内科英文版.ppt

Bronchial asthma,Department of respiration,Kong Lingfei,Asthma：human killer!,Background of asthma,Prevalence,：in the world:,1.6,hundred million,in China:,13,in Shenyang:1.24（1999）,GINA:,G,lobal,In,itiative for,A,sthma,（1994）,WHO/HLBI,Bronchial asthmatic diagnosis guideline(,1997）,Chinese Medical Academy,Mechanism:allergy theory,antigen antigen,again,atopyIgE antibodymast cells,basophils,histamine,inflammatory media LTs,PAF,ECP,immediate asthmatic reaction,IAR,bronchial smooth muscle spasm,airway narrow,Mechanism:never-receptor disorder theory,adrenergic and cholinergic nerous systems,AC,non-adrenergic and non-cholinergic nerous systems,NANC,AC:,1,-receptor、M,1-,、M,3-,receptors excitement,NANC：PS-receptor ,bronchial smooth muscle contraction,AC:,-receptor、M,2-,receptor excitement,NANC:VIP receptor ,bronchial smooth muscle dilation,asthmatic airway:a,1,、M,1,、M,3,、PS/,、M,2,、VIP,Mechanism:airway inflammation theory,antigen,allergic airway inflammation,AAI ECP,MBP,inflammatory cells inflammatory media LTs,EOS PAF,neutrophils late asthmatic reaction,LAR,T lymphocyte(Th,1,/Th,2,),Th,2,cytokine IL-3、4、5，GM-CSF IgE,acute,inflammation,chronic,inflammation,airway,remodelling,inflammation cells,epithelium injury,bronchial contraction,mucous,edema,airway sec,re,tion,airway narrow,BHR,airway,reversibility,symptoms,exacerbation,cell proliferation,excellular base,Differ mechanisms in acute and chronic asthma,Diagnosis standards of asthma,symptoms,signs,recovered ways,except other cardiac and pulmonary diseases,lung function examinationuntypical asthma,Lung functions diagnosis of asthma,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(2),PEF meter,PEF predicted value,Lung functions diagnosis of asthma(2),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(3),Bronchial challenge is positive,therapeutic properties,forbid properties,methods drug induce:methocholiner,histamine,exercise induce,The steps of chronic persistent asthma,分级 分度 喘息发作 夜间发作 日常活动 ,FEV,1,PEF,变异率,或,PEF,1 间歇发作 1次/,w 2,次/,m,不受限 80%2,次/,m,发作时受限,80%20%,1次/,w,发作时受限 6080%,2030%,4 重度持续 症状持续 频繁 受限 30%,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 120次/分 120次/次,不规则,奇脉 无,25,mmHg,无,呼衰,用,2,后,PEF 70%5070%50%,或100,L/min,PaO,2,正常 6080,mmHg 95%9195%90%,pH,降低,Correlation between asthma and COPD,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,Steroids with vein injection,methylprednisonlone 40 4 11-hydroxide,40320,Hydrocortison 100 20 11-ketone,1001000,dexamethason 5 0.75 11-ketone,10,30,steroid dose,=,dose character dose/d,(,mg),(,mg)(mg),Inhaled steroids,Baclomethason dipropionate,必可酮(,BDP)50ug200,Budesonide,普米克(,BUD)100ug 100,普米克 都保,普米克令舒 1,mg/2ml,Fluticasone propionate,辅舒酮(,FP)125ug 100,Fluticasone+Salmeterol,舒利迭 100/50,ug60,250/50ug60,Inhaled,2,-,agonists,Salbutamol,万托林 200,ug200,万托林雾化溶液 0.05%20,ml,Terbutaline,喘康速 250,ug200,博利康尼都保,250ug100,博利康尼雾化溶液 5,mg/ml,Salmeterol,施立稳 50,ug200,施立碟,50ug48,Formoterol,奥克斯都保 4.5,ug60,Oral,2,-,agonists,Terbutaline,博利康尼 2.5,mg,Procaterol,美喘清 50,ug,Formoterol,安通克 40,ug,Salbutemol,全特宁 8,mg,Bambuterol,帮备 4,mg,Classification of,2,-,agonsts,(,Politiek,),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,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,起效时间,快,慢,短 长,作用维持时间,快速缓解,维持治疗,Politiek,et al.,Eur Respir J 1999,13:988,Theophylline,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,Using principles of theophylline,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:10,20,ug/ml),长期治疗用长效制剂(治疗窗:5,10,ug/ml),夜间哮喘适用长效茶碱,Anti-cholinergic drug,Ipratropium bromide,爱全乐,20,ug200,爱全乐水溶液,20,ml,Ipratropium bromide,可必特,20,ug200,Salbutamol,可必特,2,ml,Using principles of anti-cholinergic drug,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,Non-steroid anti-inflammation drugs,Anti-histamine：inhaler,：色甘酸钠 5,mg200,oral,：酮替酚、曲尼斯特,息思敏、开瑞坦等,LTs receptor inhibitor：,顺尔宁 10,mg5,Using principles of other anti-inflammation,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,Drug therapy of asthma,快速缓解药物 长期预防药物,短效吸入,2-激动剂,吸入抗胆碱药,短效口服,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,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,严重度,Step1,间歇发作,每日控制用药,无需用药,其他选择方案,long therapy projects of asthma,GINA 2002,严重度,Step2,轻度持续,每日控制用药,吸入激素(200-500,gBDP,或等剂量),其他选择方案,缓释茶碱，或色甘酸钠，或白三烯调节剂,long therapy projects of asthma,GINA 2002,严重度,Step3,中度持续,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,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,long therapy projects of asthma,GINA 2002,严重度,Step4,重度持续,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,其他选择方案,long therapy projects of asthma,GINA 2002,Combined therapy,inhaler steroid,of,double dose,+,inhaler long active,2,-agonist(LABA),+,long active theophylline,+,LTs receptor inhibitor,exacerbation,Low dose inhaler steroid,(400,g/,d,),Barnes,Nice 2001,