WEBVTT00:00:02.080 --> 00:00:03.060大家好00:00:03.240 --> 00:00:07.060我们今天来讲的疾病是支气管哮喘00:00:07.760 --> 00:00:09.840主要从他的临床表现00:00:09.840 --> 00:00:11.440和急性发作期00:00:11.440 --> 00:00:14.140药物处理两个方面来讲解00:00:16.040 --> 00:00:18.500首先哮喘是怎么发生的呢00:00:18.960 --> 00:00:22.040我们正常人的呼吸功能也是正常的00:00:22.040 --> 00:00:26.240在某些诱发因素引发00:00:26.240 --> 00:00:28.620呼吸道发生炎症00:00:28.720 --> 00:00:30.700并分泌大量黏液00:00:30.920 --> 00:00:34.220从而引发咳嗽喘息00:00:34.320 --> 00:00:37.420胸闷气促等哮喘症状00:00:38.000 --> 00:00:40.180从微观层面上来看00:00:40.520 --> 00:00:44.220主要表现为肺泡中气体腺壁00:00:44.360 --> 00:00:46.260气道平滑肌痉挛00:00:46.480 --> 00:00:47.740气道变窄00:00:48.120 --> 00:00:50.060从而导致粘液增多00:00:52.120 --> 00:00:56.780哮喘常见的过敏原有遗传因素00:00:56.800 --> 00:01:00.260花粉尾气装修污染等00:01:04.320 --> 00:01:07.060正常时我们人呼吸功能正常00:01:08.000 --> 00:01:09.220不受影响00:01:09.600 --> 00:01:12.240而当哮喘急性发作时00:01:12.240 --> 00:01:14.060气道会发生痉挛00:01:14.600 --> 00:01:16.380气道内壁肿胀00:01:16.720 --> 00:01:19.400从而导致气道粘液增多00:01:19.400 --> 00:01:20.440呼吸困难00:01:20.440 --> 00:01:24.620严重时可导致窒息甚至死亡00:01:27.720 --> 00:01:31.180首先支气管哮喘是由多种细胞00:01:31.440 --> 00:01:33.200如嗜酸性粒细胞00:01:33.200 --> 00:01:38.020肥大细胞细淋巴细胞嗜中性粒细胞00:01:38.400 --> 00:01:42.080气道上皮细胞等核细胞组分00:01:42.080 --> 00:01:45.260参与的气道慢性炎症性结冠00:01:45.600 --> 00:01:47.600这种慢性炎症00:01:47.600 --> 00:01:50.420导致气道高反应性的增加00:01:50.960 --> 00:01:53.980并引起反复发作性的喘息00:01:54.160 --> 00:01:58.500气急胸闷或咳嗽等症状00:01:59.000 --> 00:02:03.460常在夜间和清晨发作加剧00:02:03.640 --> 00:02:07.000通常出现广泛多变的可逆性00:02:07.000 --> 00:02:08.420气流受限00:02:08.920 --> 00:02:11.040多数患者可自行缓解00:02:11.040 --> 00:02:13.300或经治疗后可缓解00:02:14.360 --> 00:02:15.560首先病因00:02:15.560 --> 00:02:17.340一是遗传因素00:02:17.640 --> 00:02:18.600哮喘患儿00:02:18.600 --> 00:02:20.200双亲大多存在00:02:20.200 --> 00:02:23.380不同程度的气道反应性增高00:02:23.920 --> 00:02:27.580患者亲属患病率高于群体患病率00:02:28.080 --> 00:02:30.100第二是环境因素00:02:30.800 --> 00:02:37.700吸入物如螨虫花粉真菌动毛屑等00:02:39.120 --> 00:02:40.900第二是感染00:02:41.240 --> 00:02:45.060如病毒细菌寄生虫00:02:46.800 --> 00:02:48.380第三是食物00:02:49.320 --> 00:02:53.580如鱼虾蟹蛋牛奶等00:02:54.200 --> 00:02:55.860第四是药物00:02:56.160 --> 00:02:59.340如阿司匹林某些降压药物等00:03:00.480 --> 00:03:03.340以及气候变化和运动00:03:03.720 --> 00:03:05.360尤其是剧烈运动00:03:05.360 --> 00:03:08.380特别是在干冷环境下运动00:03:08.680 --> 00:03:11.440从而能导致支气管收缩00:03:11.440 --> 00:03:14.020进而进一步诱发哮喘00:03:16.720 --> 00:03:20.420他的发病机制目前尚不完全清除00:03:20.840 --> 00:03:21.800多数认为00:03:21.800 --> 00:03:25.740哮喘于变态反应气道炎症00:03:25.880 --> 00:03:28.280气道高反应性增高00:03:28.280 --> 00:03:31.820及神经等因素相互作用有关00:03:33.560 --> 00:03:36.240哮喘可分为速发性哮喘00:03:36.240 --> 00:03:40.860反应一般十五到三十分钟达到高峰00:03:41.320 --> 00:03:43.780两小时后逐渐恢复正常00:03:44.760 --> 00:03:45.960迟发性哮喘00:03:45.960 --> 00:03:50.480反应多数为数十小时后方发生00:03:50.480 --> 00:03:54.540哮喘持续时间长可达数天00:03:56.840 --> 00:04:01.420它的临床表现主要为典型的四联征00:04:02.720 --> 00:04:06.340喘息这是哮喘最标志性的症状00:04:06.560 --> 00:04:08.660患者在呼气时00:04:08.920 --> 00:04:11.020肺部会发出高调00:04:11.280 --> 00:04:15.460类似笛声或咻咻声的喘鸣音00:04:16.040 --> 00:04:17.080这是因为00:04:17.080 --> 00:04:21.100气流通过严重狭窄的气道时产生的00:04:21.400 --> 00:04:25.420严重时呼吸声在身边就能听到00:04:25.720 --> 00:04:26.940轻度时00:04:27.160 --> 00:04:30.660可能需要医生用听诊器才能发现00:04:31.400 --> 00:04:36.060咳嗽通常为干咳无痰或少痰00:04:38.400 --> 00:04:42.380哮喘的咳嗽有一个非常典型的特征00:04:42.840 --> 00:04:45.020夜间或凌晨加重00:04:45.280 --> 00:04:47.060严重影响睡眠00:04:47.320 --> 00:04:50.460这种咳嗽也常在运动后00:04:50.600 --> 00:04:55.380或接触冷空气或过敏源后会出现00:04:55.800 --> 00:04:58.380有一种特殊类型的哮喘00:04:58.720 --> 00:05:01.380称为咳嗽变异性哮喘00:05:01.800 --> 00:05:05.080其唯一或主要临床表现00:05:05.080 --> 00:05:06.860就是慢性咳嗽00:05:06.960 --> 00:05:09.500而没有明显的喘息00:05:09.960 --> 00:05:11.540第三是胸闷00:05:12.160 --> 00:05:16.300患者常感受胸部有重物压迫00:05:16.640 --> 00:05:19.140仿佛被绷紧带缠绕00:05:19.600 --> 00:05:22.000或者感觉胸口发闷00:05:22.000 --> 00:05:23.220呼吸不畅00:05:23.600 --> 00:05:24.800这种感觉00:05:24.800 --> 00:05:28.900是由气道痉挛和阻塞所导致的00:05:29.360 --> 00:05:31.060还有呼吸困难00:05:32.240 --> 00:05:36.000患者常感觉空气只进不出00:05:36.000 --> 00:05:37.740或吸不出来00:05:38.040 --> 00:05:41.260尤其是在呼气时特别费力00:05:41.480 --> 00:05:44.640严重时患者为了呼吸00:05:44.640 --> 00:05:47.420动用了所有辅助呼吸机00:05:47.880 --> 00:05:49.940表现为端坐呼吸00:05:50.280 --> 00:05:51.540无法平躺00:05:51.680 --> 00:05:53.660必须坐着才能呼吸00:05:54.640 --> 00:05:57.580张口台阶额头冒冷汗00:05:57.760 --> 00:05:59.660说话断断续续00:05:59.920 --> 00:06:01.940只能单字或短句00:06:03.120 --> 00:06:03.480咳嗽00:06:03.480 --> 00:06:07.580变异性哮喘患者也可无上述症状00:06:08.160 --> 00:06:11.000上述症状的特点是来得快00:06:11.000 --> 00:06:12.180去得也快00:06:12.880 --> 00:06:14.980发作时症状明显00:06:15.120 --> 00:06:18.020但使用支气管扩张剂后00:06:18.240 --> 