幻燈copd進展慢性阻塞性肺疾病診斷管理和預(yù)防策略

1、慢性阻塞性肺疾病診斷管理和預(yù)防策略-GOLD 2014解讀首都醫(yī)科大學(xué)附屬北京朝陽醫(yī)院林英翔 GOLD的演變2001年 2006年 2011年 2003年第一次更新1998年COPD的全球創(chuàng)議組織成立（GOLD）目的：全球范圍內(nèi)提升對COPD疾病負(fù)擔(dān)的意識，改善 COPD的預(yù)防和管理，鼓勵更多的研發(fā)第一份GOLD指南發(fā)表第一次全面修訂第二次全面修訂2001年：推薦維持治療常規(guī)使用支擴劑治療中到重度COPD，長效支擴劑比短效更方便；2003年：推薦維持治療常規(guī)使用長效支擴劑，而不是短效支擴劑常規(guī)治療中到重度COPDCOPD定義的演變2001年COPD是一種以氣流受限不完全可逆為特征的一種疾病狀態(tài)

2、。氣流受限通常是進展的，同肺部對有害顆粒和氣體的異常炎癥反應(yīng)相關(guān)。 2006年COPD是一種可以預(yù)防和治療的疾病。一些嚴(yán)重的肺外表現(xiàn)和合并癥可能構(gòu)成疾病的嚴(yán)重程度。肺部的疾病以氣流受限不完全可逆為特征。氣流受限通常是進展的，同肺部對有害顆粒和氣體的異常炎癥反應(yīng)相關(guān)。COPD定義的演變2011年COPD是一種可以預(yù)防、可以治療的疾病，以氣流受限為特征，氣流受限不完全可逆，并呈進行性發(fā)展，與肺部對香煙煙霧等有害氣體或有害顆粒的異常炎癥反應(yīng)有關(guān)。急性加重和合并癥取決于患者個人的疾病嚴(yán)重程度。 COPD管理基礎(chǔ)的演變舊版GOLD對COPD的管理推薦僅僅基于肺功能的分類有足夠的證據(jù)表明，F(xiàn)EV1的水平并

3、非是疾病狀態(tài)的一個最佳的描述，基于此，COPD的管理應(yīng)該建立在目前疾病的影響（主要是癥狀的負(fù)擔(dān)和活動受限）和未來疾病進展的風(fēng)險上（尤其是急性加重加重）2011GOLD指南GOLD已經(jīng)不使用基于FEV1進行的疾病分級，因為僅根據(jù)FEV1進行分級不充分，也沒有有效分級的證據(jù)。GOLD對COPD評估的演變GOLD COPD 2014GOLD COPD 2014 策略指導(dǎo)性文件，非指南 2001年發(fā)布，每5年修訂1次，每年更新1次 2014版更簡短、清晰地重新對疾病的評估和管理策略進 行評價 2011年新的內(nèi)容：急性加重和合并癥GOLD COPD 2014：內(nèi)容要點 定義 危險因素：煙草，室內(nèi)外污染

4、臨床診斷：癥狀；危險因素；肺功能檢測是必備條件 評估：癥狀，急性加重，肺功能和合并癥藥物治療：減輕癥狀，減少急性加重次數(shù)，提高健康狀態(tài) 和運動能力 所有活動后氣短的患者均可以從康復(fù)和物理治療中獲益 急性加重的定義 合并癥可以影響COPD的病程Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage ComorbiditiesAsthma COPD Overlap Syndrome (ACOS)Updated 2014 2014 G

5、lobal Initiative for Chronic Obstructive Lung Disease2014 COPD診斷、管理和預(yù)防策略Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage ComorbiditiesAsthma COPD Overlap Syndrome (ACOS)Updated 2014 2014 Global Initiative for Chronic Obstructive Lung Dis

6、ease2014 COPD診斷、管理和預(yù)防策略GOLD 2014 COPD：定義 COPD是一種可預(yù)防、可治療的疾病。肺部病變的特征為持續(xù)存在的氣流受限，氣流受限通常呈進行性發(fā)展，與肺臟對有害顆粒或氣體的異常炎癥反應(yīng)有關(guān)。急性加重和合并癥的存在對不同患者的疾病嚴(yán)重程度起到重要作用GOLD 2014 COPD：定義 不再應(yīng)用慢性支氣管炎，阻塞性肺氣腫，并除外支氣管哮喘COPD 的癥狀呼吸困難慢性咳嗽慢性咳痰COPD氣流受限的機制Small Airways DiseaseAirway inflammationAirway fibrosis, luminal plugsIncreased airwa

