病情加重后,请确保患者了解他们的常规治疗方案并评估其吸入器使用方法。讨论依从其常规 COPD 药物治疗的重要性,并向患者解释如果不按照处方要求坚持常规用药方案,可能会出现体征和症状恶化。[164]Gross N, Levin D. Primary care of the patient with chronic obstructive pulmonary disease-part 2: pharmacologic treatment across all stages of disease. Am J Med. 2008 Jul;121(7 Suppl):S13-24.
http://www.ncbi.nlm.nih.gov/pubmed/18558103?tool=bestpractice.com
稳定期 COPD 的管理目标是减少进一步加重。[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
此外,建议患者继续采取有助于预防进一步加重的其他措施,例如接种季节性疫苗、戒烟和避免诱因;考虑酌情给予预防性药物治疗。有关更多信息,请参阅一级预防。
必要时补充维生素 D。对严重缺乏维生素 D 的患者给予补剂可降低加重和住院率。[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
与未罹患 COPD 的人群相比,COPD 患者的体力活动水平往往更低,而低体力活动水平与肺功能下降速度更快以及因 COPD 加重而住院的发生率增加相关。[158]Garcia-Aymerich J, Lange P, Benet M, et al. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax. 2006 Sep;61(9):772-8.
https://thorax.bmj.com/content/61/9/772.long
http://www.ncbi.nlm.nih.gov/pubmed/16738033?tool=bestpractice.com
[165]Pitta F, Troosters T, Probst VS, et al. Physical activity and hospitalization for exacerbation of COPD. Chest. 2006 Mar;129(3):536-44.
http://www.ncbi.nlm.nih.gov/pubmed/16537849?tool=bestpractice.com
[166]Garcia-Aymerich J, Lange P, Benet M, et al. Regular physical activity modifies smoking-related lung function decline and reduces risk of chronic obstructive pulmonary disease: a population-based cohort study. Am J Respir Crit Care Med. 2007 Mar 1;175(5):458-63.
http://www.ncbi.nlm.nih.gov/pubmed/17158282?tool=bestpractice.com
鼓励患者在有条件的情况下参与肺康复计划。肺康复是一种多学科模式的治疗照护方案,身体康复的同时还需要对疾病管理、营养、其他生活方式问题(例如戒烟、用药依从性和吸入装置使用方法、氧疗和保持体力活动)予以指导。[152]Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013 Oct 15;188(8):e13-64.
http://www.ncbi.nlm.nih.gov/pubmed/24127811?tool=bestpractice.com
这些措施可以提高运动耐量、体能和生活质量,因此在预防后续加重方面起着重要作用。[151]Puhan MA, Gimeno-Santos E, Cates CJ, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016 Dec 8;(12):CD005305.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005305.pub4/full
http://www.ncbi.nlm.nih.gov/pubmed/27930803?tool=bestpractice.com
患者病情稳定后,如果可行,请考虑居家医院(hospital-at-home)或辅助出院方案。[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
[149]Echevarria C, Gray J, Hartley T, et al. Home treatment of COPD exacerbation selected by DECAF score: a non-inferiority, randomised controlled trial and economic evaluation. Thorax. 2018 Aug;73(8):713-22.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6204956
http://www.ncbi.nlm.nih.gov/pubmed/29680821?tool=bestpractice.com
[150]Jeppesen E, Brurberg KG, Vist GE, et al. Hospital at home for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 May 16;(5):CD003573.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003573.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/22592692?tool=bestpractice.com
[ ]
What are the effects of hospital-at-home in adults with acute exacerbations of chronic obstructive pulmonary disease?/cca.html?targetUrl=http://cochraneclinicalanswers.com/doi/10.1002/cca.1062/full展示答案 决定哪些患者适合此类方案以及此类方案的实施将需要团队合作。请考虑患者因素和偏好。[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
考虑使用经过验证的预后评分,例如 DECAF 评分,以确定哪些患者适合这种方法。[149]Echevarria C, Gray J, Hartley T, et al. Home treatment of COPD exacerbation selected by DECAF score: a non-inferiority, randomised controlled trial and economic evaluation. Thorax. 2018 Aug;73(8):713-22.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6204956
http://www.ncbi.nlm.nih.gov/pubmed/29680821?tool=bestpractice.com
急性加重后出院 30 天内门诊随访有助于预防再入院和疾病复发。[167]Sharma G, Kuo YF, Freeman JL, et al. Outpatient follow-up visit and 30-day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease. Arch Intern Med. 2010 Oct 11;170(18):1664-70.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2977945
http://www.ncbi.nlm.nih.gov/pubmed/20937926?tool=bestpractice.com
行动计划可以帮助患者认识恶化的症状、开始更早期治疗和减少加重的总体影响。[81]Criner GJ, Bourbeau J, Diekemper RL, et al. Prevention of acute exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline. Chest. 2015 Apr;147(4):894-942.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388124
http://www.ncbi.nlm.nih.gov/pubmed/25321320?tool=bestpractice.com
[168]Howcroft M, Walters EH, Wood-Baker R, Walters JA. Action plans with brief patient education for exacerbations in chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016 Dec 19;(12):CD005074.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005074.pub4/full
http://www.ncbi.nlm.nih.gov/pubmed/27990628?tool=bestpractice.com
[ ]
What are the effects of action plans with limited patient education only in reducing exacerbations of chronic obstructive pulmonary disease?/cca.html?targetUrl=http://cochraneclinicalanswers.com/doi/10.1002/cca.1545/full展示答案
虽然在一些地区,可通过远程医疗实现居家疾病监测和管理干预,[169]McLean S, Nurmatov U, Liu JL, et al. Telehealthcare for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD007718.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007718.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/21735417?tool=bestpractice.com
目前不建议将其用于预防加重。[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
[81]Criner GJ, Bourbeau J, Diekemper RL, et al. Prevention of acute exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline. Chest. 2015 Apr;147(4):894-942.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388124
http://www.ncbi.nlm.nih.gov/pubmed/25321320?tool=bestpractice.com
随机对照试验显示,应用护士为中心的远程辅助方案可以减少 COPD 加重、急诊就医和住院的发生。[169]McLean S, Nurmatov U, Liu JL, et al. Telehealthcare for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD007718.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007718.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/21735417?tool=bestpractice.com
这种方法的应用可以节约费用。[170]Vitacca M, Bianchi L, Guerra A, et al. Tele-assistance in chronic respiratory failure patients: a randomised clinical trial. Eur Respir J. 2009 Feb;33(2):411-8.
https://erj.ersjournals.com/content/33/2/411.long
http://www.ncbi.nlm.nih.gov/pubmed/18799512?tool=bestpractice.com
其他分析显示,家庭远程监测可以延长不住院治疗或急诊室就诊的时间,[171]OHTAC COPD Collaborative. Chronic obstructive pulmonary disease (COPD) evidentiary framework. Ont Health Technol Assess Ser. 2012;12(2):1-97.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3384372
http://www.ncbi.nlm.nih.gov/pubmed/23074430?tool=bestpractice.com
但是总的住院次数可能不受影响,另一项随机对照试验显示没有明确获益。[172]Pinnock H, Hanley J, McCloughan L, et al. Effectiveness of telemonitoring integrated into existing clinical services on hospital admission for exacerbation of chronic obstructive pulmonary disease: researcher blind, multicentre, randomised controlled trial. BMJ. 2013 Oct 17;347:f6070.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805483
http://www.ncbi.nlm.nih.gov/pubmed/24136634?tool=bestpractice.com