哮喘(英文和中文)

1BronchialAsthma(Asthma)

支氣管哮喘（哮喘）I.Epidemiology流行病學Averycommondisease哮喘為常見病USA5%美國5％China0.5%-1.0%中國0.5%-1.0%Prevalenceisincreasingworldwide全球范圍內該病的患病率在上升II.Definition定義

Asthmaisachronicinflammatorydisorderoftheairwaysinwhichmanycellsandcellularelementsplayarole.Thechronicinflammationcausesanassociatedairwayhyperresponsivenessthatleadstorecurrentepisodesofwheezing,breathlessness,chesttightness,andcoughing,particularlyatnightorintheearlymorning.Theseepisodesareusuallyassociatedwithwidespreadbutvariableairflowobstructionthatisoftenreversibleeitherspontaneouslyorwithtreatment.KeyPointsChronicairwayinflammation氣道慢性炎癥

Airwayhyperresponsiveness氣道高反應性

Reversibleairflowobstruction可逆性氣道狹窄

Symptoms:癥狀

Wheezing喘鳴

Breathlessness氣短

Chesttightness胸悶

Coughing

咳嗽

Typicallyatnightorintheearlymorning

典型者于深夜或凌晨發(fā)作III.Etiology病因Unknown不明Geneticfactors?遺傳因素？Environmentfactors?環(huán)境因素？Thecombinationofthesetwo?遺傳與環(huán)境因素共同作用？IV.RiskFactors易患因素1.HostFactors患者的因素

Geneticpredisposition遺傳易患性

Atopy過敏體質

Airwayhyperresponsiveness氣道高反應性

Gender性別

Children:boys>girls兒童：男>女

Adults:male<female成人：女>男

Race/ethnicity

種族

2.EnvironmentalFactors環(huán)境的因素

Allergens(domesticmites,animalallergens,fungi,etc.)

過敏原（屋塵螨，動物過敏原，真菌，等等）

Respiratoryinfections(especiallyviralinfections)

呼吸道感染（尤其是病毒感染）

Exerciseandhyperventilation運動和高通氣

Weather氣候變化

Sulfurdioxide二氧化硫

Food食品

Additives食品添加劑

Drugs藥品V.Pathogenesis發(fā)病機制Envir.factors+Geneticfactors環(huán)境＋遺傳因素

ChronicAirwayInflamation慢性氣道炎癥

Acutebronchoconstriction急性支氣管收縮

Hyperresponsiveness氣道高反應性

Swellingoftheairwaywall氣道壁腫脹

Chronicmucusplugformation慢性粘液栓形成

Airwaywallremodeling氣道壁構型重建

Airflowobstruction氣流阻塞

Symptoms各種癥狀1NetworkofInflammatoryProcess炎癥反應網(wǎng)絡2GeneticFactors遺傳因素------Envir.Factors環(huán)境因素Triggers誘因3Bronchoconstriction,etc.支氣管收縮等4Symptoms癥狀Relevantcells有關的細胞

Mastcells肥大細胞

Eosinophils嗜酸細胞

Tlymphocytes(Th1/Th2)T細胞(Th1/Th2）

Basocytes嗜堿細胞

Neutrophils中性粒細胞

Alveolarmacrophages肺泡巨噬細胞

Epithelium上皮細胞

others其他Relevantmolecules有關的生物分子

InflammatoryMediators炎癥介質

Histamine組織胺

Acetylcholine乙酰膽堿

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

Pro-inflammatorycytokines促炎癥性細胞因子

Interleukin-4(IL-4)白介素-4IL-5白介素-5Tumornecrosingfactor-a(TNF-a)腫瘤壞死因子-aetc.其他Anti-inflammatorycytokines抗炎癥性細胞因子

