内科学英文课件：Bronchial-asthma

Bronchialasthma

支气管哮喘BronchialasthmaThosetoberememberedThosetoberememberedMorbidityofasthmaMorbidityofasthmaMortalityofasthma在中国有1500万，全球3亿哮喘患者，每100，000位哮喘患者中有36.7位哮喘患者会因哮喘死亡。Mortalityofasthma在中国有1500万，全DefinitionAsthmaisaheterogeneous

disease,characterizedbychronicairwayinflammation.Itisdefinedbyhistoryofrespiratorysymptomssuchaswheeze,shortnessofbreath,chesttightnessandcoughthatvaryintimeandintensity,togetherwithvariableexpiratoryflowlimitation.DefinitionAsthmaisaheteroge哮喘的定义Allergicinflammation气道慢性变态反应性炎症Inflammatorycells由多种炎症细胞：如嗜酸粒细胞、肥大细胞、T淋巴细胞、嗜中性粒细胞、Structuralcells气道结构细胞：平滑肌、气道上皮细胞等）细胞组分(cellularelements)参与的气道慢性炎症性疾病慢性炎症导致气道高反应性（airwayhypersensitivity）引起反复发作性的喘息、气急、胸闷或咳嗽等症状，常在夜间和（或）清晨发作、加剧通常出现广泛多变的可逆性气流受限，多数患者可自行缓解或经治疗缓解

哮喘的定义Allergicinflammation气道慢性PathogenesisGeneticfactorsAirwayimmunity-inflammationAllergicresponse-earlyasthmaticandlateasthmaticresponseairwayhyperresponsivenessairwayremodellingNeurologicaccomodationPathogenesisGeneticfactorsPathogenesisofasthma环境因素遗传易感个体炎症细胞、细胞因子及炎症介质相互作用气道神经调节失衡及气道平滑肌结构功能异常气道炎症气道高反应性症状性哮喘环境激发因子气道高反应性气道炎症气道重建Pathogenesisofasthma环境因素遗传易感咳嗽喘息呼吸困难

诱发因素：活动后吸入冷空气后夜间感冒后突然发作性体征呼气时产生哮鸣音规律：节律性(夜间发作)季节性(春、秋)自然/用药缓解Cardinalmanifestations-typical咳嗽喘息呼吸困难诱发因素：体征规律：CardinalCardinalfeatureofasthmaVariablesymptomsofwheeze,shortnessofbreath,chesttightnessand/orcoughVariableairflowlimitationBothsymptomsandairflowlimitationvaryovertimeandinintensityTriggers:exercise,allergen,irritantexposure,changeinweather,viralrespiratoryinfectionResolutionspontaneouslyorwithmedicationAirwayhyperresponsivenessandinflammationpersists,evenwhensymptomsareabsent/normallungfunctionCardinalfeatureofasthmaVariGenerallymorethan2typesofsymtomsSymptomsoccurvariablyovertimeandvaryinintensitySymptomsareworseatnightoronwakingSymptomsareoftentriggeredbyallergens,exercise,laughter,coldairSymptomsoftenappearorworsenwithviralinfectionCardinalmanifestationsGenerallymorethan2typesofAtypicalasthmaCoughorchesttightnessCough-variantasthma:coughonlyoftenatnightorearlyinthemorningTriggeredbyexercise\coldairRelievedwithbronchodilators\ICSAtypicalasthmaCoughorchest特殊类型哮喘Exercise-inducedasthmaAspirinasthma：asthma,nasalpolypandaspirinintoleranceAsthma-COPDoverlapsyndrome特殊类型哮喘Exercise-inducedasthmaAsthmaTRIGGERS

ENVIRONMENTALFACTORSAllergens•Indoor:Domesticmites,furredanimals(dogs,cats,mice),cockroachallergen,fungi,molds,yeasts•Outdoor:Pollens,fungi,molds,yeastsInfections(predominantlyviral)ExerciseDrugs:aspirinDiet:fish,milk,egg,prawn,crabPsychiatricOccupationalsensitizersAsthmaTRIGGERS

