1、支哮喘2015GINA解讀GlobalINitiative forA Sthma總醫(yī)院呼吸科胡紅2015-8-22Main Contents123456GINA updated 2015Main Contents123456GINA updated 2015更新內容-12015GINA增加了噻托溴銨（軟膠囊吸入器）作為新型的“其它可選藥”被列入哮喘階梯治療表格，適用于選擇Step4和5有哮喘發(fā)作史的成人哮喘患者的治療。更新內容-2Main Contents123456GINA updated 2015哮喘的定義和診斷哮喘新定義胡紅GINA 2014 and 2015哮喘是一種異質性疾病，通常以

2、慢性氣道炎癥為特征。 哮喘定義為具有呼吸道癥狀的病史，包括喘息，氣短，胸悶和咳嗽，這些癥狀及其嚴重程度可隨時間變動而變化， 同時具有可變性呼氣性氣流受限。Patient with respiratory symptomsAre the symptoms typical of asthma?哮喘初始診斷流程NOYESDetailed history/examination for asthmaHistory/examinationsupports asthma diagnosis?Further history and tests for alternative diagnosesAlterna

3、tive diagnosis confirmed?NOClinical urgency, and other diagnoses unlikelyYESPerform spirometry/PEF with reversibility testResults support asthma diagnosis?Repeat on anotherNOoccasion or arrange other testsConfirms asthma diagnosis?NOYESEmpiric treatment with ICS and prn SABAReview responseDiagnostic

4、 testing within 1-3 monthsNOYESYESConsider trial of treatment for most likely diagnosis, or refer for further investigationsTreat for ASTHMATreat for alternative diagnosis哮喘的評估哮喘治療哮喘長期管理目標：1、癥狀：達到良好癥狀及維持正常活動2、減少風險： 減少未來急性加重風險減少持續(xù)氣流限制風險減少不良反應風險Manage asthma in a continuous cycle:1.2.AssessAdjust trea

5、tment (pharmacological and non-pharmacological)Review the response3.GINA 2015 哮 喘 階 梯 治 療 方 案STEP 5STEP 4STEP 3Refer for add- on treatme nte.g. anti-IgEAdd tiotropium# Add low dose OCSSTEP 1STEP 2PREFERRED CONTROLLERCHOICEMed/high ICS/LABALow dose ICS/LABA*Low dose ICSAdd tiotropium# High dose ICS+

6、LTRA(or + theoph*)Other controller optionsRELIEVERConsider low dose ICSMed/high dose ICS Low dose ICS+LTRALeukotriene receptor antagonists (LTRA) Low dose theophylline*(or + theoph*)As-needed SABA orAs-needed short-acting beta2-agonist (SABA)low dose ICS/formoterol*For children 6-11 years, theophyll

7、ine is not recommended, and preferred Step 3 is medium dose ICS*For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy # Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of exacerbations; it is not indicated in children &

8、lt;18 years.GINA updated 2015Stepping down treatment when asthma is controlled癥狀和肺功能穩(wěn)定3或者以上。若有加重的或者持續(xù)氣流受限，無密切觀察指導不能降級選擇合適的時機：無呼吸道，未懷孕等、肺功能和每一步降級都要癥狀，提供指導，監(jiān)測癥狀、PEF，為下一步治療計劃提供時間表。胡紅對于多數，3降低25-50%ICS是安全可行的GINA 2014 and 2015哮喘和急性加重治療急性加重的定義哮喘急性加重是指出現較日常狀態(tài)改變的癥狀，如加重的氣促、喘息、胸悶、出現肺功能下降等，需要改變日常的治療。胡紅GINA upda

9、ted 2015Managing exacerbations in primary carePatient presents with acute or sub-acute asthma exacerbationPRIMARY CAREIs it asthma?Risk factors for asthma-related death? Severity of exacerbation?ASSESS the PATIENTMILD or MODERATETalks in phrases, prefers sitting to lying, not agitated Respiratory ra

10、te increased Accessory muscles not used Pulse rate 100120 bpmO2 saturation (on air) 9095% PEF >50% predicted or bestSEVERETalks in words, sits hunched forwards, agitated Respiratory rate >30/min Accessory muscles in use Pulse rate >120 bpmO2 saturation (on air) <90% PEF 50% predicted or

11、bestLIFE-THREATENINGDrowsy, confused or silent chestURGENTTRANSFER TO ACUTE CARE FACILITYSTART TREATMENTSABA410 puffs by pMDI + spacer, repeat every 20 minutes for 1 hourPrednisolone:adults 1 mg/kg, max. 50 mg,Controlled oxygen(if available): target saturation 9395%While waiting: give inhaled SABA a

12、nd ipratropium bromide, O2, systemic corticosteroidWORSENINGCONTINUE TREATMENT with SABA as neededASSESS RESPONSE AT 1 HOUR (or earlier)WORSENINGIMPROVINGASSESS FOR DISCHARGESymptoms improved, not needing SABAARRANGE at DISCHARGEReliever:continue as neededController:start, or step up. Check inhaler

13、technique, adherencePrednisolone:continue, usually for 57 days Follow up: within 27 daysPEF improving, and >60-80% of best or predictedOxygen saturation >94% room air Resources at homeadequatealFOLLOW UPReliever: reduce to as-neededController:continue higher dose for short term (12 weeks) or l

