GOLD2011对稳定期COPD患者病情评估和治疗选择的影响

目的探讨2011年慢性阻塞性肺疾病全球倡议（GOLD）对COPD稳定期患者疾病评估和治疗带来的变化和影响。方法将269例COPD患者进行了症状、肺功能、急性加重情况的记录,并根据2006及2011GOLD策略进行了分期和分组的分析,比较新旧策略对患者治疗选择的影响。结果用CAT评估与mMRC评估比较,增加了症状较多组（B和D）的患者例数,两个评估方法中C和D组患者总数相仿。对比2006及2011GOLD策略,GOLD2006中Ⅱ级患者在GOLD2011中分组变化尤为突出;新分组导致中度COPD患者中的44例（16．4％）需要改变初始治疗,急性加重的风险评估是影响分组及治疗选择的最主要的因素,FEV1与临床症状和AECOPD频率虽有相关性（P〈0．01）,但FEV1并不是评估COPD病情的敏感指标。结论2011GOLD策略对COPD稳定期患者的评估更加全面,但在临床操作上略显复杂,而且主要影响了中度COPD患者的分组及治疗选择的改变,AECOPD频率对COPD风险分级的影响非常大。     

慢性阻塞性肺疾病评估测试在慢性阻塞性肺疾病急性加重住院患者的临床应用

目的探讨慢性阻塞性肺疾病评估测试（CAT）在慢性阻塞性肺疾病急性加重（AECOPD）住院期间的临床应用价值。方法对AECOPD的住院患者在出院时进行肺功能检查,并应用CAT问卷进行症状评估,采用Pearson直线相关分析肺功能指标与CAT分值之间的相关性。根据肺功能对患者进行分级,并与根据CAT评分的分级进行比较,观察其对病情严重程度评估的一致性。结果CAT总分与FEVt％pred呈显著负相关（r=-0．557,P〈0．01）。CAT评分随患者病情加重而逐渐增加,病情严重程度不同的3组COPD患者,其CAT总分分别为（18±6）分、（21±7）分和（25±6）分,组间比较的差异有统计学意义（H=39．368,P〈0．01）。根据CAT分级和根据肺功能COPD严重程度分级比较,两者具有较高一致性。结论在AECOPD住院期间行肺功能检查及CAT评分,有助于病情严重程度的综合评估。     

2018慢性阻塞性肺疾病全球倡议病情评估的意义与思考

正2001年第一版慢性阻塞性肺疾病全球倡议(GOLD)发布,为慢性阻塞性肺疾病(COPD,简称慢阻肺)的规范化诊治提供了指导。2006年GOLD对慢阻肺的定义、肺功能评估、发病机制、治疗策略等方面进行了更新,根据肺功能将慢阻肺分为四级。2011年GOLD对慢阻肺评估方式和管理模式有了较大的更新,保留了肺功能分级系统,加入症状、急性加重风险综合评估。GOLD 2017更新了慢阻肺定     

NT-proBNP 对评估 COPD 急性加重风险的意义简

目的 主要探讨检测血浆N端脑钠肽前体（NT-proBNP）对评估慢性阻塞性肺疾病（COPD）急性加重风险的意义.方法 选取2012.1~2012.8 在我院住院治疗的COPD患者63名,根据2011版GOLD策略综合评估分为COPD低危组22人（包含A组和B组）和COPD高危组23人（包含C组和D组）,分别测定并比较2组NT-proBNP、肺功能、体重指数及并发症情况.结果 COPD低危组患者血浆NT-proBNP水平（245.7±166.2 pg/ml）明显低于COPD高危组患者（1326.7±198.8 pg/ml）（P〈0.05）.肺功能FEV1（perd%）与NT-proBNP（pg/ml）成负相关（r=-0.395,P=0.001）.而年龄、性别与体重指数则与NT-proBNP（pg/ml）无相关性（P＞0.05）.结论 NT-proBNP能较好反应COPD的急性加重风险.     

