对所有患者进行关于疾病病程、急性加重或失代偿时症状方面的教育。他们对疾病的预期、治疗和预后不应过于乐观。重要的是记住目前没有药物可以修复长期下降的肺功能,药物治疗的主要目标是控制症状和预防并发症。
一项 Cochrane 评价发现,若自我管理干预措施中纳入针对 COPD 急性加重的行动计划,则其可改善卫生健康相关的生活质量并减少由呼吸问题所致的入院次数。一项探索性分析发现,相比常规治疗,采用自我管理措施引起了患者呼吸相关死亡率统计学上的显著升高(尽管死亡率不高),但并未发现全因死亡率具有超额危险度[133]Lenferink A, Brusse-Keizer M, van der Valk PD, et al. Self-management interventions including action plans for exacerbations versus usual care in patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Aug 4;(8):CD011682.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011682.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/28777450?tool=bestpractice.com
自我管理计划应包含以下各方面的个体化建议:呼吸困难和压力管理技巧、节省能量、避免恶化因素、如何监测症状、如何管理恶化症状,以及在加重时使用的联系信息。[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2023 report [internet publication].
https://goldcopd.org/2023-gold-report-2
理想情况下,帮助患者进行自我管理应能解决社会心理问题以及患者对 COPD 及其管理的个人观念。许多患者报告在诊断为 COPD 后,出现生活方式和社交方面困扰并受到限制。 据估计,COPD 患者的自杀死亡可能性是非 COPD 患者的 1.9 倍,焦虑、抑郁和沮丧症状十分常见。[135]Sampaio MS, Vieira WA, Bernardino ÍM, et al. Chronic obstructive pulmonary disease as a risk factor for suicide: A systematic review and meta-analysis. Respir Med. 2019 May;151:11-18.
https://www.doi.org/10.1016/j.rmed.2019.03.018
http://www.ncbi.nlm.nih.gov/pubmed/31047105?tool=bestpractice.com
[136]Russell S, Ogunbayo OJ, Newham JJ, et al. Qualitative systematic review of barriers and facilitators to self-management of chronic obstructive pulmonary disease: views of patients and healthcare professionals. NPJ Prim Care Respir Med. 2018 Jan 17;28(1):2.
https://www.doi.org/10.1038/s41533-017-0069-z
http://www.ncbi.nlm.nih.gov/pubmed/29343739?tool=bestpractice.com
研究发现,认知行为治疗(behavioural therapy, CBT)对包括抑郁和焦虑症状、生活质量和急诊就诊频率在内的结局有所获益。[137]Pollok J, van Agteren JE, Esterman AJ, et al. Psychological therapies for the treatment of depression in chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2019 Mar 6;3:CD012347.
https://www.doi.org/10.1002/14651858.CD012347.pub2
http://www.ncbi.nlm.nih.gov/pubmed/30838649?tool=bestpractice.com
[138]Ma RC, Yin YY, Wang YQ, et al. Effectiveness of cognitive behavioural therapy for chronic obstructive pulmonary disease patients: a systematic review and meta-analysis. Complement Ther Clin Pract. 2020 Feb;38:101071.
http://www.ncbi.nlm.nih.gov/pubmed/31743870?tool=bestpractice.com
[139]Williams MT, Johnston KN, Paquet C. Cognitive behavioral therapy for people with chronic obstructive pulmonary disease: rapid review. Int J Chron Obstruct Pulmon Dis. 2020;15:903-19.
https://www.doi.org/10.2147/COPD.S178049
http://www.ncbi.nlm.nih.gov/pubmed/32425516?tool=bestpractice.com
需对高资源密集型与低资源密集型 CBT 的效果进行进一步研究。[139]Williams MT, Johnston KN, Paquet C. Cognitive behavioral therapy for people with chronic obstructive pulmonary disease: rapid review. Int J Chron Obstruct Pulmon Dis. 2020;15:903-19.
https://www.doi.org/10.2147/COPD.S178049
http://www.ncbi.nlm.nih.gov/pubmed/32425516?tool=bestpractice.com
一项随机对照临床试验发现,在初级医疗卫生中,旨在促进轻度 COPD 患者行为改变的电话健康指导干预可改善患者的自我管理活动,但并未改善与卫生健康相关的生活质量。[140]Jolly K, Sidhu MS, Hewitt CA, et al. Self management of patients with mild COPD in primary care: randomised controlled trial. BMJ. 2018 Jun 13;361:k2241.
