出版者 : 台灣氣喘衛教學會 目錄 Taiwan Association of Asthma Education 台灣氣喘衛教學會季刊創刊日期 : 中華民國 頁次 日期 :2012 年 4 月 28 日星期六 13:00 17:30 4 台北馬偕紀念醫院 /

Transcription

1 Asthma Education Newsletter 2012 April No ( ) 11:00-4:00 MOMO

2 出版者 : 台灣氣喘衛教學會 目錄 Taiwan Association of Asthma Education 台灣氣喘衛教學會季刊創刊日期 : 中華民國 頁次 日期 :2012 年 4 月 28 日星期六 13:00 17:30 4 台北馬偕紀念醫院 / 台灣氣喘衛教學會 ; 徐世達榮譽理事長 13 常風小兒科 ; 陳五常醫師 24 台中榮總過敏免疫風濕科 ; 蔡肇基醫師 台北誌字第 889 號 地址 : 台北市中山區天祥路 16 巷 15 號 6 樓之 9 電話 :(02) 傳真 :(02) 劃撥帳號 : 發行人 : 黃立心榮譽理事長 : 徐世達理事長 : 黃立心總編輯 : 朱斯鴻執行編輯 : 徐世達 蔡肇基 高碧霞 譚美珠編輯諮詢委員 : 闕貴玲 王弘傑 蘇有村 溫港生 李碧珠 林應然 蔡肇基 翁麗緻 蘇秦明 黃初雪 林慶雄 王世叡 高羽璇 王森洤 陳五常 朱斯鴻 吳維峰 陳宇照 廖婉智 [email protected] Http : // 歡迎來信索取, 來函請付五十元 ( 工本費及回郵 ) 地點 : 台北馬偕紀念醫院平安樓九樓大禮堂 主辦單位 : 臺北市政府衛生局 台灣氣喘衛教學會 承辦單位 : 馬偕紀念醫院 馬偕醫護管理專科學校 活動內容 : 時間 活動 講師 主持人 13:00 14:00 報到台灣氣喘衛教學會 ( 請攜帶 " 健保卡 " 或 " 身分證 " 刷到 ) 秘書處 Opening 與貴賓致詞 台灣氣喘衛教學會徐世達榮譽理事長黃立心理事長 高碧霞常務理事 13:45 14:00 臺北市衛生局長官 林奇宏局長馬偕醫護管理專科學校陳漢湘校長 14:00 14:50 過敏氣喘病人的最新全方位照護 徐世達醫師 吳維峰醫師 14:50 15:40 食物在過敏氣喘病人日常生活所扮陳五常醫師林應然醫師演的角色 15:40 15:50 Break 15:50 16:40 16:40 16:50 呼吸道感染在過敏氣喘病人日常生蔡肇基醫師溫港生醫師活所扮演的角色綜合討論與 Closing 所有講師與主持人 ( 請攜帶 " 健保卡 " 或 " 身分證 " 刷退 ) 17:00 17:30 台灣氣喘衛教學會會員大會闕貴玲秘書長 參加對象 : 台灣氣喘衛教學會會員及關心氣喘照護之醫療團隊成員及民眾 等學分 : 台灣氣喘衛教學會必修 10 學分 台灣臨床藥學會臨藥繼字第 號 3 積分 護理人員台護審字第 號專業 3 積分 台灣兒科醫學會兒教字 7920 號 2 積分 公務人員終身學習 4 積分 台灣兒童過敏氣喘免疫及風濕病醫學會第 457 號 3 分 Asthma Education Newsletter 2012 April No.26 3

