Some genetic factors increase the risk of chronic obstructive pulmonary disease. The known genetic factor is α 1- antitrypsin deficiency. Severe α 1- antitrypsin deficiency is related to the formation of emphysema in non-smokers. Emphysema caused by α 1- antitrypsin deficiency has not been officially reported in China so far. Bronchial asthma and airway hyperresponsiveness are risk factors for COPD, and airway hyperresponsiveness may be related to some genes and environmental factors.
environmental factor
1. Smoking.
2. Occupational dust and chemicals.
3. Air pollution.
4. infection.
5. Socio-economic status. (1) Chronic cough: usually the first symptom. Cough is intermittent at first, heavier in the morning, coughing in the morning and evening or all day, and coughing at night is not obvious. A few cases of cough without expectoration. There are also some cases with obvious airflow restriction, but no cough symptoms.
(2) expectoration: Generally, a small amount of mucus is expectorated after coughing, and some patients have more sputum in the morning; When complicated with infection, the amount of sputum increases, and pus and phlegm are often seen.
(3) Shortness of breath or dyspnea: it is the symbolic symptom of COPD and the main cause of patients' anxiety. It only appears in the early stage of labor, and then gradually increases, leading to shortness of breath during daily activities and even rest.
(4) wheezing and chest tightness: not specific symptoms of COPD. Some patients, especially severe patients, have wheezing; Chest tightness usually occurs after exertion, which is related to respiratory exertion and capacitive contraction of intercostal muscles.
(5) Systemic symptoms: In the clinical course of the disease, especially in severe patients, systemic symptoms may occur, such as weight loss, loss of appetite, atrophy and dysfunction of peripheral muscles, mental depression and/or anxiety. When complicated with infection, you can cough up blood, sputum or hemoptysis. The early signs of COPD are not obvious. As the disease progresses, there are often the following signs:
(1) Visual inspection and palpation: abnormal chest shape, including over-inflation, increased anteroposterior diameter, widened lower sternum angle (epigastric angle) under xiphoid process and abdominal bulge; The common breathing becomes shallow and the frequency increases, and the auxiliary respiratory muscles participate in the breathing movement. In severe cases, the contradictory movement between chest and abdomen can be seen. When dyspnea is aggravated, you often take a forward sitting posture; Hypoxemia can cause cyanosis of mucous membrane and skin, and right heart failure can cause edema of lower limbs and hepatomegaly.
(2) Percussion: Hyperinflation of the lung reduces the voiced boundary of the heart, the lung-liver boundary, and the lung percussion can be too turbid.
(3) Auscultation: Breathing sounds in both lungs can be reduced, expiratory phase can be prolonged, dry rales can be heard when breathing calmly, and wet rales can be heard at the bottom of both lungs or other lung fields; The heart sound is far away, and the xiphoid heart sound is clearer and louder. Pulmonary function examination: Pulmonary function examination is an objective index to judge airflow limitation, which has good repeatability and is of great significance to the diagnosis, severity evaluation, disease progress, prognosis and treatment response of COPD.
2. Chest X-ray examination: X-ray examination is of great significance in determining pulmonary complications and differentiating them from other diseases (such as pulmonary interstitial fibrosis and tuberculosis).
3. Chest CT examination: CT examination is generally not used as a routine examination, but it is beneficial to differential diagnosis.
4. Blood gas examination: When FEV 1
5. Other laboratory tests: pao 2: 55% can be diagnosed as polycythemia. A large number of neutrophils can be seen in sputum smear when complicated with infection, and various pathogenic bacteria can be detected in sputum culture. Common are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and Klebsiella pneumoniae. 1. Comprehensively collect medical history for evaluation: When diagnosing COPD, comprehensively collect medical history, including symptoms, past history, systematic review and contact history.
2. Diagnosis: The diagnosis of COPD should be based on the comprehensive analysis of clinical manifestations, exposure history of risk factors, signs and laboratory tests. The main symptoms of COPD are chronic cough, expectoration and/or dyspnea, and the contact history of risk factors. The existence of incomplete reversible airflow restriction is a necessary condition for the diagnosis of COPD. Pulmonary function measurement index is the gold standard for the diagnosis of COPD. After using bronchodilator, fev 1/FVC < 70% can be determined as incomplete reversible airflow restriction. Early mild airflow restriction in COPD may or may not have clinical symptoms. Chest X-ray examination is helpful to determine the degree of pulmonary hyperinflation and distinguish it from other lung diseases. Lung rehabilitation is a multidisciplinary exercise and education program for COPD patients and their families (or nurses). Although respiratory rehabilitation can't significantly improve patients' lung function, many studies show that lung rehabilitation can not only relieve dyspnea symptoms of COPD patients, improve exercise endurance and health-related quality of life (HRQL), reduce acute exacerbation rate and hospitalization days, but also improve patients' psychological barriers and social adaptability without psychological intervention, which has good social and economic benefits.
