妊娠期支气管哮喘管理中的新认识

妊娠期支气管哮喘(简称哮喘)的发病率在增加.未控制的妊娠期哮喘可以增加胎儿先天性异常的风险.妊娠期哮喘的管理应该包括避免或控制哮喘的诱发因素、个体化的药物治疗、监测肺功能和患者教育.吸入激素是不同程度妊娠期哮喘患者首选的治疗药物.妊娠期间给予哮喘治疗药物对胎儿造成的风险小于妊娠期间出现哮喘症状和哮喘急性发作而对胎儿造成的风险.妊娠期哮喘管理的目标就是保证母亲和胎儿的健康.     

妊娠期支气管哮喘治疗进展

临床研究已证明妊娠期重度及控制不佳的支气管哮喘(简称哮喘)与母亲及胎儿严重并发症相关.对于妊娠期哮喘患者,接受药物治疗比存在哮喘症状和哮喘发作更安全.所有程度的持续妊娠哮喘患者都应当应用吸入糖皮质激素作为控制药物,首选布地奈德.白三烯受体拮抗剂可以缓解支气管痉挛、减轻症状、改善肺功能.长效β2受体激动剂对于正在应用吸入糖皮质激素的患者可作为首选的添加药物.吸入短效β2受体激动剂可以作为缓解药物.对于正在接受维持量或接近维持量治疗,无不良反应、临床疗效好的妊娠哮喘患者可以继续进行变应原免疫治疗.     

支气管哮喘与妊娠

支气管哮喘是妊娠期常见合并症之一。妊娠可能使支气管哮喘加重、减轻、也可能无变化。未控制的支气管哮喘对妊娠期母体和胎儿均可产生不良作用。应该选用对胎儿安全的药物积极控制妊娠期支气管哮喘。     

妊娠期支气管哮喘治疗进展

临床研究已证明妊娠期重度及控制不佳的支气管哮喘（简称哮喘）与母亲及胎儿严重并发症相关.对于妊娠期哮喘患者,接受药物治疗比存在哮喘症状和哮喘发作更安全.所有程度的持续妊娠哮喘患者都应当应用吸入糖皮质激素作为控制药物,首选布地奈德.白三烯受体拮抗剂可以缓解支气管痉挛、减轻症状、改善肺功能.长效β2受体激动剂对于正在应用吸入糖皮质激素的患者可作为首选的添加药物.吸入短效β2受体激动剂可以作为缓解药物.对于正在接受维持量或接近维持量治疗,无不良反应、临床疗效好的妊娠哮喘患者可以继续进行变应原免疫治疗.     

妊娠期支气管哮喘35例临床分析

目的分析妊娠期哮喘急性发作的临床特点,制定合理治疗方案,控制哮喘发作,减少对胎儿的影响。方法对35例妊娠期哮喘急性发作患者的临床资料进行回顾性分析。结果 35例患者症状完全缓解,1例自然流产,34例随访至产后1个月,婴儿和母亲均正常。结论妊娠期哮喘应按病情的轻重,给予恰当治疗;妊娠早期可选用对胎儿较小影响的药物,如头孢类抗生素、β2受体激动剂、糖皮质激素等药物,妊娠中晚期可选用茶碱药物。     

特殊类型支气管哮喘的治疗问题——妊娠期支气管哮喘的药物治疗

妊娠期支气管哮喘(哮喘)是哮喘治疗和管理中的一种特殊情况。妊娠期间哮喘的发作不仅危及孕妇,且因母体缺氧而使胎儿产生一系列并发症。妊娠期哮喘患者应首选吸入型糖皮质激素,配合使用β2受体激动剂和茶碱等支气管舒张剂,给予抗炎和平喘的治疗。未良好控制的哮喘对孕妇和胎儿的危害要远远高于哮喘治疗药物对妊娠造成的风险。     

