哮喘(英文和中文).ppt

哮喘(英文和中文).ppt

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1,BronchialAsthma（Asthma）支气管哮喘（哮喘）,2,I.Epidemiology流行病学Averycommondisease哮喘为常见病USA5%美国5China0.5%-1.0%中国0.5%-1.0%Prevalenceisincreasingworldwide全球范围内该病的患病率在上升,3,II.Definition定义Asthmaisachronicinflammatorydisorderoftheairwaysinwhichmanycellsandcellularelementsplayarole.Thechronicinflammationcausesanassociatedairwayhyperresponsivenessthatleadstorecurrentepisodesofwheezing,breathlessness,chesttightness,andcoughing,particularlyatnightorintheearlymorning.Theseepisodesareusuallyassociatedwithwidespreadbutvariableairflowobstructionthatisoftenreversibleeitherspontaneouslyorwithtreatment.,4,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,5,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？

6,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:

boysgirls儿童：

男女Adults:

male男Race/ethnicity种族,7,2.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,8,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,9,NetworkofInflammatoryProcess炎症反应网络,GeneticFactors遗传因素-Envir.Factors环境因素Triggers诱因,Bronchoconstriction,etc.支气管收缩等,Symptoms症状,10,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,11,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,12,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,13,14,15,16,VI.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,17,18,19,VII.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,20,Physicalsigns体征Betweenacuteepisodes：

发作间歇期：

Canbenoabnormalities可无明显异常,21,Duringacuteattack:

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,22,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,23,VIII.Laboratory实验室检查1.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,24,Foratypicalpatients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-FEV17.8mol/LMchPD20-FEV112.8mol/L2.brobchodilatingtests支气管舒张试验FEV115%and200ml3.PEFvariation峰值流速变异率Inaday20%,25,26,27,2.Bloodgasesanalysis血气分析PaO2,PaCO2PaCO2onlyinseverecasesPaCO2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.,28,Hyperinflation过度充气征,29,IX.Diagnosis诊断Typicalcases典型病例Symptoms+signs症状体征Atypicalcases不典型病例Symptoms+signs+lab.TestsBronchoprovocatingtests气道激发试验Brobchodilatingtests支气管舒张试验PEFvariation峰值流速变异率,30,Stagingofdiseaseseverity病情严重程度分级1.Longtermevaluation（Tab.2-4-1）长期病情评价Step1:

Intermittent第一级：

间歇发作Attack1/week,Nightattack2/monthPEF,FEV180%Pr.PEForFEV1-variation20%,31,Step2:

Mildpersistent第二级：

轻度持续发作1/week2/monthPEF,FEV180%Pr.PEForFEV1-variation20-30%,32,Step3:

Moderatepersistent第三级：

中度持续发作AttackeverydayNightattack1/weekNeeddailyuseofinhaledshort-actingb2-agonistPEF,FEV160,30%,33,Step4:

Severepersistent第四级：

重度持续发作AttackfrequentlyNightattackfrequentlyLimitationofphysicalactivityPEF,FEV130%,34,2.Duringacuteexacerbation（Tab.2-4-3）急性发作期病情严重程度评价（见表2-4-3）,35,X.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,36,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,37,2.2-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,38,3.TheophyllinesOral,iv.,ivdrip有口服、静注和静滴制剂Controlsymptomseffectively控制症状有效Notveryeffectiveforinflammation控制气道炎症效不佳Fatalsideeffectsinafewcases个别患者见致死性副作用,39,4.Anticholingergics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,40,5.Leukotrieneantagonists白三烯拮抗剂6.Others其他药物Antihistamineagents抗组织胺药物Ketotifon酮替酚Cromolysodium色苷酸钠,41,XII.Treatment1.Toavoidenvironmentalriskfactors1.避免环境易患因素,42,2.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,43,Step1:

Intermittent第一级：

间歇发作None不需要长期用药,44,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,45,Step3:

Moderatepersistent第三级：

中度持续发作Medicationsofchoice首选药物Inhaledsteroids+inhaledLABA吸入激素吸入长效b-受体兴奋剂,46,OptionsInhaledsteroids+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Orinhaledsteroidsinhighdose或吸入大剂量激素Orinhaledsteroids+leukotrienemodifiers或吸入激素口服白三烯拮抗剂,47,Step4:

Severepersistent第四级:

重度持续发作Oral+inhaled（600g/d）steroids口服吸入激素（600g/d）Oralorinhaled2-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,48,Evaluatingpatientseverythreemonths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,49,3.Tomanageexacerbation急性发作期的治疗a.Mildexacerbation轻度急性发作Inhaled+oral2-agonist吸入口服b受体兴奋剂Oraltheophylline口服茶碱Inhaledsteroids吸入激素Inhaledipratropium吸入异丙托品,50,b.Moderateexacerbation中度急性发作Inhaledororal2-agonist吸入或口服b2-兴奋剂Oraloriv.Theophylline口服或静注茶碱Inhaledipratropium吸入异丙托品Largedoseofinhaledsteroids吸入大剂量激素Oralsteroid口服激素,51,c.Severeandverysevereexacerbation重、危重发作Nebulizedoriv.2-agonist吸入或静注b-兴奋剂iv.Theophyllines静注茶碱iv.Steroids静注激素Balancingfluidandelectrolytes纠正水、电解质紊乱Managingacid-baseimbalance纠正酸中毒,52,Oxygendelivery给氧Mechanicalventilation机械通气Antibioticswhenindicated抗生素（有指征时）Managingcomplications处理并发症heartfailure心衰pneumothorax气胸gastricbleeding消化道出血etc.其他并发症,53,Homework家庭作业1.Readsection4,chapter2,in“TextbookofMedicine”（pp4960）阅读内科学第二篇第四章2.Readrelevantchapterin“TextbookofPharmacology”阅读药理学相关章节,