COPD综合评估方法与管理研究进展

COPD 的发病率、病死率及致残率高。2011年 GOLD 指南首次提出根据症状,未来急性加重风险,肺功能损害程度对 COPD 进行综合评估。急性加重严重度评估及合并症管理目前进一步完善于 COPD 的管理中,胸部 CT、呼气峰流速、指脉氧监测及生物标志物已应用于目前 COPD 的评估,COPD 管理系统信息技术也已证实其在 COPD 管理中的价值。本文就 COPD 综合评估方法与管理的研究进展作一综述。     

慢性阻塞性肺疾病急性加重的异质性

2011年版的慢性阻塞性肺疾病(COPD)全球倡议(GOLD)在内容上进行了较多的修订,为COPD的诊断、治疗带来新思路的同时也带来了挑战,其中重要的一个方面就是要关注COPD急性加重(AECOPD).AECOPD是指患者以呼吸系统症状加重为特征的临床事件,其症状变化程度超过日常变异范围并导致药物治疗方案改变.AECOPD是COPD疾病病程的重要组成部分.急性加重可以降低患者生活质量,使症状加重、肺功能恶化,需数周才能恢复,加速患者肺功能下降的速率,特别在住院患者中,与患者的死亡率密切相关.因此,早期预防、早期诊断、及时治疗AECOPD对于减轻COPD负担至关重要[1].     

早期短程肺康复对老年慢性阻塞性肺疾病的疗效观察

目的探讨老年慢性阻塞性肺疾病患者急性加重期开展早期肺康复干预的临床疗效。方法将120例住院老年AECOPD患者按照随机法分为肺康复干预组和对照组分别给予肺康复治疗和单纯常规治疗,比较出院1年前后两组患者肺功能(包括用力肺活量(FVC)、第1秒用力呼气容积(FEV_1)、FEV_1占预计值百分比(FEV_1%))、改良呼吸困难指数(mMRC)分级、COPD评估测试(CAT)呼吸问卷评估、6分钟步行试验(6MWD)和1年内再入院次数。结果对照组、干预组分别有42、37例患者完成随访,两组间肺功能、mMRC分级、CAT评分、6MWD比较均无统计学差异(P0.05),但干预组1年内因AECOPD再入院次数较对照组减少(P0.05)。结论早期短程肺康复干预能减少AECOPD患者1年内的再入院次数。     

慢阻肺急性加重期肺功能与血气分析、炎症指标相关性研究

目的探讨慢性阻塞性肺疾病急性加重期(AECOPD)患者肺功能与血气分析、炎症指标的相关性。方法通过对我院2009年1月~2014年6月期间504例AECOPD患者回顾性调查,分析其血气分析、炎性指标以及肺功能的相关性。结果 Pearson相关性分析显示:AECOPD患者血气分析、炎症指标与肺功能参数显著相关,差异有统计学意义(P0.05),其中PH与GOLD分级呈负相关(r=-0.199,P=0.000),Sa O2与GOLD分级呈负相关(r=-0.143,P=0.003),Pa CO2与GOLD分级呈正相关(r=0.405,P=0.000),WBC与GOLD分级呈正相关(r=0.116 P=0.000),N与GOLD分级呈正相关(r=0.253,P=0.000),CRP与GOLD分级呈正相关(r=0.150,P=0.015),差异有统计学意义(P0.05)。结论血气分析(PH、Pa CO2及Sa O2)、炎症指标(WBC、N及CRP)水平与AECOPD患者病情严重程度密切相关,两者均可作为评估患者病情严重程度以及评估预后的参考。     

血清尿酸与AECOPD相关性分析

目的 探讨血清尿酸(UA)与COPD急性加重期(AECOPD)的关系及与COPD严重度关系,并探讨其临床意义.方法 AECOPD组80例.根据AECOPD患者治疗后肺功能分为COPD Ⅰ级组(n=10),COPDⅡ级组(n=15),COPDⅢ级组(n=29),COPDⅣ级组(n=26).健康老年组75例为对照组,分别监测血清尿酸,并计算高尿酸血症(HUA)检出率.结果 AECOPD组血尿酸显著高于健康老年对照组,两组比较差异有统计学意义,(P＜0.05).COPD分级越重,其血清尿酸水平及高尿酸血症检出率越高,差异有统计学意义(P＜0.05).结论 AECOPD组血尿酸水平与HUA检出率均高于健康老年对照组,且血清尿酸水平及高尿酸血症检出率与COPD严重程度呈正相关,可作为病情监测的指标之一.     