3 專題演講 過敏氣喘病人的最新全方位照護 Taiwan Association of Asthma Education 4 台北馬偕紀念醫院 / 台灣氣喘衛教學會 徐世達榮譽理事長 近年來醫學界已經瞭解了遺傳性過敏病基本上乃是一種與多重基因遺傳有關的障壁層 缺陷與慢性過敏性發炎反應 此炎症反應會因受到各種誘發因素的激發造成臨床上的 過敏發作, 而其發作的部位則與其所遺傳到的各別器官異常有密切的關係 當此炎症反應發生於支氣管時我們稱之為氣喘病, 發生於鼻腔 眼結膜時稱之為過敏性鼻結膜炎, 發生於胃腸時稱之為過敏性胃腸炎, 而當其發生於皮膚時我們稱之為異位性皮膚炎 (7-15 ) 近年來另外兩次的大台北地區學童氣喘病罹病率的問卷調查 ( 西元 1998 與 2002 年 ) 其比例更是快速增加到高達百分之十六與百分十九 西元 2007 年台北市衛生局相關委託調查統計也顯示氣喘在台北市國小一年級學童約有 20.34% 的盛行率 2009 年的盛行率甚至高達 20.74% 西元 2002 與 2007 年調查大台北地區與台北市國小學童過敏性鼻炎罹病率更是已經增加到約百分之五十 西元 2007 年調查台北市國小學童異位性皮膚炎罹病率更是已經增加到約百分之十三 外因性 : 佔 70-90%;IgE 總量上升 內因性 : 佔 10-30% ;IgE 總量沒有上升 極輕度但持續存在的過敏性炎症反應 (minimum persistent inflammation) 是一個非常重要的新概念, 這句話的意思就是指持續型過敏性鼻炎患者, 在一年中所接觸過敏原濃度可能在不同範圍內忽高忽低, 但是即使在此時沒有臨床過敏症狀發生, 其鼻黏膜炎症反應仍然持續存在 - 一個或以上過敏病患的高敏感家庭從懷孕的第二產期 ( 即第四個月 ) 避免接觸家族內過敏的過敏原 5 Asthma Education Newsletter 2012 April No 母親只應禁食經食物激發試驗證實的過敏食物 2. 減少塵蟎 蟑螂 黴菌 貓狗等有毛寵物, 與空氣污染物 ( 包括懸浮微粒 化學刺激 物和香煙 ) 的接觸 3. 懷孕期間可補充益生菌與富含 ω-3 多元不飽和脂肪酸食物 餵食母乳時, 母親應禁食其家族中已被證實會造成過敏的食物 ( 較常見者為乳製品 蛋 魚 豆奶或花生 ) 當不能餵食母奶時, 須使用適度水解蛋白嬰兒奶粉餵食 可補充益生菌與 ω-3 多元不 飽和脂肪酸 四至六個月開始添加副食品 減少塵蟎 蟑螂 黴菌 貓狗等有毛寵物, 與空氣污染物 ( 包括懸浮微粒 化學刺激物 和香煙 ) 的接觸 Changes in hygienic surrounding( ) 減少感染 (less infections) 過多抗生素 (more antibiotics) 無菌食物 (no infected food) Changes in food habits( ) 少發酵食物 (less fermented food) 多變化食物 (more diversified foods) 多 ω6 多元不飽和脂肪酸食物 (a shift from ω3 to ω6 fatty acid dominant foods) 少抗氧化基食物 (less antioxidants in foods) Changes in life style( ) 少兄弟姊妹 (less sibblings) 少接觸農場動物 (less contact with farm animals)

4 專題演講 過敏氣喘病人的最新全方位照護 6 專題演講 過敏氣喘病人的最新全方位照護 氣喘是一種呼吸道的慢性發炎病變 發炎導致反覆發生呼吸道氣流阻滯及呼吸道的敏感反應 最有效的處置是去除致病因而防止發炎的產生 促成氣喘罹病率及死亡率上升的因素是診斷的不足以及治療的不當 任何輕度持續型以上的氣喘, 使用抗炎性藥物比單獨使用支氣管擴張劑更有效 曾有喘鳴或反覆出現喘鳴 曾有明顯之早上醒來或夜間咳嗽 曾經在運動後, 出現咳嗽或喘鳴 當接觸到吸入型過敏原或空氣污染物後會出現咳嗽 胸悶或喘鳴 感冒超過十天又有痰或感胸悶 ( 一 ) 自然病史 ( 二 ) 理學檢查 ( 三 ) 與 IgE 有關的過敏檢測 ( 四 ) 評估肺功能 ( 五 ) 鑑別診斷和診斷同時罹患的疾病 ( 六 ) 其它檢測 - 胸部 x-ray, eno, exhaled breath condensates 等 1. 暫時性喘鳴 (transient wheezing) 2. 非異位體質喘鳴 (nonatopic wheezing ) 3. 持續性氣喘 (persistent asthma) 4. 嚴重間歇性喘鳴 (severe intermittent wheezing) 1. 暫時性喘鳴 (transient wheezing) 兒童於出生後 2 至 3 年內曾發生反復喘鳴, 但 3 歲以後就不再有此臨床表現 2. 非異位體質喘鳴 (nonatopic wheezing) 主要由病毒感染誘發, 到兒童期會減輕 7 Asthma Education Newsletter 2012 April No 持續性氣喘 (persistent asthma) : 臨床表現其他相關的過敏症狀 ( 濕疹 過敏性鼻炎和結膜炎 食物過敏 ) 血液中嗜 酸性白血球增多, 及 / 或免疫球蛋白 E(IgE) 升高 嬰兒和幼童時對食物過敏原產生特異性 IgE 的致敏反應, 之後對一般吸入的過敏原產 生特異性 IgE 的過敏反應 3 歲前對吸入性過敏原有致敏反應, 尤其是長期暴露於室內有特定過敏原而產生過敏 反應 父母親有氣喘病史 4. 嚴重間歇性喘鳴 (severe intermittent wheezing) 平時無症狀, 但發作時便會有嚴 重的喘鳴, 通常與下列情況有關 : 沒有感冒時, 症狀極輕微 合併有過敏體質, 包括濕疹 過敏原敏感反應, 以及周邊血液嗜酸性白血球增多等 我們可以根據以下的臨床指標來預測病童在孩童晚期產生氣喘病的機率會大增 : 在三 歲以前產生咳嗽喘鳴的兒童若合併有一個主要危險因子 ( 如父母親有氣喘 病人有異 位性皮膚炎或吸入型過敏原反應陽性 ), 或兩個以上次要危險因子 ( 如嗜酸性白血球 過多 無感冒時會咳嗽喘鳴 過敏性鼻炎或食入型過敏原反應陽性 ) 五歲以下的小朋友的氣喘診斷, 主要靠臨床判斷, 症狀評估, 及理學檢查 對此年齡群作確認診斷的一項有用工具, 是以速效型支氣管擴張劑及吸入型類固醇所 做的治療試驗 (Trial) 治療期間的顯著進步和停藥之後的症狀惡化可支持氣喘的診 斷 遺傳 慢性支氣管發炎 氣道高敏感度