https://www.bmj.com/content/361/bmj.k2241.long
http://www.ncbi.nlm.nih.gov/pubmed/29899047?tool=bestpractice.com
一项 meta 分析发现,包括目标设定、动机性访谈以及与 COPD 相关健康教育在内的健康指导能显著改善与健康相关的生活质量,并减少因 COPD 加重而入院的次数,但并未减少全因入院次数。[141]Long H, Howells K, Peters S, et al. Does health coaching improve health-related quality of life and reduce hospital admissions in people with chronic obstructive pulmonary disease? A systematic review and meta-analysis. Br J Health Psychol. 2019 Sep;24(3):515-46.
https://www.doi.org/10.1111/bjhp.12366
http://www.ncbi.nlm.nih.gov/pubmed/31033121?tool=bestpractice.com
患者应该尽可能保持健康和活动。停止主动或被动吸烟以及避免有毒烟雾的环境暴露非常必要。
定期内科随访对于优化治疗很有必要。如果有任何症状加重,需要立即就医。
在航空旅行之前改善患者病情,并评估他们是否需要在飞行途中吸氧。建议患者在手提行李中携带所有药物和储雾罐装置,并将急症用药放在飞行途中触手可及的地方。可能需要采取静脉血栓栓塞预防措施,尤其是对于长途飞行。接受持续氧疗的患者在飞行旅程中可能需要提高氧流量。[190]British Thoracic Society. Air travel. March 2022 [internet publication].
https://www.brit-thoracic.org.uk/quality-improvement/clinical-statements/air-travel
推荐所有 COPD 患者参与并坚持体力活动。[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2023 report [internet publication].
https://goldcopd.org/2023-gold-report-2
对随机对照临床试验进行的一项系统评价和荟萃分析发现,运动训练本身可以改善 COPD 患者的身体活动,并且通过辅以体育活动咨询可进一步改善状况。[151]Lahham A, McDonald CF, Holland AE. Exercise training alone or with the addition of activity counseling improves physical activity levels in COPD: a systematic review and meta-analysis of randomized controlled trials. Int J Chron Obstruct Pulmon Dis. 2016 Dec 8;11:3121-36.
https://www.dovepress.com/exercise-training-alone-or-with-the-addition-of-activity-counseling-im-peer-reviewed-fulltext-article-COPD
http://www.ncbi.nlm.nih.gov/pubmed/27994451?tool=bestpractice.com
另一项系统评价和 meta 分析发现,在增加腿部肌肉力量方面,将有氧运动和力量训练相结合比仅进行有氧运动更有效,但就健康相关生活质量、行走距离或运动能力而言,两者之间并无差异。[249]Iepsen UW, Jørgensen KJ, Ringbæk T, et al. A combination of resistance and endurance training increases leg muscle strength in COPD: An evidence-based recommendation based on systematic review with meta-analyses. Chron Respir Dis. 2015 May;12(2):132-45.
https://www.doi.org/10.1177/1479972315575318
http://www.ncbi.nlm.nih.gov/pubmed/25767138?tool=bestpractice.com
其他研究表明,坚持有监督和无监督的锻炼计划后,峰值摄氧量、乏力感和健康相关性生活质量均有所改善。[153]Ward TJC, Plumptre CD, Dolmage TE, et al. Change in VO2peak in response to aerobic exercise training and the relationship with exercise prescription in people with COPD: a systematic review and meta-analysis. Chest. 2020 Jul;158(1):131-14.
https://www.doi.org/10.1016/j.chest.2020.01.053
http://www.ncbi.nlm.nih.gov/pubmed/32173489?tool=bestpractice.com
[154]Paneroni M, Vitacca M, Venturelli M, et al. The impact of exercise training on fatigue in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Pulmonology. 2020 Sep - Oct;26(5):304-13.
http://www.ncbi.nlm.nih.gov/pubmed/32184070?tool=bestpractice.com
[155]Taylor D, Jenkins AR, Parrott K, et al. Efficacy of unsupervised exercise in adults with obstructive lung disease: a systematic review and meta-analysis. Thorax. 2021 Jun;76(6):591-600.
