采集病史,涵盖可能导致 COPD 加重的危险因素,包括:
经肺量测定确诊的 COPD。
询问既往急性加重情况以及是否使用过无创通气,因为过去一年内出现 ≥2 次加重或曾因急性加重而住院治疗的患者,其后续发生急性加重的风险更高。[24]Soler-Cataluña JJ, Martínez-García MA, Román Sánchez P, et al. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease. Thorax. 2005 Nov;60(11):925-31.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1747235
http://www.ncbi.nlm.nih.gov/pubmed/16055622?tool=bestpractice.com
[55]Hurst JR, Vestbo J, Anzueto A, et al. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med. 2010 Sep 16;363(12):1128-38.
https://www.nejm.org/doi/10.1056/NEJMoa0909883
http://www.ncbi.nlm.nih.gov/pubmed/20843247?tool=bestpractice.com
查看患者病历,检查最近的肺量测定结果,以确诊 COPD。[91]Royal College of Physicians. National Asthma and Chronic Obstructive Pulmonary Disease Audit Programme (NACAP): COPD clinical audit 2017/18 (people with COPD exacerbations discharged from acute hospitals in England and Wales between September 2017 and 2018) - clinical audit report. May 2019 [internet publication].
https://www.rcplondon.ac.uk/projects/outputs/national-asthma-and-copd-audit-programme-nacap-copd-clinical-audit-201718
如果没有已记录的肺量测定结果,并且患者因病情急性加重而入院,请安排肺量测定以确诊 COPD。[91]Royal College of Physicians. National Asthma and Chronic Obstructive Pulmonary Disease Audit Programme (NACAP): COPD clinical audit 2017/18 (people with COPD exacerbations discharged from acute hospitals in England and Wales between September 2017 and 2018) - clinical audit report. May 2019 [internet publication].
https://www.rcplondon.ac.uk/projects/outputs/national-asthma-and-copd-audit-programme-nacap-copd-clinical-audit-201718
社区 COVID-19 高度流行期间,肺量测定应限于需要紧急或必要的检查以诊断 COPD 和/或评估肺功能状态以考虑介入治疗操作或手术的患者。[1]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2022 report. 2022 [internet publication].
https://goldcopd.org/2022-gold-reports
[97]Association for Respiratory Technology and Physiology. ARTP COVID19 update: 9th April 2020. April 2020 [internet publication].
https://www.artp.org.uk/News/artp-covid19-april2020
询问症状变化:现有症状是否恶化?是否出现新症状?症状已出现多长时间?
近期感染[1]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2022 report. 2022 [internet publication].
https://goldcopd.org/2022-gold-reports
[88]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. July 2019 [internet publication].
https://www.nice.org.uk/guidance/ng115
询问患者最近 5 天是否出现咳嗽加剧、呼吸困难或黏液脓性痰。询问患者是否出现发热或是否注意到痰液发生变化。
病毒感染是病情加重的主要原因,而人鼻病毒是最常见的病原体。[1]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2022 report. 2022 [internet publication].
https://goldcopd.org/2022-gold-reports
病毒感染也可能单独引起痰液产生增加或导致环境改变,从而继发细菌感染。[93]White AJ, Gompertz S, Stockley RA. Chronic obstructive pulmonary disease . 6: The aetiology of exacerbations of chronic obstructive pulmonary disease. Thorax. 2003 Jan;58(1):73-80.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1746462
http://www.ncbi.nlm.nih.gov/pubmed/12511727?tool=bestpractice.com
在 COPD 加重患者中最常检出的细菌性病原体包括流感嗜血杆菌、肺炎链球菌和卡他莫拉菌。[31]Woodhead M, Blasi F, Ewig S, et al. Guidelines for the management of adult lower respiratory tract infections - full version. Clin Microbiol Infect. 2011 Nov;17 Suppl 6:E1-59.
https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(14)61404-X/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/21951385?tool=bestpractice.com
[51]Wedzicha JA, Seemungal TA. COPD exacerbations: defining their cause and prevention. Lancet. 2007 Sep 1;370(9589):786-96.
http://www.ncbi.nlm.nih.gov/pubmed/17765528?tool=bestpractice.com
病毒性和细菌性病原体同时感染并不少见。
Practical tip
询问患者既往是否出现过加重时,请记住,他们可能不会从“加重”的角度来思考,而有可能告诉您,他们之前曾因“胸部感染”而接受了抗生素和皮质类固醇治疗。
询问患者所出现的一系列症状(咳嗽加剧、呼吸困难或黏液脓性痰)或询问以下有关既往史的特定问题可能有所帮助:
既往到医院就诊的情况
既往到 GP 处就诊的情况
既往口服皮质类固醇或抗生素疗程。
加重的症状通常持续 7-10 天,但也可能更长。[1]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2022 report. 2022 [internet publication].
https://goldcopd.org/2022-gold-reports
吸烟
询问患者当前是否吸烟和/或曾暴露于大量烟草烟雾。[88]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. July 2019 [internet publication].
https://www.nice.org.uk/guidance/ng115
暴露于污染[88]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. July 2019 [internet publication].
https://www.nice.org.uk/guidance/ng115
询问是否暴露于杀虫剂、木材燃烧烟雾、粉尘和其他污染物。
这可能包括室内明火烹饪所产生的生物燃料暴露。
检查患者的职业。某些职业可能使患者暴露于污染物或刺激物,这些物质可能导致病情加重。
短期暴露于细颗粒物与急性加重致住院率增加以及死亡率增加有关。[1]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2022 report. 2022 [internet publication].
https://goldcopd.org/2022-gold-reports