WEBVTT00:00:09.000 --> 00:00:10.960嗯给大家讲一下优化治疗00:00:10.960 --> 00:00:13.000由慢阻肺管理目标出发00:00:13.000 --> 00:00:16.340看一个慢阻肺稳定期的一个治疗00:00:16.840 --> 00:00:17.660那么00:00:18.920 --> 00:00:20.520从四个方面啊00:00:20.520 --> 00:00:22.940一个是降低急性加重00:00:23.080 --> 00:00:25.700是慢阻肺管理的一个核心目标啊00:00:26.000 --> 00:00:26.640那么第二点00:00:26.640 --> 00:00:29.040就是从药理学的特征来看一下00:00:29.040 --> 00:00:30.860三联药物的一个优势00:00:31.200 --> 00:00:33.920然后现在大家临床上用的比较好的00:00:33.920 --> 00:00:35.660布迪格氟西路去污剂00:00:35.840 --> 00:00:38.360那么来谈一下它的有效00:00:38.360 --> 00:00:38.720降低00:00:38.720 --> 00:00:41.820一个慢阻肺患者的未来的一个风险00:00:42.320 --> 00:00:42.880嗯00:00:42.880 --> 00:00:43.720还有一个说00:00:43.720 --> 00:00:47.060搭载共悬浮技术的一个另畅装置00:00:47.200 --> 00:00:50.340是中国慢阻肺患者的一个优选吧00:00:51.160 --> 00:00:52.880那么慢阻肺管理的目标00:00:52.880 --> 00:00:55.000我们的目标都是缓解症状00:00:55.000 --> 00:00:57.500和降低未来急性加重的一个风险00:00:57.960 --> 00:01:00.560那么国内外的指南其实多次修订00:01:00.560 --> 00:01:02.480强调管理目标啊00:01:02.480 --> 00:01:04.760这五五个地方点00:01:04.760 --> 00:01:06.040那么主要基于症状00:01:06.040 --> 00:01:08.220和未来急性加重的一个风险00:01:08.440 --> 00:01:10.160第一个就是减轻单纯的症状00:01:10.160 --> 00:01:12.180包括缓解呼吸系统的症状00:01:12.360 --> 00:01:14.900改善运动的耐量和健康的状况00:01:15.000 --> 00:01:16.800那么降低未来的风险00:01:16.800 --> 00:01:18.620包括防止疾病的进展00:01:18.880 --> 00:01:21.620防止急性加重和减少一个病死率00:01:21.760 --> 00:01:23.680那么构的变迁是00:01:23.680 --> 00:01:26.040引入ABCD评估工具00:01:26.040 --> 00:01:27.020治疗目标00:01:27.400 --> 00:01:29.560快速的缓解和减轻一个症状00:01:29.560 --> 00:01:32.040降低未来不良事件的一个发生风险00:01:32.040 --> 00:01:33.500这是2011年的00:01:33.880 --> 00:01:35.960那么到了201第第三年00:01:35.960 --> 00:01:38.360第三版我国的指南啊00:01:38.360 --> 00:01:40.780这是中国指南的一个变迁啊00:01:40.800 --> 00:01:42.920第三版我国的指南的治疗目标00:01:42.920 --> 00:01:45.220就是减轻当前的症状00:01:45.400 --> 00:01:46.940降低未来的风险00:01:47.240 --> 00:01:48.660那么第四版00:01:48.840 --> 00:01:50.040第四版构得的00:01:50.040 --> 00:01:52.520就是提出新的ABCD的一个分组啊00:01:52.520 --> 00:01:53.320强调00:01:53.320 --> 00:01:55.980预防一个急性加重的一个重要性00:01:56.240 --> 00:01:57.660那么我国是00:01:57.720 --> 00:01:58.200然后又到00:01:58.200 --> 00:02:00.28021年 我国是21年的第四版00:02:00.280 --> 00:02:01.300我国的起来00:02:01.560 --> 00:02:02.560就是基于症状00:02:02.560 --> 00:02:04.480和未来急性加重的一个风险00:02:04.480 --> 00:02:06.940来减轻减轻当前的一个症状00:02:07.160 --> 00:02:08.580降低未来的风险00:02:08.680 --> 00:02:11.020那么2023年最新的一个go00:02:11.200 --> 00:02:12.360主要的治疗目标就是00:02:12.360 --> 00:02:15.680减轻症状和未来急性加重的风险00:02:15.680 --> 00:02:17.980强调一个降低的一个死亡率00:02:19.360 --> 