COPD COPD COPD 13 COPD COPD 75% COPD COPD COPD COPD 40 COPD 16% 76% COPD COPD 2% 1996 2001 GOLD ( Global Initiative for Chronic Obstructive Lung Disease ) Guideline 2003 GOLD Guideline 2006 GOLD Guideline COPD COPD
2020 ( ) 1996 12 2000 6 WHO Global Initiative for Chronic Obstructive Lung Disease ( GOLD) 91 12 GOLD 92 10 31 GOLD 2003 95 10 2006 GOLD 5 26 96 7 1
...3...4 COPD... 7...10...12 1
COPD...15 COPD COPD...48 2
(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
COPD COPD COPD COPD COPD COPD (spirometry) FEV 1 / FVC 70%FEV 1 80% (peak expiratory flow ; PEF) COPD COPD 4
( ) 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
( ) COPD ( ) COPD FEV 1 30 ml 150 ml 6
COPD COPD COPD COPD COPD COPD COPD 45 COPD 45 (ICD-9 A323 ) 10 (1999 ) 11 (2000 ) ICD-9 490-493 COPD ICD-9 496 ( ) ICD-9 496 21 COPD A323 (ICD-9 490-493 ) 496 2000 COPD22.2 7
21 COPD COPD COPDCOPD 8
COPD 1990 200460 COPD 3.5% 6.7% COPD ( ) 1990-1992 COPD 40 COPD (ICD-9 490-493 496 ) 15.80% 17.70% COPD ICD-9 490-493 496 ( ) : COPD ICD-9 490-493 496 ( ) 9
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
COPD (2) COPD COPD ( ) COPD COPD COPD COPD () COPD COPD COPD COPD 11
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
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
(cor pulmonale) COPD COPD COPD COPDCOPD COPD COPD ( ) COPD cachexia apoptosis TNF- IL-6 CRP COPD * * * * * * CRP 14
COPD COPD COPD FEV 1 /FVC 70% FEV 1 80% COPD COPD COPD COPD FEV 1 50% COPD COPD COPD COPD COPD COPD 1. 2. 3. 4. COPDCOPD COPD 15
COPD COPD COPD COPD COPD COPD COPD?? COPD?? COPDCOPD COPD 16
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
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
COPD COPD COPD COPD FEV 1 50% PaO 2 < 60mmHg (8.0 kpa) PaCO 2 > 50 mmhg (6.7 kpa) COPD 19
COPD COPD (A) A A A B COPD COPD 2005 (The Framework Convention on Tobacco Control, FCTC) COPD COPD 3 19962000 20
1. 2. 3. / 4. 5. A bupropion nortriptylineclonidine COPD COPD (susceptibility) COPD 21
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
COPD (B) COPD COPD 25% (A) (B ) (B) COPD COPD COPD COPD 23
COPD ( ) : * I III COPD * COPD * * * IV COPD * * * COPD COPD ( ) (B) COPD (step-up) 24
(step-down) COPD A COPD A : COPD * COPD * * * * * COPD A salmeterol formoteral 212A ipratropium 8 ACOPD tiotropium bromide 24 A 25
COPD COPD(sustain released; SR) : ( ) / Tiotropium bromide 18 (DPI) (-) (-) (-) 24 Ipratropium bromide 20-40 (MDI) 0.25-0.5 (-) (-) 6-8 Formoterol 4.5-12 (MDI DPI) 12 Salmeterol 25-50 (MDI DPI) 12 Fenoterol 100-200(MDI) 1 0.05% ( ) (-) 4-6 Salbutamol 100, 200 5 5 (MDI DPI) 0.024% ( ) 0.1,0.5 4-6 Terbutaline / Ipratropium 400,500 (DPI) (-) 2.5, 5 ( ) 0.2, 0.25 4-6 Fenoterol / Ipratropium 200/80 (MDI) 1.25/0.5 6-8 Salbutamol / Ipratropium 75/15 (MDI) 1.5 6-8 Aminophylline 200-600 ( ) 240 24 Theophylline SR 100-600 ( ) 24 Beclomethasone 50-400 (MDI DPI) 0.2-0.4 Budesonide 100, 200, 400 (DPI) 0.2, 0.25, 0.5 Fluticasone 50-500 (MDI DPI) Triamcinolone 100 (MDI) 40 4 0 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
