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.     

The exploration in community management model of asthma

目的 探讨支气管哮喘(哮喘)社区管理的有效方法.方法 根据《全球支气管哮喘防治倡议》和《支气管哮喘防治指南》的要求,结合社区门诊部的实际情况,建立支气管哮喘社区管理模式,并对实施社区管理前和1年后哮喘患者的病情、用药、医疗费用等情况进行比较和分析.结果 纳入社区管理后,哮喘患者的病情明显改善,急诊就医和住院次数较前减少,抗生素和地塞米松使用明显减少,吸入激素、制定哮喘计划、使用峰流速仪以及定期进行呼气流量峰值和哮喘控制测试监测人数均较前增加.结论 将支气管哮喘纳入社区管理,建立以患者为中心,医生和患者共同参与的社区管理模式,是提高哮喘控制水平的有效途径.     

我国八省市支气管哮喘患者对疾病管理与认知现状调查

目的 调查我国支气管哮喘(以下简称哮喘)患者对疾病管理与认知的现状.方法 对2009年9月-2010年9月全国8个省市哮喘流行病学调查中确诊的2 034例哮喘患者进行哮喘疾病管理与认知的问卷入户调查,主要内容包括:(1)患者一般情况;(2)哮喘患者的控制现状;(3)哮喘患者对疾病的认知程度;(4)哮喘对患者生命质量的影响.结果 2 034例哮喘患者中,462例(22.71％)患者在过去1年中曾进行过肺功能检查,294例(14.45％)患者拥有峰流速仪,仅33例(1.62％)患者每天使用峰流速仪进行病情监测,456例(22.42％)患者能正确认为哮喘是“气道炎症性疾病”,302例(14.85％)患者认识到哮喘治疗目标是“可以长期良好控制或完全控制”.能正确认知疾病本质的患者哮喘控制测试(ACT)评分[(20.60 ±3.92)分]明显高于不能正确认知疾病本质者[(19.95±4.43)分;t=-2.385,P=0.017].1 213例(59.64％)患者表示哮喘影响了其工作、生活和娱乐,181例(8.90％)患者表示需要依靠器具进行日常生活,甚至有93例(4.57％)患者因哮喘而产生过自杀的念头.结论 我国哮喘患者对疾病的管理和认知程度依然不佳,正确认知疾病本质有助于提高哮喘控制水平.     

支气管哮喘分级治疗与管理

尽管支气管哮喘不能完全治愈,但经有效的药物治疗和管理,通常可实现哮喘的控制.Goal研究表明[1],经过一年治疗管理,哮喘完全控制率达50%,良好控制率78%.     

现实中哮喘治疗现状的前瞻性、多中心研究

目的 过去对支气管哮喘(简称哮喘)现状的研究多采用横断面的回顾性调查,结果有局限性.本研究采用前瞻性的方法对重庆地区哮喘防治的现状进行研究,为改进目前哮喘的防治提供依据.方法 利用统一的调查问卷,采用前瞻性、多中心、非干预性的研究方法,对重庆地区9家教学医院、市区级医院就诊的184例哮喘患者进行6个月的前瞻性调查研究,调查患者的哮喘控制水平、用药和经济负担等情况.结果 入选患者以重度(62.0％)居多,哮喘控制不佳的患者比例较高,哮喘控制评分(ACT)＜20分占82.6％,采用吸入激素为主治疗方法的患者仅占29.6％.6个月后失访率为34.8％.研究结束时与基线数据比较,哮喘控制水平明显改善(P＜0.001),哮喘加重显著减少(P＜0.001),而且平均医疗费用减低33.9％.结论 地区哮喘控制现状不佳,规范化治疗的患者比例很低.但经规范治疗和管理后,哮喘控制水平显著改善,急性加重率和治疗费用均显著降低.但仍有约1/3的患者不能接受医师的随访,改善哮喘的管理还需要更多的努力.     

