過(guò)敏性鼻炎與哮喘青島市兒童醫(yī)院孫廣榮病例簡(jiǎn)介患兒男，4歲，17kg,鼻塞流涕3天咳喘1天來(lái)診3天前患兒始鼻塞流清涕，噴嚏不止，經(jīng)常揉鼻子搓眼睛，無(wú)發(fā)熱，1天前咳嗽，單聲痰較多，伴喘息，夜較劇，未服藥治療，今來(lái)就診。食欲欠佳，二便無(wú)異常。既往已確診為支氣管哮喘，有濕疹史PE：一般尚可，氣平，鼻粘膜蒼白水腫，見多量清涕，咽（-），心（-），雙肺野聞及少許哮鳴音，呼氣相為主，腹（-）病例簡(jiǎn)介輔助檢查：血MP-IgM（-）肺功能 pred67%診斷：支氣管哮喘急性發(fā)作過(guò)敏性鼻炎病例簡(jiǎn)介處理：開瑞坦糖漿5mlqN氨茶堿50mgq8h順爾寧4mgqN普米克氣霧劑200μgtidLink

Between

Allergic

Rhinitis

and

Asthma,

Sinusitis,

and

Otitis

MediaAllergic

rhinitis

has

important

links

to

other

chronic

diseases

that

cause

significant

morbidity,

includingasthma,

sinusitis,

and

otitismedia.

Substantial

evidence

indicates

that

allergic

rhinitis

frequently

coexists

withasthma

and

sinusitis

and

may

beapredisposing

factor

forboth.

The

allergic

response

appearsto

be

the

link

between

allergic

rhinitis

and

otitis

media.

The

timely

treatment

of

allergic

rhinitis

maybenefitthese

closelyassociated

conditions.Corren

J.

The

link

between

allergic

rhinitis

and

asthma,

otitis

media,

sinusitis,

and

nasal

polyps.

Immunol

Allergy

Clin

NorthAm.

2000;20:445-460.Fireman

P.

Otitis

media

and

eustachian

tube

dysfunction:

connection

to

allergic

rhinitis.

JAllergy

Clin

Immunol.

1997(suppl);99:S787-S797.Rachelefsky

GS.

National

guidelines

needed

to

manage

rhinitis

and

prevent

complications.

Ann

Allergy

Asthma

Immunol.

1999;82:1-10.過(guò)敏性疾病存在著共患疾病哮喘過(guò)敏性鼻炎(AR)中耳炎(OM)上呼吸道感染上呼吸道感染Si鼻nu竇si炎i炎tis細(xì)支氣管炎ContentsSlide

1

Asthma

and

Allergic

Rhinitis

Are

Both

Inflammatory

ConditionsEpidemiologic

Links

Between

Allergic

Rhinitis

and

AsthmaSlide

2

Allergic

Rhinitis

and

Asthma

Have

Similar

PrevalencePatternsSlide3

Allergic

Rhinitis

Is

a

Risk

Factor

for

AsthmaSlide

4

Most

Patients

withAsthma

Have

Allergic

RhinitisSlide

5

Patients

with

Allergic

Rhinitis

and

Asthma

Experience

Physical

and

Mental

ImpairmentSlide

6

Patients

withAllergic

Rhinitis

and

Asthma

Incur

Greater

CostsSlide

7

Treating

Allergic

Rhinitis

Decreased

Asthma-Related

Resource

UtilizationSlide

8

SummaryShared

Pathophysiology

of

Allergic

Rhinitis

and

AsthmaSlide

9

Allergic

Rhinitis

and

Asthma

Share

Common

TriggersSlide

10

Allergic

Rhinitis

and

Asthma

Sharea

Common

ImmunopathologySlide

11

Allergic

Rhinitis

and

Asthma

Have

Similar

Early-

and

Late-Phase

ResponsesSlide

12

Eosinophils

Characterize

Inflammation

in

Allergic

Rhinitis

and

AsthmaSlide

13

Allergic

Rhinitis

and

Asthma:Proposed

Interactive

MechanismsSlide

14

SummaryClinical

Links

Between

Allergic

Rhinitis

and

AsthmaSlide

15

Allergic

Rhinitis

Patients

Experience

Increased

BronchialHyperresponsiveness

inthe

Pollen

SeasonSlide

16

Allergen

Challenge

to

the

Nose

Increases

Bronchial

HyperresponsivenessSlide

17

Patients

withAsthma

Have

Nasal

InflammationSlide

18

Inflammatory

Changes

in

the

Nasal

and

Bronchial

Mucosa

Are

CorrelatedSlide

19

Bronchial

Allergen

Challenge

Increases

a

Marker

of

Inflammation

(Eosinophils)

in

Nasal

and

Bronchial

TissuesSlide

20

Bronchial

Allergen

Challenge

Increases

Systemic

Markers

of

InflammationSlide

21

Treatment

of

SeasonalAllergy

with

Nasal

Steroids

Reduced

Asthma

SymptomsSlide

22

Antileukotriene

TherapyImproves

Endpoints

in

Allergic

Rhinitis

and

AsthmaSlide

23

SummaryThe

Allergic

Rhinitis

and

its

Impact

on

Asthma

(ARIA)

