Delzell John E
University of Kansas School of Medicine, 3901 Rainbow Blvd Mailstop 4010, Kansas City, KS 66160,
FP Essent. 2013 Jun;409:23-31.
The etiology of chronic obstructive pulmonary disease (COPD) is chronic lung inflammation. In the United States, this inflammation most commonly is caused by smoking. COPD is diagnosed when an at-risk patient presents with respiratory symptoms and has irreversible airway obstruction indicated by a forced expiratory volume in 1 second/forced vital capacity ratio of less than 0.7. Management goals for COPD include smoking cessation, symptom reduction, exacerbation reduction, hospitalization avoidance, and improvement of quality of life. Stable patients with COPD who remain symptomatic despite using short-acting bronchodilators should start inhaled maintenance drugs to reduce symptoms and exacerbations, avoid hospitalizations, and improve quality of life. A long-acting anticholinergic or a long-acting beta2-agonist (LABA) can be used for initial therapy; these drugs have fewer adverse effects than inhaled corticosteroids (ICS). If patients remain symptomatic despite monotherapy, dual therapy with a long-acting anticholinergic and a LABA, or a LABA and an ICS, may be beneficial. Triple therapy (ie, a long-acting anticholinergic, a LABA, and an ICS) also is used, but it is unclear if triple therapy is superior to dual therapy. Roflumilast, an oral selective inhibitor of phosphodiesterase 4, is used to manage moderate to severe COPD. Continuous oxygen therapy is indicated for patients with COPD who have severe hypoxemia (ie, PaO2 less than 55 mm Hg or an oxygen saturation less than 88% on room air). Nonpharmacologic strategies also are useful to improve patient outcomes. Pulmonary rehabilitation improves dyspnea and quality of life. Pulmonary rehabilitation after an acute exacerbation reduces hospitalizations and mortality, and improves quality of life and exercise capacity. Smoking cessation is the most effective management strategy for reducing morbidity and mortality in patients with COPD. Lung volume reduction surgery, bullectomy, and lung transplantation are surgical interventions that are appropriate for some patients with COPD.
慢性阻塞性肺疾病（COPD）的病因是慢性肺部炎症。在美国，这种炎症最常见的原因是吸烟。当有风险的患者出现呼吸道症状，且1秒用力呼气量/用力肺活量比值小于0.7表明存在不可逆气道阻塞时，可诊断为COPD。COPD的管理目标包括戒烟、减轻症状、减少急性加重、避免住院以及提高生活质量。尽管使用短效支气管扩张剂但仍有症状的稳定期COPD患者应开始吸入维持药物，以减轻症状和急性加重、避免住院并提高生活质量。长效抗胆碱能药物或长效β2受体激动剂（LABA）可用于初始治疗；这些药物的不良反应比吸入性糖皮质激素（ICS）少。如果单药治疗后患者仍有症状，长效抗胆碱能药物与LABA联合治疗，或LABA与ICS联合治疗可能有益。也可使用三联疗法（即长效抗胆碱能药物、LABA和ICS），但三联疗法是否优于双联疗法尚不清楚。罗氟司特是一种口服磷酸二酯酶4选择性抑制剂，用于治疗中重度COPD。对于有严重低氧血症（即动脉血氧分压小于55 mmHg或室内空气下氧饱和度小于88%）的COPD患者，应进行持续氧疗。非药物策略对改善患者预后也很有用。肺康复可改善呼吸困难和生活质量。急性加重后进行肺康复可减少住院和死亡率，并改善生活质量和运动能力。戒烟是降低COPD患者发病率和死亡率最有效的管理策略。肺减容手术、肺大疱切除术和肺移植是适合某些COPD患者的外科干预措施。
