阻肺的發(fā)病情況在7241591名成人中9GOLD2014

慢阻肺的定義（GOLD2014)慢性阻塞性肺疾?。菏且环N可預(yù)防、可治療的常見疾病，特征為持續(xù)存在的氣流受限。氣流受限呈進(jìn)行性發(fā)展，伴有氣道和肺對(duì)有害顆粒或氣體所致慢性炎癥反應(yīng)的增加。急性加重和合并癥影響患者整體疾病的嚴(yán)重程度。GOLD2014慢阻肺的定義（GOLD2014)10慢阻肺的病理機(jī)制AdaptedfromPJBarner,2000;Fabbri,Sinigaglia,Papi,Saetta2002;Cosio,Saettaand

Cosio

2012慢阻肺的病理機(jī)制AdaptedfromPJBarner11慢阻肺作為共患病中肺部表現(xiàn)

5-FabbriLM1,LuppiF，et

al.EurRespirJ.2008Jan;31(1):204-12慢阻肺作為共患病中肺部表現(xiàn)5-FabbriLM1,Lu12PrevalenceandoutcomesofdiabeteshypertensionandcardiovasculardiseaseinCOPDThepresentstudyanalyseddatafrom20296subjectsaged>45yrsatbaselineintheAtherosclerosisriskinCommunitiesStudy(ARIC)andtheCardiovascularHealthStudy(CHS).9-D.M.Mannino,etal.EurRespirJ2008;32:962–9695-yrsmortalityPrevalenceandoutcomesofdia13慢阻肺是老年人共患病中的肺部常見疾病慢阻肺與合并癥肺康復(fù)對(duì)共患病的影響慢阻肺是老年人共患病中的肺部常見疾病慢阻肺與合并癥肺康復(fù)對(duì)共14慢阻肺主要合并癥的發(fā)病7-SmithMC1,WrobelJP2.

IntJChronObstructPulmonDis.2014Aug27;9:871-88.慢阻肺主要合并癥的發(fā)病7-SmithMC1,Wrobel15主要合并癥的臨床影響7-SmithMC1,WrobelJP2.

IntJChronObstructPulmonDis.2014Aug27;9:871-88.心血管疾病心血管疾病是慢阻肺最常見的合并癥，是慢阻肺發(fā)生率最高也是最為重要的共存疾病，心血管疾病中包括了：高血壓，缺血性心臟病，心衰以及心房顫動(dòng)、心律失常等。高血壓主要合并癥的臨床影響7-SmithMC1,Wrobel16慢阻肺合并心血管疾病的現(xiàn)狀A(yù)ECOPD存在潛在引發(fā)心血管疾病的風(fēng)險(xiǎn)，在臨床上并不少見，卻不容易被識(shí)別慢阻肺患者有高于同齡正常人群的心血管疾病患病率，肺功能越差，患病率越高1在AECOPD的住院患者中，50%以上都合并有心血管疾病2大約10%-40%的心衰患者同時(shí)合并慢阻肺3在輕-中度慢阻肺，F(xiàn)EV1每下降20%，心血管相關(guān)死亡風(fēng)險(xiǎn)升高28%，非致死性冠脈事件增加近20%41、J.Finkelstein,E,etal.Chronicobstructivepulmonarydiseaseasanindependentriskfactorforcardiovascularmorbidity.InternationalJournalofChronicObstructivePulmonaryDisease,vol.4,pp.337–349,2009.2、H.Cui,etal.PrevalenceofcardiovasculardiseaseinsubjectshospitalizedduetochronicobstructivepulmonarydiseaseinBeijingfrom2000to2010.JournalofGeriatricCardiology,vol.9,no.1,pp.5–10,2012.3、HawkinsNM,etal.Heartfailureandchronicobstructivepulmonarydisease:diagnosticpitfallsandepidemiology.EurJHeartFail2009;11:130–139.4、SinDD,etal.ProcAmThoracSoc2005;2:8-11慢阻肺合并心血管疾病的現(xiàn)狀A(yù)ECOPD存在潛在引發(fā)心血管疾病17心力衰竭是一種全身性疾病Myocardialinfarctioncausesthereleaseofinflammatorycellsfromthespleenandbonemarrowandtheirmyocardialinfiltration心肌梗塞引起脾和骨髓的炎癥細(xì)胞釋放和心肌滲出物Thisleadstoanaccumulationofmonocytesintheheart,predominantlylocatedintheinfarctborderzone,andadecreaseofmonocytesinthespleenandbonemarrowThismaybemediatedbyactivationofthesympatheticnervoussystem,angiotensinII,and/orcytokinerelease.10-HofmasnnandFrantz.EurheartJ2014;35:314-5心力衰竭是一種全身性疾病Myocardialinfarct18UnrecognizedheartfailureinelderlypatientswithstableCOPDUnrecognizedheartfailurein19HighprevalenceandunderdiagnosisoflungfunctionabnormalitiesinpatientswithishemicheartdiseaseHighprevalenceandunderdiagn20FEV1的降低及阻塞性呼吸系統(tǒng)疾病與心力衰竭發(fā)生率的升高是相關(guān)的11-Li

