COPD COPD COPD 13 COPD COPD 75% COPD COPD COPD COPD 40 COPD 16% 76% COPD COPD 2% GOLD ( Global Initiative for Chronic Obstructive Lung Disea

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2 COPD COPD COPD 13 COPD COPD 75% COPD COPD COPD COPD 40 COPD 16% 76% COPD COPD 2% GOLD ( Global Initiative for Chronic Obstructive Lung Disease ) Guideline 2003 GOLD Guideline 2006 GOLD Guideline COPD COPD

3 2020 ( ) WHO Global Initiative for Chronic Obstructive Lung Disease ( GOLD) GOLD GOLD GOLD

4 COPD

5 COPD...15 COPD COPD

6 (Chronic Obstructive Pulmonary Disease; COPD) COPD Global Initiative for Chronic Obstructive Lung Diseases GOLD WHO COPDCOPD COPD GOLD COPD4 12 3COPD4COPD COPD A B C D 3

7 COPD COPD COPD COPD COPD COPD (spirometry) FEV 1 / FVC 70%FEV 1 80% (peak expiratory flow ; PEF) COPD COPD 4

8 ( ) 1COPD FEV 1 / FVC < 70% FEV 1 80% 2COPD 3COPD 4 COPD FEV 1 / FVC < 70% 50% FEV 1 < 80% FEV 1 / FVC < 70% 30% FEV 1 <50% FEV 1 / FVC < 70% FEV 1 < 30% COPD0 COPD COPD COPDCOPD 5

9 ( ) COPD ( ) COPD FEV 1 30 ml 150 ml 6

10 COPD COPD COPD COPD COPD COPD COPD 45 COPD 45 (ICD-9 A323 ) 10 (1999 ) 11 (2000 ) ICD COPD ICD ( ) ICD COPD A323 (ICD ) COPD22.2 7

ICD-9 490-493 COPD ICD-9 496 ( ) ICD-9 496

11 21 COPD COPD COPDCOPD 8

12 COPD COPD 3.5% 6.7% COPD ( ) COPD 40 COPD (ICD ) 15.80% 17.70% COPD ICD ( ) : COPD ICD ( ) 9

13 COPD -1 ( -1 anti-trypsin deficiency) COPD COPD COPD -1 ( -1 anti-trypsin deficiency) COPD COPD (1) COPDCOPD -1 COPD COPD COPD 20% COPD 10

14 COPD (2) COPD COPD ( ) COPD COPD COPD COPD () COPD COPD COPD COPD 11

15 COPD COPD COPDCD8 + oxidative stress COPD (cor pulmonale) COPD cachexia COPD COPD COPD COPD 2~4 (re-modeling) (centri-lobular emphysema) respiratory terminal bronchiole 12

16 COPD (oxidative stress) (proteoglycans) (collagen) COPD T- CD8 + B 4 leukotriene B 4 ; LTB 4 interleukin-8; IL-8 tumor necrosis factor; TNF COPD imbalance between proteinase and anti-proteinase oxidative stress ( ) COPD Pathogenesis of COPD Cigarette smoke Biomass particles and particulates Host factors and amplifying mechanisms Anti-oxidants Lung inflammation Anti-proteinases Oxidative stress COPD pathology Proteinases Repar mechanisms 13

COPD Pathogenesis of COPD Cigarette smoke Biomass particles and particulates Host factors and amplifying

17 (cor pulmonale) COPD COPD COPD COPDCOPD COPD COPD ( ) COPD cachexia apoptosis TNF- IL-6 CRP COPD * * * * * * CRP 14

18 COPD COPD COPD FEV 1 /FVC 70% FEV 1 80% COPD COPD COPD COPD FEV 1 50% COPD COPD COPD COPD COPD COPD COPDCOPD COPD 15

19 COPD COPD COPD COPD COPD COPD COPD?? COPD?? COPDCOPD COPD 16

20 COPD FVC FEV 1 FEV 1 /FVC COPD FEV 1 FVC FEV 1 FVC FEV 1 /FVC FEV 1 /FVC = 70% GOLDCOPDFEV 1 80% FEV 1 /FVC < 70% FEV 1 /FVC COPD FEV 1 FEV 1 80% FEV 1 /FVC 70% FEV 1 /FVC GOLD FEV 1 /FVC < 70% COPD FEV 1 FVC FEV 1 /FVC < 70% COPD COPD COPD bronchodilator reversibility test FEV 1 X XCOPD HRCT COPD bullectomy lung volume reduction surgery 17

