哮喘(英文和中文).ppt

1 BronchialAsthma Asthma 支气管哮喘 哮喘 2 I Epidemiology流行病学Averycommondisease哮喘为常见病USA5 美国5 China0 5 1 0 中国0 5 1 0 Prevalenceisincreasingworldwide全球范围内该病的患病率在上升 3 II Definition定义Asthmaisachronicinflammatorydisorderoftheairwaysinwhichmanycellsandcellularelementsplayarole Thechronicinflammationcausesanassociatedairwayhyperresponsivenessthatleadstorecurrentepisodesofwheezing breathlessness chesttightness andcoughing particularlyatnightorintheearlymorning Theseepisodesareusuallyassociatedwithwidespreadbutvariableairflowobstructionthatisoftenreversibleeitherspontaneouslyorwithtreatment 4 KeyPointsChronicairwayinflammation气道慢性炎症Airwayhyperresponsiveness气道高反应性Reversibleairflowobstruction可逆性气道狭窄Symptoms 症状Wheezing喘鸣Breathlessness气短Chesttightness胸闷Coughing咳嗽Typicallyatnightorintheearlymorning典型者于深夜或凌晨发作 5 III Etiology病因Unknown不明Geneticfactors 遗传因素 Environmentfactors 环境因素 Thecombinationofthesetwo 遗传与环境因素共同作用 6 IV RiskFactors易患因素1 HostFactors患者的因素Geneticpredisposition遗传易患性Atopy过敏体质Airwayhyperresponsiveness气道高反应性Gender性别Children boys girls儿童 男 女Adults male男Race ethnicity种族 7 2 EnvironmentalFactors环境的因素Allergens domesticmites animalallergens fungi etc 过敏原 屋尘螨 动物过敏原 真菌 等等 Respiratoryinfections especiallyviralinfections 呼吸道感染 尤其是病毒感染 Exerciseandhyperventilation运动和高通气Weather气候变化Sulfurdioxide二氧化硫Food食品Additives食品添加剂Drugs药品 8 V Pathogenesis发病机制Envir factors Geneticfactors环境 遗传因素 ChronicAirwayInflamation慢性气道炎症 Acutebronchoconstriction急性支气管收缩Hyperresponsiveness气道高反应性Swellingoftheairwaywall气道壁肿胀Chronicmucusplugformation慢性粘液栓形成Airwaywallremodeling气道壁构型重建 Airflowobstruction气流阻塞 Symptoms各种症状 9 NetworkofInflammatoryProcess炎症反应网络 GeneticFactors遗传因素 Envir Factors环境因素Triggers诱因 Bronchoconstriction etc 支气管收缩等 Symptoms症状 10 Relevantcells有关的细胞Mastcells肥大细胞Eosinophils嗜酸细胞Tlymphocytes Th1 Th2 T细胞 Th1 Th2 Basocytes嗜碱细胞Neutrophils中性粒细胞Alveolarmacrophages肺泡巨噬细胞Epithelium上皮细胞others其他 11 Relevantmolecules有关的生物分子InflammatoryMediators炎症介质Histamine组织胺Acetylcholine乙酰胆碱Kinins激肽Adenosine腺苷Leukotrients LTC4 LTD4 LTE4 白三烯Prostaglandins前列腺素Platelet activatingfactor血小板活化因子etc 其他 12 Pro inflammatorycytokines促炎症性细胞因子Interleukin 4 IL 4 白介素 4IL 5白介素 5Tumornecrosingfactor a TNF a 肿瘤坏死因子 aetc 其他Anti inflammatorycytokines抗炎症性细胞因子IL 18白介素 18IL 10白介素 10etc 其他 13 14 15 16 VI Pathology病理学1 Attheearlystage早期Chronicairwayinflammation慢性气道炎症2 Later后期Chronicairwayinflammation慢性气道炎症Airwayremodeling气道构型重建ASMCproliferationASMC增生Mucusglandsenlargement黏液腺肥大Subepithelialfibrosis上皮下纤维化Others其他 17 18 19 VII Clinicalmanifestations临床表现Symptoms症状Episodicbreathlessnessandwheezing worseparticularlyatnightandintheearlyhoursofthemorning 阵发性气短 喘鸣 深夜和凌晨尤其明显 20 Physicalsigns体征Betweenacuteepisodes 发作间歇期 Canbenoabnormalities可无明显异常 21 Duringacuteattack 急性发作期Wheezing notalwaysparallelsthesymptoms哮鸣音 其强度并不总是与症状平行Signsofhyperinflation hypersonance肺过度充气症 叩诊过度反响Signsofcomplication并发症的体征Infection感染Pneumothorax气胸Respiratoryfailure呼衰Heartfailure心衰etc 其他 22 Atypicalasthma不典型哮喘Symptom症状Cough咳嗽Tightchest胸闷Breathlessness气短Signs体征Withoutwheezing没有哮鸣音 23 VIII Laboratory实验室检查1 Pulmonaryfunctiontests肺功能检查FEV1 第一秒用力肺活量下降FEV1 FVC FEV1 用力肺活量比值下降 24 Foratypicalpatients非典型患者应该进行以下检查1 Bronchoprovocatingtests气道激发试验Histamine 组织胺 PD20 FEV1 7 8 mol LMchPD20 FEV1 12 8 mol L2 brobchodilatingtests支气管舒张试验FEV1 15 