CPG asthma Thailand 2551

2. ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢
°“√¥Ÿ·≈ºŸâªÉ«¬‚√§À◊¥ æ.». 2551

3. ™Ë◊ÕÀπ—ß ◊Õ : ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ : §”π”
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
‚√§À◊¥‡ªìπªí≠À“ “Π“√≥ ÿ¢Σ’Ë ”§—≠„πª√–‡Σ»‰Σ¬ ¡’·π«‚πâ¡Σ’Ë®–æ∫
·≈–Σ«’§«“¡√ÿπ·√ß¡“°¢÷Èπ ªí≠À“Σ’Ëæ∫§◊Õ °“√«‘π‘®©—¬‚√§ ¡’§«“¡¬ÿà߬“°
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Õ“»—¬Õ”π“®μ“¡¡“μ√“ 26(8) °”°—∫Àπ૬∫√‘°“√·≈–‡§√◊Õ¢à“¬Àπ૬∫√‘°“√
„π°“√„Àâ∫√‘°“√ “Π“√≥ ÿ¢„À⇪ìπ‰ªμ“¡¡“μ√∞“πΣ’Ë§≥–°√√¡°“√°”Àπ¥
¡“μ√“ 50(1) §«∫§ÿ¡§ÿ≥¿“æ·≈–¡“μ√∞“πÀπ૬∫√‘°“√·≈–‡§√◊Õ¢à“¬
Àπ૬∫√‘°“√ (3) °”Àπ¥¡“μ√°“√§«∫§ÿ¡·≈– à߇ √‘¡§ÿ≥¿“æ·≈–¡“μ√∞“π
Àπ૬∫√‘°“√·≈–‡§√◊Õ¢à“¬Àπ૬∫√‘°“√ ·Ààßæ√–√“™∫—≠≠—μ‘À≈—°ª√–°—π ÿ¢¿“æ
·Ààß™“μ‘ æ.».2545 ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘√à«¡°—∫ ¡“§¡
¿“Õߧå°√‚√§À◊¥·Ààߪ√–‡Σ»‰Σ¬‰¥âæ—≤π“·π«Σ“߇«™ªØ‘∫—μ‘‚√§À◊¥ ”À√—∫
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∫√‘°“√ “Π“√≥ ÿ¢©∫—∫π’ȇªìπ‡æ’¬ß·π«Σ“ß°“√«‘π‘®©—¬·≈–√—°…“ºŸâªÉ«¬‡Σà“π—Èπ
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‰¥â√—∫ª√–‚¬™πå Ÿß ÿ¥
”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘ ¢Õ¢Õ∫§ÿ≥ ¡“§¡ ¿“Õߧå°√
‚√§À◊¥·Ààߪ√–‡Σ»‰Σ¬·≈–Õߧå°√Σ’Ë‡°’ˬ«¢âÕß Σ’Ë‰¥âæ—≤π“·π«Σ“ß°“√«‘π‘®©—¬
·≈–√—°…“‚√§À◊¥„πª√–‡Σ»‰Σ¬ ‡æ◊ËÕ„ÀâÀπ૬∫√‘°“√·≈–‡§√◊Õ¢à“¬Àπ૬
∫√°‘“√„™‡âªπì·π«Σ“ß„π°“√¥·Ÿ≈ √°—…“ ºªâŸ«É¬‚√§À¥◊Σ¡Ë’§’≥ÿ¿“æ·≈–¡“μ√∞“π
·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºŸâªÉ«¬‚√§À◊¥ æ.». 2551
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(𓬷æΣ¬å«‘π—¬ «— ¥‘«√)
‡≈¢“Π‘°“√ ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘
З𫓧¡ 2551
°“√¥Ÿ·≈ºŸâªÉ«¬‚√§À◊¥ æ.». 2551
æ‘¡æå§√—ÈßΣ’Ë 1 ‡¡…“¬π 2552
®”π«πæ‘¡æå 5,000 ‡≈à¡
¢âÕ¡Ÿ≈Σ“ß∫√√≥“πÿ°√¡¢Õß ”π—°ÀÕ ¡ÿ¥·Ààß™“μ‘
National Library of Thailand Cataloging in Publication Data
§≥–°√√¡°“√ª√—∫ª√ÿß·π«Σ“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥ æ.». 2551.
·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ : °“√¥Ÿ·≈ºŸâªÉ«¬‚√§À◊¥ æ.». 2551.--
°√ÿ߇Σæ¡À“π§√ : ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘, 2552
118 Àπâ“.
1. À◊¥--ºŸâªÉ«¬--°“√¥Ÿ·≈. 2. ‚√§À◊¥--ºŸâªÉ«¬--°“√√—°…“. I. ™◊ËÕ‡√◊ËÕß.
616.238
ISBN 978-611-7197-01-7
ß«π ‘ΣΠ‘Ïμ“¡æ√–√“™∫—≠≠—μ‘
®—¥æ‘¡æå‚¥¬ :
”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘ ( ª ™.)
120 À¡Ÿà 3 ™—Èπ 2-4 Õ“§“√√«¡Àπ૬√“™°“√
统π¬å√“™°“√‡©≈‘¡æ√–‡°’¬√μ‘ ¯ æ√√…“ ı З𫓧¡ Úııé
∂.·®âß«—≤π– ·¢«ßΣÿàß ÕßÀâÕß ‡¢μÀ≈—° ’Ë °√ÿ߇Σæ¡À“π§√ 10210
‚Σ√ 0-2141-4000 ‚Σ√ “√ 0-2143-9730
www.nhso.go.th
æ‘¡æåΣ’Ë : ∫√‘…—Σ »√’‡¡◊Õß°“√æ‘¡æå ®”°—¥
‚Σ√ 0-2214-4660 ‚Σ√ “√ 0-2612-4509

4. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡Σ»‰Σ¬‰¥â®—¥Σ”·π«Σ“ß°“√«‘π‘®©—¬·≈–√—°…“
‚√§À◊¥„πª√–‡Σ»‰Σ¬ ( ”À√—∫ºŸâªÉ«¬ºŸâ„À≠à) ©∫—∫Σ’Ë 3 ¢÷Èπ„πªï æ.». 2547
·≈–‰¥âæ‘¡æ出¬·æ√à„Àâ·æΣ¬åΣ—Ë«‰ª√«¡Σ—Èß∫ÿ§§≈Σ’Ë‡°’ˬ«¢âÕß„π°“√¥Ÿ·≈√—°…“
ºªâŸ«É¬‚√§À¥◊ ´ßË÷‰¥√â∫—§«“¡ π„®‡ªπìÕ¬“àß¡“° ®“°°“√Σ·Ë’æΣ¬å„π¿¡Ÿ¿‘“§μ“àßÊ
Σ—Ë«ª√–‡Σ» ‰¥âπ”·π«Σ“ß°“√«‘π‘®©—¬oe ¥—ß°≈à“«‰ª„™â ·≈–æ∫«à“°“√√—°…“‚¥¬
°“√®—¥¬“μ“¡§«“¡√ÿπ·√ߢÕß‚√§¬ÿà߬“° Σ”„Àâ·æΣ¬åºŸâ√—°…“ªØ‘∫—μ‘μ“¡
·π«Σ“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥‰¥â‰¡à ¡∫Ÿ√≥å √«¡Σ—Èß°“√Σ’Ë¡’¢âÕ¡Ÿ≈„À¡àÊ