内科学英文课件：Bronchial-asthma内科学英文课件：Bronchial-asthmaLabTesingLungfunctiontest

Bronchodilationtest:airwayreversibilitypostFEV112%,∆FEV1>200ml

Bronchialprovocationtest:bronchialhyperreactivitypost-FEV120%

PEPvariationSpecificallergentestFractionalExhalednitricoxide(FeNO)LabTesingLungfunctiontestLabtestingBloodeosinophilsChestX-rayBloodgasanalysisMild：PaCO正常或降低，PaO2正常，pH正常或呼吸性碱重度Severe：PaCO正常或降低，PaO2正常，pH偏酸，呼吸性或代谢性酸中毒LabtestingBloodeosinophils1.反复发作性喘息、呼吸困难、胸闷或咳嗽，多与接触变应原、冷空气、物理化学剌激、病毒感染、运动等有关

2.可闻哮鸣音

3.上述症状可经治疗或自行缓解

4.症状不典型者(如无明显喘息和体征)至少应有下列三项中的一项阳性∶（1）支气管激发试验或运动试验阳性；（2）支气管舒张试验阳性；（3）呼气流量峰值（PEF）日内变异率或昼夜波动率≥20％

5.除外其他疾病所引起的喘息、胸闷和咳嗽符合1～4条或4、5条者，可诊断咳嗽变异性哮喘：Diagnosis1.反复发作性喘息、呼吸困难、胸闷或咳嗽，多与接触变应SeverityandstagingSeverity:mild,moderate,severeStaging:Chronicpersistent:weeklyChronicremission:3monAcuteexacerbationSeverityandstagingSeverity:Severityof

asthma轻症哮喘Mildasthma中度哮喘Moderateasthma重度哮喘severeasthmaGINAupdated2014Severityof

asthma轻症哮喘中度哮喘重度哮喘表3哮喘急性发作时病情严重程度的分级

临床特点轻度中度重度危重气短

体位

讲话方式

精神状态

出汗

呼吸频率

辅助呼吸肌活动及三凹征

哮鸣音

脉率

奇脉

使用β2激动剂后PEF预计值PaO2（吸空气）

PaCO2

SaO2（吸空气）

PH步行、上楼时

可平卧

连续成句

可有焦虑尚安静

常无

轻度增加

常无

散在，呼吸末期

<100次／min

无，<10mmHg

>80％

正常

<45mmHg

>95％

稍事活动

喜坐位

单词

时有焦虑或烦燥

有

增加

可有

响亮、弥漫

100～120次可有

60％～80％

≥60mmHg

≤45mmHg

91％一95％

休息时

端坐呼吸

单字

常有焦虑、烦躁

大汗淋漓

常>30次／min

常有

响亮、弥漫

>120次／min

常有，

<60％或<100％

<60mmHg

>45mmHg

≤90％

不能讲话

嗜睡或意识模糊

胸腹矛盾运动

减弱、乃到无

脉率变慢不规则

无，提示呼吸肌疲劳

降低

表3哮喘急性发作时病情严重程度的分级临床特点轻度中度重度AsthmainspecialpopulationExercise-inducedasthmaDrug-inducedasthmaObesityasthmaOccupationalasthma>>>>>>>>>>>>>>>>>>>>AsthmainspecialpopulationExDifferentialdiagnosisLeftheartfailureCOPDUpperairwayobstructionAllergicbronchopulmonaryaspergillosisDifferentialdiagnosisLeftheaComplicationsPneumothoraxPneumomediastinumLungatelectasisBronchiectasisCOPDCorPulmonaleInterstitiallungdiseaseComplicationsPneumothoraxPharmacotherapyofasthmaRelieverInhaledshort-acting2agonistOralshort-acting2agonistAnticholinergicsMethylxanthinesSystemicsteroidControllerInhaledsteroidInhaledlong-acting2agonistOrallong-acting2agonistLeukotrienemodifierMethylxanthinesCromonesSystemicsteroidIgEAbImmunotherapyPharmacotherapyofasthmaRelieClassificationofß2agonists作用时间Classificationofß2agonists作Inhaledsteroid布地奈德氟替卡松二丙酸倍氯米松环索奈德Inhaledsteroid布地奈德氟替卡松二丙酸倍氯米松

