bronchial-asthma支气管哮喘

BronchialAsthmaDepartmentofRespiratoryMedicineThirdXiangyaHospitalofCentralSouthUniversityOutlineIntroductionDefinitionEtiologyandPathogenesisPathologyClinicalmanifestationDiagnosisTreatmentDiseasemanagementrecommendationsAsthma:introductionAsthmaisoneofthemostcommonchronicdiseasesworldwidePrevalenceincreasinginmanycountries,especiallyinchildrenanincreasingprevalenceofasthmaandincorrecttreatmentincreasethemortalityofasthmaTotalestimatedcostofasthmawas$6.2billion/yearintheworldInaword,asthmaisaglobaldiseasewithincreasingincidence,anditisanimportantcauseofdisability,death,andhigheconomiccost.Increasingappreciationofasthmaisveryimportant.Asthma:introductionAsthma:definition(whatisasthma?)achronicinflammatorydisorderoftheairwaysmanycellsandcellularelementsplayarolemastcells,eosinophils,Tlymphocytesthisinflammationcausesanassociatedairwayhyperresponsivenessthatleadstorecurrentepisodesofwheezing,breathlessness,chesttightness,andcoughing,particularlyatnightorintheearlymorning.Asthma:definitionTheseepisodesareusuallyassociatedwithwidespreadbutvariableairflowobstructionthatisoftenreversibleeitherspontaneouslyorwithtreatment.AchronicinflammatoryairwaydiseaseAirwayhyperresponsiveness(AHR)RecurrentepisodesofwheezingReversibleairflowobstructionAsthma:definitionAsthma:Etiology(Whatcauseasthma?)HostfactorsGeneticpredispositionAtopyAirwayhyperresponsivenessRace/EthnicityAsthma:EtiologyEnvironmentalfactors(FactorsthatExacerbateAsthma)Asthma:pathogenesis(Howasthmahappened?)MastcellDegranulationBarnesPJNormal5Seconds60SecondsAsthma:pathogenesisAsthma:pathogenesisTriggersAsthma:pathologyEosinophils,mastcells,TlymphocytesPatchynecrosisofepitheliumSub-mucosalglandularhyperplasiaHypertrophyofbronchialsmoothmuscleMucousplugInflammationoftheairwaywallAsthmaPathologyObstructedInflamedBronchiAsthma:pathologyAsthma:pathologynormalasthmaAsthma:clinicalmanifestationsAtopyTiggersFamilyhistoryseasonal,recurrent,episodicHistorycoughingwheezingshortnessofbreathchesttightnesssputumproductionAsthma:clinicalsituationsymptoms•Oftenoccuratnightorintheearlymorning•ReversibleeitherspontaneouslyorwithtreatmentVIDEO1VIDEO2VIDEO3Diffusing,expiratorywheezingprolongedphaseofforcedexhalationAsthma:clinicalsituationPhysicalexaminationVIDEO4LaboratoryExaminationPulmonaryfunctionPEF(peakexpiratoryflow)andFEV1(forcedexpiratoryvolumeinfirstsecond)islowerthanpredicted20%PEFvariability(AM:PM)20%decreaseinFEV1after6minutesofexerciseorinhalationofspecificagents15%increaseinFEV115minutesafterinhalationofashortacting2agonist流速容量正常舒张前舒张后RVTLC容量时间流速-容量曲线时间-容量曲线支气管舒张试验或强化平喘治疗前后肺功能比较LaboratoryExaminationMeasurementsofallergicstatusElevationinserumIgElevelspositiveskinprickteststocommonantigensLaboratoryExaminationOtherLaboratoryExaminationBloodtestsArterialbloodgasanalysisSputumstudiesChestX-rayAsthma:diagnosisHistoryandpatternsofsymptomsPhysicalexaminationSpirometrytodemonstratereversibilityExcludeothercausesofwheezingSymptomsNocturnalSymptomsFEV1orPEFSTEP4SeverePersistentSTEP3ModeratePersistentSTEP2MildPersistentSTEP1IntermittentContinuousLimitedphysicalactivityDailyAttacksaffectactivity1timeaweekbut1timeaday1timeaweekAsymptomaticandnormalPEFbetweenattacksFrequent1timeweek2timesamonth≤2timesamonth≤60%predictedVariability30%60-80%predictedVariability30%≥80%predictedVariability20-30%≥80%predictedVariability20%ClassificationofSeverityCLASSIFYSEVERITYClinicalFeaturesBeforeTreatment病例1男性，8岁，因反复咳嗽、气喘3年就诊。一直末予系统治疗。近月症状较频繁，白天症状每周有三至四次发作，每周夜间憋醒2至3次，FEV155%Pre。哮喘严重程度？MildPersistentModeratePersistentSeverePersistentSeverePersistentQuestion?诊断—变异性哮喘咳嗽持续或反复发作大于一月，多于夜间发作或运动后加重没有发热等感染表现或经长期抗菌治疗无效支气管舒张剂可缓解咳嗽症状肺功能确认有气道高反应性个人过敏史或家族史可辅助诊断诊断—重症哮喘哮喘严重发作，呼吸频率＞30次/分，脉搏＞120次/分,一般支气管舒张剂不能环缓解症状哮喘严重发作持续24小时以上，哮喘症状持续存在或继续恶化。MucouspluginfatalasthmaDifferentialdiagnosis心源性哮喘（Cardiacasthma）喘息型慢性支气管炎(Chronicasthmaticbronchitis)支气管肺癌(Bronchogeniccarcinoma)变态反应性肺浸润Differentialdiagnosis心源性哮喘（Cardiacasthma）多见于有心脏基础疾病的患者咳粉红色泡沫痰，端坐呼吸两肺广泛粗湿罗音和哮鸣音左心界扩大、心率增快、奔马律胸X线示心界增大和肺淤血Differentialdiagnosis慢性喘息型支气管炎多见于中老年人，病史与支气管哮喘存有差异往往先咳后喘，缓解期也有症状，急性期加重，多发生于呼吸道感染后急性加重期单纯支气管扩张剂治疗往往效果不佳，需积极控制呼吸道感染Differentialdiagnosis支气管肺癌肿瘤压迫气道时，可有哮喘样发作喘鸣症状发生常无明显诱因，常伴有痰中带血或肿瘤消耗表现大气道肿瘤肺部哮鸣音以吸气相哮鸣为主支气管扩张剂和抗炎剂效果不佳胸X线、胸CT、纤维支气管镜检查可明确诊断Differentialdiagnosis变态反应性肺浸润有变应原接触史症状较轻，伴有发热胸X线表现病灶多发，多变化，迁徙肺活检有助于鉴别TreatmentAsthmacannotbecured,butcanbecontrolled.哮喘主要治疗药物治疗目标哮喘缓解期治疗哮喘急性期发作的治疗治疗-哮喘主要治疗药物哮喘治疗药物支气管扩张药抗炎药β2受体激动剂茶碱类抗胆碱能药物糖皮质激素色苷酸钠抗组胺药白三烯调节剂哮喘主要治疗药物-支气管扩张剂短效剂：沙丁胺醇、特布他林β2受体激动剂长效剂：沙美特罗、班布特罗兴奋β2受体舒张支气管茶碱类(Theophylline)哮喘主要治疗药物-支气管扩张剂抑制磷酸二酯酶，舒张支气管平滑肌增强气道纤毛清除功能和抗炎作用改善呼吸肌功能，增加心搏出量氨茶碱、舒弗美溴化异丙托品(ipratropiumbromide)抗胆碱能药物(Anticholinergics)哮喘主要治疗药物-支气管扩张剂阻断支气管平滑肌上M1受体降低迷走神经的张力促使气道舒张糖皮质激素(glucocorticoid)甲基强的松龙、强的松、地塞米松倍氯米松、氟替卡松、布地奈德哮喘主要治疗药物-抗炎剂抗炎降低气道高反应性减轻气道水肿增强气道平滑肌β2受体的反应性色苷酸钠(SodiumCromoglycate)色苷酸钠哮喘主要治疗药物-抗炎剂抑制炎症介质的释放副作用小可缓解和预防支气管痉挛可减少激素的用量抗组胺药(Antihistamines)酮替酚(ketotifen)哮喘主要治疗药物-抗炎剂抗组胺等炎性介质作用肥大细胞膜保护效应增强气道β2受体的反应性扎鲁司特(安可来)、孟鲁司特(顺