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Bronchial asthma

Bronchial asthma. Department of respiration Kong Lingfei. Asthma：human killer!. Prevalence ：in the world: 1.6 hundred million in China: 1～3 ％ in Shenyang: 1.24 ％（1999） GINA: G lobal In itiative for A sthma （1994） WHO/HLBI Bronchial asthmatic diagnosis guideline ( 1997）

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Bronchial asthma

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  1. Bronchial asthma Department of respiration Kong Lingfei

  2. Asthma：human killer!

  3. Prevalence ：in the world: 1.6 hundred million in China: 1～3 ％ in Shenyang: 1.24 ％（1999） GINA: Global Initiative for Asthma（1994） WHO/HLBI Bronchial asthmatic diagnosis guideline (1997） Chinese Medical Academy Background of asthma

  4. Chronic airway inflammation Broncho-hyperresponsiveness, BHR Airflow limitation Definitions of asthma

  5. antigen antigen ↓ ↓again atopy→IgE antibody→mast cells, basophils ↓ histamine inflammatory media LTs ↓ PAF ECP immediate asthmatic reaction, IAR ↓ bronchial smooth muscle spasm airway narrow Mechanism: allergy theory

  6. adrenergic and cholinergic nerous systems, AC non-adrenergic and non-cholinergic nerous systems, NANC AC: α1-receptor、M1-、M3-receptors excitement NANC：PS-receptor ↓ bronchial smooth muscle contraction AC: β-receptor、M2-receptor excitement NANC: VIP receptor ↓ bronchial smooth muscle dilation asthmatic airway: a1、M1、M3、PS↑/ β 、M2、VIP↓ Mechanism: never-receptor disorder theory

  7. antigen ↓ allergic airway inflammation, AAI ECP ↑ MBP inflammatory cells →inflammatory media LTs EOS ↓ PAF neutrophils late asthmatic reaction, LAR T lymphocyte(Th1/Th2↓) ↓ Th2 cytokine IL-3、4、5，GM-CSF →IgE↑ Mechanism: airway inflammation theory

  8. Differ mechanisms in acute and chronic asthma acute inflammation chronic inflammation airway remodelling bronchial contraction mucous edema airway secretion↑ inflammation cells ↑ epithelium injury cell proliferation excellular base↑ airway narrow airway reversibility↓ BHR↑ exacerbation symptoms

  9. Allergen: pollen, acarus infection: virus or mycoplasmal infection climate and physical and chemical factors drugs: aspirin induced asthma, AIA β-receptor inhibitor heredity Gastroesophageal reflux disease, GERD Psychological, incretion factors, sports Other mechanisms: induced factors

  10. symptoms signs recovered ways except other cardiac and pulmonary diseases lung function examination→untypical asthma Diagnosis standards of asthma

  11. Cough variant asthma, CAV Asthma with gastroesphgeal reflux Exercise induced asthma, EIA Drug induced asthma, DIA Occupational asthma, OA Untypical asthma

  12. Obstructive ventilation insufficiency and reversibility of airway obstruction Variance rate of peak expired flow (PEF) in 24 hours ≥20% Bronchial challenge is positive Lung functions diagnosis of asthma

  13. FEV1 < 80 % pre, FEV1/FVC% < 70 % bronchial dilation test is positive Post FEV1 - Pre FEV1 FEV1improved rate ＝ ×100% Pre FEV1 determinant standard:FEV1 improved rate≥15％(+) FEV1 improved rate≥200ml Lung functions diagnosis of asthma(1)

  14. Lung functions diagnosis of asthma(2) PEF meterPEF predicted value

  15. PEF < 80％pre and PEF variance rate ≥20％ PEF max – PEF min PEF variance rate＝ ×100% 1/2( PEF max + PEF min ) Determinant standard：PEF variance rate(24h) ≥20% (+) Lung functions diagnosis of asthma(2)

  16. Bronchial challenge is positive therapeutic properties forbid properties methods drug induce: methocholiner histamine exercise induce Lung functions diagnosis of asthma(3)

