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VI. Pathology 病理学
1. At the early stage
Chronic airway inflammation
早期
慢性气道炎症
2. Later
Chronic airway inflammation Airway remodeling ASMC proliferation Mucus glands enlargement Subepithelial fibrosis Others
PEF or FEV1-vaersistent 第二级：轻度持续发作
1/week<attack<1/day Night attack>2/month PEF, FEV180%Pr. PEF or FEV1-variation 20-30%
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21
Atypical asthma
Symptom
不典型哮喘
症状
咳嗽
胸闷
Cough
Tight chest
Breathlessness
Signs
气短
体征
没有哮鸣音
Without wheezing
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VIII. Laboratory 实验室检查
1. Pulmonary function tests
FEV1 FEV1/FVC
急性支气管收缩 气道高反应性
Swelling of the airway wall
Chronic mucus plug formation Airway wall remodeling
气道壁肿胀
慢性粘液栓形成 气道壁构型重建
Airflow obstruction 气流阻塞 Symptoms 各种症状
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Staging of disease severity 病情严重程度分级
1. Long term evaluation (Tab.2-4-1) 长期病情评价
Step 1: Intermittent 第一级：间歇发作 Attack<1/week,
Night attack<2/month
PEF, FEV180%Pr.
Bronchial Asthma (Asthma)
支气管哮喘 （哮喘）
1
I. Epidemiology 流行病学
A very common disease 哮喘为常见病
USA 5%
China 0.5% - 1.0%
美国 5％
中国0.5% - 1.0%
Prevalence is increasing worldwide
Race/ethnicity
2. Environmental Factors 环境的因素
Allergens (domestic mites, animal allergens, fungi, etc.)
过敏原（屋尘螨，动物过敏原，真菌，等等）
Respiratory infections (especially viral infections)
Relevant molecules
有关的生物分子
Inflammatory Mediators 炎症介质 Histamine 组织胺 Acetylcholine 乙酰胆碱 Kinins 激肽 Adenosine 腺苷 Leukotrients (LTC4, LTD4, LTE4) 白三烯 Prostaglandins 前列腺素 Platelet-activating factor 血小板活化因子 etc. 其他
11
Pro-inflammatory cytokines 促炎症性细胞因子 Interleukin-4 (IL-4) 白介素-4 IL-5 白介素-5 Tumor necrosing factor-a (TNF-a) 肿瘤坏死因子-a etc. 其他 Anti-inflammatory cytokines 抗炎症性细胞因子 IL-18 白介素-18 IL-10 白介素-10 etc. 其他
Mast cells
有关的细胞
肥大细胞 嗜酸细胞 T细胞(Th1/Th2） 嗜碱细胞 中性粒细胞 肺泡巨噬细胞 上皮细胞 其他
10
Eosinophils T lymphocytes (Th1/Th2) Basocytes Neutrophils Alveolar macrophages Epithelium others
后期
慢性气道炎症
气道构型重建
ASMC增生 黏液腺肥大 上皮下纤维化 其他
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VII. Clinical manifestations 临床表现
Symptoms 症状
Episodic breathlessness and wheezing, worse
particularly at night and in the early hours of the morning.
典型者于深夜或凌晨发作
4
III. Etiology 病因
Unknown Genetic factors? Environment factors?
遗传与环境因素共同作用？ 不明 遗传因素？ 环境因素？
The combination of these two?
5
IV. Risk Factors 易患因素
Step 3: Moderate persistent 第三级：中度持续发作 Attack every day
Night attack>1/week
Need daily use of inhaled short-acting b2-agonist PEF, FEV1>60, <80% Pr. PEF or FEV1-variation>30%
呼吸道感染（尤其是病毒感染）
Exercise and hyperventilation Weather Sulfur dioxide Food Additives Drugs
运动和高通气 气候变化 二氧化硫 食品 食品添加剂 药品
7
V. Pathogenesis 发病机制
Envir. factors + Genetic factors 环 境 ＋ 遗 传 因 素 Chronic Airway Inflamation 慢性气道炎症 Acute bronchoconstriction Hyperresponsiveness
阵发性气短、喘鸣，深夜和凌晨尤其明显
19
Physical signs
Between acute episodes：
体征
发作间歇期： 可无明显异常
Can be no abnormalities
20
During acute attack: 急性发作期 Wheezing ---- not always parallels the symptoms
Typical cases
典型病例
症状＋体征
Symptoms + signs
Atypical cases
Bronchoprovocating tests Brobchodilating tests PEF variation
不典型病例
Symptoms + signs + lab. Tests
气道激发试验 支气管舒张试验 峰值流速变异率
3
Key Points
Chronic airway inflammation 气道慢性炎症 Airway hyperresponsiveness 气道高反应性 Reversible airflow obstruction 可逆性气道狭窄 Symptoms: 症状 Wheezing 喘鸣 Breathlessness 气短 Chest tightness 胸闷 Coughing 咳嗽 Typically at night or in the early morning
5. Others Blood routine Sputum culture etc.
血气分析
PaCO2仅见于严重病例
X线胸片
过度充气征 并发症表现
4. Skin tests for specific antigens 过敏原皮试
其他
血常规
痰培养
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Hyperinflation 过度充气征
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IX. Diagnosis 诊断
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Step 4: Severe persistent
Attack frequently
第四级：重度持续发作
Night attack frequently
Limitation of physical activity
PEF, FEV1<60%Pr.
PEF or FEV1 variation>30%
哮鸣音－－其强度并不总是与症状平行
Signs of hyperinflation ----hypersonance
肺过度充气症－－叩诊过度反响
Signs of complication 并发症的体征 Infection 感染 Pneumothorax 气胸 Respiratory failure 呼衰 Heart failure 心衰 etc. 其他
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2. During acute exacerbation (Tab.2-4-3)
急性发作期病情严重程度评价（见表2-4-3）
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X. Differential diagnosis
(Table
2-4-4) Left ventricular failure Chronic asthmatic bronchitis Acute bronchitis ( esp. in infants) Lung cancer Benign airway narrowing Allergic pulmonary infiltration