and200ml3 PEFvariation峰值流速变异率Inaday 20 25 26 27 2 Bloodgasesanalysis血气分析PaO2 PaCO2 PaCO2 onlyinseverecasesPaCO2 仅见于严重病例3 X rayfilmX线胸片Hyperinflation过度充气征SignsofComplications并发症表现4 Skintestsforspecificantigens过敏原皮试5 Others其他Bloodroutine血常规Sputumculture痰培养etc 28 Hyperinflation过度充气征 29 IX Diagnosis诊断Typicalcases典型病例Symptoms signs症状 体征Atypicalcases不典型病例Symptoms signs lab TestsBronchoprovocatingtests气道激发试验Brobchodilatingtests支气管舒张试验PEFvariation峰值流速变异率 30 Stagingofdiseaseseverity病情严重程度分级1 Longtermevaluation Tab 2 4 1 长期病情评价Step1 Intermittent第一级 间歇发作Attack 1 week Nightattack 2 monthPEF FEV1 80 Pr PEForFEV1 variation 20 31 Step2 Mildpersistent第二级 轻度持续发作1 week2 monthPEF FEV1 80 Pr PEForFEV1 variation20 30 32 Step3 Moderatepersistent第三级 中度持续发作AttackeverydayNightattack 1 weekNeeddailyuseofinhaledshort actingb2 agonistPEF FEV1 60 30 33 Step4 Severepersistent第四级 重度持续发作AttackfrequentlyNightattackfrequentlyLimitationofphysicalactivityPEF FEV130 34 2 Duringacuteexacerbation Tab 2 4 3 急性发作期病情严重程度评价 见表2 4 3 35 X Differentialdiagnosis鉴别诊断 Table2 4 4 Leftventricularfailure左心衰Chronicasthmaticbronchitis慢喘支Acutebronchitis esp ininfants 急性支气管炎Lungcancer肺癌Benignairwaynarrowing良性气道狭窄Allergicpulmonaryinfiltration过敏性肺浸润 36 XI Drugsusedinasthma哮喘治疗药物1 Corticosteroids糖皮质激素Inhaler oral iv ivdrip剂型包括吸入 口服 静注 静滴Bestdrugtocontrolchronicairwayinflammation是控制慢性气道炎症最有效的药物Slow acting 2w forinhaler 6hforiv 起效较慢 吸入制剂需两周 静脉注射需6小时 Sideeffects commonwhenusedsystemically butveryfewwithinhalers副作用 全身用药副作用较多 吸入用药副作用极少 37 2 2 agonist 2 受体激动剂Inhaler oral有吸入和口服制剂Controlsymptomsquickly可以迅速控制症状Short actingagentsareineffectiveforinflammation butlong termagentsare 短效制剂对于气道炎症无效 而长效制剂有效 38 3 TheophyllinesOral iv ivdrip有口服 静注和静滴制剂Controlsymptomseffectively控制症状有效Notveryeffectiveforinflammation控制气道炎症效不佳Fatalsideeffectsinafewcases个别患者见致死性副作用 39 4 Anticholingergics抗胆碱能药物ipratropiuminhaler吸入制剂 如异丙托品 actsratherweakly withfewsideeffects作用较弱 副作用少esp goodforoldpeople尤其适用于老年人 40 5 Leukotrieneantagonists白三烯拮抗剂6 Others其他药物Antihistamineagents抗组织胺药物Ketotifon酮替酚Cromolysodium色苷酸钠 41 XII Treatment1 Toavoidenvironmentalriskfactors1 避免环境易患因素 42 2 Medicationplansforlong termmanagement Tab 2 4 8 长期药物治疗方案Mostpatientsneedlong termmedicationinordertocontrolthechronicairwayinflammationandtopreventacuteexacerbation 为了控制慢性气道炎症炎症 预防急性发作 多数患者需要长期药物治疗Stepwiseapproach阶梯治疗 43 Step1 Intermittent第一级 间歇发作None不需要长期用药 44 Step2 Mildpersistent第二级 轻度持续发作Medicationsofchoice首选药物Inhaledsteroids吸入糖皮质激素Options可选药物Sustained releasetheophylline控释茶碱Orcromone或色苷酸钠Orleukotrienemodifier或白三烯拮抗剂 45 Step3 Moderatepersistent第三级 中度持续发作Medicationsofchoice首选药物Inhaledsteroids inhaledLABA吸入激素 吸入长效b 受体兴奋剂 46 OptionsInhaledsteroids theophylline long acting 吸入激素 口服长效茶碱Orinhaledsteroids oralLABA或吸入激素 口服长效b 受体兴奋剂Orinhaledsteroidsinhighdose或吸入大剂量激素Orinhaledsteroids leukotrienemodifiers或吸入激素 口服白三烯拮抗剂 47 Step4 Severepersistent第四级 重度持续发作Oral inhaled 600 g d steroids口服 吸入激素 600 g d Oralorinhaled 2 agonist口服或吸入b受体兴奋剂Oraltheophylline口服茶碱Leukotrieneantagonists白三烯拮抗剂Ipratropium异丙托品Others其他 48 Evaluatingpatientseverythreemonths每3个月评价一次疗效Stepupifdiseaseisnotwellcontrolled如果症状控制不好 升级治疗Stepdownifdiseaseiswellcontrolled如果症状控制良好 降级治疗 49 3 Tomanageexacerbation急性发作期的治疗a Mildexacerbation轻度急性发作Inhaled oral 2 agonist吸入 口服b受体兴奋剂Oraltheophylline口服茶碱