哮喘英文和中文课件

1、哮喘英文和中文哮喘英文和中文哮喘英文和中文哮喘英文和中文哮喘英文和中文哮喘英文和中文I. Epidemiology 流行病学 A very common disease 哮喘为常见病 USA 5% 美国 5 China 0.5% - 1.0% 中国0.5% - 1.0% Prevalence is increasing worldwide全球范围内该病的患病率在上升2I. Epidemiology 流行病学2II. Definition 定义 Asthma is a chronic inflammatory disorder of the airways in which many cells

2、 and cellular elements play a role. The chronic inflammation causes an associated airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespre

3、ad but variable airflow obstruction that is often reversible either spontaneously or with treatment. 3II. Definition 定义3Key PointsChronic airway inflammation 气道慢性炎症 Airway hyperresponsiveness 气道高反应性 Reversible airflow obstruction 可逆性气道狭窄 Symptoms: 症状 Wheezing 喘鸣 Breathlessness 气短 Chest tightness 胸闷

4、Coughing 咳嗽 Typically at night or in the early morning 典型者于深夜或凌晨发作4Key Points4III. Etiology 病因 Unknown 不明 Genetic factors? 遗传因素？ Environment factors? 环境因素？ The combination of these two?遗传与环境因素共同作用？5III. Etiology 病因5IV. Risk Factors 易患因素1. Host Factors 患者的因素 Genetic predisposition 遗传易患性 Atopy 过敏体质 Ai

5、rway hyperresponsiveness 气道高反应性 Gender 性别 Children: boys girls 儿童：男女 Adults: male 男 Race/ethnicity 种族 6IV. Risk Factors 易患因素62. Environmental Factors 环境的因素 Allergens (domestic mites, animal allergens, fungi, etc.) 过敏原（屋尘螨，动物过敏原，真菌，等等） Respiratory infections (especially viral infections) 呼吸道感染（尤其是病毒感

6、染） Exercise and hyperventilation 运动和高通气 Weather 气候变化 Sulfur dioxide 二氧化硫 Food 食品 Additives 食品添加剂 Drugs 药品72. Environmental Factors 环境的因V. Pathogenesis 发病机制Envir. factors + Genetic factors 环境遗传因素 Chronic Airway Inflamation 慢性气道炎症 Acute bronchoconstriction 急性支气管收缩 Hyperresponsiveness 气道高反应性 Swelling o

7、f the airway wall 气道壁肿胀 Chronic mucus plug formation 慢性粘液栓形成 Airway wall remodeling 气道壁构型重建 Airflow obstruction 气流阻塞 Symptoms 各种症状8V. Pathogenesis 发病机制8Network of Inflammatory Process 炎症反应网络Genetic Factors遗传因素 - Envir. Factors 环境因素 Triggers 诱因 Bronchoconstriction, etc. 支气管收缩等Symptoms 症状9Network of I

8、nflammatory ProcesRelevant cells 有关的细胞 Mast cells 肥大细胞 Eosinophils 嗜酸细胞 T lymphocytes (Th1/Th2) T细胞(Th1/Th2） Basocytes 嗜碱细胞 Neutrophils 中性粒细胞 Alveolar macrophages 肺泡巨噬细胞 Epithelium 上皮细胞 others 其他10Relevant cells Relevant molecules 有关的生物分子 Inflammatory Mediators 炎症介质 Histamine 组织胺 Acetylcholine 乙酰胆碱

9、Kinins 激肽 Adenosine 腺苷 Leukotrients (LTC4, LTD4, LTE4) 白三烯 Prostaglandins 前列腺素 Platelet-activating factor 血小板活化因子 etc. 其他 11Relevant molecules Pro-inflammatory cytokines 促炎症性细胞因子 Interleukin-4 (IL-4) 白介素-4 IL-5 白介素-5 Tumor necrosing factor-a (TNF-a) 肿瘤坏死因子-a etc. 其他Anti-inflammatory cytokines 抗炎症性细胞