Σ’Ë‰¥â®“°°“√«‘®—¬‡°’ˬ«°—∫°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§À◊¥‡æ‘Ë¡¢÷Èπ ¡“§¡Õÿ√‡«™™å
·Ààߪ√–‡Σ»‰Σ¬ √à«¡°—∫ ¡“§¡‚√§¿Ÿ¡‘·æâ·≈–Õ‘¡¡Ÿ‚π«‘Σ¬“·Ààߪ√–‡Σ»‰Σ¬
√“™«‘Σ¬“≈—¬Õ“¬ÿ√·æΣ¬å·Ààߪ√–‡Σ»‰Σ¬ √“™«‘Σ¬“≈—¬°ÿ¡“√·æΣ¬å·Ààߪ√–‡Σ»
‰Σ¬ √“™«‘Σ¬“≈—¬·æΣ¬å‡«™»“ μ√å§√Õ∫§√—«·Ààߪ√–‡Σ»‰Σ¬ ¡“§¡ ¿“Õߧå°√
‚√§À◊¥·Ààߪ√–‡Σ»‰Σ¬ ·≈– ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘ ®÷ß®—¥„Àâ¡’
°“√ª√–™¡ÿ‡æÕË◊Σ”·π«Σ“ß°“√«π‘®‘©¬—·≈–√°—…“‚√§À¥◊ ΣßÈ—‡¥°Á·≈–ºâŸ„À≠ à©∫∫—ªï
æ.». 2551 ¢÷Èπ„À¡à ‚¥¬¡’«—μ∂ÿª√– ߧåΣ’Ë®–„À⇪ìπ·π«Σ“ß°“√«‘π‘®©—¬·≈–
√—°…“‚√§À◊¥Σ’Ëßà“¬·≈– “¡“√∂𔉪„™â„π‡«™ªØ‘∫—쑉¥âÕ¬à“ß¡’ª√– ‘ΣΠ‘¿“æ
„ππ“¡¢Õß ¡“§¡Õÿ√‡«™™å·Ààߪ√–‡Σ»‰Σ¬ ¡“§¡‚√§¿Ÿ¡‘·æâ·≈–Õ‘¡¡Ÿ‚π
«‘Σ¬“·Ààߪ√–‡Σ»‰Σ¬ √“™«‘Σ¬“≈—¬Õ“¬ÿ√·æΣ¬å·Ààߪ√–‡Σ»‰Σ¬ √“™«‘Σ¬“≈—¬
°ÿ¡“√·æΣ¬å·Ààߪ√–‡Σ»‰Σ¬ √“™«‘Σ¬“≈—¬·æΣ¬å‡«™»“ μ√å§√Õ∫§√—«·Ààß
ª√–‡Σ»‰Σ¬ ¡“§¡ ¿“Õߧå°√‚√§À◊¥·Ààߪ√–‡Σ»‰Σ¬ ¢Õ¢Õ∫§ÿ≥«‘Σ¬“°√
√«¡Σ—ÈߺŸâ¡’ à«π‡°’ˬ«¢âÕßΣÿ°Σà“π·≈– ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘
Σ’Ë„Àâ°“√ π—∫ πÿπ°“√¥”‡π‘π°“√®—¥Σ”·π«Σ“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥
©∫—∫„À¡àπ’È ”‡√Á®≈ÿ≈à«ß‰ª‰¥â¥â«¬¥’
·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºŸâªÉ«¬‚√§À◊¥ æ.». 2551
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5. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
‚√§À¥◊‡ªπì‚√§Σ¡Ë’ ’Chronic inflammation ¢Õߺπß—Σ“ß‡¥π‘À“¬„® °“√Σ¡Ë’’
chronic inflammation ‡ªìπ√–¬–‡«≈“π“π Σ”„Àâ¡’°“√‡ª≈’ˬπ·ª≈ßΣ’Ëºπ—ß
À≈Õ¥≈¡Σ’ˇ√’¬°«à“ airway remodeling ·≈– airway remodeling π’È Σ”„Àâ
Σ“ß‡¥‘πÀ“¬„®¡’§«“¡‰« Ÿß¢÷Èπ (airway hyper-responsiveness) Σ“ß‡¥‘π
À“¬„®Σ’Ëμ’∫·§∫≈ßπ’ȇ§¬‡™◊ËÕ«à“Õ“®°≈—∫‡ªìπª°μ‘‰¥âπ—Èπ æ∫«à“À≈Õ¥≈¡Σ’Ëμ’∫
·§∫≈ß∫“ß à«π®–‰¡à¢¬“¬°≈—∫¡“‡À¡◊Õπª°μ‘·≈â«
ªí®®ÿ∫—π°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„π‡¥Á°‰¥â¡’°“√æ—≤𓉪¡“° ‚¥¬Õ“»—¬
À≈—°∞“πΣ“ß«‘Σ¬“»“ μ√åΣ’Ëπà“‡™◊ËÕ∂◊Õ √“™«‘Σ¬“≈—¬°ÿ¡“√·æΣ¬å·Ààߪ√–‡Σ»‰Σ¬
‡ÀÁπ ¡§«√Σ’Ë®–·π–π”·π«Σ“ß°“√¥Ÿ·≈ºŸâªÉ«¬ ‡æ◊ËÕ„Àâ·æΣ¬åºŸâ¥Ÿ·≈ºŸâªÉ«¬‡¥Á°
‚√§À¥◊‰¥æ⮑“√≥“«Π‘°’“√√°—…“ ”À√∫—ºªâŸ«É¬ ´ßË÷Õ“®¡ ’¿“æ°“√‡®∫Áª«É¬μ“àß°π—‰ª
„π·μà≈–√“¬μ“¡§«“¡‡À¡“– ¡
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√ÿπ·√ßÕ“®®–ªÑÕß°—π¡‘„À⺟âªÉ«¬¡’Õ“°“√¢Õß‚√§Σ“߇¥‘πÀ“¬„®∫“ß à«πμ’∫μ—π
Õ¬à“ß∂“«√ (irreversible airway obstruction)
√“™«‘Σ¬“≈—¬°ÿ¡“√·æΣ¬å·Ààߪ√–‡Σ»‰Σ¬ ¢Õ¢Õ∫§ÿ≥§≥–°√√¡°“√®—¥Σ”
§Ÿà¡◊Õoe ‰«â ≥ ‚Õ°“ π’È
»“ μ√“®“√¬å‡°’¬√쑧ÿ≥𓬷æΣ¬å ¡»—°¥‘Ï ‚≈àÀå‡≈¢“
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·≈–√—°…“‚√§À◊¥„πª√–‡Σ»‰Σ¬ ”À√—∫ºŸâªÉ«¬‡¥Á°
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𓬰 ¡“§¡Õÿ√‡«™™å 𓬰 ¡“§¡‚√§¿Ÿ¡‘·æâ·≈–
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ª√–Π“π√“™«‘Σ¬“≈—¬°ÿ¡“√·æΣ¬å·Ààߪ√–‡Σ»‰Σ¬
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ª√–Π“π√“™«‘Σ¬“≈—¬Õ“¬ÿ√·æΣ¬å·Ààߪ√–‡Σ»‰Σ¬
(𓬷æΣ¬å¢®‘μ ™Ÿªí≠≠“)
ª√–Π“π√“™«‘Σ¬“≈—¬·æΣ¬å‡«™»“ μ√å§√Õ∫§√—«·Ààߪ√–‡Σ»‰Σ¬
(»“ μ√“®“√¬å𓬷æΣ¬åª√–æ“à ¬ß„®¬ÿΣΠ)
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6. §”™’È·®ßπÈ”Àπ—°§”·π–π”·≈–§ÿ≥¿“æÀ≈—°∞“π
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
πÈ”Àπ—°§”·π–π” (Strength of Recommendation)
πÈ”Àπ—°§”·π–π” ++ À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õߧ”·π–π”„ÀâΣ”Õ¬Ÿà