Managementofasthma

一、治疗目标

1．达到并维持哮喘控制

2．保持正常活动；包括运动能力

3．维持肺功能维持在接近正常水平

4．预防哮喘急性加重5．避免哮喘药物的不良反应

6．预防哮喘死亡，降低哮喘死亡率

Managementofasthma一CombinationtherapyInhaledcorticosteroid(ICS)+long-actingbetaagonist(LABA)fluticasone+salmeterol(Advair.Seretide舒利迭)Budesonide+formoterol(Symbicort信必可)CombinationtherapyInhaledcorMDIMDI内科学英文课件：Bronchial-asthmaDiskhalerDiskhalerNebulizerNebulizerStep1:Asneededrelieverinhaler,orICS(riskexacerbation.Step2:lowdosereliever+SABAprn(ICS/LTA/theo)Step3:1or2controller+asneededreliever(lowICS+LABA/LTA/theo)Step4:2ormorecontroller+asneededreliever(moderateICS+LABA/LTA/theo)Step5:added-ontherapy:anti-IgE,thermoplasty,OCSStepwisecontrolforasthmaStep1:AsneededrelieverinhStepwisecontrolofasthmaandreducerisksStepwisecontrolofasthmaand哮喘的治疗-达到哮喘控制为基础哮喘的治疗-达到哮喘控制为基础LevelsofasthmacontrolDaytimesymptoms>2/wkNightawakingRelieverneeded>2/wkActivitylimitationNone1~2ofthose3~4ofthoseWellcontrolledPartlycontrolledUncontrolledGINAupdated2014Symptomspast4wksLevelofcontrolLevelsofasthmacontrolDaytim哮喘治疗与评价多数哮喘从2级开始，症状频繁者3级2-4wk复诊，后1-3月复诊哮喘评价：良好控制/部分控制/未控制达到控制后维持3月后减量激素减量50%低剂量改为qd联合用药者，减激素50%哮喘治疗与评价多数哮喘从2级开始，症状频繁者3级哮喘升级治疗持续升级（2-3月）：初始治疗反应差短期升级（1-2周）：病毒感染、季节过敏原日间调整：含福莫特罗制剂，维持、缓解方案哮喘升级治疗持续升级（2-3月）：初始治疗反应差哮喘长期治疗方案哮喘教育环境控制按需使用速效2-激动剂按需使用速效2-激动剂可选择的控制药物选用一种选用一种在第三级基础上，选用一种或多种在第四级基础上，加用一种低剂量ICS低剂量ICS加长效2-激动剂中/高剂量ICS加长效2-激动剂口服糖皮质激素(最小剂量)白三烯调节剂/茶碱中/高剂量ICS白三烯调节剂抗IgE治疗低剂量ICS加白三烯调节剂缓释茶碱低剂量ICS加缓释茶碱第一级第二级第三级第四级第五级升级降级5.FromtheGlobalStrategyforAsthmaManagementandPrevention,GlobalInitiativeforAsthma(GINA)2011.Availablefrom:/.哮喘长期治疗方案哮喘教育环境控制按需使用速效2-激动控制部分控制未控制急性加重控制水平维持治疗并明确最低治疗级别考虑升级治疗，已达到控制升级治疗直至达到控制按急性加重治疗治疗措施治疗级别降级升级第1级第2级第3级第4级第5级降级升级控制部分控制未控制急性加重控制水平维持治疗并明确最低治疗级别OthertherapiesAvoidanceoftriggersImmunotherapyEducationBiotherapy:monoclonalantibody:anti-IL5;anti-IL4α(blockIL13/IL14)BronchialthermoplastyOthertherapiesAvoidanceoftrOxygentherapySaO2>92%Bronchodilatortherapy:SABA+iprotropium+theophyllineSteroidtherapy:methylprednisone40-160mg/dManagementofacid-baseandelectrolytedisturbanceFluidtherapy:2500ml/dAntibiotictherapyManagementofcomplicationManagementofsevereexacerbationOxygentherapySaO2>92%ManagManagementofAsthmaExacerbationsinAcuteCareSettingManagementofAsthmaExacerbatOverallcontrolSymptomscontrolNormalactivityReducefuturerisks：AsthmaattackFixedairflowlimitationSideeffectsOverallcontrolofasthmaGINAupdated2014BatemanED,etal.JAllergyClinImmunol.2010;125(3):600-8.OverallcontrolSymptomscontroSummaryInflammatoryairwaydiseasewithBHRTriggersorenvironmentalexposureAsthmaticsymptomsAntiasthmaticdrugsManagementofasthma(includingexacerbation)SummaryInflammatoryairwaydisINTERSTITIALLUNGDISEASE弥漫性间质性肺病INTERSTITIALLUNGDISEASE肺间质肺间质包含肺泡上皮与肺血管内皮的空间，包含多种细胞如成纤维细胞、成纤维细胞母细胞、巨噬细胞，还有基质包括胶原、弹力蛋白和糖蛋白).肺间质肺间质包含肺泡上皮与肺血管内皮的空间，包含多种细胞如成Interstitium肺间质的概念Interstitium肺间质的概念