5 專題演講 過敏氣喘病人的最新全方位照護 8 誘發因素 專題演講 過敏氣喘病人的最新全方位照護 對過敏炎症反應的緩解能力異常 支氣管周邊纖維化 氣道變形 氣道變形所引起的結構變化包括有平滑肌細胞的增生, 黏液腺體的肥大, 皮下組織的纖維化, 血管生成, 神經密度和細胞外基質的改變 每一位氣喘病患的氣道變形皆不盡相同, 其造成的結果亦是多樣化 近年來的研究發現建議 : 要避免孩童氣道變形, 逐漸喪失肺功能, 過敏免疫學專科醫師需要於五歲前找出氣喘病童並加以治療 在異位性疾病自然病史的早期完全禁止接觸環境過敏原可能會大幅改善過敏疾病的日後控制 單一項目的過敏原避免措施通常是無效的 徹底且完全的居家環境過敏原防治措施來達到完全禁止接觸環境過敏原或大幅減少過敏原的接觸對過敏疾病臨床症狀的改善是有效的 當過敏原暴露與過敏症狀之間具有明顯的關聯時, 應採取避免接觸的措施 唯有能徹底避免接觸過敏原, 才有改善臨床的結果 任何年齡皆可進行過敏原測試, 以確認可能造成氣喘發作的過敏原 所有年齡的兒童以及孕婦都應避免暴露於抽菸環境中 均衡飲食且控制體重 在有效地控制氣喘的發炎反應與症狀的情況下, 應儘量鼓勵氣喘兒童參與運動 目標 : 在最少的藥物相關副作用下, 控制症狀及防止疾病惡化原則 : 根據症狀的持續性, 嚴重程度與 / 或頻率以及所呈現的表現型循序進行 類固醇 ( 全身與吸入型 ) 緩慢釋放型茶鹼 白三烯調節劑 (Leukotriene modifiers) 以類固醇的療效最佳同時具備預防與治療效果 β2 IgE ( 12 ) 速效 β2 交感神經興奮劑 副交感神經阻斷劑 短效型茶鹼 類固醇 ( 全身型 ) 以速效 β2 交感神經興奮劑的效果最佳 ( ) 急救用藥除了必要時吸入速效型乙二型交感神經興奮劑外尚可使用吸入型副交感神經阻斷劑口服短效型乙二型交感神經興奮劑部份長效型乙二型交感神經興奮劑以及短效型茶鹼 持續每天單獨使用短效型或長效型乙二型交感神經興奮劑是不被建議的除非病人有規則合併使用控制藥物尤其是吸入型類固醇 Asthma Education Newsletter 2012 April No.26 9

6 專題演講 過敏氣喘病人的最新全方位照護 10 專題演講 過敏氣喘病人的最新全方位照護 對於無其他氣喘徵象的運動誘發型氣喘, 在運動前 10 至 15 分鐘使用短效的 β2 促進劑通 常可予以控制 當結合其他氣喘症狀時, 運動誘發型氣喘最好的控制方法就是單獨使用 ICS, 若 ICS 無法達成全面性控制 : (a) 在運動前, 添加吸入型短效 β2 促進劑 (b) 除 ICS 外, 添加 LTRA (c) 除 ICS 外, 添加吸入型 LABA, 類固醇治療與兒童生長 類別效應 受使用的裝置, 劑量和類型影響 乾粉吸入器在較低劑量就會有抑制作用 吸藥輔助器 800ug/day budesonide V.S. 乾粉吸入器 ug/day 早上每日一次給藥可將生長抑制降至最低 不會影響最後身高 記錄臨床症狀評分 記錄使用之藥物 以尖峰呼氣流量計或肺功能測量器 (Spirometry) 來監測氣道功能 氣喘控制測驗 (ACT) 綠燈區 :80~100% 理想值狀況良好 黃燈區 :60~80% 理想值應小心, 一日內就醫 紅燈區 : < 60% 理想值應立即就醫 (ACT) 在過去 4 週中, 您的氣喘會讓您無法完成一般的工作 課業或家事嗎? 在過去 4 週中, 您多常發生呼吸急促的情形? 在過去 4 週中, 您多常因氣喘症狀 ( 喘鳴 咳嗽 呼吸急促 胸悶或胸痛 ) 而讓您半夜醒來或提早醒來? 在過去 4 週中, 您多常使用急救性藥物或噴霧型藥物 (Albuterol Ventolin Berotec Bricanyl) 在過去 4 週中, 您自認為氣喘控制程度如何? (Childhood ACT) 兒童部份 : 你覺得你今天的氣喘如何? 你覺得氣喘會妨礙到你跑步 運動或玩耍嗎? 你會因為氣喘而咳嗽嗎? 你會因為氣喘而半夜醒來嗎? 家長部分 : 在過去 4 週中, 您的孩子有幾天有白天氣喘症狀? 在過去 4 週中, 您的孩子有幾天因為氣喘而聽到喘鳴? 在過去 4 週中, 您的孩子有幾天因為氣喘而半夜醒來? 環境中會造成空氣污染的物質, 包括室內與室外的吸入型過敏原與空氣污染物 環境中會造成空氣污染的室內外的吸入型過敏原與空氣污染物的過度增加, 不但會造成免疫力正常的健康民眾容易產生呼吸系統疾病, 對於免疫力偏差的呼吸道過敏病人所造成的傷害, 會遠大於正常人 降低室內過敏原和空氣污染物即可使居家環境的空氣清新 我們知道反覆呼吸道疾病與過敏氣喘病症狀的發生和環境中空氣污染物與過敏原的量息息相關, 因此, 縱使無法達到完全的控制, 仍須控制室內環境以減少空氣污染物與過敏原 Asthma Education Newsletter 2012 April No.26 11

