慢性阻塞性肺病 Chronic obstructive pulmonary disease (COPD)

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慢性阻塞性肺疾病（chronic obstructive pulmonary disease，COPD）是以吸入有毒物质后促发气道炎症反应继而引起气流受限的一类疾病，促发COPD的有毒吸入物中以香烟烟雾为最常见。 在非吸烟者中，alpha1-抗胰蛋白酶缺乏及各种职业性暴露较为少见。COPD患者主要临床表现为逐年加重的咳嗽咳痰和呼吸困难症状；常见体征为呼吸音减低、呼气相时间延长和哮鸣音。病情严重患者可并发体重下降、气胸、频发的急性心力衰竭，右心衰竭和/或急性或慢性呼吸衰竭。这类疾病主要根据病史、体检、胸片、肺功能检查进行诊断。治疗上主要使用支气管舒张剂及糖皮质激素，必要时可予吸氧或使用抗生素。肺减容手术或fei移植用于晚期疾病。慢性阻塞性肺病 (COPD) 的生存率与气流受限的严重程度、病情恶化的频率以及合并症的存在有关。

 

COPD包括

  • 慢性阻塞性支气管炎（依照临床症状诊断）

  • 肺气肿（病理结合影像学确诊）

许多病人兼有两者的特征。

慢性阻塞性支气管炎是伴有气流受限的慢性支气管炎。 慢性支气管炎的定义是连续2年慢性咳嗽、咳痰，每年持续时间至少3个月。当肺功能测定有气流阻塞的证据，则慢性支气管炎已经演化为慢性阻塞性支气管炎。慢性喘息性支气管炎是一种相似的重叠症，特点为慢性咳嗽、咳痰、喘息，部分可逆的气流阻塞，常见于有哮喘史的吸烟者中。当同一患者同时患有哮喘和 COPD 时，药物治疗应遵循哮喘指南（1）。

肺气肿是肺实质的结构破坏，导致肺弹性回缩力降低，肺泡间隔减少，放射状的气道牵拉作用丧失，致使气道易于塌陷。随之，肺过度充气，气流受限，肺内气体滞留。 气腔扩大最终可发展为气泡或肺大泡。小气道闭塞被认为是肺气肿发生前最早的病变。

参考文献

  1. 1.Global Initiative for Chronic Obstructive Lung Disease (GOLD): Diagnosis and assessment.Global Strategy for the Prevention, Diagnosis, and Management of COPD: 2024 report.

重要事实

  • 慢性阻塞性肺病是全球第三大死因，2019年造成323万人死亡。
  • 70岁以下人群中近90%的慢性阻塞性肺病死亡发生在低收入和中等收入国家。
  • 慢性阻塞性肺病是全球健康状况不佳的第七大原因（以残疾调整生命年衡量）。
  • 在高收入国家，吸烟造成的慢性阻塞性肺病占病例数的70%以上。在低收入和中等收入国家，吸烟造成的慢性阻塞性肺病占病例数的30-40%，而且家庭空气污染是一个主要的风险因素。

Key facts

  • Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death worldwide, causing 3.5 million deaths in 2021, approximately 5% of all global deaths.
  • Nearly 90% of COPD deaths in those under 70 years of age occur in low- and middle-income countries (LMIC).
  • COPD is the eighth leading cause of poor health worldwide (measured by disability-adjusted life years)
  • Tobacco smoking accounts for over 70% of COPD cases in high-income countries. In LMIC tobacco smoking accounts for 30–40% of COPD cases, and household air pollution is a major risk factor.

 

概述

慢性阻塞性肺病是一种常见的肺部疾病，会导致气流受限和呼吸问题。该病有时也被称为肺气肿或慢性支气管炎。

在慢性阻塞性肺病患者中，肺部可能会受损或被痰堵塞。症状包括咳嗽，有时伴有痰，呼吸困难，喘息和疲倦。

吸烟和空气污染是慢性阻塞性肺病的最常见原因。慢性阻塞性肺病患者出现其他健康问题的风险更高。

慢性阻塞性肺病是无法治愈的，但如果避免吸烟、少接触空气污染并接种疫苗来预防感染，症状会得到改善。也可以用药物、氧气和肺部康复进行治疗。

 

Overview

Chronic obstructive pulmonary disease (COPD) is a common lung disease causing restricted airflow and breathing problems. It is sometimes called emphysema or chronic bronchitis.

