1
ะเทศไทย
(The Thai National Guideline for Diagnosis and
Management of Childhood Asthma)
1. บทนำ
2.
3. (Treatment of
acute...
2
I บทนำ
-
)
3
มำตรฐำนจำก NHLBI
(GINA)
4
5
(goal of therapy)
1.
2. กำร
3.
)
4.
และในโรงพยำบำล
5.
6.
1.
(educate patient and establish partnership)
6
2.
ของปอด (assessment of
asthma severity)
3.
ของโรค (avoidance and control of triggers)
4.
กษำระยะยำว (establish medicat...
7
II
1. Airway inflammation
2. Increased airway responsiveness to a variety of
stimuli
3. Reversible or partial reversible...
8
ยหลอดลม
1.2
ฯลฯ
1.3
(
2.1
(forced inspiratory/expiratory wheeze)
2.2 (increased A-P
diameter)
2.3
atopic
dermatitis
9
recurrent wheezing (
3.1 (chest X-
pneumothorax, atelectasis
10
3.2 (pulmonary
function test)
1
ของ FEV1
2
Peak flow variability = PEFmax - PEFmin x
100%
1/2 (PEFmax + PEFmin)
3.3
(al...
11
3.4
(bronchoprovocation test)
croup, foreign
body, vascular ring ฯลฯ
BPD
(bronchopulmonary dysplasia) ฯลฯ
3. gastroesop...
12
(Classification
of asthma severity)
4 : (Severe persistent)
อำกำรหอบตลอดเวลำ
(Exacerbation อยมำก
PEF FEV1
60%
> 30%
3 :...
13
I (Treatment of
acute asthmatic attacks)
1.
2.
FEV1, PEFR
3. as
- inhaled 2-agonist
-
- theophylline, anticholinergic ...
14
15
asthma exacerbations
Mild Moderate Severe วะ
Respiratory
arrest
อำกำร
(Symptoms
)
หำยใจลำบำก
อำกำรแสดง
(Signs)
จ
–
–
–
...
16
air)
2. asthma
exacerbations
inhaled 2-agonist
และประ
1
asthma
exacerbations
PEF)
Inhaled short-acting 2– MDI*
17
- 2-agonists
4 – 6 ชม
24 – 48 ชม.
-
–
- 2-
2 ชม.
น
- 2-
ม กษำ
MDI
MDI
3.
18
19
asthma exacerbations
ในโรงพยำบำล ( )
-
- SaO2, PEFR, EFV1
- Inhaled short-acting 2-agonist
3 doses
- oxygen SaO2 > 95%
...
20
– Oxygen
– Bronchodilators: 2-agonist, anticholinergics,
adrenaline
– Corticosteroids
–
Oxygen
–
FEV1 PEFR
SaO2 > 95%
...
21
–
water nebulizer
2 - Agonists
– inhaled short-acting 2 -
Nebulizers
– -
PEFR
– nebulization oxygen flow
6-8 L/min
–
...
22
–
0.01
mg/kg/dose 0.3 mg
23
3 ขนำดของยำแ 2-agonist ในภำวะ
asthma exacerbations
ขนำดของยำ
Inhaled short – acting
2-gonist.
- Salbutamol nebulizer
...
24
Epinephrine
–
angioedema
– 2-
– epinephrine 0.01 mg/kg 0.01
ml/kg 0.5 mL
3 doses
Anticholinergics
– inhaled 2-
acute
...
25
Ipratropium bromide
2-agonist
ipratropium bromide nebulizer solution (0.25
mg/ml) initial
-
Combivent unit dose 2.5 cc
...
26
– Severe acute episode
corticos
-
5
asthma
exacerbations
Steroid Anti-
inflammator
y
Effect
Growth
Suppre
ssion
Effect
...
27
5 ขนำดของยำ corticosteroids
อยำ ขนำดยำ
Methylprednisolon
e (IV)
loading dose 2 มก./กก.
-
6 ชม.
Methylprednisolone
succi...
28
initial bolus dose 5 mg/kg infusion 0.5-0.9
mg/kg/hr 10-20 g/dL
– Antibiotics
sinusitis, otitis media และ pneumonia
– I...
