Geriatric asthma refers to asthma patients aged 60 years or older who meet the diagnostic criteria of bronchial asthma. Recent foreign data show that geriatric asthma is not uncommon and has a rising trend, and although there is no nationwide statistical data on geriatric asthma in China, it has been found in clinical work that geriatric asthma is increasing. Due to the physiological characteristics of the elderly, asthma in the elderly differs from asthma in children and adolescents, and elderly patients with asthma often have other diseases, such as chronic obstructive pulmonary disease, coronary heart disease, hypertension, cerebrovascular disease, diabetes mellitus, etc., making the clinical manifestations of asthma in the elderly more complicated, often leading to misdiagnosis and misdiagnosis, this paper gives a systematic account of this aspect, hoping to pay sufficient attention to elderly asthma. I. Epidemiology In the past, in the identification of bronchial asthma and chronic bronchitis, it was believed that bronchial asthma occurred in children and adolescents, while chronic bronchitis occurred in the elderly, so many elderly people with asthma were misdiagnosed as chronic bronchitis. Recently, asthma in the elderly has been gradually recognized and therefore given correct and reasonable treatment. A large amount of data shows that asthma can occur in all age groups, with the highest incidence in childhood, decreasing in youth and middle age, and increasing in the elderly, with the second highest incidence of asthma in the elderly. Bronchial asthma can occur in different parts of the world, different races, different countries and regions, depending on the environment, climate and industrialization, the incidence of asthma also varies, in the past 10 years the United States asthma mortality rate has increased year by year, mainly in the elderly asthma deaths increased. The etiology of asthma is very complex and the pathogenesis has not been clarified. The etiology and pathogenesis of asthma in the elderly are both the same and different from those of general asthma, in short, the essence of asthma in the elderly is also chronic non-specific metaplastic inflammation of the airways, dominated by eosinophils, mast cells and lymphocytes, with the participation of other inflammatory cells. Its pathogenesis is caused by a combination of genetic background and environmental factors, both of which are indispensable, otherwise it will not develop. A lot of work has been done both at home and abroad on the genetics of asthma to find the genes involved in its development, and it is believed that asthma is a polygenic genetic disease. The heritability of asthma is; of patients have a positive family history, the incidence in relatives of asthma patients is higher than the incidence in the general population, and the closer their relatives are, the higher the incidence. The genetic mechanism of atopic allergy is usually of two types: genetic control of basal IgE levels and genetic control of specific IgE responses. The etiology of asthma in the elderly has the following characteristics. 1, smoking Long-term smoking division makes some people develop chronic bronchitis and emphysema, that is, it can cause chronic airway inflammation, and then cause airway hyperresponsiveness, some authors report that most elderly asthma patients have a history of smoking or are smoking, and the incidence of asthma is higher in elderly smokers than non-smokers, and the incidence of asthma is also higher in passive smokers. 2, the impact of drugs cardiovascular disease is a common disease in the elderly, such as coronary heart disease, hypertension, arrhythmia, cerebral infarction and cerebral thrombosis, often need to take β-blockers, angiotensin converting enzyme inhibitors (ACEI) and aspirin drugs, although the recent study of β1 receptors highly selective drugs, but the β2 receptors on the bronchial smooth muscle also has a certain blocking effect, this effect leads to Bronchial smooth muscle contraction and induce asthma, especially the commonly used insulin and medoxin, etc., are more likely to induce asthma in patients who take them for a long time. And aspirin, which prevents cerebral thrombosis and myocardial infarction, can inhibit the cyclooxygenase enzyme in the process of arachidonic acid metabolism, which blocks prostaglandin synthesis and increases leukotriene synthesis, leading to asthma attacks. Angiotensin-converting enzyme inhibitor (ACEI) is widely used in cardiac and renal diseases, due to the inhibition of angiotensin synthesis in the lungs, angiotensin in the lungs can diastolic bronchial, playing an important role in the maintenance of bronchial tone, once inhibited, patients can have a violent dry cough or even asthma attacks. 