10、因子 IL-18 白介素-18 IL-10 白介素-10 etc. 其他 12Pro-inflammatory cytokines 131314141515VI. Pathology 病理学1. At the early stage 早期 Chronic airway inflammation 慢性气道炎症2. Later 后期 Chronic airway inflammation 慢性气道炎症 Airway remodeling 气道构型重建 ASMC proliferation ASMC增生 Mucus glands enlargement 黏液腺肥大 Subepithelial fib

11、rosis 上皮下纤维化 Others 其他16VI. Pathology 病理学1617171818VII. Clinical manifestations 临床表现Symptoms 症状 Episodic breathlessness and wheezing, worse particularly at night and in the early hours of the morning. 阵发性气短、喘鸣，深夜和凌晨尤其明显19VII. Clinical manifestations Physical signs 体征 Between acute episodes： 发作间歇期： C

12、an be no abnormalities 可无明显异常 20Physical signs During acute attack: 急性发作期 Wheezing - not always parallels the symptoms 哮鸣音其强度并不总是与症状平行 Signs of hyperinflation -hypersonance 肺过度充气症叩诊过度反响 Signs of complication 并发症的体征 Infection 感染 Pneumothorax 气胸 Respiratory failure 呼衰 Heart failure 心衰 etc. 其他21During

13、acute attack: 急性发作期21 Atypical asthma 不典型哮喘 Symptom 症状 Cough 咳嗽 Tight chest 胸闷 Breathlessness 气短 Signs 体征 Without wheezing 没有哮鸣音22 Atypical asthma 不典VIII. Laboratory 实验室检查1. Pulmonary function tests 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23VIII. Laboratory 实验室检查23For atypical patients 非典型患者应该进

14、行以下检查1. Bronchoprovocating tests 气道激发试验 Histamine (组织胺） PD20-FEV1 7.8 mol/L Mch PD20-FEV112.8mol/L2. brobchodilating tests 支气管舒张试验 FEV1 15% and 200 ml3. PEF variation 峰值流速变异率 In a day20%24For atypical patients 非典型患者应252526262. Blood gases analysis 血气分析 PaO2, PaCO2 PaCO2only in severe cases PaCO2仅见于严

15、重病例 3. X-ray film X线胸片 Hyperinflation 过度充气征 Signs of Complications 并发症表现4. Skin tests for specific antigens 过敏原皮试5. Others 其他 Blood routine 血常规 Sputum culture 痰培养 etc.272. Blood gases analysis Hyperinflation过度充气征28Hyperinflation28 IX. Diagnosis 诊断Typical cases 典型病例 Symptoms + signs 症状体征Atypical case

16、s 不典型病例 Symptoms + signs + lab. Tests Bronchoprovocating tests 气道激发试验 Brobchodilating tests 支气管舒张试验 PEF variation 峰值流速变异率 29 IX. Diagnosis 诊断29Staging of disease severity 病情严重程度分级1. Long term evaluation (Tab.2-4-1) 长期病情评价Step 1: Intermittent 第一级：间歇发作 Attack1/week, Night attack2/month PEF, FEV180%Pr.

17、 PEF or FEV1-variation20%30Staging of disease severity 病情Step 2: Mild persistent 第二级：轻度持续发作 1/weekattack2/month PEF, FEV180%Pr. PEF or FEV1-variation 20-30%31Step 2: Mild persistent 第二级：轻Step 3: Moderate persistent 第三级：中度持续发作 Attack every day Night attack1/week Need daily use of inhaled short-acting

18、 b2-agonist PEF, FEV160, 30%32Step 3: Moderate persistent Step 4: Severe persistent 第四级：重度持续发作 Attack frequently Night attack frequently Limitation of physical activity PEF, FEV130% 33Step 4: Severe persistent 第2. During acute exacerbation (Tab.2-4-3) 急性发作期病情严重程度评价（见表2-4-3）342. During acute exacerba

19、tion (X. Differential diagnosis 鉴别诊断 (Table 2-4-4) Left ventricular failure 左心衰 Chronic asthmatic bronchitis 慢喘支 Acute bronchitis ( esp. in infants) 急性支气管炎 Lung cancer 肺癌 Benign airway narrowing 良性气道狭窄 Allergic pulmonary infiltration 过敏性肺浸润 35X. Differential diagnosis XI. Drugs used in asthma 哮喘治疗药物

