1、慢性阻塞性肺疾病合并症最新认识慢阻肺是老年人共患病中的肺部常见疾病慢阻肺与合并症肺康复对共患病的影响慢阻肺是老年人共患病中的肺部常见疾病慢阻肺与合并症肺康复对共患病的影响共患病Management of the rising prevalence ofmultiple chronic comorbidities(i.e.,patientswith two or more chronic morbidities)isa major challenge facing healthcare systemsworldwide(181).随着年龄增长，共患病越多65岁以上人群，50%有两种以上共患病2-
2、Karen Barnett,et al.Lancet.2012 Jul 7;380(9836):37-43共患病的发生机制1-Mechanisms of development of multimorbidity in the elderly共患病是由共同的危险因子（年龄，吸烟，缺乏锻炼，饮食，环境等）所诱发的。共患病的发病是同时的。心血管系统影响可能最早出现。共患病的某一单独成分相互促进恶化。对其中某一疾病的治疗会使其他疾病获益。慢阻肺是共患病中肺部的疾病表现。共患病的特点Does COPD stand for“COmorbidity with pulmonary disease”?It i
3、s of upmost importance to increase awareness amongst healthcare professional regarding comorbidity in COPD but also regarding COPD as a comorbidity in other prevalent chronic diseases在医疗中，提高对慢性阻塞性肺疾病的合并症的认识是至关重要的，同时也要认识到慢阻肺作为其他常见慢性疾病的合并症的特质4-Vanflaterern L.Eur Respir J.2015 Jan;45(1):14-7在不同慢性疾病患者中慢
4、阻肺的发病情况在7241591名成人中，909948（12.6%）患有慢阻肺 肺癌患者中50%下呼吸道感染患者中33%心血管疾病患者中33%低创性骨折患者中25%3-Andrea S.Gershon,et al.Eur Respir J 2015;45:5159GOLD 2014 慢阻肺的定义（的定义（GOLD2014)慢性阻塞性肺疾病：是一种可预防、可治疗的常见疾病，特征为持续存在的气流受限。气流受限呈进行性发展，伴有气道和肺对有害颗粒或气体所致慢性炎症反应的增加。急性加重和合并症影响患者整体疾病的严重程度。慢阻肺的病理机制Adapted from PJ Barner,2000;Fabbri
5、,Sinigaglia,Papi,Saetta 2002;Cosio,Saetta and Cosio 2012慢阻肺作为共患病中肺部表现 5-Fabbri LM1,Luppi F，et al.Eur Respir J.2008 Jan;31(1):204-12Prevalence and outcomes of diabetes hypertension and cardiovascular disease in COPDThe present study analysed data from 20296 subjects aged 45 yrs at baseline in the Ath
6、erosclerosis risk in Communities Study(ARIC)and the Cardiovascular Health Study(CHS).9-D.M.Mannino,et al.Eur Respir J 2008;32:9629695-yrs mortality慢阻肺是老年人共患病中的肺部常见疾病慢阻肺与合并症肺康复对共患病的影响慢阻肺主要合并症的发病7-Smith MC1,Wrobel JP2.Int J Chron Obstruct Pulmon Dis.2014 Aug 27;9:871-88.主要合并症的临床影响7-Smith MC1,Wrobel JP
7、2.Int J Chron Obstruct Pulmon Dis.2014 Aug 27;9:871-88.心血管疾病心血管疾病是慢阻肺最常见的合并症，是慢阻肺发生率最高也是最为重要的共存疾病，心血管疾病中包括了：高血压，缺血性心脏病，心衰以及心房颤动、心律失常 等。高血压慢阻肺合并心血管疾病的现状 AECOPD存在潜在引发心血管疾病的风险，在临床上并不少见，却不容易被识别 慢阻肺患者有高于同龄正常人群的心血管疾病患病率，肺功能越差，患病率越高1 在AECOPD的住院患者中，50%以上都合并有心血管疾病2 大约10%-40%的心衰患者同时合并慢阻肺3 在轻-中度慢阻肺，FEV1每下降20%，
8、心血管相关死亡风险升高28%，非致死性冠脉事件增加近20%41、J.Finkelstein,E,et al.Chronic obstructive pulmonary disease as an independent risk factor for cardiovascular morbidity.International Journal of Chronic Obstructive Pulmonary Disease,vol.4,pp.337349,2009.2、H.Cui,et al.Prevalence of cardiovascular disease in subjects ho
9、spitalized due to chronic obstructive pulmonary disease in Beijing from 2000 to 2010.Journal of Geriatric Cardiology,vol.9,no.1,pp.510,2012.3、Hawkins NM,et al.Heart failure and chronic obstructive pulmonary disease:diagnostic pitfalls and epidemiology.Eur J Heart Fail 2009;11:130139.4、Sin DD,et al.P
10、roc Am Thorac Soc 2005;2:8-11心力衰竭是一种全身性疾病Myocardial infarction causes the release of inflammatory cells from the spleen and bone marrow and their myocardial infiltration心肌梗塞引起脾和骨髓的炎症细胞释放和心肌渗出物This leads to an accumulation of monocytes in the heart,predominantly located in the infarct border zone,and
11、 a decrease of monocytes in the spleen and bone marrowThis may be mediated by activation of the sympathetic nervous system,angiotensin II,and/or cytokine release.10-Hofmasnn and Frantz.Eur heart J 2014;35:314-5Unrecognized heart failure in elderly patients with stable COPDHigh prevalence and underdi