For a long time, lung rehabilitation has been used as the secondary care for patients with moderate to severe stable COPD. At present, it is considered that lung rehabilitation is not only suitable for patients with mild COPD, but also for patients with extremely severe COPD, even patients with acute exacerbation after infection control and mechanical ventilation. It is found that COPD patients with different degrees of dyspnea can benefit from rehabilitation. Observation shows that rehabilitation after infection control in acute exacerbation of COPD is beneficial to patients' early discharge. take exercise
Exercise is the core content of lung rehabilitation. In the natural course of COPD, skeletal muscle consumption and dysfunction (SMD) and the decline of cardiopulmonary function are the main reasons for the gradual decline of patients' activity ability and exercise endurance, which seriously affects patients' HRQL. Recent research shows that the decline of exercise ability in patients with severe COPD is more obvious than the forced breathing volume in the first second (FEV 1). Exercise training can improve the aerobic and anaerobic metabolism of muscle cells, increase the capillary density of training muscles, improve the coordination ability of cardiopulmonary system, and significantly increase the maximal oxygen uptake (VO2m ax) of COPD patients, thus improving dyspnea, exercise endurance and HRQL.
Exercise method
Lung rehabilitation can be divided into three types according to the position of exercise. (1) Lower limb muscle movement: it is the main component of exercise, including walking, running, climbing stairs, treadmill exercise, power bicycle, etc. (2) Upper limb muscle training: It is helpful to enhance the strength and endurance of auxiliary respiratory muscles, and has been paid more and more attention in recent years, including upper limb dynamometer, weight lifting, ball throwing and so on. (3) Whole-body exercise: housework such as planting flowers and sweeping the floor, as well as various traditional physical exercises, swimming and rehabilitation exercises. Among them, Qigong, Internal Skill, Tai Ji Chuan and Taiji Sword are unique exercise methods in China, which can not only adjust the breathing proportion of patients, but also relieve tension and anxiety, and are effective methods for whole-body exercise. However, the intensity and effect of exercise lack quantitative standards and are not comparable. In addition, according to the patient's subjective efforts, it can also be divided into active exercise and passive exercise. For patients with respiratory failure, simple handshake and toe movement are also active rehabilitation activities. Although there is no obvious exercise, you can exercise related neuromuscular functions. Passive sports mainly include massage, massage, acupuncture and neuromuscular electrical stimulation. Neuromuscular electrical stimulation is characterized by low-voltage stimulation of peripheral muscle contraction to exercise related muscle functions, and has been used for patients with acute exacerbation or long-term bed rest after infection control. We found that for the acute exacerbation of COPD after infection control, it is beneficial for patients to recover as soon as possible to encourage them to take active exercises such as shaking hands and moving their limbs up and down, and to give passive activities such as massage, acupuncture and neuromuscular electrical stimulation.
Sports training time
The effect of lung rehabilitation is directly proportional to the time of exercise training. It is suggested that COPD patients should undergo long-term exercise rehabilitation training. However, there are different opinions on how long sports training should last at least to be effective. Some scholars suggest that lung exercise rehabilitation should be performed 3- 5 times a week for at least 2-3 months. There are also views that patients with mild to moderate COPD can benefit from short-term lung rehabilitation, but patients with severe COPD need at least 6 months of lung rehabilitation to achieve the same effect. In order to improve HRQL and exercise tolerance, most COPD patients need lung rehabilitation for at least 8 weeks, 3 times a week1h. Therefore, patients with chronic obstructive pulmonary disease should take exercise rehabilitation as a part of their lives, actively participate in housework such as planting flowers and sweeping the floor, or actively carry out various sports.
Exercise intensity
Exercise intensity is an important factor affecting the effect of exercise rehabilitation, and there is a positive dose-effect relationship between them. Although low-intensity (less than 30% of the maximum amount of exercise) or high-intensity (more than 60% of the maximum amount of exercise) exercise training can increase the exercise endurance of patients, after high-intensity exercise, the oxidase in the trained muscles increases, the exercise ability is obviously improved, and the physiological response (such as blood lactic acid concentration and maximum oxygen consumption) is also obviously improved, so it benefits more. But high-intensity exercise is not suitable for patients with serious illness and poor compliance. Therefore, the exercise intensity should follow the principle of individualization in principle, and the exercise intensity should be gradually increased for patients with serious illness.
At present, cardiopulmonary exercise test is a standard method to quantify and evaluate exercise intensity, including power bicycle and treadmill exercise test, in which power bicycle is more commonly used. Symptom-limited maximum exercise test can obtain the maximum exercise, oxygen uptake and heart rate of patients. Usually, 50%-80% of the maximum exercise or maximum oxygen uptake is taken as the exercise intensity of lower limbs, and high-intensity exercise means that the maximum exercise or maximum oxygen uptake is greater than 60%. However, cardiopulmonary exercise test needs certain equipment conditions, which limits its application in family and community rehabilitation exercise. However, the target heart rate (THR) and the degree of dyspnea are relatively simple and easy to obtain, which can be used as quantitative indicators of exercise intensity for most COPD patients.
