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: Global Initiative for Asthma（1994） WHO/HLBI Bronchial asthmatic diagnosis guideline (1997） Chinese Medical Academy,Definitions of asthma,Chronic airway inflammation Broncho-hyperresponsiveness, BHR Airflow limitation,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、M1-、M3-receptors excitement NANC：PS-receptor bronchial smooth muscle contraction AC: -receptor、M2-receptor excitement NANC: VIP receptor bronchial smooth muscle dilation asthmatic airway: a1、M1、M3、PS/ 、M2、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(Th1/Th2) Th2 cytokine IL-3、4、5，GM-CSF IgE,inflammation cells epithelium injury,bronchial contraction mucous edema airway secretion,airway narrow,BHR,airway reversibility,symptoms,exacerbation,cell proliferation excellular base,Differ mechanisms in acute and chronic asthma,Other mechanisms: induced factors,Allergen: pollen, acarus infection: virus or mycoplasmal infection climate and physical and chemical factors drugs: aspirin induced asthma, AIA -receptor inhibitor heredity Gastroesophageal reflux disease, GERD Psychological, incretion factors, sports,Diagnosis standards of asthma,symptoms signs recovered ways except other cardiac and pulmonary diseases lung function examinationuntypical asthma,Untypical asthma,Cough variant asthma, CAV Asthma with gastroesphgeal reflux Exercise induced asthma, EIA Drug induced asthma, DIA Occupational asthma, OA,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(1),FEV1 80 % pre, FEV1/FVC% 70 % bronchial dilation test is positive Post FEV1 - Pre FEV1 FEV1improved rate 100% Pre FEV1 determinant standard:FEV1 improved rate15(+) FEV1 improved rate200ml,Lung functions diagnosis of asthma(2),PEF meter PEF predicted value,Lung functions diagnosis of asthma(2),PEF 80pre 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 FEV1 PEF变异率 或PEF 1 间歇发作 2次/m 发作时受限 80% 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 25mmHg 无,呼衰 用2后PEF 70% 5070% 45mmHg SaO2 95% 9195% 90% pH 降低,Distinguishing diagnosis of asthma,Cardiac asthma COPD Upper airway obstruction (lung cancer) Pulmonary eosiniphil infiltration,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,Drugs for treating asthma,Glucocorticosteroid anti-inflammation 2-agonist theophylline bronchodilators anticholinergic drug non-steroid anti-inflammations,Steroids with vein injection,methylprednisonlone 40 4 11-hydroxide 40320 Hydrocortison 100 20 11-ketone 1001000 dexamethason 5 0.75 11-ketone 1030,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 1mg/2ml Fluticasone propionate 辅舒酮(FP) 125ug 100 Fluticasone + Salmeterol 舒利迭 100/50ug60 250/50ug60,Using principles of inhaler steroid,非急性发作期哮喘长期预防用药首选 替代口服激素 季节性哮喘季节发作前二周应用 急性发作期与2-激动