  17. The steps of chronic persistent asthma • 分级 分度 喘息发作 夜间发作 日常活动 ％FEV1PEF变异率 • 或％PEF • 1 间歇发作 <1次/w ≤2次/m 不受限 ≥80% <20% • 轻度持续 ≥1次/w >2次/m 发作时受限 >80% <20% • <1次/d • 3 中度持续 每日有症状 >1次/w 发作时受限 60～80% 20～30% • 4 重度持续 症状持续 频繁 受限 <60% >30%

  18. The steps of acute exacerbation asthma 临床特点 轻度 中度 重度 危重度 气短 步行,上楼时稍活动 休息时 体位 可平卧 喜坐位 前弓位 谈话方式 连续成句 字段 单词 不能讲话 精神状态 尚安静 时焦虑烦躁 常焦虑烦躁 嗜睡,意识障碍 出汗 无 有 大汗淋漓 呼吸频率 轻度增加 增加 >30次/分 三凹征 常无 可有 常有 胸腹矛盾运动 喘鸣音 呼吸末期散在 响亮弥漫 响亮弥漫 减弱或无 脉率 <100次/分 100～200次/分 >120次/分 <120次/次,不规则 奇脉 无,<10mmHg 有,10-25mmHg 常有,>25mmHg 无,呼衰 用β2后％PEF >70% 50～70% <50%或<100L/min PaO2 正常 60～80mmHg <60mmHg PaCO2 <40mmHg ≤45mmHg >45mmHg SaO2 >95% 91～95% ≤90% pH 降低

  19. Cardiac asthma COPD Upper airway obstruction (lung cancer) Pulmonary eosiniphil infiltration Distinguishing diagnosis of asthma

  20. Correlation between asthma and COPD

  21. Discrimination between asthma and COPD Asthma COPD 症状 喘息 咳嗽＋痰 呼吸困难(休息或运动) 呼吸困难(伴随运动) 胸闷 喘息 咳嗽 胸闷 经常出现夜间症状 很少夜间症状 吸烟史 部分病人 大多数病人 肺功能 可逆性好 可逆性差 激发试验 阳性 经常阴性 运动后 支气管收缩 无支气管收缩

  22. Glucocorticosteroid －anti-inflammation β2-agonist theophylline bronchodilators anticholinergic drug non-steroid anti-inflammations Drugs for treating asthma

  23. Steroids with vein injection steroid dose =dose character dose/d (mg) (mg) (mg) methylprednisonlone 40 4 11-hydroxide 40～320 Hydrocortison 100 20 11-ketone 100～1000 dexamethason 5 0.75 11-ketone 10～30

  24. Baclomethason dipropionate 必可酮(BDP) 50ug×200 Budesonide 普米克(BUD) 100ug ×100 普米克 都保 普米克令舒 1mg/2ml Fluticasone propionate 辅舒酮(FP) 125ug ×100 Fluticasone + Salmeterol 舒利迭 100/50ug×60 250/50ug×60 Inhaled steroids

  25. 非急性发作期哮喘长期预防用药首选 替代口服激素 季节性哮喘季节发作前二周应用 急性发作期与β2-激动剂伍用 长期预防可联合用药 Using principles of inhaler steroid

  26. Salbutamol 万托林 200ug×200 万托林雾化溶液 0.05% 20ml Terbutaline 喘康速 250ug×200 博利康尼都保 250ug×100 博利康尼雾化溶液 5mg/ml Salmeterol 施立稳 50ug×200 施立碟 50ug×4×8 Formoterol 奥克斯都保 4.5ug×60 Inhaled β2- agonists

  27. Terbutaline 博利康尼 2.5mg Procaterol 美喘清 50ug Formoterol 安通克 40ug Salbutemol 全特宁 8mg Bambuterol 帮备 4mg Oralβ2- agonists

  28. Classification of β2-agonsts (Politiek) 起效时间 快速缓解 4类 起效快 作用时间短 吸入型特布他林 吸入型沙丁胺醇 1类 起效快 作用时间长 吸入型福美特罗 快 维持治疗 3类 起效慢 作用时间短 口服型特布他林 口服型沙丁胺醇 口服型福美特罗 2类 起效缓慢 作用时间长 吸入型沙美特罗 口服型班布特罗 慢 Politiek, et al. Eur Respir J 1999, 13: 988 短 长作用维持时间

