慢性阻塞性肺病的新进展.pptx

慢性阻塞性肺病的新进展清华大学第一附属医院呼吸科GOLD颁布的COPD全球策略 2014年最新更新 慢性阻塞性肺疾病急性加重(AECOPD)诊治中国专家共识(草案)GlobalStrategyforDiagnosis,ManagementandPreventionofCOPD,2013:ChaptersnnDefinitionandOverviewDefinitionandOverviewnnDiagnosisandAssessmentDiagnosisandAssessmentnnTherapeuticOptionsTherapeuticOptionsnnManageStableCOPDManageStableCOPDnnManageExacerbationsManageExacerbationsnnManageComorbiditiesManageComorbiditiesUpdated20132013GlobalInitiativeforChronicObstructiveLungDiseaseCOPD的定义的定义COPD是一种可以预防和可以治疗的常见疾病,其特征是持续存在的气流受限。气流受限呈进行性发展,伴有气道和肺对有害颗粒或气体所致慢性炎症反应的增加。急性加重和合并症影响患者整体疾病的严重程度。COPD气流受限的气流受限的发病机制病机制SmallAirwaysDiseaseAirwayinflammationAirwayfibrosis,luminalplugsIncreasedairwayresistanceParenchymalDestructionLossofalveolarattachmentsDecreaseofelasticrecoilAIRFLOWLIMITATION2013GlobalInitiativeforChronicObstructiveLungDiseaseCOPD的危的危险因素因素肺的生长发育性别年龄呼吸道感染社会经济条件哮喘气道高反应性慢性支气管炎基因有害颗粒暴露吸烟职业粉尘，有机物，无机物室内燃料燃烧和通风不良室外空气污染2013GlobalInitiativeforChronicObstructiveLungDiseaseCOPD的危的危险因素因素GenesGenesInfectionsInfectionsSocio-economic Socio-economic statusstatusAging Populations2013GlobalInitiativeforChronicObstructiveLungDiseaseGlobalStrategyforDiagnosis,ManagementandPreventionofCOPD,2013:ChaptersnnDefinitionandOverviewDefinitionandOverviewnnDiagnosisandAssessmentDiagnosisandAssessmentnnTherapeuticOptionsTherapeuticOptionsnnManageStableCOPDManageStableCOPDnnManageExacerbationsManageExacerbationsnnManageComorbiditiesManageComorbiditiesUPDATED20132013GlobalInitiativeforChronicObstructiveLungDiseaseSYMPTOMS chronic coughshortness of breathEXPOSURE TO RISKFACTORS tobaccooccupationindoor/outdoor pollutionSPIROMETRY:RequiredtoestablishdiagnosisCOPD的的诊断断 sputum 2013GlobalInitiativeforChronicObstructiveLungDiseaseCOPD的诊断任何患有呼吸困难、慢性咳嗽或多痰的患者,并且有暴露于危险因素的病史,在临床上需要考虑COPD的诊断。作出COPD的诊断需要进行肺功能检查,吸入支气管扩张剂之后FEV1/FVC0.70表明存在气流受限,即可诊断COPD。COPD评估评估COPD评估的目的是决定疾病的严重程度,包括气流受限的严重程度,患者的健康状况和未来的风险程度(例如急性加重、住院或死亡),最终目的是指导治疗。2013GlobalInitiativeforChronicObstructiveLungDiseaseCOPD的评估的评估症状评估气流受限采用肺功能严重度分级急性加重风险评估合并症评估2013GlobalInitiativeforChronicObstructiveLungDisease*改良英国MRC呼吸困难指数(modifiedbritishmedicalresearchcouncil,mMRC)*COPD评估测试(COPDassessmenttest,CAT)。症状的症状的评估估2013GlobalInitiativeforChronicObstructiveLungDiseaseGlobalStrategyforDiagnosis,ManagementandPreventionofCOPDModifiedMRC(mMRC)Questionnaire2013GlobalInitiativeforChronicObstructiveLungDisease气流受限的评估气流受限程度仍采用肺功能严重度分级,即FEV1占预计值80%、50%、30%为分级标准。COPD患者的气流受限的肺功能分级分为4级(Grades),即:GOLD1轻度,GOLD2中度,GOLD3重度,GOLD4非常严重。