7、y resistanceParenchymal DestructionLoss of alveolar attachmentsDecrease of elastic recoilAIRFLOW LIMITATIONCOPD的危險因素Lung growth and development GenderAge Respiratory infectionsSocioeconomic statusAsthma/Bronchial hyperreactivityChronic BronchitisGenesExposure to particlesTobacco smokeOccupational du

8、sts, organic and inorganicIndoor air pollution from heating and cooking with biomass in poorly ventilated dwellingsOutdoor air pollutionGenesInfectionsSocio-economic statusAging PopulationsCOPD的危險因素Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage Exacerbati

9、onsManage ComorbiditiesAsthma COPD Overlap Syndrome (ACOS)Updated 2014 2014 Global Initiative for Chronic Obstructive Lung Disease2014 COPD診斷、管理和預(yù)防策略GOLD 2014 COPD：診斷臨床上任何患者出現(xiàn)氣短、慢性咳嗽或咳痰，伴有危險因素暴露史均需要考慮可能存在COPD肺功能檢查是COPD診斷的必備條件。以應(yīng)用支氣管舒張劑后FEV1/FVC 0.70來確定存在持續(xù)氣流受限，診斷COPDGlobal Strategy for Diagnosis, Ma

10、nagement and Prevention of COPDDiagnosis and Assessment: Key PointsComorbidities occur frequently in COPD patients, and should be actively looked for and treated appropriately if present. The goals of COPD assessment are to determine the severity of the disease, including the severity of airflow lim

11、itation, the impact on the patients health status, and the risk of future events. 2013 Global Initiative for Chronic Obstructive Lung DiseaseSYMPTOMS chronic coughshortness of breathEXPOSURE TO RISKFACTORS tobaccooccupationindoor/outdoor pollutionSPIROMETRY: Required to establish diagnosis sputum GO

12、LD 2014 COPD：診斷Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of Airflow Limitation: SpirometrySpirometry should be performed after the administration of an adequate dose of a short-acting inhaled bronchodilator to minimize variabilityA post-bronchodilator FEV1/FVC 0.70

13、confirms the presence of airflow limitationWhere possible, values should be compared to age-related normal values to avoid overdiagnosis of COPD in the elderly 2013 Global Initiative for Chronic Obstructive Lung DiseaseVolume, litersTime, seconds54321123456FEV1 = 1.8LFVC = 3.2LFEV1/FVC = 0.56Normal

14、ObstructiveGOLD 2014 COPD：肺功能檢測GOLD2011去除“分期”引入“肺功能分級”保留GOLD分級80%預(yù)計值（GOLD2）50%預(yù)計值（GOLD3）30%預(yù)計值 (GOLD4)GOLD 2014 COPD：嚴(yán)重度分級當(dāng)前癥狀評價應(yīng)用肺功能評價氣流受限急性加重危險因素的評價合并癥評價GOLD 2014 COPD：疾病評估癥狀評價 呼吸困難，咳嗽，咳痰呼吸困難 活動后加重，持續(xù)進展咳嗽 可能間斷出現(xiàn)或可能不出現(xiàn)咳痰 COPD患者通?？忍礕OLD 2014 COPD：疾病評估癥狀評價GOLD 2014 COPD：疾病評估Use the COPD Assessment Te

15、st(CAT) or mMRC Breathlessness scaleorClinical COPD Questionnaire (CCQ) 癥狀評價：COPD Assessment Test (CAT)問卷: 8條問題，評價COPD健康狀況( )癥狀評價：Clinical COPD Questionnaire (CCQ)問卷: Self-administered questionnaire developed to measure clinical control in patients with COPD( ). GOLD 2014 COPD：疾病評估 COPD評估測試(CAT)得分范圍

16、 0-40癥狀評價：MRC問卷GOLD 2014 COPD：疾病的評估應(yīng)用肺功能評價氣流受限應(yīng)用肺功能儀評估氣流受限根據(jù)肺功能指標(biāo)分為4級，80%預(yù)計值、50%預(yù)計值、30%預(yù)計值GOLD 2014 COPD：疾病的評估應(yīng)用肺功能評價氣流受限GOLD 2014 COPD：疾病的評估In patients with FEV1/FVC 80% predicted GOLD 2: Moderate 50% FEV1 80% predictedGOLD 3: Severe 30% FEV1 50% predictedGOLD 4: Very Severe FEV1 2，或因急性加重住院至少1次 1，無

