测定技术支气管舒张试验

测定技术支气管舒张试验 实验前准备 支气管舒张剂的选择 舒张支气管的药物～常用的有舒张支气管平滑肌的药物如 β2 受体兴奋剂、 M 受体阻滞剂、茶碱等及消除气道粘膜水肿、减轻气道炎症而使气道通畅的药物如糖皮质激素等。药物可通过雾化吸入、口服、静脉等不同途径给药。其中雾化吸入 β2 受体兴奋剂因作用快速、疗效确切、使用剂量少而副作用较小等优点而为最广泛使用。 吸入型支气管舒张剂: 吸入剂型包括 定量气雾剂, MDI , 、 干粉剂 或 悬液雾化吸入 。药物以短效 b 2 - 受体兴奋剂如沙丁胺醇及特布他林最为常用。所用剂量只为其口服剂量的 1/10 ， 1/20 。一般吸入短效 b 2 - 受体兴奋剂后 5 分钟内生效～达峰时间约 15-30 分钟。可依病情不同予病人以 200 m g ～ 300 m g ～ 400 m g 的沙丁胺醇。也可用 M 受体阻滞剂～如异丙托品 40 ， 80 m g 吸入～ 15 分钟起效～达峰时间约 30 ， 60 分钟。 非选择性的肾上腺素能兴奋剂如肾上腺素、异丙基肾上腺素等的雾化吸入因其副作用较多目前已基本弃用。 非吸入型支气管舒张剂: 口服或皮肤吸收、皮下注射、静脉注射等方式给予支气管舒张剂后～亦可测定支气管舒张的反应程度。对于部分对吸入型支气管舒张剂无反应或反应欠佳者可采用此方式进一步明确支气管的可舒张性～但该法起效较慢～需观察数小时、数天，数周。 糖皮质激素常需较长期应用,如 2 周,～才能观察到其支气管舒张作用～但疗效较为确切。 吸入药物的 定量气雾剂, MDI ,单剂量吸入法: method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of 定量气雾剂, MDI ,单剂量吸入,见影片 ～让受试者张口从残气位或功能残气位开始经口作缓慢的深吸气,吸气时间 1 ， 2 秒,～开始吸气后～操作者马上按下定量气雾药罐将药物释出～受试者吸入喷雾直至深吸气末,肺总量位,～屏气 5 ， 10 秒～或在没有感觉不适的情况下尽量屏息久些～然后才快速呼气至功能残气位。若需要多吸 1 剂～应间隔至少 1 分钟后再重新吸入。 该法为目前最为常用的方法～操作简便～价格便宜～适用于大多数受试者。对部分吸气动作配合欠佳者～可应用 辅助吸入储雾罐, spacer , ～药物喷入罐后受试者只需用口含著储雾罐～作数个平静呼吸即可。 干粉剂吸入法: 受试者口含干粉吸入器～口角不能漏气。从残气位用口,不能用鼻,作深深的、缓慢的吸气,需保证有一定的气流速度 > 60 升 / 分,。该法吸入药物效果较好～结果稳定～尤适合于年老、体弱等病者。但年龄过小,一般 <5 岁,儿童因其吸气流速较小～不宜用此法。此外～干粉药物及其吸入器成本相对较高。 潮气呼吸法: 以平静、自然的潮气呼吸连续吸入雾化悬液～如 5ml 沙丁胺醇雾化液, 0.5% 沙丁胺醇 1ml+N.S. 4ml ,。该法适用于几乎所有受试者～吸入效果好～唯需时较长。 受试者准备 试验前详细了解受试者的病史～尤其需了解其是否有对所用支气管舒张剂的过敏史～了解是否有严重心脏病史～体格检查心率应 <120 次～肺功能基线检查的试验前准备同肺功能检查。 此外～支气管舒张试验前 4 , 6 小时受试者需停用短效 b - 受体兴奋剂吸入,如为口服制剂的短效 b - 受体兴奋剂或氨茶碱需停用 12 小时,长效或缓释放型 b - 受体兴奋剂及茶碱则应停用 24 ， 48 小时。 测试步骤与结果判断 • 测试步骤 method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of 受试者先测定基础肺功能,如 FEV 1 、 PEF 或 sG AW ,～然后吸入 b 2 - 激动剂,如沙丁胺醇,。全部吸入药物后 5 分钟、 10 分钟、 15 分钟～必要时 30 分钟重复肺功能检查。其它途径给药者～按药物性质给药数分钟， 2 周后复查肺功能。 • 评定指标 评价支气管舒张试验的常用肺功能指标有 FEV 1 、 FVC 、 PEF 、 FEF 25 , 75 , 、 FEF 50 , 、 sGaw 、 Raw 、 Fres ,呼吸阻抗响应频率,等～其中以 FEV 1 最为常用～因其结果可靠且重复性好, PEF 测定简便, sGaw 及 Fres 较为敏感～但重复性稍逊。 