???????????? ????? :???????????? ????? 15 ???? 2009 ?.


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


????????????? :????????????? 1. Morbidity & Mortality Weekly Report, 2001. 2. Asthma Physician Market Dynamics Study, 2001. 3. National Center for Health Statistics, 1986-1999. 4. Scott Levin, PDDA, MAT 12/01. 5-10% ??????-??? 32% ?? 18 ??? 68% =18 ??? 18% ??????? 34% ??????-??? 22% ?????? 26% ???????? ? ????? 5,4% ????? ????… 7,2% ????? ??????… 11,7% ???-???? 55% ??????? 45% ??????????- ??????? ??????? ???? ??? ????????


?????????????????? ????? :?????????????????? ????? Global Burden of Asthma, 2004


?????????????????? ????? :?????????????????? ????? Global Burden of Asthma, 2004


?????????? ?? ?? :?????????? ?? ?? Global Burden of Asthma


???????? ???????????? ????? :???????? ???????????? ????? Yang IA et al. Thorax 2008;63;555-563 ????????: ???????? ??????? ??????????? ????????: ? ?????? ?? INF-ß ????????: ?????????? ?????????? ???????????. ?????????????? ? ??????


????? ? ?????? :????? ? ?????? ? van Motius J Allergy Clin Immunol 2004;113:373-9 1,3% 5,9% 1,8% 4,4% 3,1% 12,9%


????????? :????????? Grootendorst DC et al., AJRCCM 2000;161:A918


??????? ????? ?? ???????? ?????????????????????? ?????? :??????? ????? ?? ???????? ?????????????????????? ?????? Paul Blanc, 2004 ???????????????? ????????? ??????? ????? ??????????? ?????. ????? ??????? / ????????. ?????. ??????? ???????? ????????????? ????????? ???????


????????????? ??????????? :????????????? ??????????? ten Brinke A et al. Eur Respir J 2005; 26: 812–818. % - ?????? ?????????? - ??????? ???????? ????? ?? ??? ??????. ??????????? ??????? ???? ????????


Slide 14:?????????????????????? ?????? ???????????? ??????????


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


Slide 16:? Barnes Immunology 2008; Vol 8: 183-192


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


???????????? ?????????:????????? ? ??????? ?? :???????????? ?????????:????????? ? ??????? ?? Wenzel ARJCCM 1997;156:737-743 ? Barnes Immunology 2008; Vol 8: 183-192


???????? ??????????? ????? :???????? ??????????? ????? Holloway et al. Asthma and Rhinitis.1995.


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


?????? ?????? :?????? ?????? Holloway et al. Asthma and Rhinitis.1995.


??????????? ???? :??????????? ???? Carroll et al. ARRD 1993; 147:405-410 ??????? ????????? ?????, ??


??????????????? ??????? :??????????????? ??????? ????? 11 ??? ??????? ?? 11 ???


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


????? – ??????????????? ??????????? :????? – ??????????????? ??????????? ? Bai TR et al. Eur Respir J 2007; 30: 452–456 ? Jenkins HA et al J Allergy Clin Immunol 2002; 109: 3-13 ??????? ???1, ? ????????? ????1: ?????? ?????????? - 14,6 ??/??? ?????? ?????????? - 31,5 ??/???


??????? :??????? ??????????? ????????: ????????????? ??????, ???????????? ??????? ?????? ??????????? / ?????????????: ???????????? ???????????????? ??????????? ???????????????? ?????????????? ????????????????? ???????????? ? ????????? ? ??????????? ???????????? ??????????? ? ?????????? ?? – ???????????????????? ????


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


??????? ????? ?? GINA 1996 :??????? ????? ?? GINA 1996


??????????????? ????????????? ??? ??? :??????????????? ????????????? ??? ??? * - ???????? ????? ????????? 1 ??? ? ???? ??? ????????? ??


??????? ???????? :??????? ???????? ??????? ? ??????????? ?????????? ??, ?????? ???? – ??????????? ??-?? ????????? ??. D-s: ??????? ?????????????? ??. ???????: ????????? 2000 ???/???. ?????? 3 ???.: ???????? ?? – 1-2 ???? ? ???. ?????? ????????? ???. D-s: ? ???????: ???


