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1、 支气管哮喘BronchialAsthma Outline BurdenofAsthmaDefinitionofAsthmaEtiologyandMechanismDiagnosisandClassificationAsthmaMedicationsAsthmamanagementandPrevention BurdenofAsthma HealthcareexpendituresveryhighDevelopedeconomiesmightexpecttospend1 2percentoftotalhealthcareexpendituresonasthma Developingeconom
2、ieslikelytofaceincreaseddemandPoorlycontrolledasthmaisexpensive investmentinpreventionmedicationlikelytoyieldcostsavingsinemergencycare AsthmaPrevalenceandMortality Source MasoliMetal Allergy2004 EpidemiologyofAsthma DefinitionofAsthma AchronicinflammatorydisorderoftheairwaysManycellsandcellularelem
3、entsplayaroleChronicinflammationisassociatedwithairwayhyperresponsivenessthatleadstorecurrentepisodesofwheezing breathlessness chesttightness andcoughingWidespread variable andoftenreversibleairflowlimitation Source PeterJ Barnes MD Mechanisms Source PeterJ Barnes MD AsthmaInflammation Source PeterJ
4、 Barnes MD AsthmaInflammation RiskFactorsforAsthma Hostfactors predisposeindividualsto orprotectthemfrom developingasthmaEnvironmentalfactors influencesusceptibilitytodevelopmentofasthmainpredisposedindividuals precipitateasthmaexacerbations and orcausesymptomstopersist FactorsthatInfluenceAsthmaDev
5、elopmentandExpression HostFactorsGenetic Atopy AirwayhyperresponsivenessGenderObesity EnvironmentalFactorsIndoorallergensOutdoorallergensOccupationalsensitizersTobaccosmokeAirpollutionRespiratoryInfectionsDiet MajorIndoorAsthmaTriggers IsitAsthma RecurrentepisodesofwheezingTroublesomecoughatnightCou
6、ghorwheezeafterexerciseCough wheezeorchesttightnessafterexposuretoairborneallergensorpollutantsColds gotothechest ortakemorethan10daystoclear AsthmaDiagnosis Historyandpatternsofsymptoms Episodicsymptomsafteranincidentalallergenexposure seasonalvariabilityofsymptoms Positivefamilyhistoryofasthmaanda
7、topicdisease Symptomsimprovedbyappropriateasthmatreatment Physicalexamination Maybenormal Themostusualabnormalphysicalfindingiswheezingonauscultation AsthmaDiagnosis Measurementsoflungfunction Spirometry PeakexpiratoryflowMeasurementofairwayresponsivenessMeasurementsofallergicstatustoidentifyriskfac
8、torsExtrameasuresmayberequiredtodiagnoseasthmainchildren5yearsandyoungerandtheelderly TypicalSpirometric FEV1 Tracings 1 Time sec 2 3 4 5 FEV1 Volume NormalSubject Asthmatic AfterBronchodilator Asthmatic BeforeBronchodilator Note EachFEV1curverepresentsthehighestofthreerepeatmeasurements MeasuringVa
9、riabilityofPeakExpiratoryFlow MeasuringAirwayResponsiveness EtiologicDiagnosisIdentifyenvironmentalfactors AllergenchallengetestSkinpricktestSpecificIgE DifferentialDiagnosis Otherformsofobstructivelungdisease particularlyCOPDNon respiratorycausesofsymptoms e g leftventricularfailure Non obstructive
10、formsoflungdisease e g diffuseparenchymallungdisease Upperairwayobstructionandinhaledforeignbodies ControllerMedications InhaledglucocorticosteroidsLeukotrienemodifiersLong actinginhaled 2 agonistsSystemicglucocorticosteroidsTheophyllineCromonesLong actingoral 2 agonistsAnti IgESystemicglucocorticos
11、teroids EstimateComparativeDailyDosagesforInhaledGlucocorticosteroidsbyAge DrugLowDailyDose g MediumDailyDose g HighDailyDose g 5yAge5yAge5yAge 5y RelieverMedications Rapid actinginhaled 2 agonistsSystemicglucocorticosteroidsAnticholinergicsTheophyllineShort actingoral 2 agonists PharmacologicTherap
12、y Long termcontrolmedicationscorticosteroidsinhaledformsystemicsteroidsusedtogainpromptcontrolofdiseasewheninitiatinginhaledtxLong actingbeta2 agonistsusedconcomitantlywithanti inflammatorymedsforlong termsymptomcontrolespeciallynocturnalsymptomspreventsexercise inducedbronchospasm Long termcontrolm
13、edicationsLeukotrienemodifierszafirlukast leukotrienereceptorantagonistzileuton 5 lipoxygenaseinhibitorisalternativetherapytolowdosesofinhaledsteroids nedocromil cromolynalternativetxtolowdoseinhaledsteroids cromolyn nedocromilrecommendedfor 12yrswithmildpersistentasthma Furtherstudyneeded Pharmacol
14、ogicTherapy QuickreliefmedicationsShortactingbeta2 agonists reliefofacutesymptomsAnticholinergics mayprovideadditivebenefittobeta2drugsinsevereexacerbation Maybealternativetobeta2 agonistsSystemicsteroids moderate to severepersistentasthmainacuteexacerbationsortopreventrecurrenceofexacerbations Phar
15、macologicTherapy Treatment LongTermControl CorticosteroidsMostpotentandeffectiveReductioninsymptoms improvementinPEFandspirometry diminishedairwayhyperresponsiveness preventionofexacerbations possiblepreventionofairwaywallremodelingSuppresses cytosineproduction airwayeosinophilicrecruitment chemical
16、mediators Long actingbeta 2agonistsRelaxairwaysmoothmuscleDurationofaction 12hrsNotusedinacuteexacerbationsAdjuncttoanti inflammatorytxforlong termsymptomcontrolespeciallynocturnalsymptoms Treatment LongTermControl LeukotrienemodifiersLeukotrienesarepotentbiochemicalmediatorsreleasedfrommastcells eosinophils andbasophilsthat contractbronchialsmoothmuscleincreasevascularpermeabilityincreasemucussecretionsattract activateinflammatorycellsinairways Treatment LongTermControl AsthmaTreatment QuickRel
