哮喘(英文和中文)

1BronchialAsthma(Asthma)

支气管哮喘（哮喘）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II.Definition定义

Asthmaisachronicinflammatorydisorderoftheairwaysinwhichmanycellsandcellularelementsplayarole.Thechronicinflammationcausesanassociatedairwayhyperresponsivenessthatleadstorecurrentepisodesofwheezing,breathlessness,chesttightness,andcoughing,particularlyatnightorintheearlymorning.Theseepisodesareusuallyassociatedwithwidespreadbutvariableairflowobstructionthatisoftenreversibleeitherspontaneouslyorwithtreatment.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？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<female成人：女>男

Race/ethnicity

种族

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1NetworkofInflammatoryProcess炎症反应网络2GeneticFactors遗传因素------Envir.Factors环境因素Triggers诱因3Bronchoconstriction,etc.支气管收缩等4Symptoms症状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

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131415VI.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1718VII.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Physicalsigns体征01Betweenacuteepisodes：发作间歇期：02Canbenoabnormalities可无明显异常03Duringacuteattack: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VIII.Laboratory实验室检查Pulmonaryfunctiontests肺功能检查FEV1第一秒用力肺活量下降FEV1/FVCFEV1/用力肺活量比值下降03040201Foratypicalpatients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%25262.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.Hyperinflation过度充气征

IX.Diagnosis诊断Typicalcases典型病例

Symptoms+signs症状＋体征Atypicalcases不典型病例

Symptoms+signs+lab.Tests

Bronchoprovocatingtests气道激发试验

Brobchodilatingtests支气管舒张试验

PEFvariation

峰值流速变异率

Stagingofdiseaseseverity病情严重程度分级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,FEV180%Pr.PEForFEV1-variation<20%Step2:Mildpersistent第二级：轻度持续发作1/week<attack<1/dayNightattack>2/monthPEF,FEV180%Pr.PEForFEV1-variation20-30%Step3:Moderatepersistent第三级：中度持续发作AttackeverydayNightattack>1/weekNeeddailyuseofinhaledshort-actingb2-agonistPEF,FEV1>60,<80%Pr.PEForFEV1-variation>30%Step4:Severepersistent第四级：重度持续发作AttackfrequentlyNightattackfrequentlyLimitationofphysicalactivityPEF,FEV1<60%Pr.PEForFEV1variation>30%Duringacuteexacerbation(Tab.2-4-3)急性发作期病情严重程度评价（见表2-4-3）12X.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

……

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2-agonist2-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3.Theophyllines38Oral,iv.,ivdrip有口服、静注和静滴制剂Notveryeffectiveforinflammation控制气道炎症效不佳Controlsymptomseffectively控制症状有效Fatalsideeffectsinafewcases个别患者见致死性副作用0504020301Anticholingergics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Leukotrieneantagonists白三烯拮抗剂Others其他药物Antihistamineagents抗组织胺药物Ketotifon酮替酚Cromolysodium色苷酸钠XII.Treatment41Toavoidenvironmentalriskfactors避免环境易患因素壹贰2.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Step1:Intermittent第一级：间歇发作None不需要长期用药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Step3:Moderatepersistent第三级：中度持续发作01Medicationsofchoice首选药物02Inhaledsteroids+inhaledLABA吸入激素＋吸入长效b-受体兴奋剂03OptionsInhaledsteroids+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12345Orinhaledsteroids+leukotrienemodifiers或吸入激素＋口服白三烯拮抗剂Orinhaledsteroidsinhighdose或吸入大剂量激素Oral+inhaled(>600g/d)steroidsStep4:Severepersistent第四级:重度持续发作01Oralorinhaled2-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其他口服＋吸入激素（>600g/d)02Evaluatingpatientseverythreemonths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

Inhaledsteroids