7 專題演講 過敏氣喘病人的最新全方位照護 Taiwan Association of Asthma Education 居家塵蟎防治 維持室內陽光充足 空氣流通及降低室內濕度, 使用空調或空氣清淨機是減少室內空氣中貓 狗 蟑螂與黴菌孢子等過敏原最好的方法 避開室內空氣污染原的最有效辦法最重要的就是不吸菸也不吸二手菸 除了戒菸外, 就是要把其他的空氣污染物質儘可能的減少產生及排到室外 維持廚房燃燒系統正常運作, 充分的通風與排氣, 避免使用噴霧劑 避免接觸揮發性有機化合物 ( 如芳香劑 清潔劑 烹調油煙等 ), 以及必要時使用具 HEPA 系統的空氣清淨機等, 也是重要且有效的方法 室內外溫差指數 溼度指數 空氣污染指數 環保署依據監測資料將當日空氣中以下物質數值, 以其對人體健康的影響程度, 分別換算出不同污染物之副指標值, 再以當日各副指標之最大值為該測站當日之空氣污染指標值 (PSI) 懸浮微粒 (PM10)( 粒徑 10 微米以下之細微粒 ) 二氧化硫 (SO2) 二氧化氮 (NO2) 一氧化碳 (CO) 臭氧 (O3) 濃度值 評估每日氣候變化與空氣品質, 對誘發過敏之指數, 以紅 黃 綠燈三種警示方式提醒, 每小時更新一次 分為北部 / 中部 / 南部 / 東部進行預報 12 常風小兒科陳五常醫師 Food allergies and asthma Introduction Food allergy and asthma are common childhood conditions Children with both food allergies and asthma are at increased risk for severe anaphylaxis It is unclear whether these just coexist in children predisposed to atopic conditions (i.e. atopic march) or a causal relationship exists Epidemiology of food allergy and asthma Both food allergies and asthma appear to be increasing in prevalence The prevalence of asthma is more than doubled between 1980 and 1996 The prevalence of food allergy is 4.2% in the United There is a strong perception in the community that these are closely linked In a survey of 156 patients attending an asthma and allergy clinic, 73% of people believed that foods induced their asthma symptoms Role of food allergy in asthma Food allergies often affect young children, can precede the development of asthma, and are considered a risk factor for persistent, problematic asthma in young children Sensitization to egg, has been shown to be a risk factor for sensitization to aeroallergens and asthma later in life All of the children had developed tolerance to egg by school-age, Sensitization to egg was a marker for increased risk for later asthma, but that presence of asthma symptoms were not associated with persistence of the food sensitization There was no association between the severity of allergic reaction to foods and risk of developing asthma. Role of food allergy in asthma Epidemiologic studies 1.In a study using serum collected from the National Cooperative Inner City Asthma Study (NCICAS) that enrolled children with asthma from the inner city,. This increased prevalence of food allergy is particularly evident in those reporting current asthma and having had emergency department visits for asthma. Asthma Education Newsletter 2012 April No.26 13

