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
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
鼻敏感 : 其他不適 咳嗽 眼睛發癢 頭痛
成人鼻炎的患病率 AUTHOR YEAR AGE RANGE NUMBER OF SUBJECTS COUNTRY PREVALENCE Droste 1996 20-70 2,167 Netherlands 29.5% Sakurai 1998 19-65 (males) 2,307 Japan 35.5% Ng 1994 20-74 2,868 Singapore 10.8% Bachert 2006 > 15 4,959 Belgium 39.3% Dinmezel 2005 20-44 995 Turkey 27.7% Sibbald 1991 16-65 2,969 United Kingdom 24% Turkeltaub 1991 12-74 12,742 United States 30.5%
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
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
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
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
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!!
食物過敏症 在過敏反應中的關鍵角色 Eosinophil IgE-producing lymphocytes Mast cells
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
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 1 0.75 * Eosinophils 在刮出皮細胞上和全部粘膜的比率 0.5 0.25 0 Healthy Controls N = 25 Non-allergic Rhinitis N = 18 Allergic Rhinitis N = 25 Numata T et al:int Arch Allergy Immunol 1999;119:304-313 S. Karger AG, Basel
敏感性鼻炎性鼻炎的高道反應性 7 6 5 由組胺引起的打噴嚏 * 4 3 2 N = 25 p<0.0001 * same dose in both groups Sanico AM et al:int Arch Allergy Immunol 1999;118:154-158 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
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
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 40 35 30 p=0.017 Total With positive sinus CT 25 67.5% Number of subjects 20 15 10 5 0 Allergic rhinitis 33.4% Controls Berrettini et al., Allergy. 1999;54:242-8.
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 1.0 0.8 0.6 從基線 Placebo, N=123 0.4 * Mean baseline score: 2.3 Mometasone, N=122 0.2 0.0 Adapted from Gawchik S et al. Ann Allergy Asthma Immunol 2003;90:416
鼻炎和哮喘的關係 (European Community Respiratory Health Survey) 25 Asthma (%) 20 15 10 OR=11 no rhinitis, N=5198 rhinitis, N=1412 OR=17 5 0 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 < 0.001 Test for trend, p < 0.001 odds ratio for the association with asthma 6 3 1 rhinitis Guerra S et al. J Allergy Clin Immunol 2002;109:419
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
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?
2004;351:1068-80 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;351:1068-80
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;351:1068-80 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;351:1068-80
過敏性鼻炎及其對哮喘的影響 ALLERGIC RHINITIS AND ITS IMPACT ON ASTHMA ARIA JACI 2001:56: 813-824
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.
藥理作用管理 Agent Sneezing Itching Congestion Rhinorrhea Eye OA +++ +++ +/- ++ ++ NA + + +/- + - ICS ++ ++ +++ ++ + OD - - ++ - - ND - - +++ - - MCS + + + + - IND - - - ++ -
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 )
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 ) 25 20 15 10 5 % Bioavail 0 Mometa Flutic Budes Beclo Flunisol
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
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; 292:367 3-4 mos of ICS improved FEV1 by 0.33L Sin DD et al. JAMA 2004; 292:367
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
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. 2009 年 GINA 治療指南
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
Module 1: Allergic Rhinitis an educational program of: Updated: June 2011 Thank You! 謝謝!