Respiratory muscle training
There is systemic inflammatory reaction in COPD, inflammatory factors can cause weight loss and skeletal muscle atrophy, malnutrition can cause various types of muscle fiber atrophy and its composition variation, COPD lung over-inflation can cause abnormal geometry of thorax and diaphragm, and both can cause inspiratory muscle dysfunction. Although inspiratory muscle training can not significantly improve the 6-minute walking distance of patients, it can increase the muscle strength and endurance of inspiratory muscles, relieve patients' subjective severe breathing difficulties and improve their health-related quality of life. The American Association of Thoracic Medicine, Cardiovascular and Lung Rehabilitation (ACCP/AACVPR) also suggested that respiratory muscle training should be added to the lung rehabilitation program. At present, the training methods of respiratory muscles mainly include controlled deep and slow breathing exercise, lip and abdomen breathing exercise, resistance breathing exercise, breathing gymnastics and so on. Respiratory muscle rehabilitation exercise method is simple, non-invasive, painless, low cost, easy to be accepted by patients, and can be widely carried out in families and communities. However, the choice of reasonable respiratory exercise mode and treatment course for COPD patients with different degrees needs further discussion.
Effective cough and expectoration methods
COPD patients have a history of chronic bronchitis for many years. Every winter and spring, the symptoms of cough and expectoration are obvious, acute exacerbation, and even lung inflammation. If you can't cough and expectorate in time and effectively, it will lead to aggravation of the disease, prolonged lung inflammation and even respiratory failure. Therefore, patients should be encouraged to cough and expectorate effectively. The specific method is: sit up straight as far as possible, after inhaling deeply, press the abdomen with both hands, lean forward slightly, cough constantly, contract the abdominal muscles when coughing, and forcibly discharge the sputum deep in the lungs. Clinically, cough training is usually combined with posture change, chest patting and atomizing inhalation to keep the respiratory tract clean and unobstructed.
nutrition therapy
Because COPD is in a resting state of high metabolism, coupled with long-term insufficient nutrition intake and insufficient absorption of nutrients, COPD patients often suffer from malnutrition in different degrees. Long-term malnutrition can lead to dysfunction of skeletal muscle and respiratory muscle in COPD patients. The inspiratory muscle strength of malnourished patients is 30% lower than that of normal nutrition. After the nutritional status of malnutrition patients is improved, the function of inspiratory muscles can be partially restored and dyspnea can be partially improved. Malnutrition also increases the chance of infection in COPD patients, which is one of the decisive factors of patients' health status and disease prognosis. Therefore, it is very important to provide reasonable nutritional support for patients. For the diet of patients with chronic obstructive pulmonary disease, we can eat less and eat more, get enough energy, and increase fish, protein and fruit in moderation. Increase the amount of exercise
At present, the main methods to increase the amount of exercise and improve the effect of exercise are oxygen inhalation, noninvasive positive pressure assisted ventilation, inhalation of bronchodilators and interval training.
Absorb oxygen
Oxygen inhalation during exercise can effectively correct exercise-induced hypoxemia, reduce the work done by hypoxic breathing, enable COPD patients to achieve higher training intensity and significantly increase exercise endurance. For COPD patients, a slight increase in inhaled oxygen concentration can improve exercise tolerance, and this effect is more obvious when the inhaled oxygen concentration reaches more than 50%, which is also effective for non-hypoxic patients. The latest research found that inhaling high helium-oxygen mixed gas can also reduce the dyspnea of COPD patients, increase the intensity and duration of exercise, and thus improve the effect of lung rehabilitation.
Noninvasive positive pressure ventilation
There are different degrees of airflow restriction in COPD patients, which is related to dynamic hyperventilation of the lungs. In the exercise state, COPD patients need more tidal volume to meet the ventilation needs during exercise, so the respiratory work increases and the respiratory muscles are prone to fatigue. Non-invasive positive pressure assisted ventilation during exercise can reduce patients' respiratory work, increase ventilation per minute, and effectively relieve respiratory muscle fatigue, thus alleviating shortness of breath symptoms during exercise, prolonging exercise time and increasing exercise tolerance. Some studies have found that short-term application of nasal noninvasive positive pressure ventilation can improve the exercise intensity of patients with severe COPD in stable period. Non-invasive positive pressure ventilation mode can choose pressure support ventilation (PSV) and proportional assist ventilation (PAV) combined with positive end-expiratory pressure ventilation (PEEP). Pressure support in inspiratory phase can improve ventilation, and pressure support in expiratory phase can improve ventilation function and increase oxygen partial pressure. A 29-day prospective controlled study of lung rehabilitation under noninvasive positive pressure ventilation showed that the FEV 1, blood gas, health-related quality of life and other indicators of patients were significantly improved.
