哮喘(英文和中文)教学内容.ppt

1、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.Thechronicinflammationcausesanas

2、sociatedairwayhyperresponsivenessthatleadstorecurrentepisodesofwheezing,breathlessness,chesttightness,andcoughing,particularlyatnightorintheearlymorning.Theseepisodesareusuallyassociatedwithwidespreadbutvariableairflowobstructionthatisoftenreversibleeitherspontaneouslyorwithtreatment.,4,KeyPointsChr

3、onicairwayinflammation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

4、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(esp

5、eciallyviralinfections)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Chroni

6、cmucusplugformation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）Baso

7、cytes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Int

8、erleukin-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Mu

9、cusglandsenlargement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,Duringa

10、cuteattack: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,

11、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.Bloodga

12、sesanalysis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+

13、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,Nightattack60,30%,33,Step4:Severepersistent第四级：重度持续发作AttackfrequentlyNightattackfrequentlyLimitati

14、onofphysicalactivityPEF,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

15、,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-agon

16、ist2-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

17、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

18、.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Medicat

19、ionsofchoice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Orinhaledst

20、eroids+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Inhaledi