  29. 急性发作期快速缓解哮喘症状 与吸入激素伍用可规律使用一周 缓解期按需使用,用药次数<4次/日 运动性哮喘运动前预防性吸入 夜间哮喘选用长效制剂 Using principles ofβ2-agonist

  30. iv：aminophylline 0.25 doxofylline 0.1 po: aminophylline 0.1 short action AEA 舒氟美 0.1 long action 葆乐辉 0.4 Theophylline

  31. 应用前了解近期茶碱用药史 与西咪替丁、喹诺酮类、大环内酯类药物 合并应用时茶碱减量 肝肾功能不全、心衰、妊娠、老年人减量 急性发作期静脉应用(治疗窗: 10～20ug/ml) 长期治疗用长效制剂(治疗窗: 5～10ug/ml) 夜间哮喘适用长效茶碱 Using principles of theophylline

  32. Ipratropium bromide 爱全乐 20ug×200 爱全乐水溶液 20ml Ipratropium bromide 可必特 20ug×200 ＋Salbutamol 可必特 2ml Anti-cholinergic drug

  33. 适用于COPD合并哮喘 适用于老年人有器质性心脏疾病者 适用于夜间哮喘 复合制剂适用于快速持续缓解哮喘症状 水溶液雾化吸入适用于哮喘急性重症发作 Using principles of anti-cholinergic drug

  34. Anti-histamine ：inhaler：色甘酸钠 5mg×200 oral ： 酮替酚、曲尼斯特 息思敏、开瑞坦等 LTs receptor inhibitor： 顺尔宁 10mg×5 Non-steroid anti-inflammation drugs

  35. 抗组织胺药适用于儿童Atopy 哮喘 季节性哮喘季节发作前二个月应用 白三烯受体拮抗剂可与激素联合应用 白三烯受体拮抗剂对阿斯匹林哮喘、 运动性哮喘、过敏性鼻炎效果更好 Using principles of other anti-inflammation

  36. 短效吸入β 2-激动剂 吸入抗胆碱药 短效口服β 2-激动剂 全身性糖皮质激素 短效茶碱 吸入型糖皮质激素 长效吸入β 2-激动剂 白三烯受体拮抗剂 缓释茶碱 吸入色甘酸钠 尼多克罗米 酮替酚 Drug therapy of asthma 快速缓解药物 长期预防药物

  37. long therapy projects of asthmaGINA 2002 每日控制用药 无需用药 严重度 Step1 间歇发作 其他选择方案

  38. long therapy projects of asthmaGINA 2002 每日控制用药 吸入激素(200-500gBDP或等剂量) 严重度 Step2 轻度持续 其他选择方案 缓释茶碱，或色甘酸钠，或白三烯调节剂

  39. long therapy projects of asthmaGINA 2002 每日用药 吸入激素(200-1000g BDP或等剂量) 加上长效吸入型2-受体激动剂 严重度 Step3 中度持续 其他选择方案 吸入激素(500-1000g BDP或等剂量)加上缓释茶碱或吸入激素(500-1000g BDP或等剂量)加上口服长效2-受体激动剂或吸入高剂量激素(>1000g BDP或等剂量)或吸入激素(500-1000g BDP或等剂量)加上白三烯调节剂

  40. long therapy projects of asthmaGINA 2002 • 每日用药 • 吸入激素(>1000g BDP或等剂量)加上长效吸入型2-受体激动剂 • 根据病情需要，加用以下一种或几种药物 • 缓释茶碱 • 白三烯调节剂 • 长效口服2-受体激动剂 • 口服激素 严重度 Step4 重度持续 其他选择方案

  41. + inhaler long active 2 -agonist(LABA) + long active theophylline + LTs receptor inhibitor Combined therapy Low dose inhaler steroid (400 µg /d) ↘ exacerbation inhaler steroid of double dose Barnes, Nice 2001

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