National Heart and Lung Institute, Imperial College London , London, UK.
Expert Rev Respir Med. 2021 Jan;15(1):27-37. doi: 10.1080/17476348.2020.1804364. Epub 2020 Aug 10.
Chronic obstructive pulmonary disease (COPD) is a heterogeneous syndrome and may comprise several different phenotypes that are driven by different molecular mechanisms (endotypes). Several different clinical, genetic, and inflammatory phenotypes of COPD have been recognized and this may lead to more precise effective therapies.
The different clinical phenotypes, including smoking nonsmoking COPD, small airway disease emphysema, non-exacerbators frequent exacerbators are discussed. Rare genetic endotypes (alpha-antitrypsin deficiency, telomerase polymorphisms), and inflammatory phenotypes (eosinophilic neutrophilic) are also recognized in stable and exacerbating patients and have implications for the choice of therapy.
Clinical phenotypes have so far not proved to be very useful in selecting more personalized therapy for COPD. Even with genetic endotypes, this has not led to improved therapy. More promising is the recognition that COPD patients who have increased sputum or blood eosinophils tend to have more frequent exacerbations and inhaled corticosteroids are more effective in preventing exacerbation. Increased blood eosinophils have proved to be a useful biomarker now used to target ICS more effectively. Furthermore, COPD patients with low eosinophils are more likely to get pneumonia with ICS and to have lower airway bacterial colonization.
慢性阻塞性肺疾病（COPD）是一种异质性综合征，可能包含几种不同的表型，这些表型由不同的分子机制（表型）驱动。已经认识到 COPD 的几种不同的临床、遗传和炎症表型，这可能会导致更精确有效的治疗。
讨论了不同的临床表型，包括吸烟型和非吸烟型 COPD、小气道疾病和肺气肿、非加重者和频繁加重者。在稳定期和加重期患者中也认识到罕见的遗传表型（α-抗胰蛋白酶缺乏、端粒酶多态性）和炎症表型（嗜酸性粒细胞性和中性粒细胞性），这对治疗选择有影响。
到目前为止，临床表型在为 COPD 选择更个性化的治疗方面并没有证明非常有用。即使是遗传表型，也没有导致治疗效果的改善。更有希望的是，认识到痰液或血液中嗜酸性粒细胞增多的 COPD 患者更容易发生频繁的加重，吸入皮质类固醇对预防加重更有效。嗜酸性粒细胞增多已被证明是一种有用的生物标志物，现在用于更有效地靶向 ICS。此外，嗜酸性粒细胞水平低的 COPD 患者更容易发生 ICS 相关性肺炎，并存在下气道细菌定植。