3, gastroesophageal reflux disease Elderly people are prone to gastroesophageal reflux due to relaxation of the cardia sphincter and surrounding tissues. Gastroesophageal reflux can flow acidic gastric juice into the tracheobronchus, causing chemical inflammation of the airway, aggravating or triggering asthma, or causing bronchospasm through the vagal reflex. It is reported that elderly patients with cough and wheezing have, through 24-hour PH measurement in the esophagus and pressure measurement in the lower esophagus. of patients had gastroesophageal reflux. 4. Recurrent upper respiratory tract infections As the immune system and local defenses decline with ageing, they are susceptible to various respiratory infections, and some viral and mycoplasma chlamydia infections can cause long-term airway inflammation and damage airway epithelial cells causing airway hyperresponsiveness and even asthma attacks. Clinical manifestations Due to the unique manifestations of asthma in the elderly, clinical symptoms are atypical and complicated, and often combined with other diseases with similar symptoms, which are easy to be misdiagnosed and missed. The following aspects should be noted in the diagnosis. In addition to the present medical history, such as smoking history, past personal and family allergy history, occupational exposure history, previous similar attacks, previous history of eczema, urticaria and allergic rhinitis, each attack trigger and relief method, cardiovascular and digestive system history should also be inquired. After taking the medical history, a careful physical examination should be performed, including pulmonary, cardiovascular and gastrointestinal signs, as well as an electrocardiogram or echocardiogram. Pulmonary function tests should be done for suspected patients Pulmonary function tests include routine pulmonary function, airway reactivity test, bronchodilatation test and peak expiratory flow rate (PEF) variability measurement. The airway responsiveness test is suitable for elderly patients with no obvious airway obstruction and no serious cardiovascular or cerebrovascular disease, while the bronchodilatation test is suitable for patients with severe airway obstruction. Peak expiratory flow rate measurement is a time-saving, easy and self-measuring method with variability; it can be considered for the diagnosis of asthma. (1) Blood and sputum eosinophil examination and blood IgE determination This test can be done in units with conditions and has some reference value for asthma diagnosis. 2.Differential diagnosis Elderly asthma should be differentiated from chronic bronchitis, obstructive emphysema, left heart failure, gastroesophageal reflux, bronchopulmonary cancer, interstitial lung fibrosis and allergic bronchopulmonary aspergillosis, etc. (1) Chronic bronchitis and obstructive emphysema Asthma often has a history of allergy and previous history of the same attacks, while chronic bronchitis only has a history of chronic cough; asthma is characterized by episodic wheezing, chest tightness, cough, and coughing up foamy sputum as the main symptoms, while chronic bronchitis is characterized by chronic cough and coughing up mucous sputum, and emphysema is characterized by shortness of breath after activity, and the signs of asthma are full lung croup, prolonged expiratory time, double lung The signs of asthma are full lung croup, prolonged expiratory time, and overinflation of both lungs, which disappear after remission, while chronic bronchitis and obstructive emphysema show predominantly wet rales, a small amount of croup and persistent emphysema signs. (2) Acute left heart failure (cardiogenic asthma) Patients with acute left heart failure often have a history of cardiovascular disease, such as hypertension, coronary artery disease, but no history of asthma attacks. In addition to dry and wet lung rales, acute left heart failure also has signs such as enlargement of the left heart, arrhythmia or heart murmur, etc. Acute left heart failure often responds poorly to asthma medication and often requires cardiac diuretics, vasodilators or morphine-based drugs to relieve the process of remission. In addition, electrocardiogram and echocardiogram can be done to identify the symptoms. (3) Bronchopulmonary carcinoma Bronchopulmonary carcinoma can invade or compress the trachea or bronchus and cause dyspnea and wheezing, and croup is heard on auscultation. (4) Pulmonary embolism (4) Pulmonary embolism Pulmonary embolism has a higher incidence in the elderly, and sudden sharp chest pain with shortness of breath, coughing and hemoptysis should be considered as a possible pulmonary embolism, which rarely shows croup in the lungs and is not effective with asthma, while asthma usually has no chest pain. Chest X-ray and chest CT examination, blood gas