„π√–¥—∫ Ÿß ‡æ√“–¡“μ√°“√¥—ß°≈à“«¡’ª√–‚¬™πå
Õ¬à“߬‘ËßμàÕºŸâªÉ«¬·≈–§ÿâ¡§à“ (cost effective)
秫√Σ”é
πÈ”Àπ—°§”·π–π” + À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õߧ”·π–π”„ÀâΣ”Õ¬Ÿà„π
√–¥—∫ª“π°≈“ß ‡π◊ËÕß®“°¡“μ√°“√¥—ß°≈à“«Õ“®
¡ª’√–‚¬™πμåÕສ⟫ɬ·≈–Õ“®§¡âÿ§“à„π¿“«–®”‡æ“–
çπà“Σ”é
πÈ”Àπ—°§”·π–π” +/- À¡“¬∂÷ß §«“¡¡—Ëπ„®¬—߉¡à‡æ’¬ßæÕ„π°“√„À⧔
·π–π” ‡π◊ËÕß®“°¡“μ√°“√¥—ß°≈à“«¬—ß¡’À≈—°∞“π
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À√◊ÕÕ“®‰¡à¡’ª√–‚¬™πåμàÕºŸâªÉ«¬ ·≈–Õ“®‰¡à§ÿ⡧à“
·μà‰¡à°àÕ„À⇰‘¥Õ—πμ√“¬μàÕºŸâªÉ«¬‡æ‘Ë¡¢÷Èπ ¥—ßπ—Èπ
°“√μ¥— π‘„®°√–Σ”¢πÈ÷Õ¬°àŸ∫—ª®í®¬—ÕπË◊ Ê çÕ“®Σ”
À√◊Õ‰¡àΣ”é
πÈ”Àπ—°§”·π–π” - À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õߧ”·π–π”Àâ“¡Σ”Õ¬Ÿà„π
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ª√–‚¬™πåμàÕºŸâªÉ«¬·≈–‰¡à§ÿâ¡§à“ À“°‰¡à®”‡ªìπ
牡àπà“Σ”é
πÈ”Àπ—°§”·π–π” - - À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õߧ”·π–π”Àâ“¡Σ”Õ¬Ÿà„π
√–¥—∫ Ÿß ‡æ√“–¡“μ√°“√¥—ß°≈à“«Õ“®‡°‘¥‚Σ…
À√◊Õ°àÕ„À⇰‘¥Õ—πμ√“¬μàÕºŸâªÉ«¬ 牡৫√Σ”é
À≈—°°“√¢Õß ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢
°“√¥Ÿ·≈ºŸâªÉ«¬‚√§À◊¥ æ.». 2551
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·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºŸâªÉ«¬‚√§À◊¥ æ.». 2551 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºŸâªÉ«¬‚√§À◊¥ æ.». 2551
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°“√∫√‘°“√√—°…“‚√§À◊¥Σ’ˇÀ¡“– ¡°—∫Σ√—欓°√·≈–¢âÕ®”°—¥¢Õß —ߧ¡„π
ª√–‡Σ»‰Σ¬ ‚¥¬¡’«—μ∂ÿª√– ߧåΣ’Ë®–§«∫§ÿ¡Õ“°“√¢Õß‚√§·≈–Σ”„À⺟âªÉ«¬
¡’§ÿ≥¿“æ™’«‘μ¥’¢÷Èπ ‚¥¬°“√„Àâ°“√√—°…“Σ’Ë¡’ª√– ‘ΣΠ‘¿“æ·≈–§ÿâ¡§à“ ¢âÕ·π–π”
μà“ß Ê „π·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢©∫—∫π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘
ºâŸ„™ â“¡“√∂ªØ∫‘μ—·‘μ°μ“à߉ª®“°¢Õâ·π–π”πÈ’‰¥ â„π°√≥Σ’ Ë’∂“π°“√≥·åμ°μ“àß
ÕÕ°‰ª À√◊Õ¡’¢âÕ®”°—¥¢Õß ∂“π∫√‘°“√·≈–Σ√—欓°√À√◊Õ¡’‡Àμÿº≈Σ’Ë ¡§«√
Õ◊Ëπ Ê ‚¥¬„™â«‘®“√≥≠“≥´÷Ë߇ªìπΣ’Ë¬Õ¡√—∫·≈–Õ¬Ÿà∫πæ◊Èπ∞“πÀ≈—°«‘™“°“√·≈–
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7. §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3 À¡“¬∂÷ß À≈—°∞“πΣ’Ë‰¥â®“°
3.1 °“√»÷°…“æ√√≥π“ (descriptive studies) À√◊Õ
3.2 °“√»÷°…“§«∫§ÿ¡Σ’Ë¡’§ÿ≥¿“ææÕ„™â (fair-designed, controlled
clinical trial)
§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 4 À¡“¬∂÷ß À≈—°∞“πΣ’Ë‰¥â®“°
4.1 √“¬ß“π¢Õߧ≥–°√√¡°“√º‡âŸ™¬Ë’«™“≠ ª√–°Õ∫°∫—§«“¡‡ÀπÁæÕâß
À√◊Õ©—πΣ“¡μ‘ (consensus) ¢Õߧ≥–ºŸâ‡™’ˬ«™“≠ ∫πæ◊Èπ∞“π
ª√– ∫°“√≥åΣ“ß§≈‘π‘° À√◊Õ
4.2 √“¬ß“πÕπ°ÿ√¡ºªâŸ«É¬®“°°“√»°÷…“„πª√–™“°√μ“àß°≈¡àÿ ·≈–§≥–
ºŸâ»÷°…“μà“ߧ≥–Õ¬à“ßπâÕ¬ 2 ©∫—∫√“¬ß“πÀ√◊Õ§«“¡‡ÀÁπΣ’Ë‰¡à‰¥â
ºà“π°“√«‘‡§√“–Àå·∫∫¡’√–∫∫ ‡™àπ ‡°√Á¥√“¬ß“πºŸâªÉ«¬‡©æ“–√“¬
(anecdotal report) §«“¡‡ÀπÁ¢Õߺ‡âŸ™¬Ë’«™“≠‡©æ“–√“¬ ®–‰¡à‰¥â
√—∫°“√æ‘®“√≥“«à“‡ªìπÀ≈—°∞“πΣ’Ë¡’§ÿ≥¿“æ„π°“√®—¥Σ”·π«Σ“ß
‡«™ªØ‘∫—μ‘π’È
·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºŸâªÉ«¬‚√§À◊¥ æ.». 2551 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºŸâªÉ«¬‚√§À◊¥ æ.». 2551
Æ
§ÿ≥¿“æÀ≈—°∞“π (Quality of Evidence)
§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1 À¡“¬∂÷ß À≈—°∞“πΣ’Ë‰¥â®“°
1.1 °“√Σ∫Σ«π·∫∫¡’√–∫∫ (systematic review) ®“°°“√»÷°…“·∫∫
°≈ÿà¡ ÿà¡μ—«Õ¬à“ß-§«∫§ÿ¡ (randomize-controlled, clinical