1 /FVC GOLD FEV 1 /FVC < 70% COPD FEV 1 FVC FEV 1 /FVC < 70% COPD COPD COPD

21 COPD FEV 1 50% (central cyanosis) PaCO 2 (ear or pulse oximeter) SaO 2 < 92% -1- COPD45 COPD-1- ( -1-antitrypsin deficiency) COPD Asthma COPDAsthma COPD COPD X X X X 18

22 COPD COPD COPD COPD FEV 1 50% PaO 2 < 60mmHg (8.0 kpa) PaCO 2 > 50 mmhg (6.7 kpa) COPD 19

23 COPD COPD (A) A A A B COPD COPD 2005 (The Framework Convention on Tobacco Control, FCTC) COPD COPD

24 / A bupropion nortriptylineclonidine COPD COPD (susceptibility) COPD 21

25 COPD COPD(A) COPD A COPD A A FEV 1 < 50% COPD A A A 65 COPD 65 FEV 1 < 40% B A 15 A COPD (step-up) ---(step-down)copd COPD 22

26 COPD (B) COPD COPD 25% (A) (B ) (B) COPD COPD COPD COPD 23

27 COPD ( ) : * I III COPD * COPD * * * IV COPD * * * COPD COPD ( ) (B) COPD (step-up) 24

28 (step-down) COPD A COPD A : COPD * COPD * * * * * COPD A salmeterol formoteral 212A ipratropium 8 ACOPD tiotropium bromide 24 A 25

29 COPD COPD(sustain released; SR) : ( ) / Tiotropium bromide 18 (DPI) (-) (-) (-) 24 Ipratropium bromide (MDI) (-) (-) 6-8 Formoterol (MDI DPI) 12 Salmeterol (MDI DPI) 12 Fenoterol (MDI) % ( ) (-) 4-6 Salbutamol 100, (MDI DPI) 0.024% ( ) 0.1, Terbutaline / Ipratropium 400,500 (DPI) (-) 2.5, 5 ( ) 0.2, Fenoterol / Ipratropium 200/80 (MDI) 1.25/ Salbutamol / Ipratropium 75/15 (MDI) Aminophylline ( ) Theophylline SR ( ) 24 Beclomethasone (MDI DPI) Budesonide 100, 200, 400 (DPI) 0.2, 0.25, 0.5 Fluticasone (MDI DPI) Triamcinolone 100 (MDI) Formoterol / Budesonide 4.5/80-160, 9/320 (DPI) Salmeterol 50/100, 250, 500 (DPI) / Fluticasone 25/50, 125, 250 (MDI) Prednisolone 5-60 ( ) Methyl-prednisolone 4, 8, 16 ( ) 26

30 90 (A COPD FEV 1 < 50% (A) COPD COPD COPD ( ) COPD * FEV 1 /FVC < 70% FEV 1 /FVC < 70% FEV 1 /FVC < 70% FEV 1 /FVC< 70% FEV 1 FEV 1 FEV 1 * FEV 1 ** 65 < 65 FEV 1 < 40% FEV 1 80% 50% 80% 30% 50% 30% FEV 1 < 50% ** 27

31 1 COPD 2 4 COPD (A ) (B) B FEV 1 < 50% ( ) ( ) COPD A 2365 COPD 65 FEV 1 < 40%B A (mucokinetic, mucoregulator) ambroxol erdosteine carbocysteine iodinated glycerol COPD 28

32 COPDD N- N-acetylcysteineCOPD B N- N-acetylcysteine COPD COPD B COPD COPD D COPD - COPD COPD codeine NedocromilCOPD 29

33 COPD COPD () COPD * A * A * A * A * COPD A * B * B * C * C 30

34 % 4-10 COPD 20 COPD COPD COPD COPD 31

35 1,2 1,2,3,4 COPD COPD 25% COPD (Body Mass Index; BMI) COPD COPD 32

36 COPD COPD : % A ( ) COPD 55 88% 55~60 89% 55%

37 COPD 60 90% COPD % A 2. 55~60 89% 55% D C C 1. (respiratory drive) REM sleep 34

38 1 2REM NOD (bi-pap) Levine (pulse oximeter) (1) (2) 90 COPD

39 COPD (C) COPD (diffusing capacity, DLco) ( / ) % 39.7% COPD(C ) 36

40 35% COPD (Candida, Aspergillus, Cryptococcus, Carini) ( ) COPD COPD COPD COPD COPD XCOPD FEV 1 < 2 l 50% / DLco < 50% COPD COPD COPDCOPD 37

