23 년대한임상건강증진학회춘계합동학술대회 연수강좌 소강당 만성폐쇄성폐질환진단및치료 이진국 가톨릭대학교서울성모병원호흡기내과 정의 COPD 는비가역적인기류제한을특징으로하는폐질환으로서만성염증에의한기도와폐실질손상으로인해발생한다. Proption of 965 death rate COPD 의사망률은여전히증가 3. 2.5 2..5 +63% COPD. -7% all other causes -35% other CV disease.5-59% CHD -64% stroke 965 998 Change in age-adjusted death rates f COPD and cardiovascular diseases in the USA, 965-998. Pauwels RA and Rabe KF. Lancet 24;364:63-62. COPD has been increasing steadily since 97 Burden : 의료비용보건복지부연구과제 -COPD 지침팀 75 원 2,, 인당외래비용 인당입원비용 인당총의료비 인당입원횟수 일 5 Rate per, Population 5 25 Accidents Chronic Obstructive Pulmonary Disease,, 8,, 6,, 4,, 4 3 2 Diabetes mellitus 2,, 97 974 978 982 986 99 994 998 22 Year of Death JAMA 25 stage stage 2 stage 3 stage 4 (n=242) (n=722) (n=535) (n=25) 28
만성폐쇄성폐질환진단및치료 / 이진국 Predicted change in ranking f global causes of death 99 22 Ischemic heart disease Cerebrovascular disease Lower respiraty infections Diarrhoeal diseases Perinatal disders COPD Tuberculosis Measles 2 3 4 5 6 7 8 2 3 4 5 6 7 8 Road-traffic accidents 9 9 Trachea, bronchus, and lung cancers Yoo KH et al., Respirology. 2;6(4):659-65. Murray and Lopez Lancet 997;349:498-54 COPD 를의심해야하는경우 흡연력 + 호흡곤란, 기침, 가래 4 세이상 호흡곤란 COPD Asthma Heart failure Conary artery disease Anemia Pulmonary thromboembolism 기침 기침이만성적으로지속되는것이 COPD 의첫증상임. COPD 환자는흡연때문이라고무시하는경우가흔함. 29
23 년대한임상건강증진학회춘계합동학술대회 만성기침 만성객담 호흡곤란 위험인자노출과거력 COPD 를의심할수있는임상지표 간헐적이거나매일. 때로하루종일 ; 야간에만있는경우는드물다 만성객담배출 진행성 ( 점차악화 ) 지속적 ( 매일존재 ) 표현 ; 숨이차다, 가슴이답답하다, 숨이가쁘다 운동시악화 호흡감염중에악화 흡연 직업적인먼지및화학물질 요리및난방연료에서발생하는연기 위지표의일부가존재하면 COPD 를고려하고폐활량측정법을시행한다. 이지표는그자체로진단이이루어지는것은아니지만여러가지주요지표가존재한다는것은 COPD 진단의가능성을높인다. 폐활량측정법은 COPD 확진에필요하다. GOLD : Mild Global Strategy f Diagnosis, Management and Prevention of COPD Classification of Severity of Airflow Limitation in COPD* GOLD 2: Moderate GOLD 3: Severe In patients with FEV /FVC <.7: FEV > 8% predicted 5% < FEV < 8% predicted 3% < FEV < 5% predicted GOLD 4: Very Severe FEV < 3% predicted *Based on Post-Bronchodilat FEV FVC 에대한 FEV6 의대체 일차진료에서일반적인폐활량계를이용한폐활량측정은폐활량기계구입의가격부담, 긴검사시간, 기사교육의부족, 그리고폐활량측정의정도관리측면에서어려움이많다. 또한, 연령이많은노인들중특히기도폐쇄가심한환자들은전체폐활량검사를모두시행하기것이육체적으로큰부담이된다. 이러한단점들을고려하여, 기도폐쇄를선별하거나모니터링을위한좀더간단한폐활량검사방법이필요하다. 6 초동안의최대노력성호기량을나타내는 FEV6 가 FVC 를대체할수있는것으로보고되고있다. FEV/FEV6 를이용한기도폐쇄의기준은 73% 로한다. Emphysema 정상 3
만성폐쇄성폐질환진단및치료 / 이진국 흉부전산화단층촬영 (HRCT) 정상인 만성폐쇄성폐질환 COPD 치료목표 금연이가장중요하다! 질환의진행억제 증상악화예방 운동능력향상 건강상태호전 합병증의예방과치료 사망률의감소 치료와관련된부작용의예방또는최소화 담배를끊게하는 5 단계전략 : '5A' ASK: 모든환자에게매번방문시마다흡연상태를묻고기록한다. ADVISE: 모든흡연자에게명료하고강하게금연을권고한다. ASSESS: 모든환자의금연의지를확인하고어느시점에끊을것인지상의한다. ASSIST: 상담, 행동요법, 약물요법등을동원하여금연을도와준다. ARRANGE: 추적관찰을위해지속적으로예약스케줄을잡아준다. 3
23 년대한임상건강증진학회춘계합동학술대회 흡입기관지확장제 흡입스테로이드 PDE4 억제제 COPD 약물치료 흡입기관지확장제 속효성 ß-agonists (SABA) salbutamol (Ventolin) 흡입기관지확장제 지속성 ß-agonists (LABA) indacaterol (Onbrez) Anticholinergic () tiotropium (Spiriva) 흡입스테로이드제 (ICS) 단독사용은권고되지않음. 기관지확장제와 combination 제제로사용 ICS+LABA Fluticasone/Salmeterol (Seretide) Budesonide/Fmoterol (Symbict) 32
