COPD - national recommendations. Clinical guidelines: Chronic obstructive pulmonary disease Practical guidelines for COPD

The goals of COPD treatment can be divided into 4 main groups:
  Elimination of symptoms and improvement of quality of life;
  Reducing future risks, etc.; prevention of exacerbations;
  Slowing down the progression of the disease;
  Reduced mortality.
  Treatment of COPD includes pharmacological and non-pharmacological approaches. Pharmacologic treatments include bronchodilators, combinations of ICS and long-acting bronchodilators (LABAs), phosphodiesterase-4 inhibitors, theophylline, and influenza and pneumococcal vaccinations.
  Nonpharmacologic options include smoking cessation, pulmonary rehabilitation, oxygen therapy, respiratory support, and surgery.
  Treatment of exacerbations of COPD is discussed separately.

3.1 Conservative treatment.

Quitting smoking.

  Smoking cessation is recommended for all patients with COPD.

  Comments. Smoking cessation is the most effective intervention and has a major impact on the progression of COPD. The usual advice from a doctor leads to smoking cessation in 7.4% of patients (2.5% more than in controls), and as a result of a 3-10-minute consultation, the smoking cessation rate reaches about 12%. With more time and more complex interventions that include skills training, problem-solving training, and psychosocial support, smoking cessation rates can reach 20–30%.
  In the absence of contraindications, pharmacological treatments for tobacco dependence are recommended to support smoking cessation efforts.

  Comments. Pharmacotherapy effectively supports smoking cessation efforts. First-line drugs for the treatment of tobacco dependence include varenicline, extended-release bupropion, and nicotine replacement drugs.
  A combination of medical advice, support group, skills training and nicotine replacement therapy leads to cessation of smoking in 35% of cases after 1 year, while 22% remain non-smokers after 5 years.
  Principles of pharmacotherapy for stable COPD.
  Pharmacological classes of drugs used in the treatment of COPD are presented in Table. 5.
  Table 5. Pharmacological classes of drugs used in the treatment of COPD.

Pharmacological class	Drugs
KDBA	Salbutamol Fenoterol
DDBA	Vilanterol Indacaterol Salmeterol Olodaterol Formoterol
KDAH	Ipratropium bromide
DDAH	Aclidinium bromide Glycopyrronium bromide Tiotropium bromide Umeclidinium bromide
ICS	Beclomethasone Budesonide Mometasone Fluticasone Fluticasone furoate Cyclesonide
Fixed combinations LADAH/LABA	Glycopyrronium bromide/indacaterol Tiotropium bromide/olodaterol Umeclidinium bromide/vilanterol Aclidinium bromide/formoterol
Fixed combinations of ICS/LABA	Beclomethasone/formoterol Budesonide/formoterol Fluticasone/salmeterol Fluticasone furoate/vilanterol
Phosphodiesterase-4 inhibitors	Roflumilast
Other	Theophylline

  Note. SABA - short-acting β2-agonists, CDAC - short-acting anticholinergics, LABA - long-acting β2-agonists, LAAC - long-acting anticholinergics.
  When prescribing pharmacotherapy, it is recommended to set the goal of achieving symptom control and reducing future risks, etc.; exacerbations of COPD and mortality (Appendix G5).

  Comments. The decision to continue or terminate treatment is recommended to be made based on reducing future risks (exacerbations). This is because it is not known how a drug's ability to improve lung function or reduce symptoms correlates with its ability to reduce the risk of exacerbations of COPD. To date, there is no convincing evidence that any specific pharmacotherapy slows disease progression (as assessed by the mean rate of decline in trough FEV1) or reduces mortality, although preliminary data suggesting such effects have been published.
  Bronchodilators.
  Bronchodilators include β2-agonists and anticholinergic drugs, including short-acting (duration of effect 3-6 hours) and long-acting (duration of effect 12-24 hours) drugs.
  It is recommended that all patients with COPD be prescribed a short-acting bronchodilator for use as needed.
  Strength of recommendation: A (level of evidence: 1).
  Comments. The use of short-acting bronchodilators as needed is also possible in patients receiving treatment with LABD. At the same time, the regular use of high doses of short-acting bronchodilators (including through a nebulizer) in patients receiving LABD is not justified and should be used only in the most difficult cases. In such situations, it is necessary to fully evaluate the need for the use of LABD and the patient's ability to perform inhalations correctly.
  β2-agonists.
  For the treatment of COPD, the following long-acting β2-agonists (LABAs) are recommended: formoterol, salmeterol, indacaterol, olodaterol (Appendix G6).
  Strength of recommendation: A (level of evidence: 1).
  Comments. In terms of their effect on FEV1 and shortness of breath, indacaterol and olodaterol are at least as good as formoterol, salmeterol and tiotropium bromide. In terms of their effect on the risk of moderate/severe exacerbations, LABAs (indacaterol, salmeterol) are inferior to tiotropium bromide.
  When treating patients with COPD with concomitant cardiovascular diseases, it is recommended to assess the risk of developing cardiovascular complications before prescribing a LABA.

  Comments. Activation of cardiac β-adrenergic receptors by β2-agonists can presumably cause ischemia, heart failure, arrhythmias, and also increase the risk of sudden death. However, in controlled clinical trials in patients with COPD, there was no evidence of an increase in the incidence of arrhythmias, cardiovascular or overall mortality with the use of β2-agonists.
  In the treatment of COPD, unlike asthma, LABAs can be used as monotherapy (without ICS).
  Anticholinergic drugs.
  For the treatment of COPD, it is recommended to use the following long-acting anticholinergics (LAAs): tiotropium bromide, aclidinium bromide, glycopyrronium bromide, umeclidinium bromide (Appendix D6).
  Strength of recommendation: A (level of evidence: 1).
  Comments. Tiotropium bromide has the largest evidence base among the DDACs. Tiotropium bromide increases pulmonary function, relieves symptoms, improves quality of life, and reduces the risk of exacerbations of COPD.
  Aclidinium bromide and glycopyrronium bromide improve pulmonary function, quality of life and reduce the need for rescue medications. In studies of up to 1 year, aclidinium bromide, glycopyrronium bromide, and umeclidinium bromide reduced the risk of exacerbations of COPD, but long-term studies of more than 1 year similar to those of tiotropium bromide have not been conducted to date.
  Inhaled anticholinergics are generally well tolerated, and adverse events (AEs) with their use are relatively rare.
  In patients with COPD and concomitant cardiovascular diseases, the use of LAMA is recommended.
  Strength of recommendation: A (level of evidence: 1).
  Comments. While short-acting anticholinergics (SAAs) have been suspected of causing cardiac AEs, there have been no reports of an increased incidence of cardiac AEs with SAAs. In the 4-year UPLIFT study, patients treated with tiotropium bromide had significantly fewer cardiovascular events and overall mortality than those in the placebo group. In the TIOSPIR trial (median treatment duration 2.3 years), tiotropium bromide liquid inhaler was found to be highly safe, with no difference compared with tiotropium bromide dry powder inhaler in terms of mortality, serious cardiac AEs, and exacerbations of COPD.
  Combinations of bronchodilators.
  It is recommended to combine bronchodilators with different mechanisms of action in order to achieve greater bronchodilation and relieve symptoms.
  Strength of recommendation: A (level of evidence: 1).
  Comments. For example, the combination of a CDAC with a SABA or LABA improves FEV1 to a greater extent than either single component. A SABA or LABA may be given in combination with a LAMA if LAMA monotherapy does not provide sufficient symptom relief.
  For the treatment of COPD, the use of fixed combinations of LAMA/LABA is recommended: glycopyrronium bromide/indacaterol, tiotropium bromide/olodaterol, umeclidinium bromide/vilanterol, aclidinium bromide/formoterol.
  Strength of recommendation: A (level of evidence: 1).
  Comments. These combinations showed an advantage over placebo and their monocomponents in terms of their effect on minimum FEV1, shortness of breath and quality of life, without being inferior to them in terms of safety. When compared with tiotropium bromide, all LAMA/LABA combinations showed superior effects on pulmonary function and quality of life. In terms of the effect on dyspnea, no benefit was demonstrated for the combination of umeclidinium bromide/vilanterol, and in terms of the effect on PHI, only tiotropium bromide/olodaterol was significantly superior to tiotropium bromide monotherapy.
  At the same time, LAMA/LABA combinations have not yet demonstrated any advantages over tiotropium bromide monotherapy in terms of their effect on the risk of moderate/severe exacerbations of COPD.
  Inhaled glucocorticosteroids and their combinations with β2-adrenergic agonists.
  ICS is recommended to be prescribed only in addition to ongoing LABD therapy in patients with COPD with a history of asthma and with blood eosinophilia (the content of eosinophils in the blood outside of an exacerbation is more than 300 cells in 1 μl).
  Recommendation strength level B (evidence level 1).
  Comments. In asthma, the therapeutic and undesirable effects of ICS depend on the dose used, but in COPD there is no such dose dependence, and in long-term studies only medium and high doses of ICS were used. The response of patients with COPD to treatment with inhaled corticosteroids cannot be predicted based on the response to treatment with oral corticosteroids, the results of a bronchodilation test, or the presence of bronchial hyperresponsiveness.
  In patients with COPD and frequent exacerbations (2 or more moderate exacerbations within 1 year or at least 1 severe exacerbation requiring hospitalization), ICS is also recommended in addition to LABD.
  Recommendation strength level B (evidence level 1).
  Comments. Long-term (6 months) treatment with ICS and ICS/LABA combinations reduces the frequency of exacerbations of COPD and improves the quality of life of patients.
  ICS can be used as part of either double (LABA/ICS) or triple (LAMA/LABA/ICS) therapy. Triple therapy has been studied in studies where the addition of an ICS/LABA combination to tiotropium bromide treatment resulted in improvements in pulmonary function, quality of life, and an additional reduction in the incidence of exacerbations, especially severe exacerbations. However, triple therapy requires further study in longer studies.
  In patients with COPD at high risk of exacerbations and without blood eosinophilia, it is recommended to prescribe LAMA or ICS/LABA with the same level of evidence.
  Strength of recommendation: A (level of evidence: 1).
  Comments. The main expected effect of prescribing ICS to patients with COPD is a reduction in the risk of exacerbations. In this regard, ICS/LABAs are not superior to LAMA (tiotropium bromide) monotherapy. Recent studies show that ICS/LABA combinations have an advantage over bronchodilators in terms of their effect on the risk of exacerbations only in patients with blood eosinophilia.
  Patients with COPD with preserved pulmonary function and no history of repeated exacerbations are not recommended to use ICS.
  Recommendation strength level B (evidence level 1).
  Comments. Therapy with ICS and ICS/LABA combinations does not affect the rate of decline in FEV1 and mortality in COPD.
  Given the risk of serious adverse effects, ICS is not recommended for initial therapy in COPD.
  Recommendation strength level B (evidence level 1).
  Comments. Adverse effects of ICS include oral thrush and hoarseness. There is evidence of an increased risk of pneumonia, osteoporosis and fractures with the use of ICS and ICS/LABA combinations. The risk of pneumonia in patients with COPD increases when using not only fluticasone, but also other ICS. Initiation of ICS treatment was accompanied by an increased risk of developing diabetes mellitus in patients with respiratory pathology.
  Roflumilast.
  Roflumilast suppresses the inflammatory response associated with COPD by inhibiting the enzyme phosphodiesterase-4 and increasing intracellular cyclic adenosine monophosphate.
  Roflumilast is recommended for patients with COPD with FEV1< 50% от должного, с хроническим бронхитом и частыми обострениями, несмотря на применение ДДБД для уменьшения частоты среднетяжелых и тяжелых обострений .
  Strength of recommendation: A (level of evidence: 1).
  Roflumilast is not recommended for use to relieve symptoms of COPD.
  Strength of recommendation: A (level of evidence: 1).
  Comments. Roflumilast is not a bronchodilator, although during long-term treatment in patients receiving salmeterol or tiotropium bromide, roflumilast increases FEV1 by an additional 50–80 mL.
  The effect of roflumilast on quality of life and symptoms is weak. The drug causes significant undesirable effects, typical of which are gastrointestinal disorders and headache, as well as weight loss.
  Oral glucocorticosteroids.
  It is recommended to avoid long-term treatment with oral corticosteroids in patients with COPD, since such treatment may worsen their long-term prognosis.