使用支气管扩张剂后，患者肺功能FEV1/FVC0.70COPD分期(Stage)的概念已经被废除2013GlobalInitiativeforChronicObstructiveLungDiseaseGlobalStrategyforDiagnosis,ManagementandPreventionofCOPDClassificationofSeverityofAirflowLimitationinCOPD*InpatientswithFEV1/FVC80%predictedGOLD2:Moderate50%FEV180%predictedGOLD3:Severe 30%FEV150%predictedGOLD4:VerySevereFEV130%predicted*Based on Post-Bronchodilator FEV12013GlobalInitiativeforChronicObstructiveLungDisease急性加重风险评估急性加重风险评估采用急性加重病史和肺功能评估急性加重的风险,上一年发生2次或以上的急性加重或FEV1%pred210(C)(D)(A)(B)mMRC0-1CAT2CAT10Symptoms(mMRCorCATscore)2013GlobalInitiativeforChronicObstructiveLungDiseaseCombined Assessment of COPD(C)(D)(A)(B)mMRC0-1CAT2CAT10Symptoms(mMRCorCATscore)IfmMRC0-1orCAT2orCAT10:MoreSymptoms(BorD)首先Assesssymptomsfirst2013GlobalInitiativeforChronicObstructiveLungDiseaseCombined Assessment of COPDRisk(GOLDClassificationofAirflow Limitation)Risk(Exacerbationhistory)210(C)(D)(A)(B)mMRC0-1CAT2CAT10Symptoms(mMRCorCATscore)IfGOLD1or2and only0or1exacerbationsperyear:LowRisk(AorB)IfGOLD3or4ortwoormoreexacerbationsperyear:HighRisk(CorD)(One or more hospitalizations for COPD exacerbations should be considered high risk.)其次急性加重风险的评估2013GlobalInitiativeforChronicObstructiveLungDiseaseCombined Assessment of COPDRisk(GOLDClassificationofAirflow Limitation)Risk(Exacerbationhistory)210(C)(D)(A)(B)mMRC0-1CAT2CAT10Symptoms(mMRCorCATscore)Patientisnowinoneoffourcategories:A:Lesssymptoms,lowriskB:Moresymptoms,lowriskC:Lesssymptoms,highriskD:Moresymptoms,highrisk综合评估2013GlobalInitiativeforChronicObstructiveLungDiseaseCombined Assessment of COPDRisk(GOLDClassificationofAirflow Limitation)Risk(Exacerbationhistory)210(C)(D)(A)(B)mMRC0-1CAT2CAT10Symptoms(mMRCorCATscore)2013GlobalInitiativeforChronicObstructiveLungDiseasePatientCharacteristicSpirometric ClassificationExacerbations per yearmMRCCATALowRiskLessSymptomsGOLD1-210-1210CHighRiskLessSymptomsGOLD3-420-12210Combined Assessment of COPD2013GlobalInitiativeforChronicObstructiveLungDiseaseGlobalStrategyforDiagnosis,ManagementandPreventionofCOPDDifferentialDiagnosis:COPDandAsthmaCOPD 中年起病症状逐年加重长期吸烟 ASTHMA起病早（常儿童起病）症状变化显著夜间和清晨症状恶化常伴过敏症,鼻炎,和/或湿疹哮喘家族史2013GlobalInitiativeforChronicObstructiveLungDiseaseAsthma-COPDOverlapSyndromeACOS(1)Asthmaisaheterogeneousdisease,usuallycharacterizedbychronicairwayinflammation.Itisdefinedbythehistoryofrespiratorysymptomssuchaswheeze,shortnessofbreath,chesttightnessandcoughthatvaryovertimeandinintensity,togetherwithvariableexpiratoryairflowlimitation.GINA2014Asthma-COPDOverlapSyndromeACOS(2)COPDisacommonpreventableandtreatabledisease,characterizedbypersistentairflowlimitationthatisusuallyprogressiveandassociatedwithenhancedchronicinflammatoryresponsesintheairwaysandthelungstonoxiousparticlesorgases.Exacerbationsandcomorbiditiescontributetotheoverallseverityinindividualpatients.GOLD2014Asthma-COPDOverlapSyndromeACOS(3)Asthma-COPDoverlapsyndrome(ACOS)ischaracterizedbypersistentairflowlimitationwithseveralfeaturesusuallyassociatedwithasthmaandseveralfeaturesusuallyassociatedwithCOPD.ACOSisthereforeidentifiedbythefeaturesthatitshareswithbothasthmaandCOPD.FeatureAsthmaCOPDACOS发病年龄通常儿童期发病，也见于任何年龄段通常40岁通常40岁,但可能在儿童期或中年前出现症状症状症状多变,常有活动受限，运动、粉尘、过敏原暴露可诱发症状持续存在，活动时加重呼吸道症状持续存在但明显多变肺功能气流受限可逆，气道高反应，FEV1可以改善，但吸入支气管扩张剂后仍FEV1/FVC0.7气流受限不完全可逆，但有可逆性两次症状间的肺功能正常持续气流受限持续气流受限病史及家族史过敏史或家族哮喘史粉尘暴露史曾诊断哮喘，过敏史，粉尘暴露史病程可自行缓解，或治疗后缓解逐渐加重症状部分改善，但需持续治疗X线正常肺气肿同COPD气道炎症嗜酸细胞和/或中性粒细胞痰中中性粒细胞气道淋巴细胞浸润全身炎症反应嗜酸细胞和/中性粒细胞Global Strategy for Diagnosis,Management and Prevention of Global Strategy for Diagnosis,Management and Prevention of COPDCOPDAdditional Investigations胸部影象学:Seldomdiagnosticbutvaluabletoexcludealternativediagnosesandestablishpresenceofsignificantcomorbidities.肺容积和弥散功能:Helptocharacterizeseverity,butnotessentialtopatientmanagement.动脉血气:Pulseoximetrycanbeusedtoevaluateapatientsoxygensaturationandneedforsupplementaloxygentherapy.Alpha-1 抗胰蛋白酶:PerformwhenCOPDdevelopsinpatientsofCaucasiandescentunder45yearsorwithastrongfamilyhistoryofCOPD.2013GlobalInitiativeforChronicObstructiveLungDiseaseGlobalStrategyforDiagnosis,ManagementandPreventionofCOPD,2014:ChaptersnnDefinitionandOverviewDefinitionandOverviewnnDiagnosisandAssessmentDiagnosisandAssessmentnnTherapeuticOptionsTherapeuticOptionsnnManageStableCOPDManageStableCOPDnnManageExacerbationsManageExacerbationsnnManageComorbiditiesManageComorbiditiesUPDATED20132013GlobalInitiativeforChronicObstructiveLungDiseaseCOPD的治疗戒烟帮助患者戒烟的五步策略1.询问(ASK):系统地对所有吸烟者进行询问。建立一个相应的办公系统,保证每个吸烟者每次随访时的吸烟状态都能得到详细的询问和记录。2.建议(ADVISE):强烈建议每个吸烟者戒烟。态度要明确、坚定、有针对性,鼓励其戒烟。3.评估(ASSESS):确定患者有无戒烟意愿。询问每个吸烟者是否愿意在近期(如30d内)进行戒烟尝试。4.帮助(ASSIST):帮助患者戒烟。帮助吸烟者制定戒烟计划;提供实用可行的咨询服务;提供治疗范围内的社会支持;帮助获得治疗范围外的社会支持;推荐使用仅在某些特定场合下批准的药物;提供辅助措施等。5.安排(ARRANGE):安排随访计划。通过患者本人亲自来诊或电话联系,安排随访。2013GlobalInitiativeforChronicObstructiveLungDiseaseCOPD的治疗识别COPD的其他危险因素也相当重要,其中包括职业粉尘和化学烟雾,燃烧生物燃料所致的室内空气污染,厨房通风不佳等。这些因素在女性COPD患者的发病中尤为重要。