00:06:21.020或脱离过敏环境后00:06:21.400 --> 00:06:23.300症状可迅速缓解00:06:23.680 --> 00:06:25.220在缓解期00:06:25.280 --> 00:06:29.220患者可以像正常人一样毫无症状00:06:33.120 --> 00:06:37.400诊断标准一是反复发作性喘息00:06:37.400 --> 00:06:40.700呼吸困难胸闷或咳嗽00:06:41.080 --> 00:06:43.060多以接触变应原00:06:43.080 --> 00:06:46.260冷空气物理化学刺激00:06:46.440 --> 00:06:49.380病毒感染运动等有关00:06:49.680 --> 00:06:52.540第二是可闻及哮鸣音00:06:52.920 --> 00:06:53.640第三00:06:53.640 --> 00:06:57.580上述症状可经治疗或自行缓解00:06:58.200 --> 00:07:00.740四如果症状不典型00:07:00.960 --> 00:07:04.340如无明显喘息和体征00:07:04.720 --> 00:07:05.520至少有00:07:05.520 --> 00:07:09.700应有以下三项中的一项阳性00:07:10.000 --> 00:07:13.940支气管激发试验或运动试验阳性00:07:14.320 --> 00:07:17.540第二是支气管舒张试验阳性00:07:17.960 --> 00:07:20.480第三是呼气流量峰值00:07:20.480 --> 00:07:22.140日内变异率00:07:22.480 --> 00:07:23.840或昼夜波动率00:07:23.840 --> 00:07:26.180大于等于百分之二十00:07:26.520 --> 00:07:31.180第五除外其他疾病所引起的喘息00:07:31.320 --> 00:07:33.220胸闷和咳嗽00:07:33.720 --> 00:07:35.540符合一到四条00:07:36.000 --> 00:07:39.420过四五两条者即可诊断为哮喘00:07:41.680 --> 00:07:44.400哮喘根据临床表现不同00:07:44.400 --> 00:07:46.780可分为急性发作期00:07:47.040 --> 00:07:50.260慢性持续期和缓解期00:07:50.560 --> 00:07:54.960缓解期是指经治疗或未经治疗00:07:54.960 --> 00:07:57.020症状体征消失00:07:57.480 --> 00:08:01.540肺功能恢复到急性发作前水平00:08:01.800 --> 00:08:03.780并维持四周以上00:08:06.840 --> 00:08:11.300哮喘患者根据病情严重程度不同00:08:11.320 --> 00:08:13.300分为三个部分00:08:13.600 --> 00:08:17.760治疗前哮喘病情严重程度分级00:08:17.760 --> 00:08:21.040包括新发生的哮喘患者00:08:21.040 --> 00:08:23.520和既往已诊断为哮喘00:08:23.520 --> 00:08:26.340而长时间未应用药物治疗00:08:28.800 --> 00:08:30.760哮喘急性发病时00:08:30.760 --> 00:08:34.340病情严重程度的分级可参考这个表00:08:39.679 --> 00:08:44.500登录可在步行上楼时出现气短00:08:44.960 --> 00:08:46.780脾胃可以平卧00:08:47.000 --> 00:08:48.760讲话方式可以连00:08:48.760 --> 00:08:53.400续成句精神状态可能会有焦虑00:08:53.400 --> 00:08:54.940但上还安静00:08:55.920 --> 00:08:57.780出汗时常无出汗00:08:58.280 --> 00:09:01.540呼吸频率正常或者轻度增加00:09:02.240 --> 00:09:05.460辅助呼吸肌的活动及三凹征00:09:06.680 --> 00:09:09.920不常见哮鸣音常散在00:09:09.920 --> 00:09:13.140以及在呼吸末期时可闻及00:09:13.760 --> 00:09:16.420脉率小于一百次每分钟00:09:16.760 --> 00:09:18.060长无机脉00:09:18.400 --> 00:09:21.140在使用贝塔尔激动剂以后00:09:21.360 --> 00:09:25.700pfv剂值长大于百分之八十00:09:28.480 --> 00:09:30.720氧分压和二氧化碳分压00:09:30.720 --> 00:09:33.740长小于四十五毫米汞柱00:09:37.360 --> 00:09:41.700中度时常稍有活动即可出现气喘00:09:42.440 --> 00:09:44.160体位常喜欢喜00:09:44.160 --> 00:09:48.820作为讲话方式时是单个词的往外讲00:09:49.480 --> 00:09:53.100精神状态时持有焦虑或烦躁00:09:53.640 --> 00:09:55.860经常会伴有出汗00:09:56.200 --> 00:09:58.420呼吸频率可见增加00:09:59.880 --> 00:10:03.420可见有辅助呼吸肌及三凹征00:10:03.760 --> 00:10:07.820校名音尝试响亮甚至弥漫的00:10:08.040 --> 00:10:11.460麦率是一百到一百二十次每分00:10:11.880 --> 00:10:13.660可能会有机麦00:10:13.960 --> 00:10:15.920使用贝塔尔机动机后00:10:15.920 --> 00:10:17.780pfe机时00:10:18.120 --> 00:10:21.020长为百分之六十到百分之八十00:10:22.080 --> 00:10:24.000氧分压及二氧化氮分压00:10:24.000 --> 00:10:27.660长大于等于六十毫米汞柱00:10:28.440 --> 00:10:31.700过小于等于四十五毫米汞柱00:10:32.280 --> 00:10:33.360吸空气时00:10:33.360 --> 00:10:34.240氧饱和度00:10:34.240 --> 00:10:38.020长为百分之九十一到百分之九十五00:10:38.520 --> 00:10:41.980重度是在休息时即可出现气短00:10:42.760 --> 00:10:45.380体位是喜欢端坐呼吸00:10:45.600 --> 00:10:47.800讲话方式为单个字的00:10:47.800 --> 00:10:48.740我们来讲00:10:49.560 --> 00:10:52.780精神上常有焦虑烦躁00:10:53.560 --> 00:10:55.380常伴有大汗淋漓00:10:55.600 --> 00:10:57.500呼吸频率也是快的00:10:57.680 --> 00:11:00.180常大于三十次每分钟00:11:00.800 --> 00:11:03.920辅助呼吸机活动及三凹征00:11:03.920 --> 00:11:05.460经常能看到00:11:05.800 --> 00:11:07.760校名音是很响亮的00:11:07.760 --> 00:11:09.140并且弥漫的00:11:10.400 --> 00:11:13.460脉率是大于一百二十次每分钟00:11:14.000 --> 00:11:16.180肌脉是经常会出现00:11:17.240 --> 00:11:20.100但使用贝塔二激动剂后00:11:21.000 --> 00:11:24.280p e f v级值是小于百分之六十00:11:24.280 --> 00:11:26.020或小于百分百的00:11:26.560 --> 00:11:28.640氧分压加二氧换碳分压00:11:28.640 --> 00:11:30.980是小于六十毫米汞柱00:11:32.920 --> 00:11:37.500小于四十五毫米处吸空气时00:11:37.640 --> 00:11:41.660氧气含量是小于九十百分之九十00:11:42.560 --> 00:11:44.940其微重症是混入氧化00:11:45.320 --> 00:11:48.900出现嗜睡或意识模糊00:11:49.840 --> 00:11:50.800胸腹矛盾00:11:50.800 --> 00:11:53.740运动减弱乃至没有00:11:54.040 --> 00:11:56.180脉率变慢不规律00:11:56.280 --> 00:11:58.180提示呼吸机疲劳00:11:58.960 --> 00:12:01.220ph值会出现降低00:12:01.840 --> 00:12:03.120一旦发作期00:12:03.120 --> 00:12:07.380治疗的目的是尽快缓解气道的00:12:07.600 --> 00:12:09.340纠正低氧血症00:12:09.560 --> 00:12:11.620恢复肺功肺功能00:12:12.040 --> 00:12:15.100预防进一步恶化或再次发作00:12:15.320 --> 00:12:16.820防止并发症00:12:19.280 --> 00:12:22.220治疗根据病情的分度进行00:12:22.600 --> 00:12:24.720轻度效果不佳时00:12:24.720 --> 00:12:28.040可加用小剂量茶碱控释片00:12:28.040 --> 00:12:30.640或口服贝塔尔受体激动剂00:12:30.640 --> 00:12:34.740控释片吸入贝塔尔受体激动剂00:12:35.000 --> 00:12:38.340每日定时吸入糖皮质激素00:12:38.640 --> 00:12:43.400糖皮质激素二百到六百一微克00:12:43.400 --> 00:12:46.060或加用抗胆碱药00:12:47.760 --> 00:12:52.060中度是微则吸入杯塔尔受体激动剂00:12:52.240 --> 00:12:55.660或口服长效杯塔尔受体激动剂00:12:57.280 --> 00:13:01.220氨茶碱是零点一五到零点二五毫克00:13:01.480 --> 00:13:05.280加入百分之十的葡萄糖四十毫升中00:13:05.280 --> 00:13:06.860缓慢浸入00:13:07.600 --> 00:13:10.620加大抗皮质激素吸入剂量00:13:10.920 --> 00:13:15.180或口服强蒂松二十到六十毫克每天00:13:15.720 --> 00:13:17.780重度乃至微症状00:13:18.160 --> 00:13:21.820降低氨茶碱或沙丁胺醇00:13:22.000 --> 00:13:25.020口服白三烯抗拮抗剂00:13:25.440 --> 00:13:27.480降低抗皮质激素00:13:27.480 --> 00:13:30.460如硫酸氢烤00:13:30.800 --> 00:13:33.440病情缓解改为口服激素00:13:33.440 --> 00:13:34.700逐渐减量00:13:35.160 --> 00:13:38.660持续雾化吸入贝塔尔受体激动剂00:13:39.040 --> 00:13:41.220雾化吸入抗胆碱药00:13:41.440 --> 00:13:43.160预防呼吸道感染00:13:43.160 --> 00:13:48.260维持水水电解质和酸碱平衡00:13:48.400 --> 00:13:50.920病情恶化缺氧不能纠正00:13:50.920 --> 00:13:52.660进行机械通气00:13:54.880 --> 00:13:58.620根据哮喘患者不同的级别00:13:58.960 --> 00:14:02.880治疗方案可分为低等级是间歇发作00:14:02.880 --> 00:14:05.840每天控制的药物必服用00:14:05.840 --> 00:14:08.340第二是轻度持续00:14:08.360 --> 00:14:10.620可以吸入糖皮质激素00:14:10.960 --> 00:14:15.000代替的可用缓解茶碱或色甘酸钠00:14:15.000 --> 00:14:16.700或白三烯调节00:14:17.200 --> 00:14:19.120中度持续是吸入糖00:14:19.120 --> 00:14:20.300皮质激素00:14:23.760 --> 00:14:25.840也可吸入糖皮质激素00:14:25.840 --> 00:14:27.660可用缓解茶碱00:14:29.520 --> 00:14:33.700重度是吸吃吸入糖皮质激素00:14:33.960 --> 00:14:37.140联合吸入长效贝塔尔激动剂00:14:37.560 --> 00:14:41.000需要时可再增加一种或一种00:14:41.000 --> 00:14:43.380以上下列的药物00:14:43.880 --> 00:14:47.320缓释茶解白三洗调节剂00:14:47.320 --> 00:14:50.060长效口服贝塔尔激动剂00:14:50.440 --> 00:14:52.180口服糖皮质激素00:14:53.800 --> 00:14:55.160各级治疗中00:14:55.160 --> 00:14:58.940除了规则的每日控制药物治疗以外00:14:59.280 --> 00:15:02.840需要时可吸入短效倍弹二激动机00:15:02.840 --> 00:15:04.300以缓解症状00:15:04.520 --> 00:15:08.540但每天吸入次数不应多于三到四次00:15:08.880 --> 00:15:10.400其他药物的选择00:15:10.400 --> 00:15:13.620主要包括吸入抗胆碱能药物00:15:13.760 --> 00:15:16.380口服短效倍弹二机动机00:15:16.560 --> 00:15:20.020短作用查解间歇发作哮喘00:15:20.040 --> 00:15:23.160但发生严重急性发作者00:15:23.160 --> 00:15:25.980应按照中度持续患者处理00:15:27.000 --> 00:15:29.740上述方案为基本原则00:15:29.920 --> 00:15:32.540必须个体化联合应用00:15:32.680 --> 00:15:35.400以最小量最简单的联合00:15:35.400 --> 00:15:38.900副作用最小效果最佳为原则00:15:39.400 --> 00:15:43.060每三到六个月对病情进行一次评估00:15:43.240 --> 00:15:46.820然后根据病情进行调整治疗方案00:15:47.160 --> 00:15:49.500或升级或降级治疗00:15:52.200 --> 00:15:53.220谢谢大家