???????? ? ?????????? ??????? ??????? :???????? ? ?????????? ??????? ??????? 15.06.2009


???????? ? ?????????? ??????? ??????? :???????? ? ?????????? ??????? ??????? ???????? ? ?????????? ?????? ?????? ?????????????? ?????? ??????? ???????? ??????????


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????? ?????? ? 2 ???? ?????? ?????? ??????? ?????? :????? ?????? ? 2 ???? ?????? ?????? ??????? ?????? ?????? 2 ????? 4 ????? 3 ????? ??????? ?????? ?????? ????????????? ????????


???????????? ?????? :???????????? ??????


????? ?????? ???????????? 40 ?????? ?????? :????? ?????? ???????????? 40 ?????? ??????


????????? ???????? :????????? ????????


?????????????? ??????? :?????????????? ??????? ???????? 1.5 ??. ? ??????. ?????? ????? ???? ????????? «???????» ?? ????????? ?? 6 ?????. ?????, ??????????? ??? ?????? ????????? ???? ???? ????????? ? ??????????? ??????????? ?????: ????????? – 6 ??? ??? – 5 ????? ? ????? ?????????? – 8 ????? ? ????? J Appl Physiol.1985; 58: 1157-1163 Högger and Rohdewald, Rev Contemp Pharm 1998


????????????? ?????? ?????? :????????????? ?????? ??????


?????????? :?????????? ?????????????? ?????????????? ???????? II ???? ??????? ?? ?????? ? ???????????? ??????? ????????????? ?????????: ??????? ?? ?????? - ??? ????? ??????? ??????? (???????????? ????????) ? ?????? ???????? ???????, ??? ? ??????? (???????????? ??????????? ??????? ? ??????? ????????)


??????????? ???????????-??????????? ???????? :??????????? ???????????-??????????? ????????


?????????????? ???????? :?????????????? ???????? ????? ???????? ????? ?????????? ????? 1,6% ?? ?????? ?????? ????????????? ????. ????????????? ?????????????? ? ?????? ? 16-17 ??? ??????, ??? ?????????????? ???????? ? 2,5 ???? ?????? ?????


?????????? ?????? ? ??????? ?????? :?????????? ?????? ? ??????? ??????


????????? :????????? ??????? ?????? r1 ????????? ??????? ?????? ????????? r2 ????????? – ???????????? ???? ?????????? ??? ?????????? ?? 130% ?? ?????? ?????


??????? ????????? ? ??????? :??????? ????????? ? ??????? ???? ????????? ??????????? ?????????????? ???????


???????????? ?????? :???????????? ?????? ????? ?? ????????, %


??????? ????????????? ????? :??????? ????????????? ?????


????? ??????? ????????????? ????? :????? ??????? ????????????? ?????


?????????? ?????? ????????: :?????????? ?????? ????????: ???? ?????????? ?? ????????? ?????????, ???????????? ? ??????? ?????????? 5-? ????????? ?????????? ????????????? ???? ??????? ????????? ??????? ??????????? ???? ???????? ?????????? ?????? ? ?????????? ???????? ??????? – ???????????


????? ???? :????? ???? ??? V- ???????? ????????, P – ???????? ????????, R – ????????????? ??? ? – ???????? ????, I – ?????? ??????, r - ??????


????????????? ??????????? ????? :????????????? ??????????? ?????


????????????? ? ??????? ? ??????????? ?? ????????? :????????????? ? ??????? ? ??????????? ?? ?????????


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????????? ????????????????:(1) ??????????? :????????? ????????????????:(1) ???????????


????????? ????????????????:(2) ???? ????????????? ???? :????????? ????????????????:(2) ???? ????????????? ????


????????? ????????????????:(3) ???????? ??????? ? ??????????? ???????? :????????? ????????????????:(3) ???????? ??????? ? ??????????? ????????


??????????? ?????????? ?????? ??? ???????? ? ???? :??????????? ?????????? ?????? ??? ???????? ? ????


