304.4 📋 章末速記 Summary

304.4.1 🔑 一句話總結

Asthma = 慢性 airway inflammation + bronchial hyperresponsiveness + variable airflow limitation；GINA 2024 + 2025 強調 all asthma should have ICS-containing reliever（ICS-formoterol），不再單用 SABA；stepwise management Step 1-5；phenotypes：T2-high (allergic, eosinophilic) vs T2-low (neutrophilic)；biologics 革命：omalizumab (anti-IgE)、mepolizumab/reslizumab (anti-IL-5)、benralizumab (anti-IL-5R)、dupilumab (anti-IL-4/13)、tezepelumab (anti-TSLP 2022) 對 T2-high 與 T2-low 都有效；acute exacerbation：O2 + SABA + ipratropium + systemic steroids + magnesium for severe；special phenotypes：AERD (Samter’s triad)、EIB、occupational asthma (RADS)、cough-variant、pregnancy。

304.4.2 💊 治療精要

  • ICS (budesonide, fluticasone, mometasone, ciclesonide)：cornerstone
  • ICS-formoterol (Symbicort, Dulera)：preferred reliever + maintenance
  • LABA + ICS combo（不可 LABA 單獨用）
  • LAMA (tiotropium)：add-on for severe
  • Leukotriene modifiers (montelukast)：AERD, EIB, allergic（FDA boxed warning psych 2020）
  • Biologics：omalizumab、mepolizumab、benralizumab、reslizumab、dupilumab、tezepelumab (2022)
  • OCS：rescue exacerbations + severe refractory
  • adjunct：bronchial thermoplasty, allergen immunotherapy, aspirin desensitization (AERD)

304.4.3 🎯 盧醫師的考前提醒

  1. GINA 2024：all asthma should have ICS-containing reliever（SABA-only reliever 已淘汰）；ICS-formoterol 是 preferred
  2. diagnostic criterion: bronchodilator reversibility > 12% AND > 200 mL FEV1 improvement；methacholine challenge PC20 ≤ 8 mg/mL = positive
  3. Step 1-5 stepwise：as-needed ICS-formoterol → maintenance low-dose → medium-dose → high-dose ICS-LABA → add-on (LAMA, biologic, OCS)
  4. biologics 6 種記憶：anti-IgE (omalizumab)、anti-IL-5 (mepolizumab, reslizumab)、anti-IL-5R (benralizumab)、anti-IL-4Rα (dupilumab)、anti-TSLP (tezepelumab 2022 新利器, T2-high + T2-low)
  5. biologic 選擇：eos > 300 + ↑ FeNO → dupilumab；eos > 150 + exacerbations → anti-IL-5；↑ IgE + perennial allergen → omalizumab；severe regardless → tezepelumab
  6. AERD (Samter’s triad)：asthma + nasal polyps + aspirin sensitivity；COX-1 inhibition shifts leukotrienes；可做 aspirin desensitization；dupilumab 對 AERD 特別有效
  7. acute asthma 嚴重度：silent chest + cyanosis + bradycardia + confusion + SpO2 < 90 = life-threatening
  8. acute exacerbation 治療：O2 (target 93-95%) + SABA neb + ipratropium + systemic steroids (prednisone 40-50 PO 或 methylpred IV) + magnesium IV for severe + NIV / intubation for impending failure
  9. EIB (exercise-induced)：pre-exercise SABA 15-30 min；daily ICS reduces；LTRA 可替代；mannitol challenge for diagnosis
  10. occupational asthma：sensitizer (allergic, latency period — isocyanates, flour, animals) vs RADS (irritant, no latency — chlorine, ammonia)；workers’ comp + cessation + ICS-LABA