哮喘(英文)

BronchialasthmaDepartmentofrespirationKongLingfeiAsthma：humankiller!BackgroundofasthmaPrevalence：intheworld:1.6hundredmillioninChina:1～3％inShenyang:1.24％（1999）GINA:GlobalInitiativeforAsthma（1994）WHO/HLBIBronchialasthmaticdiagnosisguideline(1997）ChineseMedicalAcademyDefinitionsofasthma•Chronicairwayinflammation•Broncho-hyperresponsiveness,BHR•AirflowlimitationMechanism:allergytheoryantigenantigen↓↓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↓bronchialsmoothmuscledilationasthmaticairway: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↑epitheliuminjurybronchialcontractionmucousedemaairwaysecretion↑airwaynarrowBHR↑airwayreversibility↓symptomsexacerbationcellproliferationexcellularbase↑DiffermechanismsinacuteandchronicasthmaOthermechanisms:inducedfactors•Allergen:pollen,acarus•infection:virusormycoplasmalinfection•climateandphysicalandchemicalfactors•drugs:aspirininducedasthma,AIAβ-receptorinhibitor•heredity•Gastroesophagealrefluxdisease,GERD•Psychological,incretionfactors,sportsDiagnosisstandardsofasthma•symptoms•signs•recoveredways•exceptothercardiacandpulmonarydiseases•lungfunctionexamination→untypicalasthmaUntypicalasthma•Coughvariantasthma,CAV•Asthmawithgastroesphgealreflux•Exerciseinducedasthma,EIA•Druginducedasthma,DIA•Occupationalasthma,OALungfunctionsdiagnosisofasthma•Obstructiveventilationinsufficiencyandreversibilityofairwayobstruction•Variancerateofpeakexpiredflow(PEF)in24hours≥20%•BronchialchallengeispositiveLungfunctionsdiagnosisofasthma(1)FEV180%pre,FEV1/FVC%70%bronchialdilationtestispositivePostFEV1-PreFEV1FEV1improvedrate＝×100%PreFEV1determinantstandard:FEV1improvedrate≥15％(+)FEV1improvedrate≥200mlLungfunctionsdiagnosisofasthma(2)PEFmeterPEFpredictedvalueLungfunctionsdiagnosisofasthma(2)PEF80％preandPEFvariancerate≥20％PEFmax–PEFminPEFvariancerate＝×100%1/2(PEFmax+PEFmin)Determinantstandard：PEFvariancerate(24h)≥20%(+)Lungfunctionsdiagnosisofasthma(3)Bronchialchallengeispositive•therapeuticproperties•forbidproperties•methodsdruginduce:methocholinerhistamineexerciseinduceThestepsofchronicpersistentasthma分级分度喘息发作夜间发作日常活动％FEV1PEF变异率或％PEF1间歇发作1次/w≤2次/m不受限≥80%20%2轻度持续≥1次/w2次/m发作时受限80%20%1次/d3中度持续每日有症状1次/w发作时受限60～80%20～30%4重度持续症状持续频繁受限60%30%Thestepsofacuteexacerbationasthma临床特点轻度中度重度危重度气短步行,上楼时稍活动休息时体位可平卧喜坐位前弓位谈话方式连续成句字段单词不能讲话精神状态尚安静时焦虑烦躁常焦虑烦躁嗜睡,意识障碍出汗无有大汗淋漓呼吸频率轻度增加增加30次/分三凹征常无可有常有胸腹矛盾运动喘鸣音呼吸末期散在响亮弥漫响亮弥漫减弱或无脉率100次/分100～200次/分120次/分120次/次,不规则奇脉无,10mmHg有,10-25mmHg常有,25mmHg无,呼衰用β2后％PEF70%50～70%50%或100L/minPaO2正常60～80mmHg60mmHgPaCO240mmHg≤45mmHg45mmHgSaO295%91～95%≤90%pH降低Distinguishingdiagnosisofasthma•Cardiacasthma•COPD•Upperairwayobstruction(lungcancer)•PulmonaryeosiniphilinfiltrationCorrelationbetweenasthmaandCOPDDiscriminationbetweenasthmaandCOPDAsthmaCOPD症状喘息咳嗽＋痰呼吸困难(休息或运动)呼吸困难(伴随运动)胸闷喘息咳嗽胸闷经常出现夜间症状很少夜间症状吸烟史部分病人大多数病人肺功能可逆性好可逆性差激发试验阳性经常阴性运动后支气管收缩无支气管收缩Drugsfortreatingasthma•Glucocorticosteroid－anti-inflammation•β2-agonist•theophyllinebronchodilators•anticholinergicdrug•non-steroidanti-inflammationsSteroidswithveininjectionmethylprednisonlone40411-hydroxide40～320Hydrocortison1002011-ketone100～1000dexamethason50.7511-ketone10～30steroiddose=dosecharacterdose/d(mg)(mg)(mg)Inhaledsteroids•Baclomethasondipropionate必可酮(BDP)50ug×200•Budesonide普米克(BUD)100ug×100普米克都保普米克令舒1mg/2ml•Fluticasonepropionate辅舒酮(FP)125ug×100•Fluticasone+Salmeterol舒利迭100/50ug×60250/50ug×60Usingprinciplesofinhalersteroid•非急性发作期哮喘长期预防用药首选•替代口服激素•季节性哮喘季节发作前二周应用•急性发作期与β2-激动剂伍用•长期预防可联合用药Inhaledβ2-agonists•Salbutamol万托林200ug×200万托林雾化溶液0.05%20ml•Terbutaline喘康速250ug×200博利康尼都保250ug×100博利康尼雾化溶液5mg/ml•Salmeterol施立稳50ug×200施立碟50ug×4×8•Formoterol奥克斯都保4.5ug×60Oralβ2-agonists•Terbutaline博利康尼2.5mg•Procaterol美喘清50ug•Formoterol安通克40ug•Salbutemol全特宁8mg•Bambuterol帮备4mgClassificationofβ2-agonsts(Politiek)3类起效慢作用时间短口服型特布他林口服型沙丁胺醇口服型福美特罗2类起效缓慢作用时间长吸入型沙美特罗口服型班布特罗4类起效快作用时间短吸入型特布他林吸入型沙丁胺醇1类起效快作用时间长吸入型福美特罗起效时间快慢短长作用维持时间快速缓解维持治疗Politiek,etal.EurRespirJ1999,13:988Usingprinciplesofβ2-agonist•急性发作期快速缓解哮喘症状•与吸入激素伍用可规律使用一周•缓解期按需使用,用药次数4次/日•运动性哮喘运动前预防性吸入•夜间哮喘选用长效制剂Theophylline•iv：aminophylline0.25doxofylline0.1•po:aminophylline0.1shortactionAEA舒氟美0.1longaction葆乐辉0.4Usingprinciplesoftheophylline•应用前了解近期茶碱用药史•与西咪替丁、喹诺酮类、大环内酯类药物合并应用时茶碱减量•肝肾功能不全、心衰、妊娠、老年人减量•急性发作期静脉应用(治疗窗:10～20ug/ml)•长期治疗用长效制剂(治疗窗:5～10ug/ml)•夜间哮喘适用长效茶碱Anti-cholinergicdrug•Ipratropiumbromide爱全乐20ug×200爱全乐水溶液20ml•Ipratropiumbromide可必特20ug×200＋Salbutamol可必特2mlUsingprincipl