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Bronchial asthmaDepartment of respirationKong Lingfei Asthma：human killer!Background of asthma Prevalence：in the world:in the world:1.6 1.6 hundred millionhundred million in China:in China:1 13 3 in in ShenyangShenyang:1.24:1.24（19991999）GINA:GINA:G Global lobal InInitiative for itiative for A Asthmasthma（19941994）WHO/HLBIWHO/HLBI Bronchial asthmatic diagnosis guideline(Bronchial asthmatic diagnosis guideline(19971997）Chinese Medical Academy Chinese Medical Academy Definitions of asthmaChronic airway inflammationBroncho-hyperresponsiveness,BHRAirflow limitationMechanism:allergy theory antigen antigen again atopyIgE antibodymast cells,basophils histamine inflammatory media LTs PAF ECP immediate asthmatic reaction,IAR bronchial smooth muscle spasm airway narrowMechanism:never-receptor disorder theory adrenergic and cholinergic nerous systems,AC non-adrenergic and non-cholinergic nerous systems,NANC AC:1-receptor、M1-、M3-receptors excitement NANC：PS-receptor bronchial smooth muscle contraction AC:-receptor、M2-receptor excitement NANC:VIP receptor bronchial smooth muscle dilation asthmatic airway:a1、M1、M3、PS/、M2、VIP Mechanism:airway inflammation theory antigen allergic airway inflammation,AAI ECP MBP inflammatory cells inflammatory media LTs EOS PAF neutrophils late asthmatic reaction,LAR T lymphocyte(Th1/Th2)Th2 cytokine IL-3、4、5，GM-CSF IgEacuteacuteinflammationinflammationchronicchronicinflammationinflammationairwayairwayremodellingremodellinginflammation cells epithelium injury bronchial contractionmucous edemaairway secretionairway narrowBHRairway reversibilitysymptomsexacerbationcell proliferationexcellular baseDiffer mechanisms in acute and chronic asthmaDiffer mechanisms in acute and chronic asthmaOther mechanisms:induced factors Allergen:pollen,acarusinfection:virus or mycoplasmal infectionclimate and physical and chemical factors drugs:aspirin induced asthma,AIA -receptor inhibitorheredityGastroesophageal reflux disease,GERDPsychological,incretion factors,sportsDiagnosis standards of asthmasymptomssignsrecovered waysexcept other cardiac and pulmonary diseaseslung function examinationuntypical asthma Untypical asthmaCough variant asthma,CAVAsthma with gastroesphgeal reflux Exercise induced asthma,EIADrug induced asthma,DIAOccupational asthma,OALung functions diagnosis of asthmaObstructive ventilation insufficiency and reversibility of airway obstructionVariance rate of peak expired flow(PEF)in 24 hours 20%Bronchial challenge is positiveLung functions diagnosis of