Zysman M, Chabot F, Devillier P, Housset B, Morelot-Panzini C, Roche N
EA Ingres, département de pneumologie, université de Lorraine, CHU de Nancy, 54500 Vandœuvre-lès-Nancy, France.
UPRES EA 220, département des maladies des voies respiratoires, hôpital Foch, université Versailles-Saint-Quentin, 92150 Suresnes, France.
Rev Mal Respir. 2016 Dec;33(10):911-936. doi: 10.1016/j.rmr.2016.10.004. Epub 2016 Nov 25.
The Société de Pneumologie de Langue Française proposes a decision algorithm on long-term pharmacological COPD treatment. A working group reviewed the literature published between January 2009 and May 2016. This document lays out proposals and not guidelines. It only focuses on pharmacological treatments except vaccinations, smoking cessation treatments and oxygen therapy. Any COPD diagnosis, based on pulmonary function tests, should lead to recommend smoking cessation, vaccinations, physical activity, pulmonary rehabilitation in case of activity limitation, and short-acting bronchodilators. Symptoms like dyspnea and exacerbations determine the therapeutic choices. In case of daily dyspnea and/or exacerbations, a long-acting bronchodilator should be suggested (beta-2 agonist, LABA or anticholinergics, LAMA). A clinical and lung function reevaluation is suggested 1 to 3 months after any treatment modification and every 3-12 months according to the severity of the disease. In case of persisting dyspnea, a fixed dose LABA+LAMA combination improves pulmonary function (FEV1), quality of life, dyspnea and decreases exacerbations without increasing side effects. In case of frequent exacerbations and a FEV1≤70%, a fixed dose long-acting bronchodilator combination or a LABA+ inhaled corticosteroids (ICS) combination can be proposed. A triple combination (LABA+LAMA+ICS) is indicated when exacerbations persist despite one of these combinations. Dyspnea in spite of a bronchodilator combination or exacerbations in spite of a triple combination should lead to consider other pharmacological treatments (theophylline if dyspnea, macrolides if exacerbations, low-dose opioids if refractory dyspnea).
法国肺病学会提出了慢性阻塞性肺疾病（COPD）长期药物治疗的决策算法。一个工作组回顾了2009年1月至2016年5月期间发表的文献。本文件提出的是建议而非指南。它仅关注药物治疗，不包括疫苗接种、戒烟治疗和氧疗。任何基于肺功能测试的COPD诊断，都应建议戒烟、接种疫苗、进行体育活动、在活动受限的情况下进行肺康复治疗，以及使用短效支气管扩张剂。呼吸困难和急性加重等症状决定治疗选择。如果出现日常呼吸困难和/或急性加重，应建议使用长效支气管扩张剂（β2受体激动剂、长效β2受体激动剂LABA或抗胆碱能药物、长效抗胆碱能药物LAMA）。在任何治疗调整后1至3个月建议进行临床和肺功能重新评估，并根据疾病严重程度每3至12个月评估一次。如果持续存在呼吸困难，固定剂量的LABA+LAMA联合用药可改善肺功能（第一秒用力呼气容积FEV1）、生活质量、呼吸困难症状，并减少急性加重，且不会增加副作用。如果急性加重频繁且FEV1≤70%，可建议使用固定剂量的长效支气管扩张剂联合用药或LABA+吸入性糖皮质激素（ICS）联合用药。如果尽管使用了其中一种联合用药仍持续出现急性加重，则应使用三联联合用药（LABA+LAMA+ICS）。尽管使用了支气管扩张剂联合用药仍存在呼吸困难，或尽管使用了三联联合用药仍出现急性加重，应考虑使用其他药物治疗（呼吸困难时使用茶碱，急性加重时使用大环内酯类药物，难治性呼吸困难时使用低剂量阿片类药物）。
