15支气管哮喘09

AsthmaChenxinM.D.,PulmonaryMedicinezhujianghospital,southernmedicaluniversityDefinitionofAsthmaAchronicinflammatorydisorderoftheairwaysManycellsandcellularelementsplayaroleChronicinflammationisassociatedwithairwayhyperresponsivenessthatleadstorecurrentepisodesofwheezing,breathlessness,chesttightness,andcoughingWidespread,variable,andoftenreversibleairflowlimitationSource:PeterJ.Barnes,MDAsthmaInflammation:CellsandMediatorsSource:PeterJ.Barnes,MDMechanisms:AsthmaInflammationSource:PeterJ.Barnes,MDAsthmaInflammation: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Asthmaisoneofthemostcommonchronicdiseasesworldwidewithanestimated300millionaffectedindividualsPrevalenceincreasinginmanycountries,especiallyinchildrenAmajorcauseofschool/workabsenceBurdenofAsthmaHealthcareexpendituresveryhighDevelopedeconomiesmightexpecttospend1-2percentoftotalhealthcareexpendituresonasthma.DevelopingeconomieslikelytofaceincreaseddemandPoorlycontrolledasthmaisexpensive;investmentinpreventionmedicationlikelytoyieldcostsavingsinemergencycareAsthmaPrevalenceandMortalitySource:MasoliMetal.Allergy2004中国是哮喘病死率最高的国家之一5~34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。GINA2004RiskFactorsforAsthmaHostfactors:predisposeindividualsto,orprotectthemfrom,developingasthmaEnvironmentalfactors:influencesusceptibilitytodevelopmentofasthmainpredisposedindividuals,precipitateasthmaexacerbations,and/orcausesymptomstopersistFactorsthatExacerbateAsthmaAllergensRespiratoryinfectionsExerciseandhyperventilationWeatherchangesSulfurdioxideFood,additives,drugsFactorsthatInfluenceAsthmaDevelopmentandExpressionHostFactorsGenetic-Atopy-AirwayhyperresponsivenessGenderObesityEnvironmentalFactorsIndoorallergensOutdoorallergensOccupationalsensitizersTobaccosmokeAirPollutionRespiratoryInfectionsDietIsitAsthma?RecurrentepisodesofwheezingTroublesomecoughatnightCoughorwheezeafterexerciseCough,wheezeorchesttightnessafterexposuretoairborneallergensorpollutantsColds“gotothechest”ortakemorethan10daystoclearAsthmaDiagnosisHistoryandpatternsofsymptomsMeasurementsoflungfunction-Spirometry-PeakexpiratoryflowMeasurementofairwayresponsivenessMeasurementsofallergicstatustoidentifyriskfactorsExtrameasuresmayberequiredtodiagnoseasthmainchildren5yearsandyoungerandtheelderlyTypicalSpirometric(FEV1)Tracings1Time(sec)2345FEV1VolumeNormalSubjectAsthmatic(AfterBronchodilator)Asthmatic(BeforeBronchodilator)Note:EachFEV1curverepresentsthehighestofthreerepeatmeasurementsMeasuringVariabilityofPeakExpiratoryFlowMeasuringAirwayResponsivenessClinicalControlofAsthmaNo(orminimal)*daytimesymptomsNolimitationsofactivityNonocturnalsymptomsNo(orminimal)needforrescuemedicationNormallungfunctionNoexacerbations_________*Minimal=twiceorlessperweekLevelsofAsthmaControlCharacteristicControlled(Allofthefollowing)Partlycontrolled(Anypresentinanyweek)UncontrolledDaytimesymptomsNone(2orless/week)Morethantwice/week3ormorefeaturesofpartlycontrolledasthmapresentinanyweekLimitationsofactivitiesNoneAnyNocturnalsymptoms/awakeningNoneAnyNeedforrescue/“reliever”treatmentNone(2orless/week)Morethantwice/weekLungfunction(PEForFEV1)Normal80%predictedorpersonalbest(ifknown)onanydayExacerbationNoneOneormore/year1inanyweek1.DevelopPatient/DoctorPartnership2.IdentifyandReduceExposuretoRiskFactors3.Assess,TreatandMonitorAsthma4.ManageAsthmaExacerbations5.SpecialConsiderationsAsthmaManagementandPreventionProgram:FiveComponentsRevised2006AsthmaManagementandPreventionProgram:FiveInterrelatedComponents1.DevelopPatient/DoctorPartnership2.IdentifyandReduceExposuretoRiskFactors3.Assess,TreatandMonitorAsthma4.ManageAsthmaExacerbations5.SpecialConsiderationsAsthmaManagementandPreventionProgramGoalsofLong-termManagementAchieveandmaintaincontrolofsymptomsMaintainnormalactivitylevels,includingexerciseMaintainpulmonaryfunctionasclosetonormallevelsaspossiblePreventasthmaexacerbationsAvoidadverseeffectsfromasthmamedicationsPreventasthmamortalityAsthmaManagementandPreventionProgramAsthmacanbeeffectivelycontrolledinmostpatientsbyinterveningtosuppressandreverseinflammationaswellastreatingbronchoconstrictionandrelatedsymptomsEarlyinterventiontostopexposuretotheriskfactorsthatsensitizedtheairwaymayhelpimprovethecontrolofasthmaandreducemedicationneeds..AsthmaManagementandPreventionProgramAlthoughthereisnocureforasthma,appropriatemanagementthatincludesapartnershipbetweenthephysicianandthepatient/familymostoftenresultsintheachievementofcontrolGuidelinesonasthmamanagementshouldbeavailablebutadaptedandadoptedforlocalusebylocalasthmaplanningteamsClearcommunicationbetweenhealthcareprofessionalsandasthmapatientsiskeytoenhancingcomplianceAsthmaManagementandPreventionProgramComponent1:DevelopPatient/DoctorPartnershipAsthmaManagementandPreventionProgramComponent1:DevelopPatient/DoctorPartnershipEducatecontinuallyI