  Comments. Although high-dose oral corticosteroids (equal to ≥30 mg oral prednisolone per day) improve pulmonary function in the short term, there is no data on the benefit of long-term use of oral corticosteroids in low or medium-to-high doses with a significant increase in the risk of AEs. However, this fact does not prevent the prescription of a course of oral corticosteroids during exacerbations.
  Oral corticosteroids cause a number of serious undesirable effects; One of the most important in relation to COPD is steroid myopathy, the symptoms of which are muscle weakness, decreased physical activity and respiratory failure in patients with extremely severe COPD.
  Theophylline.
  There remains controversy regarding the exact mechanism of action of theophylline, but the drug has both bronchodilation and anti-inflammatory activity. Theophylline significantly improves pulmonary function in COPD and possibly improves respiratory muscle function, but it also increases the risk of AEs. There is evidence that low doses of theophylline (100 mg 2 times / day) statistically significantly reduce the frequency of exacerbations of COPD.
  Theophylline is recommended for the treatment of COPD as adjunctive therapy in patients with severe symptoms.

  Comments. The effect of theophylline on pulmonary function and symptoms in COPD is less pronounced than that of the LABAs formoterol and salmeterol.
  The exact duration of action of theophylline, including modern slow-release formulations, in COPD is unknown.
  When prescribing theophylline, it is recommended to monitor its concentration in the blood and adjust the dose of the drug depending on the results obtained.
  Strength of recommendation: C (level of evidence: 3).
  Comments. The pharmacokinetics of theophylline is characterized by interindividual differences and a tendency for drug interactions. Theophylline has a narrow therapeutic concentration range and can lead to toxicity. The most common AEs include gastric irritation, nausea, vomiting, diarrhea, increased diuresis, signs of central nervous system stimulation (headache, nervousness, anxiety, agitation) and cardiac arrhythmias.
  Antibacterial drugs.
  The administration of macrolides (azithromycin) in long-term therapy is recommended for patients with COPD with bronchiectasis and frequent purulent exacerbations.
  Strength of recommendation: C (level of evidence: 2).
  Comments. A recent meta-analysis showed that long-term treatment with macrolides (erythromycin, clarithromycin, and azithromycin) in 6 studies lasting 3 to 12 months resulted in a 37% reduction in COPD exacerbations compared with placebo. There was an additional 21% reduction in hospitalizations. The widespread use of macrolides is limited by the risk of increasing bacterial resistance to them and side effects (hearing loss, cardiotoxicity).
  Mucoactive drugs.
  This group includes several substances with different mechanisms of action. The regular use of mucolytics in COPD has been studied in several studies, with conflicting results.
  The administration of N-acetylcysteine ​​and carbocysteine ​​is recommended for patients with COPD with a bronchitis phenotype and frequent exacerbations, especially if ICS therapy is not performed.
  Strength of recommendation: C (level of evidence: 3).
  Comments. N-acetycysteine ​​and carbocysteine ​​may exhibit antioxidant properties and may reduce the number of exacerbations, but they do not improve pulmonary function or quality of life in patients with COPD.

Choosing an inhaler.

  It is recommended that patients with COPD be taught the correct use of inhalers at the beginning of treatment and then monitor their use at subsequent visits.

  Comments. A significant proportion of patients make mistakes when using inhalers. When using a metered-dose inhaler (MDI), coordination between button press and inhalation is not required, but sufficient inspiratory effort is required to generate sufficient inspiratory flow. When using a metered dose aerosol inhaler (MDI), high inspiratory flow is not required, but the patient must be able to coordinate activation of the inhaler with the initiation of inspiration.
  It is recommended to use spacers when prescribing MDIs to eliminate coordination problems and reduce drug deposition in the upper respiratory tract.
  Strength of recommendation: A (level of evidence: 3).
  In patients with severe COPD, it is recommended to give preference to a MDI (including with a spacer) or a liquid inhaler.
  Strength of recommendation: A (level of evidence: 3).
  Comments. This recommendation is due to the fact that in patients with severe COPD, when using DPI, the inspiratory flow is not always sufficient.
  The basic principles for choosing the right inhaler are described in Appendix G7.

Treatment tactics for stable COPD.

  All patients with COPD are recommended to implement non-pharmacological measures, prescribe a short-acting bronchodilator for use as needed, vaccination against influenza and pneumococcal infection, and treatment of concomitant diseases.

  Comments. Non-pharmacological measures include smoking cessation, training in inhalation techniques and basic self-control, vaccination against influenza and pneumococcal disease, encouragement of physical activity, assessment of the need for long-term oxygen therapy (LCT) and non-invasive ventilation (NIV).
  All patients with COPD are recommended to be prescribed a LABA - a combination of LAMA/LABA or one of these drugs in monotherapy (Appendix B).
  Strength of recommendation: A (level of evidence: 1).
  If the patient has severe symptoms (mMRC ≥2 or CAT≥10), it is recommended to prescribe a combination of LAMA/LABA immediately after the diagnosis of COPD is made.
  Strength of recommendation: A (level of evidence: 1).
  Comments. Most patients with COPD consult a doctor with severe symptoms - shortness of breath and decreased exercise tolerance. The administration of a LAMA/LABA combination allows, due to maximum bronchodilation, to relieve shortness of breath, increase exercise tolerance and improve the quality of life of patients.
  Initial monotherapy with one long-acting bronchodilator (LABA or LABA) is recommended for patients with mild symptoms (mMRC< 2 или САТ.
  Strength of recommendation: A (level of evidence: 1).
  Comments. The advantage of LAMA is that it has a more pronounced effect on the risk of exacerbations.
  If symptoms persist (shortness of breath and reduced exercise tolerance) during monotherapy with a single LABA, it is recommended to intensify bronchodilator therapy - transfer to a LAMA/LABA combination (Appendix B).

