慢性阻塞性肺疾病（慢阻肺）全球创议（global initiative for chronic obstructive lung disease，GOLD）2020年修订版于2019年11月5日发布，其最重要的改变是增加了起始吸入性糖皮质激素治疗需要考虑的因素，调整了慢阻肺管理循环图表，改进了非药物治疗的随访，并明确了慢阻肺急性加重的鉴别诊断。本文对新增内容进行简介和解读。

1998年慢性阻塞性肺疾病（慢阻肺）全球创议（global initiative for chronic obstructive lung disease，GOLD）启动，其目标是根据已发表的最佳研究结果制订慢阻肺的管理推荐。第1版慢阻肺诊断、治疗及预防全球策略于2001年发布，并于2006年和2011年分别根据已发表的研究进行了全面修订。GOLD 2011修订版的修订分别于2013年1月、2014年1月、2015年1月和2016年1月发布，国内呼吸领域相关专家亦分别对其进行了解读^[1-4]。2015—2016年，GOLD科学委员会发现，关于慢阻肺的病理生理、诊断、评估和治疗方法有较多新内容出现，因此需要进行全面修订，由写作委员会制订各章节大纲。2016年9月，GOLD科学委员会对各章节进行审阅，然后送至GOLD委员会之外的10名专家处，提出建议并进行修改。GOLD 2017作为第4次全面修订，于2016年11月16日在美国费城举办的GOLD慢阻肺全程管理会议上发布，笔者对GOLD 2017、GOLD2018、GOLD 2019进行了详细解读^[5-7]。GOLD 2020是GOLD 2017的第3次修改，检索了2018年1月至2019年7月发表的文献，新增文献62篇，其中有4篇来自中国学者的研究，1篇为合作研究，于2019年11月5日发布。总体来说，GOLD 2020更新幅度较小，与GOLD 2019类似，分为6个章节，GOLD 2020增加起始吸入性糖皮质激素（inhaled corticosteroid，ICS）治疗需要考虑的因素，调整了慢阻肺管理循环图表，改进了非药物治疗的随访，并明确了慢阻肺急性加重的鉴别诊断^[8]。2019年11月20日是第18个世界慢阻肺日，主题为“防控慢阻肺，你我携手行（All together, to end COPD）”。本文对GOLD2020重要更新内容进行简介和解读。

1 第一章 慢阻肺定义和概述

关键点：

•          慢阻肺是一种常见的、可预防和可治疗的疾病，其特征在于持续呼吸道症状和气流受限，这是由于气道和/或肺泡异常所致，通常是由于长期暴露于有害颗粒或气体所引起。

•          最常见的呼吸症状包括呼吸困难、咳嗽和/或咳痰。患者对这些症状的报告可能不足。

•          慢阻肺的主要危险因素是吸烟，但其他环境暴露，如生物燃料暴露和空气污染可能参与发病。除暴露外，个体宿主易感性也会导致慢阻肺的发生，其中包括基因异常、肺发育异常和加速衰老。

•          慢阻肺可伴有呼吸系统症状的急性恶化，称为慢阻肺急性加重。

•          大多数慢阻肺患者存在重大的共患慢性病，可增加慢阻肺的致残率和死亡率。

更新要点：

GOLD 2020对于慢阻肺的定义略加修改，强调了宿主因素在慢阻肺发生发展中的作用以及合并症对预后的影响：慢阻肺是一种常见的、可以预防和治疗的异质性疾病，以持续呼吸症状和气流受限为特征，通常是由于暴露于有毒颗粒或气体引起的气道和/或肺泡异常所导致，并受到宿主因素如肺发育异常的影响，合并症可增加慢阻肺的致残率和死亡率。GOLD 2020更新了慢阻肺的疾病负担，指出随着发展中国家吸烟率的升高和高收入国家老龄化加剧，预计慢阻肺的发病率在未来40年仍会继续上升，至2060年可能每年有超过540万人死于慢阻肺及其相关疾病。慢阻肺主要的危险因素是吸烟， GOLD 2020新增影响慢阻肺发生发展的危险因素包括职业暴露、固体燃料、空气污染和铜绿假单胞菌定植。最常见的呼吸症状包括呼吸困难、咳嗽和/ 或咳痰，这些症状可能被患者漏报。慢阻肺的呼吸症状在某一时期迅速恶化称为慢阻肺急性加重。 GOLD 2020新增应该进一步深入研究无气流受限但已出现肺病理改变（如肺气肿）的临床意义。

1.1 职业暴露与慢阻肺 

职业暴露因素是慢阻肺重要的、可预防的病因^[9,10]。一项基于人群的英国生物样本库队列评价了职业暴露与肺功能的关系，研究人群仅限于从不吸烟者，从而排除了最重要的吸烟混杂因素^[11]。在116 375名有完整职业暴露的受试者中，94 551人有肺功能和吸烟信息，发现有 6种职业的慢阻肺风险在从不吸烟和无哮喘的人群中增加，包括“雕刻家、画家”“园丁、公园管理员”“食品、饮料、烟草商”“塑料加工者、铸模者”“农民、渔民”“仓库管理员”，并有暴露-效应趋势。对于从不吸烟的人群，应询问他们的职业暴露，并采取针对性的预防策略，以更好地进行疾病管理。

1.2 固体燃料与呼吸系统疾病发生的风险 

虽然横断面研究和病例对照研究发现使用固体燃料造成的室内空气污染与慢阻肺发生风险相关，但不同研究得出的结论不一致。既往几乎没有大规模队列研究证据表明固体燃料的使用与主要呼吸系统疾病的住院率和死亡率之间的关系。中国慢性病前瞻性研究项目（简称CKB）是由中国医学科学院与英国牛津大学联合开展的慢性病国际合作项目^[12]。GOLD 2020纳入的研究重点关注固体燃料使用与急性和慢性呼吸系统疾病风险之间的关系。研究对277 838 名既往无重大慢性病的中国不吸烟者进行了队列研究，在9年的随访中，19 823人首次住院或因重大呼吸系统疾病死亡，包括10 553例慢性下呼吸道疾病（chronic lower respiratory disease，CLRD）、4398 例慢阻肺、7324例急性下呼吸道感染（acute lower respiratory tract infection，ALRI）。总体来说，91% 的参与者表示经常做饭，52%使用固体燃料。与清洁燃料使用者相比，固体燃料使用者对主要呼吸系统疾病的校正风险比为1.36（95%CI：1.32 ～ 1.40），而从固体燃料转向清洁燃料的使用者的校正风险比为1.14（95%CI ：1.10 ～ 1.17）。使用木材的风险比高于使用煤炭[1.37（95%CI ：1.33 ～ 1.41）︰ 1.22（95%CI ：1.15 ～ 1.29）]，长期使用的风险比升高[ ≥ 40年，1.54（95%CI：1.48 ～ 1.60）︰＜ 20年， 1.32（95%CI ：1.26 ～ 1.3

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