12、agnosis of lung function abnormalities in patients with ishemic heart diseaseFEV1的降低及阻塞性呼吸系统疾病与心力衰竭发生率的升高是相关的11-Li J et al.Circulation 2014;129:971-80慢阻肺主要合并症的发病Smith MC1,Wrobel JP2.Int J Chron Obstruct Pulmon Dis.2014 Aug 27;9:871-88.常见认知功能障碍Cleutjens，et al(2014).Cognitive functioning in obstructiv
13、e lung disease:results from the United Kingdom biobank.J Am Med Dir Assoc.15(3),214-219 与对照组相比，反应时间，前瞻记忆，视觉空间记忆以及数字短时记忆均下降 Singh,et al.(2014).A prospective study of chronic obstructive pulmonary disease and the risk for mild cognitive impairment.JAMA Neurol.71(5),581-586.与对照组相比，注意力，视觉空间感，记忆力以及语言能力均下
14、降 非记忆减退的轻度认知障碍的风险比为Hazard ratio：2.58(1.32-5.06)肺部疾病与认知功能减退和老年痴呆症的关系14 Lung disease as a determinant of cognitive decline and dementia慢阻肺主要合并症的发病Smith MC1,Wrobel JP2.Int J Chron Obstruct Pulmon Dis.2014 Aug 27;9:871-88.心血管疾病和肿瘤尤其肺癌是轻中度COPD患者的主要死因COPD.2010 Oct;7(5):375-82.轻度中度COPDCOPD与与肺癌相关的可能机制肺癌相关的可
15、能机制Nat Rev Cancer.2013 Apr;13(4):233-45COPD合并肺癌的治疗2014 GOLDCOPD 患者经常被发现合并肺癌，肺癌是轻度COPD最主要的死因；COPD 合并肺癌患者的肺癌治疗需按照指南常规治疗；然而肺功能的降低会限制肺癌的手术治疗；肺癌合并COPD 患者的COPD治疗需按照指南常规治疗。慢阻肺主要合并症的发病Smith MC1,Wrobel JP2.Int J Chron Obstruct Pulmon Dis.2014 Aug 27;9:871-88.其他慢阻肺中的代谢综合症慢阻肺患者中常见共存的代谢性疾病Watz H,et al.Chest.200
16、9 Oct;136(4):1039-46OSA and risk of cardiovascular diseasesObstructive sleep apnoea and cardiovascular diseaseManuel Snchez-de-la-Torre,PhDa,b,Francisco Campos-Rodriguez,MDc,Prof Ferran Barb,MDa,b,慢阻肺是老年人共患病中的肺部常见疾病慢阻肺与合并症肺康复对共患病的影响Generally speaking,patients with COPD and multiple chronic comorbidi
17、ties are treated according to existing standards for each individual disease.In other words,comorbidities in patients with COPD are treated the same as in patients without COPD,and COPD is treated the same regardless of the comorbidity.Indeed,observational studies suggest that mortality of patients
18、with COPD can be reduced by nonrespiratory treatments,including b-blockers,angiotensin-converting enzyme inhibitors(182),and statins(183).Pulmonary rehabilitation.Pulmonary rehabilitation is typically provided ina hospital-based,outpatient setting.Its benefitsin this setting are well established,inc
19、ludingreduced dyspnea,increased exercise capacity,improved quality of life,and reduced use ofhealthcare resources(184).肺康复肺康复肺康复通常在医院,为门诊患者提供。在此设置也建立了它的好处,包括减少呼吸困难,提高运动能力,改善生活质量,减少医疗资源的使用肺康复治疗对于慢阻肺患者合并症的影响Eur Respir Rev.2014 Mar 1;23(131):131-41.doi:10.1183/09059180.00007613.Comorbidities in patient
20、s with COPD and pulmonary rehabilitation:do they matter?肺康复治疗的意义提高运动能力减少焦虑 减少抑郁改善生活质量延长寿命（通过降低未来急性加重风险）减少住院（通过降低未来急性加重风险）减少心血管疾病风险因子（间接）改变饮食习惯（水果&蔬菜/鱼类）/吸烟/BPDose PR infulences cardiovascular risk of COPD patients10 Vanfleteren LE1，Eur Respir J.2014 May;43(5):1306-15.Arterial stiffness129 subjects w
21、ho completed the program 确保肺康复疗法的心血管安全性 The role of the assessment Examine the prerehabilitation medical history and physical examinationAnamnesis or signs of cardiovascular investigations or consultation with cardiac specialists.(Unstable coronary heart disease.Unstable heart failure.Severe aortic