  Prescribing a LAMA/LABA combination instead of monotherapy is also recommended for repeated exacerbations (2 or more moderate exacerbations within 1 year or at least 1 severe exacerbation requiring hospitalization) in patients without indications of asthma and without blood eosinophilia (Appendix B).
  Strength of recommendation: A (level of evidence: 2).
  Comments. The combination of LAMA/LABA glycopyrronium bromide/indacaterol in the FLAME study reduced the risk of moderate/severe exacerbations of COPD more effectively than the combination of ICS/LABA (fluticasone/salmeterol) in patients with COPD with an FEV1 of 25–60% predicted and the absence of high blood eosinophilia.
  If repeated exacerbations in a patient with COPD and asthma or with blood eosinophilia occur during therapy with a single LABA, then the patient is recommended to be prescribed a LABA/ICS (Appendix B).
  Strength of recommendation: A (level of evidence: 2).
  Comments. The criterion for blood eosinophilia is the content of eosinophils in the blood (out of exacerbation) of 300 cells in 1 μl.
  If repeated exacerbations in patients with COPD with asthma or eosinophilia occur during therapy with a LAMA/LABA combination, then the patient is recommended to add ICS (Appendix B).
  Strength of recommendation: A (level of evidence: 2).
  Comments. The patient may also resort to triple therapy if ICS/LABA therapy is insufficiently effective, when LAMA is added to the treatment.
  Triple therapy with LAMA/LABA/ICS can currently be carried out in two ways: 1) using a fixed combination of LAMA/LABA and a separate ICS inhaler; 2) using a fixed combination LABA/ICS and a separate LAMA inhaler. The choice between these methods depends on the initial therapy, compliance with various inhalers and availability of drugs.
  If repeated exacerbations occur on therapy with a LAMA/LABA combination in a patient without asthma and eosinophilia or relapse of exacerbations on triple therapy (LAMA/LABA/ICS), it is recommended to clarify the COPD phenotype and prescribe phenotype-specific therapy (roflumilast, N-acetylcysteine, azithromycin, etc. ; – Appendix B) .
  Strength of recommendation: B (level of evidence: 3).
  It is not recommended to reduce the volume of bronchodilator therapy (in the absence of AEs) even in the case of maximum symptom relief.
  Strength of recommendation level A (level of evidence – 2).
  Comments. This is due to the fact that COPD is a progressive disease, so complete normalization of lung function parameters is impossible.
  In patients with COPD without repeated exacerbations and with preserved pulmonary function (FEV1 50% of predicted), complete withdrawal of ICS is recommended, subject to the prescription of a LABD.
  Strength of recommendation level B (level of evidence – 2).
  Comments. If, in the opinion of the doctor, the patient does not need to continue treatment with ICS, or AEs have arisen from such therapy, then ICS can be discontinued without increasing the risk of exacerbations.
  In patients with FEV1< 50% от должного, получающих тройную терапию, рекомендуется постепенная отмена ИГКС со ступенчатым уменьшением его дозы в течение 3 месяцев .
  Strength of recommendation: A (level of evidence – 3).
  Comments. FEV1 value< 50% ранее считалось фактором риска частых обострений ХОБЛ и рассматривалось как показание к назначению комбинации ИГКС/ДДБА. В настоящее время такой подход не рекомендуется, поскольку он приводит к нежелательным эффектам и неоправданным затратам , хотя в реальной практике ИГКС и комбинации ИГКС/ДДБА назначаются неоправданно часто.

3.2 Surgical treatment.

  In COPD patients with upper lobe emphysema and low exercise tolerance, lung volume reduction surgery is recommended.
  Strength of recommendation: C (level of evidence: 3).
  Comments. Lung reduction surgery is performed by removing part of the lung to reduce hyperinflation and achieve more efficient pumping of the respiratory muscles. Currently, to reduce lung volume, it is possible to use less invasive methods - occlusion of segmental bronchi using valves, special glue, etc.;
  Lung transplantation is recommended for a number of patients with very severe COPD in the presence of the following indications: BODE index ≥ 7 points (BODE – B – body mass index, O – obstruction (obstruction), D – dyspnea (shortness of breath), E – exercise tolerance (exercise tolerance), FEV1< 15% от должных, ≥ 3 обострений в предшествующий год, 1 обострение с развитием острой гиперкапнической дыхательной недостаточности (ОДН), среднетяжелая-тяжелая легочная гипертензия (среднее давление в легочной артерии ≥35 мм) .
  Strength of recommendation: C (level of evidence: 3).
  Comments. Lung transplantation can improve quality of life and functional outcomes in carefully selected patients with COPD.

3.3 Other treatments.

Long-term oxygen therapy.

  One of the most severe complications of COPD, developing in its late (terminal) stages, is chronic respiratory failure (CRF). The main sign of CDN is the development of hypoxemia, etc.; decrease in oxygen content in arterial blood (PaO2).
  VCT today is one of the few methods of therapy that can reduce the mortality of patients with COPD. Hypoxemia not only shortens the life of patients with COPD, but also has other significant adverse consequences: deterioration in quality of life, development of polycythemia, increased risk of cardiac arrhythmias during sleep, development and progression of pulmonary hypertension. VCT can reduce or eliminate all these negative effects of hypoxemia.
  Patients with COPD and chronic respiratory failure are recommended to undergo VCT (for indications, see Appendix G8).
  Strength of recommendation level A (level of evidence – 1).
  Comments. It should be emphasized that the presence of clinical signs of cor pulmonale suggests an earlier appointment of VCT.
  Correction of hypoxemia with oxygen is the most pathophysiologically based method of treating chronic renal failure. Unlike a number of emergency conditions (pneumonia, pulmonary edema, trauma), the use of oxygen in patients with chronic hypoxemia must be constant, long-term and, as a rule, carried out at home, which is why this form of therapy is called VCT.
  Gas exchange parameters, on which the indications for DCT are based, are recommended to be assessed only when patients are in a stable condition, etc.; 3-4 weeks after an exacerbation of COPD.
  Strength of recommendation: C (level of evidence: 3).
  Comments. This is exactly the time required to restore gas exchange and oxygen transport after a period of ARF. Before prescribing VCT to patients with COPD, it is recommended to make sure that the possibilities of drug therapy have been exhausted and the maximum possible therapy does not lead to an increase in PaO2 above the limit values.
  When prescribing oxygen therapy, it is recommended to strive to achieve PaO2 values ​​of 60 mm and SaO2 90%.
  Strength of recommendation: C (level of evidence: 3).
  VCT is not recommended for patients with COPD who continue to smoke; those who do not receive adequate drug therapy aimed at controlling the course of COPD (bronchodilators, ICS); insufficiently motivated for this type of therapy.
  Strength of recommendation: C (level of evidence: 3).
  Most patients with COPD are recommended to perform VCT for at least 15 hours a day with maximum breaks between sessions not exceeding 2 hours in a row, with an oxygen flow of 1-2 l/min.
  Strength of recommendation: B (level of evidence: 2).

Long-term home ventilation.

  Hypercapnia (td; increased partial tension of carbon dioxide in arterial blood - PaCO2 ≥ 45 mm) is a marker of decreased ventilation reserve in terminal stages of pulmonary diseases and also serves as a negative prognostic factor for patients with COPD. Nocturnal hypercapnia changes the sensitivity of the respiratory center to CO2, leading to higher PaCO2 levels during the day, which has negative consequences for the function of the heart, brain and respiratory muscles. Dysfunction of the respiratory muscles in combination with a high resistive, elastic and threshold load on the respiratory apparatus further aggravates hypercapnia in patients with COPD, thus developing a “vicious circle” that can only be broken by respiratory support (ventilation).
  In patients with COPD with a stable course of CDN who do not require intensive care, it is possible to carry out long-term respiratory support on an ongoing basis at home - the so-called long-term home ventilation (LHV).
  The use of DDVL in patients with COPD is accompanied by a number of positive pathophysiological effects, the main of which are improved gas exchange parameters - increased PaO2 and decreased PaCO2, improved respiratory muscle function, increased exercise tolerance, improved sleep quality, and decreased pulmonary hypertension. Recent studies have demonstrated that, with adequately selected parameters of non-invasive ventilation (NIV), a significant improvement in survival of patients with COPD complicated by hypercapnic chronic respiratory failure is possible.
  DDVL is recommended for patients with COPD who meet the following criteria:
  - Presence of symptoms of CDN: weakness, shortness of breath, morning headaches;
  - Presence of one of the following indicators: PaCO2 55 mm, PaCO2 50-54 mm and episodes of nocturnal desaturations (SaO2< 88% в течение более 5 мин во время O2-терапии 2 л/мин), PaCO2 50-54 мм и частые госпитализации вследствие развития повторных обострений (2 и более госпитализаций за 12 мес).
  Strength of recommendation: A (level of evidence: 1).

