Microsoft PowerPoint 陳真光醫生 [相容模式]

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顿眺琬逄
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1 鼻敏感與哮喘陳真光醫生呼吸系統科專科醫生氣管結構臨床表現發病引因治病方針和方法大綱

4 鼻粘膜支氣管粘膜鼻敏感敏感的主要症狀哮喘的主要症狀鼻子癢流鼻涕打噴嚏鼻道阻塞咳嗽胸口緊悶呼吸困難鳴響聲

5 鼻敏感 : 其他不適咳嗽眼睛發癢頭痛

7 成人鼻炎的患病率 AUTHOR YEAR AGE RANGE NUMBER OF SUBJECTS COUNTRY PREVALENCE Droste ,167 Netherlands 29.5% Sakurai (males) 2,307 Japan 35.5% Ng ,868 Singapore 10.8% Bachert 2006 > 15 4,959 Belgium 39.3% Dinmezel Turkey 27.7% Sibbald ,969 United Kingdom 24% Turkeltaub ,742 United States 30.5%

8 鼻炎的類別敏感性感染性其他少見的, 如因食物刺激臭覺的因冷空氣刺激的因荷爾蒙變化的不一定是鼻炎! 鼻竇炎腦水下流外入物件腫瘤免疫性炎症

9 敏感性鼻炎是指因鼻子接觸了外來的敏感原外來的敏感原後, 身體發動局部性的敏感反應局部性的敏感反應而引起的發炎反應何謂敏感反應? 體內的幾種發炎細胞發炎細胞和發炎介質發炎介質 / 物質針對外來的敏感原所引發的反應

10 全球重要來源的過敏原季節性過敏原草樹和雜草花粉對... 產生影響常年性過敏原屋塵蟎寵物蟑螂其他可能的過敏原來源藥品職業食品阿司匹林麵包店塵洗衣粉乳膠手套 Tartazine 硫酸堅果柑橘類水果

11 鼻子和支氣管的敏感反應的特徵粘膜發炎 ( 紅和腫 ) 粘膜變得對一般刺激物過度 / 容易反應, 如環境溫度的轉變香水刺激性化學物運動

12 敏感病可大可小鼻敏感鼻敏感主要是鼻子不適引起的辛苦支氣管敏感氣管敏感可大可小, 嚴重的可引發急性呼吸袞竭, 甚至特發死亡食物或口服敏感食物或口服藥物同樣可引發急性重病千萬不能掉以輕心!!

13 食物過敏症在過敏反應中的關鍵角色 Eosinophil IgE-producing lymphocytes Mast cells

14 在過敏反應中的關鍵角色 IgE 可以在敏感的敏感的鼻粘膜上找到 In situ hybridization for Iε mrna - tissue obtained from subjects with alleric rhinitis Not exposed to ragweed Iε RNA + cells (germline transcript) Exposed to ragweed Cameron et al J Immunol 2003;171:3816

15 IgE 可以在敏感的支氣管粘膜上找到敏感與非敏感敏感鼻炎鼻炎的分別 * Eosinophils 在刮出皮細胞上和全部粘膜的比率 Healthy Controls N = 25 Non-allergic Rhinitis N = 18 Allergic Rhinitis N = 25 Numata T et al:int Arch Allergy Immunol 1999;119: S. Karger AG, Basel

16 敏感性鼻炎性鼻炎的高道反應性由組胺引起的打噴嚏 * N = 25 p< * same dose in both groups Sanico AM et al:int Arch Allergy Immunol 1999;118: S. Karger AG, Basel 1 0 Perennial Allergic Rhinitis N = 18 Healthy 鼻敏感即時反應 ( 早期階段 ) brain PRURITUS sensory nerves epithelium glands (mucous) SNEEZING blood vessels OBSTRUCTION RHINORRHEA histamine sulfidopeptide leukotrienes

17 鼻敏感反應 allergen IgE preformed & newly formed mediators/cytokines cytokines chemokines mast cell Endothelial cell activation dendritic cell allergen Leukocyte infiltration and activation (lymphocytes, eosinophils, basophils) IL-4 IL-13 T-lymphocyte B-lymphocyte IMMEDIATE (early) RESPONSE LATE-PHASE RESPONSES Sneezing Pruritus Rhinorrhea Nasal obstruction Ocular symptoms Nasal obstruction Rhinorrhea To allergens (priming) Nasal hyperresponsiveness To irritants and to atmospheric changes IgE

18 敏感牲鼻炎對其他功能的影響敏感牲鼻炎和鼻竇炎的緊密關係 p=0.017 Total With positive sinus CT % Number of subjects Allergic rhinitis 33.4% Controls Berrettini et al., Allergy. 1999;54:242-8.

