在中低收入国家(LMICs)，包括慢阻肺在内的慢性呼吸系统疾病带来了巨大的社会经济负担。LMICs在推行具有成本效益的慢阻肺预防、诊断和管理方面有特殊的挑战。指南的有效实施有助于最佳临床实践的实施。然而，在LMICs，在循证慢阻肺指南制定和实施方面仍较为薄弱(全球高达19.5亿人口没有当地慢阻肺诊疗指南)(北医三院陈亚红与CDC方立文联合课题组最新研究：探索中国慢阻肺表型与管理现状，加强在初级医疗保健中对早期慢阻肺患者的识别和管理。在我国该项研究被调查的慢阻肺患者中，仅有5.9%的慢阻肺患者曾经做过肺功能检查，3.4%的患者既往进行过吸入药物治疗，2.5%的患者接受过吸氧治疗。在吸入药物方面，0.9%的患者使用短效支扩剂治疗，0.3%的患者使用长效支扩剂治疗，0.4%的患者同时吸入长效支扩剂和短效支扩剂治疗。)

        由ATS支持，由英国专家John Hurst组织、在2020年9月29-30日召开了线上讨论会，来自世卫组织、GOLD、GACD、IPCRG等组织以及多国的与会专家就以下问题展开激烈讨论，形成应对挑战的10条推荐意见并撰写报告，近期发表在Ann Am Thorac Soc上。

        问题1. 慢阻肺指南在LMICs的知晓和使用情况，哪些指南在现实世界中被使用?

        问题2. 在LMICs实施普遍的、以证据为基础的、由指南驱动的、具有成本效益的慢阻肺干预措施的障碍和促进因素是什么?

        问题3：呼吸界应如何引领变革，从而在LMICs更广泛地引入循证慢阻肺临床实践?

        Hurst JR, Buist AS, Gaga M, Gianella GE, Kirenga B, Khoo EM, Mendes RG, Mohan A, Mortimer K, Rylance S, Siddharthan T, Singh SJ, van Boven JFM, Williams S, Zhang J, Checkley W.

        Challenges in the Implementation of Chronic Obstructive Pulmonary Disease Guidelines in Low- and Middle-Income Countries: An Official American Thoracic Society Workshop Report.

        Ann Am Thorac Soc. 2021;18(8):1269-1277.

        doi: 10.1513/AnnalsATS.202103-284ST.

        获取报告原文：

        https://pan.baidu.com/s/1khkejE65hmxT2XHdR3szrg

        提取码：qyt2

        以下为部分内容，供读者参考。

        Recommendation 1

        Relevant organizations, including societies, clinicians, and academics, should provide LMIC-specific COPD management guidance spanning from prevention, diagnosis, and management topalliative care. This should be codeveloped with primary healthcare teams and patients. The guidance should include an effective implementation plan that acknowledges clinician education and training, resource availability, and limitation in resources. Guidance should consider the diversity of conditions resulting in poorly reversible airflow obstruction that meet the criteria for COPD in LMIC settings.

        相关组织，包括学会、临床医生和学术界，应提供针对LMICs的慢阻肺管理指南，包括预防、诊断和管理以及姑息治疗。指南应该与初级保健团队和患者共同制定。指南应包括一个有效的实施计划，注意到临床医生的教育和培训、资源可用性和资源限制。指南应考虑到在LMICs中导致达到慢阻肺标准的不完全可逆性气流阻塞的各种情况。

        Recommendation 2

        Patient and professional organizations must persuade policy-makers of the importance of lung function testing programs in LMICs, including adequate provision of spirometry training. In the absence ofaccessible, high-quality spirometry, the use of micro-spirometry, PEF testing, and questionnaires that assess clinical history can support the diagnosis of COPD.

        患者和专业组织必须说服政策制定者认识到肺功能检测在LMICs的重要性，包括充分提供肺功能检测培训。在缺乏高质量肺功能仪的情况下，使用简易肺功能仪、PEF检测和评估临床病史的问卷调查有助于慢阻肺的诊断。

        Recommendation 3

        The origins of COPD may be in early life, and all clinicians, including those working in maternal and child health, therefore require education and training on basic prevention messages such that smoking in pregnancy is discouraged, premature births are reduced, and childhood respiratory infections are effectively diagnosed and treated.

        慢阻肺的起源可能是在生命早期，因此，所有的临床医生，包括从事妇幼保健工作的医生，都需要接受基本预防信息的教育和培训，以便劝阻孕妇吸烟，减少早产，并对儿童呼吸道感染进行有效的诊断和治疗。

        Recommendation 4

        Urgent action is required by governments in LMICs to apply successful tobacco control regulations from HICs and to test andextend such approaches to indoor and outdoor air pollution. New creative approaches to tobacco control should be developed and studied.