New clinical practice guidelines for the treatment of chronic obstructive pulmonary disease (COPD) in outpatients recommend the use of oral corticosteroids and antibiotics to treat exacerbations. The updated recommendations also address the use of noninvasive mechanical ventilation in hospitalized patients with acute hypercapnic respiratory failure secondary to exacerbation of COPD.

The new paper was published in the March issue of the European Respiratory Journal and is based on a review of existing research by experts from the European Respiratory Society and the American Thoracic Society. These clinical guidelines expand on the current GOLD guidelines published earlier this year.

In creating these recommendations, the expert committee focused on 6 key issues related to the treatment of exacerbations of COPD: the use of oral corticosteroids and antibiotics, the use of oral or intravenous steroids, the use of non-invasive mechanical ventilation, rehabilitation after hospital discharge, and the use of home care programs for patients.

1. A short course (⩽14 days) of oral corticosteroids is indicated for outpatients with exacerbation of COPD.
2. Antibiotics are indicated for outpatients with exacerbation of COPD.
3. In patients hospitalized for exacerbation of COPD, oral corticosteroids are preferred over intravenous agents unless gastrointestinal dysfunction is present.
4. Patients who have been in the emergency department or general ward should be told about the treatment they need to carry out at home.
5. Pulmonary rehabilitation should begin within 3 weeks after discharge from the hospital where patients were treated for exacerbation of COPD
6. or after the end of the adaptation period after discharge, but not during the hospital stay.

Discussion

• The Expert Committee notes that administration of corticosteroids for 9 to 14 days is associated with improved pulmonary function and a reduced incidence of hospitalization. However, no data were obtained on the effect on mortality.
• The choice of antibiotic should be based on local drug sensitivity. In this case, antibiotic therapy is accompanied by an increase in the time between exacerbations of COPD, but at the same time an increase in the frequency of adverse events (primarily from the gastrointestinal tract).
• Pulmonary rehabilitation, including exercise, is recommended to begin between 3 and 8 weeks after discharge from hospital. Although rehabilitation initiated during treatment improves exercise performance, it has been associated with increased mortality.

Russian Respiratory Society

chronic obstructive pulmonary disease

Chuchalin Alexander Grigorievich	Director of the Federal State Budgetary Institution "Research Institute of Pulmonology" FMBA
	Russia, Chairman of the Board of the Russian
	Respiratory Society, Chief
	freelance specialist pulmonologist
	Ministry of Health of the Russian Federation, academician of the Russian Academy of Medical Sciences, professor,
Aisanov Zaurbek Ramazanovich	Head of the Department of Clinical Physiology
	and clinical studies of the Federal State Budgetary Institution "Research Institute
Avdeev Sergey Nikolaevich	Deputy Director for Research,
	Head of the Clinical Department of the Federal State Budgetary Institution "Research Institute
	pulmonology" FMBA of Russia, professor, doctor of medical sciences.
Belevsky Andrey	Professor of the Department of Pulmonology, State Budgetary Educational Institution of Higher Professional Education
Stanislavovich	RNRMU named after N.I. Pirogova, head
	rehabilitation laboratory of the Federal State Budgetary Institution "Research Institute
	Pulmonology" FMBA of Russia , professor, doctor of medical sciences
Leshchenko Igor Viktorovich	Professor of the Department of Phthisiology and
	pulmonology GBOU VPO USMU, chief
	freelance specialist pulmonologist of the Ministry of Health
	Sverdlovsk Region and Administration
	health care of Yekaterinburg, scientific
	Head of the Medical Clinic
	association "New Hospital", professor,
	Doctor of Medical Sciences, Honored Doctor of Russia,
Meshcheryakova Natalya Nikolaevna	Associate Professor, Department of Pulmonology, State Budgetary Educational Institution of Higher Professional Education, Russian National Research Medical University
	named after N.I. Pirogova, leading researcher
	rehabilitation laboratory of the Federal State Budgetary Institution "Research Institute
	Pulmonology" FMBA of Russia, Ph.D.
Ovcharenko Svetlana Ivanovna	Professor of the Department of Faculty Therapy No.
	1st Faculty of Medicine, State Budgetary Educational Institution of Higher Professional Education First
	MSMU im. THEM. Sechenova, professor, doctor of medical sciences,
	Honored Doctor of the Russian Federation
Shmelev Evgeniy Ivanovich	Head of the Department of Differential
	diagnostics of tuberculosis Central Research Institute of the Russian Academy of Medical Sciences, doctor
	honey. Sciences, Professor, Doctor of Medical Sciences, Honored
	scientist of the Russian Federation.

	Methodology
	COPD Definition and Epidemiology
	Clinical picture of COPD
	Diagnostic principles
	Functional tests in diagnostics and monitoring
	COPD course
	Differential diagnosis of COPD
	Modern classification of COPD. Comprehensive
	assessment of severity.
	Therapy for stable COPD
	Exacerbation of COPD
	Treatment for exacerbation of COPD
	COPD and related diseases
	Rehabilitation and patient education

1. Methodology

Methods used to collect/select evidence:

search in electronic databases.

Description of methods used to collect/select evidence:

Methods used to assess the quality and strength of evidence:

Expert consensus;

					Description
	evidence
			High quality meta-analyses, systematic reviews
			randomized controlled trials (RCTs) or
			RCT with very low risk of bias
			Qualitatively conducted meta-analyses, systematic, or
			RCTs with low risk of bias
			Meta-analyses, systematic, or high-risk RCTs
			systematic errors
			High quality	systematic reviews		research
			case-control		cohort	research.
			High-quality reviews of case-control studies or
			cohort studies with very low risk of effects
			confounding or systematic errors and average probability
			causal relationship
			Well-conducted case-control studies or
			cohort studies with moderate risk of confounding effects
			or systematic errors and the average probability of causality
			relationships
			Case-control or cohort studies with
			high risk of mixing effects or systematic
			errors and the average probability of a causal relationship
			Non-analytical studies (e.g. case reports,
			case series)
			Expert opinion

Methods used to analyze evidence:

Systematic reviews with evidence tables.

Description of methods used to analyze evidence:

When selecting publications as potential sources of evidence, the methodology used in each study is examined to ensure its validity. The outcome of the study influences the level of evidence assigned to the publication, which in turn influences the strength of the resulting recommendations.

Methodological examination is based on several key questions that focus on those features of the study design that have a significant impact on the validity of the results and conclusions. These key questions may vary depending on the types of studies and questionnaires used to standardize the publication assessment process. The recommendations used the MERGE questionnaire developed by the New South Wales Department of Health. This questionnaire is designed to be assessed in detail and adapted to meet the requirements of the Russian Respiratory Society (RRS) in order to maintain an optimal balance between methodological rigor and practical applicability.

The assessment process, of course, can also be affected by a subjective factor. To minimize potential bias, each study was assessed independently, i.e. at least two independent members of the working group. Any differences in assessments were discussed by the entire group. If it was impossible to reach consensus, an independent expert was involved.

Evidence tables:

Evidence tables were completed by members of the working group.

Methods used to formulate recommendations:

	Description
	At least one meta-analysis, systematic review or RCT,
	demonstrating sustainability of results
	A body of evidence including the results of studies assessed
	overall sustainability of results
	extrapolated evidence from studies rated 1++
	A body of evidence including the results of studies assessed
	overall sustainability of results;
	extrapolated evidence from studies rated 2++
	Level 3 or 4 evidence;
	extrapolated evidence from studies rated 2+

Good Practice Points (GPPs):

Economic analysis:

No cost analysis was performed and pharmacoeconomics publications were not reviewed.

External expert assessment;

Internal expert assessment.

These draft recommendations were reviewed by independent experts who were asked to comment primarily on the extent to which the interpretation of the evidence underlying the recommendations is understandable.

Comments were received from primary care physicians and local therapists regarding the clarity of the recommendations and their assessment of the importance of the recommendations as a working tool in daily practice.

A preliminary version was also sent to a non-medical reviewer for comments from patient perspectives.

The comments received from the experts were carefully systematized and discussed by the chairman and members of the working group. Each point was discussed and the resulting changes to the recommendations were recorded. If changes were not made, then the reasons for refusing to make changes were recorded.

Consultation and expert assessment:

The preliminary version was posted for wide discussion on the RPO website so that persons not participating in the congress had the opportunity to participate in the discussion and improvement of the recommendations.

Working group:

For final revision and quality control, the recommendations were re-analyzed by members of the working group, who concluded that all comments and comments from experts were taken into account, and the risk of systematic errors in the development of recommendations was minimized.

2. Definition of COPD and epidemiology

Definition

COPD is a preventable and treatable disease characterized by persistent airflow limitation that is usually progressive and associated with a significant chronic inflammatory response of the lungs to pathogenic particles or gases. In some patients, exacerbations and comorbidities may influence the overall severity of COPD (GOLD 2014).

