Bronchialasthma

Asthma：humankiller!BackgroundofasthmaPrevalence：intheworld:1.6hundredmillioninChina:1～3％inShenyang:1.24％〔1999〕GINA:GlobalInitiativeforAsthma〔1994〕WHO/HLBIBronchialasthmaticdiagnosisguideline(1997〕ChineseMedicalAcademyDefinitionsofasthmaChronicairwayinflammationBroncho-hyperresponsiveness,BHRAirflowlimitationMechanism:allergytheory

antigenantigen↓↓againatopy→IgEantibody→mastcells,basophils↓histamineinflammatorymediaLTs↓PAFECPimmediateasthmaticreaction,IAR↓bronchialsmoothmusclespasmairwaynarrowMechanism:never-receptordisordertheoryadrenergicandcholinergicneroussystems,ACnon-adrenergicandnon-cholinergicneroussystems,NANCAC:α1-receptor、M1-、M3-receptorsexcitementNANC：PS-receptor↓bronchialsmoothmusclecontractionAC:β-receptor、M2-receptorexcitementNANC:VIPreceptor↓bronchialsmoothmuscledilation

asthmaticairway:a1、M1、M3、PS↑/β、M2、VIP↓

Mechanism:airwayinflammationtheoryantigen↓allergicairwayinflammation,AAIECP↑MBPinflammatorycells→inflammatorymediaLTsEOS↓PAFneutrophilslateasthmaticreaction,LARTlymphocyte(Th1/Th2↓)↓Th2cytokineIL-3、4、5，GM-CSF→IgE↑acuteinflammationchronicinflammationairwayremodellinginflammationcells↑epitheliuminjury

bronchialcontractionmucousedemaairwaysecretion↑airwaynarrowBHR↑airwayreversibility↓symptomsexacerbationcellproliferationexcellularbase↑DiffermechanismsinacuteandchronicasthmaOthermechanisms:inducedfactors

Allergen:pollen,acarusinfection:virusormycoplasmalinfectionclimateandphysicalandchemicalfactorsdrugs:aspirininducedasthma,AIAβ-receptorinhibitorheredityGastroesophagealrefluxdisease,GERDPsychological,incretionfactors,sports

Diagnosisstandardsofasthmasymptomssignsrecoveredwaysexceptothercardiacandpulmonarydiseaseslungfunctionexamination→untypicalasthmaUntypicalasthmaCoughvariantasthma,CAVAsthmawithgastroesphgealrefluxExerciseinducedasthma,EIADruginducedasthma,DIAOccupationalasthma,OALungfunctionsdiagnosisofasthmaObstructiveventilationinsufficiencyandreversibilityofairwayobstructionVariancerateofpeakexpiredflow(PEF)in24hours≥20%BronchialchallengeispositiveLungfunctionsdiagnosisofasthma(1)

FEV1<80%pre,FEV1/FVC%<70%

bronchialdilationtestispositive

PostFEV1-PreFEV1FEV1improvedrate＝×100%PreFEV1determinantstandard:FEV1improvedrate≥15％(+)

FEV1improvedrate≥200mlLungfunctionsdiagnosisofasthma(2)PEFmeter

PEFpredictedvalue

Lungfunctionsdiagnosisofasthma(2)PEF<80％preandPEFvariancerate≥20％

PEFmax–PEFminPEFvariancerate＝×100%1/2(PEFmax+PEFmin)Determinantstandard：PEFvariancerate(24h)≥20%(+)Lungfunctionsdiagnosisofasthma(3)Bronchialchallengeispositivetherapeuticpropertiesforbidpropertiesmethodsdruginduce:methocholinerhistamineexerciseinduce

Thestepsofchronicpersistentasthma分級分度喘息發(fā)作夜間發(fā)作日?；顒樱EV1PEF變異率或％PEF1間歇發(fā)作<1次/w≤2次/m不受限≥80%<20%輕度持續(xù)≥1次/w>2次/m發(fā)作時(shí)受限>80%<20%<1次/d3中度持續(xù)每日有病癥>1次/w發(fā)作時(shí)受限60～80%20～30%4重度持續(xù)病癥持續(xù)頻繁受限<60%>30%Thestepsofacuteexacerbationasthma臨床特點(diǎn)輕度中度重度危重度氣短步行,上樓時(shí)稍活動休息時(shí)體位可平臥喜坐位前弓位談話方式連續(xù)成句字段單詞不能講話精神狀態(tài)尚安靜時(shí)焦慮煩躁常焦慮煩躁嗜睡,意識障礙出汗無有大汗淋漓呼吸頻率輕度增加增加>30次/分三凹征常無可有常有胸腹矛盾運(yùn)動喘鳴音呼吸末期散在響亮彌漫響亮彌漫減弱或無脈率<100次/分100～200次/分>120次/分<120次/次,不規(guī)那么奇脈無,<10mmHg有,10-25mmHg常有,>25mmHg無,呼衰用β2后％PEF>70%50～70%<50%或<100L/minPaO2正常60～80mmHg<60mmHgPaCO2<40mmHg≤45mmHg>45mmHgSaO2>95%91～95%≤90%pH降低

