FeNO用于哮喘管理课件

1、- FeNO用于哮喘患者的长期管理呼出气一氧化氮 (FeNO) 的产生NO 内源性调节分子合成由一系列酶调节 NO 合成酶 (NOS)由iNOS产生的NO主要由支气管壁上皮细胞生成Th2(过敏性)引发的炎症伴随呼出气NO的增高，通常和嗜酸粒细胞性炎症相关Olin et al., Chest, 2006Smith et al., AJRCCM, 2004162200Figures in white = median and 95% C.I.Figures in orange = mean and S.D.ppb528618“Healthy”Untreated asthma部分哮喘病人为非EOS的

2、气道炎症, 用FeNO来诊断哮喘其敏感性及特异性不可能是100%健康人和未经治疗的哮喘患者FeNO值范围哮喘与非哮喘患者FeNO测定结果任旭斌，刘春涛等 .中国呼吸与危重监护杂志，2009.8（4），322-326哮喘组FeNO高于非哮喘组，P0.05 哮喘患者呼出气一氧化氮(FeNO)含量显著升高，并与气道炎症严重程度呈高度正相关FeNO与痰3%E细胞的相关性FeNO21 ppb与 3% 痰嗜酸性粒细胞密切相关在没有用激素患者敏感性97%;特异性58%; 阳性预测值86%，阴性预测值88% 在使用激素患者敏感性81%; 特异性25%;阳性预测值74%;阴性预测值22J Investig Al

3、lergol Clin Immunol. 2015;25(2):107-11 哮喘急性加重与FeNO相关性Pijnenburg MW et al. Thorax. 2005 Mar;60(3):215-8.哮喘急性加重与FeNO相关性van der Valk RJP, Baraldi E, Stern G, Frey U, de Jongste JC. Daily exhaled nitric oxide measurements and asthma exacerbations in children. Allergy 2012; 67: 265271.FeNO与依从性的相关性Positiv

4、e correlation between adherence and reduction in FeNO levels*Adherence determined by calculating number of doses taken per day/doses prescribed x 100.Delgado-Corcoran et al. Pediatr Crit Care Med. 2004;5(1):48-52.FeNO, ppb100120Adherence,* %2003000100806040200-20Severe asthma (n=5)Moderate asthma (n

5、=17)n=41 visitsr=-0.76R2=0.56P=0.001非依从性组加强药物干预后FeNO值下降更明显Am J Respir Crit Care Med ,186:11021108,2012依从性组非依从性组47ppb21%79ppb26%Am J Respir Crit Care Med ,186, :11021108, 2012Non- Adherence group FeNO识别病人对激素的依从性病人自知FeNO水平对配合改善依从性的研究Clinical and Translational Allergy 2013, 3:37高FeNO水平的患者依从性明显低于低、中FeNO

6、水平组的患者明确自己是处于高FeNO水平的患者配合改善依从性百分比明显高于低、中FeNO水平的患者FeNO策略组显著优于对照组症状评分急性复发率The Journal of Allergy and Clinical Immunology, 639-648,2013FeNO以更少激素减少急性加重率Use of Exhaled Nitric Oxide Measurements to Guide Treatment in Chronic Asthma ：N Engl J Med 2005;352:2163-73FeNO 测定可以显著减少ICS维持剂量，而不影响哮喘控制 哮喘其他控制指标、肺功能、口

7、服激素或气道炎症水平（诱导痰嗜酸粒细胞计数）无差异。FeNO组Control组病人数（n）4648平均每日ICS用量(氟替卡松)370 g641 g 减少270g (P=0.003)急性发作频率0.49 /人/年0.90 /人/年45.60%Use of Exhaled Nitric Oxide Measurements to Guide Treatment in Chronic Asthma ：N Engl J Med 2005;352:2163-73急性加重频率-FeNO策略组优于GINA策略组FeNO as a Marker of Airways Inflammation:The Pos

8、sible Implications in Childhood Asthma Management： Journal of Allergy Volume 2010 哮喘发作人数-FeNO策略组优于GINA策略组FeNO as a Marker of Airways Inflammation:The Possible Implications in Childhood Asthma Management： Journal of Allergy Volume 2010 哮喘发作无哮喘发作抗炎药物使用量FeNO组未显著增加，而GINA策略组则显著增加FeNO as a Marker of Airwa

9、ys Inflammation:The Possible Implications in Childhood Asthma Management： Journal of Allergy Volume 2010 FeNO StrategyControl StrategyStudyExacerbation RateTotal No. PatientsExacerbation RateTotal No. PatientsWeightRelative Rate (95% CI)Shaw 20070.33520.425122.1%0.79 (0.43, 1.44)Smith 20050.49460.94

10、88.1%0.54 (0.20, 1.46)Powell 20110.2881110.61510944.8%0.50 (0.33, 0.76)Combined0.312090.58208100.0%0.56 (0.42, 0.74)RR0.1 0.2 0.5 1.0 2 5 10Favors FeNO Favors Control恶化率降低47% Donohue, J.F. and N. Jain. Exhaled nitric oxide to predict corticosteroid responsiveness and reduce asthma exacerbation rates

11、. Respiratory Medicine, 2013. 107(7): p.943-952综合3个研究，显示与传统临床管理方法相比，FeNO指导的管理组哮喘急性发作率降低47%ICS剂量在FeNO管理组和对照组基本相同，或者倾向于FeNO策略组更低成人哮喘加重发生率的Meta分析FeNO较常规策略管理妊娠哮喘患者更有效降低急性发作率，减少吸入激素用量7550150Time, weeksExacerbations, nPowell et al. Lancet. 2011;378(9795):983-990.Control group (n=109)FeNO group051015202590

12、0800700600500VisitMean ICS dose, g/dControl group (n=109)FeNO group (n=111)123456P=0.043FeNO组急性发作率为28.8%，对照组急性加重率为 61.5% (P=0.011) NNT=6; 每6个基于FeNO策略治疗的患者，有1名哮喘未急性发作与对照组(17%)相比，新生儿住院时间显著减少(8%; P=0.046)更少的激素吸入量降低疾病的急性加重FeNO联合ACQ更准确判定哮喘控制2013ACQ评分一年后，FeNO策略组的控制水平与完全控制策略组相近激素用量FeNO策略组在三组中，无论ICS用量还是口服激素用量，都是最低的FeNO与FEV1联合预判哮喘发作Role of Spirometry and Exhaled Nitric