J

etal.Circulation2014;129:971-80FEV1的降低及阻塞性呼吸系統(tǒng)疾病與心力衰竭發(fā)生率的升高是相21慢阻肺主要合并癥的發(fā)病SmithMC1,WrobelJP2.

IntJChronObstructPulmonDis.2014Aug27;9:871-88.慢阻肺主要合并癥的發(fā)病SmithMC1,WrobelJ22常見認(rèn)知功能障礙Cleutjens，et

al(2014).Cognitivefunctioninginobstructivelungdisease:resultsfromtheUnitedKingdombiobank.JAmMedDirAssoc.15(3),214-219

與對(duì)照組相比，反應(yīng)時(shí)間，前瞻記憶，視覺空間記憶以及數(shù)字短時(shí)記憶均下降Singh,etal.(2014).Aprospectivestudyofchronicobstructivepulmonarydiseaseandtheriskformildcognitiveimpairment.JAMA

Neurol.71(5),581-586.

與對(duì)照組相比，注意力，視覺空間感，記憶力以及語言能力均下降非記憶減退的輕度認(rèn)知障礙的風(fēng)險(xiǎn)比為Hazardratio：2.58(1.32-5.06)

常見認(rèn)知功能障礙Cleutjens，etal(2014).23肺部疾病與認(rèn)知功能減退和老年癡呆癥的關(guān)系14Lungdiseaseasadeterminantofcognitivedeclineanddementia肺部疾病與認(rèn)知功能減退和老年癡呆癥的關(guān)系14Lungdi24慢阻肺主要合并癥的發(fā)病SmithMC1,WrobelJP2.

IntJChronObstructPulmonDis.2014Aug27;9:871-88.慢阻肺主要合并癥的發(fā)病SmithMC1,WrobelJ25心血管疾病和腫瘤尤其肺癌是

輕中度COPD患者的主要死因

COPD.2010Oct;7(5):375-82.輕度中度心血管疾病和腫瘤尤其肺癌是

輕中度COPD患者的主要死因

C26COPD與肺癌相關(guān)的可能機(jī)制NatRevCancer.2013Apr;13(4):233-45COPD與肺癌相關(guān)的可能機(jī)制NatRevCancer.27COPD合并肺癌的治療2014GOLDCOPD患者經(jīng)常被發(fā)現(xiàn)合并肺癌，肺癌是輕度COPD最主要的死因；COPD合并肺癌患者的肺癌治療需按照指南常規(guī)治療；然而肺功能的降低會(huì)限制肺癌的手術(shù)治療；肺癌合并COPD患者的COPD治療需按照指南常規(guī)治療。COPD合并肺癌的治療2014GOLDCOPD患者經(jīng)常被28慢阻肺主要合并癥的發(fā)病SmithMC1,WrobelJP2.