探讨髓系细胞触发受体-1在慢性阻塞性肺疾病急性加重期中的临床应用

目的探讨髓系细胞触发受体-1（triggeringreceptorexpressedonmyeloidcell-1,TREM-1）在慢性阻塞性肺疾病急性加重期（acuteexacerbationofchronicobstructivepulmonarydisease,AECOPD）的临床应用。方法随机抽取在我院门诊或住院部诊治的COPD稳定期患者共40例（n=40）,按GOLD（肺功能）分级：轻度5例,中度16例,重度13例,极重度6例。全部患者均于稳定期、急性加重期测定TREM1、降钙素原（PCT）,急性加重期行痰细菌培养及痰病毒PCR检查。结果AECOPD患者TREM-1水平均较稳定期升高,PCT阳性,差异具有统计学意义（P〈0．05）。痰细菌培养结果阳性患者TREM-1水平、PCT阳性率较阴性患者均升高,差异具有统计学意义（P〈0．05）。痰病毒PCR结果阳性AECOPD患者血清TREM-1水平、PCT阳性率差异无统计学意义。结论TREM-1在AECOPD中是-个敏感的炎症标志物,可作为早期诊断AECOPD的客观指标。在细菌感染相关的AECOPD患者中TREM-1水平升高,但病毒感染相关者无变化,联合PCT可用于判断细菌感染相关的AECOPD,有利于指导临床抗生素的用药。     

GOLD Classification of COPD: Discordance in Criteria for Symptoms and Exacerbation Risk Assessment

The new A-B-C-D Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification of severity of chronic obstructive pulmonary disease (COPD) is based on combined symptoms and exacerbation risk assessment. The assumed equivalence between dyspnoea modified Medical Research Council (mMRC) grade ≥2 and COPD Assessment Test (CAT) score ≥ 10 to identify more symptoms has been questioned. Whether the exacerbation risk assessment criteria, old GOLD spirometry staging and frequency of exacerbations, are equivalent has not been examined. We evaluated the extent of agreement between these alternative criteria and whether it improved by redefining the equivalence between mMRC grade and CAT score. CAT scores, mMRC grades of dyspnoea, frequency of exacerbations and spirometry stages were computed in 400 patients with COPD. Receiver operating characteristic curve was analysed to determine the best CAT score to identify more symptoms. CAT scores across mMRC grades and the frequency of exacerbations across spirometry stages showed substantial overlaps. The symptoms criteria gave discordant classification in 88 (22%) patients (kappa 0.62) and the exacerbation risk assessment criteria in 181 (45%) patients (kappa 0.12). A CAT score of ≥10 had 82% sensitivity but 24% specificity to identify mMRC grade ≥ 2, while a score of 17 had 98% specificity but a low sensitivity of 52% and did not improve the agreement. We conclude that symptoms and exacerbation risk assessment criteria of the new GOLD classification yield discordant group categorisations. Lack of any satisfactory equivalence between CAT score and mMRC grades implies that the former cannot be used alone. Using the higher of mMRC ≥ 2 and CAT score ≥ 17 to identify more symptoms would avoid discordant categorisation.     

Acute Exacerbation According to GOLD 2017 Categories in Patients with Chronic Obstructive Pulmonary Disease

IntroductionThe association between GOLD categorizations and future exacerbations has not been fully investigated. This study elucidates whether the GOLD 2017 classification is associated with different future exacerbation risk in patients with chronic obstructive pulmonary disease (COPD) compared with the previous GOLD categorization. Another objective was to investigate the impacts of the symptoms and FEV1 on the predicted future exacerbation independently of previous exacerbation history.MethodsWe analyzed patients from three prospective COPD cohorts (SNUH, KOCOSS, and KOLD) and evaluated the risk of moderate to severe exacerbation among different models, including GOLD grade (FEV1), GOLD 2011, and GOLD 2017.ResultsIn total, 611 COPD patients were included (36 from SNUH, 257 from KOCOSS, and 318 from KOLD). GOLD 2017 classification, excluding FEV1% for categorization criteria, showed no differences in future exacerbation risk compared with GOLD grade and GOLD 2011 based on c-statistics. Among those with no frequent exacerbation history and FEV1 ≥50%, the group with more symptoms was significantly associated with future exacerbations than the group with less symptoms. A lower FEV1 (FEV1 <50%) was not associated with a higher future exacerbation risk than a higher FEV1 (FEV1 ≥50%), regardless of prior exacerbation history and symptom group.ConclusionThe GOLD 2017 classification was not different from GOLD grade and GOLD 2011 regarding the association with future exacerbation risk, and there were no significant differences in exacerbation risk according to FEV1%. This suggests that FEV1 might not be an important factor in future exacerbation risk. These results partly support the GOLD 2017 assessment tool.     

