305.4 📋 章末速記 Summary

305.4.1 🔑 一句話總結

COPD = 慢性、進行性、可治療但不可逆 airflow limitation；emphysema + chronic bronchitis 兩大病理；smoking 是 #1 cause，α1-AT deficiency 是 genetic 原因；診斷靠 post-bronchodilator FEV1/FVC < 0.7；GOLD ABE 2023 framework 分 A (low symp + low exac)、B (high symp + low exac)、E (≥ 2 exac or ≥ 1 hosp)；treatment hierarchy：smoking cessation + LABA + LAMA + ICS（eosinophilic ≥ 300 or 100-299 + frequent exac）+ roflumilast + azithromycin + biologics 2024（dupilumab BOREAS/NOTUS 2023-2024、mepolizumab MATINEE 2024 for eosinophilic COPD）+ LTOT + NIV + pulmonary rehab + LVRS / endobronchial valves / transplant；acute exacerbation：SABA + ipratropium + prednisone 40 × 5d + antibiotics + NIV if pH < 7.35。

305.4.2 💊 治療精要

  • 基石：smoking cessation（單一最重要）
  • 吸入劑：LABA + LAMA combo（Group B）；triple therapy (ICS + LABA + LAMA) for eosinophilic + frequent exacerbator
  • PDE4 inhibitor：roflumilast for chronic bronchitis + frequent exacerbations
  • azithromycin 250 mg/d 或 500 mg 3x/week chronic for frequent exacerbations
  • biologics 2024：dupilumab (anti-IL-4Rα) BOREAS/NOTUS、mepolizumab (anti-IL-5) MATINEE — for eosinophilic
  • LTOT：PaO2 ≤ 55 or 56-59 + cor pulmonale；≥ 15 hr/d
  • NIV：acute hypercapnic exacerbation (pH < 7.35) + chronic stable home NIV (HOT-HMV)
  • pulmonary rehab：Class I in symptomatic
  • vaccinations：flu + pneumococcal + COVID + RSV + Tdap
  • endobronchial valves for selected severe emphysema
  • lung transplant for end-stage

305.4.3 🎯 盧醫師的考前提醒

  1. COPD 診斷準則：post-bronchodilator FEV1/FVC < 0.7（GOLD 標準）；若臨床懷疑但 spirometry 邊緣 → consider LLN
  2. GOLD ABE 2023 (updated from ABCD)：A (low symp + low exac) / B (high symp + low exac) / E (frequent exacerbator) — 治療依此決定
  3. eosinophil-guided ICS use：blood eosinophils ≥ 300 → ICS strongly benefits；100-299 + frequent exac → consider；< 100 → 不需要 ICS（會增加 pneumonia risk）
  4. 2024 biologics 革命：dupilumab BOREAS (2023) + NOTUS (2024) — FDA approved for eosinophilic COPD with frequent exacerbations；mepolizumab MATINEE (2024) pending approval — game changer for COPD
  5. α1-antitrypsin deficiency 篩檢：所有 COPD with FEV1 < 80% 都該驗一次；PiZZ phenotype + early-onset basilar emphysema + family history
  6. smoking cessation 單一最重要：reduces mortality + slows decline；varenicline + bupropion + NRT 結合最有效
  7. LTOT criteria：PaO2 ≤ 55 mmHg or SpO2 ≤ 88% 在 room air at rest；或 PaO2 56-59 + cor pulmonale / polycythemia；≥ 15 hr/d 才能改善 survival
  8. acute COPD exacerbation 治療：SABA + SAMA + prednisone 40 mg × 5 days + antibiotics (cardinal symptoms 2 of 3) + NIV if pH < 7.35（reduces intubation + mortality）+ target SpO2 88-92%
  9. HOT-HMV (2017)：chronic hypercapnia + frequent exacerbations → long-term home NIV reduces hospital readmissions + improves survival
  10. endobronchial valves > LVRS for select severe emphysema：less invasive, fewer complications；NETT trial defined LVRS subgroup (upper-lobe + low exercise capacity)