IntJChronObstructPulmonDis.2014Aug27;9:871-88.其他慢阻肺主要合并癥的發(fā)病SmithMC1,WrobelJ29慢阻肺中的代謝綜合癥慢阻肺患者中常見共存的代謝性疾病WatzH,etal.Chest.2009Oct;136(4):1039-46慢阻肺中的代謝綜合癥慢阻肺患者中常見共存的代謝性疾病Watz30OSAandriskofcardiovasculardiseasesObstructivesleepapnoeaandcardiovasculardiseaseManuelSánchez-de-la-Torre,PhDa,b,

FranciscoCampos-Rodriguez,MDc,

ProfFerranBarbé,MDa,b,,OSAandriskofcardiovascular31慢阻肺是老年人共患病中的肺部常見疾病慢阻肺與合并癥肺康復(fù)對(duì)共患病的影響慢阻肺是老年人共患病中的肺部常見疾病慢阻肺與合并癥肺康復(fù)對(duì)共32Generallyspeaking,patientswithCOPDand

multiplechronic

comorbiditiesaretreated

accordingtoexistingstandardsforeach

individualdisease.Inotherwords,

comorbiditiesinpatientswithCOPDare

treatedthesameasinpatientswithout

COPD,andCOPDistreatedthesame

regardlessofthecomorbidity.

Indeed,

observationalstudiessuggestthatmortality

ofpatientswithCOPDcanbereduced

bynonrespiratorytreatments,including

b-blockers,angiotensin-convertingenzyme

inhibitors(182),andstatins(183).Generallyspeaking,patientsw33Pulmonaryrehabilitation.Pulmonary

rehabilitationistypicallyprovidedinahospital-based,outpatientsetting.Itsbenefitsinthissettingarewellestablished,includingreduceddyspnea,increasedexercisecapacity,improvedqualityoflife,andreduceduseofhealthcareresources(184).肺康復(fù)肺康復(fù)通常在醫(yī)院,為門診患者提供。在此設(shè)置也建立了它的好處,包括減少呼吸困難,提高運(yùn)動(dòng)能力,改善生活質(zhì)量,減少醫(yī)療資源的使用Pulmonaryrehabilitation.肺康復(fù)34

肺康復(fù)治療對(duì)于慢阻肺患者合并癥的影響EurRespirRev.2014Mar1;23(131):131-41.doi:10.1183/09059180.00007613.ComorbiditiesinpatientswithCOPDandpulmonaryrehabilitation:dotheymatter?

肺康復(fù)治療對(duì)于慢阻肺患者合并癥的影響EurRespir35肺康復(fù)治療的意義提高運(yùn)動(dòng)能力減少焦慮減少抑郁改善生活質(zhì)量延長壽命（通過降低未來急性加重風(fēng)險(xiǎn)）減少住院（通過降低未來急性加重風(fēng)險(xiǎn)）減少心血管疾病風(fēng)險(xiǎn)因子（間接）改變飲食習(xí)慣（水果&蔬菜/魚類）/吸煙/BP肺康復(fù)治療的意義提高運(yùn)動(dòng)能力36DosePRinfulencescardiovascularriskofCOPDpatients10

VanfleterenLE1

，EurRespirJ.2014May;43(5):1306-15.Arterialstiffness129subjectswhocompletedtheprogramDosePRinfulencescardiovascu37確保肺康復(fù)療法的心血管安全性

Theroleoftheassessment

ExaminetheprerehabilitationmedicalhistoryandphysicalexaminationAnamnesisorsignsofcardiovascularinvestigationsorconsultationwithcardiacspecialists.(Unstablecoronaryheartdisease.Unstableheartfailure.Severeaorticstenosis….)EchocardiographyisrecommendedintheGOLDguidelinesforindividualswithCOPDwhohavesignsofcongestiveheartfailureand/orconcerningsymptoms.AbaselinerestingECGcanbeconsidered,as20%oftheindividualswithCOPDenteringapulmonaryrehabilitationprogramhaveischemicECGchanges.(Vanfleterenetal.Am就Cardiol.2011）A

cardiopulmonaryexercisetestmaybeconsideredSpruitetal.ATS/ERSstatementonPR.AmJRespirCritCareMed2013確保肺康復(fù)療法的心血管安全性