??????? ????? ?? GINA 2002 :??????? ????? ?? GINA 2002


???????????? ???????????? ???????????? ????? ? ?????? (120 ?????? ? 1362 ??????? ?? 34 ??????? ??) :???????????? ???????????? ???????????? ????? ? ?????? (120 ?????? ? 1362 ??????? ?? 34 ??????? ??) ? 55,2% ??????? ????? ??????????? ????????? ??????? ??????? ?? ? 84% ??????? ????????? ??????????? ??????? ??????? ?? ???? ???? ? ?????????? ??????? ??. ??????? ?.?., ??? ?.?., ??????? ?.?., ????????? ?.?. ?????????????, 2006; ?6: ?. 94-102


GINA 2006 :GINA 2006 «??????» ????????????? ??????? ?? ????????? ? ??????? ??????? ?? ?????? ?????????, ??? ?? ??????????????. ??????? ?? ????? ?????????? ? ???????? ??????? ? ??????? ?? ?????? ?? ????????? ?????? ???????????, ?? ? ?? ?????? ?? ???????. ???????????? ????? ????? ??????????? ?? ??????? ??????? ? ???????????? ? ?????????? GINA 1996. ?? ??????? ?? ?? ??????? ????? ???????????? ??? ??????? ???????? ? ?????? ???????? ??????? ????????. ??? ???????????? ????? ??????? ????????????? ????????????? ?? ?? ?????? ???????? ??? ????????????. GINA 2006


GINA 2006/07: ???????? ??? ???????????? :GINA 2006/07: ???????? ??? ???????????? GINA 2006-07


?????? ?? «??????? ??» ???????? ?????? ????????.. :?????? ?? «??????? ??» ???????? ?????? ????????.. Taylor DR et al. Eur Respir J 2008; 32: 545–554 ??????? ?? ?????????????? ? ??????? (??? ???????????? ??) ????????????? ???????????: ???????, ??????????????? ???????? ??????????? ? ???????? ????????? ???????, ?? ??????? ????????: ????????????? ?????????, ?????????? ??????? ? ??????????, ???????.


??????? ????? :??????? ????? ?????????? 1000 ???/???. ???????? ???? – 1-2 ???? ? ???. ?????? ??????????? – 1-2 ???? ? ???. ???????????: ????? ?????????? 1000 ???/???. ???????? – ?????????. ?????? ??????????? – ?????? ????. ???1 = 50% ?? ????????.


???????/???????????? ? ??????? ?? (???????? ATS) :???????/???????????? ? ??????? ?? (???????? ATS) ???? ??? ??? ??????? ????????: ????? ??? ?????? = ½ ???? ? ???? ????? ??????? ??? ???? ?????????????? ????????: ????????????? ????????? ?????????????? ???????? (?????????, ????-LT) ?????????? ??????????? ? SABA ?????????? ???????????????? (???1<80% ?? ????????) ???????? ????? ??? ?????? =3 ??? ? ??? ????????? ?? ?????? ??????????? ??????? =1 ???? ? ??? ??????? ????????? ????????? ??? ???????? ???? ??? ?? 25% ?????????? ????? ?????????? ?? ? ???????? American Thoracic SocietyWorkshop. Proceedings of the ATS workshop on refractory asthma. Current understanding, recommendations, and unanswered questions. Am J Respir Crit Care Med 2000;162:2341-51.


??????? ??????? ????? :??????? ??????? ????? Wenzel SE et al. , Am J Respir Crit Care Med 2000;162:2341-51.


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


???????????? GOAL :???????????? GOAL Bateman ED et al. Am J Respir Crit Care Med 2004;170:836-844. ? ????? ???????????? GOAL 1000 ??? FLU ???????? 68% ??????? ? ?????? ???????? ? 72% ??????? ? ?????? ??????????.


???? ??????? ? ?????????????? ?????? :???? ??????? ? ?????????????? ?????? 70 60 50 40 30 20 10 GOAL & SUND EXCEL ???????? GINA


Slide 43:???????? ?????????? ??????????? ?????


?????????? ????????? ?? ?????? ????????, ??? ?????????? ?????????????? :?????????? ????????? ?? ?????? ????????, ??? ?????????? ?????????????? 0 100 200 400 600 800 ???? ??????????, ??? 100 80 60 40 20 0 % ?? max Pedersen S. et al. J. Allergy Clin. Immunol. 1995; 95:29–33. Alving, K., et al. Am. J. Respir. Crit. Care Med. 1995; 151:A129.