Inhaled bronchodilator
Bronchodilator can improve the airflow obstruction of COPD patients and meet the increased ventilation demand during exercise. However, due to the fatigue of lower limbs and other muscles in COPD patients, the intensity and time of exercise will be affected. Patients can not fully benefit from bronchodilators, but muscle fatigue can be improved through exercise. Therefore, the use of bronchodilators and exercise have a synergistic effect. Evidence shows that even for patients with severe COPD, lung rehabilitation is more effective when bronchodilators are used. In addition, the use of bronchodilators before exercise rehabilitation is conducive to enhancing patients' confidence and helping to achieve the predetermined amount of exercise.
Education and management
Pulmonary rehabilitation of COPD patients is a long-term work, and it is very important to educate, guide and manage patients reasonably and effectively. Through education and management, we can improve patients' understanding of COPD and their ability to cope with diseases, improve patients' compliance with lung rehabilitation and other treatments, reduce repeated aggravation and improve their quality of life. The contents of education mainly include: the basic knowledge of pathophysiology and clinic of COPD, the importance of quitting smoking and lung rehabilitation, prevention, early identification and treatment of acute exacerbation, etc.
psychological intervention
The long-term recurrent symptoms of chronic obstructive pulmonary disease have obviously increased the psychological burden of patients and caused great mental harm to patients. Most patients do not cooperate with lung rehabilitation and other related treatments because of anxiety and depression. In clinical work, patients' psychological disorders should be routinely evaluated. For mild patients, psychological support such as communication, induction, inspiration and encouragement can help patients build confidence and turn passivity into initiative. For patients with serious psychological disorders, professional psychotherapy should be carried out. Group rehabilitation exercise for inpatients is helpful for patients to overcome psychological barriers and actively cooperate with rehabilitation treatment. Acute exacerbation is an important cause of pulmonary function and quality of life decline and even death in COPD patients. Without pulmonary rehabilitation treatment, the pulmonary function and quality of life of patients with acute exacerbation of COPD can further deteriorate during hospitalization, and it will take a long time to recover or not fully recover to the basic level. The feasibility and effect of early lung rehabilitation exercise (within 1826 days after remission) in 10 patients with AECOPD were studied retrospectively. It is found that no matter the severity of dyspnea, early low-intensity lung rehabilitation is feasible for patients with AECOPD, and their exercise endurance is obviously improved. Mu rphy et al studied the effect of early lung rehabilitation (6 weeks on the day of discharge) in 365,438+0 AECOPD patients by prospective control, and found that the exercise endurance, quality of life and dyspnea symptoms of AECOPD patients with early lung rehabilitation were significantly improved. Therefore, in order to make more COPD patients benefit from lung rehabilitation, early rehabilitation exercise should be carried out for AECOPD patients.
start time
Although the feasibility and effect of early lung rehabilitation in patients with AECOPD have been recognized, there is no argument about when to carry out early lung rehabilitation in acute exacerbation so that patients can benefit from lung rehabilitation to the greatest extent. After the acute exacerbation of infection is controlled, exercise rehabilitation can be started, which is conducive to shortening the hospitalization time. For patients with tracheal intubation and mechanical ventilation, lung rehabilitation after infection control is beneficial to offline and offline cough and expectoration.
Exercise amount and exercise method
The amount of exercise should start from a small intensity, step by step, until the maximum. For those who can't complete the scheduled training plan due to dyspnea, it is feasible to do intermittent exercise, that is, alternating exercise and rest can alleviate dyspnea and accumulation of lactic acid in muscles during exercise, thus increasing the amount of exercise and improving the intensity of exercise. The initial exercise methods mainly include passive exercise, such as massage, myoelectric stimulation, shaking hands, turning over, changing sitting and lying position, standing on the bed, walking, noninvasive ventilation and/or active activities under oxygen inhalation.
In a word, comprehensive lung rehabilitation therapy can improve the dyspnea symptoms of COPD patients, improve exercise tolerance and HRQL. In the lung rehabilitation treatment of COPD patients, we should follow the principles of early stage, combination of different methods and individualization, and establish a planned and feasible rehabilitation plan for everyone. For a long time, because many patients with chronic obstructive pulmonary disease have relatively backward treatment concepts, are highly dependent on drug treatment, and ignore or do not understand the importance of active lung function rehabilitation, patients with chronic obstructive pulmonary disease have not received low-cost and efficient lung rehabilitation treatment. Therefore, respiratory medical staff should actively encourage COPD patients to carry out comprehensive lung rehabilitation treatment.