COPD的治疗药物Beta2-agonistsShort-actingbeta2-agonistsLong-actingbeta2-agonistsAnticholinergicsShort-actinganticholinergicsLong-actinganticholinergicsCombinationshort-actingbeta2-agonists+anticholinergicinoneinhalerMethylxanthinesInhaledcorticosteroidsCombinationlong-actingbeta2-agonists+corticosteroidsinoneinhalerSystemiccorticosteroidsPhosphodiesterase-4inhibitors2013GlobalInitiativeforChronicObstructiveLungDisease支气管扩张剂是用来改善肺功能FEV1或改善其他肺功能参数的药物,其主要是通过改变气道平滑肌的张力以扩张支气管,而不能改善肺弹性回缩力,因而这类药物称为“支气管扩张剂”主要的支气管扩张剂：beta2-agonists,anticholinergics,theophyllineorcombinationtherapy.支气管扩张剂2013GlobalInitiativeforChronicObstructiveLungDisease支气管扩张剂在COPD稳定期中的应用支气管扩张剂是控制COPD症状的主要治疗措施首选吸入疗法如何选择2激动剂、抗胆碱能药、茶碱类或联合使用,取决于药物是否可以获得以及不同个体的反应(包括症状是否能控制、不良反应等)短期按需使用支气管扩张剂可缓解症状,长期规律使用可预防和减轻症状吸入长效支气管扩张剂更为方便,而且效果更好与应用一种支气管扩张剂的剂量相比,联合应用多种支气管扩张剂可以增加疗效,减少不良反应磷酸二酯酶-4抑制剂InpatientswithsevereandverysevereCOPD(GOLD3and4)andahistoryofexacerbationsandchronicbronchitis,thephospodiesterase-4inhibitor(PDE-4),roflumilast,reducesexacerbationstreatedwithoralglucocorticosteroids.GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDTherapeuticOptions:Phosphodiesterase-4Inhibitors2013GlobalInitiativeforChronicObstructiveLungDisease茶碱目前,关于甲基黄嘌呤类药物的具体作用还存在争议。甲基黄嘌呤是非选择性的磷酸二酯酶抑制剂,除支气管扩张作用外,还有其他一些非支气管扩张剂的作用,但仍有争议。低剂量茶碱能减少COPD患者急性加重发作,但不能增加应用支气管扩张剂后的肺功能。不良反应:不良反应与剂量相关。2013GlobalInitiativeforChronicObstructiveLungDisease吸入糖皮质激素(ICS)可以改善症状，肺功能，生活质量，减少急性加重的次数。吸入糖皮质激素2013GlobalInitiativeforChronicObstructiveLungDisease在重度COPD患者中推荐联合ICS和LABA/LAMA.可以减少肺炎的风险联合治疗2013GlobalInitiativeforChronicObstructiveLungDisease避免长期使用全身糖皮质激素TherapeuticOptions:SystemicCorticosteroids2013GlobalInitiativeforChronicObstructiveLungDiseaseInfluenza vaccines canreduceseriousillness.PneumococcalpolysaccharidevaccineisrecommendedforCOPDpatients65yearsandolderandforCOPDpatientsyoungerthanage65withanFEV115hoursperday)topatientswithchronicrespiratoryfailurehasbeenshowntoincreasesurvivalinpatientswithsevere,restinghypoxemia.Ventilatory Support:Combinationofnoninvasiveventilation(NIV)withlong-termoxygentherapymaybeofsomeuseinaselectedsubsetofpatients,particularlyinthosewithpronounceddaytimehypercapnia.GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDTherapeuticOptions:OtherTreatments2013GlobalInitiativeforChronicObstructiveLungDiseaseLung volume reduction surgery(LVRS)ismoreefficaciousthanmedicaltherapyamongpatientswithupper-lobepredominantemphysemaandlowexercisecapacity.LVRSiscostlyrelativetohealth-careprogramsnotincludingsurgery.InappropriatelyselectedpatientswithverysevereCOPD,lung transplantation