IL-18白介素-18IL-10白介素-10etc.其他131415VI.Pathology病理學1.Attheearlystage早期

Chronicairwayinflammation慢性氣道炎癥2.Later后期

Chronicairwayinflammation慢性氣道炎癥

Airwayremodeling氣道構型重建

ASMCproliferationASMC增生

Mucusglandsenlargement黏液腺肥大

Subepithelialfibrosis上皮下纖維化

Others其他1718VII.Clinicalmanifestations臨床表現(xiàn)Symptoms癥狀Episodicbreathlessnessandwheezing,worseparticularlyatnightandintheearlyhoursofthemorning.陣發(fā)性氣短、喘鳴，深夜和凌晨尤其明顯Physicalsigns體征01Betweenacuteepisodes：發(fā)作間歇期：02Canbenoabnormalities可無明顯異常03Duringacuteattack:急性發(fā)作期

Wheezing----notalwaysparallelsthesymptoms

哮鳴音－－其強度并不總是與癥狀平行

Signsofhyperinflation----hypersonance

肺過度充氣癥－－叩診過度反響

Signsofcomplication并發(fā)癥的體征

Infection感染

Pneumothorax氣胸

Respiratoryfailure呼衰

Heartfailure心衰

etc.其他Atypicalasthma不典型哮喘Symptom癥狀Cough咳嗽Tightchest胸悶Breathlessness氣短Signs體征Withoutwheezing沒有哮鳴音VIII.Laboratory實驗室檢查Pulmonaryfunctiontests肺功能檢查FEV1第一秒用力肺活量下降FEV1/FVCFEV1/用力肺活量比值下降03040201Foratypicalpatients非典型患者應該進行以下檢查1.Bronchoprovocatingtests氣道激發(fā)試驗

Histamine(組織胺）

PD20-FEV1<7.8

mol/LMchPD20-FEV1<12.8

mol/L2.brobchodilatingtests支氣管舒張試驗

FEV1

15%and200ml3.PEFvariation峰值流速變異率

Inaday

20%25262.Bloodgasesanalysis血氣分析

PaO2

,PaCO2

PaCO2

onlyinseverecasesPaCO2

僅見于嚴重病例

3.X-rayfilmX線胸片

Hyperinflation過度充氣征

SignsofComplications并發(fā)癥表現(xiàn)4.Skintestsforspecificantigens過敏原皮試5.Others其他

Bloodroutine血常規(guī)

Sputumculture痰培養(yǎng)

etc.Hyperinflation過度充氣征

IX.Diagnosis診斷Typicalcases典型病例

Symptoms+signs癥狀＋體征Atypicalcases不典型病例

Symptoms+signs+lab.Tests

Bronchoprovocatingtests氣道激發(fā)試驗

Brobchodilatingtests支氣管舒張試驗

PEFvariation

峰值流速變異率

Stagingofdiseaseseverity病情嚴重程度分級Longtermevaluation(Tab.2-4-1)長期病情評價Step1:Intermittent第一級：間歇發(fā)作Attack<1/week,Nightattack<2/monthPEF,FEV180%Pr.PEForFEV1-variation<20%Step2:Mildpersistent第二級：輕度持續(xù)發(fā)作1/week<attack<1/dayNightattack>2/monthPEF,FEV180%Pr.PEForFEV1-variation20-30%Step3:Moderatepersistent第三級：中度持續(xù)發(fā)作AttackeverydayNightattack>1/weekNeeddailyuseofinhaledshort-actingb2-agonistPEF,FEV1>60,<80%Pr.PEForFEV1-variation>30%Step4:Severepersistent第四級：重度持續(xù)發(fā)作AttackfrequentlyNightattackfrequentlyLimitationofphysicalactivityPEF,FEV1<60%Pr.PEForFEV1variation>30%Duringacuteexacerbation(Tab.2-4-3)急性發(fā)作期病情嚴重程度評價（見表2-4-3）12X.Differentialdiagnosis鑒別診斷

(Table2-4-4)

Leftventricularfailure左心衰

Chronicasthmaticbronchitis慢喘支

Acutebronchitis(esp.ininfants)急性支氣管炎

Lungcancer肺癌

Benignairwaynarrowing良性氣道狹窄

Allergicpulmonaryinfiltration過敏性肺浸潤

……

XI.Drugsusedinasthma哮喘治療藥物1.Corticosteroids糖皮質激素

Inhaler,oral,iv.,ivdrip劑型包括吸入、口服、靜注、靜滴

Bestdrugtocontrolchronicairwayinflammation

是控制慢性氣道炎癥最有效的藥物

Slow-acting(2w.forinhaler,6hforiv.)