17、急性加重住院 0(C)(D) (A)(B)mMRC 0-1CAT 2CAT 10 癥狀(mMRC or CAT評分)(C)(D) (A)(B)mMRC 0-1CAT 2CAT 10 癥狀如果mMRC 0-1 或 CAT 2 或CAT 10: 癥狀較多(B or D) 首先評估癥狀（根據(jù)mMRC或CAT評分）COPD全面評估（1）風(fēng)險 (氣流受限GOLD 分級)風(fēng)險(急性加重病史) 2 1 0(C)(D) (A)(B)mMRC 0-1CAT 2CAT 10 癥狀如果 GOLD 1 或 2 和每年僅0 或1次急性加重: 低危(A 或 B)如果GOLD 3 或 4 或 每年2次或以上急性加重，或因急

18、性加重住院至少1次: 高危(C 或 D)其次評估風(fēng)險（氣流受限GOLD分級和急性加重病史） COPD全面評估（2）注：上述方法取提示高危的方法（如果在某些患者中兩種方法提示危險度不一）風(fēng)險 (氣流受限GOLD分級)風(fēng)險 (急性加重病史) 2 1 0(C)(D) (A)(B)mMRC 0-1CAT 2CAT 10 癥狀(mMRC or CAT score) A: 癥狀較少, 低危B: 癥狀較多, 低危C: 癥狀較少, 高危D： 癥狀較多, 高?，F(xiàn)在患者可被歸入4組之一COPD全面評估（3）評估合并癥，并參照無COPD患者治療策略給予同等程度治療。最常見合并癥包括心血管疾?。–VD）、焦慮、抑郁和

19、骨質(zhì)疏松GOLD2014對合并癥的評估心血管疾病是COPD的主要合并癥之一，可能是COPD最常見和最重要的合并癥骨質(zhì)疏松和焦慮、抑郁也是COPD主要的合并癥，經(jīng)常因診斷率低而誤診，與健康狀況差和預(yù)后有關(guān)COPD患者常可合并肺癌，這也是輕型COPD最常見死因呼吸道感染，糖尿病，支氣管擴張 PatientCharacteristicSpirometric ClassificationExacerbations per yearmMRCCATALow Risk Less SymptomsGOLD 1-2 10-1 2 10CHigh Risk Less SymptomsGOLD 3-4 20-1 2

20、 2 10When assessing risk, choose the highest risk according to GOLD grade or exacerbation history. One or more hospitalizations for COPD exacerbations should be considered high risk.) GOLD 2014 COPD：疾病評估 合并癥評價評價合并癥并予以適當(dāng)?shù)闹委熤饕喜Y：心血管疾病抑郁骨質(zhì)疏松呼吸道感染糖尿病肺部惡性腫瘤支氣管擴張GOLD 2014 COPD：疾病的評估COPD Onset in mid-life

21、 Symptoms slowly 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 asthma 2013 Global Initiative for Chronic Obstructive Lung DiseaseGlobal Strat

22、egy for Diagnosis, Management and Prevention of COPD Differential Diagnosis: COPD and AsthmaGlobal Strategy for Diagnosis, Management and Prevention of COPDAdditional InvestigationsChest X-ray: Seldom diagnostic but valuable to exclude alternative diagnoses and establish presence of significant como

23、rbidities.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 to evaluate a patients oxygen saturation and need for supplemental oxygen therapy. Alpha-1 Antitrypsin Deficiency Screen

24、ing: Perform when COPD develops in patients of Caucasian descent under 45 years or with a strong family history of COPD. 2013 Global Initiative for Chronic Obstructive Lung DiseaseExercise Testing: Objectively measured exercise impairment, assessed by a reduction in self-paced walking distance (such

25、 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 walking distance or peak oxygen consumption, weight loss and re

26、duction in the arterial oxygen tension) identify patients at increased risk for mortality. Global Strategy for Diagnosis, Management and Prevention of COPDAdditional Investigations 2013 Global Initiative for Chronic Obstructive Lung DiseaseDefinition and Overview Diagnosis and AssessmentTherapeutic