hasbeenshowntoimprovequalityoflifeandfunctionalcapacity.GlobalStrategyforDiagnosis,ManagementandPreventionofCOPDTherapeuticOptions:SurgicalTreatments2013GlobalInitiativeforChronicObstructiveLungDiseaseGlobalStrategyforDiagnosis,ManagementandPreventionofCOPD,2014:MajorChaptersnnDefinitionandOverviewDefinitionandOverviewnnDiagnosisandAssessmentDiagnosisandAssessmentnnTherapeuticOptionsTherapeuticOptionsnnManageStableCOPDManageStableCOPDnnManageExacerbationsManageExacerbationsnnManageComorbiditiesManageComorbiditiesUPDATED20132013GlobalInitiativeforChronicObstructiveLungDiseaseRelievesymptomsImproveexercisetoleranceImprovehealthstatusPreventdiseaseprogressionPreventandtreatexacerbationsReducemortalityReducesymptomsReduceriskManage Stable COPD:Goals of Therapy2013GlobalInitiativeforChronicObstructiveLungDiseaseAvoidanceofriskfactors-smokingcessation-reductionofindoorpollution-reductionofoccupationalexposureInfluenzavaccinationManage Stable COPD:All COPD Patients2013GlobalInitiativeforChronicObstructiveLungDiseaseManage Stable COPD:非药物非药物PatientGroupEssentialRecommendedDepending on local guidelinesA戒烟(可以包括药物治疗)体育活动流感疫苗肺炎疫苗B,C,D戒烟(可以包括药物治疗)肺康复体育活动流感疫苗肺炎疫苗2013GlobalInitiativeforChronicObstructiveLungDiseaseManage Stable COPD:Pharmacologic Manage Stable COPD:Pharmacologic TherapyTherapyPatient首选首选第二选择第二选择备选备选ASAMAprnorSABAprnLAMAorLABAorSABAandSAMATheophyllineBLAMAorLABALAMAandLABASABAand/orSAMATheophyllineCICS+LABAorLAMALAMAandLABAorLAMAandPDE4-inh.orLABAandPDE4-inh.SABAand/orSAMATheophyllineDICS+LABAand/orLAMAICS+LABAandLAMAorICS+LABAandPDE4-inh.orLAMAandLABAorLAMAandPDE4-inh.CarbocysteineSABA and/orSAMATheophyllineExacerbationsperyear210mMRC0-1CAT2CAT10GOLD3GOLD2GOLD1SAMAprnorSABAprnLABAorLAMAICS+LABAorLAMAManage Stable COPD:Manage Stable COPD:药物治疗药物治疗药物治疗药物治疗RECOMMENDED RECOMMENDED FIRST CHOICEFIRST CHOICEABDCICS+LABAand/orLAMA2013GlobalInitiativeforChronicObstructiveLungDisease210mMRC0-1CAT2CAT10GOLD3GOLD2GOLD1LAMAorLABAorSABAandSAMALAMAandLABAorLAMAandPDE4-inhorLABAandPDE4-inhICS+LABAandLAMAorICS+LABAandPDE4-inhorLAMAandLABAorLAMAandPDE4-inh.LAMAandLABAManage Stable COPD:Manage Stable COPD:药物治疗药物治疗药物治疗药物治疗ALTERNATIVE CHOICEALTERNATIVE CHOICEADCBExacerbationsperyear2013GlobalInitiativeforChronicObstructiveLungDisease210mMRC0-1CAT2CAT10GOLD3GOLD2GOLD1TheophyllineSABA and/or SAMATheophyllineCarbocysteineSABA and/or SAMATheophylline SABA and/or SAMATheophyllineManage Stable COPD:Manage Stable COPD:药物治疗药物治疗药物治疗药物治疗OTHER POSSIBLE TREATMENTSOTHER POSSIBLE TREATMENTSADCBExacerbationsperyear2013GlobalInitiativeforChronicObstructiveLungDiseaseGlobalStrategyforDiagnosis,ManagementandPreventionofCOPD,2013:MajorChaptersnnDefinitionandOverviewDefinitionandOverviewnnDiagnosisandAssessmentDiagnosisandAssessmentnnTherapeuticOptionsTherapeuticOptionsnnManageStableCOPDManageStableCOPDnnManageExacerbationsManageExacerbationsnnManageComorbiditiesManageComorbiditiesUPDATED20132013GlobalInitiativeforChronicObstructiveLungDiseaseCOPD常常和其他疾病合并存在,可对疾病的进展产生显著影响。