支气管哮喘双语专家讲座

WhatIsAsthma?

Asthmaisadiseasethatcharacterizedby:AirwayobstructionthatisreversibleeitherspontaneouslyorwithtreatmentchronicairwayinflammationIncreasedairwayresponsivenesstoavarietyofstimuliInflammationcausesrecurrentepisodesofwheezing,breathlessness,chesttightnessandcoughing,particularlyatnightorearlymorning

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Epidemiology17-20millionAmericans(6-10%prevalence)1%estimatedprevalenceinmainlandofChina10millionmedicalvisits2millionemergencyvisits0.5millionhospitalization5000deathsannuallyMajorcauseofschoolandworkabsenceAtleast12billionperyear

Increasingburdenforyears支气管哮喘双语专家讲座第2页ImpactOfAsthmaOnPatients

Psychosocial:Poorself-esteemAnxietyaboutasthmaFearofbecomingillatout-doorAnxietyaboutexerciseFearofbeingdifferent

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Asthmakillspeopleequallyregardlessofseveritylevel1/3ofdeathsareinthosewithmildasthma1/3ofdeathsareinthosewithmoderateasthma1/3ofdeathsareinthosewithsevereasthma支气管哮喘双语专家讲座第4页WhatCausesAsthma?Asthmamaybecausedbygenetic,immuneand/orenvironmentalfactors,andisoftenassociatedwitheczemaandallergiesWedonotunderstandallofthecausesofasthmaoritsincreasingprevalenceItboilsdownto“Wejustdon’treallyknowforsure”支气管哮喘双语专家讲座第5页WhatCausesAsthmaOfthe17millionasthmasufferersintheUS,10Million(approx.60%)haveallergicasthma.3millionofthosearechildrenExposuretocertainallergenstriggerasthmasymptomstobeginExposuretocertainirritantscanalsosetanasthmaepisodeinmotion支气管哮喘双语专家讲座第6页TriggersandIrritants支气管哮喘双语专家讲座第7页CommonAllergens(Triggers) SeasonalPollensAnimaldandersaliva/urineDustMitesCockroaches/Mice/RatdroppingsandurineMoldSomemedicationsSomeFoods

支气管哮喘双语专家讲座第8页CommonIrritants(Triggers)ExerciseColdAirChalkDustViral/upperrespiratoryinfectionsAirpollutionTobaccosmokeorsecondhandsmokeChemicalirritantsandstrongsmellsStrongemotionalfeelingsDieselfumesCleaningsupplies支气管哮喘双语专家讲座第9页AirwayHyperresponsivenessPlasmaleakageMucushypersecretionInflammatorycellrecruitmentandactivationNeuralactivationVirus-infectedepitheliumRV-InducedAirwayInflammation支气管哮喘双语专家讲座第10页VirusescauseasthmaexacerbationsRVscause~60%ofvirus-inducedexacerbationsofasthmaRVsdirectlyinfectthebronchialairwaysTheresponsetoviralinfectionisshapedbythehost’santiviralresponseRV-InducedAsthma支气管哮喘双语专家讲座第11页Nakano,Y.etal.Chest;122:271S-a-275S-aPathophysiologicschemaforthedevelopmentofasthma支气管哮喘双语专家讲座第12页

TheAllergicReaction支气管哮喘双语专家讲座第13页TheAsthmaCascade支气管哮喘双语专家讲座第14页支气管哮喘双语专家讲座第15页MediatorPhasesEarly-phasereactioncausedbymediatorrelease,usuallypeakswithinanhourafterinitialexposuretotheallergen.Threetofourhoursafteranacuteasthmaepisode,a"late-phasereaction"mayoccurandmaylastupto24hours支气管哮喘双语专家讲座第16页TheEndResultsOfTheCascade LocalizedmucosaledemainthewallsofthesmallbronchiolesSecretionofthickmucusintothebronchiolarlumens(Clogsandnarrowstheairways)Spasticcontractionofbronchiolarsmoothmuscle支气管哮喘双语专家讲座第17页NormalBronchioleInflamedBronchiole

withMucus 支气管哮喘双语专家讲座第18页AirwayObstructionCopyright3MPharmaceuticals支气管哮喘双语专家讲座第19页支气管哮喘双语专家讲座第20页RemodelingPhasesAirwaywallthickening.SubepithelialfibrosisSmoothmusclehyperplasiaandhypertrophyMyofibroblasthyperplasiaMucusmetaplasia支气管哮喘双语专家讲座第21页Vignola,A.M.etal.Chest;123:417S-a-422S-aIncreasedthicknessofthebasementmembrane(arrow),andenhancedandabnormaldepositionoffibronectin,whichisidentifiedbyimmunohistochemistryusingaspecificmonoclonalantibody(dashedarrow),inthebronchialsubmucosa支气管哮喘双语专家讲座第22页Increasedthicknessofthebasementmembrane,andenhancedandabnormaldepositionofcollageninthebronchialsubmucosa支气管哮喘双语专家讲座第23页ALotGoingOnBeneathTheSurfaceAirwayinflammationAirflowobstructionBronchialhyperresponsiveness