27、OptionsManage Stable COPDManage ExacerbationsManage ComorbiditiesAsthma COPD Overlap Syndrome (ACOS)Updated 2014 2014 Global Initiative for Chronic Obstructive Lung DiseaseGOLD2014診斷、管理和預(yù)防策略GOLD2014:COPD穩(wěn)定期的管理目標(biāo)減少癥狀COPD穩(wěn)定期治療目標(biāo)降低風(fēng)險緩解癥狀改善運動耐量改善健康狀況預(yù)防疾病進展防治急性加重降低死亡率 COPD的穩(wěn)定期管理（非藥物治療）患者基本推薦根據(jù)當(dāng)?shù)刂改螦戒煙（包括戒

28、煙的藥物療法）體力活動接種流感疫苗接種肺炎球菌疫苗B-D戒煙（包括戒煙的藥物療法）肺疾病康復(fù)訓(xùn)練*體力活動接種流感疫苗接種肺炎球菌疫苗*肺康復(fù)訓(xùn)練的和鍛煉的益處不應(yīng)被過分強調(diào)Global Strategy for Diagnosis, Management and Prevention of COPDTherapeutic Options: COPD MedicationsBeta2-agonists Short-acting beta2-agonists Long-acting beta2-agonistsAnticholinergics Short-acting anticholinerg

29、ics Long-acting anticholinergicsCombination short-acting beta2-agonists + anticholinergic in one inhaler MethylxanthinesInhaled corticosteroids Combination long-acting beta2-agonists + corticosteroids in one inhalerSystemic corticosteroidsPhosphodiesterase-4 inhibitors 2013 Global Initiative for Chr

30、onic Obstructive Lung DiseaseExacerbations per year 0mMRC 0-1CAT 2CAT 10 GOLD 3 GOLD 2 GOLD 1 SAMA prnor SABA prnLABA or LAMAICS + LABAor LAMA穩(wěn)定期管理:首選藥物治療ABDCICS + LABAand/or LAMA 2or more or 1 leading to hospital admission1 (not leading to hospital admission) 2or more or 1 leading to hospital admis

31、sion1 (not leading to hospital admission) 0mMRC 0-1CAT 2CAT 10 GOLD 3 GOLD 2 GOLD 1 LAMA or LABA orSABA and SAMALAMA and LABA orLAMA and PDE4-inh orLABA and PDE4-inhICS + LABA and LAMA orICS + LABA and PDE4-inh orLAMA and LABA orLAMA and PDE4-inh.LAMA and LABA穩(wěn)定期管理:次選藥物治療ADCBExacerbations per year 0

32、mMRC 0-1CAT 2CAT 10 GOLD 3 GOLD 2 GOLD 1 TheophyllineSABA and/or SAMATheophyllineCarbocysteineSABA and/or SAMATheophylline SABA and/or SAMATheophylline穩(wěn)定期管理:其他藥物治療ADCBExacerbations per year 2or more or 1 leading to hospital admission1 (not leading to hospital admission)COPD穩(wěn)定期：藥物治療策略 患者首選次選備選A組SAMA或

33、SABA（必要時）LAMA 或 LABA（長效受體激動劑）或SAMA+SABA茶堿B組LAMA或LABALAMA+LABASABA和/或SAMA 茶堿C組LAMA或ICS+LABALAMA + LABA或LAMA + PDE4-inh. 或LABA+ PDE4-inh. SABA和/或SAMA 茶堿D組ICS+LABA和/或LAMAICS+LABA和LAMA, 或ICS+LABA和磷酸二酯酶4抑制劑；或LAMA和LABA，或LAMA+磷酸二酯酶4抑制劑羧甲司坦SABA和/或 SAMA茶堿減少危險因素戒煙減少室內(nèi)污染減少職業(yè)暴露接種流感疫苗穩(wěn)定期管理: 針對所有患者PatientEssentia

34、l mendedDepending on local guidelinesASmoking cessation (can include pharmacologic treatment)Physical activityFlu vaccinationPneumococcal vaccinationB, C, DSmoking cessation (can include pharmacologic treatment)Pulmonary rehabilitationPhysical activityFlu vaccinationPneumococcal vaccination穩(wěn)定期管理: 非藥