慢性阻塞性肺疾病患者中的血清脂联素与IL-2、IL-8的相关性研究

目的探讨脂联素与COPD患者血清脂联素水平与IL-2、IL-8的相关性,以明确脂联素在COPD慢性炎症中的作用。方法选取正常体质量指数（〈24kg／m2）的男性健康志愿者30名作为对照组,COPD急性加重期30例患者,稳定期30例患者。COPD的诊断标准符合中华人民共和国卫生部颁发的《慢性阻塞性肺疾病诊断标准（2013年修订版）》。采用酶联免疫吸附试验（Enzyme—linked Immunosorbent Assay,ELISA）测定3组血清脂联素浓度及IL-2、IL-8的含量,比较COPD急性加重期、稳定期与对照组脂联素、IL-2、II。-8的差异,分析血清脂联素与IL-2、IL-8的相关性。结果COPD急性加重期、稳定期血清脂联素、IL-8显著高于对照组,差异有统计学意义（P〈0．01）,稳定期血清脂联素浓度及IL-8显著高于对照组,差异有统计学意义（P〈0．01）;COPD急性加重期及稳定期IL-2显著低于对照组（P〈0．01）,且COPD急性加重期血清IL-2浓度较稳定期进一步降低,差异有统计学意义（P〈0．01）。COPD急性加重期及稳定期患者血清脂联素与IL-2呈负相关,差异有统计学意义（相关系数r分别为-0．654,-0．643,P〈0．05）,与IL-8呈正相关,差异具有统计学意义（相关系数r分别为0．545,0．649,P〈0．01）。结论血清脂联素在COPD发病机制过程中起重要作用,推测血清脂联素可能是COPD新型的促炎因子。     

Classification of Chronic Obstructive Pulmonary Disease (COPD) according to the new Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017: Comparison with GOLD 2011

Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and mortality worldwide. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) project has been working to improve awareness, prevention and management of this disease. The aim of this study is to evaluate how COPD patients are reclassified by the 2017 GOLD system (versus GOLD 2011), to calculate the level of agreement between these two classifications in allocation to categories and to compare the performance of each classification to predict future exacerbations. Two-hundred COPD patients (>40 years, post bronchodilator forced expiratory volume in one second/forced vital capacity<0.7) followed in pulmonology consultation were recruited into this prospective multicentric study. Approximately half of the patients classified as GOLD D [2011] changed to GOLD B [2017]. The extent of agreement between GOLD 2011 and GOLD 2017 was moderate (Cohen's Kappa = 0.511; p < 0.001) and the ability to predict exacerbations was similar (69.7% and 67.6%, respectively). GOLD B [2017] exacerbated 17% more than GOLD B [2011] and had a lower percent predicted post bronchodilator forced expiratory volume in one second (FEV1). GOLD B [2017] turned to be the predominant category, more heterogeneous and with a higher risk of exacerbation versus GOLD B [2011]. Physicians should be cautious in assessing the GOLD B [2017] patients. The assessment of patients should always be personalized. More studies are needed to evaluate the impact of the 2017 reclassification in predicting outcomes such as future exacerbations and mortality.     