InitiativeSlide

24

Aims

of

the

ARIA

InitiativeSlide

25

ARIA

Guidelines

Recommend

a

Combined

Approach

to

Managing

Upper

and

Lower

AirwaysSummarySlide

26

SummaryReferences過(guò)敏性鼻炎和哮喘：同一氣道,同一疾病變應(yīng)性鼻炎和哮喘的臨床平行關(guān)系慢性變應(yīng)性呼吸道綜合征（chronic

allergic

respiratosyndrome）在上、下呼吸道的不同表現(xiàn)如果疾病不嚴(yán)重，盡管下呼吸道的病理表現(xiàn)已經(jīng)存在，但是疾病的惟一表現(xiàn)就是鼻炎，隨著鼻炎的加重，下呼吸道的癥狀可能變得明顯一旦癥狀同時(shí)表現(xiàn)，上下呼吸道癥狀的嚴(yán)重程度平行，這種平行關(guān)系受鼻腔和下呼吸道的多種因素制約包括鼻腔對(duì)吸入空氣的溫度、濕度的調(diào)節(jié)作用，以及局部變應(yīng)性反應(yīng)與系統(tǒng)性變應(yīng)反應(yīng)雙向相互作用的表現(xiàn)變應(yīng)性鼻炎與哮喘密切相關(guān)：1998年的一項(xiàng)研究表明哮喘患者中變應(yīng)性鼻炎的發(fā)病率為78%,而哮喘在普通人群中的發(fā)病率為5~20%。哮喘患者中過(guò)敏性鼻炎的發(fā)病率敏性鼻炎的發(fā)病率%Corren

J.

J

Allergy

Clin

Immunology.

1998;

101:

S352-356

AAAAI

data.5-20%78%變應(yīng)性鼻炎與哮喘密切相關(guān)：1998年的一項(xiàng)研究表明哮喘患者中變應(yīng)性鼻炎的發(fā)病率為78%,而哮喘在普通人群中的發(fā)病率為5~20%。過(guò)敏性鼻炎患者中支氣管哮喘的發(fā)病率哮喘的發(fā)病率%Corren

J.

J

Allergy

Clin

Immunology.

1998;

101:

S352-356

AAAAI

data.3－5%38%Slide

3Allergic

rhinitis

is

an

important

risk

factor

for

asthma.

In

one

long-term

follow-up

study,

college

freshmenwith

allergic

rhinitis

were

approximatelythree

times

more

likely

to

develop

asthma

over

the

ensuing

23

years

than

individuals

without

allergic

rhinitis.

This

observed

difference

in

the

relative

risk

of

developing

asthma

was

significant

between

the

two

groups

(p<0.002).12In

fact,

allergic

rhinitis

frequently

precedes

development

of

asthma.2

One

large

population-based

study

of

11,540

adult

twin

pairs

in

Finlandshowed

that

the

diagnosis

of

“hay

fever”

was

almost

always

made

before

or

concurrently

withadiagnosis

of

asthma,

but

rarely

afterward;

hayfever

was

a

strong

predictorof

newasthma.13These

associations

may

reflect

the

shared

atopy

that

underlies

allergic

rhinitis

and

asthma,

thus

explaining,

at

least

in

part,

the

frequent

coexistenceof

these

disorders.14過(guò)敏性鼻炎能增加哮喘的危險(xiǎn)約3倍23-year

follow-up

of

college

freshmen

undergoing

allergy

testing; data

based

on

7individuals

(69%

male)

with

average

age

of

40

years.Adapted

from

Settipane

RJ

et

al

Allergy

Proc

1994;15:21-25.12108010.5過(guò)敏性鼻炎患者(n=162)3.6不罹患過(guò)敏性鼻炎的人群(n=528)P

<

0.0026展成為哮喘患者4

的百分比%2過(guò)敏性鼻炎常見癥狀鼻癢：包括鼻部和非鼻部的（眼、耳、上腭等）噴嚏鼻涕鼻塞Reference:《實(shí)用耳鼻喉科學(xué)》人民衛(wèi)生出版社1998是過(guò)敏性鼻炎還是感冒？Reference:《變態(tài)反應(yīng)并診斷治療學(xué)》北京協(xié)和醫(yī)院1998過(guò)敏性鼻炎和哮喘有相似的發(fā)病誘因鼻炎和哮喘的誘因吸入性過(guò)敏原與鼻炎和哮喘均相關(guān)室內(nèi)過(guò)敏原(塵螨等)主要引起哮喘室外過(guò)敏原(花粉等)主要引起鼻炎In

practical

terms,

a

patient

withcomplete

nasal

blockage

resulting

fromsevere

allergic

rhinitis

must

resort

to

mouthbreathing,

and

this

mayadversely

affect

the

lower

airways

because

of

a

lack

of

nasal

“air

conditioning”

and

warming,

humidification,

and

filtration

of

inspired

air.

