1、COPD病例分享,LOREM IPSUM DOLOR,患者，男，44岁,主诉：因“慢性咳嗽、咳痰、喘息6年，加重1周 ”于2016年4月23日入院,该患缘于6年前无明显诱因出现咳嗽、咳痰、喘息，咳黄色粘痰，量不多，易咳出，以晨起为著，喘息多于夜间出现，无咯血及胸痛，自行抗炎治疗（具体不详）后好转。此后上述症状于着凉和秋冬季节反复发作，每年症状持续3个月以上，经抗炎、平喘治疗（具体药名和剂量不详）好转，未系统诊治。1周前“感冒”后上述症状再次加重，痰为黄色粘痰，量少，不易咳出，自己可听到喘鸣音，活动后明显，于当地医院行抗感染（阿奇霉素0.5g每日一次静点）1天无明显好转，为求系统诊治来我院门诊，
2、以“慢性阻塞性肺病”收入我科。病程中无发热，无头晕、头痛，无心前区不适，无恶心、呕吐，无腹痛、腹泻，饮食、睡眠尚可，二便如常，近期体重无明显减轻。,现病史,LOREM IPSUM DOLOR,农民,否认高血压、心脏病及糖尿病病史,吸烟20年，每日20支，未戒。无饮酒史,无家族病史,查体,T 36.3, P 100次/分, R 28次/分, Bp 120/75mmHg一般状态尚可，坐位，神清口唇及甲床无发绀，球结膜无水肿，颈静脉无充盈桶状胸，肋间隙增宽，双侧触觉语颤减弱，叩诊过清音，肝浊音界下移，听诊双肺散在哮鸣音，未闻及湿啰音心率：100次/分，律整，无杂音及额外心音腹平软，无压痛反跳痛，肝脾
3、肋下未触及双下肢无水肿神经系统查体无阳性体征,肺CT,1、支气管炎并少许炎症，建议治疗后复查 2、双肺肺气肿 3、胸主动脉及冠状动脉硬化,eNO 18ppb肺功能： 吸入支气管舒张剂后FEV1/FVC70%,LOREM IPSUM DOLOR,血气分析,血常规,心电：正常心电图心彩：左室舒张功能减低，三尖瓣轻度返流,临床诊断,慢性阻塞性肺病急性加重,治疗,抗炎：磺苄西林 4.0 每日三次 静点解痉：（1）普米克令舒2mg+沙丁胺醇0.4mg 每日三次 雾化吸入（2）多索茶碱 0.2 每日两次 静点（3）孟鲁司特钠 10mg 每日一次 睡前口服化痰：（1）溴己新 100ml 每日两次 静点（2）
4、富露施 600mg 每日两次 口服,治疗后,症状：咳嗽、咳痰、喘息减轻体征：双肺无干啰音肺功能：FEV1/FVC70%,COPD,LOREM IPSUM DOLOR,GOLD对COPD的定义： 持续的气流受限 吸入支气管舒张剂后 FEV1/FVC70%,更正临床诊断,慢性支气管炎急性发作,慢性阻塞性肺气肿,总结及教训,诊断需结合吸烟等高危因素史、临床症状、体征，并排除其他已知病因或具有气道阻塞和气流受限的疾病,治疗前后多次查肺功能，取最佳值,即使存在过度诊断，但用药也是合理的,指南解读：过度诊断,The use of the fixed FEV1/FVC ratio to define air
5、flow limitation will result in more frequent diagnosis of COPD in the elderly, and less frequent diagnosis in adults younger than 45 years. The risk of misdiagnosis and over-treatment of individual patients using the fixed ratio as a diagnostic criterion is limited, as spirometry is only one paramet
6、er for establishing the clinical diagnosis of COPD, the others being symptoms and risk factors.,指南解读：信必可相关,Formoterol and salmeterol significantly improve FEV1 and lung volumes, dyspnea, health-related quality of life and exacerbation rate (Evidence A)Short-term combination therapy using formoterol
7、and tiotropium has been shown to have a bigger impact on FEV1 than the single components (Evidence B).Regular treatment with inhaled corticosteroids improves symptoms, lung function, and quality of life, and reduces the frequency of exacerbations144 in COPD patients with an FEV1 60% predicted (Evide
8、nce A).Regular treatment with inhaled corticosteroids does not modify the long-term decline of FEV1 nor mortality in patients with COPD (Evidence A).inhaled corticosteroid combined with a longacting beta2-agonist is more effective than the individual components in improving lung function and health
9、status and reducing exacerbations in patients with moderate (Evidence B) to very severe COPD (Evidence A).The addition of a long-acting beta2-agonist/ inhaled corticosteroid combination to tiotropium improves lung function and quality of life and may further reduce exacerbations (Evidence B) but mor
10、e studies of triple therapy are needed.Combination therapy is associated with an increased risk of pneumonia, but no other significant side effect (Evidence A).,信必可,ICS（如布地奈德）,LABA（如福莫特罗）,糖皮质激素受体,抗炎作用,支气管扩张, 糖皮质激素受体易位 与激素反应元件结合 抗炎效应, 2受体表达 2受体偶合 2受体受体下调防止对激动剂的耐受性,Barnes PJ. Eur Respir J. 2007; 29: 58795.,COPD,速效、长效且具量效关系,适中的亲脂性和亲水性延长其在气道的停留时间,协同 互补,
