Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and, Tygerberg Hospital, Cape Town.
S Afr Fam Pract (2004). 2020 Dec 8;62(1):e1-e6. doi: 10.4102/safp.v62i1.5198.
International and national guidelines on chronic obstructive pulmonary disease (COPD) emphasise bronchodilators as first-line therapy. However, in considering them the 'foundation' of treatment, attention has shifted from the fact that COPD is fundamentally an inflammatory disease. The mainstay ought to be anti-inflammatory medication, and inhaled corticosteroids (ICS) are the best agents we have presently. There was initial scepticism about their role, but ICS were subsequently shown to have numerous anti-inflammatory effects. They are synergistic with bronchodilators at a molecular and clinical level and unequivocally improve dyspnoea, quality of life, exacerbation frequency and, more recently, mortality. These benefits are most apparent in the COPD eosinophilic phenotype. These beneficial effects have been met with some reservations because of the predisposition to pneumonia of ICS. This must be seen in context: over 90% of COPD patients in all clinical trials do not get pneumonia. The fact that patients with COPD are predisposed to pneumonia because of the disease itself is disregarded; this is a crucial omission as this constitutes the baseline incidence of about 3%. When one allows for this, then in the clinical reports, the excess risk of pneumonia ranges from zero to a maximum of 3%. Equally, some of the systemic effects attributed to ICS fail to appreciate that the disease, smoking and older age are risk factors in themselves, and ICS do not aggravate these. Chronic obstructive pulmonary disease has considerable impact on respiratory reserve and is associated with increasing morbidity; optimal outcomes are best achieved with long-acting bronchodilators and ICS co-prescription.
国际和国家慢性阻塞性肺疾病（COPD）指南强调支气管扩张剂为一线治疗药物。然而，在将其视为治疗的“基础”时，人们的注意力已经从 COPD 从根本上说是一种炎症性疾病这一事实转移开了。主要的治疗方法应该是抗炎药物，吸入性皮质类固醇（ICS）是我们目前拥有的最佳药物。人们最初对它们的作用持怀疑态度，但随后发现 ICS 具有许多抗炎作用。它们在分子和临床水平上与支气管扩张剂协同作用，并明确改善呼吸困难、生活质量、加重频率，最近还改善了死亡率。这些益处在 COPD 嗜酸性表型中最为明显。这些益处引起了一些保留意见，因为 ICS 容易导致肺炎。这必须从背景中考虑：在所有临床试验中，超过 90%的 COPD 患者不会得肺炎。事实上，由于疾病本身，COPD 患者容易患肺炎，但这一事实被忽视了；这是一个至关重要的遗漏，因为这构成了约 3%的基线发病率。当考虑到这一点时，那么在临床报告中，肺炎的额外风险从 0 到最大 3%不等。同样，一些归因于 ICS 的全身作用未能认识到疾病、吸烟和年龄增长本身就是危险因素，ICS 不会加重这些因素。慢性阻塞性肺疾病对呼吸储备有很大影响，并与发病率增加有关；长效支气管扩张剂和 ICS 联合处方可实现最佳治疗效果。
