How Do I Choose the Best Bronchial Asthma Treatment?
Bronchial asthma (abbreviation: asthma) is a common and frequently-occurring disease. The main symptoms are paroxysmal wheezing, shortness of breath, chest tightness, and cough. Bronchial asthma is a chronic inflammatory disease of the airway involving a variety of cells (eosinophils, mast cells, T lymphocytes, neutrophils, airway epithelial cells, etc.) and cell components. High responsiveness of the tract is associated with widespread and variable reversible airflow limitation, which often causes recurrent wheezing, shortness of breath, chest tightness, and / or cough, and most often occur at night and / or early in the morning. Patients can resolve on their own or after treatment
Bronchial asthma
bronchus
The well-known and favorite famous singer Deng Lijun was killed by asthma. At present, there are about 300 million people with asthma in the world and about 30 million people with asthma in China. Asthma is an important disease affecting people's physical and mental health. Asthma may be fatal if treatment is not timely and standardized, and standardized treatments, today's treatments can make nearly 80% of asthma patients have very good disease control, and their work life is almost unaffected by the disease. The first Tuesday of May each year is World Asthma Day, which aims to remind the public of the disease and improve the level of prevention and treatment of asthma.
Western medicine name: bronchial asthma
Department: Internal Medicine-Respiratory Medicine
The risk factors for asthma include host factors (genetic factors) and environmental factors. Genetic factors can be reflected in many patients. For example, the relatives of most patients (related to blood, recent three generations) can be traced back to asthma (repeated cough, wheezing) or other allergic diseases (allergic rhinitis). , Atopic dermatitis) history. Most people with asthma are allergic and may be accompanied by allergic rhinitis and / or atopic dermatitis, or for common airborne allergens (mites, pollen, pets, molds, etc.), certain foods (nuts, Milk, peanuts, seafood, etc.), drug allergies, etc.
The pathogenesis of asthma includes: it is not completely clear, including: allergies, chronic airway inflammation, airway hyperresponsiveness, airway neuroregulation, genetic mechanisms, respiratory viral infections, neural signal transduction mechanisms, and airway remodeling And their interactions.
The difference between bronchial stenosis in asthmatic patients and normal people, as shown in the figure.
According to clinical manifestations, asthma can be divided into acute attack, chronic duration and clinical remission. Chronic duration refers to the occurrence of symptoms (wheezing, shortness of breath, chest tightness, cough, etc.) at different frequencies and / or to varying degrees each week; clinical remission refers to treated or untreated symptoms, signs of disappearance, and recovery of lung function To the level before the acute attack, and maintained for more than 3 months.
1. Grade of asthma severity in remission
Currently, asthma control level classification standards are generally used, which have a large guiding effect on clinical treatment and are easy to be grasped by doctors. See table one
Table 1 Asthma control level classification | Full control (all of the following conditions are met) | Partial control (1 or 2 of the following evidences in any 1 week) | Not controlled (Within any 1 week) |
Daytime symptoms | None (or 2 times / week) | 2 times / week | |
Restricted activity | no | Have | |
Nocturnal symptoms / waking | no | Have | 3 partial control features appear |
Number of times a reliever is needed | None (or 2 times / week) | 2 times / week | |
Pulmonary function (PEF or FEV1) | Normal or normal expected value / 80% of my best value | <80% of normal expected value (or my best value) | |
Acute attack | no | once a year | Appears once in any 1 week |
2. Grading of acute asthma
Acute asthma refers to the sudden occurrence of symptoms such as wheezing, shortness of breath, cough, and chest tightness, or the sudden exacerbation of symptoms, often with difficulty breathing, which is characterized by reduced expiratory flow, often due to exposure to allergens, irritants or the respiratory tract Induced by infection. The severity varies, and the condition can worsen, which can occur within hours or days, and occasionally can be life-threatening within minutes. Therefore, the condition should be properly evaluated in order to give timely and effective emergency treatment. If the patient has shortness of breath, sitting breathing, speaking a single word, sweating heavily, breathing more than 30 times per minute, heart rate more than 120 times per minute, the duration of action after inhaling a bronchodilator (albuterol aerosol) is less than 2 hours, when the oxygen is not inhaled, the arterial oxygen partial pressure is lower than 60mmHg, or the arterial carbon dioxide partial pressure is greater than 45mmHg, or the oxygen saturation is not more than 90%, etc. As long as these symptoms or auxiliary examination indicators meet one or more than one, the patient's condition is serious It needs to be taken seriously, and fast and effective treatment should be started as soon as possible.