Traditionally, COPD combines chronic bronchitis and emphysema. Chronic bronchitis is usually defined clinically as the presence of a cough with

sputum production for at least 3 months over the next 2 years.

Emphysema is defined morphologically as the presence of persistent dilation of the airways distal to the terminal bronchioles, associated with destruction of the alveolar walls, not associated with fibrosis.

In patients with COPD, both conditions are most often present, and in some cases it is quite difficult to clinically distinguish between them in the early stages of the disease.

The concept of COPD does not include bronchial asthma and other diseases associated with poorly reversible bronchial obstruction (cystic fibrosis, bronchiectasis, bronchiolitis obliterans).

Epidemiology

Prevalence

COPD is currently a global problem. In some countries around the world, the prevalence of COPD is very high (over 20% in Chile), in others it is lower (about 6% in Mexico). The reasons for this variability are differences in people's lifestyles, behavior and exposure to a variety of damaging agents.

One of the Global Studies (BOLD Project) provided a unique opportunity to estimate the prevalence of COPD using standardized questionnaires and pulmonary function tests in populations of adults over 40 years of age in both developed and developing countries. The prevalence of COPD stage II and higher (GOLD 2008), according to the BOLD study, among people over 40 years of age was 10.1 ± 4.8%; including for men – 11.8±7.9% and for women – 8.5±5.8%. According to an epidemiological study on the prevalence of COPD in the Samara region (residents 30 years of age and older), the prevalence of COPD in the total sample was 14.5% (men - 18.7%, women - 11.2%). According to the results of another Russian study conducted in the Irkutsk region, the prevalence of COPD in people over 18 years of age among the urban population was 3.1%, among the rural population 6.6%. The prevalence of COPD increased with age: in the age group from 50 to 69 years, 10.1% of men in the city and 22.6% in rural areas suffered from the disease. Almost every second man over the age of 70 living in rural areas was diagnosed with COPD.

Mortality

According to WHO, COPD is currently the 4th leading cause of death in the world. About 2.75 million people die from COPD each year, accounting for 4.8% of all causes of death. In Europe, mortality from COPD varies significantly: from 0.20 per 100,000 population in Greece, Sweden, Iceland and Norway, to 80 per 100,000

V Ukraine and Romania.

IN period from 1990 to 2000 mortality from cardiovascular diseases

V overall and from stroke decreased by 19.9% ​​and 6.9%, respectively, while mortality from COPD increased by 25.5%. A particularly pronounced increase in mortality from COPD is observed among women.

Predictors of mortality in patients with COPD are factors such as the severity of bronchial obstruction, nutritional status (body mass index), physical endurance according to the 6-minute walk test and severity of shortness of breath, frequency and severity of exacerbations, pulmonary hypertension.

The main causes of death in patients with COPD are respiratory failure (RF), lung cancer, cardiovascular diseases and tumors of other localizations.

Socio-economic significance of COPD

IN In developed countries, the total economic costs associated with COPD in the structure of pulmonary diseases occupy 2nd place after lung cancer and 1st place

in terms of direct costs, exceeding the direct costs of bronchial asthma by 1.9 times. The economic costs per patient associated with COPD are three times higher than for a patient with bronchial asthma. The few reports on direct medical costs for COPD indicate that more than 80% of costs are spent on inpatient care and less than 20% on outpatient care. It was found that 73% of costs are for 10% of patients with severe disease. The greatest economic damage comes from treating exacerbations of COPD. In Russia, the economic burden of COPD, taking into account indirect costs, including absenteeism (absenteeism) and presenteeism (less effective work due to poor health), amounts to 24.1 billion rubles.

3. Clinical picture of COPD

Under conditions of exposure to risk factors (smoking, both active and passive, exogenous pollutants, bioorganic fuel, etc.), COPD usually develops slowly and progresses gradually. The peculiarity of the clinical picture is that for a long time the disease proceeds without pronounced clinical manifestations (3, 4; D).

The first signs with which patients consult a doctor are a cough, often with sputum production, and/or shortness of breath. These symptoms are most pronounced in the morning. During cold seasons, “frequent colds” occur. This is the clinical picture of the onset of the disease, which the doctor regards as a manifestation of smoker’s bronchitis, and the diagnosis of COPD at this stage is practically not made.

Chronic cough, usually the first symptom of COPD, is often underestimated by patients, as it is considered an expected consequence of smoking and/or exposure to adverse environmental factors. Typically, patients produce a small amount of viscous sputum. An increase in cough and sputum production occurs most often in the winter months, during infectious exacerbations.

Dyspnea is the most important symptom of COPD (4; D). It is often the reason for seeking medical help and the main reason limiting the patient’s work activity. The health impact of breathlessness is assessed using the British Medical Council (MRC) questionnaire. Initially, shortness of breath occurs with relatively high levels of physical activity, such as running on level ground or walking up stairs. As the disease progresses, shortness of breath intensifies and can limit even daily activity, and later occurs at rest, forcing the patient to stay at home (Table 3). In addition, the assessment of dyspnea using the MRC scale is a sensitive tool for predicting the survival of patients with COPD.

Table 3. Dyspnea score using the Medical Research Council Scale (MRC) Dyspnea Scale.

			Description
			I only feel short of breath during intense physical activity.
			load
			I get out of breath when I walk quickly on level ground or
			walking up a gentle hill
			Shortness of breath makes me walk slower on level ground,
			than people of the same age, or it stops me
			breathing when I walk on level ground in the usual
			tempo for me

When describing the clinical picture of COPD, it is necessary to take into account the features characteristic of this disease: its subclinical onset, the absence of specific symptoms, and the steady progression of the disease.

The severity of symptoms varies depending on the phase of the disease (stable course or exacerbation). A condition in which the severity of symptoms does not change significantly over weeks or even months should be considered stable, and in this case, the progression of the disease can only be detected with long-term (6-12 months) follow-up of the patient.

Exacerbations of the disease have a significant impact on the clinical picture - periodically occurring deterioration of the condition (lasting at least 2-3 days), accompanied by an increase in the intensity of symptoms and functional disorders. During an exacerbation, there is an increase in the severity of hyperinflation and the so-called. air traps in combination with a reduced expiratory flow, which leads to increased shortness of breath, which is usually accompanied by the appearance or intensification of distant wheezing, a feeling of constriction in the chest, and a decrease in exercise tolerance. In addition, the intensity of the cough increases, the amount of sputum, the nature of its separation, color and viscosity changes (increases or sharply decreases). At the same time, indicators of the function of external respiration and blood gases deteriorate: speed indicators (FEV1, etc.) decrease, hypoxemia and even hypercapnia may occur.

The course of COPD is an alternation of a stable phase and exacerbation of the disease, but it varies from person to person. However, progression of COPD is common, especially if the patient continues to be exposed to inhaled pathogenic particles or gases.

The clinical picture of the disease also seriously depends on the phenotype of the disease, and vice versa, the phenotype determines the characteristics of the clinical manifestations of COPD. For many years, there has been a division of patients into emphysematous and bronchitis phenotypes.

The bronchitis type is characterized by a predominance of signs of bronchitis (cough, sputum production). Emphysema in this case is less pronounced. In the emphysematous type, on the contrary, emphysema is the leading pathological manifestation, shortness of breath prevails over cough. However, in clinical practice it is very rarely possible to distinguish the emphysematous or bronchitis phenotype of COPD in the so-called. “pure” form (it would be more correct to talk about a predominantly bronchitis or predominantly emphysematous phenotype of the disease). The features of the phenotypes are presented in more detail in Table 4.

Table 4. Clinical and laboratory features of the two main phenotypes of COPD.

Peculiarities	external	Reduced nutrition			Increased nutrition
		Pink complexion			Diffuse cyanosis
		Extremities are cold			Limbs are warm
Predominant symptom
		Scanty – often mucous			Abundant – often mucous-
Bronchial infection
Pulmonary heart
		terminal stage
Radiography		Hyperinflation,			Gain	pulmonary
chest		bullous	changes,			increase
		"vertical" heart			heart size
Hematocrit, %
PaO2
PaCO2
Diffusion						small
ability					decline

If it is impossible to distinguish the predominance of one phenotype or another, one should speak of a mixed phenotype. In clinical settings, patients with a mixed type of disease are more common.

In addition to the above, other phenotypes of the disease are currently identified. First of all, this applies to the so-called overlap phenotype (a combination of COPD and asthma). Although it is necessary to carefully differentiate between patients with COPD and asthma and the significant difference in chronic inflammation in these diseases, in some patients COPD and asthma may be present simultaneously. This phenotype can develop in smoking patients suffering from bronchial asthma. Along with this, as a result of large-scale studies, it has been shown that about 20–30% of patients with COPD may have reversible bronchial obstruction, and eosinophils appear in the cellular composition during inflammation. Some of these patients can also be attributed to the “COPD + BA” phenotype. Such patients respond well to corticosteroid therapy.

