Title: Bronchial asthma
1Bronchial asthma
- Department of respiration
- Kong Lingfei
2 Asthmahuman killer!
3Background 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
4Definitions of asthma
- Chronic airway inflammation
- Broncho-hyperresponsiveness, BHR
- Airflow limitation
5Mechanism allergy theory
- antigen antigen
- ?
?again - atopy?IgE antibody?mast cells,
basophils -
? histamine - inflammatory
media LTs -
? PAF -
ECP - immediate asthmatic
reaction, IAR -
? - bronchial smooth
muscle spasm - airway
narrow
6Mechanism never-receptor disorder theory
- adrenergic and cholinergic nerous systems, AC
- non-adrenergic and non-cholinergic nerous
systems, NANC - AC a1-receptor?M1-?M3-receptors
excitement - NANCPS-receptor
? - bronchial smooth muscle
contraction - AC ß-receptor?M2-receptor
excitement - NANC VIP receptor
? - bronchial smooth muscle
dilation - asthmatic airway a1?M1?M3?PS?/ ß ?M2?VIP?
7Mechanism 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?
8Differ mechanisms in acute and chronic asthma
inflammation cells ? epithelium injury
bronchial contraction mucous edema airway
secretion?
cell proliferation excellular base?
airway narrow
airway reversibility?
BHR?
exacerbation
symptoms
9Other mechanisms induced factors
- Allergen pollen, acarus
- infection virus or mycoplasmal infection
- climate and physical and chemical factors
- drugs aspirin induced asthma, AIA
- ß-receptor inhibitor
- heredity
- Gastroesophageal reflux disease, GERD
- Psychological, incretion factors, sports
10Diagnosis standards of asthma
- symptoms
- signs
- recovered ways
- except other cardiac and pulmonary diseases
- lung function examination?untypical asthma
11 Untypical asthma
- Cough variant asthma, CAV
- Asthma with gastroesphgeal reflux
- Exercise induced asthma, EIA
- Drug induced asthma, DIA
- Occupational asthma, OA
12Lung 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
13Lung functions diagnosis of asthma(1)
- FEV1 lt 80 pre, FEV1/FVC lt 70
- bronchial dilation test is positive
- Post FEV1 - Pre FEV1
- FEV1improved rate 100
- Pre FEV1
- determinant standardFEV1 improved rate15()
- FEV1 improved rate200ml
14Lung functions diagnosis of asthma(2)
PEF meter PEF predicted
value
15Lung functions diagnosis of asthma(2)
- PEF lt 80pre and PEF variance rate 20
-
- PEF max PEF min
- PEF variance rate 100
- 1/2( PEF max PEF min )
- Determinant standardPEF variance rate(24h) 20
()
16Lung functions diagnosis of asthma(3)
- Bronchial challenge is positive
- therapeutic properties
- forbid properties
- methods drug induce methocholiner
-
histamine - exercise induce
-
17The steps of chronic persistent asthma
- ?? ?? ???? ???? ???? FEV1
PEF??? -
?PEF - 1 ???? lt1?/w 2?/m ???
80 lt20 - ???? 1?/w gt2?/m ????? gt80
lt20 - lt1?/d
- 3 ???? ????? gt1?/w ????? 6080
2030 - 4 ???? ???? ?? ??
lt60 gt30
18The steps of acute exacerbation asthma
???? ?? ??
?? ??? ??
??,??? ??? ??? ??
??? ??? ??? ???? ????
?? ?? ???? ????
??? ????? ????? ??,???? ??
? ?
???? ???? ???? ??
gt30?/? ??? ?? ??
?? ?????? ??? ??????
???? ???? ???? ??
lt100?/? 100200?/? gt120?/? lt120?/?,??? ??
?,lt10mmHg ?,10-25mmHg ??,gt25mmHg
?,?? ?ß2?PEF gt70 5070
lt50?lt100L/min
PaO2 ?? 6080mmHg
lt60mmHg PaCO2 lt40mmHg 45mmHg
gt45mmHg SaO2 gt95 9195
90 pH
??
19Distinguishing diagnosis of asthma
- Cardiac asthma
- COPD
- Upper airway obstruction (lung cancer)
- Pulmonary eosiniphil infiltration
20Correlation between asthma and COPD
21Discrimination between asthma and COPD
Asthma
COPD ?? ?? ??? ????(?????) ????(??
