Kaplan Alan, Thomas Mike
Family Physician Airways Group of Canada, University of Toronto, Toronto, ON, Canada
Primary Care and Population Sciences Division, University of Southampton, Southampton, UK.
Eur Respir Rev. 2017 Mar 15;26(143). doi: 10.1183/16000617.0113-2016. Print 2017 Jan.
Chronic obstructive pulmonary disease (COPD) is a common disease leading to further morbidity and significant mortality. The first step for any condition is to make the appropriate diagnosis, and spirometry barriers abound in practice around the world. It is tempting to undertake mass screening on all smokers to detect COPD. While this would pick up cases of COPD, results of studies of its effect on COPD end-points such as exacerbations, hospitalisations and mortality are disappointing. As such, aggressive case finding of COPD by screening for symptoms that patients may not themselves perceive is very important in primary care, with subsequent spirometry defining the diagnosis.We also have to separate out population screening from individual patient interactions. Performing spirometry, even on a truly asymptomatic patient, may allow earlier diagnosis and modification of risk factors such as smoking (mostly) and exacerbation risk. It also recognises patients with early disease who are at high risk of comorbidities such as cardiac illness, such that appropriate treatment strategies can be implemented. Making a diagnosis, and even the fact of worrying about such a diagnosis, can affect the motivational level of the individual patient to cease smoking; all patients should of course be counselled to stop smoking. As such, consider the individual patient in front of you for unrecognised symptoms and therefore unrecognised illness, as making a diagnosis earlier can allow the institution of care, including smoking cessation, vaccination, bronchodilators and comorbidity management.
慢性阻塞性肺疾病（COPD）是一种常见疾病，可导致进一步的发病和显著的死亡率。对于任何疾病，首要步骤都是做出恰当诊断，而在全球范围内的实际操作中，肺功能测定存在诸多障碍。对所有吸烟者进行大规模筛查以检测COPD颇具吸引力。虽然这样能查出COPD病例，但其对COPD终点指标（如病情加重、住院和死亡率）影响的研究结果却令人失望。因此，在初级保健中，通过筛查患者自身可能未察觉的症状来积极发现COPD病例非常重要，随后通过肺功能测定来明确诊断。我们还必须区分人群筛查和个体患者互动。即使对真正无症状的患者进行肺功能测定，也可能实现早期诊断并调整危险因素，如吸烟（主要是）和病情加重风险。这也能识别出患有早期疾病且有心脏病等合并症高风险的患者，从而实施恰当的治疗策略。做出诊断，甚至仅是担心这样的诊断，都可能影响个体患者戒烟的积极性；当然，所有患者都应接受戒烟咨询。因此，要考虑眼前个体患者是否存在未被识别的症状以及未被诊断的疾病，因为早期诊断能促使开展护理，包括戒烟、接种疫苗、使用支气管扩张剂以及合并症管理。