Another phenotype that has been reported recently is that of patients with frequent exacerbations (2 or more exacerbations per year, or 1 or more exacerbations leading to hospitalization). The importance of this phenotype is determined by the fact that the patient emerges from an exacerbation with reduced functional indicators of the lungs, and the frequency of exacerbations directly affects the life expectancy of patients and requires an individual approach to treatment. The identification of numerous other phenotypes requires further clarification. Several recent studies have drawn attention to differences in the clinical presentation of COPD between men and women. As it turned out, women are characterized by more pronounced hyperreactivity of the respiratory tract, they report more pronounced shortness of breath at the same levels of bronchial obstruction as men, etc. With the same functional indicators, oxygenation occurs better in women than in men. However, women are more likely to develop exacerbations, they show less effect of physical training in rehabilitation programs, and they rate their quality of life lower according to standard questionnaires.

It is well known that patients with COPD have numerous extrapulmonary manifestations of the disease due to the systemic effect of chronic

Chronic obstructive pulmonary disease (COPD) is serious problem for modern society.

Hundreds of thousands of people become disabled due to COPD. This is primarily due to the irreversibility of the process of changes in lung tissue and deterioration of the condition.

In the terminal stages of COPD severe respiratory failure develops and the need for continuous respiratory support.

Also, over time, the body loses its natural resistance to any infectious diseases, especially those that affect the respiratory tract. Unfortunately, COPD is not a curable disease, but it can be controlled and prevented from getting worse. To do this, you need to take therapy seriously and strictly adhere to the recommendations.

Federal clinical guidelines for the treatment of chronic obstructive pulmonary disease

1. eliminating symptoms and improving quality of life;
2. preventing exacerbations to reduce future risks;
3. slowing down the progression of the disease;
4. reduction in mortality.

Based on these goals, therapy for pulmonary obstruction disease has been developed to alleviate the condition. An important aspect of it is an integrated approach to therapy. Treatment for COPD includes non-pharmacological and pharmacological approaches.

First place in this document, as well as in GOLD-2018(Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease or COPD) calls for smoking cessation. Giving up a bad habit will become a favorable background for controlling COPD disease and will help delay serious measures in the form of oxygen therapy.

Medication therapy

Drug treatment of COPD involves taking the following groups of drugs:

• bronchodilators;
• combinations of inhaled glucocorticosteroids(IGCS);
• long-acting bronchodilators(DDBD);
• phosphodiesterase-4 inhibitors;
• theophylline;
• vaccination against influenza and pneumococcal infection.

The choice of drug combination depends on the stage of COPD disease. For any severity exclude risk factors and carry out vaccination. Additionally, various drugs and their combinations are used.

In the later stages of COPD, a serious complication of the condition develops: chronic respiratory failure. The main manifestation is hypoxemia, a condition in which the oxygen content in the arterial blood decreases. Negative consequences of hypoxemia:

• quality of life deteriorates;
• polycythemia develops(excess production of blood cells);
• the risk of cardiac arrhythmias during sleep increases;
• pulmonary hypertension develops and progresses;
• life expectancy is reduced.

Long-term oxygen therapy (LOT) can minimize or completely eliminate the negative manifestations of COPD.

Another serious indication for VCT is development of the pulmonary heart. This condition develops due to increased pulmonary pressure and leads to heart failure.

Photo 1. Patient on oxygen therapy, this procedure reduces the negative manifestations of COPD lung disease.

For the procedure in therapy, not pure oxygen is used, but passed through special defoamers. For most patients with COPD, it is sufficient flow rate 1-2 l/min. Sometimes, with a significant deterioration of the patient’s condition and severe severity of the patient, the speed is increased up to 4-5 l/min.

Important! To achieve an effect, therapy for COPD is best carried out at least 15 hours a day, with maximum breaks between sessions no more than 2 hours straight. The optimal regimen is considered to be VCT of at least 20 hours a day.

Hypoxemia is always accompanied by hypercapnia, i.e. an increase in the level of carbon dioxide in the blood. This condition indicates a decrease in ventilation reserve and is a harbinger of an unfavorable prognosis with COPD. An increase in carbon dioxide in the blood is negative affects other organs and systems. The functions of the heart, brain, and respiratory muscles suffer. To combat the progressive deterioration of the condition, ventilation is used.

Ventilation therapy for COPD is carried out over a long period of time. Therefore, provided there is no need for intensive care Ventilators are used at home(long-term home ventilation LDVL).

Portable respirators are often used for the treatment of DDVL COPD. They are small-sized, relatively cheap, easy to use, however, they are unable to assess the severity of the patient's condition.

Selection of the oxygen dosing regimen and supply rate is carried out in the hospital. In the future, equipment maintenance will be carried out by specialists at home.

When choosing therapy, it is important to accurately determine the severity of the condition. For this purpose, in addition to diagnostics, there are international scales (CAT, mMRC) and questionnaires for diagnosing COPD. Modern classifications divide the disease COPD for 4 classes.

Depending on the COPD disease group, combinations of drugs are selected for therapy. The presented diagrams show international nonproprietary names of medicines.

• Group A: short-acting bronchodilators (salbutamol or fenoterol).
• Group B: long-acting anticholinergics (DDACP: tiotropium bromide, aclidinium bromide, etc.) or long-acting β2-agonists (LABA: formoterol, salmaterol, indacaterol, olodaterol).

Photo 2. The drug Spiriva Respimat with one cartridge and inhaler, 2.5 mcg/dose, from the manufacturer Boehringer Ingelheim.

• Group C: DDACP or the use of combined drugs DDACP + LABA (Glycopyrronium bromide/indacaterol, Tiotropium bromide/olodaterol, etc.).
• Group D: DDACP+DDBA, another scheme DDACP+DDBA+ICS is also possible. For frequently recurring exacerbations, therapy is supplemented with roflumilast or macrodide.

Attention! Therapy is prescribed by a doctor based on clinical data. Changing the drug on your own without prior consultation may lead to to adverse consequences and worsen the condition.

National recommendations for vaccination to prevent infectious diseases

Vaccination is one of the components of treatment for COPD, and its implementation is indicated for any degree of disease. Since the body’s natural resistance to infections decreases, during epidemically unfavorable periods, patients with COPD easily become ill.

This affects the course of the underlying disease, there is a noticeable deterioration in the condition, and the infectious disease occurs with a number of complications. In particular, respiratory failure develops, with the need for respiratory support.

According to the literature, the main place in the development of infectious exacerbations of COPD is occupied by bacterial pathogens. The influenza virus causes an exacerbation of COPD both independently and by contributing to the addition of bacterial flora.

According to the recommendations of the National and Russian Respiratory Society, the standard of care for patients with COPD includes vaccination against influenza and pneumococcal infection. These measures do not require specific drug preparation of patients. Influenza vaccine reduces severity of COPD by 30-80%. Vaccination with a polyvalent pneumococcal vaccine is carried out for all patients with COPD at the age of 65 and older and patients with COPD at FEV 1<40% должного.

There are two vaccination schemes:

• Annual one-time. It is carried out in the autumn, preferably in October or the first half of November.
• Annual double Vaccination is carried out during the most epidemically unfavorable periods: autumn and winter.

Important! Vaccination is a mandatory component of therapy for COPD, improving the course and prognosis of the disease. Refusal to use vaccines may negatively affect the results already obtained from therapy.

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To improve the quality of life with COPD, you must follow the following practical tips: diet, take into account the geographical climate and physical activity, attend health school.

Diet: nutritional features

Nutrition is an important element in improving the quality of life of patients with COPD. As a result of the disease, changes occur in the body, resulting in foods are less digestible, and their metabolites are sometimes not enough.

In addition, some patients refuse to eat food, experiencing difficulty swallowing and chewing. This applies to a greater extent to persons with severe COPD

Nutrition for COPD must meet the following requirements:

• Total energy value of all meals per day should be from 2,600 to 3,000 kcal.
• Foods should be rich in proteins, and animal proteins should predominate in the diet. In absolute numbers per day you need to consume 110-120 g protein.
• Fats should not exceed 80-90 g.
• Carbohydrates should be at a physiological level (approximately 350-400 g per day). A reduction in carbohydrate consumption is provided only during an exacerbation period.
• The diet should contain a lot of fruits, berries, and vegetables. They serve as sources of vitamins and antioxidants. Although fish also has these properties, its consumption should be treated with caution, especially by those with a history of allergies.
• The consumption of table salt is limited to 6 g per day.
• In case of cardiovascular pathologies, restriction of free fluid is indicated.

Reference! Patients with malnourished COPD have more severe respiratory failure and lack of classic symptoms chronic bronchitis.

As an example, here is a possible diet for patients with COPD:

• Breakfast: 100 g low-fat cottage cheese, 1 apple, 1 slice of grain bread, 2-3 slices of cheese(not fatty), tea.

Photo 3. Low-fat cottage cheese and a few pieces of apple in a plate are suitable for breakfast for patients with COPD.