Theroleofth38慢阻肺合并癥對(duì)于肺康復(fù)的影響ThepresenceofcomorbiditiesshouldnotperseprecludeaccesstoandEffectivenessofpulmonaryrehabilitationinCOPDObservationalsinglecentreprospectivecohort,N=315Self-reported/chartbasedassessedcomorbidities(CharlsonCI)15Crisafullietal.ERJ2010Charlsonindex共病指數(shù)骨骼肌疾病代謝性疾病心臟疾病6MWD改善SGRQ改善呼吸困難改善慢阻肺合并癥對(duì)于肺康復(fù)的影響Thepresenceof39認(rèn)知功能與肺康復(fù)Kozora,E.,TranZ.V.,Make,B.(2002)Neurobehavioralimprovementafterbriefrehabilitationinpatientswithchronicobstructivepulmonarydisease.J.Cardiopulmrehabilitation.22:426-430.發(fā)現(xiàn)視覺注意力,口頭記憶,和視覺空間功能的臨床改善。AntonelliIncaizi,R.,Corsonello,A.,Trojano,L.,Pedone,C.,Acanfora,D.,Spada,A.,etal.(2008).CognitivetrainingisineffectiveinhypoxemicCOPD:Asix-monthrandomizedcontrolledtrial.RejuvenationResearch,11,293-250.AntonelliIncaizi,R.,Corsonello,A.,Pedone,C.,Trojano,L.,Acanfora,D.,Spada,A.,etal.(2006).DrawingimpairmentpredictsmortalityinsevereCOPD.Chest,130,1687-1694.認(rèn)知功能與肺康復(fù)Kozora,E.,TranZ.V.40合并癥的存在對(duì)肺康復(fù)的影響

Mesquite.Vanfleteren.2015.EurRespirJacceptedIndividualobjectivelyidentifiedcomorbiditiedonotpreventpatientstoimproveduringPR!合并癥的存在對(duì)肺康復(fù)的影響

Mesquite.Vanfle41合并不同疾病的慢阻肺肺康復(fù)的表現(xiàn)

DifferentialPRoutcomeindifferentclustersofcomorbidity?Odds

RatioforreachingtheMIDafterPRcomparedtothelesscomorbidityclusterIngeneralPRoutcomesinclustersofcomorbiditiesarenotdifferentfromthelesscomorbidityclusterSomedifferencesarenoticed!Mesquite.Vanfleteren.2015.EurRespirJinrevision合并不同疾病的慢阻肺肺康復(fù)的表現(xiàn)

Differential42參與肺康復(fù)治療的慢阻肺患者的合并癥與藥物負(fù)擔(dān)

ComorbiditiesandmedicationburdeninpatientswithCOPDattendingPRMedicationbyType/ClassProportionUsing(%)Respiratorymedication99Cardiovascularmedication59Othermedication80Painmedication30Prescriptiononlypainmedication16Nonprescriptionpainmedication23Comorbiditiesandmedicationburdeninpatientswithchronicobstructivepulmonarydiseaseattendingpulmonaryrehabilitation.參與肺康復(fù)治療的慢阻肺患者的合并癥與藥物負(fù)擔(dān)

Comorbi43小結(jié)1，在進(jìn)行肺康復(fù)治療患者中，共病是普遍存在的Multimorbidityinthepulmonaryrehabilitationsettingisratherrulethanexception.2,心血管疾病是慢阻肺最主要的合并癥，并影響慢阻肺的預(yù)后CardiovasculardiseaseismajorcomponentofthemultimorbidconditionCOPDandprognosticallyimportant.3,心血管疾病以及其他慢阻肺合并癥常常被漏診ComorbiditiesandcardiovasculardiseasesareoftennotdiagnosesinCOPD.4,共五個(gè)不同的集群可以與類似為了安全起見也作為一個(gè)整體研究的一部分,公關(guān)代表fivedifferentclustersofcomorbiditiescanbeidentifiedwithsimilarforsafetyreasonsasalsoasapartoftheholisticapproachthatPRstandsfor6,共病的發(fā)病率不阻止病人改善肺康復(fù)，穩(wěn)定的共病不排除肺康復(fù)Comorbidityandclustersofcomorbiditydonotpreventpatientstoimprovefrompulmonaryrehabilitation.Stablecomorbiditiesarenotanexclusionforpulmonaryrehabilitation7,肺康復(fù)治療對(duì)合并癥能夠產(chǎn)生影響incontrary,PRhasthepotentialtoinfluencecomorbidities小結(jié)1，在進(jìn)行肺康復(fù)治療患者中，共病是普遍存在的Multim44ComorbiditiesinCOPD:whatwedon’tknowMultimorbidityispreventable(butwehopeso)WhethertreatingearlieronecomponentwillpreventtheothersWhethertreatingonecomponentwillaffecttheprognosisoftheothersHowtoassess,nameandtreatmultimorbidityComorbiditiesinCOPD:whatwe45Thank