In people with COPD, the lungs can get damaged or clogged with phlegm. Symptoms include cough, sometimes with phlegm, difficulty breathing, wheezing and tiredness.

Smoking and air pollution are the most common causes of COPD. People with COPD are at higher risk of other health problems.

COPD is not curable but symptoms can improve if one avoids smoking and exposure to air pollution and gets vaccines to prevent infections. It can also be treated with medicines, oxygen and pulmonary rehabilitation.

 

症状

慢性阻塞性肺病最常见的症状是呼吸困难，慢性咳嗽（有时伴有痰）和感到疲倦。

慢性阻塞性肺病症状可以迅速恶化。这被称为急性发作。通常会持续数天，并常常需要额外的药物。

慢性阻塞性肺病患者出现其他健康问题的风险也更高。其中包括：

  • 肺部感染，如流感或肺炎
  • 肺癌
  • 心脏问题
  • 肌肉无力和骨骼脆弱
  • 抑郁和焦虑。

慢性阻塞性肺病的常见症状会在步入中年后开始显现。随着慢性阻塞性肺病的发展，人们会发现越来越难以进行正常的日常活动，这常常是由呼吸急促造成的。工作场所和家庭劳作能力受限，再加上医疗费用，可能会造成相当大的经济负担。

慢性阻塞性肺病有时也被称为肺气肿或慢性支气管炎。肺气肿通常指肺部气道末端的小肺泡受损。慢性支气管炎则指气道炎症引起的慢性咳嗽，同时伴有痰液产生。慢性阻塞性肺病和哮喘的症状相同（咳嗽、喘鸣和呼吸困难），人们可能会同时患有这两种疾病。

 

Symptoms

The most common symptoms of COPD are difficulty breathing, chronic cough (sometimes with phlegm) and feeling tired.

COPD symptoms can get worse quickly. These are called flare-ups. These usually last for a few days and often require additional medicine.

People with COPD also have a higher risk for other health problems. These include:

  • lung infections, like the flu or pneumonia
  • lung cancer
  • heart problems
  • weak muscles and brittle bones
  • depression and anxiety.

Common symptoms of COPD develop from mid-life onwards. As COPD progresses, people find it more difficult to carry out their normal daily activities, often due to breathlessness. There may be a considerable financial burden due to limitation of workplace and home productivity, and costs of medical treatment.

COPD is sometimes called emphysema or chronic bronchitis. Emphysema usually refers to destruction of the tiny air sacs at the end of the airways in the lungs. Chronic bronchitis refers to a chronic cough with the production of phlegm resulting from inflammation in the airways. COPD and asthma share common symptoms (cough, wheeze and difficulty breathing) and people may have both conditions.

起因

若干过程可以导致气道变窄并导致慢性阻塞性肺病。部分肺部可能会受到破坏，粘液阻塞气道，气道内壁出现炎症和肿胀。

慢性阻塞性肺病是随时间推移逐渐发展起来的，常常是多种危险因素综合作用的结果：

  • 烟草暴露：主动吸烟或被动接触二手烟雾；
  • 职业暴露于灰尘、烟雾或化学品；
  • 室内空气污染：低收入和中等收入国家经常使用生物质燃料（木材、动物粪便、作物残渣）或煤炭来做饭和取暖，造成较高的烟雾暴露水平；
  • 阻碍肺部最大限度发育的早期生活事件，如子宫内发育不良、早产及儿童期频繁或严重的呼吸道感染；
  • 儿童期哮喘；
  • 一种罕见的遗传性疾病，即α-1抗胰蛋白酶缺乏症，可在年轻时即引起慢性阻塞性肺病。

一个人如有典型症状，即应怀疑是否患有慢性阻塞性肺病，并通过一种称为肺活量测定法的呼吸测试来证实诊断，该测试可测量肺部的工作状况。在低收入和中等收入国家，通常不能提供肺活量测定法，因此可能会出现漏诊。

Causes

Several processes can cause the airways to become narrow and lead to COPD. There may be destruction of parts of the lung, mucus blocking the airways, and inflammation and swelling of the airway lining.