肺脏基本功能单位与肺间质肺脏基本功能单位与肺间质肺容积缩小弥散量降低低氧血症呼吸困难肺容积缩小弥散量降低低氧血症呼吸困难间质性肺病的概念间质性肺病（InterstitialLungDisease，ILD）为累及肺泡壁以及肺泡周围组织和其周围结构的非感染、非肿瘤性一组疾病。

ILD可累及细支气管与肺实质，又被称为弥漫性实质性肺病(DiffuseParenchymalLungDisease，DPLD)间质性肺病的概念间质性肺病（InterstitialLun间质性肺病的共性肺容积缩小肺弥散功能减低呼吸困难，特别运动后运动后或疾病低氧血症好影像学弥漫性改变病理学表现为肺实质/间质不同程度纤维化/炎症间质性肺病的共性肺容积缩小已知原因的DPLD职业性肺病药物性肺病结缔组织疾病相关性ILD特发性间质性肺炎（IIP）肉芽肿所致DPLD结节病过敏性肺炎肉芽肿并血管炎少见DPLD肺泡蛋白沉积症肺出血-肾炎综合征淋巴管平滑肌肌瘤病朗格汉斯组织细胞增生症特发性含铁血黄素沉着症慢性嗜酸细胞性肺炎弥漫性肺间质疾病（DPLD）间质性肺病的分类已知原因的DPLD职业性肺病症状与体征

RespiratorySymptomsandSignsDyspnea:Progressivedyspnea,exertional/resting--themostcommoncomplaint.10%ILDmaypresentwithdyspneawithanormalchestradiograph.SuspectionafterexclusionofCOPD,Pulmonarythromboembolism.Cough:IPF,sarcoidosis,HP,COPChestPain:CTD-ILD,pneomothoraxwithLMWheezing:sarcoidosis,Hypersensitivitypneumonia症状与体征

RespiratorySymptomsandBibasilarinspiratorycrackles(爆裂音):characteristicphysicalsigninILD.Mechanism.DryralesDigitalclubbing,(杵状指)amarkerofadvancedfibroticdisease,ofteninIPF;症状与体征RespiratorySymptomsandSignsBibasilarinspiratorycrackles实验室检查