29
–
–
–
signs, symptoms และ
functional assessment
–
–
–
–
pulse oxim
–
30
กษำในโรงพยำบำ
ล
– blood
gases โดยเฉพำะ PaCO2
5.
2
impending
respiratory failure ค
-
-
-
31
-
retraction ของ paradoxical
thoracoabdominal movement
-
ง wheeze เลย (silent chest)
-
- Pulsus paradoxus 20 mmHg
- PEF...
32
7.
-
- inhaler และ peak flow meter
-
-
-
33
IV แนวทำงก (Chronic
therapy for childhood asthma)
1 ยำขยำยหลอดลม (Bronchodilator)
acute asthma
2 (Anti-inflamma
(Preven...
34
1
-
2-
2
35
FEV1 (
(variability) ประมำณ 20-30%
: inhaled low-dose corticostero
leukotriene receptor
antagonists
-
-
oral long-actin...
36
-
-
sustained-release
theophylline, long-acting inhaled 2-
long acting oral 2-agonist
leukotriene-receptor antagonist...
37
รงของโรค
-
high-dose inhaled corticosteroid
low-dose inhaled steroid
peak flow meter
peak flow meter
38
(life-threatening asthma)
6
(long-term preventive
medications for asthma in children)
ำ
1. Inhaled
corticoster
oid
-
แล...
39
receptor
antagoni
st
กกำร
4.
Ketotifen
- (1 mg/5
ml)
- (1
mg/tab)
ขนำด
0.5 mg
bid
1 mg bid
-
-
-
-
-
-
1-3
40
3
องโรค
ยะยำว
(Long-term Preventive) (Quick-Relief)
4   short acting 2- ลดลง (Step
down)
 inhaled medium-to-
high do...
41
- sustained-release theophylline
- long-acting oral 2- agonist
- leukotriene-receptor antagonist
2  inhaled low dose c...
42
7 ขนำดของ corticosteroid
Types of corticosteroids Low dose
(g)
Medium
dose
(g)
High
dose
(g)
Beclomethasone
-MDI (50...
43
-
MDI with spacer
DPI
MDI with or without spacer
DPI
MDI = metered-dose inhaler
DPI = dry powder inhaler
IV
1. Primary ...
44
ก. มำ
25-30
ข. และ
1.2.1. (Indoor environment)
1.2.2. (Outdoor environment)
1.2.3.
1.2.4.
45
1.2.5
1.2.6
1)
2)
1.2.7. อำหำรและโภชนำกำร
-
46
indo
2. Secondary prevention
1.
2.
1.
10
2.
3.
(identify and avoid triggers)
1. house dust mite)
47
2. สำบ
3.
4.
5.
6.
7.
8.
9.
48
19
550
ทำควำมส
)
(exterminator)
49
HEPA (high efficiency
particulate air
สำมำรถก
50
- long-acting
cromolyn
-
- -
51
I. บทนำ
1. National Heart, Lung and Blood Institute, National
Institutes of Health. Global initiative for Asthma.
NIH/N...
52
1. National Heart, Lung and Blood Institute, National
Institutes of Health. Global initiative for Asthma.
NIH/NHLBI pub...
53
Anticholinergic Agents in Acute Asthma
1. Brian J L. Treatment of acute asthma. Lancet
1997;350(suppl II):18-23.
2. O'D...
54
1. Janson C. Plasma levels and effects of salbutamol after
inhaled or iv administration for stable asthma. Eur Respir
J...
55
acute exacerbation of asthma. Ann Intern Med 1993; 119:
1155-60.
8. DiGiulio G, Kercsmar C, Krug S, Alpert S, Marx C.
H...
56
American Academy of Allergy, Asthma, and Immunology,
The American College of Allergy, Asthma, and
Immunologyand the Joi...
57
wheezing disorders. London: Chapman & Hill, 1995:357-
74.
58
V. ด
1. National Heart, Lung and Blood Institute, National
Institutes of Health. Global initiative for Asthma.
NIH/NHLB...
59
1.
2.
1.
2.
3.
4.
3.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
60
13.
14.
15.