trials) À√◊Õ
1.2 °“√»÷°…“·∫∫°≈ÿà¡ ÿà¡μ—«Õ¬à“ß-§«∫§ÿ¡Σ’Ë¡’§ÿ≥¿“楒‡¬’ˬ¡
Õ¬à“ßπâÕ¬ 1 ©∫—∫ (a well-designed, randomize-controlled,
clinical trial)
§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 2 À¡“¬∂÷ß À≈—°∞“πΣ’Ë‰¥â®“°
2.1 °“√Σ∫Σ«π·∫∫¡√’–∫∫¢Õß°“√»°÷…“§«∫§¡ÿ·μà‰¡à‰¥ â¡àÿμ«—Õ¬“àß
(non-randomized-controlled, clinical trials) À√◊Õ
2.2 °“√»÷°…“§«∫§ÿ¡·μà‰¡à ÿà¡μ—«Õ¬à“ßΣ’Ë¡’§ÿ≥¿“楒‡¬’ˬ¡ (well-designed,
non-randomized-controlled, clinical trial) À√◊Õ
2.3 À≈—°∞“π®“°√“¬ß“π°“√»÷°…“μ“¡·ºπμ‘¥μ“¡‡Àμÿ‰ªÀ“º≈
(cohort) À√◊Õ°“√»÷°…“«‘‡§√“–À姫∫§ÿ¡°√≥’¬âÕπÀ≈—ß (case
control analytic studies) Σ’Ë‰¥â√—∫°“√ÕÕ°·∫∫«‘®—¬«‘‡§√“–Àå
§«∫§ÿ¡°√≥’¬âÕπÀ≈—ß (case control analytic studies) Σ’Ë‰¥â√—∫
°“√ÕÕ°·∫∫«‘®—¬‡ªìπÕ¬à“ߥ’ ´÷Ëß¡“®“° ∂“∫—πÀ√◊Õ°≈ÿà¡«‘®—¬¡“°
°«à“Àπ÷Ëß·Ààß/°≈ÿà¡ À√◊Õ
2.4 À≈°—∞“π®“°æÀ°ÿ“≈“π°ÿ√¡ (multiple time series) ´ßË÷¡À’√Õ◊‰¡¡à’
¡“μ√°“√¥”‡π‘π°“√ À√◊ÕÀ≈—°∞“πΣ’Ë‰¥â®“°°“√«‘®—¬Σ“ߧ≈‘π‘°
√Ÿª·∫∫Õ◊ËπÀ√◊ÕΣ¥≈Õß·∫∫‰¡à¡’°“√§«∫§ÿ¡ ´÷Ëß¡’º≈ª√–®—°…å
∂ß÷ª√–‚¬™πÀå√Õ◊‚Σ…®“°°“√ªØ∫‘μ—¡‘“μ√°“√Σ‡Ë’¥πà™¥—¡“° ‡™πà º≈
¢Õß°“√𔬓‡æÁππ‘´‘≈‘π¡“„™â„π√“« æ.». 2480 ®–‰¥â√—∫°“√®—¥
Õ¬Ÿà„πÀ≈—°∞“πª√–‡¿Σπ’È
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·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºŸâªÉ«¬‚√§À◊¥ æ.». 2551 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºŸâªÉ«¬‚√§À◊¥ æ.». 2551
“√∫—≠
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
§”π” °
À≈—°°“√¢Õß·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ ´
°“√¥Ÿ·≈ºŸâªÉ«¬‚√§À◊¥ æ.». 2551
§”™’È·®ßπÈ”Àπ—°§”·π–π” ·≈– §ÿ≥¿“æÀ≈—°∞“π ¨
μ—«¬àÕ Ø
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𑬓¡ 3
æ¬“Π‘°”‡π‘¥ 4
°“√«‘π‘®©—¬ 5
ª√–«—μ‘ 5
°“√μ√«®√à“ß°“¬ 6
°“√μ√«®Σ“ßÀâÕߪؑ∫—μ‘°“√ 6
°“√√—°…“ 8
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°“√„À⧫“¡√Ÿâ·°àºŸâªÉ«¬ ≠“μ‘ ·≈–ºŸâ„°≈♑¥ 9
‡æ◊ËÕ„À⇰‘¥§«“¡√à«¡¡◊Õ„π°“√√—°…“
°“√·π–π”«‘Π’À≈’°‡≈’ˬßÀ√◊Õ¢®—¥ ‘Ëßμà“ß Ê 10
Σ’Ë°àÕ„À⇰‘¥ªØ‘°‘√‘¬“¿Ÿ¡‘·æâ
°“√ª√–‡¡‘π√–¥—∫§«“¡√ÿπ·√ߢÕß‚√§À◊¥ 11
·≈–°“√ª√–‡¡‘πº≈°“√§«∫§ÿ¡‚√§À◊¥
✧ °“√ª√–‡¡‘π√–¥—∫§«“¡√ÿπ·√ߢÕß‚√§À◊¥ 11
∞
μ—«¬àÕ
AIA Aspirin-induced asthma
DPI Dry powder inhaler
FVC Forced vital capacity
HEPA High efficiency particulate air filter
ICS Inhaled corticosteroid
LABA Long-acting β2-agonist
Max Maximum
Min Minimum
MDI Metered-dose inhaler
NB Nebulized solution (respiratory solution, respules)
NSAIDs Non-steroidal anti-inflammatory drugs
PEF Peak expiratory flow
SABA Short-acting β2- agonist
Ø

9. 𑬓¡ 56
æ¬“Π‘ √’√«‘Σ¬“ 57
°“√«‘π‘®©—¬ 57
ª√–«—μ‘ 57
°“√μ√«®√à“ß°“¬ 58
°“√μ√«®Σ“ßÀâÕߪؑ∫—μ‘°“√ 58
°“√√—°…“ 61
‡ªÑ“À¡“¬¢Õß°“√√—°…“‚√§À◊¥„π‡¥Á° 61
À≈—°°“√√—°…“ ”À√—∫ºŸâªÉ«¬‚√§À◊¥ 61
°“√„À⧫“¡√Ÿâ·°àºŸâªÉ«¬·≈–§√Õ∫§√—« 61
‡æ◊ËÕ √â“ߧ«“¡¡’ à«π√à«¡„π°“√√—°…“‚√§À◊¥
°“√§âπÀ“·≈–À≈’°‡≈’Ë¬ß “√°àÕ¿Ÿ¡‘·æâ·≈–ªí®®—¬‡ ’ˬßμà“ß Ê 62
°“√ª√–‡¡‘π√–¥—∫§«“¡√ÿπ·√ߢÕß‚√§À◊¥ 65
·≈–°“√ª√–‡¡‘πº≈°“√§«∫§ÿ¡‚√§À◊¥
✧ °“√ª√–‡¡‘π√–¥—∫§«“¡√ÿπ·√ߢÕß‚√§À◊¥ 65
✧ °“√ª√–‡¡‘πº≈°“√§«∫§ÿ¡‚√§À◊¥ 65
°“√®—¥·ºπ°“√√—°…“ ”À√—∫ºŸâªÉ«¬‚√§À◊¥‡√◊ÈÕ√—ß 66
✧ °“√√—°…“‡æ◊ËÕ∫√√≈ÿ‡ªÑ“À¡“¬ 66
✧ °“√‡ΩÑ“√–«—ßμ‘¥μ“¡Õ“°“√ 73
✧ ¬“Σ’Ë„™â„π°“√√—°…“‚√§À◊¥‡¥Á° 74
✧ °“√√—°…“‚¥¬„™â allergen immunotherapy 79
°“√«“ß·ºπ°“√¥Ÿ·≈√—°…“‚√§À◊¥„π¢≥–¡’Õ“°“√°”‡√‘∫ 80