支气管哮喘与妊娠

支气管哮喘是妊娠期常见合并症之一,妊娠可能使支气管哮喘加重,减轻,也可能无变化,应该选用对胎儿安全的药物积极控制妊娠期支气管哮喘。     

妊娠期支气管哮喘药物治疗进展

妊娠期支气管哮喘（简称哮喘）是哮喘管理中的一种特殊情况。这一特殊时期既要控制哮喘，使妊娠妇女顺利渡过孕期至分娩，又要避免药物对胎儿可能导致的危害。妊娠期哮喘发作与婴儿死亡、早产及低体重儿等不良事件具有明显的相关性。因此，妊娠期哮喘的管理及合理的治疗是非常重要的。美国哮喘教育和预防项目组织（NAEPP）1993年首次制定了妊娠哮喘的治疗指南，并先后几次进行了修订，2005年在总结了近10多年的管理和治疗经验后再次更新了这一指南，为妊娠期哮喘的用药提出了重要的指导原则，为此，我们对妊娠期哮喘药物治疗新的认识进行了综述。     

妊娠期哮喘用药的安全性

哮喘是女性妊娠期最常见的慢性疾病之一,未控制的哮喘可以显著影响孕期女性的生活质量,引起不良妊娠结局。因此,对妊娠期哮喘予以适当的药物治疗,对保护母子健康非常重要。本文回顾性分析常用哮喘药物在妊娠期使用的安全性问题。大量文献表明,吸入糖皮质激素不会增加新生儿畸形的风险,也不会影响新生儿的体质量和孕周数。而全身糖皮质激素或支气管扩张剂对妊娠患者及其胎儿有无不良影响文献中尚存在分歧,部分研究发现的不良妊娠结局不除外是哮喘症状本身所致。因此,在患者病情需要时,仍然应当选择适宜的方案积极进行治疗。     

哮喘和妊娠(附198次娠娠的前瞻性研究)

作者为了探讨哮喘对妊娠的影响,而对181例哮喘妇女198次妊娠(妊娠期24周或更长)作了前瞻性研究。根据妊娠期平喘药应用情况和哮喘恶化程度,将哮喘患者分为4组(Ⅰ组较轻,Ⅱ组轻度,Ⅲ组中等,Ⅳ组严重),同时根据皮肤划痕试验和特异性血清IgE 值测定,将患者分为特应性(62%)和非特应性(38%)两种类型。此外设198例无哮喘妇女作为对照组。     

Asthma in pregnancy.

Most gravidas with asthma can be managed with an inhaled beta-adrenergic agonist (terbutaline or epinephrine) and beclomethasone dipropionate. The administration of prednisone to control exacerbation of asthma is appropriate and should not be withheld if current medications are inadequate. The outcome of pregnancy in gravidas with asthma can approach that of the general population if asthma is controlled effectively. There may be an increased incidence of preterm deliveries or preeclampsia in women with asthma during pregnancy.     

Managing Asthma in Expectant Mothers

Pregnancy does not appear to have a consistent effect on the frequency or severity of asthma. The most common cause of worsening asthma in pregnancy is likely to be noncompliance with medication. Emphasizing to the patient in advance that fetal well-being is dependent on maternal well-being may help prevent this.In general, well controlled asthma is not associated with a higher risk of adverse pregnancy outcomes. Essential to successful asthma management is patient education that helps to ensure effective medication use, avoidance of triggers, and prompt treatment. This education should include measurement of peak expiratory flow rate and a written asthma action plan. Most of the medications that are used to control asthma in the general population can be safely used in pregnant women. Inhaled beta-adrenoceptor agonists (beta-agonists), cromolyn sodium (sodium cromoglycate), and inhaled and systemic corticosteroids all appear to be very well tolerated by the fetus. Budesonide and beclomethasone should be considered as the preferred inhaled corticosteroids for the treatment of asthma in pregnancy. Use of the leukotriene receptor antagonists zafirlukast and montelukast in pregnancy is probably safe but should be limited to special circumstances, where they are viewed essential for asthma control. Zileuton should not be used in pregnancy.Acute asthma exacerbations in pregnant women should be treated in a similar manner to that in non-pregnant patients. Maternal blood glucose levels should be monitored periodically in pregnant women receiving systemic corticosteroids because of the deleterious effects of hyperglycemia upon embryos and fetuses. During pregnancy, maternal arterial oxygen saturations should be kept above 95% if possible for fetal well-being. Ambulatory oxygenation should be checked prior to discharge to ensure that women do not desaturate with their daily activities.Acute exacerbations of asthma during labor and delivery are rare. Dinoprost, ergometrine, and other ergot derivatives can cause severe bronchospasm, especially when used in combination with general anesthesia, and should be avoided in asthmatic patients. Pregnant women who have been treated with corticosteroids in the past year may require stress-dose corticosteroids during labor and delivery. Most asthma medications, including oral prednisone, are considered compatible with breast-feeding.     