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Asthma guideline for children

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Asthma guideline for children

  1. 1. 1 ะเทศไทย (The Thai National Guideline for Diagnosis and Management of Childhood Asthma) 1. บทนำ 2. 3. (Treatment of acute exacerbations) 4. (Chronic therapy for childhood asthma) 5. (Prevention of asthma) ร
  2. 2. 2 I บทนำ - )
  3. 3. 3 มำตรฐำนจำก NHLBI (GINA)
  4. 4. 4
  5. 5. 5 (goal of therapy) 1. 2. กำร 3. ) 4. และในโรงพยำบำล 5. 6. 1. (educate patient and establish partnership)
  6. 6. 6 2. ของปอด (assessment of asthma severity) 3. ของโรค (avoidance and control of triggers) 4. กษำระยะยำว (establish medication plans for long- term management) 5. กำรวำง (establish plans for managing exacerbations) 6. (provide regular follow-up care)
  7. 7. 7 II 1. Airway inflammation 2. Increased airway responsiveness to a variety of stimuli 3. Reversible or partial reversible airway obstruction 1. 2. กษำ (reversible airway obstruction) 3. ด (wheeze) โดย 1.1
  8. 8. 8 ยหลอดลม 1.2 ฯลฯ 1.3 ( 2.1 (forced inspiratory/expiratory wheeze) 2.2 (increased A-P diameter) 2.3 atopic dermatitis
  9. 9. 9 recurrent wheezing ( 3.1 (chest X- pneumothorax, atelectasis
  10. 10. 10 3.2 (pulmonary function test) 1 ของ FEV1 2 Peak flow variability = PEFmax - PEFmin x 100% 1/2 (PEFmax + PEFmin) 3.3 (allergy skin prick test)
  11. 11. 11 3.4 (bronchoprovocation test) croup, foreign body, vascular ring ฯลฯ BPD (bronchopulmonary dysplasia) ฯลฯ 3. gastroesophageal reflux (GER), congestive heart failure ฯลฯ (Classification of asthma by severity) NHLBI (National Heart Lung and Blood I (intermitte 1)
  12. 12. 12 (Classification of asthma severity) 4 : (Severe persistent) อำกำรหอบตลอดเวลำ (Exacerbation อยมำก PEF FEV1 60% > 30% 3 : (Moderate persistent) อำ (Exacerbation 2- agonist PEF FEV1 >60% - <80% >30% 2 : (mild persistent) (Exacerbation PEF FEV1 80% 20-30% 1: (Intermittent) (Exacerbation exacerbation PEF FEV1 80% <20%
  13. 13. 13 I (Treatment of acute asthmatic attacks) 1. 2. FEV1, PEFR 3. as - inhaled 2-agonist - - theophylline, anticholinergic drug ฯลฯ - 4. asthma exacerbations 1. asthma exacerbations
  14. 14. 14
  15. 15. 15 asthma exacerbations Mild Moderate Severe วะ Respiratory arrest อำกำร (Symptoms ) หำยใจลำบำก อำกำรแสดง (Signs) จ – – – หำยใจ wheeze หำยใจออก wheeze ) < 100 100 – 120 > 120 – – – Pulsus paradoxus (< 10 mm Hg) (10–25 mm Hg) – ศษ (Functional Assessment) PEF % predicted or % personal best > 80% ประมำณ 50– 80% < 50% PaO2 (on air) > 60 mm Hg < 60 mm Hg PaCO2 < 42 mm Hg < 42 mm Hg > 42 mm Hg SaO2% (on > 95% 91 – 95% < 91%
  16. 16. 16 air) 2. asthma exacerbations inhaled 2-agonist และประ 1 asthma exacerbations PEF) Inhaled short-acting 2– MDI*
  17. 17. 17 - 2-agonists 4 – 6 ชม 24 – 48 ชม. - – - 2- 2 ชม. น - 2- ม กษำ MDI MDI 3.