Asthma is a chronic disease that has a significant impact on patients, their families and society. Airway inflammation is a common feature of almost all types of asthma and is the basis for clinical symptoms and airway hyperresponsiveness. Airway inflammation is present at all times in asthma. Although asthma cannot be cured at present, standardized treatment based on inhibiting inflammation can control the clinical symptoms of asthma. An international study showed that asthma control rate was close to 80% with fluticasone / salmeterol fixed dose upgrade and maintenance treatment. Although the cost of controlling asthma seems to be high from a patient and social perspective, incorrect treatment of asthma can be more costly.
Asthma treatment should adopt comprehensive treatment methods, including: avoiding exposure to allergens and other asthma triggers, standardized drug treatment, specific immunotherapy and patient education.
Introduction to commonly used drugs
Medicines for treating asthma can be divided into control medicines and relieving medicines.
Controlled drugs: Drugs that require long-term daily use. These drugs maintain clinical control of asthma mainly through anti-inflammatory effects, including inhaled glucocorticoids (hormones) systemic hormones, leukotriene modulators, long-acting 2-receptor agonists (long-acting beta2-receptor agonists Must be used in combination with inhaled hormones), slow-release theophylline, anti-IgE antibodies, and other drugs that help reduce systemic hormone doses;
Relief drugs: Drugs that are used on demand. These drugs alleviate asthma symptoms by rapidly releasing bronchospasm, including fast-acting inhaled 2-receptor agonists, systemic hormones, inhaled anticholinergics, short-acting theophylline, and short-acting oral 2-receptor agonists. .
1.hormones
Hormones are the most effective drugs for controlling airway inflammation. The route of administration includes inhalation, oral and intravenous application, etc. Inhalation is the preferred route.
(1) Inhalation: The local anti-inflammatory effect of inhaled hormones is strong; through the inhalation process, the drug directly affects the respiratory tract, and the required dose is small. Most of the drugs that enter the blood through the digestive and respiratory tracts are inactivated by the liver, so there are fewer systemic adverse reactions.
The results show that inhaled hormones can effectively reduce asthma symptoms, improve quality of life, improve lung function, reduce airway hyperresponsiveness, control airway inflammation, reduce the frequency and severity of asthma attacks, and reduce mortality. Most adult asthma patients can better control asthma by inhaling small doses of hormones.
Local adverse effects of inhaled hormones in the oropharynx include hoarseness, throat discomfort, and candida infection. After inhaling the drug, rinse the mouth and throat with water in time, and use dry powder inhaler or add a mist reservoir to reduce the above adverse reactions. There is currently evidence that adults with asthma inhale low to medium doses of hormones daily without significant systemic adverse effects. Systemic adverse reactions that may occur after long-term high-dose inhalation of hormones include skin ecchymosis, inhibition of adrenal function, and decreased bone density.
(2) Solution administration: Budesonide solution is inhaled through a jet device powered by compressed air. The requirements for inhalation of patients are not high, and the effect is relatively fast. It is suitable for the treatment of mild to moderate asthma. .
(3) Oral administration: It is suitable for patients with moderate asthma attacks, chronic persistent asthma who fail to respond to inhaled high-dose inhaled hormone combined therapy, and as sequential treatment after intravenous hormone therapy. Shorter half-life hormones are generally used. For hormone-dependent asthma, daily or alternate morning administration can be used to reduce the inhibitory effect of exogenous hormones on the hypothalamus-pituitary-adrenal axis.
Long-term oral hormones can cause osteoporosis, hypertension, diabetes, suppression of the hypothalamus-pituitary-adrenal axis, obesity, cataracts, glaucoma, thin skin, and skin wrinkles, bruising, and weakness. For asthma patients with tuberculosis, parasitic infections, osteoporosis, glaucoma, diabetes, severe depression or peptic ulcer, caution should be exercised in the systemic administration of hormone therapy and follow-up should be followed closely. Asthma patients with systemic use of hormones in the long-term or short-term can be infected with the deadly herpes virus, and it is necessary to avoid these patients as much as possible.