00:02:21.680那么随着行政医学的积累啊00:02:21.680 --> 00:02:23.240慢阻肺的一个临床科研00:02:23.240 --> 00:02:24.940是不断的在突破的00:02:24.960 --> 00:02:26.520那么它这个管理的理念00:02:26.520 --> 00:02:28.940也是在不断的更新和变迁00:02:29.560 --> 00:02:33.320那么呃在慢阻肺症状加重的患者00:02:33.320 --> 00:02:33.720急性00:02:33.720 --> 00:02:36.300发生急性加重的一个风险会更高00:02:36.560 --> 00:02:38.900那么症状的严重程度加剧00:02:38.920 --> 00:02:41.080和急性加重发生风险的增加00:02:41.080 --> 00:02:42.140是有关的00:02:42.240 --> 00:02:44.620例如那么在这个00:02:44.640 --> 00:02:46.280从这张图我们可以看出来00:02:46.280 --> 00:02:47.640这个病人的呼吸困难的00:02:47.640 --> 00:02:49.900一个严重程度的加剧啊00:02:50.360 --> 00:02:52.940例如你这个是啊00:02:53.400 --> 00:02:56.320慢阻肺中坐标是一个慢阻肺的患者00:02:56.320 --> 00:02:58.660他可以随法12个月期间00:02:58.680 --> 00:03:00.840中重度急性加重的发生频率00:03:00.840 --> 00:03:03.120例如一次大于等于两次00:03:03.120 --> 00:03:04.580这些可以看得出来00:03:04.840 --> 00:03:06.840这是一项回顾性的一个观察00:03:06.840 --> 00:03:07.820队列研究00:03:07.920 --> 00:03:10.240是纳入了英国临床实践研究00:03:10.240 --> 00:03:11.040数据链中00:03:11.040 --> 00:03:11.900已经确诊00:03:12.160 --> 00:03:15.400确诊了58,589例的一个慢阻肺的患者00:03:15.400 --> 00:03:16.460然后评估00:03:16.480 --> 00:03:18.640和急性加重发生频率相关的00:03:18.640 --> 00:03:19.900一个危险因素00:03:20.240 --> 00:03:20.480那么00:03:20.480 --> 00:03:23.000即使没有急性加重病史的一个患者00:03:23.000 --> 00:03:25.180也会发生一个急性加重00:03:25.320 --> 00:03:26.440那么在随访期间00:03:26.440 --> 00:03:27.760如果发生一次中00:03:27.760 --> 00:03:30.020或者重度的急性加重的患者中00:03:30.160 --> 00:03:33.180约一半是没有急性加重的病史的00:03:33.480 --> 00:03:34.400那么血管肌间路00:03:34.400 --> 00:03:36.920发生两次中重度急性加重的患者中00:03:36.920 --> 00:03:40.820约1/4是没有急性加重的一个病史00:03:41.760 --> 00:03:43.200这是呃00:03:43.200 --> 00:03:45.480这是像那个英国00:03:45.480 --> 00:03:46.920的一个临床实践研究啊00:03:46.920 --> 00:03:50.060是也是上面说的58,589亿患者00:03:50.360 --> 00:03:51.080那么00:03:51.080 --> 00:03:53.840评估了个跟急性加重的一个呃00:03:53.840 --> 00:03:55.920发生频率相关的一个危险因素00:03:55.920 --> 00:03:57.760那么在12个月的随访中啊00:03:57.760 --> 00:03:59.080有24%的患者00:03:59.080 --> 00:04:01.640发生了一次中道重度的急性加重00:04:01.640 --> 00:04:03.160而23%的患者00:04:03.160 --> 00:04:04.340发生了两次00:04:04.360 --> 00:04:06.940大于等于两次中重度的急性加重00:04:07.400 --> 00:04:07.680那么00:04:07.680 --> 00:04:09.080我国慢阻肺患者啊00:04:09.080 --> 00:04:11.480中重度急性加重的比例比较多00:04:11.480 --> 00:04:14.220未来急性加重的风险也是比较高的00:04:16.040 --> 00:04:17.980啊我国慢阻肺患者00:04:18.000 --> 00:04:20.400呃年均呃年龄的呃00:04:20.400 --> 00:04:22.680年均急性加重次数在两次以上00:04:22.680 --> 00:04:25.900高于美国欧洲和世界水平平均水平00:04:26.120 --> 00:04:28.000而且近一半的急性加重事件00:04:28.000 --> 00:04:30.180多为重度急性加重事件00:04:30.440 --> 00:04:31.740例如在男性中00:04:32.040 --> 00:04:34.04051.6%的急性加重啊00:04:34.040 --> 00:04:35.520是为重度急性加重00:04:35.520 --> 00:04:37.880女性有44.5%啊00:04:37.880 --> 00:04:40.360是一个急性重度加呃急性加重00:04:40.360 --> 00:04:42.060为重度的一个急性加重00:04:42.600 --> 00:04:43.160那么00:04:43.160 --> 00:04:44.780中外指南一致强调00:04:44.960 --> 00:04:45.880慢阻肺的管理00:04:45.880 --> 00:04:47.980必须重视急性加重风险00:04:48.040 --> 00:04:49.920这是23年购的指南00:04:49.920 --> 00:04:51.320在呃再次强调了00:04:51.320 --> 00:04:52.920一个慢阻肺管理目标00:04:52.920 --> 00:04:55.220是降低一个急性加重的风险00:04:55.280 --> 00:04:57.600那么21版的中国慢阻肺的指南00:04:57.600 --> 00:04:59.140同样强调啊00:04:59.320 --> 00:05:00.520就是慢阻肺管理中00:05:00.520 --> 00:05:02.480一定要重视这个急性加重的风险00:05:02.480 --> 00:05:03.940降低风险有什么呀00:05:04.160 --> 00:05:05.840有预防疾病的进展00:05:05.840 --> 00:05:07.760预防和治疗急性加重00:05:07.760 --> 00:05:09.500减呃减少死亡率00:05:10.360 --> 00:05:12.720那么这一块的小结就是说00:05:12.720 --> 00:05:13.760只能一致强调00:05:13.760 --> 00:05:17.040慢阻肺的管理目标是减轻当前症状00:05:17.040 --> 00:05:19.620和降低包括防止疾病的进展00:05:19.640 --> 00:05:22.120防治急性加重和减少病死率00:05:22.120 --> 00:05:23.660的一个未来的风险00:05:24.000 --> 00:05:24.320那么00:05:24.320 --> 00:05:26.220我国慢阻肺的患者00:05:26.920 --> 00:05:28.200患处费的患者00:05:28.200 --> 00:05:29.600症状负担比较重00:05:29.600 --> 00:05:31.600未来急性加重的风险比较高00:05:31.600 --> 00:05:33.160即使没有急性加重病史00:05:33.160 --> 00:05:35.500也会发生急性加重症状00:05:35.520 --> 00:05:36.760负担越重的患者00:05:36.760 --> 00:05:37.480发生急00:05:37.480 --> 00:05:39.980中重度急性加重的风险就会越高00:05:40.160 --> 00:05:40.800那么第二个00:05:40.800 --> 00:05:42.600我们从药理学的特性看00:05:42.600 --> 00:05:44.360上面药物的一个优势00:05:44.360 --> 00:05:46.140我们讲一下布地格氟吧00:05:46.440 --> 00:05:46.960布地格福00:05:46.960 --> 00:05:47.880西路清雾剂00:05:47.880 --> 00:05:50.380三分子药理特性各具优势00:05:50.480 --> 00:05:52.960它的布地它是由布地啊00:05:52.960 --> 00:05:53.920布地奈德00:05:53.920 --> 00:05:58.040呃格那个格隆溴阿伏默特罗组成的00:05:58.040 --> 00:05:59.940这个药叫布地格福啊00:06:00.120 --> 00:06:02.120布地奈德有高效的局部抗炎00:06:02.120 --> 00:06:03.180起效迅速00:06:03.520 --> 00:06:04.160持久00:06:04.160 --> 00:06:05.920肺炎发生的绝对风险比较小00:06:05.920 --> 00:06:07.180安全性良好00:06:07.240 --> 00:06:09.640它有比较适中的亲子性和亲水性00:06:09.640 --> 00:06:11.400具有独特的解化作用00:06:11.400 --> 00:06:12.680可以长效的抗炎00:06:12.680 --> 00:06:13.940全身效应低00:06:14.040 --> 00:06:16.320然后发生肺炎的绝对风险比较小00:06:16.320 --> 00:06:17.700安全系数比较高00:06:17.720 --> 00:06:19.280那么FDA批准过的00:06:19.280 --> 00:06:21.520唯一妊娠安全风险低级的一个00:06:21.520 --> 00:06:22.240糖皮质激素00:06:22.240 --> 00:06:23.500就是不定耐德00:06:23.800 --> 