对COPD住院患者应重点预防急性加重

亚特兰大——数据显示，仅1/3的慢性阻塞性肺病(COPD)住院患者接受了适当治疗，而通过优化入院标准和出院治疗方案等措施可改善预后。

Darcy Marciniuk博士

虽然目前尚缺乏有关何时患者应入院的科学指导原则，但指南和共识声明建议符合以下标准的加重患者应入院治疗：

·呼吸困难明显加重

·患有重度基础COPD且储备功能低

·初始治疗失败

·患有心力衰竭、心律失常或肾功能损害等合并症

·老龄

·经常发生严重急性加重

·家庭支持不足

根据全球慢性阻塞性肺病倡议(GOLD)指南，一旦患者入院，应给予可控的适当补氧；遵循该指南有助于确保足量补氧，不会出现过量补氧的情况。

必要时可给予非侵入性通气支持，后者是目前治疗COPD患者急性高碳酸血症型呼吸衰竭的方案，可使插管率降低60%并显著降低院内死亡率。目前有大量证据表明，非侵入性通气对COPD患者有益，特别是pH低于7.35、PCO2高于45且明显呼吸困难的呼吸性酸中毒患者。

一开始应给予积极治疗，并且应考虑使用抗生素或全身性皮质激素。

在ICU治疗的COPD患者的死亡率实际上明显低于许多其他疾病的患者。例如，COPD患者的死亡率约为脓毒症或急性呼吸窘迫综合症患者的1/2。因此，有ICU作为后备将有助于患者获得良好预后。

此外，还应查找诱发因素、识别或预防合并症、预防并发症及解决抑郁和焦虑问题。研究发现抑郁患者的住院时间较长(为非抑郁患者的2倍)、出院后1年较常发生加重且死亡率较高。

另外，出院时，应制定适当的方案以降低患者未来发生急性加重的风险。

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By: SHARON WORCESTER, Internal Medicine News Digital Network

ATLANTA – Data suggest that only about a third of patients hospitalized for chronic obstructive pulmonary disease receive appropriate care, but a number of steps – beginning with decisions about when to admit and ending with proper discharge management – can be taken to improve outcomes, according to Dr. Darcy Marciniuk.

Although scientific guidance on when patients should be admitted is lacking, guidelines and consensus statements suggest that patients with an exacerbation should be admitted:

If they experience a marked increase in dyspnea.
If they have severe underlying COPD with little reserve, "such that there’s no room for error."
If they fail to respond to initial management.
If they have comorbidities, including heart failure, arrhythmias, or renal impairment.
If they have advanced age.
If they experience frequent severe exacerbations.
If they have insufficient home support.

Once a patient is admitted, controlled appropriate supplemental oxygen should be administered as directed by Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, noninvasive ventilation should be used when indicated, aggressive therapies should be used at the outset, and use of antibiotics or systemic corticosteroids should be considered, said Dr. Marciniuk, AACP president, and head of the division of respirology, critical care, and sleep medicine at the University of Saskatchewan, Saskatoon, Canada.

An effort should also be made to identify the precipitating factor, to recognize and optimize, or prevent comorbid conditions, to prevent complications, and to address depressions and anxiety, he said.

With respect to supplemental oxygen, the GOLD guidelines will help ensure there is "always enough, but never too much," Dr. Marciniuk said.

"Now, with saturation monitors, life is good; it’s very easy to make sure patients receive appropriate therapy," he added.

He also spotlighted noninvasive ventilation. It has revolutionized in-hospital COPD management, lowering intubation rates by 60% and substantially decreasing in-hospital mortality, he said.

"Noninvasive ventilation has been incredible for our patients," he said.

Although it was first used in the 1980s, it is now "really the treatment of choice for acute hypercapnic respiratory failure in this setting," he added.

Contrary to some beliefs about outcomes with COPD in the intensive care unit, mortality is actually much lower than for many other conditions. For example, mortality in COPD patients in the ICU is about half that of patients with sepsis or acute respiratory distress syndrome.

"So, even though a patient may look short of breath, and someone may think they have a poor quality of life, it is the patients who should be judging that," he said, adding: "There needs to be that comfort, that back-up, of the ICU, because data would suggest the outcomes are pretty good."

There is significant evidence of benefit with the use of noninvasive ventilation, particularly with respiratory acidosis of pH less than 7.35, PCO2 greater than 45, and significant dyspnea, which is easily detected by clinical means, he added.

Depression in COPD patients is also particularly important to address.

Studies show that patients with depression have longer hospital stays (twice as long, according to one observational study), more frequent exacerbations in the year following discharge, and higher mortality rates, he said, acknowledging that "our understanding of the co-presence of depression and anxiety (in COPD patients) is growing, but our understanding that it appears to [have an impact] in this setting is also growing."

As for discharge planning, appropriate methods and practices must be put in place for reducing the future risk of acute exacerbations, he said.

Dr. Marciniuk reported having no financial disclosures, with the exception of research funding directed to and managed by his institution.