哮喘的炎症指标最新进展-节选VIP免费

哮喘炎症的非创伤性检测指标及临床意义苏州大学附属儿童医院郝创利AirwaysNarrowing哮喘的病理TriggerfactorMucuspluggingAirwaywalloedemaSmoothmusclespasm确定是否有气道阻塞:用肺功能仪Sensitivity=35%Smithetal.AJRCCM.,2004litresFEV1seconds123456NORMALOBSTRUCTEDGINA哮喘的定义…chronicinflammatorydisorderoftheairways……increaseinairwayhyper-responsiveness……recurrentepisodesofrespiratorysymptoms……variableairflowobstruction……reversiblespontaneouslyorwithtreatment.GlobalINitiativeforAsthma2007ABCDSimpsonetalRespirology2006;11:54-61哮喘的炎症亚型A.NeutrophilicB.EosinophilicC.MixedcellularityD.PaucigranularIsairwayinflammationrelatedto…•cigarettesmoking…..activeorpassive?•infection…..bronchiectasis?•airpollution…..e.g.dieselfumes?•allergic(IgE-mediated)asthma?…..e.g.ascarislumbricoides?-Dependingonthecause,thetypeofairwayinflammationmaybedifferent.-Thisisimportantbecauseitwillinfluencethepotentialresponsetoanti-inflammatorytreatmentOnlyeosinophilicinflammationissteroidresponsiveRelationshipbetweensputumeosinophilsandresponsetoICStherapyN=120“Unstableasthma”RxTrialof:1.FLU500µg/dayOR2.FLU2000µg/dayOR3.oralprednisolone30mg/dayMeijeretal.Clin.Exp.Allergy2002;32:1096-1103Baselinesputumeosinophils%RelationshipbetweensputumneutrophilsandresponsetoICStherapyinasthmaGreenetal.Thorax2002PC20FEV1VASAllothersn=38Neutros>65%Eos<2%,n=11BUD800µg/dayfor2monthsEosinophilicinflammationissteroidresponsiveinflammationBrown,1958“Asthma”symptomsCo-existingpathologye.g.rhinitiswithpost-nasaldripAnxietyleadingtohyperventilationorvocalcorddysfunctionOtherpathologye.g.bronchiectasis,GErefluxPoorcompliance,inadequateanti-inflammatorytreatmentRespiratorysymptomsinpatientswith“asthma”“Asthma”symptomsCo-existingpathologye.g.rhinitiswithpost-nasaldripAnxietyleadingtohyperventilationorvocalcorddysfunctionOtherpathologye.g.bronchiectasis,GErefluxPoorcomplianceorinadequateICSdoseleadstouncontrolledairwayinflammationRespiratorysymptomsinpatientswith“asthma”炎症检测术（Inflammometry）Inflammometry标本采集方法•有创技术经纤支镜支气管粘膜活检支气管肺泡灌洗（BAL）手术切除标本有创气道炎症检测•优点：可直接检测气道炎症是气道炎症的“金标准”•缺点：属于侵入性检测可引起气道高反应不适用于哮喘发作期(特别是重症哮喘)•结论：可作为研究工具，但不可能作为临床常规技术开展炎症无创检测技术气道反应性测定诱导痰技术呼出气NO检测呼出气冷凝物检测体液检测（外周血、尿液）基于气道反应性的哮喘治疗策略以气道反应性作为附加指标指导哮喘长期治疗对临床控制和组织学指标的影响•2年随机对照研究•以AHR作为评定哮喘严重程度和指导ICS（氟替卡松和布地奈德）升降级治疗的指标•方法：AHR和疾病严重程度均分为4级，对照组以疾病严重程度为依据进行升降级治疗，AHR组根据疾病严重程度和AHR进行调整SontJK,Willems,LN,BelEH,etal.ClinicalControlandHistopathologicOutcomeofAsthmawhenUsingAirwayHyperresponsivenessasanAdditionalGuidetoLong-TermTreatmentAm.J.Respir.Crit.CareMed.1999,159:1043~1051•结果AHR组急性发作减少1.8倍，肺功能改善更为显著支气管粘膜活检表明AHR组较对照组患者上皮下网状层增厚明显减轻。•结论GINA分级治疗方案仅仅针对是否达到最佳的症状控制和肺功能改善，没有针对AHR，不能在不同的个体达到理想的哮喘控制。气道反应性监测指导哮喘联合治疗方案调整•轻至中度非急性发作期哮喘患者分为固定剂量组（A）、临床调整组（B）、AHR（C）组，初始治疗均为ICS＋LABA联合治疗。•A组维持固定剂量不变，B组根据哮喘控制水平进行降级或停药，C组在哮喘控制前提下...