最后审阅: 18 九月 2021
最后更新: 26 五月 2021
23 Apr 2021

国际指南更新了针对 COVID-19 大流行期间 COPD 急性加重患者的建议

慢性阻塞性肺疾病全球倡议(Global Initiative for Chronic Obstructive Lung Disease, GOLD)已发布 2021 版 COPD 诊断和管理报告

鉴于持续的 COVID-19 大流行,关于急性加重的新管理建议包括以下内容

  • 如果 COPD 患者出现新发或不断恶化的呼吸道症状、发热和/或任何其他可能与 COVID-19 相关的症状(即使是轻度症状),安排进行严重急性呼吸综合征冠状病毒2(severe acute respiratory syndrome coronavirus 2, SARS-CoV-2)聚合酶链反应检测。在实践中,可能很难在临床上鉴别 COVID-19 和 COPD 急性加重

  • 社区 COVID-19 高度流行期间,只有在肺量测定会明确影响或改变患者的紧急或基础管理方案时,才采用该检查

  • 根据常规适应证使用全身性皮质类固醇治疗 COPD 急性加重,无论是否存在 SARS-COV-2 感染的证据

    • 没有证据表明这种方法会改变患者对 SARS-CoV-2 感染的易感性,或会使结局恶化

  • 根据常规适应证使用抗生素治疗 COPD 急性加重,无论是否存在 SARS-COV-2 感染的证据

    • 这一点特别重要,因为同时患有 COVID-19 的 COPD 患者经常发生细菌或真菌性同时感染

在 COVID-19 大流行期间,使用雾化器之前,请寻求呼吸专科医师的意见并查阅当地指南。目前,对于使用雾化器是否会产生气溶胶,不同国家/地区的组织存在不同看法

  • GOLD 建议尽量少使用雾化器,建议理想情况下应使用吸入器实现药物递送。GOLD 认同,接受通气支持的 COVID-19 危重患者可能需要使用雾化器。GOLD 建议在绝对必要时(例如,针对接受通气支持的患者)使用网式雾化器(以保持回路完整并防止病毒传播)

  • 然而,根据英格兰公共卫生部和英国国家卫生与临床优化研究所的意见,认为雾化器并不代表显著的 COVID-19 感染风险。[90][91]

有关 COVID-19 的更多详细信息,请参阅主题 Coronavirus disease 2019 (COVID-19). external link opens in a new window

查看诊断:诊断建议

查看治疗:治疗路径

更新原始来源external link opens in a new window

小结

定义

病史和体格检查

关键诊断因素

  • 呼吸困难
  • 咳嗽
  • 痰液脓性成分增加、痰量增多
  • 喘鸣
  • 胸闷/胸痛
  • 呼吸急促
  • 心动过速
  • 危险因素
  • 肺心病

其他诊断因素

  • 呼吸衰竭体征
  • 发热
  • 胃食管反流和/或吞咽功能障碍

危险因素

  • 细菌感染
  • 胃食管反流和/或吞咽功能障碍
  • 病毒感染
  • 污染物
  • 非典型细菌感染
  • 天气变化

诊断性检查

首要检查

  • 动脉血气(医院)
  • 脉搏血氧测定(医院及社区情境)
  • ECG(适用于医院情境,如社区有条件,也可使用)
  • FBC,包括血小板(医院)
  • 尿素、电解质和肌酐(医院)
  • CRP(医院)
  • CXR(医院)
  • 痰液镜检、培养和革兰染色(医院)
  • 维生素 D(医院或社区)

需考虑的检查

  • 血液培养
  • 呼吸道病毒诊断
  • 心肌肌钙蛋白
  • 血清茶碱水平
  • 脑利钠肽(brain natriuretic peptide, BNP)前体
  • 胸部 CT 扫描
  • 肺量测定法

新兴检查

  • 降钙素原
  • 床旁即时 CRP

治疗流程

急症处理
持续性治疗

撰稿人

专家顾问

Jonathan Bennett, MD

Honorary Professor of Respiratory Sciences

University of Leicester

Respiratory Consultant

Glenfield Hospital

Leicester

UK

简介

JB is Chair of the British Thoracic Society.

利益声明

JB declares that he has no competing interests.

Richard Russell,

Specialty Registrar in Respiratory Medicine

Glenfield Hospital

Leicester

UK

利益声明

RJR received sponsorship from AstraZeneca to attend a conference, May 2018 (covering travel, accommodation, and conference fee).

Acknowledgements,

BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work has been retained in parts of the content:

Carolyn L. Rochester MD

Associate Professor

Yale University School of Medicine

New Haven

VA Connecticut Healthcare System

West Haven

CT

Richard A. Martinello MD

Associate Professor

Yale University School of Medicine

New Haven

Veterans Health Administration

Office of Public Health

West Haven

CT

利益声明

CLR serves on the COPD scientific advisory board for GlaxoSmithKline Pharmaceuticals but has no competing interests pertaining to this publication. RAM declares that he has no competing interests.

同行评议者

Carlos Echevarria,

Consultant Respiratory Physician

Royal Victoria Infirmary

Newcastle upon Tyne

UK

利益声明

CE declares that he has no competing interests.

编辑

Emma Quigley,

Section Editor, BMJ Best Practice

利益声明

EQ declares that she has no competing interests.

Tannaz Aliabadi-Oglesby,

Lead Section Editor, BMJ Best Practice

利益声明

TAO declares that she has no competing interests.

