Updated Key Points Interpretation of Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2023 Report)

doi:10.12114/j.issn.1007-9572.2023.0052

Chinese General Practice ›› 2023, Vol. 26 ›› Issue (11): 1287-1298.DOI: 10.12114/j.issn.1007-9572.2023.0052

Special Issue: 指南/共识最新文章合辑；呼吸疾病文章合辑

• Guide·Consensus • Next Articles

Updated Key Points Interpretation of Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2023 Report)

1. The First Affiliated Hospital of Guangzhou Medical University/Guangzhou Institute of Respiratory Health, Department of Pulmonary and Critical Care Medicine/National Center for Respiratory Medicine/National Clinical Research Center for Respiratory Disease/State Key Laboratory of Respiratory Disease, Guangzhou 510120, China
2. Department of Pulmonary and Critical Care Medicine, Shenzhen People's Hospital/Shenzhen Institute of Respiratory Disease, Shenzhen 518020, China

Received:2023-02-01 Revised:2023-02-06 Published:2023-04-15 Online:2023-02-09
Contact: CHEN Rongchang
About author:
LIANG Z Y, WANG F Y, CHEN Z Z, et al. Updated key points interpretation of Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2023 Report) [J]. Chinese General Practice, 2023, 26 (11): 1287-1298.

2023年GOLD慢性阻塞性肺疾病诊断、管理及预防全球策略更新要点解读

1．510120　广东省广州市，广州医科大学附属第一医院　广州呼吸健康研究院呼吸与危重症医学科　国家呼吸医学中心　国家呼吸系统疾病临床医学研究中心　呼吸疾病国家重点实验室
2．518020　广东省深圳市人民医院　深圳市呼吸疾病研究所呼吸与危重症医学科

通讯作者: 陈荣昌

作者简介:

梁振宇，医学博士，临床医学博士后，主治医师，硕士生导师。广州医科大学附属第一医院/广州呼吸健康研究院呼吸与危重症医学科主治医师，国家呼吸系统疾病临床医学研究中心项目研究与随访部副主任，广州市高层次人才（青年后备）。主要研究方向为慢性阻塞性肺疾病临床异质性、定量影像学等。学术任职：中华医学会呼吸病学分会慢性阻塞性肺疾病学组秘书；广州市医师协会青年医师分会常委；《中国全科医学》青年编委、《中华健康管理学杂志》通讯编委；ERJ Open Research、Clinical Epidemiology、Journal of Thoracic Disease、International Journal of COPD等杂志审稿人。学术成果：主持和参与国家重大专项、国家自然科学基金等科研项目十余项；参编诊疗指南、专家共识4部；获得广东省科技进步奖（二等奖）、广东省医学科技奖（二等奖）。

陈荣昌，主任医师，教授，博士生导师。深圳市人民医院/深圳市呼吸疾病研究所所长，广州呼吸健康研究院前任院长，国家呼吸系统疾病临床医学研究中心副主任。国务院特殊津贴专家、卫生部有突出贡献青中年专家。主要从事呼吸力学与机械通气、呼吸与危重症医学、慢性阻塞性肺疾病等领域的工作。学术任职：中华医学会呼吸病学分会前任主任委员；中华医学会呼吸病学分会慢性阻塞性肺疾病学组组长；中国医师协会呼吸医师分会副会长；广东省医学会呼吸病学分会第七届主委（2011—2015年）；慢性阻塞性肺疾病全球防治倡议（GOLD）理事会理事；中国慢性阻塞性肺疾病联盟主席。学术成果：主持国家重点研发计划（重大慢病专项）、国家自然科学基金（国际合作、面上项目）等科研项目数十项。先后获得国家科技进步二等奖和三等奖、教育部自然科学奖一等奖等奖项。

梁振宇，王凤燕，陈子正，等. 2023年GOLD慢性阻塞性肺疾病诊断、管理及预防全球策略更新要点解读[J].中国全科医学，2023，26（11）：1287-1298.[www.chinagp.net]

作者贡献：梁振宇负责指南解读及论文撰写；王凤燕负责修改论文及核对文献；陈子正负责参考文献整理及核对；陈荣昌负责论文指导和修改，对论文负责。

基金资助:
国家自然科学基金资助项目(82270044，82200044，82170042); 广州市科技计划项目(202201020451)

Abstract

Abstract:

Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2023 Report) (GOLD 2023) maintains the basic framework of GOLD 2022, but with major revisions in the definition, assessment, initial therapy and follow-up management of chronic obstructive lung disease (COPD) as follow: (1) Chapter 1: The definition and overview section was rewritten to propose a new definition of COPD, incorporating new background information, therapeutic strategies and classifications for COPD, with the addition of content on chronic bronchitis; (2) Chapter 2: Content on screening and case-finding of COPD has been included, the ABCD assessment tool has been revised to the ABE assessment tool (no further grouping of high-risk population of acute exacerbation of COPD based on symptom levels), information on imaging and computed tomography scans (CT) has been included in the diagnosis and assessment section; (3) Chapter 3: Recommendations for Streptococcus pneumoniae vaccination have been updated, information on therapeutic interventions to reduce COPD mortality has been included, issues related to inhalation delivery have been updated, content on inhaled medications adherence and remote rehabilitation has been included, information on interventional and surgical therapies of COPD has been expanded in the prevention and maintenance treatment section; (4) Chapter 4: Information on the selection of inhalation devices has been included, information on initial drug therapy and follow-up drug therapy has been updated in the management of stable COPD section; (5) Chapter 5: A new definition of and set of acute exacerbation of COPD assessment parameters have been proposed, information on differential diagnoses of acute exacerbation of COPD has been expanded in the acute exacerbation of COPD section management; (6) Chapter 6 and 7: Updating content on COPD and complications (Chapter 6), COPD (Chapter 7) and COVID-19 based on the latest evidence. The above updates will be an important guide to the clinical management of COPD.

Key words: Pulmonary disease, chronic obstructive, Global initiative for chronic obstructive lung disease, Bronchitis, chronic, Diagnostic screening programs, Symptom assessment, Therapy, Inhalants, Treatment adherence and compliance, Acute exacerbation

摘要： 2023年慢性阻塞性肺疾病全球倡议（GOLD）维持了2022年的基本框架，但在慢性阻塞性肺疾病（以下简称慢阻肺）定义、评估、初始治疗和随访期管理等方面进行了较大修订，主要包括：（1）第1章定义和概述部分被重写，提出慢阻肺新定义，纳入慢阻肺新的背景信息、治疗策略和分类，新增慢性支气管炎的内容；（2）第2章诊断和评估部分增加慢阻肺筛查和病例发现的相关内容，将ABCD评估工具修订为ABE评估工具（即慢阻肺急性加重高风险人群不再根据症状水平进一步分组），更新影像学和计算机断层扫描（CT）信息；（3）第3章预防和维持治疗部分更新了肺炎链球菌疫苗接种建议，新增了降低慢阻肺死亡率的干预措施的信息，更新吸入制剂递送相关问题，新增吸入药物依从性的内容，更新了远程康复相关证据，扩充了慢阻肺介入和手术治疗的内容；（4）第4章慢阻肺稳定期管理部分新增吸入装置选择的内容，更新了初始药物治疗和随访期药物治疗的信息；（5）第5章慢阻肺急性加重管理部分提出慢阻肺急性加重的新定义和一套新参数以评估慢阻肺急性加重严重程度，扩展了慢阻肺急性加重鉴别诊断的内容；（6）第6、7章根据最新证据更新了关于慢阻肺与合并症、慢阻肺与新型冠状病毒感染的内容。以上更新对慢阻肺的临床诊疗具有重要的指导意义。

关键词: 肺疾病, 慢性阻塞性, 慢性阻塞性肺疾病全球倡议, 支气管炎, 慢性, 诊断筛查项目, 症状评估, 治疗, 吸入剂, 治疗依从性, 急性加重

LIANG Zhenyu,WANG Fengyan,CHEN Zizheng, et al. Updated Key Points Interpretation of Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2023 Report)[J]. Chinese General Practice, 2023, 26(11): 1287-1298. DOI: 10.12114/j.issn.1007-9572.2023.0052.
梁振宇,王凤燕,陈子正等. 2023年GOLD慢性阻塞性肺疾病诊断、管理及预防全球策略更新要点解读[J]. 中国全科医学, 2023, 26(11): 1287-1298. DOI: 10.12114/j.issn.1007-9572.2023.0052.

Figures/Tables 10

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分类		描述
遗传决定的慢阻肺（COPD-G）		α-1抗胰蛋白酶缺乏（AATD）其他影响较小的基因变异共同作用
肺发育异常导致慢阻肺（COPD-D）		早期生活事件，包括：早产和低体质量等
环境性慢阻肺
	吸烟相关慢阻肺（COPD-C）	·烟草暴露，包括在母胎或通过被动吸烟
		·电子烟
		·大麻
	生物燃料与污染暴露相关慢阻肺（COPD-P）	暴露于居家污染、大气污染、野火烟雾、职业危险因素
感染导致慢阻肺（COPD-I）		儿童时期感染，结核相关性慢阻肺，野火烟雾，职业危险因素
慢阻肺合并哮喘（COPD-A）		尤其是儿童时期的哮喘
不明原因的慢阻肺（COPD-U）		—