✧ °“√¥Ÿ·≈√—°…“ asthma exacerbation Σ’Ë∫â“π 82
✧ °“√√—°…“ asthma exacerbation „π‚√ß欓∫“≈ 85
✧ ¢âÕ∫àß™’È„π°“√√—∫‰«â„π‚√ß欓∫“≈ 87
°“√μ‘¥μ“¡°“√√—°…“Õ¬à“ß ¡Ë”‡ ¡Õ 88
°“√¥Ÿ·≈√—°…“‚√§ºŸâªÉ«¬À◊¥„π°√≥’摇»… 89
✧ ºŸâªÉ«¬Σ’ËμâÕ߉¥â√—∫°“√ºà“μ—¥ 89
·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºŸâªÉ«¬‚√§À◊¥ æ.». 2551 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºŸâªÉ«¬‚√§À◊¥ æ.». 2551
≤
✧ °“√ª√–‡¡‘πº≈°“√§«∫§ÿ¡‚√§À◊¥ 13
°“√®—¥·ºπ°“√√—°…“ ”À√—∫ºŸâªÉ«¬‚√§À◊¥‡√◊ÈÕ√—ß 14
✧ ¬“Σ’Ë„™â„π°“√√—°…“ 14
✧ ¬“Σ’Ë„™â„π°“√§«∫§ÿ¡‚√§ 17
✧ ¬“∫√√‡Σ“Õ“°“√ 20
✧ °“√√—°…“ºŸâªÉ«¬‚√§À◊¥‡√◊ÈÕ√—ß 21
°“√®—¥·ºπ°“√√—°…“ ”À√—∫ºŸâªÉ«¬‚√§À◊¥™π‘¥°”‡√‘∫‡©’¬∫æ≈—π 29
✧ °“√√—°…“ºŸâªÉ«¬‚√§À◊¥°”‡√‘∫‡©’¬∫æ≈—π„πÀâÕß©ÿ°‡©‘π 30
✧ ¢âÕ∫àß™’È¢Õß°“√√—∫ºŸâªÉ«¬‰«â√—°…“„π‚√ß欓∫“≈ 33
✧ °“√√—°…“μàÕ‡π◊ËÕß„π‚√ß欓∫“≈ 33
✧ °“√‡ΩÑ“√–«—ß·≈–μ‘¥μ“¡Õ“°“√ 34
°“√®—¥„Àâ¡’√–∫∫°“√¥Ÿ·≈√—°…“μàÕ‡π◊ËÕßÕ¬à“ß¡’ª√– ‘ΣΠ‘¿“æ 34
°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§À◊¥„π°√≥’摇»… 35
✧ ÕÕ°°”≈—ß°“¬ 35
✧ °“√μ—Èߧ√√¿å 35
✧ °“√ºà“μ—¥ 36
∫Σ √ÿª 37
¿“§ºπ«° 38
✧ °“√§”π«≥ PEF variability 38
®“°°“√«—¥§à“ PEF „πμÕπ‡™â“
✧ ·∫∫ª√–‡¡‘πº≈°“√§«∫§ÿ¡‚√§À◊¥ 38
Asthma Control Test (ACT)
∫√√≥“πÿ°√¡ 41
§≥–°√√¡°“√ª√—∫ª√ÿß·π«Σ“ß°“√«‘π‘®©—¬ 52
·≈–√—°…“‚√§À◊¥„πª√–‡Σ»‰Σ¬ ”À√—∫ºŸâªÉ«¬ºŸâ„À≠à æ.». 2551
·π«Σ“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡Σ»‰Σ¬ 55
”À√—∫ºŸâªÉ«¬‡¥Á°
∫Σπ” 56
±

10. ✧ ‚√§®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâ 89
✧ ‚√§‰´π— Õ—°‡ ∫ 90
✧ ‚√§√‘¥ ’¥«ß®¡Ÿ° (nasal polyps) 90
✧ ‚√§μ‘¥‡™◊ÈÕΣ“ß‡¥‘πÀ“¬„® 91
✧ ¿“«–°√¥‰À≈¬âÕπ (gastro esophageal 91
reflux disorder)
✧ Aspirin-induced asthma (AIA) 92
✧ Anaphylaxis ·≈–‚√§À◊¥ 94
°“√ªÑÕß°—π‚√§À◊¥ 94
∫Σ √ÿª 96
∫√√≥“πÿ°√¡ 97
§≥–°√√¡°“√ª√—∫ª√ÿß·π«Σ“ß°“√«‘π‘®©—¬ 100
·≈–√—°…“‚√§À◊¥„πª√–‡Σ»‰Σ¬ ”À√—∫ºŸâªÉ«¬‡¥Á° æ.». 2551
·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºŸâªÉ«¬‚√§À◊¥ æ.». 2551
≥

11. ·π«Σ“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥
„πª√–‡Σ»‰Σ¬ ”À√—∫ºŸâªÉ«¬ºŸâ„À≠à
æ.». 2551

12. ·π«Σ“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡Σ»‰Σ¬
”À√—∫ºŸâªÉ«¬ºŸâ„À≠à æ.». 2551
𑬓¡
‚√§À¥◊‡ªπì‚√§Σ¡Ë’°’“√Õ°—‡ ∫‡√ÕÈ◊√ß—¢ÕßÀ≈Õ¥≈¡Σ¡Ë’º’≈Σ”„ÀÀâ≈Õ¥≈¡¢Õß
ºŸâªÉ«¬¡’ªØ‘°‘√‘¬“μÕ∫ πÕßμàÕ “√°àÕ¿Ÿ¡‘·æâ·≈– ‘Ëß·«¥≈âÕ¡¡“°°«à“§πª°μ‘
(bronchial hyper-responsiveness, BHR) ºŸâªÉ«¬¡—°¡’Õ“°“√‰Õ ·πàπÀπâ“Õ°
À“¬„®¡’‡ ’¬ßÀ«’¥À√◊Õ ÀÕ∫‡Àπ◊ËÕ¬‡°‘¥¢÷Èπ‡¡◊ËÕ‰¥â√—∫ “√°àÕ‚√§À√◊Õ ‘Ëß°√–μÿâπ
·≈–Õ“°“√‡À≈à“π’ÈÕ“®À“¬‰ª‰¥â‡Õß À√◊ÕÀ“¬‰ª‡¡◊ËÕ‰¥â√—∫¬“¢¬“¬À≈Õ¥≈¡
‚√§À◊¥‡ªìπ‚√§Σ’Ë®—¥«à“¡’§«“¡™ÿ° Ÿß ·≈–‡ªìπªí≠À“ “Π“√≥ ÿ¢Õ¬à“ß
Àπ÷ËߢÕߪ√–‡Σ»‰Σ¬ ¥—ß· ¥ß‰«â„πμ“√“ßΣ’Ë 1
μ“√“ßΣ’Ë 1 §«“¡™ÿ°¢Õß‚√§À◊¥„πª√–‡Σ»‰Σ¬
æ.».
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25441
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25452
(§ÿ≥¿“æÀ≈—°∞“π 3,454 20 › 44 16.4 3.25 3.31 2.91
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√—°…“¥â«¬ corticosteroid ™π‘¥ Ÿ¥1 (§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 2) ¥â«¬‡Àμÿº≈
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cytokine Õ—π‰¥â·°à interleukin (IL)-4 IL-5 ·≈– IL-13 ´÷Ëß √â“ß®“°