00:06:25.960那么呃格隆溴胺呢00:06:25.960 --> 00:06:27.320它是高M3受体的00:06:27.320 --> 00:06:28.900一个选择性的结碳剂00:06:29.040 --> 00:06:31.780速效长效的抑制气道的一个收缩00:06:31.920 --> 00:06:34.720对M3受体的一个高选择性00:06:34.720 --> 00:06:36.780而且解离速度比较缓慢00:06:36.880 --> 00:06:39.080与M2受体的解离速度比较快00:06:39.080 --> 00:06:40.340险灾风险小00:06:40.560 --> 00:06:42.560然后用药后5分钟就能起效00:06:42.560 --> 00:06:43.840且维持支气管舒张00:06:43.840 --> 00:06:46.100作用可以持续12-24小时00:06:46.320 --> 00:06:47.800那么福莫特罗00:06:47.800 --> 00:06:49.280是高北塔奥受体的00:06:49.280 --> 00:06:50.900一个选择性激动剂00:06:51.080 --> 00:06:52.640起效快啊00:06:52.640 --> 00:06:53.880速效量效00:06:53.880 --> 00:06:56.960还有长效的一个或支气管那么高00:06:56.960 --> 00:06:58.600较高的北塔奥受体亲和力00:06:58.600 --> 00:07:00.380还有较高的内在活性00:07:00.600 --> 00:07:02.080然后起效3分钟左右00:07:02.080 --> 00:07:03.080能改善肺功能00:07:03.080 --> 00:07:05.100并且维持作用也在12小时00:07:05.480 --> 00:07:08.360所以布地德芙我们可以一天吸00:07:08.360 --> 00:07:09.580一般是Q1200:07:10.400 --> 00:07:13.500那么三种成分的一个协同增效啊00:07:13.640 --> 00:07:15.300那个和ICS00:07:16.400 --> 00:07:18.400那个拉吧和那个拉嘛00:07:18.400 --> 00:07:20.940或者拉吧的一个联合治疗相比00:07:21.040 --> 00:07:23.400这三个的联合用药00:07:23.400 --> 00:07:26.160更好的改善肺功能疾病的症状00:07:26.160 --> 00:07:28.580和减少慢阻肺的一个急性加重00:07:30.240 --> 00:07:32.040那么这里面我们说了00:07:32.040 --> 00:07:33.440SS是抗原作用嘛00:07:33.440 --> 00:07:36.000然后拉把是北岛2受体的一个结合00:07:36.000 --> 00:07:37.700抑制气道的一个收缩00:07:37.840 --> 00:07:39.240那么这里协同作用的话00:07:39.240 --> 00:07:41.640可以联合增强抗原作用00:07:41.640 --> 00:07:43.540抑制气道的重构因子00:07:43.600 --> 00:07:44.400那么拉嘛呢00:07:44.400 --> 00:07:46.560就阻断m m 3受体啊00:07:46.560 --> 00:07:48.180舒张支气管的平滑肌00:07:48.360 --> 00:07:50.880那么喇嘛和喇叭的协同作用呢00:07:50.880 --> 00:07:53.980可以进一步的增强支气管扩张作用00:07:54.120 --> 00:07:55.600所以呃00:07:55.600 --> 00:07:58.380这三灵药就可以改善肺功能00:07:58.720 --> 00:08:00.120他的一个疾病的状态00:08:00.120 --> 00:08:01.200症状啊00:08:01.200 --> 00:08:02.920减少慢阻肺的一个急性加重00:08:02.920 --> 00:08:03.980起效又快00:08:04.000 --> 00:08:05.040然后时间呢00:08:05.040 --> 00:08:07.700却是啊12-24小时00:08:07.920 --> 00:08:09.000那么布丁赖德00:08:09.000 --> 00:08:11.680进入气道后快速溶解与黏液发00:08:11.680 --> 00:08:12.960发挥一个抗炎作用00:08:12.960 --> 00:08:14.540它有清水清子性00:08:14.960 --> 00:08:15.440那么布地奈德00:08:15.440 --> 00:08:17.800具有适中的一个水溶性和脂溶性00:08:17.800 --> 00:08:18.840可以在气道中00:08:18.840 --> 00:08:21.320快速6分钟就溶解于黏液00:08:21.320 --> 00:08:22.740快速地通过里面00:08:22.840 --> 00:08:24.280然后通过细胞膜00:08:24.280 --> 00:08:26.100来发挥它的抗凝作用00:08:26.320 --> 00:08:28.360那么布地奈德的溶解时间00:08:28.360 --> 00:08:29.320我们该已经说了00:08:29.320 --> 00:08:30.240是6分钟左右00:08:30.240 --> 00:08:32.300从这个图我们可以看出来啊00:08:32.560 --> 00:08:32.600把00:08:32.600 --> 00:08:34.400你看作用于啊00:08:34.400 --> 00:08:36.720人未溶解的纤毛运动啊00:08:36.720 --> 00:08:37.940弹力的清除00:08:38.040 --> 00:08:39.120然后全身吸收00:08:39.120 --> 00:08:41.580结合受体发挥它的抗炎作用00:08:41.600 --> 00:08:43.640因为它用了嗯清00:08:43.640 --> 00:08:46.500它具有水溶性还有亲子性00:08:46.760 --> 00:08:49.120快速的能够快速的透过细胞膜00:08:49.120 --> 00:08:50.340发挥抗炎作用00:08:50.800 --> 00:08:51.520那么吸入00:08:51.520 --> 00:08:51.960常见的00:08:51.960 --> 00:08:54.000吸入性含毒性激素的药理学参数00:08:54.000 --> 00:08:54.840我们可以看到00:08:54.840 --> 00:08:57.920布丁奈德它水溶性是16微克每毫升00:08:57.920 --> 00:08:59.460脂溶性是2.3200:08:59.480 --> 00:09:01.280而那个丙酸00:09:01.280 --> 00:09:03.440菩提卡松水溶性0.1400:09:03.440 --> 00:09:05.040脂溶性3.8900:09:05.040 --> 00:09:06.580也就水溶性比较差00:09:06.840 --> 00:09:10.640那么嗯康刷菩提塔松水溶性更差00:09:10.640 --> 00:09:12.4800.03 脂溶性比较好00:09:12.480 --> 00:09:13.4204.0700:09:15.440 --> 00:09:16.300然后00:09:16.360 --> 00:09:18.680格隆溴安弗默特罗起效迅速00:09:18.680 --> 00:09:20.180改善患者的肺功能00:09:20.320 --> 00:09:20.680嗯00:09:20.680 --> 00:09:23.800那个格隆溴安和伏默特罗对比啊00:09:23.800 --> 00:09:25.5203研究结果显示啊00:09:25.520 --> 00:09:26.980相比于安慰剂00:09:27.040 --> 00:09:29.940那么格隆秀安伏默特罗起效快00:09:30.040 --> 00:09:32.780而且显著的改善患者的FUV万00:09:33.440 --> 00:09:35.420这是两张图的一个对比啊00:09:36.440 --> 00:09:38.240前面是用药后的小时00:09:38.240 --> 00:09:39.120单位是小时00:09:39.120 --> 00:09:41.620后面后面一张图是用药后的分钟00:09:42.040 --> 00:09:44.000那么这个呃00:09:44.000 --> 00:09:45.860灰色的这个是沙丁胺醇00:09:46.280 --> 00:09:50.020然后黄色的是福莫特罗那么00:09:50.240 --> 00:09:52.700这个绿色的这个安慰剂00:09:53.680 --> 00:09:54.320那么00:09:54.320 --> 00:09:55.680布地格氟吸入去雾剂00:09:55.680 --> 00:09:57.7005分钟就可以快速的起效00:09:58.080 --> 00:09:59.280然后是00:09:59.280 --> 00:10:00.080这里是一个00:10:00.080 --> 00:10:02.000429名患者00:10:02.000 --> 00:10:03.960使用布地格氟吸入去雾剂00:10:03.960 --> 00:10:04.480用药后00:10:04.480 --> 00:10:07.7205分钟的一个肺功能检测的一个呃00:10:07.720 --> 00:10:08.540测定值00:10:08.720 --> 00:10:09.200那么00:10:09.200 --> 00:10:12.460FEV one机械平均改善了175毫升00:10:15.200 --> 00:10:16.160那么小结一下00:10:16.160 --> 00:10:17.080布地格服气雾00:10:17.080 --> 00:10:19.520气雾剂还有布地奈德啊00:10:19.520 --> 00:10:21.240格隆溴安普莫特罗00:10:21.240 --> 00:10:23.420三种药物成分协同增效00:10:23.440 --> 00:10:25.160然后5分钟就可以起效00:10:25.160 --> 00:10:26.700安全性比较良好00:10:27.200 --> 00:10:27.480那么00:10:27.480 --> 00:10:28.400我们再说一下00:10:28.400 --> 00:10:29.600布地和氟西路去污剂00:10:29.600 --> 00:10:32.500有效降低慢阻肺患者的未来风险啊00:10:32.680 --> 00:10:33.400慢阻肺治疗00:10:33.400 --> 00:10:35.860已经进入了三联吸入治疗时代00:10:35.880 --> 00:10:37.520疾病的进展到一定的阶段00:10:37.520 --> 00:10:39.880三联的呃疗法的获益比较小00:10:39.880 --> 00:10:40.760应尽早开始00:10:40.760 --> 00:10:42.420三联的一个疗法00:10:42.840 --> 00:10:45.020那么这里是一个支付00:10:45.240 --> 00:10:46.240然后拉嘛00:10:46.240 --> 00:10:47.000嗯拉吧00:10:47.000 --> 00:10:48.280还有拉嘛的联合00:10:48.280 --> 00:10:50.120或者ICS和拉吧的联合00:10:50.120 --> 00:10:51.300和三点疗法00:10:51.440 --> 00:10:53.140这是到了一个后期的一个00:10:53.160 --> 00:10:55.480那么如果是一次中度急性加重00:10:55.480 --> 00:10:56.840可能导致肺功能下降00:10:56.840 --> 00:10:57.920加倍的话00:10:57.920 --> 00:11:00.060那么这里我们是否就要开始00:11:00.200 --> 00:11:01.740这时间节点在这里00:11:02.360 --> 00:11:04.340然后就是到了后期00:11:04.520 --> 00:11:06.280疾病进展到一定阶段的时候00:11:06.280 --> 00:11:07.440用三联疗法00:11:07.440 --> 00:11:09.100那么它获益就比较少00:11:09.800 --> 00:11:10.440然后00:11:10.440 --> 00:11:13.080三联疗法在慢阻肺治疗中的获益00:11:13.080 --> 00:11:13.880已经被证实了00:11:13.880 --> 00:11:15.440这是18年的一个研究00:11:15.440 --> 00:11:17.340这是20年的研究00:11:17.640 --> 00:11:18.780嗯那么00:11:21.600 --> 00:11:22.600就是20年00:11:22.600 --> 00:11:23.640说下20年吧00:11:23.640 --> 00:11:25.200我们纳入了一个00:11:25.200 --> 00:11:26.480中国慢阻肺急性加重00:11:26.480 --> 00:11:27.800高风险的一个人群嘛00:11:27.800 --> 00:11:29.400那么慢阻肺领域中00:11:29.400 --> 00:11:31.920将全因死亡率作为次要终点00:11:31.920 --> 00:11:34.220观察的大型临床结论就是00:11:34.240 --> 00:11:35.740相比于双联治疗00:11:36.040 --> 00:11:36.800布丁奈德福00:11:36.800 --> 00:11:39.600莫特罗呃格隆溴胺在减少00:11:39.600 --> 00:11:40.960就是三药联合用00:11:40.960 --> 00:11:42.880在减少慢阻肺患者中00:11:42.880 --> 00:11:45.460重度急性加重或痊愈死亡分解00:11:45.480 --> 00:11:46.780有显著的获益00:11:49.200 --> 00:11:51.080这是一个原车设计啊00:11:51.080 --> 00:11:52.640主要的一个入组标准00:11:52.640 --> 00:11:54.400FEV one小于80的ET值00:11:54.400 --> 00:11:57.060FEV one不及FEC小于0.700:11:57.440 --> 00:11:57.880那么没有00:11:57.880 --> 00:12:00.140慢阻肺急性加重时的一个要求00:12:00.200 --> 00:12:01.600然后这个是筛选00:12:01.600 --> 00:12:02.960那么在筛选的时候00:12:02.960 --> 00:12:05.140他的那个CF要大于等于10分00:12:05.280 --> 00:12:06.280然后筛选前00:12:06.280 --> 00:12:07.080大于等于6周00:12:07.080 --> 00:12:10.280使用大于两种大于等于两种吸入剂00:12:10.280 --> 00:12:12.100进行慢阻肺的一个维持治疗00:12:12.160 --> 00:12:13.400那么这是例数00:12:13.400 --> 00:12:14.720患者的例数啊00:12:14.720 --> 00:12:16.740全球总共有640例啊00:12:17.480 --> 00:12:19.740那么中国都有14400:12:20.560 --> 00:12:23.800然后是28天左右的一个20周00:12:23.800 --> 00:12:25.66024周的一个治疗期00:12:25.960 --> 00:12:26.880然后我们再看00:12:26.880 --> 00:12:28.460第一个是三年用药00:12:28.600 --> 