???????????? ?????????? ??????????? ????? :???????????? ?????????? ??????????? ?????


??????????????? ????????? ? ??????? ???? :??????????????? ????????? ? ??????? ???? ????? ???? ????? ???????????? ?????? ???? ????. ????????? ??????? ??????? ???? ??????? ????????? ?????? ????????????


???????? ? ?????????? ??????? ??????? :???????? ? ?????????? ??????? ??????? ???????? ? ?????????? ?????? ?????? ?????????????? ?????? ??????? ???????? ??????????


???????????????? ????? ? 158 ??????????? ????????????? ?? :???????????????? ????? ? 158 ??????????? ????????????? ?? ATS/ERS Task Force Asthma Control, 2005


???????? ?????? :???????? ??????


?????????????????? :??????????????????


?????????????? :??????????????


?????? ????? - ????? :?????? ????? - ?????


????????????? ????????????? ????? ? ??????? 25%-75% ?? ???? :????????????? ????????????? ????? ? ??????? 25%-75% ?? ????


????????????? :????????????? 590,00 EUR


????????????? :????????????? Reddel et al. Lancet 1999;353:364-369


???? ?? ??????????? ???????????????? :???? ?? ??????????? ???????????????? postFEV1 - preFEV1 preFEV1 ???????? ???????????: ?? FEV1: >12 % ? >200 ?? ?? PEF: > 60 ?/??? Quanjer et al. ERJ 1993;6(suppl.16):5-40 ?100%


???????????????????? ???? :???????????????????? ???? % ??????? ???1 ???????????? ??????????, ??/??


???????? PC20 ?? ???? ??????? ???? :???????? PC20 ?? ???? ??????? ???? Booms et al., JACI 1997;99:330-337 ????????? ??????? ????????? PC20 ?????? 2.0 1.5 1.0 0.5 0.0 -0.5 ?????? ??????? -1 0 4 8 12 13 14


Medical Research Council Dyspnea Scale :Medical Research Council Dyspnea Scale Brooks 1982


Borg CR 10 Scale (Dyspnea Assessment) :Borg CR 10 Scale (Dyspnea Assessment) Borg,G., Med Sci Sports Exerc 1982; 14:377-81 ???????????? ?????? ?????, ????? ??????? ????? ??????? ??????? ????????? ????????? ?????? ????? ?????? ???


????????? ACQ (?? ??????? ??????? ??????????? ?? 0 ?? 6-?? ??????) :????????? ACQ (?? ??????? ??????? ??????????? ?? 0 ?? 6-?? ??????) ??? ????? ?? ??????????? ??-?? ???????????? ????? ????? ? ??????? ?? ????????? ??????? ????????? ? ??? ???? ???????? ???????? ???????????? ????? ????? ? ?????? ??????????, ? ??????? ?? ????????? ??????? ????????? ???? ?????????? ???? ???????????? ??-?? ???????????? ????? ? ????? ?? ????????? ??????? ????????? ??????? ?????? ?? ?????????? ??-?? ???????????? ????? ? ????? ?? ????????? ??????? ? ??????? ?????? ???????, ? ????? ?? ????????? ??????, ?? ?????????? ????????? ???????? ???????, ? ??????? ?? ????????? ??????, ????????? ?????? ?????? ?????????????????? ???????? ????????? ????????? ???????? ???1 ? % ?? ???????? ?? ?????? ?????????? ??????. Juniper EF, Svensson K, Mork AC, Stahl E. Respir Med 2005;99: 553–8.


????????? SMART vs ??????? :????????? SMART vs ??????? COSMOS Trial ACQ5 ????? (0–6) 1.0 1.2 1.4 1.6 1.8 2.0 0 4 12 26 52 p=0.07 SMART ??????? ???.


The St Georges respiratory questionnaire (SGRQ) :The St Georges respiratory questionnaire (SGRQ) ??? ?????? ?? 7 ????????? ??????????? ??????? ?????????????? ???????????? ??? ?????? ???????? ????? Jones PW, Quirk FH, Baveystock CM (1991) The St Georges respiratory questionnaire Respiratory Medicine 85 (supplement B) 25-31


?????????, ??????? ? ?? ??????????: ??????? ?? ???????? ????? :?????????, ??????? ? ?? ??????????: ??????? ?? ???????? ?????