起效較慢（吸入制劑需兩周，靜脈注射需6小時）

Sideeffects:commonwhenusedsystemically,butveryfewwithinhalers

副作用：全身用藥副作用較多，吸入用藥副作用極少2-agonist2-受體激動劑Inhaler,oral有吸入和口服制劑Controlsymptomsquickly可以迅速控制癥狀Short-actingagentsareineffectiveforinflammation,butlong-termagentsare.短效制劑對于氣道炎癥無效，而長效制劑有效3.Theophyllines38Oral,iv.,ivdrip有口服、靜注和靜滴制劑Notveryeffectiveforinflammation控制氣道炎癥效不佳Controlsymptomseffectively控制癥狀有效Fatalsideeffectsinafewcases個別患者見致死性副作用0504020301Anticholingergics抗膽堿能藥物ipratropiuminhaler吸入制劑（如異丙托品）actsratherweakly,withfewsideeffects作用較弱，副作用少esp.goodforoldpeople尤其適用于老年人Leukotrieneantagonists白三烯拮抗劑Others其他藥物Antihistamineagents抗組織胺藥物Ketotifon酮替酚Cromolysodium色苷酸鈉XII.Treatment41Toavoidenvironmentalriskfactors避免環(huán)境易患因素壹貳2.Medicationplansforlong-termmanagement(Tab.2-4-8)長期藥物治療方案

Mostpatientsneedlong-termmedicationinordertocontrolthechronicairwayinflammationandtopreventacuteexacerbation.

為了控制慢性氣道炎癥炎癥，預防急性發(fā)作，多數(shù)患者需要長期藥物治療

Stepwiseapproach

階梯治療Step1:Intermittent第一級：間歇發(fā)作None不需要長期用藥Step2:Mildpersistent第二級：輕度持續(xù)發(fā)作

Medicationsofchoice首選藥物

Inhaledsteroids吸入糖皮質激素

Options可選藥物

Sustained-releasetheophylline控釋茶堿

Orcromone或色苷酸鈉

Orleukotrienemodifier或白三烯拮抗劑Step3:Moderatepersistent第三級：中度持續(xù)發(fā)作01Medicationsofchoice首選藥物02Inhaledsteroids+inhaledLABA吸入激素＋吸入長效b-受體興奮劑03OptionsInhaledsteroids+theophylline(long-acting)吸入激素＋口服長效茶堿Orinhaledsteroids+oralLABA或吸入激素＋口服長效b-受體興奮劑12345Orinhaledsteroids+leukotrienemodifiers或吸入激素＋口服白三烯拮抗劑Orinhaledsteroidsinhighdose或吸入大劑量激素Oral+inhaled(>600g/d)steroidsStep4:Severepersistent第四級:重度持續(xù)發(fā)作01Oralorinhaled2-agonist口服或吸入b受體興奮劑Oraltheophylline口服茶堿Leukotrieneantagonists白三烯拮抗劑Ipratropium異丙托品Others其他口服＋吸入激素（>600g/d)02Evaluatingpatientseverythreemonths每3個月評價一次療效Stepupifdiseaseisnotwellcontrolled如果癥狀控制不好，升級治療Stepdownifdiseaseiswellcontrolled如果癥狀控制良好，降級治療3.Tomanageexacerbation急性發(fā)作期的治療

a.Mildexacerbation輕度急性發(fā)作

Inhaled+oral

2-agonist吸入＋口服b受體興奮劑

Oraltheophylline口服茶堿

Inhaledsteroids