支气管哮喘控制的中国专家共识

 国内外支气管哮喘(以下简称哮喘)防治指南均指出,哮喘管理目标是达到并维持哮喘的症状控制,主张在哮喘的管理中按照哮喘控制水平调整治疗方案,并进行哮喘长期管理,包括评估、治疗和监测三个基本内容^［1-2］。指南强调,大多数哮喘患者经药物治疗,特别是实施有效管理后可达到哮喘控制的治疗目标^［1-2］。2009年全球哮喘防治创议（GINA）的更新版,是在原来哮喘控制定义的基础上,提出了哮喘总体控制的概念,提出既要达到当前的控制,又要降低未来的风险^［3］。然而多项国内外调研结果显示,哮喘的控制率远低于指南的目标^［4-9］。哮喘控制不佳严重影响患者的日常生活、工作、学习,导致反复急性发作、急诊就医和住院,肺功能损害,治疗成本增加,造成社会生产能力降低和严重社会经济负担^［4-9］。因此,更新哮喘控制的概念,改进现有的哮喘管理模式,强化哮喘控制的治疗策略,对提高哮喘的总体控制水平具有重要的意义。鉴于此,中华医学会呼吸病学分会哮喘学组组织国内有关专家,参照相关指南与共识,特别是近年发表的有关哮喘控制的重要文献,制定了本共识,供临床实践参考。     

支气管哮喘防治指南(支气管哮喘的定义、诊断、治疗和管理方案)

支气管哮喘(简称哮喘)是常见的慢性呼吸道疾病之一,近年来其患病率在全球范围内有逐年增加的趋势.许多研究表明规范化的诊断和治疗,特别是长期管理对提高哮喘的控制水平,改善患者生命质量有重要作用.本"指南"是在我国2003年修订的"支气管哮喘防治指南"的基础上,参照2006年版全球哮喘防治创议(GINA),结合近年来国内外循证医学研究的结果重新修订,为我国的哮喘防治工作提供指导性文件.     

支气管哮喘合并胃食管反流

支气管哮喘(简称哮喘)患者合并胃食管反流性疾病(GERD)的发生率高于一般人群,GERD和哮喘关系密切,互为因果,是哮喘控制不良和难治性哮喘的重要原因.GERD的诊断应纳入哮喘诊断常规程序.合理的抗反流治疗有助于改善哮喘控制.     

慈溪市乡镇医师支气管哮喘认知状况的调查分析

目的 了解乡镇医师对支气管哮喘(简称哮喘)基本概念、治疗及管理的认知状况,为基层医师的培训提供依据.方法 对慈溪市25家不同级别医院共198名内科医师进行有关哮喘相关知识问卷调查,其中.三级医院1家,内科医师24名;二级医院5家,内科医师70名;一级医院19家,内科医师104名.问题涉及:哮喘定义、一线控制药物、预后、治疗中抗菌药物应用情况、GINA知晓率及医院是否备有吸入激素药物等.结果 对哮喘属气道慢性炎症及可控制性疾病,回答正确率分别为85.4%与96%,上述两问题在三级与一、二级医院间差异无统计学意义.对吸入糖皮质激素者为哮喘一线控制性用药、发作时是否应用抗菌药物、GINA知晓率方面.正确率分别为68.7%、29.3%和58.6%.三级医院与一、二级医院间存在显著差异(P<0.05).关于医院备有吸入糖皮质激素方面.全市共4家医院备有(1家三级医院、3家二级医院).一级医院均无吸入激素的备药.结论 基层医院,尤其是一、二级乡镇医院对哮喘的防治管理认知方面尚存在较多问题,知识较陈旧,对GINA知晓率较低,不利于基层大量哮喘患者的治疗及管理,规范培训基层医务人员,使其掌握哮喘防治指南,从而有效指导哮喘患者是基层哮喘管理亟待解决的问题.     

积极推广我国新版支气管哮喘防治指南

支气管哮喘(简称哮喘)是常见的慢性呼吸道疾病之一.据估计,我国目前至少有2000万左右的哮喘患者.随着人们生活水平的提高,哮喘的发病率逐年增加,哮喘已成为严重的公共卫生问题.大量的临床研究表明,规范化的诊断和治疗,特别是长期管理对提高哮喘的控制水平,改善哮喘患者生活质量有重要作用.1994年美国国立卫生院心肺血液研究所与世界卫生组织共同发起,组织了17个国家的30多名哮喘专家首次制定了全球哮喘防治创议(global initial for asthma, GINA),于1995年发表,以后在1998年、2002年和2006年分别对GINA作了修订.GINA文件对世界各国的哮喘防治工作起到了非常积极的作用.     