8 14 2. Although 14.9% of those with no asthma had sensitization to at least one food, only 0.9% had levels that suggested likely food allergy; this is in contrast to 27.5% of those with asthma having sensitization to at least one food, of which 1.9% likely have clinical food allergy. children with sensitization to foods had increased asthma morbidity, with higher rate of asthma hospitalization, and higher requirement of steroid medications Patients with asthma and food allergy are more likely to have a severe asthma exacerbation as compared with asthmatic patients without evidence of food allergy children with life-threatening asthma were more likely to have clinical food allergy than children who had nonlife-threatening asthma exacerbations Simpson et al reported that having peanut allergy was associated with increased rates of hospitalization and use of systemic steroids There was no association between asymptomatic food sensitization and asthma prevalence or severity Objective measurements of lung dysfunction Children with IgE-mediated milk allergy at 7 months of age had increased risk of elevated BHR (using histamine challenge) and exhaled nitric oxide at 8 years of age. Increased BHR (using methacholine challenge) in food allergic children as compared with healthy children without food allergy; as well, these children did not have asthma or allergic rhinitis. Even in children with asthma, respiratory symptoms were observed in only 26% of food allergic children during oral food challenge. Among those without asthma, 47% of food allergic children had increased BHR as compared with 17% of those without food allergy, demonstrating a limitation of using BHR as a surrogate marker for asthma food allergic reactions can trigger lower respiratory symptoms, food allergy generally does not present with chronic or isolated respiratory symptoms Bock reported on 279 asthmatic patients with a history of food-induced wheezing who underwent DBPCFC,only five participants had isolated wheezing Respiratory symptoms may not always accompany food allergic reactions, a concurrent diagnosis of asthma appears to worsen the general prognosis for food allergy The risk of anaphylaxis was higher in those with severe asthma as compared with those classified as having nonsevere asthma. What is the link between asthma and food allergy? asthma and food allergies coexist There are still unanswered questions regarding the relationship between these entities. It is possible that greater atopy is associated with more severe and food sensitization, with no direct causal relationship A major limitation of current epidemiologic studies investigating rates of food sensitization based on serology alone is that clinical reactivity to potential allergens is not assessed Positive tests to food were in part due to cross reactivity to environmental allergens, these tests may be indirectly measuring the level of their environmental allergies. For example, people with birch tree pollen allergies can test positive to peanut and those with dust mite and/or cockroach allergies can test positive to shrimp In a study in which 20% of children with reported food allergy also had asthma, the association between food allergy and asthma was stronger when participants were stratified for concurrent sensitization to aeroallergens. What is the link between asthma and food allergy? A subset of patients, respiratory symptoms, including wheezing, are induced by foods up to 30% of the time for food allergic individuals Reports have indicated that severe asthma is risk factor for fatal food anaphylaxis. Food-induced respiratory symptoms should be managed differently from asthma exacerbations triggered by other common triggers, with injectable epinephrine as the treatment of choice as opposed to inhaled beta-agonists. The evidence supporting a causal relationship between food allergies and asthma should not be ignored Management of coexisting asthma and food allergies Patients with both diagnoses are at risk for poor outcomes and should be well managed to prevent potential morbidity and mortality. Accurate diagnoses are the first step Assessments of asthma symptoms, triggers, and response to bronchodilators are essential to establish the diagnosis Asthma Education Newsletter 2012 April No.26 15

9 16 Conventional asthma management, can achieve good control in the large majority The history should be used as a guide to determine appropriate testing, including the use of oral food challenges Management of coexisting asthma and food allergies Eexercise-associated food-induced anaphylaxis, gastro-esophageal reflux, and vocal cord dysfunction are some alternatives that should be considered Situations in which food allergy should be suspected in asthmatic patients,these may include 1.Acute life-threatening asthma with no identifiable triggers or outside the typical season for viral infections 2.Highly atopic children with severe persistent asthma resistant to medical treatment in whom the history linking food ingestion to asthma may not be reliable due to fragmented care (e.g. children in foster care or children alternately living with divorced parents). Once the diagnoses are confirmed, education is essential 1.Patients need to be educated about the importance of food allergen avoidance,how to read food labels,the appropriate use of emergency medications in case of allergic reaction 2.Because uncontrolled asthma is a risk factor for severe anaphylaxis, optimal management is required. 3.Patients can often be confused about whether symptoms are due to asthma or food allergy; if suspicion of food-induced anaphylaxis is high, injectable epinephrine is the treatment of choice. Treatment of coexisting asthma and food allergies A treatment that can potentially target both food allergies and asthma are anti-ige antibodies. Combination therapy of anti-ige and allergen immunotherapy was investigated An on-going trial of omalizumab in conjunction with milk oral immunotherapy Conclusion Having food allergy and asthma places people at greater risk for morbidity and mortality. With heightened awareness of the relationship between these two entities, management of food allergy and asthma and recognition of food-triggered asthma exacerbations may improve treatment A multifaceted approach to managing this subset of patients can lead to optimal care. Diets and asthma Vitamins and Asthma Cross-sectional studies suggest that increasing the amount of fruit you eat decreases your risk of developing asthma and decreases asthma symptoms Scientists began to look at relationships between asthma and specific vitamins in fruit that are thought to have antioxidant and other anti-inflammatory properties. These include: Vitamin C: Vitamin C is a potent antioxidant that is thought to provide some anti-inflammatory properties. Foods such as broccoli, bell peppers, oranges, strawberries, and lemons contain significant amounts of vitamin C. Asthmatic children have lower vitamin C levels compared to children without asthma, lower levels of vitamin C might increased inflammation and increased risk of asthma. Vitamin E: higher vitamin E levels are associated with less skin sensitization, lower IgE levels, and decreased inflammation in asthma pathophysiology. People with increased dietary, but not supplemental, intake of vitamin E less commonly develop asthma. Vitamin A and Beta-carotene: vitamin A and beta-carotene are thought to have antioxidant properties that may improve inflammation in asthma. Zinc: Low levels of zinc have been found in patients with asthma and zinc deficiency is associated with inflammation, but may or may not actually impact asthma. Flavones and Flavenoids Flavones and flavenoids are other antioxidant compounds found in foods such as citrus fruits, tea, red wine, and dark chocolate. These compounds are thought to stabilize mast cells, a type of cell prominent in the pathophysiology of asthma. While at least one study has shown that intake of flavones and flavenoids can improve chronic obstructive pulmonary disorder (COPD), a disease with a number of components similar to asthma, no studies have directly looked at asthma. Asthma Education Newsletter 2012 April No.26 17