Although systemic use of hormones is not a commonly used method to relieve symptoms of asthma, it is needed for severe acute asthma because it can prevent the worsening of asthma, reduce the chance of emergency department or hospitalization due to asthma, prevent early recurrence, and reduce death rate. The specific use should be based on the severity of the disease. When the symptoms are alleviated or the lung function has reached the personal best value, drug withdrawal or reduction can be considered.
(4) Intravenous administration: In the case of severe acute asthma, it should be given intravenously in a timely manner. Those who have no tendency to hormone dependence can stop the medicine within a short period (3 to 5 days); those who have hormone dependence tendency should extend the administration time and Asthma symptoms were changed to oral administration, and the amount of hormones was gradually reduced.
2-receptor agonists
It can relieve asthma symptoms by relaxing airway smooth muscles, reducing the permeability of microvessels, and increasing the swing of airway epithelial cilia.
(1) Short-acting 2-receptor agonist
Inhalation: It usually takes effect within minutes, and the effect can be maintained for several hours. It is the drug of choice for alleviating the symptoms of mild to moderate acute asthma. It can also be used for exercise asthma. Such drugs should be used intermittently as needed, not for long-term, single use, or overdose, or they may cause adverse reactions such as skeletal muscle tremor, hypokalemia, and heart rhythm disorders. Too much use indicates an acute onset of the disease, or the intensity of the daily control treatment plan is insufficient and needs to be strengthened. Pressure-type quantitative manual aerosols and dry powder inhalation devices for inhaled short-acting 2-receptor agonists are not suitable for severe asthma attacks, and their solutions are inhaled through a nebulizing pump for mild to severe asthma attacks.
Oral administration: If there is no short-acting 2-receptor agonist in the inhaled form, the oral form can be used in the short term instead. Although it is more convenient to use, adverse reactions such as palpitations and skeletal muscle tremor are more obvious than when inhaled. The asthmatic effect of sustained-release and controlled-release dosage forms can be maintained for 8-12 hours.
Patch administration: It is a transdermal absorption dosage form. Because the crystalline storage system is used to control the release of the drug and the drug is absorbed through the skin, it can reduce systemic adverse reactions. It only needs to be applied once a day, and the effect can be maintained for 24 hours. It's easy to use.
Long-acting 2-receptor agonist
: Long-term use of long-acting B2-receptor agonists alone is not recommended. These drugs relax the bronchial smooth muscle for more than 12 hours. Salmeterol: administered via aerosol or dish device, it takes effect 30 minutes after administration, and the asthma effect is maintained for more than 12 hours. The recommended dose is 50 g, inhaled twice daily.
In recent years, a combination of inhaled hormones and long-acting B2-receptor agonists has been recommended for the treatment of asthma. These two have synergistic anti-inflammatory and asthma effects, which can achieve the effect equivalent to (or better than) the application of double doses of inhaled hormones, and can increase patient compliance and reduce adverse reactions caused by larger doses of inhaled hormones, especially Suitable for long-term treatment of patients with moderate to severe persistent asthma.
3. Leukotriene receptor antagonist
This product can reduce asthma symptoms, improve lung function, and reduce the worsening of asthma. This kind of drug is used alone in the department of patients with mild asthma, but its effect is not as good as inhaled hormones. Such drugs can be used as a combination therapy in patients with moderate to severe asthma. This product can reduce the daily dose of inhaled hormones in patients with moderate to severe asthma, and can improve the clinical efficacy of inhaled hormone therapy. The effect is slightly worse.
This product is easy to take. It is especially suitable for the treatment of aspirin asthma, exercise asthma and asthma patients with allergic rhinitis. This product is safer to use.
4. Theophylline: It has the effect of relaxing bronchial smooth muscle, and has the effects of strengthening the heart, diuretic, dilating the coronary arteries, exciting the respiratory center and the respiratory muscles. Low concentrations of theophylline have anti-inflammatory and immunomodulatory effects.