        LMICs政府需要采取紧急行动，应用高收入国家行之有效的烟草控制法规，并评估和推广这些方法到室内和室外空气污染。应开发和研究新的创造性的烟草控制方法。

        Recommendation 5

        Guidance for COPD in LMICs should be set in the framework of universal health coverage and should be explicitly linked across WHO and national EMLs and the WHO Package of Essential NCD Interventionsfor Primary Health Care in Low-Resource Settings. Guidance should consider the availability, affordability, sustainability (incorporating environmental impact), and cost-effectiveness of medicines and their use and should include supporting patients to use inhalers correctly, which may require adjuncts such as spacers.

        LMICs的慢阻肺指南应在全民医保的框架内制定，并应明确对接世卫组织和国家EML以及世卫组织低资源环境下初级卫生保健基本非传染性疾病干预措施包(PEN)。指导意见应考虑药品及其使用的可及性、可负担性、可持续性(包括环境影响)和成本效益，并应包括支持患者正确使用吸入装置，这可能需要储雾罐等辅助工具。

        Recommendation 6

        The pharmaceutical industry should work with national governments to make effective COPD and tobacco-dependence medicines globally accessible and affordable to everyone who needs them.

        制药行业应与各国政府合作，使每个需要药物的人都能在全球范围内获得并负担得起有效的慢阻肺和烟草依赖治疗药物。

        Recommendation 7

        Implementation of locally adapted, cost-effective PR programs should be an international priority. This will require investment and workforce planning that consider staff training, awareness, referral, and novel approaches to delivery.

        实施适合当地的、具有成本效益的肺康复项目应该是一个国际优先事项。这将需要投资和人员规划，考虑人员的培训、认识、转诊和新的肺康复提供方法。

        Recommendation 8

        The WHO Global Action Plan for the Prevention and Control of NCDs should specify how the relative reduction of premature mortality from CRD will be achieved and should also focus on morbidity. As interim targets, by 2030,

        • ≥50% of people with chronic respiratory symptoms should have access to appropriate assessments, including accurate and timely diagnosis;

        • ≥60% of those with CRD should have access to effectivenon pharmacological and pharmacological treatments; and

        • ≥70% of those treated for CRD should have well-controlled disease.

        世卫组织《预防和控制非传染性疾病全球行动计划》应明确规定如何实现减少慢性气道病(CRD)的过早死亡，同时也应关注发病率。作为中期目标，到2030年

        ≥50%的有慢性呼吸道症状的人应能获得适当的评估，包括准确和及时的诊断。

        ≥60%的CRD患者应能获得有效的非药物治疗和药物治疗;以及

        ≥70%接受治疗的CRD患者应该得到良好的疾病控制。

        Future targets should transition frommeasurement to monitoring improvement. LMICs are diverse, and in those settings where differentiation among COPD, asthma, and other CRDs is possible (and this must be the aim), specific targets should be developed for COPD.

        未来的目标应从调查过渡到监测改进。LMICs国家是多样化的，在那些有可能区分慢阻肺、哮喘和其他CRD的地区(必须以此为目标)，应该为慢阻肺制定具体的目标。

        Recommendation 9

        Research funders should increase the proportion of funding allocated to COPD in LMICs to be commensurate with the burden of disease. Funders should convene a meeting with LMIC researchers and their collaborators to develop a respiratory research roadmap to ensure the best use of limited research funding.

        研究资助机构应增加分配给中LMICs慢阻肺的资金比例，使之与疾病的负担相称。资助机构应与LMICs的研究人员及其合作者召开会议，制定呼吸系统研究路线图，以确保有限的研究资金得到最佳使用。

        Recommendation 10

        The respiratory community should leverage the skills and enthusiasm of earlier-career clinicians and researchers and empower them through investment and global partnerships to take on the challenges of research and clinical care for COPD in LMICs.

        呼吸界应该充分发挥年轻临床医生和研究人员的作用(包括技能和热情)，并通过投资和全球合作对之加以增强，以应对LMICs国家慢阻肺研究和临床照护的挑战。

        小结和展望

        慢阻肺指南所面临的挑战的相对重要性取决于环境，在各个LMICs之间，甚至在各个LMICs内部，都会有所不同。战略的制定和实用工具的开发毫无疑问是非常重要的。同时，呼吸界必须以一个声音站在一起。此外，要想取得成功，必须与世卫组织领导的国际非传染性疾病战略和目标相结合，吸引年轻专业人员参与其中，并进行全球推介。