00:12:30.220第二个是两年00:12:33.200 --> 00:12:35.700那么主要的疗效的一个评估00:12:35.840 --> 00:12:37.720有主要的目的肺功能啊00:12:37.720 --> 00:12:39.040次要目的呼吸困难00:12:39.040 --> 00:12:39.840生活质量00:12:39.840 --> 00:12:41.420症状急性加重00:12:41.480 --> 00:12:43.260还有一个起效的时间00:12:43.560 --> 00:12:45.240那么他的研究终点是什么00:12:45.240 --> 00:12:47.860协同主要终点和次要终点00:12:48.400 --> 00:12:49.260嗯00:12:49.720 --> 00:12:51.040协同的主要终点00:12:51.040 --> 00:12:53.660如FEV one a C00:12:53.880 --> 00:12:57.080然后这些与极限相比00:12:57.080 --> 00:12:59.560早上比较前的FEV one的分子变化00:12:59.560 --> 00:13:00.78024周左右00:13:00.920 --> 00:13:02.600那么次要终点尊重度00:13:02.600 --> 00:13:04.340急性加重的一个发生率00:13:04.880 --> 00:13:07.580然后是CID的一个时间00:13:07.880 --> 00:13:09.080然后FEV one00:13:09.080 --> 00:13:12.020AUC的一个24周的一个时间吧00:13:12.440 --> 00:13:13.460然后还有00:13:13.600 --> 00:13:15.120嗯早上给药钱00:13:15.120 --> 00:13:18.020FV one股值相对基线的一个变化00:13:18.240 --> 00:13:19.480还有早上给药钱00:13:19.480 --> 00:13:20.800FV one的股值00:13:20.800 --> 00:13:24.580相对基线变化的一个pgfmmdi00:13:25.560 --> 00:13:27.880然后有个SPRQ的一个总分00:13:27.880 --> 00:13:28.920也是20周00:13:28.920 --> 00:13:31.960平均每天挽救药物使用量00:13:31.960 --> 00:13:33.780相对机械的一个变化00:13:33.920 --> 00:13:36.760还有那个RS total平方00:13:36.760 --> 00:13:39.74024周GDI的一个局调性的平方00:13:39.960 --> 00:13:41.480还有给药4小时内00:13:41.480 --> 00:13:43.640FEV外相对机械的一个分子变化00:13:43.640 --> 00:13:44.900也是24周00:13:45.480 --> 00:13:48.260还有第一天的一个起哨时间00:13:52.400 --> 00:13:54.480那么与双磷制剂相比啊00:13:54.480 --> 00:13:56.260布比格呼吸露气雾剂00:13:56.360 --> 00:13:58.600能够显著的改善一个肺的功能00:13:58.600 --> 00:14:00.540我们从这张图上来看00:14:00.720 --> 00:14:02.520跟拉马拉把的相比00:14:02.520 --> 00:14:04.980和跟SS拉拉把的相比00:14:05.640 --> 00:14:07.100我们可以显著的改善00:14:07.200 --> 00:14:09.160那么相比于双支破剂00:14:09.160 --> 00:14:10.560腹地和呼吸入气入剂00:14:10.560 --> 00:14:13.360则显著的降低慢阻肺的一个重度00:14:13.360 --> 00:14:14.860急性加重的风险00:14:15.120 --> 00:14:15.960就是降低了00:14:15.960 --> 00:14:18.300第一张我们看到降低了60%00:14:18.600 --> 00:14:20.240然后中重度的话00:14:20.240 --> 00:14:22.740急性加重的风险降低了52%00:14:23.600 --> 00:14:25.680就是相比于双支破剂00:14:25.680 --> 00:14:27.000不及得呼吸入气雾剂00:14:27.000 --> 00:14:28.840极度的延长手势00:14:28.840 --> 00:14:31.020中重度执行加重的一个时间00:14:31.160 --> 00:14:32.820疗法的一个进展00:14:33.240 --> 00:14:33.800那么还有00:14:33.800 --> 00:14:35.000跟其他作者相比00:14:35.000 --> 00:14:37.380不得不吸入气雾剂治疗慢阻肺00:14:37.480 --> 00:14:39.280会增加主要的心血管时间00:14:39.280 --> 00:14:40.520和肺炎发生的风险00:14:40.520 --> 00:14:42.380安全显示比较高00:14:43.360 --> 00:14:44.720这是创新00:14:44.720 --> 00:14:45.78030制药00:14:45.920 --> 00:14:47.520然后为慢阻肺的高00:14:47.520 --> 00:14:50.340风险病毒获益增添了一个新的证据00:14:52.720 --> 00:14:54.220那么这是一个00:14:54.840 --> 00:14:56.540啊研究设计00:14:57.000 --> 00:14:58.280我们上面看一下00:14:58.280 --> 00:15:00.880就是3:0 ss和拉把的一个不低头00:15:00.880 --> 00:15:02.020不吸力切入镜00:15:02.240 --> 00:15:03.720降低了一个急性加重00:15:03.720 --> 00:15:05.040导致的住院风险00:15:05.040 --> 00:15:06.160所以我们可以看到00:15:06.160 --> 00:15:07.700降低到20%左右00:15:12.920 --> 00:15:13.840我们小结一下00:15:13.840 --> 00:15:14.280患者肺00:15:14.280 --> 00:15:16.700已经进入了三年治疗的一个时代00:15:16.800 --> 00:15:18.280这个在他的治疗00:15:18.280 --> 00:15:20.540在三年治疗应该尽早的启动00:15:20.800 --> 00:15:22.940它能显著的降低急性加重00:15:23.160 --> 00:15:24.560嗯低风险的人群00:15:24.560 --> 00:15:28.260而且可以可以降低急性加重的风险00:15:28.840 --> 00:15:30.220然后说一下00:15:30.280 --> 00:15:32.160八载供学啊00:15:32.160 --> 00:15:34.560供悬壶技术的另唱专制00:15:34.560 --> 00:15:35.840是中国曼土菲的首选00:15:35.840 --> 00:15:38.720这是一个西路专制和西路呃00:15:38.720 --> 00:15:39.320西路疗法00:15:39.320 --> 00:15:41.640西路专制在曼土菲的一个重要性00:15:41.640 --> 00:15:43.160跟口服静脉相比啊00:15:43.160 --> 00:15:44.040这个西路北亚00:15:44.040 --> 00:15:46.320在曼土菲是首首要地位的00:15:46.320 --> 00:15:48.020多个指南都是一致推荐的00:15:48.640 --> 00:15:49.200时效快00:15:49.200 --> 00:15:50.400直接作用把器官00:15:50.400 --> 00:15:51.560疗效佳操作简用00:15:51.560 --> 00:15:52.860产生不良反应少00:15:53.200 --> 00:15:55.160然后这个单一装置的一个转弯00:15:55.160 --> 00:15:55.840水洗就多00:15:55.840 --> 00:15:57.580装置开放3年00:15:59.880 --> 00:16:01.080当一张是闭合00:16:01.080 --> 00:16:01.880上面00:16:03.680 --> 00:16:06.400由于由于中老年患者出现能力差00:16:06.400 --> 00:16:08.440所以这种方式就越简单00:16:08.440 --> 00:16:10.540越提高他们的依从性00:16:13.560 --> 00:16:15.240然后他这个专治呢00:16:15.240 --> 00:16:17.760就是生物大小气道比较稳定的00:16:17.760 --> 00:16:19.180均匀的输送药物00:16:19.280 --> 00:16:21.280还有成分就比较成呃00:16:21.280 --> 00:16:22.040均匀的沉积00:16:22.040 --> 00:16:23.380成分稳定的输入00:16:24.160 --> 00:16:26.000然后还有就是这个00:16:26.000 --> 00:16:27.680供悬浮给药技术的专治00:16:27.680 --> 00:16:30.080对流气吸气流的要求比较低00:16:30.080 --> 00:16:30.720适合人生00:16:30.720 --> 00:16:32.880更多的还有他00:16:32.880 --> 00:16:35.540他在肺里的沉积率可以达到48%00:16:35.800 --> 00:16:37.780所以这个装置呢00:16:37.840 --> 00:16:40.160呃叫空悬浮硬颤装置00:16:40.160 --> 00:16:40.680伸入肺部00:16:40.680 --> 00:16:41.360大小气道00:16:41.360 --> 00:16:44.200稳定的输送到3微米左右的颗粒标00:16:44.200 --> 00:16:45.560啊吸气的流速要求00:16:45.560 --> 00:16:46.420也比较低00:16:46.520 --> 00:16:48.680适合哪怕中重度的病人都可以使用00:16:48.680 --> 00:16:50.740然后肺部沉积率也48了00:16:50.920 --> 00:16:53.060达到了肺部中央和外侧的区域00:16:55.120 --> 00:16:56.100好谢谢了