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Asthma
Jiang Sheng-hua
Department of
respiration
© 2009 Jiang sheng-hua
Outline
epidemiology
pathophysiology
diagnosis
pharmacotherapy
disease management
recommendations
Epidemiology and © 2009 Jiang sheng-hua
Statistics
Affecting men and women
equally
Affecting approximately 2% ~
5 % of the adult population of
China
Most cases begin in children,
may develop at any time
throughout life
Prevalence rate: more than
© 2009 Jiang sheng-hua
© 2009 Jiang sheng-hua
Death rate
Burden of Asthma”, Masoli M et al. Global Initiative for Asthma (GINA), 2004
© 2009 Jiang sheng-hua
Definition of
Asthma
Ag 抗原
巨噬细胞 /
树突状细胞 肥大细胞
平滑肌收缩
definition
“A chronic inflammatory
disorder of the airways
associated with recurrent
episodes of:
wheezing,
breathlessness,
cough,
variable airflow obstruction,
and
© 2009 Jiang sheng-hua
Pathogenesis
The “Tip” of the
Iceberg
TITANIC syndrome
airway
obstruction
airway
hyperresponsiveness
inflammation
© 2009 Jiang sheng-hua
Asthma:
pathophysiology
chronic inflammation makes
the airways hypersensitive to
certain triggers:
allergens, chemicals,
smoke, cold, exercise, food
additives, aspirin, extreme
emotional expressions
© 2009 Jiang sheng-hua
© 2009 Jiang sheng-hua
Asthma: © 2009 Jiang sheng-hua
pathophysiology
upon exposure to these
stimuli, airways:
swell, constrict, fill with
mucus
become hyperresponsive
to stimuli
© 2009 Jiang sheng-hua
Normal Asthmatic
© 2009 Jiang sheng-hua
A
Panel A Specimen of Bronchial
Mucosa
From a Subject without Asthma.
The epithelium is intact; there is no
thickening of the sub-basement
membrane,
and there is no cellular infiltrate.
B
Panel B Specimen of Bronchial Mucosa from
a Subject with Asthma. There is evidence
of goblet-cell hyperplasia in the epithelial
-cell lining. The sub-basement membrane
is thickened, with collagen deposition
in the submucosal area, and there is a
cellular infiltrate.
Airway Remodeling
(structural changes)
Airway edema
Histamine
Released from mast cells
A potent endogenous bronchoactive agent
Minor efficacy in asthma
© 2009 Jiang sheng-hua
Asthma
Airway obstruction
Clinical Presentation
History
Shortness of breath accompanied by chest tightness,
cough, wheezing and anxiety
recurrent episodes
may be obvious at night or in the early morning
reversible either spontaneously or with treatment
Variants of asthma:
no wheezing, only cough or chest tightness
Cold dry air may induce airway narrowing
© 2009 Jiang sheng-hua
History
Extrinsic asthma, intrinsic asthma, exercise-
induced asthma, aspirin-induced asthma,
occupational
Identification of provoking stimulus
Asthma clusters in families, personal
history of other allergic IgE-mediated
diseases: allergic rhinitis
atopic dermatitis and eczema
© 2009 Jiang sheng-hua
Environmental Allergens
Pollens from trees, grass and weeds
Mold
Common occupational © 2009 Jiang sheng-hua
stimulus
Prowns ( 大虾 )
Gun acacia (金合欢树胶, Printers )
Papain (番木瓜酶)
Platinum (铂)
© 2009 Jiang sheng-hua
Physical Examination
Vital signs:
A rapid respiratory rate
---often 25- -40 bpm
Tachycardia>100bpm
Pulsus paradoxus( 吸气时收缩压较呼气时低
10mmHg 以上 )
© 2009 Jiang sheng-hua
Thoracic Examination
Laboratory Findings
Pulmonary function findings
(objective measures of airflow)
A decrease in airflow rates throughout the vital
capacity
Peak expiratory flow rate (PEFR)
Forced expiratory volume in the first second (FEV1)
Maximal midexpiratory flow rate (MMEFR)
Total lung capacity (TLC)↑
Residual volume (RV)↑
© 2009 Jiang sheng-hua
Sputum findings
Clear or opaque with a green or yellow tinge
eosinophils
Charcot-Leygen Crystals
(crystallized eosinophil lysophosphlipase )
Curschman’s spiral
(bronchiolar cast composed of mucus and cells)
Creola bodies
(clusters of airway epithelial cells)
Asthma: © 2009 Jiang sheng-hua
diagnosis
episodic breathlessness