만성폐쇄성폐질환진단및치료 / 이진국 Roflumilast (Daxas) PED4 억제제 THE PDE4 ENZYME IS EXPRESSED IN KEY INF LAMMATORY CELLS INVOLVED IN COPD SIGNIFICANTLY PROLONGED TIME TO ONSET OF FIRST MODERATE OR SEVERE EXACERBATION VS PLACEBO, POOLED M2-24 AND M2-25 Leukocyte PDE isofm Structural Cells PDE isofm Mast cells 4, 7 Airway smooth muscle, 2, 3, 4, 5, 7 Eosinophils 4, 7 Epithelial cells, 2, 3, 4, 5, 7, 8 Neutrophils 4, 7 Endothelial cells 2, 3, 4, 5.9.8.7.6.5 Hazard ratio =.89 (CI.8;.98) p =.85 Monocytes, 3, 4, 7 Macrophages, 3, 4, 5, 7 T cells (CD4 + and CD8 + ) 3, 4, 7 Sensy nerve, 3, 4 Cholinergic nerves, 3, 4.4.3.2 5 5 2 25 3 35 Days Placebo Roflumilast 5µg A hazard ratio < means a lower risk f the test treatment Adapted from: Giembycz MA. Monaldi Arch Chest Dis 22;57:48 64. Calverley P, Rabe K et al. Lancet. 29;374:685-94. Median Time to First COPD Exacerbation: (mild, moderate severe) COPD 중증도에따른단계별치료 Probability of not experiencing an exacerbation..9.8.7.6 M2 28 tiotropium tiotropium + placebo tiotropium + roflumilast 5 µg 4 8 2 8 24 Weeks Hazard ratio =.7 (IQR.5;.) p =.264 중증도 제기 제2기 제3기 제4기 경증 중등증 중증 고도중증 특징 FEV /FVC<7% FEV 8% FEV /FVC<7% 5% FEV <8% FEV /FVC<7% 3% FEV <5% FEV /FVC<7% FEV <3% 혹은 FEV <5% 이면서만성호흡부전동반 위험인자회피 : 인플루엔자백신 필요시속효성기관지확장제추가 한가지이상의지속성기관지확장제정규치료추가 호흡재활추가 반복악화시 흡입부신피질호르몬제추가 만성호흡부전시엔 장기산소요법추가 외과적치료고려 FABBRI LM, CALVERLEY PMA, IZQUIERDO-ALONSO JL, BUNDSCHUH DS, BROSE M, MARTINEZ FJ, RABE KF. LANCET 29;374:695 73 33
23 년대한임상건강증진학회춘계합동학술대회 Global Strategy f Diagnosis, Management and Prevention of COPD Combined Assessment of COPD Risk (GOLD Classification of Airflow Limitation) 4 3 2 Use combined assessment (C) (A) mmrc - CAT < (D) (B) mmrc > 2 CAT > Symptoms (mmrc CAT sce)) > 2 Risk (Exacerbation histy) Patient is now in one of four categies: A: Les symptoms, low risk B: Me symtoms, low risk C: Less symptoms, high risk D: Me Symtoms, high risk http://www.catestonline.g/english/index_kea.htm Global Strategy f Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy (Medications in each box are mentioned in alphabetical der, and therefe not necessarily in der of preference.) Global Strategy f Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy FIRST CHOICE Patient First choice Second choice Alternative Choices A B C D SAMA prn SABA prn LABA ICS + LABA ICS + LABA LABA SABA and SAMA and LABA and LABA ICS and ICS + LABA and ICS+LABA and PDE4-inh. and LABA and PDE4-inh. SABA and/ SAMA PDE4-inh. SABA and/ SAMA Carbocysteine SABA and/ SAMA GOLD 4 GOLD 3 GOLD 2 GOLD C A ICS + LABA SAMA prn SABA prn mmrc - CAT < ICS + LABA LABA mmrc > 2 CAT > D B > 2 Exacerbations per year 34
만성폐쇄성폐질환진단및치료 / 이진국 Global Strategy f Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy SECOND CHOICE Global Strategy f Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy ALTERNATIVE CHOICES GOLD 4 GOLD 3 GOLD 2 GOLD C and LABA A LABA SABA and SAMA D ICS and ICS + LABA and ICS + LABA and PDE4-inh and LABA and PDE4-inh. and LABA B > 2 Exacerbations per year GOLD 4 GOLD 3 GOLD 2 GOLD C PDE4-inh. SABA and/ SAMA A Carbocysteine SABA and/ SAMA SABA and/ SAMA D B > 2 Exacerbations per year mmrc - CAT < mmrc > 2 CAT > mmrc - CAT < mmrc > 2 CAT > 추적관찰 적어도 년에한번이상폐활량검사를시행한다. 매방문시마다흡연상태를평가하고금연을권고한다. 매방문시마다약물에대한순응도를확인하고흡입제사용이적절한지평가한다. 중증환자나반복적인악화를보이는환자는전문가에게의뢰하는것을고려한다. 35