You！ThankYou！46慢性阻塞性肺疾病合并癥

最新認(rèn)識(shí)慢性阻塞性肺疾病合并癥

最新認(rèn)識(shí)47慢阻肺是老年人共患病中的肺部常見疾病慢阻肺與合并癥肺康復(fù)對(duì)共患病的影響慢阻肺是老年人共患病中的肺部常見疾病慢阻肺與合并癥肺康復(fù)對(duì)共48慢阻肺是老年人共患病中的肺部常見疾病慢阻肺與合并癥肺康復(fù)對(duì)共患病的影響慢阻肺是老年人共患病中的肺部常見疾病慢阻肺與合并癥肺康復(fù)對(duì)共49共患病Managementoftherisingprevalenceofmultiplechroniccomorbidities(i.e.,patientswithtwoormorechronicmorbidities)isamajorchallengefacinghealthcaresystemsworldwide(181).共患病Managementoftherisingpr50隨著年齡增長，共患病越多

65歲以上人群，50%有兩種以上共患病2-KarenBarnett,etal.Lancet.2012Jul7;380(9836):37-43隨著年齡增長，共患病越多

65歲以上人群，50%有兩種以上共51共患病的發(fā)生機(jī)制1-Mechanismsofdevelopmentofmultimorbidityintheelderly共患病的發(fā)生機(jī)制1-Mechanismsofdevelo52共患病是由共同的危險(xiǎn)因子（年齡，吸煙，缺乏鍛煉，飲食，環(huán)境等）所誘發(fā)的。共患病的發(fā)病是同時(shí)的。心血管系統(tǒng)影響可能最早出現(xiàn)。共患病的某一單獨(dú)成分相互促進(jìn)惡化。對(duì)其中某一疾病的治療會(huì)使其他疾病獲益。慢阻肺是共患病中肺部的疾病表現(xiàn)。共患病的特點(diǎn)共患病是由共同的危險(xiǎn)因子（年齡，吸煙，缺乏鍛煉，飲食，環(huán)境等53DoesCOPDstandfor“COmorbiditywithpulmonarydisease”?

ItisofupmostimportancetoincreaseawarenessamongsthealthcareprofessionalregardingcomorbidityinCOPDbutalsoregardingCOPDasacomorbidityinotherprevalentchronicdiseases在醫(yī)療中，提高對(duì)慢性阻塞性肺疾病的合并癥的認(rèn)識(shí)是至關(guān)重要的，同時(shí)也要認(rèn)識(shí)到慢阻肺作為其他常見慢性疾病的合并癥的特質(zhì)4-VanflaterernL.EurRespirJ.2015Jan;45(1):14-7DoesCOPDstandfor“COmorbid54在不同慢性疾病患者中慢阻肺的發(fā)病情況在7241591名成人中，909948（12.6%）患有慢阻肺肺癌患者中50%

下呼吸道感染患者中33%

心血管疾病患者中33%

低創(chuàng)性骨折患者中25%

3-AndreaS.Gershon,etal.EurRespirJ2015;45:51–59在不同慢性疾病患者中慢阻肺的發(fā)病情況在7241591名成人中55GOLD2014

慢阻肺的定義（GOLD2014)慢性阻塞性肺疾?。菏且环N可預(yù)防、可治療的常見疾病，特征為持續(xù)存在的氣流受限。氣流受限呈進(jìn)行性發(fā)展，伴有氣道和肺對(duì)有害顆?；驓怏w所致慢性炎癥反應(yīng)的增加。急性加重和合并癥影響患者整體疾病的嚴(yán)重程度。GOLD2014慢阻肺的定義（GOLD2014)56慢阻肺的病理機(jī)制AdaptedfromPJBarner,2000;Fabbri,Sinigaglia,Papi,Saetta2002;Cosio,Saettaand

Cosio

2012慢阻肺的病理機(jī)制AdaptedfromPJBarner57慢阻肺作為共患病中肺部表現(xiàn)