10 18 Diet and Asthma - Minerals Selenium: Cross-sectional studies have identified low selenium levels in asthma patients compared to non-asthmatics. Patients taking selenium supplements report improved asthma control, but these results are not substantiated with improvements in objective asthma measurements Magnesium: Magnesium is a bronchodilator that has long been used in the acute treatment of asthma exacerbations. However, magnesium supplementation has not been scientifically demonstrated as a useful supplement to improve or prevent asthma. Sodium: While there is evidence that high-sodium diets are associated with airway hyperresponsiveness and increased smooth muscle contraction, studies restricting sodium intake have not provided evidence that this practice might improve asthma. Fatty acids, such as omega-3 polyunsaturated fatty acids from fish oils, are thought to stabilize cell membranes and provide leukotriene inhibition. Cross-sectional studies have demonstrated that increased fatty acid intake may protect against asthma, but individual trials with fatty acids have not demonstrated much protective effects. Some foods can provoke asthma attacks by causing an allergic reaction. Foods that trigger attacks (according to your susceptibility), can be: 1. Foods containing the additives benzoates(e210-19), sulphites (E220-8) or gallates (E310-12) such as Cider, wine and beer 2. Foods containing yeast or mould, such as bread and blue cheeses 3. Foods, drinks and snacks containing colorings E102, E104 and E Cow s milk, cereals (wheat), eggs, fish, soy, and nuts (especially peanuts) Food can also help to control the severity of an attack The best-known foods is coffee, due to the caffeine Some Foods can actually dilate air passageways, by thinning the mucus and opening them up for freer breathing. The foods in this category include the spicy, pungent foods like chili, hot mustard, garlic and onions. These hot foods work by stimulating nerves, resulting in the release of watery fluid in the mouth, throat and lungs. Thirdly, some foods can control inflammation of the airways because of their antiinflammatory components. Foods that help to do this include onions (these are particularly good), fatty fish (fish oil is a proven anti-inflammatory high in omega 3 fatty acids) and vitamin C-packed foods. Food can also help to control the severity of an attack Foods rich in the B vitamins such as green leafy vegetables and pulses Good sources of magnesium such as sunflower seeds and dried figs Broccoli may help protect against respiratory inflammation low levels of vitamin D are associated with higher rates of asthma-related hospitalization, inhaled corticosteroid use, and airway hyper-reactivity in children. Lack of adequate sun exposure was the most likely reason for low vitamin D levels in the study POTENTIAL TRIGGERS: Allergy is highly individual condition. Those who suspect that foods are triggering their asthmatic attacks should keep a food diary and seek expert medical help. Common foods that may trigger asthma in susceptible individuals include cow s milk, wheat and other cereals, yeast and foods containing mould, such as blue cheeses. Nuts (especially peanuts), fish and eggs Certain food additives may also be potential triggers in some people. Sulphites are used in cider, beers and wines. These products may pose a risk for susceptible asthmatics, Some wines also contain levels of histamine that may occasionally prompt asthmatic reactions in susceptible people. POTENTIAL TRIGGERS: Benzoate preservatives, which are present in a range of products from soft drinks and reduced-calorie jams to chewing gum and fish roe, may bring on asthmatic attacks. Other potential triggers include the less common antioxidant additives - the gallates(e ), butylated hydroxyanisole (BHA or E320), and also butylated hydroxytoluene (BHT or E321) - which are used in certain fats and oils, as well as in some breakfast cereals. Asthma Education Newsletter 2012 April No.26 19

11 20 In susceptible people, the food colourings E 102 (tartrazine, yellow), #104 (quinoline yellow) and E110 (sunset yellow) may also trigger asthma. HELPFUL FOODS: Foods containing the B vitamins, for example leafy green vegetables and pulses, may help asthmatics whose attacks are provoked by stress. asthmatics may have a tendency to be deficient in niacin and vitamins B6 and C. Antioxidants - vitamin A from liver; betacarotene from brightly-coloured fruit and vegetables such as apricots, carrots and red or yellow peppers, and dark green leafy vegetables such as spinach; vitamin C from citrus fruits; and vitamin E from olive oil-may strengthen the lungs defences by mopping up Free radicals- as part of an asthmatic s inflammatory response Magnesium, found in fish, green vegetables, sunflower seeds and dried figs, may help by relaxing the airways. Fatty fish such as salmon, mackerel, herring, sardines and cod may help to protect against asthma.they are a rich source of the omega-3 fatty acids- an anti-inflammatory effect. Caffeine is chemically similar to theophylline, used in some medications to dilate the bronchial tubes and assist breathing. In emergencies, two cups of strong coffee should bring relief within 2 hours, with the effects lasting for up to 6 hours. coffee, tea and caffeine-containing cola drinks should be avoided by those taking theophylline as the combined effect can be toxic. A high intake of caffeine is also inadvisable if your attacks are triggered by anxiety. Preventing Asthma Triggered by Foods: The best way to avoid food-induced or aggravated asthma is by avoiding or eliminating the food or food ingredient from your diet or the environment. These substances can be both released into the air or consumed when eating or drinking. Read ingredient labels on food packages and know where food triggers are found in foods. Work with your physician on a care plan and proper use of medications, you will be prepared to act in case of an asthma attack. Recommended Diet For Asthma Patients Asthma can trigger off due to various factors Diet is very important in controlling and correcting certain symptoms. It is important thus to have proper diet regulations when dealing with asthma. The general guidelines remain very straightforward. 1. To keep the diet very simple and without much spices. 2. To not eat very heavy meals as they tend to put additional pressure over the system. 3. At night time an asthmatic person should never ever take a heavy meal because it may cause discomfort in breathing and may even lead to an attack. 4. excess consumption of sweets leads to exertion on the system 5. The food that is fried and oily should also be avoided 6. Sour food items should also not be consumed as they may cause coughing and lead to undue pressure on the chest region. 7. Several food allergens cause allergic reactions leading to triggering off of asthmatic symptoms. 8. Many food additives create adverse reactions in the asthma patients so they are best avoided. concentrate more on eating vegetarian diets rather than non vegetarian ones The diet regulations have to be followed for life so it is better to induce variety in the diet to eat lighter and more frequent meals than heavier and standard meals. to have the dinner at least two hours before sleeping time so that the system is relatively relaxed owing to stomach being almost empty at night time just before sleeping. Not make the diet too oily or too spicy. Too much of cooking destroys the nutrient levels of the food and also cause much of stress on the system A regular pattern of a healthy and wholesome breakfast, nutritious lunch and a light dinner is very important Diet for elderly people suffering with asthma: In the old people the physical activity is less and so their calorie requirement is also very less. Asthma Education Newsletter 2012 April No.26 21