  18. 18. 18
  19. 19. 19 asthma exacerbations ในโรงพยำบำล ( ) - - SaO2, PEFR, EFV1 - Inhaled short-acting 2-agonist 3 doses - oxygen SaO2 > 95% - systemic corticosteroid - อำกำร, อำกำรแสดง - SaO2, PEFR, FEV1 - inhaled short-acting 2- agonist - systemic corticosteroid - - - inhaled short-acting 2-agonist continuous nebulization inhaled anticholinergic - oxygen - systemic corticosteroid - distress - SaO2 > 95% - PEF > 70% ง - - SaO2 < 95% - PEF 50% - 70% - - PEF < 30% - PCO2 > 45 mm Hg - SaO2 < 90% - PaO2 < 60 mm Hg Discharge - inhaled 2- agonist systemic corticoste short course - กษำ - ล - inhaled 2-agonist - oxygen - systemic corticosteroid - anticholinergic - theophylline intensive care - inhaled 2-agonist - systemic corticosteroid - oxygen - systemic 2-agonist: SC, IV, IM - continuous 2-agonist IV theophylline - anticholinergic -
  20. 20. 20 – Oxygen – Bronchodilators: 2-agonist, anticholinergics, adrenaline – Corticosteroids – Oxygen – FEV1 PEFR SaO2 > 95% – face mask – SaO2
  21. 21. 21 – water nebulizer 2 - Agonists – inhaled short-acting 2 - Nebulizers – - PEFR – nebulization oxygen flow 6-8 L/min – Metered-dose inhaler (MDI) with spacer – - bronchodilatation nebulizers Injection
  22. 22. 22 – 0.01 mg/kg/dose 0.3 mg
  23. 23. 23 3 ขนำดของยำแ 2-agonist ในภำวะ asthma exacerbations ขนำดของยำ Inhaled short – acting 2-gonist. - Salbutamol nebulizer solution - - - continuous nebulization selective 2- 2.5 – 4 6-8 L/min - Salbutamol MDI (100 g/puff) - - Systemic (injected) 2- agonists - Terbutaline - aerosol therapy
  24. 24. 24 Epinephrine – angioedema – 2- – epinephrine 0.01 mg/kg 0.01 ml/kg 0.5 mL 3 doses Anticholinergics – inhaled 2- acute exacerbation – inhaled 2- severe airflow obstruction (Ipratropium bromide - Atroven Beta2- salbutamol)
  25. 25. 25 Ipratropium bromide 2-agonist ipratropium bromide nebulizer solution (0.25 mg/ml) initial - Combivent unit dose 2.5 cc ½ unit dose/ 10 kgs anticholinergics (hypertrophic subaortic stenosi atropine Corticosteroids acute asthmatic a – inhaled 2-agonists – inhaled 2- 3-4 inhaled 2-
  26. 26. 26 – Severe acute episode corticos - 5 asthma exacerbations Steroid Anti- inflammator y Effect Growth Suppre ssion Effect Salt- retaining Effect Plasma Half-life (min) Biologi cal Half-life (hr) Hydrocortison e 1.0 1.0 1.0 80-120 8 Prednisolone 4 7.5 0.8 120-300 16-36 Methylprednis olone 5 7.5 0.5 120-300 16-36 Dexamethaso ne 30 80 0 150-300 36-54
  27. 27. 27 5 ขนำดของยำ corticosteroids อยำ ขนำดยำ Methylprednisolon e (IV) loading dose 2 มก./กก. - 6 ชม. Methylprednisolone succinate (Solu-Medrol ) 40 mg/1 ml = 159 บำท 125 mg/ 2 ml = 336 บำท Hydrocortisone (IV) loading dose 5-7 มก./กก. 4-6 ชม. Hydrocortisone succinate (Solu-Cortef ) 100 mg/2 ml = 50 บำท Prednisolone (oral) - - 1 tablet = 5 mg Other treatments – Theophylline first line drug acute asthmatic attack therapeutic index side effect inhaled 2- asthmatic attack
  28. 28. 28 initial bolus dose 5 mg/kg infusion 0.5-0.9 mg/kg/hr 10-20 g/dL – Antibiotics sinusitis, otitis media และ pneumonia – I – C – S 4. asthma exacerbations – –
  29. 29. 29 – – – signs, symptoms และ functional assessment – – – – pulse oxim –
  30. 30. 30 กษำในโรงพยำบำ ล – blood gases โดยเฉพำะ PaCO2 5. 2 impending respiratory failure ค - - -