Julie Costello,

Comorbidities Editor, BMJ Best Practice

利益声明

JC declares that she has no competing interests.

Adam Mitchell,

Drug Editor, BMJ Best Practice

利益声明

AM declares that he has no competing interests.

专家顾问:合并症

Martyn Patel, BMBcH, FRCP, MA

Consultant, Older People's Medicine

Norfolk and Norwich University Hospitals

NHS Foundation Trust

Norwich

UK

利益声明

MP has accepted speaker fees and/or travel expenses to deliver lectures from: University of East Anglia, Leicester University (speaker fees only); Astellas Pharma Ltd (speaker fees and travel expenses). MP has accepted travel expenses from Newton Europe to present a joint project conducted by his main employer (Norfolk and Norwich University Hospitals NHS Trust) and Newton Europe at the NHS Confederation conference (Manchester 2018). MP has accepted sponsorship for travel expenses and accommodation costs from Astellas Pharma Ltd to attend the European Geriatric Society Meeting (Lisbon 2016).

Andrew Lewington, BSc (Hons), MBBS, MEd, MD, FRCP

Consultant Renal Physician

Honorary Associate Professor

Nephrology Department

Leeds Teaching Hospitals NHS Trust

Leeds

UK

利益声明

AL is Associate Clinical Director of NIHR Leeds In-Vitro Diagnostics Co-operative, Co-Chair of UK Kidney Research Consortium Renal Clinical Study Group, Member of Kidney Research UK Research Grant Committee, Committee Member of NICE Kidney Injury Clinical Guideline Update 2018-20, Committee Member of NICE Diagnostic Assessment for Point of Care Creatinine Testing 2018-19. AL attended the Acute Dialysis Quality Initiative Meeting in San Diego 2018 (accommodation expenses); AL was a speaker at the AKI & CRRT Conference in San Diego 2019 (travel and accommodation expenses), the AKI Conference in Coventry 2019 (travel expenses), and the NIHR AKI and Sepsis Meeting in Leeds 2019 (no expenses).

Martin Cowie, MD, MSc, FRCP, FRCP (Ed), FESC, FHFA, FACC

Professor of Cardiology

Imperial College London (Royal Brompton Hospital)

London

UK

利益声明

MC is a non-executive director of NICE and chair of the Digital Health Committee of the European Society of Cardiology. MC’s university receives support for his research from Abbott, ResMed, Boston Scientific, and Medtronic. MC speaks at educational events and provides consultancy advice to several device, diagnostic, and pharmaceutical companies including Novartis, Servier, Bayer, Pfizer, AstraZeneca, Boehringer Ingelheim, Roche Diagnostics, Medtronic, Abbott, ResMed, and Boston Scientific. MC declares that none of these interests is directly related to topics advised on for this project.

Rachael Evans, MBChB, FRCP (UK), PhD

Associate Professor (Clinical)

University of Leicester

Honorary Consultant Respiratory Physician

Glenfield Hospital

Leicester

UK

利益声明

RAE has been reimbursed for a GSK Advisory Board meeting on Physical Activity and Asthma in November 2016, and three Chiesi Education meetings for GPs on COPD care in 2019. RAE received a travel award for ERS 2017 from Chiesi and participated in the GSK clinical experience programme - respiratory in August 2018. RAE participated in the BTS/SIGN guidelines for asthma update 2016 (no fee).

Gerry Rayman, MD, FRCP

Consultant Physician and Head of Service

Diabetes and Endocrine Centre and the Diabetes Research Unit

Ipswich Hospitals NHS Trust

Ipswich

UK

利益声明

GR has been paid for advisory board meetings with the following companies: Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Bayer. GR has received lecture fees from Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Novonordisk, Napp Pharmaceuticals Ltd.

Sotiris Posporelis, MD, MRCPsych

Consultant Liaison Neuropsychiatrist

King’s College Hospital

South London and Maudsley NHS Foundation Trust

Honorary Senior Clinical Lecturer

Institute of Psychiatry, Psychology & Neuroscience

King’s College London

London

UK

利益声明

SP declares that he has no competing interests.

Hamish McAuley, MBBS, BSc, MRCP

Clinical Research Fellow

Specialist Registrar (ST5)

Department of Respiratory Sciences

University of Leicester

Respiratory Biomedical Research Unit

Glenfield Hospital

Leicester

UK

利益声明

HM declares that he has no competing interests.

同行评议:合并症

Martyn Patel, BMBcH, FRCP, MA

Consultant, Older People's Medicine

Norfolk and Norwich University Hospitals

NHS Foundation Trust

Norwich

UK

利益声明

MP has accepted speaker fees and/or travel expenses to deliver lectures from: University of East Anglia, Leicester University (speaker fees only); Astellas Pharma Ltd (speaker fees and travel expenses). MP has accepted travel expenses from Newton Europe to present a joint project conducted by his main employer (Norfolk and Norwich University Hospitals NHS Trust) and Newton Europe at the NHS Confederation conference (Manchester 2018). MP has accepted sponsorship for travel expenses and accommodation costs from Astellas Pharma Ltd to attend the European Geriatric Society Meeting (Lisbon 2016).

Simon Conroy, MBChB, FRCP, PhD

Professor of Geriatric Medicine

University of Leicester

Honorary Geriatrician

University Hospitals of Leicester

Leicester

UK

利益声明

SC declares that he has no competing interests.

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