LaboratoryInvestigationAutoantibodies(rheumatoidfactor,antinuclearfactors)CVD,IPF,WG,MPA,NSIPSerumangiotensinconvertingenzyme:SarcoidosisEosinophilia:EosinophilicpneumoniaAntibasementmembraneantibody:Antineutrophiliccytoplasmicantibody:WG,MPAIncreasedserumLDH:IPF实验室检查

LaboratoryInvestigation影像学检查

RadiographicFeaturesGround-glassopacification毛玻璃影Reticularornodular网格/结节影Honey-combing蜂窝影影像学检查

RadiographicFeaturesGroReticularpattern网格影Reticularpattern网格影Nodule-结节影Nodule-结节影Honey-combing蜂窝肺IPFHoney-combing蜂窝肺IPFGroundglassopacity(GGO)pulmonaryalveolarproteinosisGroundglassopacity(GGO)pulmoBronchoalveolarLavage肺泡灌洗Normal：细胞总数5~10x106，巨噬细胞85~90%，L10~15%，N+E1%Diagnosis:E>25%eosinophilicpneumoniaperiodicacid–Schiff(PAS)+:alveolarproteinosisBALlymphocytes(>35%)sarcoidosis,HP,LIP,drug-inducedILDResponsetotherapy:lymphocytosisBronchoalveolarLavage肺泡灌洗Norm内科学英文课件：Bronchial-asthmaBAL-AlveolarproteinosisBAL-AlveolarproteinosisPhysiologicTestingRestrictionDiffusiondefectPreservationofairflowIncreaseinP(A-a)O2Exercise-inducedhypoxaemiaHyperventilationPhysiologicTestingRestrictionPFTPFTLungBiopsy-definitivediagnosisThefinalstepinthediagnosticevaluationofapatientwithILDistodecidewhetheritisnecessarytoobtainlungtissue.TranbronchialLungBiopsy经气管镜肺活检Percutaneouslungbiopsy经皮肺活检Video-assitedthoracosopiclungbiopsy胸腔镜活检Openlungbiopsy开胸肺活检LungBiopsy-definitivediagnosDiagnosisDiagnosisThyerapyAvoidanceofexposureSteroidtherapyAntifibrotictherapySymptomatictherapyOthersThyerapyAvoidanceofexposureIDIOPATHICPULMONARYFIBROSIS(IPF)特发性肺纤维化IDIOPATHICPULMONARYFIBROSIS(IDIOPATHICINTERSTITIALPNEUMONIA(IIP)

特发性间质性肺炎IIPsareagroupofdiffuseparenchymallungdiseases(DPLDs),agroupalsodescribedasinterstitiallungdiseasesTheIIPsareaheterogeneousgroupofnonneoplasticdisordersresultingfromdamagetothelungparenchymabyvaryingpatternsofinflammationandfibrosis.Idiopathicindicatesunknowncauseandinterstitialpneumoniareferstoinvolvementofthelungparenchymabyvaryingcombinationsoffibrosisandinflammation,incontrasttoairspacediseasetypicallyseeninbacterialpneumonia.IDIOPATHICINTERSTITIALPNEUMO特发性间质性肺炎（IIP）特发性肺纤维化（IPF/UIP）呼吸性细支气管炎伴间质性肺病（RBILD）隐原性机化性肺炎（COP）脱屑型间质性肺炎（DIP）急性间质性肺炎（AIP）非特异性间质性肺炎(NSIP)淋巴细胞间质性肺炎(LIP)间质性肺病的分类主要IIP少见