存在合并症不需要改变COPD的治疗。根据各种合并症的指南进行治疗合并症的治疗合并症的治疗2013GlobalInitiativeforChronicObstructiveLungDiseaseGlobalStrategyforDiagnosis,ManagementandPreventionofCOPD,2013:ChaptersnnDefinitionandOverviewDefinitionandOverviewnnDiagnosisandAssessmentDiagnosisandAssessmentnnTherapeuticOptionsTherapeuticOptionsnnManageStableCOPDManageStableCOPDnnManageExacerbationsManageExacerbationsnnManageComorbiditiesManageComorbiditiesUPDATED20132013GlobalInitiativeforChronicObstructiveLungDiseaseManageExacerbations慢性阻塞性肺疾病急性加重(AECOPD)诊治中国专家共识(草案)2012年12月ManageExacerbationsAECOPDAECOPD的概述、病因及诊断的概述、病因及诊断AECOPDAECOPD的住院治疗指征和分级治疗的住院治疗指征和分级治疗AECOPDAECOPD患者的药物治疗患者的药物治疗AECOPDAECOPD患者的机械通气患者的机械通气AECOPDAECOPD出院和预防出院和预防AECOPD 定义定义 COPD急急性性加加重重是是指指一一种种急急性性起起病病的的过过程程，其其特特征征是是患患者者呼呼吸吸系系统统症症状状恶恶化化，超超出出日日常常的的变变异异，并并且且导导致致需需要要改改变变药药物治疗。物治疗。如果胸片出现肺部阴影，符合感染表现，则如果胸片出现肺部阴影，符合感染表现，则诊断为诊断为社区获得性肺炎社区获得性肺炎。-2011年欧洲成人下呼吸道感染的诊治指南年欧洲成人下呼吸道感染的诊治指南 AECOPD versus CAP AECOPD CAP +COPDAECOPD is not CAPAECOPD的概述原因：上呼吸道病毒感染、气管-支气管细菌感染治疗目标：减轻急性加重的病情，预防再次急性加重治疗：支气管扩张剂、糖皮质激素、抗菌药，不推荐抗病毒药物预防：戒烟、接种疫苗、掌握治疗知识、单用吸入支气管扩张剂或联用吸入糖皮质激素、应用磷酸二酯酶-4抑制剂AECOPD 病因Sethietal.Chest2000;117:380s-385s80%80%感染感染感染感染20%20%非感染非感染非感染非感染细菌病原体细菌病原体细菌病原体细菌病原体40-50%40-50%病毒感染病毒感染病毒感染病毒感染40-50%40-50%非典型病原体非典型病原体非典型病原体非典型病原体5-10%5-10%环境因素环境因素环境因素环境因素吸烟吸烟 大气污染大气污染 吸入变应原吸入变应原未遵循医嘱未遵循医嘱未遵循医嘱未遵循医嘱进行治疗进行治疗进行治疗进行治疗*AECOPD可能起源于病毒感染、可能起源于病毒感染、细菌感染或非感染因素（吸烟、细菌感染或非感染因素（吸烟、环境污染和未进行有效治疗等）环境污染和未进行有效治疗等）AECOPD AECOPD 的病毒感染的病毒感染Hurst,J.R.,Wedzicha,J.A.,2004.Chronic obstructive pulmonary disease:the clinical management of an acute exacerbation.Postgrad Med J 80,497-505.鼻病毒鼻病毒冠状病毒冠状病毒流感病毒流感病毒腺病毒腺病毒呼吸道合胞体病毒（呼吸道合胞体病毒（RSV)RSV)副流感病毒副流感病毒AECOPD病毒感染率以鼻病病毒感染率以鼻病毒和毒和RSV 最为常见最为常见混合感染混合感染 冠状病毒冠状病毒 肺炎衣原体肺炎衣原体 呼吸道合胞体病毒呼吸道合胞体病毒 腺病毒腺病毒 副流感病毒副流感病毒 流感病毒流感病毒B 流感病毒流感病毒A 鼻病毒鼻病毒 病毒和病毒和 AECOPD Seemungal et al Am J Respir Crit Care Med 200140-50%AECOPD合并合并上呼吸道病毒感染，上呼吸道病毒感染，常见为鼻病毒属常见为鼻病毒属(64%)、呼吸道合胞病毒和、呼吸道合胞病毒和流感病毒。流感病毒。COPD慢性疾病慢性疾病 逐渐进展逐渐进展 肺功能肺功能 症状症状 合并症合并症急性加重急性加重 典型病例每年典型病例每年1 13 3次急性加重次急性加重 发生频率与发生频率与COPDCOPD严重程度成比严重程度成比例例 经常发生经常发生AECOPDAECOPD者病情加速进者病情加速进展，导致：展，导致：生活质量生活质量 反复住院反复住院 死亡率增加死亡率增加COPD 与与 AECOPD原因：可由多种因素所致。最常见为病毒性上呼吸道感染和气管支气管感染。诊断：唯一依靠患者急性起病和症状加重的临床表现（呼吸困难、咳嗽、多痰），这些