http://www.ncbi.nlm.nih.gov/pubmed/33685962?tool=bestpractice.com
一项 Cochrane 评价发现,在体力活动辅导、运动训练和 COPD 药物管理改善体力活动方面,证据有限。作者指出,由于缺少方法学细节,质量评估受到限制,并且各种干预措施主要是在单项研究中被评估。[156]Burge AT, Cox NS, Abramson MJ, et al. Interventions for promoting physical activity in people with chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2020 Apr 16;4:CD012626.
https://www.doi.org/10.1002/14651858.CD012626.pub2
http://www.ncbi.nlm.nih.gov/pubmed/32297320?tool=bestpractice.com
[
]
Which interventions lead to increased regular physical activity for people with chronic obstructive pulmonary disease (COPD)?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.3155/full展示答案 改善体力活动的最佳时机、因素、持续时间和模式尚不清楚。荟萃分析表明,瑜伽、气功和其他居家呼吸练习可改善 COPD 患者运动能力和肺功能。[157]Cramer H, Haller H, Klose P, et al. The risks and benefits of yoga for patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Clin Rehabil. 2019 Dec;33(12):1847-62.
http://www.ncbi.nlm.nih.gov/pubmed/31353959?tool=bestpractice.com
[158]Tong H, Liu Y, Zhu Y, et al. The therapeutic effects of qigong in patients with chronic obstructive pulmonary disease in the stable stage: a meta-analysis. BMC Complement Altern Med. 2019 Sep 4;19(1):239.
https://www.doi.org/10.1186/s12906-019-2639-9
http://www.ncbi.nlm.nih.gov/pubmed/31484521?tool=bestpractice.com
[159]Lu Y, Li P, Li N, et al. Effects of home-based breathing exercises in subjects with COPD. Respir Care. 2020 Mar;65(3):377-87.
https://www.doi.org/10.4187/respcare.07121
http://www.ncbi.nlm.nih.gov/pubmed/31719191?tool=bestpractice.com
与常规治疗相比,太极拳已被证明可以改善运动能力。[160]Liu X, Fu C, Hu W, et al. The effect of Tai Chi on the pulmonary rehabilitation of chronic obstructive pulmonary disease: a systematic review and meta-analysis. Ann Palliat Med. 2021 Apr;10(4):3763-82.
https://www.doi.org/10.21037/apm-20-940
http://www.ncbi.nlm.nih.gov/pubmed/33894710?tool=bestpractice.com
已发现饮食建议和口服补剂可改善体重、生活质量、呼吸肌力量和 6 分钟步行距离。[161]Collins PF, Elia M, Stratton RJ. Nutritional support and functional capacity in chronic obstructive pulmonary disease: a systematic review and meta-analysis. Respirology. 2013 May;18(4):616-29.
https://www.doi.org/10.1111/resp.12070
http://www.ncbi.nlm.nih.gov/pubmed/23432923?tool=bestpractice.com
[162]Ferreira IM, Brooks D, White J, et al. Nutritional supplementation for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Dec 12;12:CD000998.
https://www.doi.org/10.1002/14651858.CD000998.pub3
http://www.ncbi.nlm.nih.gov/pubmed/23235577?tool=bestpractice.com
然而,营养支持并未一致发现对于肺功能有所改善。[162]Ferreira IM, Brooks D, White J, et al. Nutritional supplementation for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Dec 12;12:CD000998.
https://www.doi.org/10.1002/14651858.CD000998.pub3
http://www.ncbi.nlm.nih.gov/pubmed/23235577?tool=bestpractice.com
使用吸入治疗的患者应接受吸入器装置使用方法培训。多数患者在使用吸入器时至少犯一种错误,并且错误使用吸入器与疾病控制能力下降有关。[142]Cho-Reyes S, Celli BR, Dembek C, et al. Inhalation technique errors with metered-dose inhalers among patients with obstructive lung diseases: a systematic review and meta-analysis of US Studies. Chronic Obstr Pulm Dis. 2019 Jul 24;6(3):267-80.
