哮喘(英文)ppt课件.ppt

Bronchialasthma DepartmentofrespirationKongLingfei Asthma humankiller Backgroundofasthma Prevalence intheworld 1 6hundredmillioninChina 1 3 inShenyang 1 24 1999 GINA GlobalInitiativeforAsthma 1994 WHO HLBIBronchialasthmaticdiagnosisguideline 1997 ChineseMedicalAcademy Definitionsofasthma ChronicairwayinflammationBroncho hyperresponsiveness BHRAirflowlimitation Mechanism allergytheory antigenantigen againatopy IgEantibody mastcells basophils histamineinflammatorymediaLTs PAFECPimmediateasthmaticreaction IAR bronchialsmoothmusclespasmairwaynarrow Mechanism never receptordisordertheory adrenergicandcholinergicneroussystems ACnon adrenergicandnon cholinergicneroussystems NANCAC 1 receptor M1 M3 receptorsexcitementNANC PS receptor bronchialsmoothmusclecontractionAC receptor M2 receptorexcitementNANC VIPreceptor bronchialsmoothmuscledilationasthmaticairway a1 M1 M3 PS M2 VIP Mechanism airwayinflammationtheory antigen allergicairwayinflammation AAIECP MBPinflammatorycells inflammatorymediaLTsEOS PAFneutrophilslateasthmaticreaction LARTlymphocyte Th1 Th2 Th2cytokineIL 3 4 5 GM CSF IgE inflammationcells epitheliuminjury bronchialcontractionmucousedemaairwaysecretion airwaynarrow BHR airwayreversibility symptoms exacerbation cellproliferationexcellularbase Differmechanismsinacuteandchronicasthma Othermechanisms inducedfactors Allergen pollen acarusinfection virusormycoplasmalinfectionclimateandphysicalandchemicalfactorsdrugs aspirininducedasthma AIA receptorinhibitorheredityGastroesophagealrefluxdisease GERDPsychological incretionfactors sports Diagnosisstandardsofasthma symptomssignsrecoveredwaysexceptothercardiacandpulmonarydiseaseslungfunctionexamination untypicalasthma Untypicalasthma Coughvariantasthma CAVAsthmawithgastroesphgealrefluxExerciseinducedasthma EIADruginducedasthma DIAOccupationalasthma OA Lungfunctionsdiagnosisofasthma ObstructiveventilationinsufficiencyandreversibilityofairwayobstructionVariancerateofpeakexpiredflow PEF in24hours 20 Bronchialchallengeispositive Lungfunctionsdiagnosisofasthma 1 FEV1 80 pre FEV1 FVC 70 bronchialdilationtestispositivePostFEV1 PreFEV1FEV1improvedrate 100 PreFEV1determinantstandard FEV1improvedrate 15 FEV1improvedrate 200ml Lungfunctionsdiagnosisofasthma 2 PEFmeterPEFpredictedvalue Lungfunctionsdiagnosisofasthma 2 PEF 80 preandPEFvariancerate 20 PEFmax PEFminPEFvariancerate 100 1 2 PEFmax PEFmin Determinantstandard PEFvariancerate 24h 20 Lungfunctionsdiagnosisofasthma 3 Bronchialchallengeispositivetherapeuticpropertiesforbidpropertiesmethodsdruginduce methocholinerhistamineexerciseinduce Thestepsofchronicpersistentasthma 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2次 m发作时受限 80 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120次 分25mmHg无 呼衰用 2后 PEF 70 50 70 45mmHgSaO2 95 91 95 90 pH降低 Distinguishingdiagnosisofasthma CardiacasthmaCOPDUpperairwayobstruction lungcancer Pulmonaryeosiniphilinfiltration CorrelationbetweenasthmaandCOPD DiscriminationbetweenasthmaandCOPD AsthmaCOPD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 2 agonisttheophyllinebronchodilatorsanticholinergicdrugnon steroidanti inflammations Steroidswithveininjection methylprednisonlone40411 hydroxide40 320Hydrocortison1002011 ketone100 1000dexamethason50 7511 ketone10 30 steroiddose dosecharacterdose d mg mg mg Inhaledsteroids Baclomethasondipropionate必可酮 BDP 50ug 200Budesonide普米克 BUD 100ug 100普米克都保普米克令舒1mg 2mlFluticasonepropionate辅舒酮 FP 125ug 100Fluticasone Salmeterol舒利迭100 50ug 60250 50ug 60 Usingprinciplesofinhalersteroid 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 2 激动剂伍用长期预防可联合用药 Inhaled 2 agonists Salbutamol万托林200ug 200万托林雾化溶液0 05 20mlTerbutaline喘康速250ug 200博利康尼都保250ug 100博利康尼雾化溶液5mg mlSalmeterol施立稳50ug 200施立碟50ug 4 8Formoterol奥克斯都保4 5ug 60 Oral 2 agonists Terbutaline博利康尼2 5mgProcaterol美喘清50ugFormoterol安通克40ugSalbutemol全特宁8mgBambuterol帮备4mg Classificationof 2 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 13 988 Usingprinciplesof 2 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 1po aminophylline0 1shortactionAEA舒氟美0 1longaction葆乐辉0 4 Usingprinciplesoftheophylline 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20mlIpratropiumbromide可必特20ug 200 Salbutamol可必特2ml Usingprinciplesofanti cholinergicdrug 适用于COPD合并哮喘适用于老年人有器质性心脏疾病者适用于夜间哮喘复合制剂适用于快速持续缓解哮喘症状水溶液雾化吸入适用于哮喘急性重症发作 Non steroidanti inflammationdrugs Anti histamine inhaler 色甘酸钠5mg 200oral 酮替酚 曲尼斯特息思敏 开瑞坦等LTsreceptorinhibitor 顺尔宁10mg 5 Usingprinciplesofotheranti inflammation 抗组织胺药适用于儿童Atopy哮喘季节性哮喘季节发作前二个月应用白三烯受体拮抗剂可与激素联合应用白三烯受体拮抗剂对阿斯匹林哮喘 运动性哮喘 过敏性鼻炎效果更好 Drugtherapyofasthma快速缓解药物长期预防药物 短效吸入 2 激动剂吸入抗胆碱药短效口服 2 激动剂全身性糖皮质激素短效茶碱 吸入型糖皮质激素长效吸入 2 激动剂白三烯受体拮抗剂缓释茶碱吸入色甘酸钠尼多克罗米酮替酚 严重度Step1间歇发作 每日控制用药无需用药 其他选择方案 longtherapyprojectsofasthmaGINA2002 严重度Step2轻度持续 每日控制用药吸入激素 200 500 gBDP或等剂量 其他选择方案缓释茶碱 或色甘酸钠 或白三烯调节剂 longtherapyprojectsofasthmaGINA2002 严重度Step3中度持续 每日用药吸入激素 200 1000 gBDP或等剂量 加上长效吸入型 2 受体激动剂 其他选择方案吸入激素 500 1000 gBDP或等剂量 加上缓释茶碱或吸入激素 500 1000 gBDP或等剂量 加上口服长效 2 受体激动剂或吸入高剂量激素 1000 gBDP或等剂量 或吸入激素 500 1000 gBD