Asthma management and control in the United States: results of the 2009 Asthma Insight and Management survey

Past asthma surveys have shown suboptimal management and control of asthma in the United States. No major survey of asthma management has been conducted since the Third Expert Panel Report for the National Asthma Education and Prevention Program (NAEPP) guidelines on diagnosis and treatment of asthma (August 2007). This study was designed to report asthma management and control results from the Asthma Insight and Management survey of U.S. patients and physicians. A telephone-based survey was conducted during 2009 in 2500 patients with asthma, aged ≥12 years, and 309 physicians (104 allergists, 54 pulmonologists, 101 family practitioners, and 50 internists). Patients' asthma control perceptions (71% "completely controlled" or "well controlled") were inconsistent with their NAEPP control level as determined by self-reported symptoms (29% well controlled). Patients and physicians had low expectations for effective asthma management; patients considered asthma well managed if rescue medication was used three times per week (46%), urgent care visits occurred twice per year (67%), or emergency department visits occurred once per year (60%). Asthma-related syncope, seizure, intensive care unit admission, and intubation were associated with uncontrolled asthma based on NAEPP guidelines. Respiratory specialists (allergists/pulmonologists) implemented asthma management recommendations more than other physicians surveyed. However, only 22% of patients visited a specialist for usual asthma care and 48% had never visited a specialist. Despite detailed NAEPP guidance, asthma management and control in U.S. patients is unsatisfactory. Improved asthma control assessment (impairment and risk) and implementation of NAEPP management recommendations are needed to improve asthma control and outcomes.     

Does personality influence how people with asthma manage their condition?

Objective: Personality traits have been found to be associated with the management of chronic disease, however, there is limited research on these relationships with respect to asthma. Asthma management and asthma control are often suboptimal, representing a barrier to patients achieving good health outcomes. This explorative study aimed to investigate the relationship between correlates of asthma management and personality traits. Methods: Participants completed a postal survey comprising validated self-report questionnaires measuring personality traits (neuroticism, extraversion, openness to experiences, agreeableness, conscientiousness), asthma medication adherence, asthma control and perceived control of asthma. Relationships between asthma management factors and personality traits were examined using correlations and regression procedures. Results: A total of 77 surveys were returned from 94 enrolled participants. Significant relationships were found between personality traits and (i) adherence to asthma medications, and (ii) perceived control of asthma. Participants who scored high on the conscientiousness dimension of personality demonstrated higher adherence to their asthma medications. Women who scored low on the agreeableness dimension of personality and high on the neuroticism dimension had significantly lower perceived confidence and ability to manage their asthma. No statistically significant associations were found between asthma control and personality traits. Conclusions: Three of the five personality traits were found to be related to asthma management. Future research into the role of personality traits and asthma management will assist in the appropriate tailoring of interventional strategies to optimize the health of patients with asthma.     

An overview of EPR3 asthma guidelines: what's different?

Updated asthma care guidelines have recently been released. This review will focus on several elements in the Expert Panel Report (EPR) 3 guidelines that reflect substantial differences compared with recommendations of the EPR2 guidelines, issued in 1997 and updated in 2002. A major difference is the emphasis on asthma control. The revised paradigm for asthma management now recommends that asthma management decisions should be initially based on categorization of asthma severity, and subsequently on assessment of asthma control. Asthma control can be assessed serially by use of validated instruments. The goal of asthma therapy is to achieve asthma control by reducing current impairment and future risk. Recommendations for asthma pharmacotherapy have also been revised since release of updated EPR2 guidelines. The revisions in asthma management proposed in these guidelines offer the potential for improved normative care outcomes in asthmatic patients in the United States.     

"三位一体"支气管哮喘教育管理模式对支气管哮喘患者病情控制水平的影响

目的 评价"三位一体"支气管哮喘教育管理模式对支气管哮喘患者病情控制水平的影响.方法 由经过培训的北京市6所大型教学医院的呼吸科医生,以面对面的方式连续不加选择地问卷调查各自医院门诊成年支气管哮喘患者病情控制水平,比较以"三位一体"(哮喘专病门诊、哮喘宣教中心、哮喘患者协会)模式系统教育管理的支气管哮喘患者(教育组)与未进行"三位一体"系统教育管理的支气管哮喘患者(对照组)的问卷调查结果.结果 教育组患者100例,对照组患者427例.教育组支气管哮喘控制测试(ACT)评分达20分以上的占85%,显著高于对照组的37%(χ2=74.345,P<0.01);过去1年中教育组因支气管哮喘加重住院、急诊就诊、误工的分别占4%、18%、20%(10/49),显著低于对照组的23%、32%、55%(76/137)(χ2值分别为19.431、7.515、17.853,P值均小于0.01).结论 "三位一体"支气管哮喘教育管理模式可显著提高患者的病情控制水平.     