5-FabbriLM1,LuppiF，et

al.EurRespirJ.2008Jan;31(1):204-12慢阻肺作為共患病中肺部表現(xiàn)5-FabbriLM1,Lu58PrevalenceandoutcomesofdiabeteshypertensionandcardiovasculardiseaseinCOPDThepresentstudyanalyseddatafrom20296subjectsaged>45yrsatbaselineintheAtherosclerosisriskinCommunitiesStudy(ARIC)andtheCardiovascularHealthStudy(CHS).9-D.M.Mannino,etal.EurRespirJ2008;32:962–9695-yrsmortalityPrevalenceandoutcomesofdia59慢阻肺是老年人共患病中的肺部常見疾病慢阻肺與合并癥肺康復(fù)對(duì)共患病的影響慢阻肺是老年人共患病中的肺部常見疾病慢阻肺與合并癥肺康復(fù)對(duì)共60慢阻肺主要合并癥的發(fā)病7-SmithMC1,WrobelJP2.

IntJChronObstructPulmonDis.2014Aug27;9:871-88.慢阻肺主要合并癥的發(fā)病7-SmithMC1,Wrobel61主要合并癥的臨床影響7-SmithMC1,WrobelJP2.

IntJChronObstructPulmonDis.2014Aug27;9:871-88.心血管疾病心血管疾病是慢阻肺最常見的合并癥，是慢阻肺發(fā)生率最高也是最為重要的共存疾病，心血管疾病中包括了：高血壓，缺血性心臟病，心衰以及心房顫動(dòng)、心律失常等。高血壓主要合并癥的臨床影響7-SmithMC1,Wrobel62慢阻肺合并心血管疾病的現(xiàn)狀A(yù)ECOPD存在潛在引發(fā)心血管疾病的風(fēng)險(xiǎn)，在臨床上并不少見，卻不容易被識(shí)別慢阻肺患者有高于同齡正常人群的心血管疾病患病率，肺功能越差，患病率越高1在AECOPD的住院患者中，50%以上都合并有心血管疾病2大約10%-40%的心衰患者同時(shí)合并慢阻肺3在輕-中度慢阻肺，F(xiàn)EV1每下降20%，心血管相關(guān)死亡風(fēng)險(xiǎn)升高28%，非致死性冠脈事件增加近20%41、J.Finkelstein,E,etal.Chronicobstructivepulmonarydiseaseasanindependentriskfactorforcardiovascularmorbidity.InternationalJournalofChronicObstructivePulmonaryDisease,vol.4,pp.337–349,2009.2、H.Cui,etal.PrevalenceofcardiovasculardiseaseinsubjectshospitalizedduetochronicobstructivepulmonarydiseaseinBeijingfrom2000to2010.JournalofGeriatricCardiology,vol.9,no.1,pp.5–10,2012.3、HawkinsNM,etal.Heartfailureandchronicobstructivepulmonarydisease:diagnosticpitfallsandepidemiology.EurJHeartFail2009;11:130–139.4、SinDD,etal.ProcAmThoracSoc2005;2:8-11慢阻肺合并心血管疾病的現(xiàn)狀A(yù)ECOPD存在潛在引發(fā)心血管疾病63心力衰竭是一種全身性疾病Myocardialinfarctioncausesthereleaseofinflammatorycellsfromthespleenandbonemarrowandtheirmyocardialinfiltration心肌梗塞引起脾和骨髓的炎癥細(xì)胞釋放和心肌滲出物Thisleadstoanaccumulationofmonocytesintheheart,predominantlylocatedintheinfarctborderzone,andadecreaseofmonocytesinthespleenandbonemarrowThismaybemediatedbyactivationofthesympatheticnervoussystem,angiotensinII,and/orcytokinerelease.10-HofmasnnandFrantz.EurheartJ2014;35:314-5心力衰竭是一種全身性疾病Myocardialinfarct64UnrecognizedheartfailureinelderlypatientswithstableCOPDUnrecognizedheartfailurein65HighprevalenceandunderdiagnosisoflungfunctionabnormalitiesinpatientswithishemicheartdiseaseHighprevalenceandunderdiagn66FEV1的降低及阻塞性呼吸系統(tǒng)疾病與心力衰竭發(fā)生率的升高是相關(guān)的11-Li

J

etal.Circulation2014;129:971-80FEV1的降低及阻塞性呼吸系統(tǒng)疾病與心力衰竭發(fā)生率的升高是相67慢阻肺主要合并癥的發(fā)病SmithMC1,WrobelJP2.