• Lunch: a glass of fruit juice, 50 g of bran.
• Lunch: 180 g of fish (meat) broth, 100 g of boiled beef liver (or 140 g of beef meat), 100 g of boiled rice, 150 g of fresh vegetable salad, a glass of drink made from dried berries (for example, rose hips).
• Afternoon snack: 1 orange.
• Dinner: 120 g of boiled lentils, steamed chicken cutlets, beetroot salad with nuts, tea with dried fruits.
• At night: a glass of kefir (low-fat).

Permissible physical activity

The main goal of training as a therapy for COPD is to improve the condition of the respiratory muscles, which has a beneficial effect on the general condition and quality of life in COPD.

Such activities can reduce the degree of shortness of breath.

The training plan is developed individually depending on age, concomitant pathologies from other systems and the severity of COPD. They mainly use exercises on a treadmill or bicycle ergometer. Optimal time 10-45 minutes.

Exercise therapy can be used as an additional therapy. A training complex can include both general activities and specific ones aimed at the respiratory muscles. With this addition, it is important to remember that physical training should be beneficial and not to exhaust the patient and cause discomfort. You should not overload the patient and work too hard.

Geographic climate of patients

The most favorable climatic conditions for people with COPD are:

Health schools for the sick

After the selected set of therapy measures, the patient is taught to act in emergency situations, Monitor your health and use medications correctly. For this purpose, medical institutions open special schools for patients with COPD.

Important! COPD school is an important stage in therapy, since in 1.5-2 hours and after several sessions the patient can fully understand how to properly treat COPD and how to live with this disease. The patient can ask all the necessary questions that have arisen since the start of treatment with the therapist.

Courses vary depending on the medical organization. They may consist of 8 lessons of 90 minutes, or be three days old, 120 minutes each.

The courses will make it much easier for you to cope with COPD, and longer communication with specialists will help you quit smoking and improve your condition and prognosis for the future at the very beginning of therapy.

Useful video

From the video you can find out how COPD differs from other diseases of the respiratory system and the causes of the development of the pathology.

Conclusion

The main task of patients with COPD is to adhere to proper nutrition, stop smoking and carefully approach therapy. If you follow the recommendations and take careful care of your health, you can achieve minimal manifestations of the disease and live a full life with COPD.

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1
Russian Respiratory Society
Federal clinical
recommendations for diagnosis and
treatment
chronic obstructive disease
lungs
2014

2
Team of authors
Chuchalin Alexander Grigorievich Director of the Federal State Budgetary Institution "Research Institute of Pulmonology" FMBA
Russia, Chairman of the Board of the Russian Respiratory Society, chief freelance specialist pulmonologist
Ministry of Health of the Russian Federation, academician of the Russian Academy of Medical Sciences, professor, doctor of medical sciences.
Aisanov Zaurbek Ramazanovich
Head of the Department of Clinical Physiology and Clinical Research, Federal State Budgetary Institution "Research Institute of Pulmonology" FMBA of Russia, Professor, Doctor of Medical Sciences.
Avdeev Sergey Nikolaevich
Deputy Director for Scientific Work, Head of the Clinical Department of the Federal State Budgetary Institution "Research Institute of Pulmonology" FMBA of Russia, Professor, Doctor of Medical Sciences.
Belevsky Andrey
Stanislavovich
Professor of the Department of Pulmonology, State Budgetary Educational Institution of Higher Professional Education
RNRMU named after N.I. Pirogova, head of the rehabilitation laboratory
FSBI "Research Institute of Pulmonology" FMBA of Russia
, professor, doctor of medical sciences
Leshchenko Igor Viktorovich
Professor of the Department of Phthisiology and Pulmonology of the State Budgetary Educational Institution of Higher Professional Education of the USMU, chief freelance pulmonologist of the Ministry of Health
Sverdlovsk region and the Health Department of Yekaterinburg, scientific director of the clinic “Medical Association “New Hospital”, professor, doctor of medical sciences, honored doctor of Russia,
Meshcheryakova Natalya Nikolaevna
Associate Professor of the Department of Pulmonology, State Budgetary Educational Institution of Higher Professional Education, Russian National Research Medical University named after N.I. Pirogova, leading researcher at the rehabilitation laboratory
FSBI "Research Institute of Pulmonology" FMBA of Russia, Ph.D.
Ovcharenko Svetlana Ivanovna
Professor, Department of Faculty Therapy No. 1, Faculty of Medicine, State Budgetary Educational Institution of Higher Professional Education First
MSMU im. THEM. Sechenova, professor, doctor of medical sciences,
Honored Doctor of the Russian Federation
Shmelev Evgeniy Ivanovich
Head of the Department of Differential Diagnosis of Tuberculosis, Central Research Institute of Infectious Diseases of the Russian Academy of Medical Sciences, Doctor of Medical Sciences. Sciences, Professor, Doctor of Medical Sciences, Honored Scientist of the Russian Federation.

3
TABLE OF CONTENTS
1.
Methodology
4
2.
COPD Definition and Epidemiology
6
3.
Clinical picture of COPD
8
4.
Diagnostic principles
11
5.
Functional tests in diagnostics and monitoring
14
COPD course
6.
Differential diagnosis of COPD
18
7.
Modern classification of COPD. Comprehensive
20
assessment of severity.
8.
Therapy for stable COPD
24
9.
Exacerbation of COPD
29
10.
Treatment for exacerbation of COPD
31
11.
COPD and related diseases
34
12.
Rehabilitation and patient education
36

4
1. Methodology
Methods used to collect/select evidence:
search in electronic databases.
Description of methods used to collect/select evidence: the evidence base for recommendations is the publications included in
Cochrane Library, EMBASE and MEDLINE databases. The search depth was 5 years.
Methods used to assess the quality and strength of evidence:

Expert consensus;

Assessment of significance in accordance with the rating scheme (see Table 1).
Table 1. Rating scheme for assessing the strength of recommendations.
Levels
evidence
Description
1++
High quality meta-analyses, systematic reviews of randomized controlled trials (RCTs) or
RCT with very low risk of bias
1+
Qualitatively conducted meta-analyses, systematic, or
RCTs with low risk of bias
1-
Meta-analyses, systematic, or RCTs with a high risk of bias
2++
High-quality systematic reviews of case-control or cohort studies.
High-quality reviews of case-control or cohort studies with very low risk of confounding effects or bias and moderate probability of causality
2+
Well-conducted case-control or cohort studies with moderate risk of confounding effects or bias and moderate likelihood of causality
2-
Case-control or cohort studies with a high risk of confounding effects or bias and a moderate probability of causality
3
Non-analytical studies (eg case reports, case series)
4
Expert opinion
Methods used to analyze evidence:

Reviews of published meta-analyses;

Systematic reviews with evidence tables.
Description of methods used to analyze evidence:
When selecting publications as potential sources of evidence, the methodology used in each study is examined to ensure its validity. The outcome of the study influences the level of evidence assigned to the publication, which in turn influences the strength of the resulting recommendations.

5
Methodological examination is based on several key questions that focus on those features of the study design that have a significant impact on the validity of the results and conclusions. These key questions may vary depending on the types of studies and questionnaires used to standardize the publication assessment process. The recommendations used the MERGE questionnaire developed by
New South Wales Department of Health. This questionnaire is designed for detailed assessment and adaptation according to requirements
Russian Respiratory Society (RRO) in order to maintain an optimal balance between methodological rigor and the possibility of practical application.
The assessment process, of course, can also be affected by a subjective factor.
To minimize potential bias, each study was assessed independently, i.e. at least two independent members of the working group.
Any differences in assessments were discussed by the entire group.
If it was impossible to reach consensus, an independent expert was involved.
Evidence tables:
Evidence tables were completed by members of the working group.
Methods used to formulate recommendations:
Expert consensus.
Table 2. Rating scheme for assessing the strength of recommendations
Strength
Description
A
At least one meta-analysis, systematic review or RCT rated 1++, directly applicable to the target population and demonstrating robustness of the results, or a body of evidence including results from studies rated 1+, directly applicable to the target population and demonstrating overall robustness results
IN
A body of evidence that includes results from studies rated 2++ that are directly applicable to the target population and demonstrate general robustness of the results, or evidence extrapolated from studies rated 1++ or 1+
WITH
A body of evidence that includes findings from studies rated 2+, directly applicable to the target population, and demonstrating overall robustness of the results; or extrapolated evidence from studies rated 2++
D
Level 3 or 4 evidence; or extrapolated evidence from studies rated 2+
Good Practice Points (GPPs):
Recommended good practice is based on the clinical experience of the guideline working group members.
Economic analysis:

6
No cost analysis was performed and pharmacoeconomics publications were not reviewed.
Recommendation validation method:

External expert assessment;