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°“√ √â“ß “√§—¥À≈—Ëß (mucus) ¢ÕßÀ≈Õ¥≈¡ Σ”„À⺟âªÉ«¬‡°‘¥Õ“°“√‰Õ·≈–
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ºŸâªÉ«¬‰¥âÕ¬à“ß¡’ª√– ‘ΣΠ‘¿“æ
°“√«‘π‘®©—¬‚√§À◊¥Õ“»—¬ª√–«—μ‘ √à«¡°—∫≈—°…≥–Σ“ß§≈‘π‘°‡ªì𠔧—≠·≈–Õ“®
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‡æ‘Ë¡‡μ‘¡μ“¡§«“¡‡À¡“– ¡ ¥—ßμàÕ‰ªπ’È : ‰ª‚√‡¡μ√’¬å (πÈ”Àπ—°§”·π–π” ++),
PEF (peak expiratory flow) (πÈ”Àπ—°§”·π–π” ++)
ª√–«—μ‘
1. ‰Õ ·πàπÀπâ“Õ° À“¬„®¡’‡ ’¬ßÀ«’¥ ·≈–ÀÕ∫‡Àπ◊ËÕ¬‡ªìπ Ê À“¬ Ê
ºŸâªÉ«¬¡—°®–¡’Õ“°“√¥—ß°≈à“«‡°‘¥¢÷Èπ„π‡«≈“°≈“ߧ◊πÀ√◊Õ‡™â“¡◊¥ Õ“°“√¥—ß°≈à“«
Õ“®æ∫‰¥â‡æ’¬ßÕ¬à“ß„¥Õ¬à“ßÀπ÷Ëß À√◊Õ Õ“®æ∫Õ“°“√À≈“¬ Ê Õ“°“√‡°‘¥¢÷Èπ
æ√âÕ¡°—π°Á‰¥â
2. Õ“°“√®–‡°‘¥¢÷Èπ‡¡◊ËÕ‰¥â√—∫ ‘Ëß°√–μÿâπ ·≈–Õ“°“√¥—ß°≈à“«Õ“®À“¬‰ª
‰¥â‡ÕßÀ√◊ÕÀ“¬‰ª ‡¡◊ËÕ‰¥â√—∫¬“¢¬“¬À≈Õ¥≈¡
3. ¡’Õ“°“√‡¡◊ËÕ‰¥â√—∫ ‘Ëß°√–μÿâπ Õ“Σ‘ “√°àÕ¿Ÿ¡‘·æâ °“√μ‘¥‡™◊ÈÕ‰«√—
§«“¡‡§√’¬¥ §«—πæ‘… ·≈–¡≈æ‘…Õ◊Ëπ Ê
4. ¡—°æ∫√à«¡°—∫Õ“°“√¿Ÿ¡‘·æâÕ◊Ëπ Ê ‡™àπ allergic rhinitis, allergic
4 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 5

14. conjunctivitis ·≈– allergic dermatitis
5. ¡’ª√–«—μ‘ ¡“™‘°„π§√Õ∫§√—« ‡™àπ æàÕ ·¡à À√◊Õæ’ËπâÕߪɫ¬‡ªìπ‚√§À◊¥
6. ¡’Õ“°“√ÀÕ∫À◊¥‡°‘¥¢÷ÈπÀ≈—ß°“√ÕÕ°°”≈—ß°“¬
°“√μ√«®√à“ß°“¬
Õ“®¡’§«“¡·μ°μà“ß°—π„π·μà≈–√“¬ ‡™àπ Õ“®μ√«®‰¡àæ∫ ‘Ëߺ‘¥ª°μ‘‡¡◊ËÕ
‰¡à¡’Õ“°“√ÀÕ∫À◊¥ „π¢≥–Σ’Ë∂â“¡’Õ“°“√ÀÕ∫À◊¥®–μ√«®æ∫«à“¡’Õ—μ√“°“√
À“¬„®‡æ¡Ë‘¢πÈ÷ ¡Õ’“°“√À“¬„®≈”∫“°À√Õ◊ÀÕ∫ ·≈–Õ“®‰¥¬â𑇠¬’ßÀ«¥’®“°ªÕ¥
Σ—Èß Õߢâ“ß Σ—Èßπ’È®“°≈—°…≥–Σ“ß§≈‘π‘°¥—ß°≈à“« ®”‡ªìπμâÕß«‘π‘®©—¬·¬°‚√§
®“°‚√§À√◊Õ ¿“«–Õ◊Ëπ Ê Σ’Ë¡—°¡’Õ“°“√§≈⓬§≈÷ß°—𠇙àπ
- COPD
- Acute pulmonary edema
- Foreign body aspiration
- Gastro-esophageal reflux
- Bronchiectasis
- Upper airway obstruction
°“√μ√«®Σ“ßÀâÕߪؑ∫—μ‘°“√
°“√μ√«®Σ“ßÀÕâߪØ∫‘μ—°‘“√Σ Ë’”§≠— ‰¥·â°°à“√μ√«® ¡√√∂¿“æ°“√Σ”ß“π
¢Õߪե ( ‰ª‚√‡¡μ√’¬å) ‡æ◊ËÕμ√«®À“°“√Õÿ¥°—Èπ¢ÕßΣ“ß‡¥‘πÀ“¬„® (πÈ”Àπ—°
§”·π–π” ++) ºŸâªÉ«¬‚√§À◊¥ à«π„À≠à®–¡’ reversible airflow obstruction
‚¥¬¡’°“√‡æ‘Ë¡¢÷Èπ®“°‡¥‘¡¢Õß FEV1 (forced expiratory volume in one second)
¿“¬À≈—ß°“√„Àâ Ÿ¥¬“¢¬“¬À≈Õ¥≈¡¡“°°«à“√âÕ¬≈– 12 ·≈– FEV1 Σ’Ë Ÿß¢÷Èπ®–
μâÕß¡’®”π«π¡“°°«à“ 200 ¡≈. À√◊Õ¡’§à“ PEF ‡æ‘Ë¡¢÷Èπ¡“°°«à“ 60 ≈‘μ√/π“Σ’
À√◊Õ¡“°°«à“√âÕ¬≈– 20 (πÈ”Àπ—°§”·π–π” ++) °“√μ√«®æ∫ reversible
airflow obstruction ¥—ß°≈à“«®–™à«¬ π—∫ πÿπ°“√«‘π‘®©—¬‚√§ À“°º≈°“√μ√«®
‰ª‚√‡¡μ√’¬å‰¡à‰¥âº≈μ“¡‡°≥±å¥—ß°≈à“« À√◊Õ∂÷ß·¡â«à“º≈°“√μ√«® ‰ª‚√‡¡μ√’¬å
Õ¬Ÿà„π‡°≥±åª°μ‘ °Á¬—߉¡à “¡“√∂μ—¥°“√«‘π‘®©—¬‚√§À◊¥ÕÕ°‰ª‰¥â ‡æ√“–ºŸâªÉ«¬
‚√§À◊¥‡√◊ÈÕ√—ßÕ“®‰¡à¡’°“√μÕ∫ πÕߥ—ß°≈à“«À≈—ß Ÿ¥¬“¢¬“¬À≈Õ¥≈¡‡æ’¬ß
20 π“Σ’ πÕ°®“°π’ȺŸâªÉ«¬‚√§À◊¥Σ’Ë¡’§«“¡√ÿπ·√ßπâÕ¬ ·≈–Õ¬Ÿà„π√–¬–‚√§ ß∫
À√Õ◊‚√§À¥◊ΣμË’Õ∫ πÕß®”‡æ“–μÕà ßË‘°√–μπâÿ∫“ßÕ¬“àß (‡™πà °“√ÕÕ°°”≈ß—°“¬,
Aspirin›induced asthma) °“√μ√«® ‰ª‚√‡¡μ√¬’Õå“®æ∫«“àÕ¬àŸ„π‡°≥±ªå°μ‘
”À√—∫ºŸâªÉ«¬ COPD Σ’Ë¡’¿“«–À≈Õ¥≈¡‰«‡°‘π Õ“®¡’°“√μÕ∫ πÕßμ“¡‡°≥±å
‡∫◊ÈÕßμâπ‰¥â‡™àπ°—π „π°√≥’‡™àππ’È°“√μ‘¥μ“¡°“√μ√«® ‰ª‚√‡¡μ√’¬å‡æ◊ËÕª√–‡¡‘π
°“√μÕ∫ πÕßμàÕ°“√√—°…“„π√–¬–¬“« ®– “¡“√∂™à«¬„π°“√«‘π‘®©—¬·¬°‚√§‰¥â
‡™àπ À“°º≈°“√μ√«®°≈—∫¡“Õ¬Ÿà„π‡°≥±åª°μ‘ ºŸâªÉ«¬√“¬π—Èπ‰¡àπà“®–‰¥â√—∫°“√
«π‘®‘©¬—«“à‡ªπì COPD ÕπßË÷°“√Σ¥ Õ∫ ¡√√∂¿“æ°“√Σ”ß“π¢Õߪե®–μÕâ߉¥â
√—∫°“√μ√«®‚¥¬∫ÿ§≈“°√Σ’Ë™”π“≠ À√◊Õ‰¥âºà“π°“√Ωñ°Õ∫√¡¡“·≈⫇ªìπÕ¬à“ߥ’
‡Σà“π—Èπ10
„π°√≥Σ’ºË’ªâŸ«É¬‰¡¡àÕ’“°“√ÀÕ∫‡ÀπÕË◊¬ ·≈–‰¡æà∫ ßË‘º¥‘ª°μ„‘π°“√μ√«®«¥—