Ref

16:

Simons,

ER.

“Allergic

rhinobronchitis:

The

asthma-allergic

rhinitis

link,”

Journal

of

Allergy

and

Clinical

Immunology1999Sep;

104(3):

534-40.

Mouth

Breathing

Caused

by

Nasal

Obstruction

worsens

exercise-induced

bronchospasm(REF

11)Study

of

9

asymptomatic

asthmatics

and

5

normal

subjects

who

inhaled

subfreezingair

througheither

nose

or

mouth

randomly,

showed

that

nasalventilation

minimizes

airwaycooling

in

both

normal

and

asthmatic

individuals

through

more

efficient

conditioning

of

inspired

air,

and

it

is

through

this

mechanismthat

this

formof

respiration

protects

against

exercise-induced

bronchospasm.

Reference

14:

Griffin

MP,

McFadden

ER

Jr,IngramRH

Jr.

“Airway

cooling

in

asthmatic

and

nonasthmatic

subjects

during

nasal

and

oral

breathing,”

Journal

of

Allergy

and

Clinical

Immunology

1982Apr;

69(4):354-9.Improvements

in

asthma

associated

with

nasal

breathing

may

be

the

result

ofsuperior

humidification

and

warming

of

inspired

air(REF

11)Similarly,

it

would

be

expected

that

airborne

allergens

and

pollutants

would

also

be

less

likely

to

enter

the

lungs

during

periods

of

normal

nasalfunction

(REF

11)Reference

11:

Corren,

J.

“The

impact

of

allergic

rhinitis

on

bronchial

asthma,”

Journal

ofAllergy

and

Clinical

Immunology

1998

Feb;

101(2

Pt

2):S352-6.哮喘和過(guò)敏性鼻炎臨床上的聯(lián)系鼻塞引起的張口呼吸加重運(yùn)動(dòng)誘導(dǎo)的支氣管收縮哮喘癥狀的改善與鼻部癥狀的改善相關(guān)，可能是由于鼻部對(duì)于吸入空氣的加溫、加濕作用的恢復(fù)Corren,

J.

“The

impact

of

allergic

rhinitis

on

bronchial

asthma,”Journal

of

Allergy

and

Clinical

Immunology

1998

Feb;

101(2

Pt

2):

S352-6.Slide

15Many

examples

of

“communication”

between

the

nose

and

lungs

link

allergic

rhinitis

and

asthma.

One

such

example

is

the

bronchialhyperresponsiveness

(BHR)

observed

in

patients

with

allergic

rhinitis.

The

prevalence

of

BHR(defined

as

PD20

<1

mg*

after

carbacholchallenge)

was

evaluated

during

and

outof

pollen

season

in

27

nonasthmatic

patients

with

hay

fever.

BHR

increased

significantly

from

11%

out

ofpollen

season

to

48%

during

pollen

season

(p<0.02).

Thus,

the

expression

of

allergic

symptoms,

even

when

confined

to

the

nose,

is

associatedwith

aspecific

bronchial

hyperactivityinthe

lungs.32*PD20

refers

to

the

provocative

dose

of

a

substance,

such

as

carbachol

in

this

study,

resulting

in

a

20%

fall

in

lung

function

(FEV1).哮喘和過(guò)敏性鼻炎臨床上的聯(lián)系平均年齡20歲的枯草熱患者;激發(fā)試驗(yàn)在秋季以及季節(jié)后6個(gè)月進(jìn)行*激發(fā)劑量<1

mg引起FEV

20%下降A(chǔ)dapted

from

Madonini

E

et

al

J

Allergy

Clin

Immunol

1987;79:358-363.6050403020100病人%(n=27)11非花粉季節(jié)

花粉季節(jié)48p<0.02過(guò)敏性鼻炎的患者在花粉季節(jié)會(huì)有更多的氣道高反應(yīng)氣道高反應(yīng)的發(fā)生率*Slide

17In

a

recent

study

of

27

non-atopic

patients,

eosinophil

counts

in

nasal

biopsyspecimens

from

asthmatic

patients

(with

or

without

rhinitissymptoms)

were

consistently

and

significantly

greater

than

those

in

normal

controls

(p<0.001).

Of

the

27

subjects

who

participated,

nine

patientshad

both

asthma

and

allergic

rhinitis,

eight