IntJChronObstructPulmonDis.2014Aug27;9:871-88.慢阻肺主要合并癥的發(fā)病SmithMC1,WrobelJ68常見認(rèn)知功能障礙Cleutjens，et

al(2014).Cognitivefunctioninginobstructivelungdisease:resultsfromtheUnitedKingdombiobank.JAmMedDirAssoc.15(3),214-219

與對(duì)照組相比，反應(yīng)時(shí)間，前瞻記憶，視覺空間記憶以及數(shù)字短時(shí)記憶均下降Singh,etal.(2014).Aprospectivestudyofchronicobstructivepulmonarydiseaseandtheriskformildcognitiveimpairment.JAMA

Neurol.71(5),581-586.

與對(duì)照組相比，注意力，視覺空間感，記憶力以及語言能力均下降非記憶減退的輕度認(rèn)知障礙的風(fēng)險(xiǎn)比為Hazardratio：2.58(1.32-5.06)

常見認(rèn)知功能障礙Cleutjens，etal(2014).69肺部疾病與認(rèn)知功能減退和老年癡呆癥的關(guān)系14Lungdiseaseasadeterminantofcognitivedeclineanddementia肺部疾病與認(rèn)知功能減退和老年癡呆癥的關(guān)系14Lungdi70慢阻肺主要合并癥的發(fā)病SmithMC1,WrobelJP2.

IntJChronObstructPulmonDis.2014Aug27;9:871-88.慢阻肺主要合并癥的發(fā)病SmithMC1,WrobelJ71心血管疾病和腫瘤尤其肺癌是

輕中度COPD患者的主要死因

COPD.2010Oct;7(5):375-82.輕度中度心血管疾病和腫瘤尤其肺癌是

輕中度COPD患者的主要死因

C72COPD與肺癌相關(guān)的可能機(jī)制NatRevCancer.2013Apr;13(4):233-45COPD與肺癌相關(guān)的可能機(jī)制NatRevCancer.73COPD合并肺癌的治療2014GOLDCOPD患者經(jīng)常被發(fā)現(xiàn)合并肺癌，肺癌是輕度COPD最主要的死因；COPD合并肺癌患者的肺癌治療需按照指南常規(guī)治療；然而肺功能的降低會(huì)限制肺癌的手術(shù)治療；肺癌合并COPD患者的COPD治療需按照指南常規(guī)治療。COPD合并肺癌的治療2014GOLDCOPD患者經(jīng)常被74慢阻肺主要合并癥的發(fā)病SmithMC1,WrobelJP2.

IntJChronObstructPulmonDis.2014Aug27;9:871-88.其他慢阻肺主要合并癥的發(fā)病SmithMC1,WrobelJ75慢阻肺中的代謝綜合癥慢阻肺患者中常見共存的代謝性疾病WatzH,etal.Chest.2009Oct;136(4):1039-46慢阻肺中的代謝綜合癥慢阻肺患者中常見共存的代謝性疾病Watz76OSAandriskofcardiovasculardiseasesObstructivesleepapnoeaandcardiovasculardiseaseManuelSánchez-de-la-Torre,PhDa,b,

FranciscoCampos-Rodriguez,MDc,

ProfFerranBarbé,MDa,b,,OSAandriskofcardiovascular77慢阻肺是老年人共患病中的肺部常見疾病慢阻肺與合并癥肺康復(fù)對(duì)共患病的影響慢阻肺是老年人共患病中的肺部常見疾病慢阻肺與合并癥肺康復(fù)對(duì)共78Generallyspeaking,patientswithCOPDand

multiplechronic

comorbiditiesaretreated

accordingtoexistingstandardsforeach

individualdisease.Inotherwords,

comorbiditiesinpatientswithCOPDare

treatedthesameasinpatientswithout

COPD,andCOPDistreatedthesame

regardlessofthecomorbidity.