22、stenosis.)Echocardiography is recommended in the GOLD guidelines for individuals with COPD who have signs of congestive heart failure and/or concerning symptoms.A baseline resting ECG can be considered,as 20%of the individuals with COPD entering a pulmonary rehabilitation program have ischemic ECG c
23、hanges.(Vanfleteren et al.Am 就Cardiol.2011）A cardiopulmonary exercise test may be consideredSpruit et al.ATS/ERS statement on PR.Am J Respir Crit Care Med 2013慢阻肺合并症对于肺康复的影响The presence of comorbidities should not per se preclude access to and Effectiveness of pulmonary rehabilitation in COPD Observ
24、ational single centre prospective cohort,N=315Self-reported/chart based assessed comorbidities(Charlson CI)15 Crisafulli et al.ERJ 2010Charlson index共病指数骨骼肌疾病代谢性疾病心脏疾病6MWD改善SGRQ改善呼吸困难改善认知功能与肺康复Kozora,E.,Tran Z.V.,Make,B.(2002)Neurobehavioral improvement after brief rehabilitation in patients with ch
25、ronic obstructive pulmonary disease.J.Cardio pulm rehabilitation.22:426-430.发现视觉注意力,口头记忆,和视觉空间功能的临床改善。Antonelli Incaizi,R.,Corsonello,A.,Trojano,L.,Pedone,C.,Acanfora,D.,Spada,A.,et al.(2008).Cognitive training is ineffective in hypoxemic COPD:A six-month randomized controlled trial.Rejuvenation Res
26、earch,11,293-250.Antonelli Incaizi,R.,Corsonello,A.,Pedone,C.,Trojano,L.,Acanfora,D.,Spada,A.,et al.(2006).Drawing impairment predicts mortality in severe COPD.Chest,130,1687-1694.合并症的存在对肺康复的影响Mesquite.Vanfleteren.2015.Eur Respir J acceptedIndividual objectively identified comorbiditie do not preven
27、t patients to improve during PR!合并不同疾病的慢阻肺肺康复的表现 Differential PR outcome in different clusters of comorbidity?Odds Ratio for reaching the MID after PR compared to the less comorbidity clusterIn general PR outcomes in clusters of comorbidities are not different from the less comorbidity clusterSome d
28、ifferences are noticed!Mesquite.Vanfleteren.2015.Eur Respir J in revision参与肺康复治疗的慢阻肺患者的合并症与药物负担Comorbidities and medication burden in patients with COPD attending PRMedication by Type/ClassProportion Using(%)Respiratory medication99Cardiovascular medication59Other medication80Pain medication30Prescr
29、iption only pain medication16Nonprescription pain medication23Comorbidities and medication burden in patients with chronic obstructive pulmonary disease attending pulmonary rehabilitation.小结1，在进行肺康复治疗患者中，共病是普遍存在的Multimorbidity in the pulmonary rehabilitation setting is rather rule than exception.2,心
30、血管疾病是慢阻肺最主要的合并症，并影响慢阻肺的预后Cardiovascular disease is major component of the multimorbid condition COPD and prognostically important.3,心血管疾病以及其他慢阻肺合并症常常被漏诊Comorbidities and cardiovascular diseases are often not diagnoses in COPD.4,共五个不同的集群可以与类似为了安全起见也作为一个整体研究的一部分,公关代表five different clusters of comorbid
31、ities can be identified with similar for safety reasons as also as a part of the holistic approach that PR stands for6,共病的发病率不阻止病人改善肺康复，稳定的共病不排除肺康复Comorbidity and clusters of comorbidity do not prevent patients to improve from pulmonary rehabilitation.Stable comorbidities are not an exclusion for pu
32、lmonary rehabilitation7,肺康复治疗对合并症能够产生影响in contrary,PR has the potential to influence comorbiditiesComorbidities in COPD:what we dont know Multimorbidity is preventable(but we hope so)Whether treating earlier one component will prevent the others Whether treating one component will affect the prognosis of the others How to assess,name and treat multimorbidity
