早在古希腊时期,盖伦医生发现清除病人的鼻分泌物能够改善其肺部症状,随后研究发现支气管哮喘与过敏性鼻炎常常共同存在于同一患者,过敏性鼻炎是哮喘的一个重要危险因素,过敏性鼻炎与哮喘有类似的治疗策略,治疗过敏性鼻炎可以使哮喘减轻。支气管哮喘和过敏性鼻炎发病的相关性研究日趋受到人们重视。 1 支气管哮喘与过敏性鼻炎相关性的流行病学研究 2 支气管哮喘与过敏性鼻炎的发病机制 2.1 支气管哮喘与过敏性鼻炎的危险因素 2.1.1 微生物感染 在呼吸道病原中,病毒感染与过敏性疾病发生的关系极为密切,尤其是5岁以下的小儿。此外,肺炎支原体和肺炎衣原体感染与哮喘的关系也成为近年来的热门话题。病毒致过敏性疾病的机制可能是:(1)呼吸道病毒感染可直接损伤气道粘膜上皮细胞,使上皮细胞下神经末梢裸露,β受体的兴奋性下调而致气道高反应性;(2)病毒侵犯呼吸道的上皮细胞,在多种细胞因子的参与下激活毛细血管内皮,导致粘附分子活性增加,促进炎性细胞在毛细血管聚集;(3)病毒感染可通过超抗原影响机体免疫。土耳其的一项关于过敏性疾病的流行病学与危险因素的调查资料显示,既往有呼吸道感染史者,其哮喘、喘息、过敏性鼻炎、湿疹等过敏性疾病的发病率显著增加[12]。 2.1.2 变应原及特应性体质 胎儿的免疫发育特征为Th2免疫反应占优势,而Th1细胞的功能受到抑制。出生后婴儿在吸入变应原刺激下,纠正胎儿期以Th2细胞为主的免疫反应;而特应体质个体针对变应原刺激,继续激发Th2免疫反应,抑制Th1免疫反应,加重了Th1和Th2免疫失衡状态,从而导致过敏性疾病的发生。变应原可在特应性体质人群引起下列呼吸道的病理生理变化:(1)促进T细胞向Th2细胞转化,而Th2细胞在启动和调节气道炎症反应中起主导作用;(2)使细胞因子种类和数量发生改变,如IL4、IL5、IL13产生增多和干扰素合成减少;(3)可使体内IgE水平增高,和其他过敏性疾病一样,体内总IgE水平和特异性IgE水平增高是过敏性疾病的主要特征和重要诊断指标,IgE水平的高低和过敏性疾病的严重程度呈正相关;(4)可使外周血嗜酸性粒细胞和组织肥大细胞/嗜碱性粒细胞增多。 2.1.3 环境卫生假说 Strachan在1989年就观察到家庭中出生的第一个子女更易发生过敏性疾病,提出免疫系统发育早期缺乏环境因素刺激如微生物感染是发生过敏性疾病的危险因素,这导致了环境卫生假说的形成。即儿童发育期的感染性免疫反应,有助于降低变应性疾病的发生率。幼年感染对哮喘起保护作用的假说虽然还没有得到承认,但流行病学的研究印证了这些结果:随着人们生活卫生条件的改善,结核、麻疹等感染性疾病的发病率呈降低趋势,而过敏性疾病患病率却逐年上升[13]。 2.2 过敏性鼻炎致哮喘的相关机制 2.2.1 鼻部分泌物吸入是引起哮喘发作的因素 2.2.2 鼻肺反射 由自主神经介导,传入神经为三叉神经,传出神经为迷走神经。当鼻和鼻窦粘膜上的三叉神经末梢受到刺激兴奋时,能反射性地引起支气管平滑肌收缩,导致支气管内阻力增加和肺顺应性降低,甚至氧分压降低,出现支气管哮喘的临床表现。有人用硅土微粒或冷空气刺激受试者的鼻粘膜,下气道阻力立即明显增高,而口服阿托品或切断三叉神经可以阻断其支气管痉挛,提示胆碱能神经反射也在其中起了重要的作用。遗憾的是,此后很少有类似的研究结果发表[15]。 2.2.3 呼吸方式的改变 鼻是气体进出体内的门户,对空气的过滤、加温、湿化可保持下呼吸道内环境的稳定。当过敏性鼻炎患者鼻塞,张口呼吸时,这种保护防御机制削弱而使下呼吸道稳定的内环境遭到破坏,并使变应原直接进入下气道导致炎症。 3 治疗 3.1 激素 3.2 白三烯受体拮抗剂 3.3 抗IgE单克隆抗体Omalizumab 3.4 特异性免疫治疗 3.5 DNA疫苗CpG motifs(GACGTC) 4 小结 【参考文献】 [2] Sazonov KV, Thomas J, Jonsson L, et al. 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支气管哮喘与过敏性鼻炎相关性研究进展简介:
早在古希腊时期,盖伦医生发现清除病人的鼻分泌物能够改善其肺部症状,随后研究发现支气管哮喘与过敏性鼻炎常常共同存在于同一患者,过敏性鼻炎是哮喘的一个重要危险因素,过敏性鼻炎与哮喘有类似的治疗 ... 责任编辑:admin |
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