支氣管哮喘-英文版課件

1、Bronchial asthmaDepartment of respirationKong Lingfei Asthma：human killer!Background of asthma Prevalence ：in the world: 1.6 hundred million in China: 13 in Shenyang: 1.24 （1999） GINA: Global Initiative for Asthma（1994） WHO/HLBI Bronchial asthmatic diagnosis guideline (1997） Chinese Medical Academy

2、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 nar

3、rowMechanism: 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 b

4、ronchial 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

5、 IgEacuteinflammationchronicinflammationairwayremodellinginflammation cells epithelium injury bronchial contractionmucous edemaairway secretionairway narrowBHRairway reversibilitysymptomsexacerbationcell proliferationexcellular baseDiffer mechanisms in acute and chronic asthmaOther mechanisms: induc

6、ed 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 asthmasymptomssignsr

7、ecovered 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 ventil

8、ation 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) FEV1 80 % pre, FEV1/FVC% 70 % bronchial dilation test is positive Post FEV1 - Pre FEV1FEV1improved rate 100% Pre FEV

9、1determinant standard:FEV1 improved rate15(+) FEV1 improved rate200mlLung functions diagnosis of asthma(2) PEF meter PEF predicted value Lung functions diagnosis of asthma(2)PEF 80pre and PEF variance rate 20 PEF max PEF minPEF variance rate 100% 1/2( PEF max + PEF min )Determinant standard：PEF vari

10、ance rate(24h) 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分級(jí) 分度 喘息發(fā)作 夜間發(fā)作 日?；顒?dòng) FEV1 PEF變異率 或PEF1 間歇發(fā)作 1次/w 2次/m 不受限 80% 2次/m 發(fā)作時(shí)受限

11、 80% 20% 1次/w 發(fā)作時(shí)受限 6080% 2030%4 重度持續(xù) 癥狀持續(xù) 頻繁 受限 30% The steps of acute exacerbation asthma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(dòng) 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(shí)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(dòng)喘鳴音 呼吸末期散在 響亮彌漫 響亮彌漫 減弱或無脈率 120次/分 120次/次,不規(guī)則奇脈 無,25mmHg 無,呼衰用2后

12、PEF 70% 5070% 50%或100L/min PaO2 正常 6080mmHg 60mmHgPaCO2 45mmHg SaO2 95% 9195% 90%pH 降低 Distinguishing diagnosis of asthmaCardiac asthmaCOPDUpper airway obstruction (lung cancer)Pulmonary eosiniphil infiltrationCorrelation between asthma and COPDDiscrimination between asthma and COPD Asthma COPD癥狀喘息咳

13、嗽痰呼吸困難(休息或運(yùn)動(dòng))呼吸困難(伴隨運(yùn)動(dòng))胸悶喘息咳嗽胸悶經(jīng)常出現(xiàn)夜間癥狀很少夜間癥狀吸煙史部分病人大多數(shù)病人肺功能可逆性好可逆性差激發(fā)試驗(yàn)陽(yáng)性經(jīng)常陰性運(yùn)動(dòng)后支氣管收縮無支氣管收縮Drugs for treating asthmaGlucocorticosteroid anti-inflammation 2-agonisttheophylline bronchodilatorsanticholinergic drugnon-steroid anti-inflammationsSteroids with vein injectionmethylprednisonlone 40 4 11-hy

14、droxide 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(BDP) 50ug200 Budesonide 普米克(BUD) 100ug 100 普米克 都保 普米克令舒 1mg/2mlFluticasone propionate 輔舒酮(FP) 125ug 100Fluticasone +

15、Salmeterol 舒利迭 100/50ug60 250/50ug60 Using principles of inhaler steroid非急性發(fā)作期哮喘長(zhǎng)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2-激動(dòng)劑伍用長(zhǎng)期預(yù)防可聯(lián)合用藥Inhaled 2- agonistsSalbutamol 萬托林 200ug200 萬托林霧化溶液 0.05% 20mlTerbutaline 喘康速 250ug200 博利康尼都保 250ug100 博利康尼霧化溶液 5mg/mlSalmeterol 施立穩(wěn) 50ug200 施立碟 50ug48Formoterol 奧克斯都保 4.5

16、ug60Oral2- agonistsTerbutaline 博利康尼 2.5mgProcaterol 美喘清 50ugFormoterol 安通克 40ugSalbutemol 全特寧 8mgBambuterol 幫備 4mgClassification of 2-agonsts (Politiek)3類起效慢 作用時(shí)間短口服型特布他林口服型沙丁胺醇口服型福美特羅2類起效緩慢 作用時(shí)間長(zhǎng)吸入型沙美特羅口服型班布特羅4類起效快 作用時(shí)間短吸入型特布他林吸入型沙丁胺醇1類起效快 作用時(shí)間長(zhǎng)吸入型福美特羅起效時(shí)間快慢 短 長(zhǎng) 作用維持時(shí)間快速緩解維持治療Politiek, et al.Eur Respir J 1999, 13: 988Using principles of2-agonist急性發(fā)作期快速緩解哮喘癥狀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)1000g BDP或等劑量)或吸入激素(500-1000g BDP或等劑量)加上白三烯調(diào)節(jié)劑long therapy projects of asthma GINA 2002嚴(yán)重度Step4重度持續(xù)每日用藥吸入激素(1000g BDP或等劑量)加上長(zhǎng)效吸入型2-受體激動(dòng)劑根據(jù)病情需要，加