Internal expert assessment.
Description of the method for validating recommendations:
These draft recommendations were reviewed by independent experts who were asked to comment primarily on the extent to which the interpretation of the evidence underlying the recommendations is understandable.
Comments were received from primary care physicians and local therapists regarding the clarity of the recommendations and their assessment of the importance of the recommendations as a working tool in daily practice.
A preliminary version was also sent to a non-medical reviewer for comments from patient perspectives.
The comments received from the experts were carefully systematized and discussed by the chairman and members of the working group. Each point was discussed and the resulting changes to the recommendations were recorded. If changes were not made, then the reasons for refusing to make changes were recorded.
Consultation and expert assessment:
A preliminary version was posted for wide discussion on the website
RPO to ensure that persons not participating in the congress have the opportunity to participate in the discussion and improvement of the recommendations.
The draft guidelines were also peer-reviewed by independent experts, who were asked to comment primarily on the clarity and accuracy of the interpretation of the evidence base underlying the recommendations.
Working group:
For final revision and quality control, the recommendations were re-analyzed by members of the working group, who concluded that all comments and comments from experts were taken into account, and the risk of systematic errors in the development of recommendations was minimized.
Basic recommendations:
Strength of recommendations (A – D), levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) and good practice points (GPPs) are given in the text. recommendations.
2. Definition of COPD and epidemiology
Definition
COPD is a preventable and treatable disease
characterized by persistent air speed limitation
flow, which is usually progressive and associated with severe chronic
inflammatory response of the lungs to the action of pathogenic particles or gases.
In some patients, exacerbations and concomitant diseases may affect
overall severity of COPD (GOLD 2014).
Traditionally, COPD combines chronic bronchitis and emphysema
Chronic bronchitis is usually defined clinically as the presence of a cough producing sputum for at least 3 months over the next 2 years.

7
Emphysema is defined morphologically as the presence of persistent dilation of the airways distal to the terminal bronchioles, associated with destruction of the alveolar walls, not associated with fibrosis.
In patients with COPD, both conditions are most often present, and in some cases it is quite difficult to clinically distinguish between them in the early stages of the disease.
The concept of COPD does not include bronchial asthma and other diseases associated with poorly reversible bronchial obstruction (cystic fibrosis, bronchiectasis, bronchiolitis obliterans).
Epidemiology
Prevalence
COPD is currently a global problem. In some countries around the world, the prevalence of COPD is very high (over 20% in Chile), in others it is lower (about 6% in Mexico). The reasons for this variability are differences in people's lifestyles, behavior and exposure to a variety of damaging agents.
One of the Global Studies (BOLD Project) provided a unique opportunity to estimate the prevalence of COPD using standardized questionnaires and pulmonary function tests in populations of adults over 40 years of age in both developed and developing countries. Prevalence
COPD stage II and higher (GOLD 2008), according to the BOLD study, among people over 40 years old was 10.1±4.8%; including for men – 11.8±7.9% and for women – 8.5±5.8%. According to an epidemiological study on the prevalence of COPD in the Samara region (residents 30 years of age and older), the prevalence of COPD in the total sample was 14.5% (men - 18.7%, women - 11.2%). According to the results of another Russian study conducted in the Irkutsk region, the prevalence of COPD in people over 18 years of age among the urban population was 3.1%, among the rural

6,6 %.
The prevalence of COPD increased with age: in the age group from 50 to
69 years old, 10.1% of men in the city and 22.6% suffered from the disease

in rural areas. Almost every second man over the age of 70 living in rural areas was diagnosed with COPD.
Mortality
According to WHO, COPD is currently the 4th leading cause of death in the world. About 2.75 million people die from COPD every year, which is
4.8% of all causes of death. In Europe, mortality from COPD varies significantly, from
0.20 per 100,000 population in Greece, Sweden, Iceland and Norway, up to 80 per 100,000 in Ukraine and Romania.
In the period from 1990 to 2000. mortality from cardiovascular diseases in general and from stroke decreased by 19.9% ​​and 6.9%, respectively, while mortality from COPD increased by 25.5%. A particularly pronounced increase in mortality from
COPD occurs among women.
Predictors of mortality in patients with COPD are factors such as the severity of bronchial obstruction, nutritional status (body mass index), physical endurance according to the 6-minute walk test and severity of shortness of breath, frequency and severity of exacerbations, pulmonary hypertension.
The main causes of death in patients with COPD are respiratory failure (RF), lung cancer, cardiovascular diseases and tumors of other localizations.
Socio-economic significance of COPD
In developed countries, the total economic costs associated with COPD in the structure of pulmonary diseases occupy 2nd place after lung cancer and 1st place

8 in terms of direct costs, exceeding the direct costs of bronchial asthma by 1.9 times.
The economic costs per patient associated with COPD are three times higher than for a patient with bronchial asthma. The few reports on direct medical costs for COPD indicate that more than 80% of costs are spent on inpatient care and less than 20% on outpatient care. It was found that 73% of costs are for 10% of patients with severe disease. The greatest economic damage comes from treating exacerbations of COPD. In Russia, the economic burden of COPD, taking into account indirect costs, including absenteeism (absenteeism) and presenteeism (less effective work due to poor health), amounts to 24.1 billion rubles.
3. Clinical picture of COPD
Under conditions of exposure to risk factors (smoking, both active and passive, exogenous pollutants, bioorganic fuel, etc.), COPD usually develops slowly and progresses gradually. The peculiarity of the clinical picture is that for a long time the disease proceeds without pronounced clinical manifestations (3, 4; D).
The first signs with which patients consult a doctor are a cough, often with sputum production, and/or shortness of breath. These symptoms are most pronounced in the morning. During cold seasons, “frequent colds” occur.
This is the clinical picture of the onset of the disease,
which the doctor regards as a manifestation of smoker’s bronchitis, and the diagnosis of COPD at this stage is practically not made.
Chronic cough, usually the first symptom of COPD, is often underestimated by patients, as it is considered an expected consequence of smoking and/or exposure to adverse environmental factors. Typically, patients produce a small amount of viscous sputum. An increase in cough and sputum production occurs most often in the winter months, during infectious exacerbations.
Dyspnea is the most important symptom of COPD (4; D). It is often the reason for seeking medical help and the main reason limiting the patient’s work activity. The health impact of breathlessness is assessed using the British Medical Council Questionnaire.
(MRC). Initially, shortness of breath occurs with relatively high levels of physical activity, such as running on level ground or walking up stairs. As the disease progresses, shortness of breath intensifies and can limit even daily activity, and later occurs at rest, forcing the patient to stay at home (Table 3). In addition, the assessment of dyspnea using the MRC scale is a sensitive tool for predicting the survival of patients with COPD.
Table 3. Dyspnea rating according to the Medical Research Council Scale (MRC)
Dyspnea Scale.
Degree Severity
Description
0 no
I feel short of breath only during intense physical activity
1 light
I get out of breath when I walk quickly on level ground or up a gentle hill
2 medium
Shortness of breath causes me to walk on level ground slower than people of the same age, or I stop breathing when I walk on level ground at my usual pace

9 3 heavy
I get out of breath after walking about 100 m, or after walking for a few minutes on level ground
4 very heavy
I am too short of breath to leave the house or feel out of breath when getting dressed or undressed
When describing the clinical picture of COPD, it is necessary to take into account the features characteristic of this disease: its subclinical onset, the absence of specific symptoms, and the steady progression of the disease.
The severity of symptoms varies depending on the phase of the disease (stable course or exacerbation). A condition in which the severity of symptoms does not change significantly over weeks or even months should be considered stable, and in this case, the progression of the disease can only be detected with long-term (6-12 months) follow-up of the patient.
Exacerbations of the disease have a significant impact on the clinical picture - periodically occurring deterioration of the condition (lasting at least 2-3 days), accompanied by an increase in the intensity of symptoms and functional disorders. During an exacerbation, there is an increase in the severity of hyperinflation and the so-called. air traps in combination with a reduced expiratory flow, which leads to increased shortness of breath, which is usually accompanied by the appearance or intensification of distant wheezing, a feeling of constriction in the chest, and a decrease in exercise tolerance.
In addition, the cough intensity increases, changes
(increases or sharply decreases) the amount of sputum, the nature of its separation, color and viscosity. At the same time, indicators of external respiration function and blood gases deteriorate: speed indicators (FEV) decrease
1
etc.), hypoxemia and even hypercapnia may occur.
The course of COPD is an alternation of a stable phase and exacerbation of the disease, but it varies from person to person. However, progression of COPD is common, especially if the patient continues to be exposed to inhaled pathogenic particles or gases.
The clinical picture of the disease also seriously depends on the phenotype of the disease, and vice versa, the phenotype determines the characteristics of the clinical manifestations
COPD For many years, there has been a division of patients into emphysematous and bronchitis phenotypes.
Bronchitic type is characterized by a predominance of signs of bronchitis
(cough, sputum production). Emphysema in this case is less pronounced. In the emphysematous type, on the contrary, emphysema is the leading pathological manifestation, shortness of breath prevails over cough. However, in clinical practice it is very rarely possible to distinguish the emphysematous or bronchitis phenotype of COPD in the so-called. “pure” form (it would be more correct to talk about a predominantly bronchitis or predominantly emphysematous phenotype of the disease).
The features of the phenotypes are presented in more detail in Table 4.