https://www.doi.org/10.15326/jcopdf.6.3.2018.0168
http://www.ncbi.nlm.nih.gov/pubmed/31342732?tool=bestpractice.com
[143]Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011 Jun;105(6):930-8.
https://www.doi.org/10.1016/j.rmed.2011.01.005
http://www.ncbi.nlm.nih.gov/pubmed/21367593?tool=bestpractice.com
当患者使用多种装置或从未接受过吸入器装置使用方法培训时,更可能使用不当。[144]Rootmensen GN, van Keimpema AR, Jansen HM, et al. Predictors of incorrect inhalation technique in patients with asthma or COPD: a study using a validated videotaped scoring method. J Aerosol Med Pulm Drug Deliv. 2010 Oct;23(5):323-8.
http://www.ncbi.nlm.nih.gov/pubmed/20804428?tool=bestpractice.com
临床医生演示吸入器用法、选用合适的装置以及在后续复诊时检查使用方法均可改善吸入器使用技术。[145]Price D, Keininger DL, Viswanad B, et al. Factors associated with appropriate inhaler use in patients with COPD - lessons from the REAL survey. Int J Chron Obstruct Pulmon Dis. 2018;13:695-702.
https://www.doi.org/10.2147/COPD.S149404
http://www.ncbi.nlm.nih.gov/pubmed/29520137?tool=bestpractice.com
对于 ≥65 岁的成人,使用安慰剂装置示范对教授吸入器使用方法可能最有效。[146]Maricoto T, Monteiro L, Gama JMR, et al. Inhaler technique education and exacerbation risk in older adults with asthma or chronic obstructive pulmonary disease: a meta-analysis. J Am Geriatr Soc. 2019 Jan;67(1):57-66.
http://www.ncbi.nlm.nih.gov/pubmed/30291745?tool=bestpractice.com
应让患者将吸入器带到门诊,以便检查吸入器的使用情况。[1]Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2023 report [internet publication].
https://goldcopd.org/2023-gold-report-2
药师主导的干预和非专业健康指导可改善 COPD 患者吸入器使用技术和依从性。[147]Jia X, Zhou S, Luo D, et al. Effect of pharmacist-led interventions on medication adherence and inhalation technique in adult patients with asthma or COPD: a systematic review and meta-analysis. J Clin Pharm Ther. 2020 Oct;45(5):904-17.
https://www.doi.org/10.1111/jcpt.13126
http://www.ncbi.nlm.nih.gov/pubmed/32107837?tool=bestpractice.com
[148]Willard-Grace R, Chirinos C, Wolf J, et al. Lay health coaching to increase appropriate inhaler use in COPD: a randomized controlled trial. Ann Fam Med. 2020 Jan;18(1):5-14.
https://www.doi.org/10.1370/afm.2461
http://www.ncbi.nlm.nih.gov/pubmed/31937527?tool=bestpractice.com
吸入装置的优点(例如快速缓解症状以及小巧便携)已在患者偏好研究中有所体现。[149]Navaie M, Dembek C, Cho-Reyes S, et al. Inhaler device feature preferences among patients with obstructive lung diseases: A systematic review and meta-analysis. Medicine (Baltimore). 2020 Jun 19;99(25):e20718.
https://www.doi.org/10.1097/MD.0000000000020718
http://www.ncbi.nlm.nih.gov/pubmed/32569208?tool=bestpractice.com
[150]Tervonen T, Hawken N, Hanania NA, et al. Maintenance inhaler therapy preferences of patients with asthma or chronic obstructive pulmonary disease: a discrete choice experiment. Thorax. 2020 Sep;75(9):735-43.
https://www.doi.org/10.1136/thoraxjnl-2019-213974
http://www.ncbi.nlm.nih.gov/pubmed/32631932?tool=bestpractice.com
定量气雾剂一位主管药剂师向患者展示如何使用定量吸入器,并讨论改善吸入器使用技术的方法。
定量吸入器加储雾罐一位主管药剂师向患者展示如何使用定量吸入器加储雾罐,并讨论改善吸入器使用技术的方法。
干粉吸入剂一位主管药剂师向患者展示如何使用干粉装置,并讨论改善吸入器使用技术的方法。
软雾吸入器一位主管药剂师向患者展示如何使用软雾吸入器,并讨论改善吸入器使用技术的方法。