14、ong term (3 months), depending on background to exacerbationRisk factors: check and correct modifiable risk factors that may have contributed to exacerbation, including inhaler technique and adherenceAction plan:Is it understood? Was it used appropriately? Does it need modification?GINA updated 2015

15、Managing exacerbations in acute care settingsINITIAL ASSESSMENTA: airway B: breathing C: circulationAre any of the following present?Drowsiness, Confusion, Silent chestNOYESFurther TRIAGE BY CLINICAL STATUSaccording to worst featureConsult ICU, start SABA and O2, and prepare patient for intubationMI

16、LD or MODERATETalks in phrases Prefers sitting to lying Not agitatedRespiratory rate increased Accessory muscles not used Pulse rate 100120 bpmO2 saturation (on air) 9095% PEF >50% predicted or bestSEVERETalks in wordsSits hunched forwards AgitatedRespiratory rate >30/min Accessory muscles bei

17、ng used Pulse rate >120 bpmO2 saturation (on air) < 90% PEF 50% predicted or bestShort-acting beta2-agonists Ipratropium bromide Controlled O2 to maintain saturation 9395%Oral or IV corticosteroids Consider IV magnesium Consider high dose ICSShort-acting beta2-agonists Consider ipratropium bro

18、mide Controlled O2 to maintain saturation 9395%Oral corticosteroidsIf continuing deterioration, treat as severe and re-aassess for ICUASSESS CLINICAL PROGRESS FREQUENTLY MEASURE LUNG FUNCTIONin all patients one hour after initial treatmentFEV1 or PEF <60% of predicted oral best,or lack of clinica

19、l response SEVEREContinue treatment as above and reassess frequentlyFEV1 or PEF 60-80% of predicted or al best and symptoms improvedMODERATEConsider for discharge planningGINAupdated 2015哮喘-COPD重疊綜合癥診斷DIAGNOSE CHRONIC AIRWAYS DISEASEDo symptoms suggest chronic airways disease?STEP 1YesNoConsider oth

20、er diseases firstSYNDROMIC DIAGNOSIS IN ADULTS(i) Assemble the features for asthma and for COPD that best describe the patient. (ii) Compare number of features in favour of each diagnosis and selectSTEP 2gnosisFeatures: if present suggestASTHMACOPDAfter age 40 yearsPersistent despite treatmentGood a

21、nd bad days but always daily symptoms and exertional dyspnea Chronic cough & sputum preceded onset of dyspnea, unrelated to triggersRecord of persistent airflow limitation (FEV1/FVC < 0.7 post-BD)AbnormalAge of onsetPattern of symptomsBefore age 20 yearsVariation over minutes, hours or days W

22、orse during the night or early morning. Triggered by exercise, emotions including laughter, dust or exposure to allergensRecord of variable airflow limitation (spirometry or peak flow)For an adult who presents with respiratory symptoms:Lung functionLung function between symptomsPast history or famil

23、y historyNormalPrevious doctor diagnosis of COPD, chronic bronchitis or emphysema Heavy exposure to risk factor: tobacco smoke, biomass fuelsPrevious doctor diagnosis of asthma Family history of asthma, and other allergic conditions (allergic rhinitis or eczema)No worsening of symptoms over time. Va

24、riation in symptoms either seasonally, or from year to yearMay improve spontaneously or have an immediate response to bronchodilators or to ICS over weeksNormal1.Does the patient have chronic airways disease?Syndromic diagnosis of asthma, COPD and ACOSSpirometryCommence initial therapyReferral for s

25、pecialized investigations (if necessary)GINA updated 2015Time courseSymptoms slowly worsening over time (progressive course over years)Rapid-acting bronchodilator treatment provides only limited relief2.Chest X-raySevere hyperinflationNOTE: These features best distinguish between asthma and COPD. Se

26、veral positive features (3 or more) for either asthma or COPD suggest that diagnosis. If there are a similar number for both asthma and COPD, consider diagnosis of ACOSSome features of asthmaAsthmaSome features of COPD Possibly COPDDIAGNOSISCONFIDENCE IN DIAGNOSISAsthmaCOPDAsthmaCOPD3.4.5.STEP 3 PER

27、FORM SPIROMETRYMarkedreversible airflow limitation(pre-post bronchodilator) or other proof of variable airflow limitationFEV1/FVC < 0.7post-BDSTEP 4 INITIAL TREATMENT*Asthma drugsAsthma drugsCOPDdrugsCOPDdrugsNo LABANo LABAmonotherapy monotherapy*Consult GINA and GOLD documents for recommended tr

28、eatments. Persistent symptoms and/or exacerbations despite treatment. Diagnostic uncertainty (e.g. suspected pulmonary hypertension, cardiovascular diseases and other causes of respiratory symptoms). Suspected asthma or COPD with atypical or additional symptoms or signs (e.g. haemoptysis, weight los

29、s, night sweats, fever, signs of bronchieis or other structural lung disease). Few features of either asthma or COPD. Comorbidities present. Reasons for referral for either diagnosis as outlined in the GINA and GOLD strategy reports.STEP 5 SPECIALISED INVESTIGATIONSor REFER IF:ICS, and usually LABA+/orFeatures of bothCould beACOSStepwise approach to diagnosis and initial treatment for ACOSGINA 201