Oral administration: Including aminophylline and controlled (slow) release theophylline. For mild to moderate asthma attacks and maintenance treatments. The general dose is 6 to 10 mg / kg per day. The oral and controlled (slow-release) theophylline has a stable circadian blood concentration after day and night, and the asthma effect can be maintained for 12 to 24 hours, which is especially suitable for the control of nocturnal asthma symptoms. The combined use of theophylline, hormones, and anticholinergics has a synergistic effect. However, when this product is used in combination with 2-receptor agonist, it is prone to rapid heart rate and arrhythmia, and it should be used with caution and the dose should be appropriately reduced. The concentration of drug in the serum is too high, which may easily cause drug poisoning.
Intravenous administration: As a symptom reliever, intravenous theophylline is used to dilate the bronchial tubes in the treatment of severe asthma. There is no advantage compared with a fast 2-receptor agonist when used in sufficient amount. Method of use: Aminophylline is added to the glucose solution, and slowly intravenously (injection rate should not exceed 0.25 mg · kg-1 · min-1) or intravenous drip. The loading dose is 4-6 mg / kg, and the maintenance dose is 0.6-0.8 mg · kg-1 · h-1. Doxofylline has the same effect as aminophylline, but with less adverse reactions.
5.Anticholinergic drugs
Inhaled anticholinergic drugs such as ipratropium bromide, oxytropium bromide, and tiotropium bromide, etc., have a weaker bronchodilator effect than 2-receptor agonists, and they have a slower onset of action, but they are not prone to drug resistance in long-term application. The effect on the elderly is not lower than that of young people. The combination of this product and 2-receptor agonist has synergistic and complementary effects.
Isotropium bromide aerosol: the usual dose is 20 to 40 g, 3 to 4 times a day; the usual dose to inhale the ipratropium bromide solution through an atomizing pump is 50 to 125 g, 3 to 4 times a day.
This product is more suitable for elderly asthma patients with a history of smoking, but should be used with caution in early pregnancy women and patients with glaucoma or enlarged prostate.
6.Anti-IgE treatment
Anti-IgE monoclonal antibodies can be used in asthmatic patients with elevated serum IgE levels. At present, it is mainly used for patients with severe asthma whose symptoms have not been controlled after combined treatment with inhaled glucocorticoids and long-acting B2-receptor agonists. At present, no significant adverse effects of anti-IgE treatment have been found in the treatment research of asthma patients aged 11 to 50 years, but the long-term efficacy and safety of this drug need to be further observed because of its short clinical use. The high price also limits its clinical application.
Allergen-specific immunotherapy (SIT)
Common inhaled allergen extracts (such as dust mites, cat hair, ragweed, etc.) administered subcutaneously or sublingually can alleviate asthma symptoms and reduce airway hyperresponsiveness, and are suitable for those allergens that are clear but difficult to avoid Asthma patients. There is evidence that this treatment can reduce the dosage of commonly used asthma drugs (including hormone drugs), improve asthma symptoms, reduce airway hyperresponsiveness, reduce the risk of asthma in the future of allergic rhinitis patients, and reduce new allergens in the future The type and long-term effect can save medical expenses.
Asthma patients should use this therapy strictly under the guidance of a physician and in a qualified medical unit.
Determination of long-term treatment options
When developing a treatment plan for asthma patients, doctors should choose an appropriate treatment plan based on the level of control based on the severity of the condition. The choice of asthma medicine should take into account both the efficacy and safety of the medicine, as well as the actual condition of the patient, such as economic income and local medical resources. An asthma prevention and treatment plan should be formulated for each newly diagnosed patient, and follow-up and monitoring should be carried out regularly to improve patient compliance, and timely modify the treatment plan according to the changes in the patient's condition. The long-term treatment plan for asthma patients is divided into 5 levels, as shown in the figure.
Designated treatment plan based on asthma patients' disease control grading
For patients with newly diagnosed asthma who have not been treated in the past, a level 2 treatment plan can be selected. Asthma patients have obvious symptoms, and a level 3 treatment plan should be directly selected. Relief medication should be used at each level as needed to quickly relieve asthma symptoms. It can be used as a control and relief drug when combined therapy is performed using a single inhalation device containing formoterol and budesonide.
If asthma control cannot be achieved using this graded treatment regimen, the treatment regimen should be upgraded until asthma control is achieved.
After asthma is controlled and maintained for at least 3 months, treatment options may be considered with caution in downgrading the treatment, such as reducing the number and type of medications.