??) ?? ?? ?? ?? ???????? ?????? ??? ??
?? ????? ??? ???? ???? ???? ?? ???? ??? ???
?? ??????
22Drugs for treating asthma
- Glucocorticosteroid -anti-inflammation
- ß 2-agonist
- theophylline bronchodilators
- anticholinergic drug
- non-steroid anti-inflammations
23Steroids with vein injection
steroid dose dose character
dose/d (mg) (mg)
(mg)
methylprednisonlone 40 4
11-hydroxide 40320 Hydrocortison
100 20 11-ketone 1001000 dexamethas
on 5 0.75 11-ketone
1030
24Inhaled steroids
- Baclomethason dipropionate ???(BDP) 50ug200
- Budesonide
???(BUD) 100ug 100 -
??? ?? -
????? 1mg/2ml - Fluticasone propionate ???(FP)
125ug 100 - Fluticasone Salmeterol ???
100/50ug60 -
250/50ug60 -
25Using principles of inhaler steroid
- ????????????????
- ??????
- ??????????????
- ??????ß2-?????
- ?????????
26Inhaled ß2- agonists
- Salbutamol ???
200ug200 - ???????
0.05 20ml - Terbutaline ???
250ug200 - ??????
250ug100 - ????????
5mg/ml - Salmeterol ???
50ug200 - ???
50ug48 - Formoterol ?????
4.5ug60
27Oralß2- agonists
- Terbutaline ???? 2.5mg
- Procaterol ??? 50ug
- Formoterol ??? 40ug
- Salbutemol ??? 8mg
- Bambuterol ?? 4mg
28Classification of ß2-agonsts (Politiek)
????
????
4? ??? ????? ??????? ???????
1? ??? ????? ???????
?
????
3? ??? ????? ??????? ??????? ???????
2? ???? ????? ??????? ???????
?
Politiek, et al. Eur Respir J 1999, 13 988
? ? ??????
29Using principles ofß2-agonist
- ?????????????
- ??????????????
- ???????,????lt4?/?
- ?????????????
- ??????????
30Theophylline
- ivaminophylline 0.25
- doxofylline 0.1
- po aminophylline 0.1 short action
- AEA
- ??? 0.1 long
action - ??? 0.4
31Using principles of theophylline
- ????????????
- ??????????????????
- ?????????
- ??????????????????
- ?????????(??? 1020ug/ml)
- ?????????(??? 510ug/ml)
- ??????????
32Anti-cholinergic drug
- Ipratropium bromide ??? 20ug200
- ??????
20ml - Ipratropium bromide ??? 20ug200
- Salbutamol ??? 2ml
33Using principles of anti-cholinergic drug
- ???COPD????
- ???????????????
- ???????
- ?????????????????
- ??????????????????
34Non-steroid anti-inflammation drugs
- Anti-histamine inhaler???? 5mg200
- oral
???????? -
???????? - LTs receptor inhibitor ??? 10mg5
-
35Using principles of other anti-inflammation
- ??????????Atopy ??
- ???????????????
- ????????????????
- ????????????????
- ???????????????
36 Drug therapy of asthma ??????
??????
- ????ß 2-???
- ??????
- ????ß 2-???
- ????????
- ????
- ????????
- ????ß 2-???
- ????????
- ????
- ??????
- ?????
- ???
37 long therapy projects of asthma
GINA 2002
??? Step1 ????
?????? ????
??????
38long therapy projects of asthma
GINA 2002
??? Step2 ????
?????? ????(200-500?gBDP????)
?????? ????,?????,???????
39long therapy projects of asthma
GINA 2002
??? Step3 ????
???? ????(200-1000?g BDP????) ????????2-?????
?????? ????(500-1000?g BDP????)???????????(500-10
00?g BDP????)???????2-?????????????(gt1000?g
BDP????)?????(500-1000?g BDP????)????????
40long therapy projects of asthma
GINA 2002
??? Step4 ????
- ????
- ????(gt1000?g BDP????)????????2-?????
- ??????,???????????
- ????
- ??????
- ?????2-?????
- ????
??????
41Combined therapy
Low dose inhaler steroid (400 µg /d)
?
exacerbation
inhaler steroid of double dose
Barnes, Nice 2001