12 22 Very high restriction of fat intake in the diet. to meet the requirements of the body vitamin and mineral supplementation If the patient is under any medication its side effects should be studied. Counteracting the side effects through diet is very beneficial. Recommended Diet for children suffering with asthma: The basic metabolic rate of a child is higher than an adult and the children also engage more in hectic physical activity. The stage of the body is fast changing and supposed to be rapidly growing so more calories are needed to support the growth requirement of the body. The calorie requirement of a child s body is much higher than that of an adult The children need more of proteins and carbohydrates. Their diet needs to be balanced for vitamins and minerals. should not be made too heavy in any nutrient The child s diet should not have sour items The meal hours should be fixed To keep the variety and likes and dislikes of the child in mind It is best to avoid monotony as the kids grow bored very quickly and need to have their interest enlivened all the time. the child needs to be encouraged to consume more water. This is helpful in counteracting the sweat that is secreted often during the attacks and at other times. The sweets should be allowed to be consumed in very little quantities. Effect of diet on asthma and allergic sensitisation in the ISAAC Phase Two. METHODS: 1.Between 1995 and 2005, cross-sectional studies were performed in 29 centres in 20 countries. 2. Parental questionnaires were used to collect information from randomly selected schoolchildren (8-12 years, with skin prick testing). 3. Random effect models for meta-analysis were applied to calculate combined ORs RESULTS: 1. Fruit intake was associated with a low prevalence of current 2. Consumption of fish and of cooked green vegetables was associated with a lower prevalence of current wheeze. 3. Overall, more frequent consumption of fruit, vegetables and fish was associated with a lower lifetime prevalence of asthma 4. High burger consumption was associated with higher lifetime asthma prevalence. 5. None of the food items was associated with allergic sensitisation. Except for fruit juice and fruit consumption, no associations were found with atopic wheeze. 6. Food selection according to the Mediterranean diet was associated with a lower prevalence of current wheeze and asthma ever (p(trend)=0.03)., Effect of diet on asthma and allergic sensitisation in the ISAAC CONCLUSION: 1. Diet is associated with wheeze and asthma but not with allergic sensitisation in children. 2. These results provide further evidence that adherence to the Mediterranean diet may provide some protection against wheeze and asthma in childhood. There may be a compound in food that we have not yet identified that improves asthma. Mediterranean diet consists of fruit, vegetables, nuts, whole grains, and unsaturated fatty acids. Patients adhering to the complete cocktail of a Mediterranean diet have been found to: 1. Achieve better asthma control as measured by both symptoms and lung function 2. Have decreased allergy symptoms 3. Have decreased development of asthma This overall healthy diet seems to improve asthma among those people who stick to it. Asthma Education Newsletter 2012 April No.26 23