35、物治療PatientFirst choiceSecond choiceAlternative ChoicesASAMA prnor SABA prnLAMA orLABA orSABA and SAMATheophyllineBLAMA or LABALAMA and LABASABA and/or SAMATheophyllineCICS + LABAor LAMALAMA and LABAPDE4-inh.SABA and/or SAMATheophyllineDICS + LABAor LAMAICS and LAMA orICS + LABA and LAMA or ICS+LABA

36、and PDE4-inh. orLAMA and LABA orLAMA and PDE4-inh.CarbocysteineSABA and/or SAMATheophylline穩(wěn)定期管理: 藥物治療吸入糖皮質(zhì)激素FEV1%預(yù)計值60%的穩(wěn)定期患者考慮肺炎的風(fēng)險不推薦單用吸入激素治療，但可以采用聯(lián)合治療，但聯(lián)合治療的時機尚不確定，臨床醫(yī)師需要權(quán)衡利弊采取個體化治療穩(wěn)定期管理: 藥物治療吸入糖皮質(zhì)激素與支氣管擴張劑聯(lián)合治療較單藥應(yīng)用可以使患者更獲益考慮肺炎的風(fēng)險穩(wěn)定期管理: 藥物治療吸入支氣管舒張劑中心治療藥物遵循個體化原則主張應(yīng)用長效支氣管舒張劑，聯(lián)合治療獲益更多對于有呼吸道癥狀且FEV1

37、%預(yù)計值60%的穩(wěn)定期患者，推薦應(yīng)該用吸入抗膽堿藥或長效受體激動劑等支氣管擴張劑單藥治療，有助于降低急性加重，改善生活質(zhì)量穩(wěn)定期管理: 藥物治療不推薦長期口服激素治療推薦應(yīng)用PDE-4和Methylxanthines其他疫苗流感疫苗：每年一次肺炎疫苗：65歲及以上患者；65歲以下，F(xiàn)EV1%低于40%a-1抗胰蛋白酶治療：不推薦不推薦穩(wěn)定期抗生素治療痰液溶解劑治療有限不推薦鎮(zhèn)咳藥物和血管擴張劑穩(wěn)定期管理: 藥物治療康復(fù)對于對于FEV1%預(yù)計值50%預(yù)計值如果藥物充分治療后仍然有癥狀或活動受限，臨床醫(yī)師也可以考慮進行肺康復(fù)穩(wěn)定期管理: 非藥物治療All COPD patients benefit

38、 from exercise training programs with improvements in exercise tolerance and symptoms of dyspnea and fatigue. Although an effective pulmonary rehabilitation program is 6 weeks, the longer the program continues, the more effective the results. If exercise training is maintained at home, the patients

39、health status remains above pre-rehabilitation levels. 2014 Global Initiative for Chronic Obstructive Lung DiseaseGlobal Strategy for Diagnosis, Management and Prevention of COPDTherapeutic Options: Rehabilitation氧療對于存在重度靜息低氧血癥（PaO255 mmHg或SpO288%）的COPD患者，推薦每天15小時以上的持續(xù)氧療無創(chuàng)通氣治療外科手術(shù) 肺減容和肺移植穩(wěn)定期管理: 非藥物治

40、療Palliative Care, End-of-life Care, Hospice Care: Communication with advanced COPD patients about end-of-life care and advance care planning gives patients and their families the opportunity to make informed decisions.Global Strategy for Diagnosis, Management and Prevention of COPDTherapeutic Option

41、s: Other Treatments 2013 Global Initiative for Chronic Obstructive Lung DiseaseGlobal Strategy for Diagnosis, Management and Prevention of COPD, 2014: Chapters Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage ComorbiditiesAsthma COPD Ove

42、rlap Syndrome (ACOS)Updated 2014 2014 Global Initiative for Chronic Obstructive Lung DiseaseCOPD急性加重的危害急性加重導(dǎo)致 對生活質(zhì)量 不良影響 癥狀和肺功能影響 肺功能 減退加速 死亡率升高 經(jīng)濟成本 升高 氣道炎癥加重GOLD COPD 2013:急性加重定義 COPD患者的疾病自然史中發(fā)生的事件，特征為患者的基線呼吸困難、咳嗽和/或咳痰改變超過正常的逐日波動范圍，為急性發(fā)作，可能需要改變常規(guī)藥物治療 GOLD 2006版 急性事件，特征為患者的呼吸癥狀加重，超過正常的逐日波動范圍，且導(dǎo)致藥物治