Indeed,

observationalstudiessuggestthatmortality

ofpatientswithCOPDcanbereduced

bynonrespiratorytreatments,including

b-blockers,angiotensin-convertingenzyme

inhibitors(182),andstatins(183).Generallyspeaking,patientsw79Pulmonaryrehabilitation.Pulmonary

rehabilitationistypicallyprovidedinahospital-based,outpatientsetting.Itsbenefitsinthissettingarewellestablished,includingreduceddyspnea,increasedexercisecapacity,improvedqualityoflife,andreduceduseofhealthcareresources(184).肺康復(fù)肺康復(fù)通常在醫(yī)院,為門診患者提供。在此設(shè)置也建立了它的好處,包括減少呼吸困難,提高運(yùn)動(dòng)能力,改善生活質(zhì)量,減少醫(yī)療資源的使用Pulmonaryrehabilitation.肺康復(fù)80

肺康復(fù)治療對(duì)于慢阻肺患者合并癥的影響EurRespirRev.2014Mar1;23(131):131-41.doi:10.1183/09059180.00007613.ComorbiditiesinpatientswithCOPDandpulmonaryrehabilitation:dotheymatter?

肺康復(fù)治療對(duì)于慢阻肺患者合并癥的影響EurRespir81肺康復(fù)治療的意義提高運(yùn)動(dòng)能力減少焦慮減少抑郁改善生活質(zhì)量延長壽命（通過降低未來急性加重風(fēng)險(xiǎn)）減少住院（通過降低未來急性加重風(fēng)險(xiǎn)）減少心血管疾病風(fēng)險(xiǎn)因子（間接）改變飲食習(xí)慣（水果&蔬菜/魚類）/吸煙/BP肺康復(fù)治療的意義提高運(yùn)動(dòng)能力82DosePRinfulencescardiovascularriskofCOPDpatients10

VanfleterenLE1

，EurRespirJ.2014May;43(5):1306-15.Arterialstiffness129subjectswhocompletedtheprogramDosePRinfulencescardiovascu83確保肺康復(fù)療法的心血管安全性

Theroleoftheassessment

ExaminetheprerehabilitationmedicalhistoryandphysicalexaminationAnamnesisorsignsofcardiovascularinvestigationsorconsultationwithcardiacspecialists.(Unstablecoronaryheartdisease.Unstableheartfailure.Severeaorticstenosis….)EchocardiographyisrecommendedintheGOLDguidelinesforindividualswithCOPDwhohavesignsofcongestiveheartfailureand/orconcerningsymptoms.AbaselinerestingECGcanbeconsidered,as20%oftheindividualswithCOPDenteringapulmonaryrehabilitationprogramhaveischemicECGchanges.(Vanfleterenetal.Am就Cardiol.2011）A

cardiopulmonaryexercisetestmaybeconsideredSpruitetal.ATS/ERSstatementonPR.AmJRespirCritCareMed2013確保肺康復(fù)療法的心血管安全性

Theroleofth84慢阻肺合并癥對(duì)于肺康復(fù)的影響ThepresenceofcomorbiditiesshouldnotperseprecludeaccesstoandEffectivenessofpulmonaryrehabilitationinCOPDObservationalsinglecentreprospectivecohort,N=315Self-reported/chartbasedassessedcomorbidities(CharlsonCI)15Crisafullietal.ERJ2010Charlsonindex共病指數(shù)骨骼肌疾病代謝性疾病心臟疾病6MWD改善SGRQ改善呼吸困難改善慢阻肺合并癥對(duì)于肺康復(fù)的影響Thepresenceof85認(rèn)知功能與肺康復(fù)Kozora,E.,TranZ.V.,Make,B.(2002)Neurobehavioralimprovementafterbriefrehabilitationinpatientswithchronicobstructivepulmonarydisease.J.Cardiopulmrehabilitation.22:426-430.發(fā)現(xiàn)視覺注意力,口頭記憶,和視覺空間功能的臨床改善。AntonelliIncaizi,R.,Corsonello,A.,Trojano,L.,Pedone,C.,Acanfora,D.,Spada,A.,etal.(2008).CognitivetrainingisineffectiveinhypoxemicCOPD:Asix-monthrandomizedcontrolledtrial.RejuvenationResearch,11,293-250.AntonelliIncaizi,R.,Corsonello,A.,Pedone,C.,Trojano,L.,Acanfora,D.,Spad