  31. 31. 31 - retraction ของ paradoxical thoracoabdominal movement - ง wheeze เลย (silent chest) - - Pulsus paradoxus 20 mmHg - PEF 50% ของ predicted/personal base value - PaO2 - PaCO2 42 mmHg - SaO2 room air 90% - pneumomediastinum 6. emergency department Criteria - - peak expiratory flow personal base value Medications - -
  32. 32. 32 7. - - inhaler และ peak flow meter - - -
  33. 33. 33 IV แนวทำงก (Chronic therapy for childhood asthma) 1 ยำขยำยหลอดลม (Bronchodilator) acute asthma 2 (Anti-inflamma (Preventer, Controller) - 6)
  34. 34. 34 1 - 2- 2
  35. 35. 35 FEV1 ( (variability) ประมำณ 20-30% : inhaled low-dose corticostero leukotriene receptor antagonists - - oral long-acting 2- 3 FEV1 - 30%
  36. 36. 36 - - sustained-release theophylline, long-acting inhaled 2- long acting oral 2-agonist leukotriene-receptor antagonist 4 FEV1 ≤ 30 % - - inhaled long-acting 2-agonist, sustained-release theophylline, long-acting oral 2-agonist, leukotriene-receptor antagonist ตลอดเวลำ อ
  37. 37. 37 รงของโรค - high-dose inhaled corticosteroid low-dose inhaled steroid peak flow meter peak flow meter
  38. 38. 38 (life-threatening asthma) 6 (long-term preventive medications for asthma in children) ำ 1. Inhaled corticoster oid - และคว 2) - - - - ดม - ) 2. Cromolyn sodium - nebulized (20 mg/2ml) - - MDI (1และ 5 mg/puff) - - - - ก - กกำร - รำคำแพง - - 3. Leukotrie ne - - - - รำคำแพง -
  39. 39. 39 receptor antagoni st กกำร 4. Ketotifen - (1 mg/5 ml) - (1 mg/tab) ขนำด 0.5 mg bid 1 mg bid - - - - - - 1-3
  40. 40. 40 3 องโรค ยะยำว (Long-term Preventive) (Quick-Relief) 4   short acting 2- ลดลง (Step down)  inhaled medium-to- high dose มำก (severe corticosteroid persistent) - long-acting inhaled 2--agonist จำรณำลด - sustained-release theophylline ขนำดและจำนวนยำลง - long-acting oral 2- agonist - leukotriene-receptor antagonist  prednisolone 3  inhaled medium-dose corticosteroid  short acting 2- (Step up) ปำนกลำง  inhaled low-dose corticosteroid - (moderate persistent) - long-acting inhaled 2- agonist
  41. 41. 41 - sustained-release theophylline - long-acting oral 2- agonist - leukotriene-receptor antagonist 2  inhaled low dose corticosteroid  short acting 2 (mild  inhaled cromolyn sodium - persistent)  sustained-release theophylline  leukotriene-receptor antagonist  ketotifen 1   short acting 2- - (intermittent inhaled 2- inhaled asthma)
  42. 42. 42 7 ขนำดของ corticosteroid Types of corticosteroids Low dose (g) Medium dose (g) High dose (g) Beclomethasone -MDI (50,250 g) -Diskhaler (100,200,400 g) 100-400 400-600 >600 Budesonide -Turbuhaler (100,200 g) -MDI (50, 100,200 g) -Nebulized solution (500,1000 g) 100-200 100-400 - 200-400 400-600 1,000-2000 >400 >600 >2,000 Fluticasone (MDI 25,125,250 g) 50-200 200-300 >300 8 nebulizer MDI with spacer (with mask)
  43. 43. 43 - MDI with spacer DPI MDI with or without spacer DPI MDI = metered-dose inhaler DPI = dry powder inhaler IV 1. Primary prevention
  44. 44. 44 ก. มำ 25-30 ข. และ 1.2.1. (Indoor environment) 1.2.2. (Outdoor environment) 1.2.3. 1.2.4.
  45. 45. 45 1.2.5 1.2.6 1) 2) 1.2.7. อำหำรและโภชนำกำร -
  46. 46. 46 indo 2. Secondary prevention 1. 2. 1. 10 2. 3. (identify and avoid triggers) 1. house dust mite)
  47. 47. 47 2. สำบ 3. 4. 5. 6. 7. 8. 9.