Asthma control and need for future asthma controller therapy among inner-city Hispanic asthmatic children engaged in a pediatric asthma disease management program (the Breathmobile program,Mobile Asthma Care for Kids Network)

Objective: To determine whether significant numbers of asthmatic children with initially rated intermittent asthma later suffer poor asthma control and require the addition of controller medications. Methods: Inner-city Hispanic children were followed prospectively in an asthma-specific disease management system (Breathmobile) for a period of 2 years. Clinical asthma symptoms, morbidity treatment, and demographic data were collected at each visit. Treatment was based upon National Heart, Lung, and Blood Institute (NHLBI) Expert Panel Report 3 asthma guidelines. Primary outcome was percentage of patients with intermittent asthma who had not well or poorly controlled asthma during subsequent visits and required controller agents. Secondary outcomes were factors associated with the maintenance of asthma control. Results: About 30.9% of the patients with initial rating of intermittent asthma had not well controlled and poorly controlled asthma during subsequent visits and required the addition of controller agents. Factors associated with good asthma control were compliance, no previous emergency room visits and previous visit during spring season. Conclusion: Asthmatic children with intermittent asthma often lose asthma control and require controller therapy. This justifies asthma guideline recommendations to assess asthma control at follow-up visits and adjust therapy accordingly.     

Asthma und Schwangerschaft

Approximately 4-12 % of pregnant women suffer from asthma. The aims of asthma therapy in pregnant women are sufficient control of the asthma and oxygen supply to the fetus during pregnancy. Pharmacotherapy of pregnant women with asthma is no different from that in non-pregnant women. The possibility of severe side effects of medications can be disregarded when compared to the potential benefits for mother and fetus. The risk of congenital malformations is low but increases with the severity of the disease. Regular surveillance and control of asthmatics during pregnancy combined with a structured patient education contribute to a better control of asthma. In cases of asthma attacks, pregnant women should be treated in hospital and kept under close surveillance.     

Asthma during Pregnancy: The Experiences,Concerns and Views of Pregnant Women with Asthma

Objective. To investigate how pregnant women manage their asthma during pregnancy and factors influencing their behavior. Methods. In-depth interviews (telephone or face-to-face) with a purposive sample of 23 asthmatic women at various stages of pregnancy and with varying severity of asthma. Results. Five major themes were discerned relating to health behavior of pregnant women with asthma. Many of the participants decreased or discontinued their asthma medications themselves and refrained from taking doses when necessary during pregnancy without consulting their doctors. Reasons behind their decisions revolved around lack of support and information about what to do, concerns about the safety of the medications, past experiences, and desire for an “all natural” pregnancy. Asthma monitoring during pregnancy was seen as a low priority for some women and their doctors. Communication between pregnant women and health professionals regarding asthma management was poor. The health behavior of pregnant women with asthma could be explained using the Health Beliefs Model. Conclusions. Pregnant women are not well supported in managing asthma during pregnancy, despite being concerned about outcomes. Interventions, education, and more support are warranted and wanted by pregnant women with asthma to optimize pregnancy and neonatal outcomes.     

Combination Therapy: Appropriate for Everyone?