analysis, EEG, lung ventilation/perfusion scan can be done to differentiate. The treatment of elderly asthma is basically the same as that of young and middle-aged asthma, but the treatment of elderly asthma has its special features, such as heavy disease, many concomitant diseases and comorbidities, poor lung function, etc. Therefore, the treatment of elderly asthma should be more active and reasonable, and also take into account the treatment of concomitant diseases and comorbidities, and pay attention to the effects of therapeutic drugs on other diseases and drug interactions and contraindications. The graded treatment of modern asthma control program in China is also applicable to elderly asthma, with anti-inflammatory therapy as the main treatment, together with theophylline, β2 agonists, choline receptor blockers, etc. For patients with chronic asthma, inhalation therapy is advocated as the main treatment. 1.Adrenal glucocorticoids With the development of asthma research, glucocorticoids have become the drug of choice for asthma treatment, and are the most effective and long-lasting drugs for asthma treatment. Due to their powerful and extensive anti-inflammatory effects, they are also effective preventive drugs, with clinical effects including reducing clinical symptoms of asthma, improving peak expiratory flow and lung volume, reducing airway hyperresponsiveness, preventing acute exacerbations and preventing airway reconstruction . The mechanism of action is unclear and is mainly inhibition of cytokine production, eosinophil aggregation and release of inflammatory mediators. Glucocorticoids can be administered by nebulized inhalation, oral, intramuscular and intravenous routes, and most elderly asthmatic patients can be treated with inhaled hormones, except for those with severe disease. Usually, beclomethasone dipropionate (BDP) and budesonide (BUD) aerosol should be used at a dose of 400-1000 μg, depending on the severity of the disease and sensitivity to hormones. Since COPD is often combined with asthma in the elderly, systemic hormones can be applied for 2-3 weeks to determine the degree of reversible airway obstruction. Systemic hormone application can lead to excitement, agitation and abnormal glucose metabolism, resulting in abnormal calcium and phosphorus metabolism, which can occur even with high doses of inhaled hormones. Aggravating osteoporosis in elderly asthmatic patients, calcium and Vitmin D should be supplemented for these patients, and estrogen should be applied if necessary. 2.β2 agonists There are more β2 agonists available clinically, including salbutamol, terbutaline, procaterol, bambuterol, salmeterol and other varieties, oral, aerosol and injectable. With age, the number and function of β2 receptors decrease, and the efficacy of β2 agonists in elderly asthmatic patients decreases, while elderly people often suffer from cardiovascular diseases, tremor, palpitations The incidence of tremor and tachycardia increases, so care should be taken not to use too large doses of drugs. Theophylline is a commonly used drug for elderly asthma, commonly used varieties of aminophylline, slow-release theophylline, etc. The heart, liver and kidney function of the elderly is reduced, the metabolism and excretion of theophylline in the body is slowed down, the dose of medication should be small to medium. If possible, the blood theophylline concentration should be monitored in the process of medication, blood theophylline concentration is best at 5~10mg/L, and toxic reactions such as nausea, vomiting, headache and cardiac arrhythmia start to appear when 15mg/L or more, especially the elderly asthmatic patients with coronary heart disease are prone to serious arrhythmia. 4.Anticholinergics In the treatment of asthma attacks in the elderly, anticholinergics play an important role, often combined with β2 agonists and theophylline, which can improve the efficacy and reduce the adverse effects of β2 agonists and theophylline. The widely used variety is ipratropium bromide (AiQuanle) aerosol, 40-80μg each time, 3~4 times a day, which should be used with caution or prohibited for patients suffering from glaucoma and prostatic hyperplasia. In addition, it can also be administered by jet nebulization. Leukotriene receptor antagonists and sodium cromoglycate Leukotriene receptor antagonists include zallust (Encore) and montelukast, whose effects are to relieve bronchial asthma attacks through anti-inflammation, improve lung function, reduce the dosage of β2 agonists and glucocorticoids, zallust dosage is 20mg twice a day for 2-3 months as a course of treatment, adverse effects include headache, gastrointestinal reactions or allergic reactions The drug should not be used in combination with theophylline and terfenadine, otherwise it will reduce the efficacy.