???? ? 6-?? ???????? ??????? (6MWT) ? ????????? ?????????? ? ??????? ???? :???? ? 6-?? ???????? ??????? (6MWT) ? ????????? ?????????? ? ??????? ???? V.M. Pinto-Plata et al. Eur Respir J 2004; 23: 28–33. ?=0,003 ??????????, %


?????? ????? ???? (BMI) :?????? ????? ???? (BMI) ???: m — ????? ???? ? ??????????? h — ???? ? ?????? (? ?????????? ? ??/?2).


Slide 55:FEV1 < 35% PT # 1 58 y FEV1: 28 % MRC: 2/4 PaO2: 70 mmHg 6MWD: 540 mt BMI: 30 BODE: 3 1 2 3 4 PT # 2 62 y FEV1: 33% MRC: 2/4 PaO2: 57 mmHg 6MWD: 400 m BMI: 21 BODE: 6 PT # 3 69 y FEV1: 35% MRC: 3/4 PaO2: 66 mmHg 6MWD: 230 m BMI: 34 BODE: 7 PT # 4 72 y FEV1: 34% MRC: 4/4 PaO2: 60 mmHg 6MWD: 154 m BMI: 24 BODE: 9


?????? ????? ???? (BMI) ? ???????????? ??????? ???? :?????? ????? ???? (BMI) ? ???????????? ??????? ???? Chailleux E et al. CHEST 2003; 123:1460–1466 ???? ???????????? ????????????


NO :NO


NO :NO Ricciardolo et al. Thorax 2003 De Gouw et al. Eur Respir J 1998 ??????? ? ?????????? ???????? ????????


?????? :??????


??????? IgE :??????? IgE Burrows B, et al. N Engl J Med 1989 ??????? IgE ? ?????? (??/??)* n=2,657 0.32 1 3.2 10 32 100 320 1,000 3,200 1.0 2.5 5.0 10 20 40 ????? (??????? ?????????????) Log


???????????????? ????? :???????????????? ?????


???????? ? ?????????? ??????? ??????? :???????? ? ?????????? ??????? ??????? ???????? ? ?????????? ?????? ?????? ?????????????? ?????? ??????? ???????? ??????????


??????????????? ????????????? ?????????? :??????????????? ????????????? ?????????? ????????? ??????????? ???? ???????? ????????? ????????? ???????? ??? ??????


??????????? ?????? ???????? :??????????? ?????? ???????? ??????? ???????? ?????????? ????????


??????? ???????????? ????????? :??????? ???????????? ????????? ??????? ??????? ??????, ??? ??????? ???????????? ????????? ??????????? ?????. ?????? ?? ????. ?????? ?? ????????


????????? ? ??????? ?????? ???????? :????????? ? ??????? ?????? ???????? ??. ???????, ??????? ???? ???????? ?????????? ?????? ?????????????? ?? ??????????? ?? ???? ?????????, %


????????? ? ??????? ?????? ???????? :????????? ? ??????? ?????? ????????


????????? ? ???????? ????? :????????? ? ???????? ????? ??????? ???? ????????? ????


?????????? ??????????? ????????? ?????????? :?????????? ??????????? ????????? ?????????? ???? ????? ???????? ???? ?????????????


???????????????? :???????????????? Saari SM et al. Chest 1998; 113:1573-79 0 1 ??? 2 ???? 4 ???? 24 ????


???????? ???????? :???????? ???????? ?????????? ???????????? ???????? ??????? ?????????? ??????????


????????????? ?????????? :????????????? ?????????? OMRON (??????) PARI (????????)


????????????? ?????? :????????????? ?????? ?????? ??? ????????? ?? ??????????? ?????? ????????? ????????. ?????? ??????????? ??????? 15-30 ??? ??????? 2-5 ???