19 兒童中耳炎的危險因素 Multivariate logistic regression for risk of OME Case-control study in children 1-7 years (N=88 cases, N=88 controls) Chantzi FM et al. Allergy 2006;61:332 鼻治療可以改善季節性過敏鼻炎患者的咳嗽 (15-day treatment ) 平均改善咳嗽症狀評分從基線 Placebo, N= * Mean baseline score: 2.3 Mometasone, N= Adapted from Gawchik S et al. Ann Allergy Asthma Immunol 2003;90:416

20 鼻炎和哮喘的關係 (European Community Respiratory Health Survey) 25 Asthma (%) OR=11 no rhinitis, N=5198 rhinitis, N=1412 OR= Atopic Non atopic Adapted from Leynaert B et al. J Allergy Clin Immunol 1999; 104:301 過敏性鼻炎和哮喘的關係 (173 incident cases and 2,177 controls; approx. 10-yr follow-up) 9 Test for trend, p < Test for trend, p < odds ratio for the association with asthma rhinitis Guerra S et al. J Allergy Clin Immunol 2002;109:419

21 AR 和共患呼吸道疾病中耳炎媒體與積液上呼吸道感染過敏性鼻炎鼻息肉哮喘鼻竇炎過敏皮膚點刺測試 Skin prick test / positive result

22 抽血化驗和友膚測試的比較費用準確性敏銳性控制環境可減輕病情嗎?

23 2004;351: 在城市的美國兒童患有哮喘的環境干預 937 subjects randomized 469 assigned to environmental intervention 468 assigned to control 444 included in Year 2 analyses 407 included in Year 2 analyses 425 included in Year 1 analyses 414 included in Year 2 analyses Adapted from Morgan WJ et al. New Engl J Med 2004;351:

24 Environmental intervention in urban US children with asthma Tailored to Skin test profile Environmental exposure Caretaker s report House dust mite Passive smoking Cockroaches Pets Rodents Mold Adapted from Morgan WJ et al. New Engl J Med 2004;351: 在城市的美國兒童患有哮喘的環境干預治療組之間的差異統計學顯著性意義 (P <0.001), 在這兩個階段的研究 Morgan WJ et al. New Engl J Med 2004;351:

25 過敏性鼻炎及其對哮喘的影響 ALLERGIC RHINITIS AND ITS IMPACT ON ASTHMA ARIA JACI 2001:56:

26 過敏性鼻炎的管理 : ARIA 準則 mild intermittent moderate severe intermittent intranasal steroid oral or local nonsedative H1-blocker mild persistent moderate severe persistent intranasal decongestant (<10 days) or oral decongestant leukotriene receptor antagonists avoidance of allergens, irritant and pollutants immunotherapy Modified from Bousquet J et al. J Allergy Clin Immunol. 2001;108:S147.

27 藥理作用管理 Agent Sneezing Itching Congestion Rhinorrhea Eye OA / NA + + +/- + - ICS OD ND MCS IND

28 口服抗組胺藥第一代 : Hydroxyzine (Atarax ) Diphenhydramine (Benadryl ) Chlorphenarimine (Piriton ) 第二代 : Certirizine (Xyzal, Zyrtec, ) Loratidine (Clarityne ) Fexofenadine (Telfast ) Desloratadine (Aerius )

29 鼻用噴霧劑鼻類固醇 Cromolyn (Nasocrom ) Oxymetolazone (Afrin ) Nasal saline (Ocean ) 鼻類固醇 Mometasone (Nasonex ) Fluticasone (Flixonase ) Budesonide (Rhinocort ) Beconse (Beclomethasone ) Flunisolide (Nasalide ) % Bioavail 0 Mometa Flutic Budes Beclo Flunisol

30 正常 & 哮喘細支氣管吸入的 CS 是維持治療的支柱 Normal Asthmatic Treated w ICS

31 ICS reduced asthma exacerbations by 50% compared w/ placebo Pharmacological management to reduce exacerbations in adults with asthma: A systemic review and meta-analysis Sin DD et al. JAMA 2004; 292: mos of ICS improved FEV1 by 0.33L Sin DD et al. JAMA 2004; 292:367

32 Higher dose (>500 ug/d beclomethasone) reduced exacerbations more than low dose Sin DD et al. JAMA 2004; 292:367 F/45 Caucasian IgE 339, Cat dander 4/6 Dog dander 3/6 Rodent pets 3/6 Dust mites 2/6

33 GINA 2009 年哮喘控制分類 B. Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side-effects) Features that are associated with increased risk of adverse events in the future include: Poor clinical control, frequent exacerbations in past year, ever admission to critical care for asthma, low FEV 1, exposure to cigarette smoke, high dose medications 年 GINA 治療指南

34 2006 年 GINA 指南 : 控制藥的處理步驟結論 1. 氣管和外界有很大的關係 2. 對一些比較敏感的人來說, 鼻敏感和哮喘是長期病患, 會帶來身體不適, 學校工作社交不方便, 不能上學上班, 以至有生命危險 3. 鼻敏感和哮喘有密切關係 1. 有鼻敏感的人要留意氣管 2. 處理哮喘時也要處理鼻的健康 4. 醫療方針 1. 要針對敏感原 2. 要抗炎 3. 要處理不適的病徵

35 Module 1: Allergic Rhinitis an educational program of: Updated: June 2011 Thank You! 謝謝!

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