DistinguishingdiagnosisofasthmaCardiacasthmaCOPDUpperairwayobstruction(lungcancer)Pulmonaryeosiniphilinfiltration

CorrelationbetweenasthmaandCOPDDiscriminationbetweenasthmaandCOPDAsthmaCOPD病癥 喘息 咳嗽＋痰 呼吸困難(休息或運(yùn)動) 呼吸困難(伴隨運(yùn)動) 胸悶 喘息 咳嗽 胸悶 經(jīng)常出現(xiàn)夜間病癥 很少夜間病癥吸煙史 局部病人 大多數(shù)病人肺功能 可逆性好 可逆性差激發(fā)試驗(yàn) 陽性 經(jīng)常陰性運(yùn)動后 支氣管收縮 無支氣管收縮DrugsfortreatingasthmaGlucocorticosteroid－anti-inflammationβ

2-agonisttheophyllinebronchodilatorsanticholinergicdrugnon-steroidanti-inflammationsSteroidswithveininjectionmethylprednisonlone40411-hydroxide40～320Hydrocortison1002011-ketone100～1000dexamethason50.7511-ketone10～30

steroiddose=dosecharacterdose/d(mg)(mg)(mg)InhaledsteroidsBaclomethasondipropionate必可酮(BDP)50ug×200Budesonide普米克(BUD)100ug×100普米克都保

普米克令舒1mg/2mlFluticasonepropionate輔舒酮(FP)125ug×100Fluticasone+Salmeterol舒利迭100/50ug×60250/50ug×60

Usingprinciplesofinhalersteroid非急性發(fā)作期哮喘長期預(yù)防用藥首選替代口服激素季節(jié)性哮喘季節(jié)發(fā)作前二周應(yīng)用急性發(fā)作期與β2-沖動劑伍用長期預(yù)防可聯(lián)合用藥Inhaledβ2-agonistsSalbutamol萬托林200ug×200萬托林霧化溶液0.05%20mlTerbutaline喘康速250ug×200博利康尼都保250ug×100博利康尼霧化溶液5mg/mlSalmeterol施立穩(wěn)50ug×200施立碟50ug×4×8Formoterol奧克斯都保4.5ug×60Oralβ2-agonistsTerbutaline博利康尼2.5mgProcaterol美喘清50ugFormoterol安通克40ugSalbutemol全特寧8mgBambuterol幫備4mgClassificationofβ2-agonsts(Politiek)2類起效緩慢作用時(shí)間長吸入型沙美特羅口服型班布特羅1類起效快作用時(shí)間長吸入型福美特羅起效時(shí)間快慢

短長

作用維持時(shí)間快速緩解維持治療Politiek,etal.EurRespirJ1999,13:988Usingprinciplesofβ2-agonist急性發(fā)作期快速緩解哮喘病癥與吸入激素伍用可規(guī)律使用一周緩解期按需使用,用藥次數(shù)<4次/日運(yùn)動性哮喘運(yùn)動前預(yù)防性吸入夜間哮喘選用長效制劑Theophyllineiv：aminophylline0.25doxofylline0.1po:aminophylline0.1shortactionAEA舒氟美0.1longaction葆樂輝0.4Usingprinciplesoftheophylline應(yīng)用前了解近期茶堿用藥史與西咪替丁、喹諾酮類、大環(huán)內(nèi)酯類藥物合并應(yīng)用時(shí)茶堿減量肝腎功能不全、心衰、妊娠、老年人減量急性發(fā)作期靜脈應(yīng)用(治療窗:10～20ug/ml)長期治療用長效制劑(治療窗:5～10ug/ml)夜間哮喘適用長效茶堿Anti-cholinergicdrugIpratropiumbromide愛全樂20ug×200

愛全樂水溶液20mlIpratropiumbromide可必特20ug×200＋Salbutamol可必特2mlUsingprinciplesofanti-cholinergicdrug適用于COPD合并哮喘適用于老年人有器質(zhì)性心臟疾病者適用于夜間哮喘復(fù)合制劑適用于快速持續(xù)緩解哮喘病癥水溶液霧化吸入適用于哮喘急性重癥發(fā)作Non-steroidanti-inflammationdrugsAnti-histamine：inhaler：色甘酸鈉5mg×200oral：酮替酚、曲尼斯特息思敏、開瑞坦等LTsreceptorinhibitor：順爾寧10mg×5

Usingprinciplesofotheranti-inflammationDrugtherapyofasthma

快速緩解藥物長期預(yù)防藥物短效吸入β2-沖動劑吸入抗膽堿藥短效口服β2-沖動劑全身性糖皮質(zhì)激素短效茶堿吸入型糖皮質(zhì)激素長效吸入