¡√√∂¿“æ°“√Σ”ß“π¢Õߪե °“√μ√«®«—¥§à“§«“¡º—πº«π (variability) ¢Õß
PEF Σ’Ë‡°‘¥¢÷Èπ„π·μà≈–™à«ß‡«≈“¢Õß«—π„π√–¬–‡«≈“ 1 › 2 —ª¥“ÀåÕ“®π”¡“„™â
„π°“√«‘π‘®©—¬‚√§‰¥â ºŸâªÉ«¬Σ’Ë¡’§«“¡º—πº«π¢Õß§à“ Ÿß ÿ¥°—∫§à“μË” ÿ¥¡“°°«à“
√âÕ¬≈– 20 ®—¥«à“‡ªìπ‚√§À◊¥ (πÈ”Àπ—°§”·π–π” ++) °“√§”π«≥„™â Ÿμ√ ¥—ßπ’È
§à“§«“¡º—πº«π = (PEF Ÿß ÿ¥ › PEF μË” ÿ¥) x 100
1 / 2 (PEF Ÿß ÿ¥ + PEF μË” ÿ¥)
À√◊ÕÕ’°«‘Π’ §”π«≥ PEF variability ®“°°“√«—¥ PEF „πμÕπ‡™â“ °àÕπΣ’Ë
®– Ÿ¥¬“¢¬“¬À≈Õ¥≈¡μ‘¥μàÕ°—π‡ªìπ‡«≈“ 1 ª—¥“Àå ·≈â«π”§à“ PEF Σ’Ë«—¥‰¥â
πâÕ¬Σ’Ë ÿ¥¡“§”π«≥‡ªìπ√âÕ¬≈–¢Õß§à“ PEF Σ’Ë«—¥‰¥â Ÿß ÿ¥
PEF min x 100
PEF max
§à“ —¥ à«πΣ’Ë§”π«≥‰¥âπ’È®–·ª√º°º—π°—∫ variability11 (§ÿ≥¿“æÀ≈—°∞“π √–¥—∫ 1,
πÈ”Àπ—°§”·π–π” ++) ¥Ÿ√“¬≈–‡Õ’¬¥„π¿“§ºπ«°
„π°√≥Σ’ºË’≈°“√μ√«® ¡√√∂¿“æ°“√Σ”ß“π¢Õߪե‰¡ à“¡“√∂π”¡“™«à¬„π
°“√«‘π‘®©—¬‰¥â Õ“®„™â°“√«—¥§«“¡‰«À≈Õ¥≈¡ (bronchial hyper-responsiveness)
6 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 7

15. ‚¥¬«¥—°“√‡ª≈¬Ë’π·ª≈ߢÕߧ“à FEV1 ¿“¬À≈ß—°√–μπâÿ¥«â¬°“√ ¥Ÿ methacholine
(methacholine challenge test)12 (§ÿ≥¿“æÀ≈—°∞“π √–¥—∫ 2, πÈ”Àπ—°
§”·π–π” ++)
„πºŸâªÉ«¬∫“ß√“¬Σ’ËμâÕß°“√«‘π‘®©—¬·¬°®“°‚√§Õ◊Ëπ Õ“® àßμ√«®Σ“ßÀâÕß
ªØ‘∫—μ‘°“√‡æ‘Ë¡‡μ‘¡ ‡™àπ ¿“æ√—ß ’Σ√«ßÕ° °“√μ√«®‡ ¡À– ‡ªìπμâπ
°“√√—°…“
‚¥¬ΣË’‚√§À¥◊‡ªπì‚√§Σ¡Ë’°’“√Õ°—‡ ∫‡√ÕÈ◊√ß—¢ÕßÀ≈Õ¥≈¡ Σ‡Ë’°¥‘®“°ªØ°‘√‘¬‘“
Σ“ß¿Ÿ¡‘·æâ¢Õß√à“ß°“¬μàÕ “√°àÕ‚√§ ¥—ßπ—Èπ ºŸâªÉ«¬‚√§À◊¥‡√◊ÈÕ√—ßΣÿ°√“¬®÷ߧ«√‰¥â
√—∫°“√√—°…“¥â«¬ corticosteroid ™π‘¥ Ÿ¥ √à«¡°—∫¬“¢¬“¬À≈Õ¥≈¡·≈–¬“Õ◊Ëπ
μ“¡§«“¡√ÿπ·√ߢÕßÕ“°“√ (πÈ”Àπ—°§”·π–π” ++) ¥—ß®–‰¥â°≈à“«μàÕ‰ª πÕ°®“°
°“√√°—…“¥«â¬¬“ ºªâŸ«É¬§«√®–À≈°’‡≈¬Ë’ßÀ√Õ◊¢®¥— ßË‘μ“àß Ê ΣÕË’“®Σ”„À‡â°¥‘ªØ°‘√‘¬‘“
¿Ÿ¡‘·æâÀ√◊Õ°√–μÿâπÕ“°“√ÀÕ∫À◊¥„À⇰‘¥¢÷Èπ (πÈ”Àπ—°§”·π–π” ++) °“√øóôπøŸ
¡√√∂¿“æ°“√Σ”ß“π¢Õß√à“ß°“¬¡’¢âÕ∫àß™’È„πºŸâªÉ«¬‚√§À◊¥Σ’Ë¡’°“√Õÿ¥°—Èπ¢Õß
À≈Õ¥≈¡„π¢π“¥¡“° À√◊Õ¡’¿“«– airway remodeling ‡°‘¥¢÷Èπ (πÈ”Àπ—°
§”·π–π” ++)
‡ªÑ“À¡“¬¢Õß°“√√—°…“ºŸâªÉ«¬‚√§À◊¥
1. “¡“√∂§«∫§ÿ¡Õ“°“√¢Õß‚√§„Àâ ß∫≈߉¥â
2. ªÑÕß°—π‰¡à„À⇰‘¥°“√°”‡√‘∫¢Õß‚√§ ¬°√–¥—∫ ¡√√∂¿“æ°“√Σ”ß“π
¢Õߪե¢ÕߺŸâªÉ«¬„Àâ¥’Σ—¥‡Σ’¬¡°—∫§πª°μ‘À√◊Õ„Àâ¥’Σ’Ë ÿ¥‡Σà“Σ’Ë®–Σ”‰¥â
3. “¡“√∂¥”√ß™’«‘μÕ¬Ÿà‰¥â‡™àπ‡¥’¬«°—∫À√◊Õ„°≈⇧’¬ß°—∫§πª°μ‘
4. À≈’°‡≈’ˬ߿“«–·Σ√°´âÕπμà“ß Ê ®“°¬“√—°…“‚√§À◊¥„ÀâπâÕ¬Σ’Ë ÿ¥
5. ªÑÕß°—πÀ√◊Õ≈¥Õÿ∫—μ‘°“√≥å°“√‡ ’¬™’«‘μ®“°‚√§À◊¥
°“√Σ’Ë®–Σ”„Àâ∫√√≈ÿ‡ªÑ“À¡“¬¥—ß°≈à“«¢â“ßμâπ ®–μâÕß¡’°“√
¥”‡π‘π°“√¥—ßμàÕ‰ªπ’È
1. °“√„À⧫“¡√Ÿâ·°àºŸâªÉ«¬ ≠“μ‘ ·≈–ºŸâ„°≈♑¥‡æ◊ËÕ„À⇰‘¥§«“¡√à«¡¡◊Õ
„π°“√√—°…“
2. °“√·π–π”«Π‘À’≈°’‡≈¬Ë’ß À√Õ◊¢®¥— ßË‘μ“àß Ê Σ°Ë’Õà„À‡â°¥‘ªØ°‘√‘¬‘“¿¡Ÿ·‘æâ
·≈–Õ“°“√ÀÕ∫À◊¥Õ¬à“߇ªìπ√ŸªΠ√√¡ §◊Õ “¡“√∂π”¡“ªØ‘∫—쑉¥â®√‘ß
3. °“√ª√–‡¡‘π√–¥—∫§«“¡√ÿπ·√ߢÕß‚√§À◊¥ ·≈–°“√ª√–‡¡‘πº≈°“√
§«∫§ÿ¡‚√§À◊¥
4. °“√®—¥·ºπ°“√√—°…“ ”À√—∫ºŸâªÉ«¬‚√§À◊¥‡√◊ÈÕ√—ß
5. °“√®¥—·ºπ°“√√°—…“ ”À√∫—ºªâŸ«É¬‚√§À¥◊°”‡√∫‘‡©¬’∫æ≈π— (asthma
exacerbation)
6. °“√®—¥√–∫∫„Àâ¡’°“√¥Ÿ·≈√—°…“μàÕ‡π◊ËÕßÕ¬à“ß¡’ª√– ‘ΣΠ‘¿“æ
7. °“√√—°…“ºŸâªÉ«¬‚√§À◊¥„π°√≥’摇»…
1. °“√„À⧫“¡√Ÿâ·°àºŸâªÉ«¬ ≠“μ‘ ·≈–ºŸâ„°≈♑¥ ‡æ◊ËÕ„À⇰‘¥§«“¡
√à«¡¡◊Õ„π°“√√—°…“
°“√„À⧫“¡√Ÿâ·°àºŸâªÉ«¬ ≠“μ‘ ·≈–ºŸâ„°≈♑¥‡ªìπ ‘Ëß ”§—≠·≈–®”‡ªìπ„π°“√
¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§À◊¥ ºŸâªÉ«¬·≈– ¡“™‘°„π§√Õ∫§√—«§«√‰¥â√—∫Σ√“∫¢âÕ¡Ÿ≈
μà“ß Ê ‡°’ˬ«°—∫‚√§À◊¥ ´÷Ë߉¥â·°à
1. Π√√¡™“μ‘¢Õß‚√§
2. ªí®®—¬À√◊Õ ‘Ëß°√–μÿâπΣ’ËÕ“®Σ”„À⇰‘¥°“√°”‡√‘∫¢Õß‚√§