Slide 45:??? ??????? + 8% ? 2,7 ???? ??? ??? ??? 200 ??? 800 ??? + LABA ? 1,7 ???? + 10% + 31% - 36% ??????? ???????? ???? ?????????? O’Byrne MP et al. AJRCCM, 2001 Pauwels RA et al. NEMJ, 1997


???????, ?? ??????? ?????????? ?????????? ???????? ? ??????????? ???????: :???????, ?? ??????? ?????????? ?????????? ???????? ? ??????????? ???????: ??????? (?? ????? ¼ ???? ???????? ???????) ????????? ?? ? ???? (?? ????? 10% ???????) ???????? ???????? ?????????? ?????????? ??????? ?????????? ?????? ????????? ???????? ?????????????????? ??????? ?????????? ???-??????????? ???????????? «??????»: ??????? ??????????, ????????? ????? ß-?????????? ??????????????? ???????? Humbert M., Allergy 2007: 62: 95–101


??????? ? ???????? ??? ?? :??????? ? ???????? ??? ?? ????????? ????? ??? ?? ?????, ??? ????????. ? ??????? ??????? ?? ??????? ???????? ????, ? ??????? ????????? ?? ???. ??????? – ????, ??? ? ?????????. ? ??????? ?????????? ???????????? ????????? ?????????? ????, ? ???????? ????? – ????. ??????? ????????????? ? ????? ???????? ??????? ????????? ?????? ???1. ????????? ??????? ???????? ???????? ??? ?? ? ? ???????? ? ? ?????. ??????? ??????? ????????????? ???. ? ??????? ??????????: ???????????? ? ??? ????????????? ???????? ??????????. ??????????? ?????????????????-2 ??????? TNF-a ? IL-8. Wakefield M. Aust N Z J Med 1995; Boulet LP Chest 2006; Eisner MD Am J Respir Crit Care Med 1998; Lange P N Engl J Med 1998; Bousquet J Allergy 2001; Chalmers GW Thorax 2002; Chaudhuri R Am J Respir Crit Care Med 2003; Chalmers GW Chest 2001; Ito K FASEB J 2001; Keatings VM Am J Respir Crit Care Med 1996; Gagliardo R Am J Respir Crit Care Med 2003;


??????????? ??????? ???????? ??? ?????? :??????????? ??????? ???????? ??? ?????? ???????? ??? ?????????? «??????» ???????? ?????????? ???1 ?????????? ??? ??????????? ? SABA ????, ???????, ????????? (????. ????) ?????? ???????? ??? ?????? ??????????? ? ??????? 13-14 ???. ? ???????? ? ?????? ????????? ??????????? ?????????? ????? ? ????????? ????: 27% (?????? 3). Bateman ED et al. Allergy 2008: 63: 932–938


?????? ????????? ???????? ? ?????????? :?????? ????????? ???????? ? ?????????? Dahl R. et al. Respir Med, 2006; Vol. 100: 152–1162. Aalbers R at al. Current Med Res and Opinion VOL. 20, NO. 2, 2004, 225–240 Kuna P et al. Abstract presented at the ERS Congress 2006 Bousquet J. et al. Abstract presented at the ERS Congress 2008 Vogelmeier C. et al. Eur Respir J 2005; 26: 819–828


??????????? ??????? ???????? ??? ?????? :??????????? ??????? ???????? ??? ?????? ???????? ??? ?????????? «??????» ???????? ?????????? ???1 ?????????? ??? ??????????? ? SABA ????, ???????, ????????? (????. ????)


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


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


??????????? :??????????? «??????, ??????, ?? ????, ??? ?????????» ?.?. ??????


???????? ?????????? :???????? ?????????? Wark PAB et al. Clin Exp Allergy 2002;32:1750–6.


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


Slide 56:???????? ????? Th-2 ????????? ????. ?????? IL-5 IL-8 ????????? ????????? ?????? ?????? ???????????? ?????? / ?????????? ?? ?-?????????


?????????? ????? :?????????? ????? Tattersfield: Am J Respir Crit Care Med 160:594–599, 1999 100 80 60 40 20 0 -15 -5 -10 5 0 10 15 ??? (?? ? ????? ??????????) ????? SABA ???????? ??? ?????? ????????