<link rel="stylesheet" href="https://studioyszimg.yxj.org.cn/css/video-js.min.css?v=1"><link rel="stylesheet" href="https://studioyszimg.yxj.org.cn/article/css/base.css?v=5"><link rel="stylesheet" href="https://studioyszimg.yxj.org.cn/article/css/index.css?v=35"><link rel="stylesheet" href="https://ysz-web.yxj.org.cn/live/dist/static/base/index.css?ysz_v=2.0"><script src="https://studioyszimg.yxj.org.cn/js/dsbridge.js?v=13" type="text/javascript"></script><script src="https://ysz-web.yxj.org.cn/dsBridge/main.js?v=26" type="text/javascript"></script><script src="https://ysz-web.yxj.org.cn/live/dist/static/base/fun.js?ysz_v=3" type="text/javascript"></script><script src="https://ysz-web.yxj.org.cn/live/dist/static/js/nativeToWeb.js?v=1" type="text/javascript"></script><div id="ysz-header" style="margin:0;overflow:hidden;"><h1 style="font-size:24px;line-height:1.8;color:#333333;word-wrap:break-word;">哮喘稳定后,降阶梯治疗「七步」走</h1><h2 style="font-size:16px;color:#999999;word-wrap:break-word;"><em style="font-style:normal;margin-right:10px;color:#7f7f7f;display:inline-block;">2022-01-26</em><em style="font-style:normal;margin-right:10px;color:#7f7f7f;display:inline-block;">小布</em><em style="font-style:normal;margin-right:10px;color:#7f7f7f;display:inline-block;">原创:医学界呼吸频道</em></h2></div><p class="brief">降阶梯治疗很重要!</p><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">大家都知道,慢性持续期哮喘的药物治疗方案采用的是阶梯治疗,控制不佳了升阶梯,控制好了自然要降阶梯。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">正所谓“上山容易下山难”,如何降阶梯治疗才能够保持哮喘的良好控制,“降得下来稳得住”才是硬道理。今天咱们就来聊聊哮喘患者降阶梯治疗那些事。</span></section><section><br/></section><section><section><section><section><section><section><section></section></section></section></section><section><section><section><section></section></section></section><section><section><section><p style="text-align: justify;"><span class="ysz-ueditor-title-one" style="font-size: 16px; line-height: 28px; font-weight: bold; color: rgb(215, 0, 15); text-align: left;">什么时候可以降阶梯治疗?</span></p></section></section></section></section><section><section><section><section></section></section></section></section></section></section></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">《支气管哮喘防治指南(2020年版)》(以下简称2020版指南)指出,当哮喘症状得到控制并维持至少3个月,且肺功能恢复正常并维持平稳状态,可考虑降级治疗。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">我们可以看到,哮喘降阶梯治疗的前提是症状得到控制、肺功能恢复正常,并且维持稳定。不过,并非达到了上述条件就可以顺利安全地降阶梯治疗了,研究表明,过去12个月内有过急性发作病史的患者在降阶梯治疗时急性发作的风险会有增加。</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">因此,降阶梯治疗需要因人而异,2020版指南强调,如果存在以下危险因素,一般不推荐降阶梯治疗:</span></section><section><br/></section><ul class="custom_macula list-paddingleft-1" style="list-style-type: macula;"><li class="list-macula list-macula-paddingleft"><p><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">SABA用量每月>1支(200喷/支);</span></p></li><li class="list-macula list-macula-paddingleft"><p><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">依从性或吸入技术差;</span></p></li><li class="list-macula list-macula-paddingleft"><p><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">FEV1占预计值%<60%;</span></p></li><li class="list-macula list-macula-paddingleft"><p><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">吸烟或暴露于变应原;</span></p></li><li class="list-macula list-macula-paddingleft"><p><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">痰或血嗜酸性粒细胞增高;</span></p></li><li class="list-macula list-macula-paddingleft"><p><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">存在持续气流受限等。</span></p></li></ul><section><section><section><section><section><section><section><section><section style="text-align: justify;"></section><section style="text-align: justify;"></section><section style="text-align: justify;"></section><section style="text-align: justify;"></section><section style="text-align: justify;"></section><section style="text-align: justify;"></section></section></section></section></section></section></section></section></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">如果哮喘控制良好,达到了上述条件,你就可以考虑降阶梯治疗了。那么,降阶梯治疗的最佳时机是什么呢?2020版指南认为,降阶梯治疗需要避开呼吸道感染、妊娠和旅行期等。</span></section><section><br/></section><section><section><section><section><section><section><section></section></section></section></section><section><section><section><section></section></section></section><section><section><section><p style="text-align: justify;"><span class="ysz-ueditor-title-one" style="font-size: 16px; line-height: 28px; font-weight: bold; color: rgb(215, 0, 15); text-align: left;">降阶梯治疗的具体流程?