?????????? ?????????? :?????????? ?????????? Omron NE-U14


???????? ???????? :???????? ???????? ?????????? ???????????? ???????? ??????? ?????????? ??????????


?????????? ?????????? :?????????? ?????????? ??????????? ????????? ???????? ??????? ???????? 30 ?/?


????????? ????????? ? ??????????? :????????? ????????? ? ???????????


??????????? ?????????? ???? :??????????? ?????????? ????


??????????, ???????????? ?????? :??????????, ???????????? ??????


?????????? ???????? :?????????? ????????


??????????? :??????????? HFA – ??????????????? ??????? ?????? ???????? ?????? CFC – ??????????????? (?????)


Slide 82:??????????? HFA – ?????????????? ??. Ø 1,1 ??? CFC – ??????????????? (?????) ??. Ø 3,5 ???


??????????? :???????????


Slide 84:Leach CL et al. Eur Respir J 1998; 12(6): 1346-53 HFA – ?????????????? ??. Ø 1,1 ??? CFC – ??????????????? ??. Ø 3,5 ???


???????? ?????????????? :???????? ?????????????? Crim C et. al. Clin Ther 2001;23:1339–1354. Mackie AE et. al. Clin Pharmacokinet 2000;39:17–22. Mackie A et. al. Clin Pharmacokinet 2000;39:23–30. Daley-Yates P et. al. Br J Clin Pharmacol 2001;51:400–409. Thorsson L et. al. Rhinology 1993;31:7–10. Brutsche MH et. al. Lancet 2000;356:556–561. Rohatagi S et. al. J Clin Pharmacol 2003;43:1–11.


?????????? BDP :?????????? BDP Br J Clin Pharmacol. 2001 May; 51(5): 400–409. RRA ????????????? = 100 BDP F=2% (?????? ??????) BMP ? 25 ??? ???????? BMP F=62% (???- 26% , ?????? – 36%) ???????????? F=33% (???- 13% , ?????? – 20%)


???????????? BDP ? ?????? ??? ????????????? ??????????? ?????? ????? :???????????? BDP ? ?????? ??? ????????????? ??????????? ?????? ????? Chet Leach, www.fda.gov


?????? vs ????????? :?????? vs ????????? Papi A et al. Eur Respir J 2007; 29:682-689 ???, ???. ?/??? ???. ?????? BDP/F 100/6 ??? * 2 ???? ????????? BUD/F 200/6 ??? * 2 ???? ? <0.001


????????? ????? ? ??? ?? ???? (1200 ???): ???????????? ????????? ? ????? :????????? ????? ? ??? ?? ???? (1200 ???): ???????????? ????????? ? ????? Thorax 2000;55:345


????????? ?? ?????? HFC ?? ?????????? ????? :????????? ?? ?????? HFC ?? ?????????? ?????


???????? ???????? :???????? ???????? ?????????? ???????????? ???????? ??????? ?????????? ??????????


?????? ????????? :?????? ?????????


???????? ???? :???????? ???? % ?? ??????????? ???? ? ???? ??????????? ??????? ??????? ? ??????????????? ?????????


???????? ???????? :???????? ???????? ?????????? ???????????? ???????? ??????? ?????????? ??????????


?????????? ??????? ???????? :?????????? ??????? ???????? Aerolizer Novartis


?????????? ??????? ???????? :?????????? ??????? ???????? Handihaler Boehringer Ingelheim


?????????? ??????? ???????? :?????????? ??????? ???????? Diskus GSK


?????????? :?????????? ????????? ??? ???????? ????????? (1) ??????????? ????? ?????????? ??????????? (2) ?????? ??? ?????? ????????? (3) ? ???? ??????????? ??????? ?? ???? ?????????? ??????? (4) ??????? ??? (5)


??????????? ???????????? ??????? ? ?????????? ??????? ???????? ????????? ?????????? :??????????? ???????????? ??????? ? ?????????? ??????? ???????? ????????? ??????????


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