The severity of asthma often varies throughout the course of the disease. At times the symptoms and underlying inflammation that are characteristic of asthma can worsen. Thus during an episode of viral-induced asthma or during a seasonal increase in asthma severity, a patient may be directed to increase his or her dosage of asthma controllers (i.e., inhaled corticosteroid) or add a long-acting bronchodilator (or other controller medications such as antileukotrienes) to manage symptoms, as recommended in guidelines published by the National Institutes of Health (NIH). Similarly, when symptoms are stable, decreasing dosages or discontinuing certain medications may be appropriate. The recent introduction of a combination product, of a long-acting bronchodilator formulated in the same dry powder device with an inhaled corticosteroid raises new challenges for the step care approach to asthma management recommended by the NIH in 1997. Although unquestionably more convenient for the patient, a combination formulation has the potential to decrease the flexibility required to successfully manage asthma over long periods. In addition, controversy exists regarding long-acting beta-agonists alone because their regular use may mask inflammation in the lung and decrease responsiveness to the bronchodilating effects of rescue medications (i.e., short-acting beta-agonists). The purpose of this article is to help physicians make informed therapeutic decisions for their patients with asthma. It focuses on the advantages and potential disadvantages of using combination products, which contain both an inhaled corticosteroid and a long-acting beta-agonist in the context of the NIH step care approach. Recent publications outlining the use of other add-on controller medications are also discussed.     

Combination Therapy: Appropriate for Everyone?

The severity of asthma often varies throughout the course of the disease. At times the symptoms and underlying inflammation that are characteristic of asthma can worsen. Thus during an episode of viral-induced asthma or during a seasonal increase in asthma severity, a patient may be directed to increase his or her dosage of asthma controllers (i.e., inhaled corticosteroid) or add a long-acting bronchodilator (or other controller medications such as antileukotrienes) to manage symptoms, as recommended in guidelines published by the National Institutes of Health (NIH). Similarly, when symptoms are stable, decreasing dosages or discontinuing certain medications may be appropriate. The recent introduction of a combination product, of a long-acting bronchodilator formulated in the same dry powder device with an inhaled corticosteroid raises new challenges for the step care approach to asthma management recommended by the NIH in 1997. Although unquestionably more convenient for the patient, a combination formulation has the potential to decrease the flexibility required to successfully manage asthma over long periods. In addition, controversy exists regarding long-acting beta-agonists alone because their regular use may mask inflammation in the lung and decrease responsiveness to the bronchodilating effects of rescue medications (i.e., short-acting beta-agonists). The purpose of this article is to help physicians make informed therapeutic decisions for their patients with asthma. It focuses on the advantages and potential disadvantages of using combination products, which contain both an inhaled corticosteroid and a long-acting beta-agonist in the context of the NIH step care approach. Recent publications outlining the use of other add-on controller medications are also discussed.     

Emergency department utilization by patients not meeting Health Plan and Employer Data and Information Set (HEDIS) criteria for persistent asthma.

Emergency hospital utilization rates for asthma remain high despite advances in asthma controller medications and the presence of widely accepted asthma treatment guidelines. To explore this phenomenon, we analyzed administrative data to determine characteristics of patients seen in the emergency department (ED) for asthma. Complete pharmacy and diagnostic coding records were obtained from consecutive adults (aged 19-56 years) treated for asthma in the ED of a closed-network health maintenance organization between April and July of 2002. Subjects were stratified into asthma severity categories (persistent or non-persistent) based on the National Committee for Quality Assurance 2006 Health Plan and Employer Data and Information Set (HEDIS) criteria for persistent asthma. Eighty-one unique patients made a total of 89 ED visits for asthma during the study period. Of the 89 total ED visits for asthma, 44 (49%) occurred in patients that did not meet HEDIS criteria for persistent asthma. Of the 81 unique patients making asthma-related ED visits, 41 (51%) did not meet HEDIS criteria for persistent asthma. Over one-half (51%) of this nonpersistent population were not given either asthma reliever or asthma controller medications during the 12-month period before their index ED visit. Over the 24-month period before their index ED visit, 37% of nonpersistent patients were dispensed neither asthma reliever nor controller medications. Patients that do not meet HEDIS criteria for persistent asthma account for a substantial percentage of asthma-related ED visits. These patients have a history of low use of asthma medications before their ED visit.