1、COPD病例分享,LOREM IPSUM DOLOR,,患者，男，44歲,,,,主訴：因“慢性咳嗽、咳痰、喘息6年，加重1周 ”于2016年4月23日入院,,,該患緣于6年前無明顯誘因出現(xiàn)咳嗽、咳痰、喘息，咳黃色粘痰，量不多，易咳出，以晨起為著，喘息多于夜間出現(xiàn)，無咯血及胸痛，自行抗炎治療（具體不詳）后好轉(zhuǎn)。此后上述癥狀于著涼和秋冬季節(jié)反復發(fā)作，每年癥狀持續(xù)3個月以上，經(jīng)抗炎、平喘治療（具體藥名和劑量不詳）好轉(zhuǎn)，未系統(tǒng)診治。1周前“感冒

2、”后上述癥狀再次加重，痰為黃色粘痰，量少，不易咳出，自己可聽到喘鳴音，活動后明顯，于當?shù)蒯t(yī)院行抗感染（阿奇霉素0.5g每日一次靜點）1天無明顯好轉(zhuǎn)，為求系統(tǒng)診治來我院門診，以“慢性阻塞性肺病”收入我科。病程中無發(fā)熱，無頭暈、頭痛，無心前區(qū)不適，無惡心、嘔吐，無腹痛、腹瀉，飲食、睡眠尚可，二便如常，近期體重無明顯減輕。,現(xiàn)病史,LOREM IPSUM DOLOR,,農(nóng)民,,,,否認高血壓、心臟病及糖尿病病史,,,,吸煙20年，每日20支，

3、未戒。無飲酒史,,,,無家族病史,,,,查體,T 36.3℃, P 100次/分, R 28次/分, Bp 120/75mmHg一般狀態(tài)尚可，坐位，神清口唇及甲床無發(fā)紺，球結(jié)膜無水腫，頸靜脈無充盈桶狀胸，肋間隙增寬，雙側(cè)觸覺語顫減弱，叩診過清音，肝濁音界下移，聽診雙肺散在哮鳴音，未聞及濕啰音心率：100次/分，律整，無雜音及額外心音腹平軟，無壓痛反跳痛，肝脾肋下未觸及雙下肢無水腫神經(jīng)系統(tǒng)查體無陽性體征,肺CT,1、支氣管炎

4、并少許炎癥，建議治療后復查 2、雙肺肺氣腫 3、胸主動脈及冠狀動脈硬化,eNO 18ppb肺功能： 吸入支氣管舒張劑后FEV1/FVC﹤70%,LOREM IPSUM DOLOR,血氣分析,血常規(guī),,,心電：正常心電圖心彩：左室舒張功能減低，三尖瓣輕度返流,臨床診斷,,慢性阻塞性肺病急性加重,,,,,治療,抗炎：磺芐西林 4.0 每日三次 靜點解痙：（1）普米克令舒2mg+沙丁胺醇0.4mg 每日三次 霧化吸入

5、（2）多索茶堿 0.2 每日兩次 靜點（3）孟魯司特鈉 10mg 每日一次 睡前口服化痰：（1）溴己新 100ml 每日兩次 靜點（2）富露施 600mg 每日兩次 口服,治療后,癥狀：咳嗽、咳痰、喘息減輕體征：雙肺無干啰音肺功能：FEV1/FVC﹥70%,,COPD,×,,LOREM IPSUM DOLOR,GOLD對COPD的定義： 持續(xù)的氣流受限 吸入支氣管舒張劑后 FEV1

6、/FVC﹤70%,更正臨床診斷,,慢性支氣管炎急性發(fā)作,,,,慢性阻塞性肺氣腫,,,總結(jié)及教訓,,診斷需結(jié)合吸煙等高危因素史、臨床癥狀、體征，并排除其他已知病因或具有氣道阻塞和氣流受限的疾病,,,,治療前后多次查肺功能，取最佳值,,,,即使存在過度診斷，但用藥也是合理的,,,指南解讀：過度診斷,The use of the fixed FEV1/FVC ratio to define airflow limitation will re

7、sult in more frequent diagnosis of COPD in the elderly, and less frequent diagnosis in adults younger than 45 years. The risk of misdiagnosis and over-treatment of individual patients using the fixed ratio as a diagnos

8、tic criterion is limited, as spirometry is only one parameter for establishing the clinical diagnosis of COPD, the others being symptoms and risk factors.,,指南解讀：信必可相關(guān),Formoterol and salmeterol significantly improve FEV1

9、and lung volumes, dyspnea, health-related quality of life and exacerbation rate (Evidence A)Short-term combination therapy using formoterol and tiotropium has been shown to have a bigger impact on FEV1 than the single c

10、omponents (Evidence B).Regular treatment with inhaled corticosteroids improves symptoms, lung function, and quality of life, and reduces the frequency of exacerbations144 in COPD patients with an FEV1 < 60% predicted

11、 (Evidence A).Regular treatment with inhaled corticosteroids does not modify the long-term decline of FEV1 nor mortality in patients with COPD (Evidence A).inhaled corticosteroid combined with a longacting beta2-agonis

12、t is more effective than the individual components in improving lung function and health status and reducing exacerbations in patients with moderate (Evidence B) to very severe COPD (Evidence A).The addition of a long-

13、acting beta2-agonist/ inhaled corticosteroid combination to tiotropium improves lung function and quality of life and may further reduce exacerbations (Evidence B) but more studies of triple therapy are needed.Combinati

14、on therapy is associated with an increased risk of pneumonia, but no other significant side effect (Evidence A).,,信必可,,,ICS（如布地奈德）,LABA（如福莫特羅）,,糖皮質(zhì)激素受體,抗炎作用,,,√,√,支氣管擴張,,,,⊕,⊕,↑ 糖皮質(zhì)激素受體易位↑ 與激素反應(yīng)元件結(jié)合↑ 抗炎效應(yīng),↑ β2受體表達↑ β