Management of acute attacks
Patients with high risk factors for asthma-related death need to be given high priority, and these patients should see a medical institution as soon as possible. High-risk patients include: (1) history of near-lethal asthma with tracheal intubation and mechanical ventilation; (2) hospitalization or emergency department visits due to asthma in the past year; (3) currently in use or recently discontinued Oral hormones; (4) currently not using inhaled hormones; (5) excessive dependence on fast-acting 2-receptor agonists; (6) having mental illness or psychosocial problems, including the use of sedatives; (6) having non-compliance with asthma treatment plans history.
Mild and partially moderate acute attacks can be treated at home or in the community. The treatment in the home or community is mainly repeated inhalation of fast-acting 2-receptor agonists, inhaled 2 to 4 sprays every 20 minutes during the first hour. Subsequently, according to the treatment response, mild acute attacks can be adjusted to 2 to 4 sprays every 3 to 4 hours, and moderate acute attacks to 6 to 10 sprays every 1 to 2 hours. The combined use of 2-receptor agonists and anticholinergic agents can achieve better bronchodilator effect. Theophylline has a weaker bronchodilator effect than SABA, and should be used with caution if the adverse reactions are greater. If the response to inhaled 2-receptor agonists is good (respiratory dyspnea is significantly relieved, PEF accounts for> 80% of the expected value or the best value for the individual, and the effect is maintained for 3 to 4 hours), other drugs are usually not required. If the treatment response is incomplete, especially if an acute attack occurs on the basis of controlled treatment, oral hormones should be taken as soon as possible, and if necessary, go to the hospital for treatment.
Some moderate and all severe acute attacks should be treated in the emergency room or hospital. In addition to oxygen therapy, fast-acting 2-receptor agonists should be repeatedly used, which can be administered through a pressure-dispensed aerosol reservoir or a jet nebulizer. Continuous spray administration is recommended during the initial treatment, followed by intermittent administration as needed (every 4 h).
Systemic hormones should be used as soon as possible for acute exacerbations of moderate to severe asthma, especially in patients who have incomplete response to the initial treatment of fast-acting 2-receptor agonists or whose efficacy cannot be maintained, and who still have acute exacerbations based on oral hormones. Oral hormones have the same effect as intravenous administration, with little side effects. Recommended Usage: Prednisone 30-50 mg is administered once a day. For severe acute attacks or when oral hormones cannot be tolerated, intravenous injection or instillation can be used, such as 80-160 mg of methylprednisolone or 400-1000 mg of hydrocortisone in divided doses. Dexamethasone is generally not recommended due to its long half-life and strong inhibitory effect on adrenal function. Sequential therapy of intravenous and oral administration may reduce hormone dosage and adverse reactions, such as intravenous administration of hormones for 2 to 3 days, followed by oral hormones for 3 to 5 days.
After severe and severe asthma exacerbations, the above-mentioned medications have not improved or even worsened the clinical symptoms and pulmonary function. Mechanical ventilation should be given in time (non-invasive mechanical ventilation or invasive mechanical ventilation).
Antibiotics "Most asthma exacerbations are not caused by bacterial infections, and indications for the use of antimicrobials should be strictly controlled, unless there is evidence of a bacterial infection or an acute exacerbation of severe or critical asthma.
Asthma control is usually achieved and maintained through effective asthma management (see Table 1 for definition of asthma control).
The goals of successful asthma management are: to achieve and maintain the control of symptoms; to maintain normal activities, including exercise capacity; to maintain the level of lung function as close to normal as possible; to prevent the acute exacerbation of asthma; to avoid adverse reactions caused by asthma medications; Prevent death from asthma.
Establishing a cooperative relationship between doctors and patients is the first step to achieve effective asthma management. Effective treatment is achieved through the effective implementation of the patient. Physicians should guide patients in self-management, reach consensus on treatment goals, and develop individualized written management plans, including self-monitoring, periodic assessment of treatment options and asthma control levels, and changes in symptoms and / or PEF to indicate changes in asthma control levels Next, adjust the treatment to the level of control in time to achieve and maintain asthma control. Among them, asthma education for patients is the most basic link.
Asthma education must be part of all mutual assistance relationships between doctors and patients. Patient education can increase understanding, enhance skills, increase self-confidence, increase compliance and self-management capabilities, improve health and reduce the use of health care resources.