  48. 48. 48 19 550 ทำควำมส ) (exterminator)
  49. 49. 49 HEPA (high efficiency particulate air สำมำรถก
  50. 50. 50 - long-acting cromolyn - - -
  51. 51. 51 I. บทนำ 1. National Heart, Lung and Blood Institute, National Institutes of Health. Global initiative for Asthma. NIH/NHLBI publication no 95-3659. Washington DC:NIH;1995. 2. National Heart, Lung and Blood Institute, National Institutes of Health. Guidelines for the diagnosis and management of asthma. Expert panel report 2. NIH/NHLBI publication no. 97-4051. Washington DC:NIH:1997. 3. Vichyanond P, Jirapongsananuruk O, Visitsuntorn N, Tuchinda M. Prevalence of asthma, rhinitis, and eczema in children from the Bangkok area using the ISAAC (International study for asthma and allergy in children) questionnaires. J Med Assoc Thai 1998;81:175-81. 4. Vichyanond P, et al. Guidelines on the diagnosis and treatment of childhood asthma in Thailand. Thai J Pediatrics 1995;34:3:194-211. 5. Sullivan SD. Cost and cost-effectiveness in asthma. Immunol Allergy Clin N America 1996;16:819-38. II.
  52. 52. 52 1. National Heart, Lung and Blood Institute, National Institutes of Health. Global initiative for Asthma. NIH/NHLBI publication No 96-3659. Washington DC:NIH;1998. 2. National Heart, Lung and Blood Institute, National Institutes of Health. Guidelines for the diagnosis and management of asthma. Expert panel report 2. NIH/NHLBI publication No. 97-4051. Washington DC:NIH:1997. III. 1. National Heart, Lung and Blood Institute, National Institutes of Health. Guidelines for the diagnosis and management of asthma. Expert panel report 2. NIH/NHLBI publication No. 97-4051. Washington DC:NIH:1997. 2. Global NHLBI/WHO Workshop Report: Global Strategy for Asthma Management and Prevention. NIH Publication No. 96-3659A. December 1995
  53. 53. 53 Anticholinergic Agents in Acute Asthma 1. Brian J L. Treatment of acute asthma. Lancet 1997;350(suppl II):18-23. 2. O'Driscoll RB, Taylor RJ, Horsley MG, Chambers DK, Bernstein A. Nebulised salbutamol with and without ipratropium bromide in acute airflow obstruction. Lancet 1989;i:1418-20. 3. Schuh S, Johnson DW, Callahan S, Cally G, Levison H. Effects of frequent nebulised ipratropium bromide added to frequent high dose albuterol therapy in severe childhood asthma. J Paediatr 1995;126:639-45. 4. Karpel JP, Schacter NE, Fanta C, et al. A comparison of ipratropium and albuterol versus albuterol alone for the treatment of acute asthma. Chest 1996;110:611-16. 5. Fitzgerald MK, Grunfeld A, Parae PD, et al. The clinical efficacy of combination nebulised anticholinergic and adrenergic bronchodilators versus nebulised adrenergic bronchodilator alone in acute asthma. Chest 1997;111:311-15. Intravenous bronchodilator therapy for acute asthmatic attack
  54. 54. 54 1. Janson C. Plasma levels and effects of salbutamol after inhaled or iv administration for stable asthma. Eur Respir J 1991;4:544-50. 2. Swedish Society of Chest Medicine. High dose inhaled versus intravenous salbutamol combined with theophylline in severe acute asthma. Eur Respir J 1990;3:163-70. 3. Salmeron S, Brochard L, Mal H, et al. Nebulised versus intravenous albuterol in hypercapnic acute asthma. Am J Respir Crit Care Med 1994;149:1466-70. 4. Cheong B, Reynolds SR, Rajan G, Ward MJ. Intravenous 2-agonist in severe acute asthma. BMJ 1988;297:448- 50. 5. Browne GJ, Penna AS, Phung X, Soo M. Randomised trial of intravenous salbutamol in early management of acute severe asthma in children. Lancet 1997; 349: 301- 05. 6. Murphy DG, McDermott MF, Rydman RJ, Sloan EP, Zalenski RJ. Aminophylline in the treatment of acute asthma when -adrenergics and steroids are provided. Arch Intern Med 1993;153:1784-88. 7. Huang D, O'Brien RG, Harman E, et al. Does aminophylline benefit adults admitted to the hospital in
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