asthma(1)FEVFEV1 1 80%80%pre,FEVpre,FEV1 1/FVC%70%/FVC%70%bronchial dilation test is positivebronchial dilation test is positive Post FEVPost FEV1 1-Pre FEV-Pre FEV1 1FEVFEV1 1improved rate improved rate 100%100%Pre FEV Pre FEV1 1determinant standard:FEVdeterminant standard:FEV1 1 improved rateimproved rate1515(+)(+)FEVFEV1 1 improved rateimproved rate200200mlmlLung functions diagnosis of asthma(2)PEF meter PEF predicted value Lung functions diagnosis of asthma(2)PEF PEF 8080pre and PEF variance rate pre and PEF variance rate 2020 PEF max PEF minPEF max PEF minPEF variance ratePEF variance rate 100%100%1/2(1/2(PEF max+PEF min)PEF max+PEF min)Determinant standardDeterminant standard：PEF variance rate(24h)PEF variance rate(24h)20%(+)20%(+)Lung functions diagnosis of asthma(3)Bronchial challenge is positivetherapeutic propertiesforbid propertiesmethods drug induce:methocholiner histamine exercise induce The steps of chronic persistent asthma分级分级 分度分度 喘息发作喘息发作 夜间发作夜间发作 日常活动日常活动 FEV1 PEF变异率变异率 或或PEF1 间歇发作间歇发作 1次次/w 2次次/m 不受限不受限 80%2次次/m 发作时受限发作时受限 80%20%3 1次次/w 发作时受限发作时受限 6080%2030%54 重度持续重度持续 症状持续症状持续 频繁频繁 受限受限 30%The steps of acute exacerbation asthmaThe steps of acute exacerbation asthma临床特点临床特点临床特点临床特点 轻度轻度轻度轻度 中度中度中度中度 重度重度重度重度 危重度危重度危重度危重度 气短气短气短气短 步行步行步行步行,上楼时上楼时上楼时上楼时 稍活动稍活动稍活动稍活动 休息时休息时休息时休息时体位体位体位体位 可平卧可平卧可平卧可平卧 喜坐位喜坐位喜坐位喜坐位 前弓位前弓位前弓位前弓位谈话方式谈话方式谈话方式谈话方式 连续成句连续成句连续成句连续成句 字段字段字段字段 单词单词单词单词 不能讲话不能讲话不能讲话不能讲话精神状态精神状态精神状态精神状态 尚安静尚安静尚安静尚安静 时焦虑烦躁时焦虑烦躁时焦虑烦躁时焦虑烦躁 常焦虑烦躁常焦虑烦躁常焦虑烦躁常焦虑烦躁 嗜睡嗜睡嗜睡嗜睡,意识障碍意识障碍意识障碍意识障碍出汗出汗出汗出汗 无无无无 有有有有 大汗淋漓大汗淋漓大汗淋漓大汗淋漓呼吸频率呼吸频率呼吸频率呼吸频率 轻度增加轻度增加轻度增加轻度增加 增加增加增加增加 30 30次次次次/分分分分三凹征三凹征三凹征三凹征 常无常无常无常无 可有可有可有可有 常有常有常有常有 胸腹矛盾运动胸腹矛盾运动胸腹矛盾运动胸腹矛盾运动喘鸣音喘鸣音喘鸣音喘鸣音 呼吸末期散在呼吸末期散在呼吸末期散在呼吸末期散在 响亮弥漫响亮弥漫响亮弥漫响亮弥漫 响亮弥漫响亮弥漫响亮弥漫响亮弥漫 减弱或无减弱或无减弱或无减弱或无脉率脉率脉率脉率 100 120 120次次次次/分分分分 120 120次次次次/次次次次,不规则不规则不规则不规则奇脉奇脉奇脉奇脉 无无无无,10,25,25mmHg mmHg 无无无无,呼衰呼衰呼衰呼衰用用用用 2 2后后后后PEF 70%50PEF 70%5070%50%70%50%或或或或100100L/min L/min PaOPaO2 2 正常正常正常正常 60 608080mmHg 60mmHgmmHg 60mmHgPaCOPaCO22 45mmHg 45mmHg SaOSaO2 2 95%91 95%9195%90%95%90%pH pH 降低降低降低降低 Distinguishing diagnosis of asthmaCardiac asthmaCOPDUpper airway obstruction(lung cancer)Pulmonary eosiniphil infiltrationCorrelation between asthma and COPDDiscrimination between asthma and COPDDiscrimination between asthma and COPD Asthma COPDAsthma COPD症状症状症状症状喘息喘息喘息喘息咳嗽痰咳嗽痰咳嗽痰咳嗽痰呼吸困难呼吸困难呼吸困难呼吸困难(休息或运动休息或运动休息或运动休息或运动)呼吸困难呼吸困难呼吸困难呼吸困难(伴随运动伴随运动伴随运动伴随运动)胸闷胸闷胸闷胸闷喘息喘息喘息喘息咳嗽咳嗽咳嗽咳嗽胸闷胸闷胸闷胸闷经常出现夜间症状经常出现夜间症状经常出现夜间症状经常出现夜间症状很少夜间症状很少夜间症状很少夜间症状很少夜间症状吸烟史吸烟史吸烟史吸烟史部分病人部分病人部分病人部分病人大多数病人大多数病人大多数病人大多数病人肺功能肺功能肺功能肺功能可逆性好可逆性好可逆性好可逆性好可逆性差可逆性差可逆性差可逆性差激发试验激发试验激发试验激发试验阳性阳性阳性阳性经常阴性经常阴性经常阴性经常阴性运动后运动后运动后运动后支气管收缩支气管收缩支气管收缩支气管收缩无支气管收缩无支气管收缩无支气管收缩无支气管收缩Drugs