D-二聚体、纤维蛋白原测定评价COPD严重程度的分级

目的探讨COPD患者不同疾病严重程度的血浆D-D、FG水平,以评估不同分级方法间的差异。方法收集142例COPD患者及59例健康体检者的血浆D-D、FG。结果 COPD组血浆D-D、FG水平明显高于健康体检组,COPD患者死亡组的血浆D-D、FG水平明显高于存活组,均具有统计学意义(P0.05)。COPD D组患者的D-D、FG高于B、C组,具有统计学意义(P0.05),而B、C组间比较D-D、FG均无统计学差异;COPDⅣ级患者的D-D、FG高于Ⅱ、Ⅲ级,具有统计学意义(P0.05),而Ⅱ、Ⅲ级间比较D-D、FG均无统计学差异。结论 COPD患者处于高凝状态,GOPD GOLD分级相对于GOLD 2011ABCD组可能更有利于评价患者的高凝状态及病情严重程度。     

舒利迭治疗后慢性阻塞性肺疾病患者症状改善与气道限闭的相关性研究

目的探讨重度稳定期COPD患者治疗后症状改善与气道限闭改善的相关性。方法2012年1～9月纳人重度稳定期COPD患者77例,男性53例,女性24例,分为A组37例（GOLD临床分级C级）,B组40例（临床分级I）级）。纳入后予舒利迭50／500μg2次/d吸入治疗4个月,纳入时及4个月后分别行肺功能检查,测量FVC、FEV1、计算△FVC／△FEV1（代表气道限闭改善程度）、呼吸困难分级评分（MMRC）及COPD评估表（CAT）评分,测量6分钟步行距离（6MWD）。结果治疗后FVC、FEV1、CAT评分、6MWI）有不同程度改善。A组及B组△FVC／△FEV1分别为3．55±1．15及3．38±1．23,两组间差异无统计学意义（z=-0．78,P〉0．05）。A、B组△CAT分别为（2．23±1．32）分及（2．40±1．43）分（t=0．78,组间P〉0．05）,△6MWD分别为（69±53）m及（52±40）m（t=2．28,组间P=0．05）。△FVC／△FEV。与△CAT及△6MWD呈正相关（r分别为0．685,0．702,P〈0．05）。结论经舒利迭治疗后COPDC级及D级患者气道限闭改善程度相当,但气道限闭改善与症状及运动耐力相关,气道限闭改善越显著,症状及运动耐力改善越明显。△FVC／△FEV,作为一项简捷指标,提示限闭气体的排除及症状的改善值得关注。     

Reanalysis of the Japanese experience using the combined COPD assessment of the 2011 GOLD classification

BackgroundThe Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 consensus report proposed a new classification system, incorporating symptoms with future risk, in subjects with chronic obstructive pulmonary disease (COPD). We hypothesized it could be applied to Japanese COPD patients.MethodsWe previously analyzed clinical factors related to 5-year mortality in 150 male outpatients with COPD. We reviewed the data and reanalyzed the relationships between the new GOLD classification and various outcomes including mortality.ResultsThere were 51 (34.0%), 12 (8.0%), 57 (38.0%), and 30 (20.0%) patients in GOLD A (forced expiratory volume in 1 s [FEV₁]≥50% predicted and modified Medical Research Council [mMRC] 0–1), GOLD B (FEV₁≥50% predicted and mMRC≥2), GOLD C (FEV₁<50% predicted and mMRC 0–1), and GOLD D (FEV₁ <50% predicted and mMRC≥2), respectively. The GOLD 2011 classification correlated significantly with exercise capacity and multi-dimensional disease staging. Cox proportional hazards analysis revealed that, among several methods categorizing symptoms, the GOLD A-D classification was significantly associated with mortality (p=0.0055).ConclusionAlthough the relative number of patients in each category of the combined COPD assessment classification depended on the choice of symptom measures, the categories defined by the mMRC scale (score 0–1 versus ≥2) were most useful for future risk assessed as mortality. GOLD A had the lowest mortality, followed by GOLD B and C, and D had the highest mortality. Exercise capacity was also stratified by the new GOLD classification.     

无创正压通气对AECOPD合并高乳酸血症患者的疗效分析

目的观察无创正压通气(NIPPV)对AECOPD合并高乳酸血症的治疗效果。方法选择符合AECOPD诊断标准并且血乳酸>2mmol/L的患者44例,随机分成NIPPV组23例及常规治疗组21例。结果治疗3 d后,两组患者的血气分析结果、呼吸频率、血乳酸、心率、脉搏氧饱和度等指标均较治疗前显著改善(P<0.05 or P<0.01),但NIPPV组的血乳酸水平、PaO2及PaCO2的改善效果明显(P<0.05)。结论 AECOPD患者早期使用NIPPV能迅速降低患者的CO2蓄积、改善缺氧、降低血乳酸水平,提高救治成功率。