Symptoms支气管哮喘双语专家讲座第24页CommonSymptomsOfAsthmaFrequentcough,especiallyatnightShortnessofbreathorrapidbreathingChesttightnessChestpainWheezingFatigue支气管哮喘双语专家讲座第25页Early

SignsOfAnAsthma“Episode”MildcoughDropinPeakFlowreadingItchy,wateryorglassyeyesItchy,scratchyorsorethroatRunnynoseStomachacheHeadacheSneezingCongestionRestlessnessDarkcirclesundereyesIrritability支气管哮喘双语专家讲座第26页MeasuresOfAssessment

AndMonitoringTwoAspects:InitialassessmentanddiagnosisofasthmaPeriodicassessmentandmonitoring支气管哮喘双语专家讲座第27页InitialAssessment&

DiagnosisofAsthmaDeterminesThat:PatienthasahistoryorpresenceofepisodicsymptomsofairflowobstructionAirflowobstructionisatleastpartiallyreversibleAlternativediagnosesareexcluded支气管哮喘双语专家讲座第28页

MethodsforEstablishing

DiagnosisDetailedmedicalhistoryPhysicalexam:wheezeandrhonchus(rhonchi)Spirometrytodemonstratereversibility支气管哮喘双语专家讲座第29页Diagnosisofasthma

Objectivemeasurements>20%diurnalvariationon3daysin

aweekfor2weeksonPEFdiaryorFEV1

15%(and200ml)increaseaftershortactingß2agonistorsteroidtabletsorFEV115%decreaseafter6minutesofrunningexercisehistamineormethacholinechallengeindifficultcasesSymptoms(episodic/variable)wheezeshortnessofbreathchesttightnesscoughSignsnone(common)wheeze–diffuse,bilateral,expiratory(inspiratory)tachypneaHelpfuladditionalinformationpersonal/familyhistoryofasthmaoratopyhistoryofworseningafteraspirin/NSAID,

blockeruserecognisedtriggers–pollens,dust,animals,exercise,viralinfections,chemicals,irritantspatternandseverityofsymptomsandexacerbationsConsiderthediagnosisofasthmainpatientswithsomeorallofthesefeatures支气管哮喘双语专家讲座第30页

AsthmaLungAssessment

Spirometry

SpirometryisGoldstandardtoassistinasthmadiagnosisPerformedbeforeandafterbronchodilatordosetolookforairwayobstruction

reversibilityCanalsobedonewithhistamineormethylcholinechallenge,oranexercisechallengeinthecaseofexercise-inducedasthma

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IsAirflowObstructionAtLeastPartiallyReversible?Use

spirometrytoestablishairflowobstructionFEV1<80%ofpredictedFEV1/FVC<70%UsespirometrytoestablishreversibilityFEV1increases>15%andatleast200mLafterusingashort-actinginhaledbeta2-agonist支气管哮喘双语专家讲座第32页PeakExpiratoryFlowVariability

AnanotherwaytoevaluateairwayobstructionThereisthedifferencebetweenthemorningandeveningPEFreadingsPEFreadingstendtobehigherintheeveningthaninthemorning支气管哮喘双语专家讲座第33页PeakFlowMeters支气管哮喘双语专家讲座第34页

Differentialdiagnosisof

asthma

SomeofsymptomsofasthmaaresharedwithdiseasesofothersystemsNumerousrelativelycommonlungdiseasesNeedtodifferentiatefrominfectionsandrestrictivelung

disorders,andbetweenlocalandgeneralisedobstructionDifferentialdiagnosesinclude:COPDcardiacdiseaselaryngeal,trachealorlungtumourbronchiectasisforeignbodyinterstitiallungdiseasepulmonaryemboliaspirationvocalcorddysfunctionhyperventilation支气管哮喘双语专家讲座第35页AsthmaSeverityLevelsMildIntermittentMildPersistentModeratePersistentSeverePersistent支气管哮喘双语专家讲座第36页AsthmaSeverityLevelsBySymptomsMildIntermittent-Sx<2days/week Sx<2nights/monthMildPersistent-Sx>2x/weekbut<1x/day Sx>2nights/monthModeratePersistent-Sxeveryday Sx>1night/weekSeverePersistent- ContinualdaytimeSx FrequentSxatnight