分类		描述
遗传决定的慢阻肺（COPD-G）		α-1抗胰蛋白酶缺乏（AATD）其他影响较小的基因变异共同作用
肺发育异常导致慢阻肺（COPD-D）		早期生活事件，包括：早产和低体质量等
环境性慢阻肺
	吸烟相关慢阻肺（COPD-C）	·烟草暴露，包括在母胎或通过被动吸烟
		·电子烟
		·大麻
	生物燃料与污染暴露相关慢阻肺（COPD-P）	暴露于居家污染、大气污染、野火烟雾、职业危险因素
感染导致慢阻肺（COPD-I）		儿童时期感染，结核相关性慢阻肺，野火烟雾，职业危险因素
慢阻肺合并哮喘（COPD-A）		尤其是儿童时期的哮喘
不明原因的慢阻肺（COPD-U）		—

应用场景	描述
鉴别诊断	·伴有大量咳痰的频繁慢阻肺急性加重，需要警惕支气管扩张或不典型的感染
鉴别诊断	·症状超出了基于肺功能的疾病严重程度
肺减容术评价	·如患者吸入支气管舒张剂后FEV₁%在15%~45%并且有过度充气的证据，支气管内活瓣置入可作为治疗选择
肺减容术评价	·对于伴有过度充气、严重的上叶为主的肺气肿以及肺康复后仍为低活动耐量的患者，外科肺减容术作为治疗选择
肺癌筛查	·对于由吸烟导致的慢阻肺患者，推荐以低剂量CT扫描进行肺癌筛查

应用场景	描述
鉴别诊断	·伴有大量咳痰的频繁慢阻肺急性加重，需要警惕支气管扩张或不典型的感染
鉴别诊断	·症状超出了基于肺功能的疾病严重程度
肺减容术评价	·如患者吸入支气管舒张剂后FEV₁%在15%~45%并且有过度充气的证据，支气管内活瓣置入可作为治疗选择
肺减容术评价	·对于伴有过度充气、严重的上叶为主的肺气肿以及肺康复后仍为低活动耐量的患者，外科肺减容术作为治疗选择
肺癌筛查	·对于由吸烟导致的慢阻肺患者，推荐以低剂量CT扫描进行肺癌筛查

◆药物在该装置的可及性
◆需要评估和考量患者的理念、对当前和以往使用装置的满意度和偏好
◆尽量减少每个患者使用的不同装置类型的数量，理想情况是只需要一种装置
◆在没有临床判断或没有给予适当的信息、宣教和随访的情况下，不应更换装置类型
◆共享决策是吸入装置选择的最合适的策略
◆必须考虑到患者的认知能力、操作灵巧性和吸气力量
◆必须评估患者对该装置进行正确吸入操作的能力：
	·患者能用力深吸气时，才适合使用干粉吸入器。检查患者能否通过装置用力吸气，如存疑，则应客观评估或选择替代装置
	·MDI和SMI需要在装置触发和吸气之间的协调，患者需要能进行缓慢深吸气。检查患者能否从装置上缓慢深吸气，如存疑，则考虑增加储雾罐或选择替代装置
	·对于不能使用MDI（带或不带储雾罐）、SMI或DPI的患者，应考虑使用雾化器
◆其他需要考虑的因素包括装置尺寸大小、便携性、花费
◆如果在依从性/持久性或吸入技术存在问题，可以考虑使用智能吸入装置
◆医生应该只开具他们（以及护理团队的其他成员）知道如何使用的吸入装置

Updated Key Points Interpretation of Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2023 Report)

2023年GOLD慢性阻塞性肺疾病诊断、管理及预防全球策略更新要点解读

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需鉴别的疾病		评估方法
最常见	肺炎	胸部影像学
	肺栓塞	临床可能性评估（咯血，外科手术，骨折，恶性肿瘤病史，DVT） D-二聚体 CTPA
	心力衰竭	胸部影像学 NT Pro-BNP和BNP 超声心动图
次常见	气胸、胸腔积液	胸部影像学胸腔超声
	心肌梗死和/或心律失常（心房颤动/心房扑动）	心电图肌钙蛋白

步骤	实施内容
1	对慢阻肺和潜在的呼吸系统及非呼吸系统伴随疾病的证据进行全面的临床评估，包括考虑引起患者症状、体征的其他原因：主要有肺炎、心力衰竭和肺栓塞
2	评估：
	a.症状，可以通过视觉模拟评分法（VAS）确定呼吸困难的严重程度，以及记录咳嗽的存在
	b.体征（呼吸急促、心动过速）、痰量和颜色、呼吸窘迫（辅助呼吸肌参与呼吸）
3	使用恰当的额外检查来评估严重程度，如脉氧仪、实验室评估、CRP、动脉血气分析
4	确定事件的原因（病毒、细菌、环境、其他）

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