wheezing
chest tightness
cough
Asthma: © 2009 Jiang sheng-hua
diagnosis
asthma is the likely diagnosis if:
symptoms occur at night or in early
morning
episodes recur following one or more
triggers
relief of symptoms occurs with a
bronchodilator
© 2009 Jiang sheng-hua
challenge testing
Differential Diagnosis
© of 2009 Jiang sheng-hua
measurements
typically, asthmatics have poor
recognition of their symptoms
and poor perception of their
severity
use of peak flow meters
provides direct assessment of
airflow limitation, variability and
reversibility
essential for accurate
Goals of © 2009 Jiang sheng-hua
management
minimal or no symptoms
minimal asthma episodes /
attacks
no emergency visits to MD or
hospital
minimal need for as needed β 2
agonist
no limitations on physical
activities
© 2009 Jiang sheng-hua
Treatment
Directed at airway obstruction and inflammation
use of bronchodilators (rescue ) for acute asthma
airway obstruction
use of controllers for modifying the airway inflammatory
environment
The intensity of asthma treatment depends on
severity of disease
Except mildest forms, this chronic disease should be
treated chronically
Resolution of obstruction should be documented by
objective measures
© 2009 Jiang sheng-hua
Asthma Severity
Mild intermittent asthma
(in the large group of patient with asthma )
Normal or near normal lung function
Infrequent asthma symptoms
Usually sleep thought the night without
asthma symptoms
The only treatment is an inhaled medium-
acting bronchodilator
© 2009 Jiang sheng-hua
iCS
short-acting 1972
1968
bronchodila
tor
1975
1980
ICS increase combination
1985
2000
long-acting bronchodilator 1995
支气管痉挛 炎症 重塑
© 2009 Jiang sheng-hua
都保
准纳器
© 2009 Jiang sheng-hua
STEP 4: 严重持 续
• 吸入激素 >1 00 0 µg+ 长效吸入 ß2
激动剂
•缓释茶碱
• 白三烯调 节剂
•口服长效 ß2 激动剂
•口服激素
避免或控制激发因素
STEP 3: 中度持 续
避免或控制激发因素
STEP 2: 轻度持续
吸入 激素
BDP≤ 500 µg 或相当 量
避免或控制激发因素
STEP 1: 间歇性 发作
不需 用控 制药
避免或控制激发因素
每日控制 药治 疗 GINA Guidelines 2002
© 2009 Jiang sheng-hua
Reliever Treatment
β -Adrenergic agent
β2-selectivity
stimulation of β2- adrenergic receptors
inhaled , oral or parenteral preparation
given by inhaled on an as-needed basis
correct method of inhalation
when coordinating inspiration and inhaler
actuation is difficult, aerosol ‘spacers’ or
nebulization are available
© 2009 Jiang sheng-hua
Controller treatment
Inhaled Corticosteroids
Effective controller treatment for patient
with persistent asthma
Less systemic impact than systemic steroid
but potent for systemic effect
Every inhaled corticosteroid products
produce the same therapeutic effect
Antileukotrienes © 2009 Jiang sheng-hua
Antileukotrienes
asthma
© 2009 Jiang sheng-hua
Long-acting β2-agonist
Theophylline
Recommended for moderate or severe
persistent asthma in combination with inhaled
steroid
Intravenous preparation is used for acute severe
asthma attack
Therapeutic serum concentration is between 10
and 20 ug/ml
Some adverse effect (seizure ) is catastrophic
© 2009 Jiang sheng-hua
Systemic Corticosteroids
(1)
admission to hospital
© 2009 Jiang sheng-hua
Status Asthmatics
no response to emergent treatment
PaCO2 ↑ without improvement of indices of airflow
obstruction
development of major complications
Close monitoring
Frequent inhaled β-agonist
Intravenous aminophylline
High-dose intravenous steroid
Oxygen supplement by face mask or nasal cannula
Management plan © 2009 Jiang sheng-hua
for asthma
classify the severity of the
illness
identify the appropriate
regimen that will maintain
control of the illness
review classification and
management plan every 1 to 6
months
gain control as quickly as
© 2009 Jiang sheng-hua
Patient education
use of MDIs
use of spacers
use of nebulizers
use of peak flow meters
avoidance of triggers
action plan
© 2009 Jiang sheng-hua
Comments?
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Questions??