(1) Identify and reduce exposure to risk factors.
Although pharmacological intervention in patients with asthma diagnosed is very effective in controlling symptoms and improving quality of life, exposure to risk factors should be avoided or reduced as far as possible to prevent asthma from developing and exacerbating symptoms.
A number of risk factors can cause acute exacerbations of asthma, known as "trigger factors," including allergens, viral infections, pollutants, tobacco smoke, and drugs. Reducing patient exposure to risk factors can improve asthma control and reduce the need for treatment medications. Early identification of occupational allergens and prevention of further patient exposure are important components of occupational asthma management.
(B) Evaluation, treatment and monitoring
The patient's initial treatment and adjustments are based on the patient's level of asthma control, including a continuous cycle of assessment of asthma control, treatment to achieve control, and monitoring to maintain control.
The asthma control test (ACT) questionnaire T is only comprehensively judged by answering 5 questions about asthma symptoms and quality of life. 25 points are controlled, 20-24 are partially controlled, and 19 or less are uncontrolled. The patient checks lung function. Maintaining asthma control through long-term continuous testing is particularly suitable for promotion in primary medical institutions. As a supplement to lung function, it is suitable for both doctors and patients to self-assess asthma control. Patients can complete asthma at home or hospital, before or during the consultation Self-assessment of level of control. See Table 3.
Table 3 Asthma Control Test (ACT) Question 1 | Quotation note below question one |
All time 1 | Most of the time 2 | Sometimes 3 | Rarely 4 | No 5 | Score |
Question 2 | How many times have you had difficulty breathing in the past 4 weeks? |
More than once a day 1 | Once a day 2 | 3 to 6 times per week 3 | 1 to 2 times per week 4 | No 5 at all | Score |
Question 3 | Citation Question 2 |
4 nights or more per week | 2 to 3 nights per week 2 | Once a week 3 | 1 to 2 times 4 | No 5 | Score |
Question 4 | How many times have you used emergency medication (such as salbutamol) in the past 4 weeks? |
More than 3 times a day1 | 1 to 2 times per day 2 | 2 to 3 times per week 3 | 1 or less per week 4 | No 5 | Score |
Question 5 | How would you rate your asthma control in the past 4 weeks? |
No control 1 | Poor control 2 | Be in control 3 | Good control 4 | Full control 5 | Score |
Remarks:
This is cited because of form limitations.
Question 1: How many times during the past four weeks did your asthma prevent you from doing your daily activities at work, study or home?
Question 2: In the past 4 weeks, because of asthma symptoms (wheezing, coughing, dyspnea, chest tightness or pain), how many times did you wake up at night or wake up earlier than usual in the morning?
1. After receiving standardized treatment for most asthma patients, symptoms will soon be relieved, and lung function will gradually improve. Tips for all asthma patients: Asthma is a chronic disease and many patients require long-term treatment. The formulation and modification of treatment plans, the reduction and withdrawal of drugs should be carried out under the guidance of a doctor, and should not be decided on their own, otherwise it is likely to cause the loss of previous treatment effects and the worsening of the disease.
2. After standardizing the treatment according to the treatment plan recommended by the experts for a period of time, the effect is not satisfactory, and you should actively cooperate with the doctor to find the cause, such as: whether continuous exposure to asthma triggers (allergens, environmental chemicals, etc.), whether due to drug devices Inappropriate use, whether it is associated with asthma-refractory comorbidities (nasal-sinusitis, gastroesophageal reflux, obstructive sleep apnea syndrome, etc.), whether smoking or passive smoking, whether there are drug factors (oral beta-blockers) Agents, oral angiotensin-converting enzyme inhibitors, antipyretic analgesics, etc.), whether they have other diseases with asthma-like symptoms (such as allergic bronchopulmonary aspergillosis, allergic granulomatous vasculitis, etc.) .
3. Acute attacks of asthma usually have triggering factors, and many patients are caused by changing their treatment plans (reducing or discontinuing asthma control drugs). Other common causes include: triggering factors such as viral infection, exposure to allergens, and after the exacerbation of asthma, review the patient's correct use of drugs, inhalation devices and peak flow meters, find the cause of the acute attack and formulate measures to avoid contact, formulate and adjust Controlled treatment regimen to prevent another acute attack.