13 專題演講 呼吸道感染在過敏氣喘病人日常生活所扮演的角色 Taiwan Association of Asthma Education 台中榮總過敏免疫風濕科 蔡肇基醫師 The distribution of house dust mite:? 過敏原 : 如, 花粉, 黴菌孢子, 動物毛屑, 家塵... 等, 都是常見的過敏原 感染 : 不論是病毒 細菌 或黴菌的呼吸道感染, 都可引起呼吸道發炎而誘發過敏反應 氣溫的變化 藥物 : 貝他交感神經阻斷劑, 阿斯匹靈, 某些食用色素... 情緒因素 運動 : 某些病人可因運動而誘發氣喘, 尤其是較激烈的運動, 或是在在乾泠環境下所從事的運動 其他 : 如, 油漆, 香水, 香煙, 空氣污染, 月經週期的變化, 胃食道逆流... 等 氣喘病是氣管慢性發炎很容易被環境中的刺激物或過敏原誘發 氣喘病之防範成功與否, 全靠你對氣喘誘因之了解而定 如果無法避免時, 就應採取特殊治療 ( 減敏治療 ) 特殊治療可以預防並且阻止病發時繼續惡化? 呼吸困難 喘鳴 胸悶 慢性咳嗽? 久咳不癒 經常性感冒的狀況發生 特別在夜間及清晨咳嗽且有胸悶的症狀 發生喘鳴及呼吸急促等症狀且持續兩週以上 24? 傳染源 : 主要為病人或潛伏感染者 傳播途徑 : 主要經飛沫傳播, 也可通過直接密切接觸或間接接觸傳播 在空氣相對靜止的室內, 帶有病菌 病毒的飛沫, 大多數要在 30 至 60 分鐘後才能從空氣中消失, 有的甚至在空氣中飄浮長達 30 小時 人在室內待的時間長, 空氣又不新鮮, 自然容易感染 感受性與抵抗力 : 人群對多數呼吸道傳染病普遍易感 有的病後有一定免疫力或持久免疫力, 或者通過接種疫苗獲得一定的免疫力 寒冷的空氣會使鼻黏膜的血管收縮, 降低呼吸道的抵抗力, 這也是容易得病的一個原因 呼吸道感染可激發氣喘病人的急性喘鳴發作, 此種現象在小孩尤其明顯 以學齡層兒童為例, 氣喘盛行率大約 10%, 而此年齡層兒童每年平均經歷 5-10 次的上呼吸道感染 病毒性感染而非細菌性感染會誘發氣喘發作 大約有 24% 至 54% 的急性喘鳴同時伴隨病毒感染 2 歲以下嬰兒, 主要為呼吸道合體病毒和冠狀病毒, 較大小孩則以 A 型流行感冒為主, 鼻病毒則在任何年齡兒童均可培養出 病毒性呼吸道感染與氣喘急性惡化的關係在成人就不那麼明顯 呼吸道上皮細胞的損傷 病毒特異性 IgE 抗體的生成 發炎物質的增加 過敏延遲性反應的增加 (Influenza)? 老年人 兒童 糖尿病 慢性支氣管炎 肺氣腫 支氣管擴張 支氣管哮喘 肺間質纖維化 風濕病 慢性腎炎患者都是發生流感的高危人群 不宜接種流感疫苗的對象 Asthma Education Newsletter 2012 April No.26 25

14 專題演講 呼吸道感染在過敏氣喘病人日常生活所扮演的角色 26 專題演講 呼吸道感染在過敏氣喘病人日常生活所扮演的角色 心 肝 肺 腎功能嚴重受損的患者 某種疾病處於急性發作期的患者 過敏體質比較明顯的患者? 流感疫苗不等於感冒疫苗 接種流感疫苗只防特定流感病毒株, 不能預防所有感冒 傳染性 : 例如來自上呼吸道感染或流行性感冒 : 例如來自有毒氣體 化學物及有毒煙霧, 或吸入水 食物 嘔吐物等 保護機轉受破壞 : 黏液纖毛受抑制 ( 如 : 抽煙 ) : 吞嚥有問題 使用藥物致咳嗽反射受抑制 軟弱致咳嗽變差 長期臥床之個案, 因呼吸淺易使痰液積存 酒精中毒影響纖毛活動 癌症或阻塞性肺疾病等造成分泌物增加或干擾肺臟分泌物排除 肺炎黴漿菌和肺炎披衣菌所造成的非典型肺炎為已知的兩種可能誘發氣喘發作的細菌 革蘭式陽性的雙球菌 細菌表面的莢膜多醣與治病率有關 主要會引起肺炎 中耳炎 菌血症 腦膜炎等死亡率極高 國內約每一千人中就有 11~12 人曾感染肺炎雙球菌 半數以上的肺炎雙球菌菌珠己對 Penicilline 產生抗藥性 兒童感染此症死亡率可以高達 40% 患有鎌球性貧血的兒童是一般兒童的 600 倍? 全身性症狀 : 倦怠 體重減輕 發燒 夜間盜汗 呼吸道症狀 : 長期 ( 三週以上 ) 咳嗽 喀痰 ; 咯血 呼吸短促 胸痛 其他系統症狀 : 合併喉結核時可能會喉痛聲音嘶啞 合併結核性腦膜炎時可能會頭痛昏迷 合併腸結核時可能會腹痛腹瀉 X? 注意環境衛生, 保持室內空氣流通 注意個人衛生, 經常洗手, 特別是被口鼻分泌物污染時, 以保持雙手清潔 打噴嚏或咳嗽時應掩口鼻, 並小心處理口鼻排出的分泌物 避免前往人多擠迫, 空氣流通情況欠佳的公眾地方 均衡飲食, 足夠的水份, 適量運動, 充足休息, 避免過度疲勞和避免吸煙, 以增強抵抗力 如有不適, 應盡早就診? 良好的衛生習慣, 經常洗手用肥皂和溫水清洗, 可以減少病毒感染 防止感染的傳播 預防流行性感冒, 每年接受流感疫苗 此外, 嚴重哮喘病人可考慮接種肺炎球菌疫苗 鼻竇炎可能誘發氣喘症狀惡化, 留意鼻竇感染症, 以預防哮喘發作 保持呼吸設備清潔, 不要讓他人使用您的哮喘藥物, 包括哮喘吸入器, 哮喘霧化器, 霧化器管和喉舌 Asthma Education Newsletter 2012 April No.26 27

15 北之特廣告