Asthma control and differences in management practices across seven European countries

Failure to follow asthma management guidelines may result in poor asthma control for many patients. The Asthma Insights and Reality in Europe (AIRE) survey, a multi-national survey assessing the level of asthma control from the patients perspective in seven Western European countries, previously demonstrated that the Global Initiative for Asthma (GINA) guideline goals were not achieved in Western Europe and that both adults and children with asthma were poorly controlled. Using additional data on asthma management practices from each of the seven countries in the AIRE survey, we compared variations in asthma morbidity and asthma management practices across countries to provide insight into the reasons for poor asthma control. Asthma management practices and asthma control among adults and children with current asthma were suboptimal in each of seven countries surveyed. Among patients with symptoms of severe persistent asthma, over 40% reported their asthma was well or completely controlled. School absence due to asthma was reported by upto 52.7% of children and up to 27.6% of adult reported work absence due to asthma. Lung function testing in the past year was uncommon: ranging from 13.5% of children in the U.K. to 68.8% of adults in Germany. Written asthma management plans were used by less than 50% of adults and less than 61% of children in all seven countries. Most adults (49.5-73.0%) and a large proportion of children (38.4-70.6%) had follow-up visits for their asthma only when problems developed. The ratio of recent inhaled corticosteroid use to recent short-acting beta-agonist use was inappropriate (<1) among patients with symptoms of severe asthma in all countries. This disparity was greatest among adults in Italy and France, where recent inhaled corticosteroid use was reported by less than one in nine patients reporting recent use of short-acting bronchodialators (IS:SAB <0.11). Management practices differ between countries and additional public health interventions and resources may be necessary to reduce patient suffering. Further efforts to fully implement asthma management guidelines are required to improve asthma control in Europe.     

Severe Asthma in Primary Care: Identification and Management

Most patients with asthma are managed by primary care providers. Severe asthma is associated with substantial morbidity and health care resource use, and long-term sequelae of severe asthma include airway remodeling and a greater risk of developing chronic obstructive pulmonary disease. These consequences highlight the importance of early identification and improved management of patients with severe asthma. Although treatment guidelines can be confusing and it can be difficult to keep abreast of updates, routine assessments of lung function, frequency and severity of exacerbations, symptom control, and medication adherence in the primary care setting provide the necessary information for identifying severe asthma and determining appropriate management strategies. An increased understanding of asthma pathophysiology and its relationship to disease activity has identified therapeutic targets and associated biomarkers. Biologic therapies directed at these targets offer individualized targeted treatment of severe asthma. We review evidence-based guidelines for identification and management of severe asthma, clarify the relationship of asthma control and asthma severity, and provide an overview of new biologic therapies offering additional treatment options for patients with severe asthma.     

Poor perceptions and expectations of asthma control: results of the International Control of Asthma Symptoms (ICAS) survey of patients and general practitioners.

AIMS: To assess current levels of asthma control and to identify barriers to optimal asthma management. METHODS: A survey was conducted of 802 asthma patients (via computer-aided telephone interviewing) and 809 general practitioners (GPs; via the internet) from the UK, Italy, France, Germany, Spain, Canada and Australia. RESULTS: Over three-quarters (82%) of patients surveyed reported an absence of asthma control, with the vast majority (80%) experiencing subsequent lifestyle restrictions. Although most (58%) GPs questioned believed that total asthma control was possible, half (52%) agreed that their patients were not achieving best possible asthma control. CONCLUSIONS: Action is required to encourage patients to view their asthma more seriously and to be more proactive in reporting symptoms to their GP. These actions, coupled with greater prompting of patients by GPs about their asthma, should help to optimize asthma management.     

Guidelines management of asthma in a busy urban practice

PURPOSE OF REVIEW: The purpose of this article is to review how optimal asthma management can be applied in a variety of clinical settings that are used to care for high-risk, urban asthma patients, especially those who live in the inner city, utilizing the 2007 National Heart, Lung, and Blood Institute/National Asthma Education Prevention Program 'Guidelines for the diagnosis and management of asthma', and adapting them to be applied in a variety of urban clinical settings, independent of practice infrastructure. RECENT FINDINGS: Previous asthma guidelines stressed asthma severity classification. A renewed focus on asthma control has led to better asthma outcomes. Consequently, it was deemed necessary to establish a new asthma paradigm that characterizes both asthma severity and control within the context of current impairment and future risk. This new paradigm can be effectively applied to high-risk, inner-city asthma patients, while allowing for individualization of care within systems of varied healthcare delivery infrastructures. SUMMARY: Assessment of asthma severity and control, with special emphasis on literacy and ethno-cultural beliefs and philosophies, will facilitate appropriate adaptations of long-term asthma management to provide optimal outcomes in urban asthmatics. It is essential to anticipate the worst-case, while planning for the best-case scenario.