for treating asthmaGlucocorticosteroid anti-inflammation 2-agonisttheophylline bronchodilatorsanticholinergic drugnon-steroid anti-inflammationsSteroids with vein injectionmethylprednisonlone 40 4 11-hydroxide 40320Hydrocortison 100 20 11-ketone 1001000dexamethason 5 0.75 11-ketone 1030 steroid dose =dose character dose/d (mg)(mg)(mg)Inhaled steroidsBaclomethason dipropionate 必可酮必可酮(BDP)50ug200 Budesonide 普米克普米克(BUD)100ug 100 普米克普米克 都保都保 普米克令舒普米克令舒 1mg/2mlFluticasone propionate 辅舒酮辅舒酮(FP)125ug 100Fluticasone+Salmeterol 舒利迭舒利迭 100/50ug60 250/50ug60 Using principles of inhaler steroidUsing principles of inhaler steroid 非急性发作期哮喘长期预防用药首选非急性发作期哮喘长期预防用药首选非急性发作期哮喘长期预防用药首选非急性发作期哮喘长期预防用药首选 替代口服激素替代口服激素替代口服激素替代口服激素 季节性哮喘季节发作前二周应用季节性哮喘季节发作前二周应用季节性哮喘季节发作前二周应用季节性哮喘季节发作前二周应用 急性发作期与急性发作期与急性发作期与急性发作期与2-2-2-2-激动剂伍用激动剂伍用激动剂伍用激动剂伍用 长期预防可联合用药长期预防可联合用药长期预防可联合用药长期预防可联合用药Inhaled 2-agonistsSalbutamol 万托林万托林 200ug200 万托林雾化溶液万托林雾化溶液 0.05%20mlTerbutaline 喘康速喘康速 250ug200 博利康尼都保博利康尼都保 250ug100 博利康尼雾化溶液博利康尼雾化溶液 5mg/mlSalmeterol 施立稳施立稳 50ug200 施立碟施立碟 50ug48Formoterol 奥克斯都保奥克斯都保 4.5ug60Oral2-agonistsTerbutaline 博利康尼博利康尼 2.5mgProcaterol 美喘清美喘清 50ugFormoterol 安通克安通克 40ugSalbutemol 全特宁全特宁 8mgBambuterol 帮备帮备 4mgClassification of Classification of 2 2-agonstsagonsts(PolitiekPolitiek)3 3类类起效慢起效慢 作用时间短作用时间短口服型特布他林口服型特布他林口服型沙丁胺醇口服型沙丁胺醇口服型福美特罗口服型福美特罗2 2类类起效缓慢起效缓慢 作用时间长作用时间长吸入型沙美特罗吸入型沙美特罗口服型班布特罗口服型班布特罗4 4类类起效快起效快 作用时间短作用时间短吸入型特布他林吸入型特布他林吸入型沙丁胺醇吸入型沙丁胺醇1 1类类起效快起效快 作用时间长作用时间长吸入型福美特吸入型福美特罗罗起效时间起效时间起效时间起效时间快快快快慢慢慢慢 短短短短 长长长长 作用维持时间作用维持时间作用维持时间作用维持时间快速缓解快速缓解快速缓解快速缓解维维维维持持持持治治治治疗疗疗疗PolitiekPolitiek,et al.,et al.Eur Respir Eur Respir J 1999,13:988J 1999,13:988Using principles ofUsing principles of2 2-agonistagonist 急性发作期快速缓解哮喘症状急性发作期快速缓解哮喘症状急性发作期快速缓解哮喘症状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与吸入激素伍用可规律使用一周与吸入激素伍用可规律使用一周与吸入激素伍用可规律使用一周 缓解期按需使用缓解期按需使用缓解期按需使用缓解期按需使用,用药次数用药次数用药次数用药次数4441000(1000 g g BDPBDP或等剂量或等剂量)或吸入激素或吸入激素(500-1000(500-1000 g BDPg BDP或等剂量或等剂量)加上白三烯调节剂加上白三烯调节剂long therapy projects of asthma GINA 2002严重度严重度Step4重度持续重度持续每日用药每日用药吸入激素吸入激素(1000(1000 g BDPg BDP或等剂量或等剂量)加上长效吸入加上长效吸入型型 2-2-受体激动剂受体激动剂根据病情需要，加用以根据病情需要，加用以下一种或几种药物下一种或几种药物缓释茶碱缓释茶碱白三烯调节剂白三烯调节剂长效口服长效口服 2-2-受体激动剂受体激动剂口服激素口服激素其他选择方案其他选择方案long therapy projects of asthma GINA 2002Combined therapyinhaler steroid of double dose+inhaler long active 2 2-agonist(LABA)+long active theophylline+LTs receptor inhibitorexacerbationLow dose inhaler steroid(400 g/d)Barnes,Nice 2001
