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[107]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. 2021 [internet publication].
https://goldcopd.org/wp-content/uploads/2020/11/GOLD-REPORT-2021-v1.1-25Nov20_WMV.pdf
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。诊断为 COPD 后,许多患者报告其生活方式和社交出现损失和受到限制。焦虑、抑郁和沮丧等症状常见。[109]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
一项系统评价发现,与宣教或不采取干预措施相比,基于认知行为疗法的心理治疗和抑郁症状治疗有轻微的益处,但证据因以下因素而受限:试验之间存在异质性,以及无法使参与者和研究人员对干预不知情。[110]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
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。[111]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。[112]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。
定期的医疗随访对于优化治疗是必须的。如果有任何症状加重,需要立即就医。进行持续氧疗的患者在飞行过程中需要增加氧流量。
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. 2021 [internet publication].
https://goldcopd.org/wp-content/uploads/2020/11/GOLD-REPORT-2021-v1.1-25Nov20_WMV.pdf
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。[120]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。[188]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
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。[122]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
改善体力活动的最佳时机、因素、持续时间和模式尚不清楚。meta 分析表明,瑜伽和气功可以改善 COPD 患者的运动能力和肺功能。[123]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
[124]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
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。[113]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
[114]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。[115]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。[116]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。[117]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. 2021 [internet publication].
https://goldcopd.org/wp-content/uploads/2020/11/GOLD-REPORT-2021-v1.1-25Nov20_WMV.pdf
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。[118]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
[119]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