???????? ? ?????????? ??????? ??????? :???????? ? ?????????? ??????? ??????? 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) ???????? ??????? ? ??????????? ????????
??????????? ?????????? ?????? ??? ???????? ? ???? :??????????? ?????????? ?????? ??? ???????? ? ????
???????????? ?????????? ??????????? ????? :???????????? ?????????? ??????????? ?????
??????????????? ????????? ? ??????? ???? :??????????????? ????????? ? ??????? ???? ????? ???? ????? ???????????? ?????? ???? ????.
????????? ???????
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????????????
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?????? ?????????????? ?????? ???????
???????? ??????????
???????????????? ????? ? 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
???????????????? ????? :???????????????? ?????
???????? ? ?????????? ??????? ??????? :???????? ? ?????????? ??????? ??????? ???????? ? ?????????? ??????
?????? ?????????????? ?????? ???????
???????? ??????????
??????????????? ????????????? ?????????? :??????????????? ????????????? ?????????? ????????? ???????????
???? ????????
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??????? ???????????? ????????? :??????? ???????????? ????????? ??????? ??????? ??????, ??? ??????? ???????????? ????????? ???????????
?????. ?????? ??
????. ?????? ??
????????
????????? ? ??????? ?????? ???????? :????????? ? ??????? ?????? ???????? ??. ???????, ??????? ???? ????????
??????????
??????
?????????????? ??
??????????? ?? ???? ?????????, %
????????? ? ??????? ?????? ???????? :????????? ? ??????? ?????? ????????
????????? ? ???????? ????? :????????? ? ???????? ????? ??????? ???? ????????? ????
?????????? ??????????? ????????? ?????????? :?????????? ??????????? ????????? ?????????? ???? ????? ???????? ???? ?????????????
???????????????? :???????????????? 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 ?? ?????????? ?????
???????? ???????? :???????? ???????? ??????????
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???????
?????????? ??????????
?????????? ??????? ???????? :?????????? ??????? ???????? Aerolizer
Novartis
?????????? ??????? ???????? :?????????? ??????? ???????? Handihaler
Boehringer Ingelheim
?????????? ??????? ???????? :?????????? ??????? ???????? Diskus
GSK
?????????? :?????????? ????????? ??? ???????? ????????? (1)
??????????? ?????
?????????? ??????????? (2)
?????? ??? ?????? ????????? (3) ? ????
???????????
??????? ?? ???? ?????????? ??????? (4)
??????? ??? (5)
??????????? ???????????? ??????? ? ?????????? ??????? ???????? ????????? ?????????? :??????????? ???????????? ??????? ? ?????????? ??????? ???????? ????????? ??????????
???????????? :???????????? ????????
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