Zykov Kirill A, Ovcharenko Svetlana I
Laboratory of Pulmonology, Moscow State University of Medicine and Dentistry named after A.I. Evdokimov.
I.M. Sechenov First Moscow State Medical University, Moscow, Russia.
Int J Chron Obstruct Pulmon Dis. 2017 Apr 11;12:1125-1133. doi: 10.2147/COPD.S125594. eCollection 2017.
Until recently, there have been few clinical algorithms for the management of patients with COPD. Current evidence-based clinical management guidelines can appear to be complex, and they lack clear step-by-step instructions. For these reasons, we chose to create a simple and practical clinical algorithm for the management of patients with COPD, which would be applicable to real-world clinical practice, and which was based on clinical symptoms and spirometric parameters that would take into account the pathophysiological heterogeneity of COPD. This optimized algorithm has two main fields, one for nonspecialist treatment by primary care and general physicians and the other for treatment by specialized pulmonologists. Patients with COPD are treated with long-acting bronchodilators and short-acting drugs on a demand basis. If the forced expiratory volume in one second (FEV) is ≥50% of predicted and symptoms are mild, treatment with a single long-acting muscarinic antagonist or long-acting beta-agonist is proposed. When FEV is <50% of predicted and/or the COPD assessment test score is ≥10, the use of combined bronchodilators is advised. If there is no response to treatment after three months, referral to a pulmonary specialist is recommended for pathophysiological endotyping: 1) eosinophilic endotype with peripheral blood or sputum eosinophilia >3%; 2) neutrophilic endotype with peripheral blood neutrophilia >60% or green sputum; or 3) pauci-granulocytic endotype. It is hoped that this simple, optimized, step-by-step algorithm will help to individualize the treatment of COPD in real-world clinical practice. This algorithm has yet to be evaluated prospectively or by comparison with other COPD management algorithms, including its effects on patient treatment outcomes. However, it is hoped that this algorithm may be useful in daily clinical practice for physicians treating patients with COPD in Russia.
直到最近，慢性阻塞性肺疾病（COPD）患者的临床管理算法仍较少。当前基于证据的临床管理指南可能显得复杂，且缺乏清晰的分步说明。出于这些原因，我们选择创建一种简单实用的COPD患者临床管理算法，该算法适用于现实世界的临床实践，并基于临床症状和肺功能参数，同时考虑到COPD的病理生理异质性。这种优化算法有两个主要领域，一个用于初级保健医生和普通内科医生的非专科治疗，另一个用于专科肺科医生的治疗。COPD患者按需使用长效支气管扩张剂和短效药物进行治疗。如果一秒用力呼气容积（FEV）≥预测值的50%且症状较轻，建议使用单一长效毒蕈碱拮抗剂或长效β受体激动剂进行治疗。当FEV<预测值的50%和/或COPD评估测试得分≥10时，建议联合使用支气管扩张剂。如果三个月后治疗无反应，建议转诊至肺专科医生进行病理生理分型：1）嗜酸性粒细胞型，外周血或痰液嗜酸性粒细胞>3%；2）中性粒细胞型，外周血中性粒细胞>60%或痰液呈绿色；或3）少粒细胞型。希望这种简单、优化的分步算法将有助于在现实世界的临床实践中实现COPD治疗的个体化。该算法尚未进行前瞻性评估，也未与其他COPD管理算法进行比较，包括其对患者治疗结果的影响。然而，希望该算法可能对俄罗斯治疗COPD患者的医生在日常临床实践中有用。