41 COPD B COPD A B non-invasive positive pressure ventilation NIPPV A COPD COPD COPD X 38

42 COPD COPD % 50 (ph 7.36) X X COPD COPD X 60 (Hct 55%) (Streptococcus pneumoniae) (Hemophilus influenzae) (Moraxella catarrhalis) COPD COPD 39

43 COPD 50%prednisolone 30-40mg 7-10 Streptococcus pneumoniae, Hemophilus influenzae, Moraxella catarrhalis COPD COPDCOPD COPD COPD * * * * * * * * * * 40

44 COPD * * * 40/ 60 / ph 7.25 * * : * X * 30 * (methylxanthium) * --- * --- * * ( ) --- COPD 60 90% (venturi mask) 41

45 COPD A --- COPD (methylxanthium) (1) (2) Ipratropium bromide (3) (synergistic effect) (4) (loading dose) / / 80% COPD A 30~40mg prednisolone 7~10 C 42

46 * COPD B * COPD C * COPD B COPD (S. pneumoniae) (H. influenzae) (M. catarralis) Mycoplasma pneumoniae Chlamydia pneumoniae COPD COPD FEV 1 Pseudomonas aeruginosa COPD COPD A * H. influenzae S. pneumoniae M. catarrhalis Chlamydia pneumoniae Viruses B * Group A plus, presence of resistant organisms ( -lactamase producing, penicillin-resistant S. pneumoniae), Enterobacteriaceae (K.pneumoniae, E. coli, Proteus, Enterobacter, etc) C P. aeruginosa Group B plus, P. aeruginosa * COPD COPD ( 3 ) 3 43

47 COPD COPD D Streptococcus pneumoniae Penicilin MIC 1 µg / ml Penicillin 1 cephalosporins Penicillin or amoxicillin 2 µg / /ml Penicillin (12-18 MU/d) 3 or 4 cephalosporins a Ampicllin or amoxicillin Telithromycin 4 µg/ml 3 or 4 cephalosporinsa Vancomycin or teicoplanin Vancomycin or teicoplanin + Rifampicin Newer fluoroquinolones b Telithromycin Haemophilus influenzae -lactamase (-) Ampicillin or amoxicillin New macrolides c TMP/SMX -lactamase (+) Ampicillin/sulbactam 3 cephalosporins Amoxicillin/clavulanate New macrolides c 2 cephalosporins Fluoroquinolones Telithromycin Moraxella catarrhalis 2 cephalosporins Erythromycin or Ampicillin/sulbactam new macrolides c Amoxicillin/clavulanate 3 cephalosporins Fluoroquinolones Telithromycin Legionella species Erythromycin or Erythromycin or new macrolides c new macrolides c a Cefotaxime, ceftriaxone, cefepime, and cefpirome b Moxifloxacin, levofloxacin: c Clarithromycin and azithromycin 44 + Rifampicin Tetracyclines Fluoroquinolones Mycoplasma pneumoniae Erythromycin or Tetracyclines new macrolides c Fluoroquinolones Chlamydia pneumoniae Tetracyclines Fluoroquinolones Erythromycin or new macrolides c

48 COPD / (1) NIPPV %4 ph A * paradoxical abdominal motion * ph 7.35> 45 * 25 * * * * * * * * (2) ( ) --(assistant-control mode) (pressure support mode) ( pressure support + intermittent mandatory ventilation ) 45

49 COPD ( )COPD COPD * * * 35 * < 40 / < 200 PaO2 / FiO2 < 200mmHg * (ph < 7.25) (60) * * * * (3) COPD T A COPD 60 C low-molecular weight heparin 46

50 COPD ( ) COPD * 4 * * * 12~24 * 12~24 * * * COPD 4-6 * * * * * COPD 47

51 COPD COPD COPD COPD COPD COPD COPD Questionnaire COPD COPDpeak flow meter 48

52 6525% 10% 75 40% 25% COPD COPD COPD COPD COPD COPD COPD COPD GOLD COPD COPD COPD GOLDhttp:// COPD 49

Chin J Respir Crit Care Med, January 2012, Vol. 11, No. 1 COPD : ;, COPD ( AECOPD) COPD COPD, COPD, FEV 1 COPD, COPD COPD, COPD FEV 1,,

2012 1 11 1 Chin J Respir Crit Care Med, January 2012, Vol. 11, No. 1 1 ( 2011 ) ( 100730) 2001 1 ( COPD), 10, 10 COPD 2011 Global :, E-mail: caibq2009 @ hotmail. com strategy for the diagnosis, management,