通常根据这些指标变化率及绝对值的改变来进行结果判断。 1 (变化率:可用下式计算: 用药后肺功能值,用药前肺功能值 肺功能指标变化率,,, = × 100% 用药前肺功能值 2 (绝对值改变:绝对值改变,用药后肺功能值,用药前肺功能值 • 结果判断 • 支气管舒张试验阳性: 以 FEV 1 判断:若用药后 FEV 1 变化率较用药前增加 15 ,或以上,美国胸科学会, ATS ,建议 12 ,或以上,～且 FEV 1 绝对值增加, 200ml ～则判断支气管舒张试验为阳性。 其它指标阳性判断:用药后较用药前 FVC 、 PEF 增加 15 ,或以上～ FEF 25 , 75 , 、 FEF 50 , 增加 25 ,或以上～ sGaw 增加 35 ,或以上～ Zr 增加 1 倍或以上～ Fres 减少 1 倍或以上。 临床意义:支气管舒张试验阳性～意味着缩窄的气道具有可舒张性～且对所用药物敏感～对于临床选用支气管舒张药物有十分重要的指导意义。 method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of • 支气管舒张试验阴性: 若使用舒张药物后肺功能指标达不到上述标准～则支气管舒张试验阴性 支气管舒张试验阴性～有以下可能原因: • 轻度气道缩窄者～因其肺功能接近正常～用药后气道舒张的程度较小, • 狭窄的气道内有较多的分泌物堵塞气道～如重症哮喘患者支气管腔内常有大量粘液栓～影响吸入药物在气道的沉积和作用, • 药物吸入方法不当～致使药物作用不佳,为保证药物的吸入～可采用雾化吸入方法, • 使用药物剂量不足～故有时为明确了解支气管的可舒张性～常用较大剂量～如 MDI 或干粉吸入 400 ug 沙丁胺醇, 缩窄的气道对该种支气管舒张剂不敏感～但并不一定对所有的支气管舒张剂• 都不敏感～此时应考虑改用别的支气管舒张剂再作检测,如由沙丁胺醇转为异丙托品。 • 在作支气管舒张试验前数小时内已经使用了舒张剂～气道反应已达到极限～故此时再应用舒张剂效果不佳～但并不等于气道对该舒张剂不起反应。因此～在作舒张试验前应停用支气管舒张剂一段时间～吸入性短效 b 2 ,受体兴奋剂或抗胆碱能药停用 4 ， 6 小时、口服短效 b 2 ,受体兴奋剂或茶碱停 8 小时、长效或缓释型停用 12 ， 24 小时以上。 狭窄的气道无可舒张性。作此一结论应排除上述 6 点因素。 临床应用 诊断支气管哮喘: 支气管哮喘的特征之一是支气管平滑肌的痉挛具有可逆性。故在支气管舒张试验时～表现出狭窄的支气管舒张～肺功能有相当程度的改善。支气管舒张试验阳性支持支气管哮喘的诊断。 method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of 对疑似支气管哮喘患者的应用:有些支气管哮喘患者肺功能较差～例如FEV1,60%预计值～不宜作支气管激发试验时～可采用本试验。若舒张试验阳性～可证实支气管哮喘。 对一些无明显气道阻塞症状的支气管哮喘病人或支气管哮喘的非急性发作期～当其肺功能不正常时～经吸入支气管舒张药～肺功能指标有明显的改善～亦可作为判断支气管哮喘,发作期,的依据。 由于支气管哮喘患者病情常有波动～试验本身即使在同一个人～在不同时间内～也有一定程度变异～故有时需间隔一段时间～两次或两次以上的结果才比较可靠。 指导用药: 支气管舒张试验还可用于评价某种支气管舒张药物的疗效～以指导治疗。可通过本试验了解或比较某种支气管舒张剂的疗效。有不少支气管哮喘病人～自诉用B2受体激动剂后效果不佳～不愿吸入～但如舒张试验阳性～表示气道痉挛可逆～可据此向病人耐心解释～指导病人正确用药～提高病人的依从性。 出现阴性结果时并不表示支气管狭窄程度一定是不可逆的～需仔细～有时试验阴性～需口服强的松30mg/d, 连续1，2周后再做试验～如肺功能仍无改善者～方可认为是不可逆病变～可以考虑停用激素。 在COPD患者中的应用: 少数COPD患者～可合并有支气管哮喘或为COPD的喘息型者～有时可出现舒张试验阳性结果。本试验须结合临床资料才能作出正确判断。如COPD病者对本试验阳性～其意义与气道反应性增高一样～预示肺功能逐年下降的趋势比较快～应长期使用支气管舒张剂治疗。 method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of