McCrory D C, Brown C, Gelfand S E, Bach P B
Center for Clinical Health Policy Research, Duke Evidence-Based Practice Center and Duke University Medical Center, Durham, NC, USA.
Chest. 2001 Apr;119(4):1190-209. doi: 10.1378/chest.119.4.1190.
To critically review the available data on the diagnostic evaluation, risk stratification, and therapeutic management of patients with acute exacerbations of COPD.
DESIGN, SETTING, AND PARTICIPANTS: English-language articles were identified from the following databases: MEDLINE (from 1966 to week 5, 2000), EMBASE (from 1974 to week 18, 2000), HealthStar (from 1975 to June 2000), and the Cochrane Controlled Trials Register (2000, issue 1). The best available evidence on each subtopic then was selected for analysis. Randomized trials, sometimes buttressed by cohort studies, were used to evaluate therapeutic interventions. Cohort studies were used to evaluate diagnostic tests and risk stratification. Study design and results were summarized in evidence tables. Individual studies were rated as to their internal validity, external validity, and quality of study design. Statistical analyses of combined data were not performed.
Limited data exist regarding the utility of most diagnostic tests. However, chest radiography and arterial blood gas sampling appear to be useful, while short-term spirometry measurements do not. In terms of the risk of relapse and the risk of death after hospitalization for an acute exacerbation, there are identifiable clinical variables that are associated with these outcomes. Therapies for which there is evidence of efficacy include bronchodilators, corticosteroids, and noninvasive positive-pressure ventilation. There is also support for the use of antibiotics in patients with more severe exacerbations. Based on limited data, mucolytics and chest physiotherapy do not appear to be of benefit, and oxygen supplementation appears to increase the risk of respiratory failure in an identifiable subgroup of patients.
Although suggestions for appropriate management can be made based on available evidence, the supporting literature is spotty. Further high-quality research is needed and will require an improved, generally acceptable, and transportable definition of the syndrome "acute exacerbation of COPD" and improved methods for observing and measuring outcomes.
严格审查关于慢性阻塞性肺疾病（COPD）急性加重患者的诊断评估、风险分层及治疗管理的现有数据。
设计、研究地点与参与者：从以下数据库中检索英文文章：医学索引数据库（MEDLINE，1966年至2000年第5周）、荷兰医学文摘数据库（EMBASE，1974年至2000年第18周）、健康之星数据库（HealthStar，1975年至2000年6月）以及Cochrane对照试验注册库（2000年第1期）。然后选取每个子主题的最佳现有证据进行分析。采用随机试验（有时辅以队列研究）评估治疗干预措施。采用队列研究评估诊断试验和风险分层。研究设计和结果汇总在证据表中。对各项研究的内部效度、外部效度及研究设计质量进行评分。未对合并数据进行统计分析。
关于大多数诊断试验的效用，现有数据有限。然而，胸部X线检查和动脉血气采样似乎有用，而短期肺功能测量则不然。就急性加重住院后的复发风险和死亡风险而言，存在与这些结局相关的可识别临床变量。有证据表明有效的治疗方法包括支气管扩张剂、皮质类固醇和无创正压通气。对于病情较重的加重患者使用抗生素也有依据。基于有限的数据，黏液溶解剂和胸部物理治疗似乎并无益处，且在一个可识别的患者亚组中，补充氧气似乎会增加呼吸衰竭的风险。
尽管可根据现有证据提出适当管理的建议，但支持性文献参差不齐。需要进一步开展高质量研究，这将需要对“COPD急性加重”综合征进行改进的、普遍可接受且可推广的定义，以及改进观察和测量结局的方法。