COPD develops gradually over time, often resulting from a combination of risk factors:

  • tobacco exposure from active smoking or passive exposure to second-hand smoke;
  • occupational exposure to dusts, fumes or chemicals;
  • indoor air pollution: biomass fuel (wood, animal dung, crop residue) or coal is frequently used for cooking and heating in low- and middle-income countries with high levels of smoke exposure; 
  • early life events such as poor growth in utero, prematurity, and frequent or severe respiratory infections in childhood that prevent maximum lung growth;
  • asthma in childhood; and
  • a rare genetic condition called alpha-1 antitrypsin deficiency, which can cause COPD at a young age.

COPD should be suspected if a person has typical symptoms, and the diagnosis confirmed by a breathing test called spirometry, which measures how the lungs are working. In low- and middle-income countries, spirometry is often not available and so the diagnosis may be missed. 

治疗

慢性阻塞性肺病是无法治愈的，但可以通过不吸烟，避免空气污染和接种疫苗来改善症状。可以通过药物、氧气和肺部康复进行治疗。

有若干种用于慢性阻塞性肺病的治疗方法。

可以打开并减少气道肿胀的吸入性药物是主要的治疗方法。

吸入性支气管扩张剂是治疗慢性阻塞性肺病最重要的药物。该药可以使气道放松以保持畅通。

短效支气管扩张剂在几秒钟内开始起作用，效果可持续4-6小时。这类药物常常在急性发作期间使用。

长效支气管扩张剂需要更长的时间才能开始起作用，但效果持续时间更长。这些药物应每天使用，并可以与吸入类固醇结合使用。

也可以使用其他治疗方法：

  • 类固醇药丸和抗生素常常用于治疗急性发作。
  • 氧气用于长期患有慢性阻塞性肺病或患有严重慢性阻塞性肺病的人。
  • 肺部康复教导如何进行锻炼，以改善呼吸和运动能力。
  • 手术可能会改善一些慢性阻塞性肺病重症患者的症状。

有些吸入剂能打开气道，可以定期使用，以预防或减少症状并在急性发作期间缓解症状。有时会将吸入性皮质激素与这些药物结合使用，以减轻肺部炎症。

使用吸入剂时，必须采用正确的技术，在某些情况下，可使用“间隔器”装置来协助更有效地将药物输送至气道。在许多低收入和中等收入国家，获得吸入剂的机会有限；2021年，半数低收入和中低收入国家的初级公共卫生保健机构一般可以提供沙丁胺醇吸入剂。

发作常常由呼吸道感染引起，除视需要进行吸入或雾化治疗外，患者可能还要服用抗生素或类固醇片剂。

 

Treatment

COPD isn’t curable, but it can get better by not smoking, avoiding air pollution and getting vaccines. It can be treated with medicines, oxygen and pulmonary rehabilitation.

There are several treatments available for COPD.

Inhaled medicines that open and reduce swelling in the airways are the main treatments.

Bronchodilator inhalers are the most important medicines for treating COPD. They relax the airways to keep them open.

Short-acting bronchodilators start to work in seconds and can last for 4–6 hours. These are often used during flare-ups.

Long-acting bronchodilators take longer to start working but last longer. These are taken daily and can be combined with inhaled steroids.

Other treatments may also be used:

  • Steroid pills and antibiotics are often used to treat flare-ups.
  • Oxygen is used for people who have had COPD for a long time or have severe COPD.
  • Pulmonary rehabilitation teaches exercises to improve your breathing and ability to exercise.
  • Surgery may improve symptoms for some people with severe COPD.

Some inhalers open the airways and may be given regularly to prevent or reduce symptoms, and to relieve symptoms during acute flare-ups. Inhaled corticosteroids are sometimes given in combination with these to reduce inflammation in the lungs. 

Inhalers must be taken using the correct technique, and in some cases with a spacer device to help deliver the medication into the airways more effectively. Access to inhalers is limited in many low- and middle-income countries; in 2021 salbutamol inhalers were generally available in public primary health care facilities in half of low- and low-middle income countries.

Flare-ups are often caused by a respiratory infection, and people may be given an antibiotic or steroid tablets in addition to inhaled or nebulised treatment as needed. 