</span></p></section></section></section></section><section><section><section><section></section></section></section></section></section></section></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">终于可以降阶梯治疗了,具体应该如何操作呢?</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">哮喘的本质是慢性气道炎症,糖皮质激素则是哮喘治疗的基石,但是副作用也相对比较大,因此,降阶梯治疗的核心就在于最大限度地把激素的用量减下来。</span></section><section><br/></section><section><section><section><section><section><section><section><section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">第一步:减少口服或吸入激素的用量,2020版指南认为,每3个月减少吸入性糖皮质激素(ICS)剂量的25%~50%通常是安全可行的;<br/></span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">第二步:别急!先观察激素减量后的反应,如降级过度或过快,即使症状控制良好的患者,其哮喘急性发作的风险也会增加,减药后需要密切观察患者症状的控制情况并定期随访,激素减量时,气道高反应性测定(PEF变化)和痰嗜酸粒细胞计数可以预测急性加重的风险,一旦症状恶化,需要恢复到原来的治疗方案;</span></section><section></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">第三步:减少激素的使用频率,由每日2次减至每日1次;</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">第四步:重复第二步;</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">第五步:减去与激素合用的控制药物[长效β2受体激动剂(LABA)等];</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">第六步:重复第二步;</span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">第七步:以最低剂量ICS维持治疗(按需使用低剂量ICS-福莫特罗或按需使用SABA时联合低剂量ICS),完全停用ICS有可能增加急性发作的风险。</span></section></section></section></section></section></section></section></section></section><section><br/></section><section style="text-align: center;"><span style="line-height: 28px; font-size: 14px; color: rgb(136, 136, 136);">表1 成人和青少年(12岁及以上)临床上常用的ICS每日低、中、高剂量</span></section><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/AC14B1E0017E94271A98B76710CACAD7.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 677px ; visibility: visible ;"/></section><section><br/></section><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/AC14B1E0017E94271DE7E1155A48EAB7.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 677px ; visibility: visible ;"/></section><section style="text-align: center;"><span style="line-height: 28px; font-size: 14px; color: rgb(136, 136, 136);">图1 哮喘患者降阶梯治疗流程图<br/></span></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">以上就是哮喘患者降阶梯治疗的整体原则和流程,那么处于不同治疗阶段的患者应该如何具体执行呢?咱们来看看全球哮喘防治创议(GINA)2021怎么说。</span></section><section><br/></section><section style="text-align: center;"><span style="line-height: 28px; font-size: 14px; color: rgb(136, 136, 136);">表2 哮喘控制良好后降阶梯治疗的推荐方案</span></section><section style="text-align: center;"><img class="rich_pages wxw-img" src="https://studioyszimg.yxj.org.cn/AC14B1E0017E9427211C853D492622A4.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 677px ; visibility: visible ;"/></section><section><br/></section><section style="text-align: justify;"><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">最后简单给大家回顾一下哮喘降阶梯治疗的要点:</span></section><section><br/></section><ul class="custom_macula list-paddingleft-1" style="list-style-type: macula;"><li class="list-macula list-macula-paddingleft"><p><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">哮喘症状控制良好和肺功能恢复正常,维持3个月以上可以考虑降阶梯治疗;</span></p></li><li class="list-macula list-macula-paddingleft"><p><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">存在哮喘急性加重危险因素的患者,不建议降阶梯治疗;</span></p></li><li class="list-macula list-macula-paddingleft"><p><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">降阶梯治疗需要避开呼吸道感染、妊娠和旅行期等;</span></p></li><li class="list-macula list-macula-paddingleft"><p><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">降阶梯治疗的核心在于减少糖皮质激素的用量,最后以最低剂量ICS维持治疗;</span></p></li><li class="list-macula list-macula-paddingleft"><p><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">降阶梯治疗过程中需要密切监测患者症状和肺功能,必要时恢复原来的治疗方案。</span></p></li></ul><section><section><section><section><section><section><section><section><section style="text-align: justify;"></section><section style="text-align: justify;"></section><section style="text-align: justify;"></section><section style="text-align: justify;"></section><section style="text-align: justify;"></section></section></section></section></section></section></section></section></section><div class="footer"><div class="item"><p class="ysz-ueditor-references-label" >参考文献 <span>共2篇<i></i></span></p><div class="ysz-ueditor-references-content textLine2" lang="en"><section><span style="color: rgb(0, 0, 0); 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