支气管哮喘双语专家讲座第37页MildIntermittentSymptoms£2days/weekwithnighttimesymptoms£2nights/monthAsymptomaticwithnormalpeakflowsbetweenexacerbationsExacerbationsarebrief(hourstoafewdays)PeakFlows³80%predictedwithvariability<20%支气管哮喘双语专家讲座第38页MildPersistentSymptoms>2days/weekbut<1x/daywithnighttimesymptomsgreaterthan2nights/monthExacerbationsmayaffectactivityPeakflow³80%predictedwithvariabilityof<20-30%支气管哮喘双语专家讲座第39页ModeratePersistentChildislikelytohavedailysymptomsanduserelieverdailyChildiswakingupatleastonceaweekduetoasthmasymptomsPeakflows60-80%ofpredictedwithvariabilityof>30%Activityisaffectedandexacerbationsmaylastdays支气管哮喘双语专家讲座第40页SeverePersistentContinualdaytimesymptomswithfrequentnighttimesymptomsVerylimitedphysicalactivityFrequentexacerbationsPeakflows£60%ofpredictedandvariabilityofmorethan30%Treatmentinvolvesacombinationofmanydrugtherapies支气管哮喘双语专家讲座第41页GoalsOfAsthmaTherapyPreventchronicandtroublesomesymptomsMaintain“normal”pulmonaryfunctionMaintainnormalactivitylevels-includingexerciseandotherphysicalactivityMinimizetheneedforemergencyroom/urgentcarevisitsorhospitalizations支气管哮喘双语专家讲座第42页

GoalsOfAsthmaTherapy

Continued…PreventrecurrentexacerbationsofsymptomsProvideoptimalpharmacotherapywithminimalornoadverseeffectsSatisfythepatient’sandthefamily’sgoalsforasthmacare支气管哮喘双语专家讲座第43页

StepwiseApproachTo Asthma TherapyOutcome:BestPossibleResultsReliever:InhaledbetaagonistprnReliever:InhaledbetaagonistprnReliever:InhaledbetaagonistprnReliever:InhaledbetaagonistprnController:OnedailymedicationPossiblyaddlongactingbronchodilatorAnti-leukotrienesController:DailyinhaledcorticosteroidDailylongactingbronchodilatorAnti-leukotrieneController:DailyinhaledcorticosteroidDailylongactingbronchodilatorDaily/alternatedayoralcorticosteroidWhencontrolled,reducetherapyMonitorPEF:≥80%PEF:≥80%PEF:<60%STEP1:IntermittentSTEP2:MildPersistentSTEP3:ModeratePersistentSTEP4:SeverePersistentStepdownOutcome:ControlofAsthmaPEF:60-80%支气管哮喘双语专家讲座第44页BronchodilatorsRelaxingbronchialsmoothmuscletoopenuptheairway.Anti-inflammatoryagentsInhibitingthedevelopmentofairwayinflammationandstoppingongoinginflammation.Incombination,treatandpreventreversibleairwayobstructionandairwayhyperresponsiveness,relievethesymptomanddecreasetheexacerbation.CommonDrugsforAsthma支气管哮喘双语专家讲座第45页Long-termcontrolmedication(Controller)CorticosteriodsCromolyn/nedocromilLongactingb2agonists(LABA)LeukotrienemodifierQuickreliefmedication(Rescuer)Short-actingb2agonistsTheophyllineAnticholinergicsSystemicCorticosteriodsCommonDrugsforAsthma支气管哮喘双语专家讲座第46页支气管哮喘双语专家讲座第47页Stepwisemanagementof

asthmainadultsStep1:MildintermittentasthmaInhaledshortactingß2agonistasrequired支气管哮喘双语专家讲座第48页Stepwisemanagementof

asthmainadultsStep1:MildintermittentasthmaStep2:RegularpreventertherapyAddinhaledsteroid200-800mcg/day*400mcgisanappropriatestartingdoseformanypatientsStartatdoseofinhaledsteroidappropriatetoseverityofdisease.*BDPorequivalent支气管哮喘双语专家讲座第49页Stepwisemanagementof

asthmainadultsStep1:MildintermittentasthmaStep3:Add-ontherapys1.Addinhaledlong-actingß2agonist(LABA)2.Assesscontrolofasthma:good

responsetoLABA–continueLABAbenefitfromLABAbutcontrolstillinadequate–continueLABAandincreaseinhaledsteroiddoseto800mcg/day*(ifnotalreadyonthisdose)noresponsetoLABA–stopLABAandincreaseinhaledsteroidto

800mcg/day*.Ifcontrolstillinadequate,institutetrialofothertherapies

(e.g.leukotrienereceptorantagonistorSRtheophylline)Step2:RegularpreventertherapyStartatdoseofinhaledsteroidappropriatetoseverityofdisease.*BDPorequivalent支气管哮喘双语专家讲座第50页Stepwisemanagementof

asthmainadultsStep1:MildintermittentasthmaStep2:RegularpreventertherapyStartatdoseofinhaledsteroidappropriatetoseverityofdisease.*BDPorequivalentStep3:Add-ontherapyStep