15支气管哮喘09.ppt

Asthma,ChenxinM.D.,PulmonaryMedicinezhujianghospital,southernmedicaluniversity,DefinitionofAsthma,AchronicinflammatorydisorderoftheairwaysManycellsandcellularelementsplayaroleChronicinflammationisassociatedwithairwayhyperresponsivenessthatleadstorecurrentepisodesofwheezing,breathlessness,chesttightness,andcoughingWidespread,variable,andoftenreversibleairflowlimitation,Source:PeterJ.Barnes,MD,AsthmaInflammation:CellsandMediators,Source:PeterJ.Barnes,MD,Mechanisms:AsthmaInflammation,Source:PeterJ.Barnes,MD,AsthmaInflammation:CellsandMediators,哮喘病理生理学,支气管高反应性平滑肌增生/体积增大炎症介质释放增多,炎症细胞数增加黏膜水肿支气管高反应气道分泌物增加上皮损伤,细胞增生（平滑肌细胞、黏液腺）基质蛋白沉积增加基底膜增厚血管新生,平滑肌功能障碍,气道炎症,气道重塑,BurdenofAsthma,Asthmaisoneofthemostcommonchronicdiseasesworldwidewithanestimated300millionaffectedindividualsPrevalenceincreasinginmanycountries,especiallyinchildrenAmajorcauseofschool/workabsence,BurdenofAsthma,HealthcareexpendituresveryhighDevelopedeconomiesmightexpecttospend1-2percentoftotalhealthcareexpendituresonasthma.DevelopingeconomieslikelytofaceincreaseddemandPoorlycontrolledasthmaisexpensive;investmentinpreventionmedicationlikelytoyieldcostsavingsinemergencycare,AsthmaPrevalenceandMortality,Source:MasoliMetal.Allergy2004,中国是哮喘病死率最高的国家之一,534岁年龄组患者哮喘病死率（case-fatalityrates）,36.7/10万(10.0/10万，处于高水平),MasoliM(2004).TheglobalburdenofasthmaGINAreport.,在中国，每100,000位哮喘患者中有36.7位哮喘患者会因哮喘死亡。GINA2004,RiskFactorsforAsthma,Hostfactors:predisposeindividualsto,orprotectthemfrom,developingasthmaEnvironmentalfactors:influencesusceptibilitytodevelopmentofasthmainpredisposedindividuals,precipitateasthmaexacerbations,and/orcausesymptomstopersist,FactorsthatExacerbateAsthma,AllergensRespiratoryinfectionsExerciseandhyperventilationWeatherchangesSulfurdioxideFood,additives,drugs,FactorsthatInfluenceAsthmaDevelopmentandExpression,HostFactorsGenetic-Atopy-AirwayhyperresponsivenessGenderObesity,EnvironmentalFactorsIndoorallergensOutdoorallergensOccupationalsensitizersTobaccosmokeAirPollutionRespiratoryInfectionsDiet,IsitAsthma?,RecurrentepisodesofwheezingTroublesomecoughatnightCoughorwheezeafterexerciseCough,wheezeorchesttightnessafterexposuretoairborneallergensorpollutantsColds“gotothechest”ortakemorethan10daystoclear,AsthmaDiagnosis,HistoryandpatternsofsymptomsMeasurementsoflungfunction-Spirometry-PeakexpiratoryflowMeasurementofairwayresponsivenessMeasurementsofallergicstatustoidentifyriskfactorsExtrameasuresmayberequiredtodiagnoseasthmainchildren5yearsandyoungerandtheelderly,TypicalSpirometric(FEV1)Tracings,1,Time(sec),2,3,4,5,FEV1,Volume,NormalSubject,Asthmatic(AfterBronchodilator),Asthmatic(BeforeBronchodilator),Note:EachFEV1curverepresentsthehighestofthreerepeatmeasurements,MeasuringVariabilityofPeakExpiratoryFlow,MeasuringAirwayResponsiveness,ClinicalControlofAsthma,No(orminimal)*daytimesymptomsNolimitationsofactivityNonocturnalsymptomsNo(orminimal)needforrescuemedicationNormallungfunctionNoexacerbations_*Minimal=twiceorlessperweek,LevelsofAsthmaControl,1.DevelopPatient/DoctorPartnership2.IdentifyandReduceExposuretoRiskFactors3.Assess,TreatandMonitorAsthma4.ManageAsthmaExacerbations5.SpecialConsiderations,AsthmaManagementandPreventionProgram:FiveComponents,AsthmaManagementandPreventionProgram:FiveInterrelatedComponents,1.DevelopPatient/DoctorPartnership2.IdentifyandReduceExposuretoRiskFactors3.Assess,TreatandMonitorAsthma4.ManageAsthmaExacerbations5.SpecialConsiderations,AsthmaManagementandPreventionProgramGoalsofLong-termManagement,AchieveandmaintaincontrolofsymptomsMaintainnormalactivitylevels,includingexerciseMaintainpulmonaryfunctionasclosetonormallevelsaspossiblePreventasthmaexacerbationsAvoidadverseeffectsfromasthmamedicationsPreventasthmamortality,AsthmaManagementandPreventionProgram,AsthmacanbeeffectivelycontrolledinmostpatientsbyinterveningtosuppressandreverseinflammationaswellastreatingbronchoconstrictionandrelatedsymptomsEarlyinterventiontostopexposuretotheriskfactorsthatsensitizedtheairwaymayhelpimprovethecontrolofasthmaandreducemedicationneeds.,.,AsthmaManagementandPreventionProgram,Althoughthereisnocureforasthma,appropriatemanagementthatincludesapartnershipbetweenthephysicianandthepatient/familymostoftenresultsintheachievementofcontrol,GuidelinesonasthmamanagementshouldbeavailablebutadaptedandadoptedforlocalusebylocalasthmaplanningteamsClearcommunicationbetweenhealthcareprofessionalsandasthmapatientsiskeytoenhancingcompliance,AsthmaManagementandPreventionProgramComponent1:DevelopPatient/DoctorPartnership,AsthmaManagementandPreventionProgramComponent1:DevelopPatient/DoctorPartnership,EducatecontinuallyIncludethefamilyProvideinformationaboutasthmaProvidetrainingonself-managementskillsEmphasizeapartnershipamonghealthcareproviders,thepatient,andthepatientsfamily,AsthmaManagementandPreventionProgramComponent1:DevelopPatient/DoctorPartnership,Keyfactorstofacilitatecommunication:FriendlydemeanorInteractivedialogueEncouragementandpraiseProvideappropriateinformationFeedbackandreview,AsthmaManagementandPreventionProgramFactorsInvolvedinNon-Adherence,MedicationUsageDifficultiesassociatedwithinhalersComplicatedregimensFearsabout,oractualsideeffectsCostDistancetopharmacies,Non-MedicationFactorsMisunderstanding/lackofinformationFearsaboutside-effectsInappropriateexpectationsUnderestimationofseverityAttitudestowardillhealthCulturalfactorsPoorcommunication,AsthmaManagementandPreventionProgramComponent2:IdentifyandReduceExposuretoRiskFactors,Measurestopreventthedevelopmentofasthma,andasthmaexacerbationsbyavoidingorreducingexposuretoriskfactorsshouldbeimplementedwhereverpossible.Asthmaexacerbationsmaybecausedbyavarietyofriskfactorsallergens,viralinfections,pollutantsanddrugs.Reducingexposuretosomecategoriesofriskfactorsimprovesthecontrolofasthmaandreducesmedicationsneeds.,ReduceexposuretoindoorallergensAvoidtobaccosmokeAvoidvehicleemissionIdentifyirritantsintheworkplaceExploreroleofinfectionsonasthmadevelopment,especiallyinchildrenandyounginfants,AsthmaManagementandPreventionProgramComponent2:IdentifyandReduceExposuretoRiskFactors,AsthmaManagementandPreventionProgramInfluenzaVaccination,InfluenzavaccinationshouldbeprovidedtopatientswithasthmawhenvaccinationofthegeneralpopulationisadvisedHowever,routineinfluenzavaccinationofchildrenandadultswithasthmadoesnotappeartoprotectthemfromasthmaexacerbationsorimproveasthmacontrol,AsthmaManagementandPreventionProgramComponent3:Assess,TreatandMonitorAsthma,Thegoalofasthmatreatment,toachieveandmaintainclinicalcontrol,canbeachievedinamajorityofpatientswithapharmacologicinterventionstrategydevelopedinpartnershipbetweenthepatient/familyandthehealthcareprofessional,AsthmaManagementandPreventionProgramComponent3:Assess,TreatandMonitorAsthma,Dependingonlevelofasthmacontrol,thepatientisassignedtooneoffivetreatmentstepsTreatmentisadjustedinacontinuouscycledrivenbychangesinasthmacontrolstatus.Thecycleinvolves:-AssessingAsthmaControl-TreatingtoAchieveControl-MonitoringtoMaintainControl,基于哮喘临床控制的哮喘管理,2006GINA,哮喘管理模式,AstepwiseapproachtopharmacologicaltherapyisrecommendedTheaimistoaccomplishthegoalsoftherapywiththeleastpossiblemedicationAlthoughinmanycountriestraditionalmethodsofhealingareused,theirefficacyhasnotyetbeenestablishedandtheirusecanthereforenotberecommended,AsthmaManagementandPreventionProgramComponent3:Assess,TreatandMonitorAsthma,Thechoiceoftreatmentshouldbeguidedby:LevelofasthmacontrolCurrenttreatmentPharmacologicalpropertiesandavailabilityofthevariousformsofasthmatreatmentEconomicconsiderationsCulturalpreferencesanddifferinghealthcaresystemsneedtobeconsidered,AsthmaManagementandPreventionProgramComponent3:Assess,TreatandMonitorAsthma,LevelsofAsthmaControl,Thechoiceoftreatmentshouldbeguidedby:LevelofasthmacontrolCurrenttreatmentPharmacologicalpropertiesandavailabilityofthevariousformsofasthmatreatmentEconomicconsiderationsCulturalpreferencesanddifferinghealthcaresystemsneedtobeconsidered,AsthmaManagementandPreventionProgramComponent3:Assess,TreatandMonitorAsthma,Component4:AsthmaManagementandPreventionProgramControllerMedications,InhaledglucocorticosteroidsLeukotrienemodifiersLong-actinginhaled2-agonistsSystemicglucocorticosteroidsTheophyllineCromonesLong-actingoral2-agonistsAnti-IgESystemicglucocorticosteroids,EstimateComparativeDailyDosagesforInhaledGlucocorticosteroidsbyAge,DrugLowDailyDose(g)MediumDailyDose(g)HighDailyDose(g)5yAge5yAge5yAge5y,Component4:AsthmaManagementandPreventionProgramRelieverMedications,Rapid-actinginhaled2-agonistsSystemicglucocorticosteroidsAnticholinergicsTheophyllineShort-actingoral2-agonists,Component4:AsthmaManagementandPreventionProgramAllergen-specificImmunotherapy,GreatestbenefitofspecificimmunotherapyusingallergenextractshasbeenobtainedinthetreatmentofallergicrhinitisTheroleofspecificimmunotherapyinasthmaislimitedSpecificimmunotherapyshouldbeconsideredonlyafterstrictenvironmentalavoidanceandpharmacologicintervention,includinginhaledglucocorticosteroids,havefailedtocontrolasthmaPerformonlybytrainedphysician,Step1As-neededrelievermedicationPatientswithoccasionaldaytimesymptomsofshortdurationArapid-actinginhaled2-agonististherecommendedrelievertreatment(EvidenceA)Whensymptomsaremorefrequent,and/orworsenperiodically,patientsrequireregularcontrollertreatment(step2orhigher),TreatingtoAchieveAsthmaControl,Step2RelievermedicationplusasinglecontrollerAlow-doseinhaledglucocorticosteroidisrecommendedastheinitialcontrollertreatmentforpatientsofallages(EvidenceA)Alternativecontrollermedicationsincludeleukotrienemodifiers(EvidenceA)appropriateforpatientsunable/unwillingtouseinhaledglucocorticosteroids,TreatingtoAchieveAsthmaControl,Step3RelievermedicationplusoneortwocontrollersForadultsandadolescents,combinealow-doseinhaledglucocorticosteroidwithaninhaledlong-acting2-agonisteitherinacombinationinhalerdeviceorasseparatecomponents(EvidenceA)Inhaledlong-acting2-agonistmustnotbeusedasmonotherapyForchildren,increasetoamedium-doseinhaledglucocorticosteroid(EvidenceA),TreatingtoAchieveAsthmaControl,AdditionalStep3OptionsforAdolescentsandAdultsIncreasetomedium-doseinhaledglucocorticosteroid(EvidenceA)Low-doseinhaledglucocorticosteroidcombinedwithleukotrienemodifiers(EvidenceA)Low-dosesustained-releasetheophylline(EvidenceB),TreatingtoAchieveAsthmaControl,Step4RelievermedicationplustwoormorecontrollersSelectionoftreatmentatStep4dependsonpriorselectionsatSteps2and3Wherepossible,patientsnotcontrolledonStep3treatmentsshouldbereferredtoahealthprofessionalwithexpertiseinthemanagementofasthma,TreatingtoAchieveAsthmaControl,Step4RelievermedicationplustwoormorecontrollersMedium-orhigh-doseinhaledglucocorticosteroidcombinedwithalong-actinginhaled2-agonist(EvidenceA)Medium-orhigh-doseinhaledglucocorticosteroidcombinedwithleukotrienemodifiers(EvidenceA)Low-dosesustained-releasetheophyllineaddedtomedium-orhigh-doseinhaledglucocorticosteroidcombinedwithalong-actinginhaled2-agonist(EvidenceB),TreatingtoAchieveAsthmaControl,TreatingtoAchieveAsthmaControl,Step5RelievermedicationplusadditionalcontrolleroptionsAdditionoforalglucocorticosteroidstoothercontrollermedicationsmaybeeffective(EvidenceD)butisassociatedwithseveresideeffects(EvidenceA)Additionofanti-IgEtreatmenttoothercontrollermedicationsimprovescontrolofallergicasthmawhencontrolhasnotbeenachievedonothermedications(EvidenceA),TreatingtoMaintainAsthmaControl,Whencontrolasbeenachieved,ongoingmonitoringisessentialto:-maintaincontrol-establishloweststep/dosetreatmentAsthmacontrolshouldbemonitoredbythehealthcareprofessionalandbythepatient,TreatingtoMaintainAsthmaControl,Steppingdowntreatmentwhenasthmaiscontrolled,Whencontrolledonmedium-tohigh-doseinhaledglucocorticosteroids:50%dosereductionat3monthintervals(EvidenceB)Whencontrolledonlow-doseinhaledglucocorticosteroids:switchtoonce-dailydosing(EvidenceA),TreatingtoMaintainAsthmaControl,Steppingdowntreatmentwhenasthmaiscontrolled,Whencontrolledoncombinationinhaledglucocorticosteroidsandlong-actinginhaled2-agonist,reducedoseofinhaledglucocorticosteroidby50%whilecontinuingthelong-acting2-agonist(EvidenceB)Ifcontrolismaintained,reducetolow-doseinhaledglucocorticosteroidsandstoplong-acting2-agonist(EvidenceD),TreatingtoMaintainAsthmaControl,Steppinguptreatmentinresponsetolossofcontrol,Rapid-onset,short-actingorlong-actinginhaled2-agonistbronchodilatorsprovidetemporaryrelief.Needforrepeateddosingovermorethanone/twodayssignalsneedforpossibleincreaseincontrollertherapy,MDI使用方法,MDI使用方法,贮雾罐使用方法,贮雾罐使用方法,雾化吸入方法,雾化吸入方法,TreatingtoMaintainAsthmaControl,Steppinguptreatmentinresponsetolossofcontrol,Useofacombinationrapidandlong-actinginhaled2-agonist(e.g.,formoterol)andaninhaledglucocorticosteroid(e.g.,budesonide)inasingleinhalerbothasacontrollerandrelieveriseffectinginmaintainingahighlevelofasthmacontrolandreducesexacerbations(EvidenceA)Doublingthedoseofinhaledglucocortico-steroidsisnoteffective,andisnotrecommended(EvidenceA),大多数哮喘患者可以达到哮喘控制,控制改善,良好控制,完全控制,BatemanEDetal.AJRCCM2004,哮喘控制,基于哮喘临床控制的哮喘管理,2006GINA,使用哮喘管理工具评估哮喘控制,哮喘控制测试(ACT)、哮喘控制问卷(ACQ)、哮喘治疗评估问卷（ATAQ）是：经验证的、用于评估哮喘控制的工具，通过提供具体数值区分哮喘控制的不同水平不仅被推广用于研究，也用于基层医疗单位中患者哮喘控制评估可改善对哮喘控制的评估，并提供可反复使用的客观指标，有助于改善医生和患者间的交流,Schatzetal.2004.,基于哮喘临床控制的哮喘管理,25分：哮喘完全控制2024分：哮喘良好控制20分：哮喘未得到控制需要改变治疗方案，以达到哮喘控制,ACT评分的使用,基于哮喘临床控制的哮喘管理,控制：确定维持哮喘控制所需最低治疗级别,部分控制：考虑升级治疗以达到哮喘控制,未控制：升级治疗直至达到哮喘控制,2006GINA,为达到哮喘控制的治疗方案,Exacerbationsofasthmaareepisodesofprogressiveincreaseinshortnessofbreath,cough,wheezing,orchesttightnessExacerbationsarecharacterizedbydecreasesinexpiratoryairflowthatcanbequantifiedandmonitoredbymeasurementoflungfunction(FEV1orPEF)Severeexacerbationsarepotentiallylife-threateningandtreatmentrequiresclosesupervision,AsthmaManagementandPreventionProgramComponent4:ManageAsthmaExacerbations,AsthmaMana