90 (A COPD FEV 1 < 50% (A) COPD COPD COPD ( ) COPD * 1 2 3 4 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
1 COPD 2 4 COPD (A ) (B) B FEV 1 < 50% ( ) ( ) COPD A 2365 COPD 65 FEV 1 < 40%B 1-1 - A (mucokinetic, mucoregulator) ambroxol erdosteine carbocysteine iodinated glycerol COPD 28
COPDD N- N-acetylcysteineCOPD B N- N-acetylcysteine COPD COPD B COPD COPD D COPD - COPD COPD codeine NedocromilCOPD 29
COPD COPD () COPD * A * A * A * A * COPD A * B * B * C * C 30
6 10-45 50% 4-10 COPD 20 COPD COPD COPD COPD 31
1,2 1,2,3,4 COPD COPD 25% COPD (Body Mass Index; BMI) COPD COPD 32
COPD COPD 1. 2. 3. 4. 5. : 15 60 90% A ( ) COPD 55 88% 55~60 89% 55% 1 2 3 4 33
COPD 60 90% COPD 1. 55 88% A 2. 55~60 89% 55% D C C 1. (respiratory drive) REM sleep 34
1 2REM NOD 130 90 2 90 5 85 (bi-pap) Levine (pulse oximeter) 88 2. (1) (2) 90 COPD 1 2 50 3 70 35
COPD (C) COPD (diffusing capacity, DLco) ( / ) 1200 4.3 54% 39.7% COPD(C ) 36
35% 5055-60 COPD (Candida, Aspergillus, Cryptococcus, Carini) ( ) COPD COPD COPD COPD COPD 2.7 4.7 XCOPD FEV 1 < 2 l 50% / DLco < 50% COPD COPD COPDCOPD 37
COPD B COPD A B non-invasive positive pressure ventilation NIPPV A COPD COPD COPD 12 345 6 X 38
COPD COPD100 1.00 60 90% 50 (ph 7.36) 45-60 X X COPD COPD X 60 (Hct 55%) (Streptococcus pneumoniae) (Hemophilus influenzae) (Moraxella catarrhalis) COPD COPD 39
COPD 50%prednisolone 30-40mg 7-10 Streptococcus pneumoniae, Hemophilus influenzae, Moraxella catarrhalis COPD COPDCOPD COPD COPD * * * * * * * * * * 40
COPD * * * 40/ 60 / ph 7.25 * * : * X * 30 * --- --- --- --- (methylxanthium) * --- * --- * * --- --- --- ( ) --- COPD 60 90% (venturi mask) 41
COPD A --- COPD (methylxanthium) (1) 30 60 (2) Ipratropium bromide (3) (synergistic effect) (4) (loading dose)2.5 530 30 3 0.5 8 12 / 18 20 / 80% COPD A 30~40mg prednisolone 7~10 C 42
* 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
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
COPD / (1) NIPPV 5 80-85%4 ph A * paradoxical abdominal motion * ph 7.35> 45 * 25 * * * * * * * * (2) ( ) --(assistant-control mode) (pressure support mode) ( pressure support + intermittent mandatory ventilation ) 45
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
25 4 6 COPD ( ) COPD * 4 * * * 12~24 * 12~24 * * * COPD 4-6 * * * * * COPD 47
COPD COPD COPD COPD COPD COPD COPD Questionnaire COPD COPDpeak flow meter 48
6525% 10% 75 40% 25% COPD COPD COPD COPD COPD COPD COPD COPD GOLD COPD COPD COPD GOLDhttp://www.goldcopd.org/WCDindex.asp http://www.who.int/respiratory/gard/en/. COPD 49