IIP未能分类的IIP特发性胸膜肺实质的弹力纤维增生症AmJRespirCritCareMedVol188,Iss.6,pp733–748,Sep15,2013特发性间质性肺炎（IIP）特发性肺纤维化（IPF/UIP）呼ClassificationsofIIPsClassificationsofIIPs特发性间质性肺炎的病理学特征特发性间质性肺炎的病理学特征IIP的临床病理相关分类临床-影像-病理诊断临床和/或病理形态学类型慢性至纤维化性IP特发性肺纤维化IPF特发性非特异性间质性肺炎INSIP普通型间质性肺炎UIP非特异性间质性肺炎NSIP吸烟相关性IP呼吸性细支气管炎-间质性肺炎RB-ILD脱屑型间质性肺炎DIP呼吸性细支气管炎RB脱屑型间质性肺炎DIP急性/亚急性IP隐源性机化性肺炎COP急性间质性肺炎AIP机化性肺炎OP弥漫性肺泡损伤DADIIP的临床病理相关分类临床-影像-病理诊断临床和/或病理形根据病情IIP分类根据病情IIP分类Idiopathicpulmonaryfibrosis(IPF)isdefinedasaspecificformofchronic,progressivefibrosinginterstitialpneumoniaofunknowncause,occurringprimarilyinolderadults,andlimitedtothelungs.Itischaracterizedbyprogressiveworseningofdyspneaandlungfunctionandisassociatedwithapoorprognosis.IPFasadistinctclinicalentityassociatedwiththehistologicappearanceofusualinterstitialpneumonia(UIP).IPF-DefinitionIdiopathicpulmonaryfibrosisPotentialRiskFactorsGeneticfactorsCigarettesmokingEnvironmentalfactorMicrobialagentsGastroesophagealrefluxPotentialRiskFactorsGeneticClinicalFeaturesSymptoms&SignsExertionaldyspneaCoughClubbingfingerBasilarcrackle（Velcro啰音）ClinicalFeaturesSymptoms&SignHRCT诊断UIP征象UIP征象(所有4项)可能UIP征象(所有3项)不符合UIP征象(任何1项)胸膜下、基地分布网格样改变蜂窝肺+伴支气管扩张无不符合UIP征象胸膜下、基地分布网格样改变无不符合UIP征象上或中肺野分布支气管周围分布广泛磨玻璃阴影为主广泛微结节分散囊样病变弥漫马赛克征肺支气管叶、段实变SubjectedtoexternalreviewHRCT诊断UIP征象UIP征象可能UIP征象不符合UIDEFINITIONOFUIPPATTERNDEFINITIONOFUIPPATTERNInconsistentwithUIPpatternInconsistentwithUIPpatternUIP的病理诊断典型UIP不符合UIP很可能UIP可能UIPUIP的病理诊断典型UIP不符合UIP很可能UIP可能UIPDiagnosisofIPFDiagnosisofIPFIPF诊断标准

DiagnosticCriteria1.除外其它已知原因ILD(如室内或职业性环境暴露，结缔组织病、药物毒性等).2.HRCT具备典型UIP特征无需性外科肺活检。3.不典型需要结合HRCT及外科活检病理特征。肺功能、症状、体征---辅助作用IPF诊断标准

DiagnosticCriteria1.影像-病理-临床诊断影像-病理-临床诊断AcuteExacerbationofIPF（AEIPF）CriteriaforAEIPF:unexplainedworseningofdyspneawithin1month,Hypoxemianewradiographicalveolarinfiltratesabsenceofanalternativeexplanationinfectionpulmonaryembolismpneumothoraxheartfailure.AcuteExacerbationofIPF（AEIPTherapyforIPFTherapyforIPFIPF–Evidence-BasedTreatment:Strongrecommendationagainsttheuse:Corticosteroidmonotherapy(verylow)Colchicine(verylow)秋水仙碱CyclosporineA(verylow)环孢霉素Combinedcorticosteroidandimmune-modulatortherapy(low)激素+免疫调节剂Interferongamma1b(high)干扰素Bosentan(moderate)波生坦IPF–Evidence-BasedTreatment激素+免疫调节剂无效

NEnglJMed2012;366:1968-77.激素+免疫调节剂无效

NEnglJMed2012;3华法令与IPF华法令与IPF吡非尼酮