Терапия ХОБЛ

??????? ???? : 

??????? ???? 15 ???? 2009 ?.

??????????? : 

??????????? ERS-ATS COPD Guidelines www.ersnet.org/copd Eur Respir J 2004; 23: 932–946 GOLD http://www.goldcopd.org

??????? : 

??????? Sutherland ER and Cherniack RM. N Engl J Med 2004;350:2689-97. ???????????????? ??????????? ???????? ???1 100 50 20 ???????? ??? ????? ?? ???????, ?????????? ?????????? ?????????? ?? ?????? SABA PRN ??????????? ????. ???????? ????????? ????????????? ???? ???????? ????????. ???.

????? ?? ??????? : 

????? ?? ??????? Scanlon et al . Am J Respir Crit Care Med 2000; 161: 381–390. ????????? ?????? ?????????? ?????? ???1 (?) ????? ???????????? Follow-up (????)) 2.9 2.8 2.7 2.6 2.5 2.4 0 2 3 4 5 1 n=5887 (LHS I)

????????? : 

????????? ? ??????????? ??????????? ? ??????? ???????? ?????????? ????, ??? ?????? ???????????? ???????? ????????????? ??????? Ram FSF et al. Oral theophylline for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2002;(4):CD003902

ß2-????????????????? ????????? ???????? : 

ß2-????????????????? ????????? ???????? ???????????????? ???????? (???????) ??????????? ?? ?????? ?? ???1 ?? ?????? ?? ???????? ????? ? ???? ?????????? ???????? ?????????? ???????????? ??????????? ????? ??????????????, ?? ????????? ? ?????? ??????????? ? ?????? ?? ???????????

ß2-????????????????? ??????????? ???????? : 

ß2-????????????????? ??????????? ???????? ???????????????? ???????? (???????) ? ???1 ??????? ????? ?????????? ???? (? ?? 11%) ?????????? ? ????????????? ?????????? ???????? ?????????? ? ???????? ?????, ? ??????????? ? SABA ???????? ???????? ??????? R. Aalbers et al. Eur Respir J 2002; 19: 936–943.

Slide 8: 

M-ACh R M-ACh R a,ß-Adr R ???????????? ????? ????????????? ????? ???????????????? ?????, eg. n. vagus

?-???????????? : 

?-???????????? ??????????? ?????????? ???????? ??????? ????????

???????????????? ?????????? ? - ???????????????? : 

???????????????? ?????????? ? - ????????????????

??????????? : 

??????????? ?? ????????????? ?? ?????????? ?? SABA ???????? LABA ? ??????????? ?? ?????? ?? ??????? ?????????? ????????? SABA ? LABA COMBIVENT Inhalation Aerosol Study Group. Chest 1994; 105:1411-19

?????????? : 

?????????? ????????? 24 ???? ??????????? ??????????? ?? ????????????????? ???????? SABA ? ??????????? ? ????????????? ? ???????? ? ???????? ????? ? ???? ?????????? ?? 20-28% (vs SABA) ? ?? 14% (vs LABA) ??????? ???? ????????? ??????? ?? 16% (?=0.016) Van Noord et al. Thorax 2000 Tashkin DP et al. UPLIFT Study Investigators. N Engl J Med 2008;359:1543-54

UPLIFT: ???1 ?? ? ????? ????????? ????????????? : 

UPLIFT: ???1 ?? ? ????? ????????? ????????????? Tashkin DP et al. UPLIFT Study Investigators. N Engl J Med 2008;359:1543-54

?????????? ? ?????????? – ?????????? : 

?????????? ? ?????????? – ?????????? Rossi A et al. 2002; 121:1058–1069 ?????, ???. ???1, ? ?????????? ?????????? ?????????? + ??????????

???? : 

???? ?? ?????? ?? ???1 ? ????????, ?? ????????????? ????????? ?????? ???1 ? ??????? ??????? ???? ?????? ?? ???????? ????? ? ???? ?????????? ?? 15-25% vs SABA: ????? ?????????? ????????????? ??????? ?????????? ??????????? ? ??????? ? ??????? ???????? ???? ? ??????? ???????????? Burge PS. BMJ 2000;320;1297-1303 Pauwels RA N Engl J Med 1999; 340: 1948–1943. Jones PW. Eur Respir J 2003; 21: 68–73

?????? : 

?????? Tashkin DP Chest. 2004;125:249-259. (c ?????? ????? ??????? ??????)

???? ????????? ??????? (???????: n= 32 130, ????????: n= 320 501) : 

???? ????????? ??????? (???????: n= 32 130, ????????: n= 320 501) Lee TA Ann Intern Med. 2008;149:380-390

????????? ? ??????? : 

????????? ? ???????

?????????? ?? ????? ?????? : 

?????????? ?? ????? ??????

??????? ?????? ? ???????????? TORCH : 

??????? ?????? ? ???????????? TORCH

???????? ????? ??????? ??????????:????????? ? ??????? : 

???????? ????? ??????? ??????????:????????? ? ???????

???????????? OPTIMAL : 

???????????? OPTIMAL ??????? + ??????? vs ??????? ???????? ????? ?????????? ? ?????? ??????????????? ??????? vs ???????: 0.85 [0.65-1.11] NS ? ???????????? CLIMB: 0,38 [0,25–0,57] P < 0,001 Ann Intern Med.2007;146:545-555.

???????? ????? ?????????? ???? : 

???????? ????? ?????????? ???? Casaburi 2002, Vincken 2002, Szafranski 2003, Calverley 2007, Aaron 2007 ???????????? ????????? ????????

Slide 24: 

GOLD ???????? ???? ??? ????? ??????????? ??????????? ????????* ???????? ???????????? ???????? ????????????? ??? ??? ??????? ?????????? ???? ???????? ?2 ????????????? ??????? II ????????? III ??????? IV ????? ???. I ?????? * - ??? ?????????????

??????? ??? : 

??????? ??? Proc Am Thorac Soc Vol 3. pp 635–640, 2006 20 16 12 8 4 ?????????? ?? 1 ???, % SOLVD 1991 -23% CIBIS-II 1999 MERIT-HF 1999 COPERNICUS 2001 -34% CHARM 2003 -28%

??????? ?????????? ???? : 

??????? ?????????? ???? ??????? ? ??????????? ???? ? ? ???????????? ?????????? ???????? ?????? ??????????? ????? ( ?????????? ?????? ? ????? ??????? ?/??? ????????? ??????????? ????) ????? ????? ?????? ?? ??????? ????????????? (??????? ?) ????????????? ???????????? (ß2-a??????? ?/??? ???), ????????? ? ????????? ??? (??????????????? ???????????) ?????????? ??? ??????? ?????????? ???? (??????? A).