20、1. Corticosteroids 糖皮质激素 Inhaler, oral, iv. , iv drip 剂型包括吸入、口服、静注、静滴 Best drug to control chronic airway inflammation 是控制慢性气道炎症最有效的药物 Slow-acting (2 w. for inhaler, 6 h for iv.) 起效较慢（吸入制剂需两周，静脉注射需6小时） Side effects: common when used systemically, but very few with inhalers 副作用：全身用药副作用较多，吸入用药副作用极少36

21、XI. Drugs used in asthma 哮喘2. 2-agonist 2-受体激动剂 Inhaler, oral 有吸入和口服制剂 Control symptoms quickly 可以迅速控制症状 Short-acting agents are ineffective for inflammation, but long-term agents are. 短效制剂对于气道炎症无效，而长效制剂有效372. 2-agonist 2-受体激动剂373. Theophyllines Oral, iv., iv drip 有口服、静注和静滴制剂 Control symptoms effect

22、ively 控制症状有效 Not very effective for inflammation 控制气道炎症效不佳 Fatal side effects in a few cases 个别患者见致死性副作用383. Theophyllines384. Anticholingergics 抗胆碱能药物 ipratropium inhaler 吸入制剂（如异丙托品） acts rather weakly, with few side effects 作用较弱，副作用少 esp. good for old people 尤其适用于老年人394. Anticholingergics 抗胆碱能药物39

23、5. Leukotriene antagonists 白三烯拮抗剂6. Others 其他药物 Antihistamine agents 抗组织胺药物 Ketotifon 酮替酚 Cromoly sodium 色苷酸钠405. Leukotriene antagonists 白XII. Treatment1. To avoid environmental risk factors1. 避免环境易患因素41XII. Treatment412. Medication plans for long-term management (Tab. 2-4-8) 长期药物治疗方案 Most patients

24、 need long-term medication in order to control the chronic airway inflammation and to prevent acute exacerbation. 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 Stepwise approach 阶梯治疗422. Medication plans for long-tStep 1: Intermittent 第一级：间歇发作 None 不需要长期用药43Step 1: Intermittent Step 2: Mild persistent 第二级：轻度持续发作

25、 Medications of choice 首选药物 Inhaled steroids 吸入糖皮质激素 Options 可选药物 Sustained-release theophylline 控释茶碱 Or cromone 或色苷酸钠 Or leukotriene modifier 或白三烯拮抗剂44Step 2: Mild persistent Step 3: Moderate persistent 第三级：中度持续发作 Medications of choice 首选药物 Inhaled steroids + inhaled LABA 吸入激素吸入长效b-受体兴奋剂 45Step 3:

26、Moderate persistent 第Options Inhaled steroids + theophylline (long- acting) 吸入激素口服长效茶碱 Or inhaled steroids + oral LABA 或吸入激素口服长效b-受体兴奋剂 Or inhaled steroids in high dose 或吸入大剂量激素 Or inhaled steroids + leukotriene modifiers 或吸入激素口服白三烯拮抗剂46Options46Step 4: Severe persistent 第四级:重度持续发作 Oral + inhaled (6

27、00g/d ) steroids 口服吸入激素（ 600g/d ) Oral or inhaled 2-agonist 口服或吸入b受体兴奋剂 Oral theophylline 口服茶碱 Leukotriene antagonists 白三烯拮抗剂 Ipratropium 异丙托品 Others 其他47Step 4: Severe persistent 第四级Evaluating patients every three months 每3个月评价一次疗效 Step up if disease is not well controlled 如果症状控制不好，升级治疗 Step down if disease is well controlled 如果症状控制良好，降级治疗48Evaluating patients every thre3. To manage exacerbation 急性发作期的治疗 a. Mild exacerbation 轻度急性发作 Inhaled + oral 2-agonist 吸入口服b受体兴奋剂 Oral theophylline 口服茶碱 Inhaled