2016年更新版《慢性阻塞性肺疾病全球倡议》(GOLD) 解读

2016年GOLD指南更新的内容

1. 在COPD急性加重的诊断中，提出对于稳定期患者，目前尚无有效的可用于急性加重病因学诊断的临床标志物。

(However, clinically useful biomarkers for COPD patients in stable condition have yet to be identified.)

2. 在促进COPD发生发展的因素方面，首次提及咳嗽合并咳痰与轻中度COPD患者死亡率上升相关。

(Cough and sputum production is associated with increased mortality in mild to moderate COPD.)

3. 在COPD的评估方面，首次提及COPD临床问卷(CCQ)对肺康复情况有反应时的最小临床重要差异(minimally clinical important differences, MCID)值为-0.4。

(A minimally clinical important differences (MCID) during rehabilitation of -0.4 for the CCQ has been identified.)

4. 在COPD的药物治疗方面：

a) 纳入了OPTIMO研究，认为低加重风险的COPD患者在使用长效支气管扩张剂维持治疗的情况下，撤除吸入性糖皮质激素是安全的。

(Withdrawal of inhaled corticosteroids, in COPD patients at low risk of exacerbation, can be safe provided that patients are left on maintenance treatment with long-acting bronchodilators.)

b) 纳入的一项研究发现，给予Fluticasone furoate/vilanterol (FF/VI) 100/25mcg每日一次的疗效，与给予fluticasone propionate/salmeterol (FP/SAL) 250/50mcg每日二次的疗效相当，从而认为应用吸入性糖皮质激素/长效β2受体激动剂的联合药物时，每日一次的疗效与每日二次的疗效无显著差异。

(An inhaled corticosteroid/long-acting beta2 agonist combination given once daily does not show relevant differences regarding efficacy compared to twice daily.)

c)首次明确提及全身应用糖皮质激素治疗COPD急性加重，可以改善症状、肺功能，降低治疗失败率，以及缩短住院时间。另外，一项荟萃分析显示，COPD急性加重时，全身应用糖皮质激素可以降低因急性加重复发而导致的30天住院率。

(However, systemic corticosteroids for treating acute exacerbations have been shown to improve symptoms, lung function, reduce rate of treatment failure, and shorten length of hospital stay. The effect of preventing a subsequent exacerbation has been shown in a pooled data analysis and it was demonstrated that systemic corticosteroids when being used to treat acute exacerbations can reduce 30-day readmission rates due to recurrent exacerbations.)

5. 在COPD的非药物治疗方面：

a) 纳入的研究发现心情抑郁是未能完成康复计划的危险因素之一。

(Depressed mood is a risk factor for non-completion of rehabilitation programs.)

b) 在获得更多的数据之前，非手术的支气管镜肺减容技术不应该应用于临床试验以外的情况中。

(Non-surgical bronchoscopic lung volume reduction techniques should not be used outside clinical trials until more data are available.)

6. 在COPD的治疗药物方面：

a) 长效β2受体激动剂中，增加了奥达特罗(Olodaterol)，吸入剂量5mcg(SMI)，药效持续时间24h。

(Long-acting beta2-agonists: Olodaterol 5 mcg (SMI), 24 hours.)

b) 长效β2受体激动剂和抗胆碱药物的的联合吸入剂中，增加了奥达特罗/噻托溴铵(Olodaterol/tiotropium)，吸入剂量为5mcg/5mcg (SMI)， 药效持续时间24h。

(Combination long-acting beta2-agonist plus anticholinergic in one inhaler: Olodaterol/tiotropium 5mcg/5mcg (SMI), 24 hours.)

2016年GOLD指南参考文献的更新

a) 罗氟司特仅对有重度加重的高危风险的COPD患者(一年内有一次急性加重风险>22%)有净效益(利大于弊)：Yu T, Fain K, Boyd CM, Singh S, Weiss CO, Li T, et al. Benefits and harms of roflumilast in moderate to severe COPD. Thorax. 2014 Jul;69(7):616-22.

b) COPD的严重程度与心率失常(AF/AFL, 和NSVT)独立相关：Konecny T, Park JY, Somers KR, Konecny D, Orban M, Soucek F, et al. Relation of chronic obstructive pulmonary disease to atrial and ventricular arrhythmias. Am J Cardiol. 2014 Jul 15;114(2):272-7.

c) 增加一篇中国的研究，进一步证实吸水烟增加COPD风险：She L Yang P, Wang Y, Qin X, Fan, L Wang Y, Gao G, Luo G, et al. Chinese water-pipe smoking and the risk of COPD. Chest. 2014 Oct;146(4):924-31.

d) 增加一篇墨西哥的研究，进一步证实室内生物燃料造成的空气污染是COPD的危险因素：Ramirez-Venegas A, Sansores RH, Quintana-Carrillo RH, Velazquez-Uncal M, Hernandez-Zenteno RJ, Sanchez-Romero C, et al. FEV1 decline in patients with chronic obstructive pulmonary disease associated with biomass exposure. Am J Respir Crit Care Med. 2014 Nov 1;190(9):996-1002.

e) 来源于Copenhagen General Population Study(2003-2008)的数据分析显示：他汀类药物的使用不会减少整体COPD患者加重的风险：Ingebrigtsen TS, Marott JL, Nordestgaard BG, Lange P, Hallas J, Vestbo J. Statin use and exacerbations in individuals with chronic obstructive pulmonary disease. Thorax. 2015 Jan; 70(1): 33-40.

f) 一项干预实验的系统性评价进一步为COPD急性加重期的激素治疗提供依据，即：服用泼尼松40mg, qd x 5d可能是足够的(Evidence B)：Walters JA, Tan DJ, White CJ, WoodBaker R. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2014 Dec 10;12:CD006897.