43、療的改變 GOLD 2014版GOLD Revision 2011 2013 Global Initiative for Chronic Obstructive Lung DiseaseGOLD COPD 2014:急性加重評價 動脈血氣分析: PaO26.7 kPa胸部影像學(xué): 用于排除診斷心電圖: 幫助診斷有無心臟問題血常規(guī)急性加重期間出現(xiàn)膿性痰生化檢查: 電解質(zhì)，血糖，營養(yǎng)不良肺功能: 急性加重期不推薦盡量減小本次急性加重的危害，預(yù)防下次急性加重的發(fā)生治療目標(biāo) 短效支氣管擴張劑（SAMA和/或SABA）急性加重時長效支氣管擴張劑聯(lián)合吸入性糖皮質(zhì)激素是否效果更好尚不確定茶堿僅適用短效支氣管

44、擴張劑效果不佳時 全身糖皮質(zhì)激素 抗生素主要藥物選擇Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease (2011). Summary Handout.AECOPD的管理藥物治療包括三大類支氣管擴張劑、糖皮質(zhì)激素、抗生素單一吸入短效2-激動劑，或短效2-激動劑短效支氣管舒張劑為急性加重時優(yōu)先選擇的藥物茶堿僅適用于短效支氣管擴張劑效果不好的患者者，副作用較常見糖皮質(zhì)激素糖皮質(zhì)激素：改善肺功能（FEV1）和低氧血癥降低治療失敗的風(fēng)險，縮短住院時間，

45、推薦每日口服30-40mg強的松，5天潑尼松3040mg/d，1014天;霧化糖皮質(zhì)激素治療AECOPD與全身用藥相近霧化糖皮質(zhì)激素治療非酸中毒AECOPD, 替代或減少全身激素的劑量；并減輕全身激素的副作用，作用；霧化吸入布地奈德 8mg 治療AECOPD與全身潑尼松龍40mg療效相當(dāng)。抗菌藥物適應(yīng)癥：AECOPD具有三個癥狀；即：呼吸困難、痰量增加、膿性痰時推薦使用，僅有2個癥狀其中一個是膿性痰時也推薦使用。病情危重需要機械通氣者也推薦使用抗菌藥物的推薦治療療程為 510 天抗菌藥物的應(yīng)用途徑（口服或靜脈給藥），取決于患者的進食能力和藥代動力學(xué)，最好予以口服治療。COPD急性加重期的處理表

46、5.4 重度但非危及生命的急性加重的管理*評估癥狀的嚴(yán)重度、血氣、胸片吸氧治療，獲取系列動脈血氣分析結(jié)果支氣管擴張劑：增加劑量和/或提高速效支氣管擴張劑的使用頻率速效2-激動劑與抗膽堿能制劑聯(lián)用使用儲霧罐或空氣驅(qū)動的霧化器增加口服或靜脈注射的激素有細(xì)菌性感染的表現(xiàn)時，考慮使用抗生素（口服或偶爾靜脈注射）考慮無創(chuàng)機械通氣在任何時候都應(yīng)：監(jiān)測液體平衡和營養(yǎng)考慮皮下注射肝素或低分子量肝素識別并治療相關(guān)狀況（如心衰，心律失常）密切監(jiān)測患者的病情Global Strategy for Diagnosis, Management and Prevention of COPD, 2014: Chapters

47、 Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage ComorbiditiesAsthma COPD Overlap Syndrome (ACOS)Updated 2014 2014 Global Initiative for Chronic Obstructive Lung DiseaseGOLD COPD 2014:合并癥的管理 心血管疾?。喝毖孕募〔?，心衰，房顫和高血壓；選擇性受體阻滯劑不推薦用于COPD治療骨質(zhì)疏

48、松和焦慮抑郁肺癌：在COPD患者中多發(fā)，是輕度COPD死亡的常見原因嚴(yán)重感染：嚴(yán)重呼吸道感染代謝綜合癥和糖尿病支氣管擴張Global Strategy for Diagnosis, Management and Prevention of COPD, 2014: Chapters Definition and Overview Diagnosis and AssessmentTherapeutic OptionsManage Stable COPDManage ExacerbationsManage ComorbiditiesAsthma COPD Overlap Syndrome (ACOS)Updated 2014 2014 Global Initiative for Chronic Obstructive Lung DiseaseGINA與GOLD聯(lián)合