与慢性阻塞性肺病共处

改变生活方式可以帮助改善慢性阻塞性肺病的症状。

戒除吸烟或电子烟。这是最重要的事情。即使你已经吸烟多年，戒烟仍然有帮助。

避免二手烟雾或室内灶火产生的烟雾。

坚持身体活动。

防止自己的肺部感染：

  • 每年接种流感疫苗。
  • 接种肺炎疫苗。
  • 接种所有可得的COVID-19疫苗，并确保你接种了最新的加强剂。

必须让慢性阻塞性肺病患者了解其病情、治疗情况和自我护理方法，以帮助他们尽可能地保持身体活动和健康。

 

Living with COPD

Lifestyle changes can help improve symptoms of COPD.

Quit smoking or vaping. This is the most important thing to do. Even if you have been smoking for many years, quitting can still help.

Avoid second-hand smoke or smoke from indoor cooking fires.

Stay physically active.

Protect yourself from lung infections:

  • Get a flu vaccine every year.
  • Get the pneumonia vaccine.
  • Get all available COVID-19 vaccines and make sure you have had the latest boosters.

People living with COPD must be given information about their condition, treatment and self-care to help them to stay as active and healthy as possible.

世卫组织的反应

慢性阻塞性肺病已被列入世卫组织《预防和控制非传染性疾病全球行动计划》和联合国《2030年可持续发展议程》。

世卫组织正在采取行动，以多种方式扩大慢性阻塞性肺病诊断和治疗服务。

世卫组织制定了一揽子非传染性疾病基本干预措施（PEN），以帮助改善资源匮乏环境中初级卫生保健人员对非传染性疾病的管理工作。这些措施包括慢性呼吸系统疾病（哮喘和慢性阻塞性肺病）评估、诊断和管理规程以及健康生活方式咨询课程（包括戒烟和自我护理等）。

“康复2030”是一项新的战略方针，旨在优先考虑和加强卫生系统中的康复服务。作为世卫组织该项倡议的一部分，目前正在制定一揽子康复干预措施，其中就包含了慢性阻塞性肺病的肺部康复。

减少接触烟草烟雾对慢性阻塞性肺病的初级预防和疾病管理至关重要。《烟草控制框架公约》以及世卫组织推出的MPOWER措施和手机戒烟应用程序等推动了这一领域的进展。

进一步的预防活动包括世卫组织清洁家庭能源解决方案工具包，其目的在于促进家中的清洁和安全干预措施，并为制定政策提供便利，促进在地方、规划和国家一级采用清洁家庭能源。

全球抗击慢性呼吸疾病联盟为世卫组织努力防控慢性呼吸道疾病作出了贡献。它是国家和国际组织以及许多国家机构的自愿联盟，致力于实现全球各地人民自由呼吸的愿景。

 

WHO response

COPD is included in the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases (NCDs) and the United Nations 2030 Agenda for Sustainable Development.

WHO is taking action to extend diagnosis of and treatment for COPD in a number of ways.

The WHO Package of Essential Noncommunicable Disease Interventions (PEN) was developed to help improve NCD management in primary health care in low-resource settings. PEN includes protocols for the assessment, diagnosis and management of chronic respiratory diseases (asthma and chronic obstructive pulmonary disease), and modules on healthy lifestyle counselling, including tobacco cessation and self-care. 

Rehabilitation 2030 is a new strategic approach to prioritize and strengthen rehabilitation services in health systems. Pulmonary rehabilitation for COPD is included in the Package of Interventions for Rehabilitation, recently developed as part of this WHO initiative. 

Reducing tobacco smoke exposure is important for both primary prevention of COPD and disease management. The Framework Convention on Tobacco Control is enabling progress in this area as are WHO initiatives such as MPOWER and mTobacco Cessation.

Further prevention activities include the WHO Clean Household Energy Solutions Toolkit (CHEST) to promote clean and safe interventions in the home and facilitate the design of policies that promote the adoption of clean household energy at local, programmatic and national levels.

The Global Alliance against Chronic Respiratory Diseases (GARD) contributes to WHO’s work to prevent and control chronic respiratory diseases. GARD is a voluntary alliance of national and international organizations and agencies from many countries committed to the vision of a world where all people breathe freely. 

 

 

#慢性阻塞性肺病#COPD#慢性阻塞性支气管炎；肺气肿