3. ™π‘¥¢Õ߬“Σ’Ë„™â„π°“√√—°…“‚√§À◊¥ ·≈–«‘Π’°“√„™â¬“Σ’Ë∂Ÿ°μâÕß ‚¥¬
‡©æ“–°“√„™¬â“ª√–‡¿Σ ¥Ÿ ·æΣ¬§å«√Ω°ñ„ÀºâªâŸ«É¬∫√À‘“√¬“Σ“ß°“√ ¥Ÿ‰¥Õ⬓àß
∂Ÿ°μâÕß ·≈–¡’°“√Σ¥ Õ∫°“√∫√‘À“√¬“‡ªìπ√–¬– Ê ‡æ◊ËÕªÑÕß°—𧫓¡º‘¥æ≈“¥
Σ’ËÕ“®‡°‘¥¢÷Èπ®“°°“√∫√‘À“√¬“º‘¥«‘Π’ (πÈ”Àπ—°§”·π–π” ++)
4. °“√„™‡â§√ÕË◊ß peak flow meter Σ∂Ë’°Ÿ«Π‘ ’‡æÕË◊𔉪„™â„π°√≥Σ’μË’Õâß°“√
μ‘¥μ“¡°“√‡ª≈’ˬπ·ª≈ߢÕß ¡√√∂¿“æ°“√Σ”ß“π¢ÕßªÕ¥μ“¡·ºπ°“√¥Ÿ·≈
8 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 9

16. μπ‡ÕߢÕߺŸâªÉ«¬Σ’Ë·æΣ¬å‰¥â®—¥„Àâ
5. °“√ª√–‡¡‘πº≈°“√§«∫§ÿ¡‚√§À◊¥ ·≈–§”·π–π”„π°“√ªØ‘∫—μ‘μ—«
√«¡ΣßÈ—°“√ª√∫—¢π“¥¢Õ߬“ΣË’„™â„π°√≥Σ’¡Ë’°’“√‡ª≈¬Ë’π·ª≈ߢÕß°“√§«∫§¡ÿ‚√§
·≈–§”·π–π”„ÀºâªâŸ«É¬√∫’°≈∫—¡“√∫—°“√μ√«®√°—…“®“°·æΣ¬Σåπ—Σ‡’¡ÕË◊¡Õ’“°“√
ÀÕ∫À◊¥√ÿπ·√ߢ÷Èπ (πÈ”Àπ—°§”·π–π” ++)
2. °“√·π–π”«‘Π’À≈’°‡≈’ˬßÀ√◊Õ¢®—¥ ‘Ëßμà“ß Ê
Σ’Ë°àÕ„À⇰‘¥ªØ‘°‘√‘¬“¿Ÿ¡‘·æâ (πÈ”Àπ—°§”·π–π”++)
‚¥¬Σ—Ë«‰ª ªí®®—¬·≈– ‘Ëß°√–μÿâπΣ’ËΣ”„À⇰‘¥Õ“°“√ÀÕ∫À◊¥¢÷Èπ ‰¥â·°à
1. “√°àÕ¿Ÿ¡‘·æâ (allergen) ·∫à߇ªìπ °≈ÿà¡ “√°àÕ¿Ÿ¡‘·æâ„πÕ“§“√ ‡™àπ
‰√ΩÿÉπ ·¡≈ß “∫ —μ«å‡≈’È¬ß ªÕ√凙◊ÈÕ√“ ·≈– °≈ÿà¡ “√°àÕ¿Ÿ¡‘·æâπÕ°Õ“§“√
‡™àπ ‡° √À≠â“ «—™æ◊™ ªÕ√凙◊ÈÕ√“ ‡ªìπμâπ
2. “√√–§“¬‡§◊Õß ‡™àπ πÈ”ÀÕ¡ °≈‘Ëπ ’ Σ‘π‡πàÕ√å πÈ”¬“À√◊Õ “√‡§¡’
≈–ÕÕ߬“ ¶à“·¡≈ßμà“ß Ê ΩÿÉπ°àÕ √â“ß ΩÿÉπÀ‘π ΩÿÉπ¥‘𠧫—π∫ÿÀ√’Ë §«—πΠŸª §«—π
‡Σ’¬π §«—π‰ø §«—πΣàÕ‰Õ‡ ’¬√∂¬πμå ´—≈‡øÕ√剥ÕÕ°‰´¥å ‚Õ‚´π ‡ªìπμâπ
3. ¿“«–Σ“ß°“¬¿“æ·≈–°“√‡ª≈’ˬπ·ª≈ߢÕßÕ“°“» ‡™àπ ≈¡æ—¥
ª–Σ–Àπâ“‚¥¬μ√ß √«¡Σ—ÈßÕ“°“»√âÕπ®—¥ ‡¬Áπ®—¥ Ωπμ° Õ“°“»·Àâß À√◊Õ ™◊Èπ
‡ªìπμâπ
4. ¬“ ‚¥¬‡©æ“–°≈ÿà¡ NSAID aspirin ·≈– β-blocker
5. °“√μ‘¥‡™◊ÈÕ‰«√— ¢ÕßΣ“ß‡¥‘πÀ“¬„® à«πμâπ
6. Õ“√¡≥凧√’¬¥
7. “‡ÀμÿÕ◊Ëπ Ê ‡™àπ À◊¥Σ’Ë∂Ÿ°°√–μÿâπ¥â«¬°“√ÕÕ°°”≈—ß°“¬ À◊¥Σ’Ë∂Ÿ°
°√–μÿâπ¥â«¬ “√°àÕ¿Ÿ¡‘·æâ À√◊Õ “√√–§“¬‡§◊Õß®“°°“√ª√–°Õ∫Õ“™’æ
8. ‚√§ΣæË’∫√«à¡‰¥∫âÕଷ≈–Σ”„À§â«∫§¡ÿÕ“°“√À¥◊‰¥â‰¡¥à ’À√Õ◊¡Õ’“°“√
°”‡√‘∫∫àÕ¬ Ê ‰¥â·°à ‚√§¿Ÿ¡‘·æâ¢Õß‚æ√ß®¡Ÿ° ‚√§‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß ‚√§
°√¥‰À≈¬âÕ𠇪ìπμâπ
·æΣ¬å¡’Àπâ“Σ’Ë§âπÀ“ªí®®—¬μà“ß Ê Σ’ËΣ”„À⇰‘¥Õ“°“√ÀÕ∫À◊¥ √«¡Σ—Èß„À⧔
·π–𔇰’ˬ«°—∫°“√§«∫§ÿ¡ ¿“æ·«¥≈âÕ¡Σ—Èß„π·≈–πÕ°Õ“§“√ ‡™àπ °“√®—¥
√–∫∫∂“ଇΣÕ“°“»Σ¥Ë’ ’®¥—„À¡â·’ ß·¥¥ ÕàßÕ¬“àßΣ«Ë—∂ß÷ À≈°’‡≈¬Ë’ß°“√„™æâ√¡ ππàÿ
À√◊Õ¡’ —μ«å‡≈’È¬ß „πÀâÕßπÕπ ÀâÕßΣ”ß“π °“√§«∫§ÿ¡·≈–À≈’°‡≈’Ë¬ß indoor
pollutant ‡™à𠧫—π∫ÿÀ√’Ë ¬“¶à“·¡≈ß §«—πΠŸª ‡ªìπμâπ à«π°“√„™â‡§√◊ËÕß
ª√—∫Õ“°“»·≈–‡§√◊ËÕß°√ÕßÕ“°“»„Àâ∫√‘ ÿΣΠ‘ÏÕ“®™à«¬≈¥¡≈æ‘… ·≈–ª√‘¡“≥
“√¿Ÿ¡‘·æâ„πÕ“°“»≈߉¥â (πÈ”Àπ—°§”·π–π” +/-) °“√√—°…“‚√§Σ’Ëæ∫√à«¡°—∫
‚√§À◊¥‰¥â∫àÕ¬ ‡™àπ allergic rhinitis oe≈oe ‰ªæ√âÕ¡ Ê °—π°—∫°“√√—°…“‚√§À◊¥
®–Σ”„Àâ “¡“√∂§«∫§ÿ¡Õ“°“√¢Õß‚√§À◊¥‰¥â¥’¢÷Èπ (πÈ”Àπ—°§”·π–π” ++)
3. °“√ª√–‡¡‘π√–¥—∫§«“¡√ÿπ·√ߢÕß‚√§À◊¥ ·≈–°“√ª√–‡¡‘πº≈
°“√§«∫§ÿ¡‚√§À◊¥
3.1 °“√ª√–‡¡‘π√–¥—∫§«“¡√ÿπ·√ߢÕß‚√§À◊¥10, 13
°“√®”·π°§«“¡√ÿπ·√ߢÕß‚√§À◊¥¡’ª√–‚¬™πå„π°“√𔉪„™âæ‘®“√≥“
ºŸâªÉ«¬√“¬Σ’ˬ—߉¡à‡§¬ºà“π°“√√—°…“¡“°àÕπ«à“√“¬„¥§«√‰¥â√—∫°“√√—°…“¥â«¬¬“
corticosteroid ™π‘¥ Ÿ¥ °“√®”·π°§«“¡√ÿπ·√ߢÕß‚√§À◊¥μâÕßÕ“»—¬Õ“°“√
Σ“ß§≈‘π‘° √à«¡°—∫ ¡√√∂¿“æ°“√Σ”ß“π¢ÕßªÕ¥Σ’Ëμ√«®æ∫ °àÕπ°“√√—°…“
‡æ◊ËÕ§«“¡ –¥«°·≈–ßà“¬μàÕ°“√𔉪„™â ®÷ß®”·π°ºŸâªÉ«¬ÕÕ°®“°°—π‡ªìπ
intermittent ·≈– persistent asthma ‚¥¬Õ“»—¬‡°≥±åμ“¡μ“√“ßΣ’Ë 2
10 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 11

17. PEF or FEV1
PEF variability
> 80 %
< 20 %
> 80 %
< 20 -30 %
60 - 80 %
> 30 %
< 60 %
> 30 %
μ“√“ßΣ’Ë 2 °“√ª√–‡¡‘π√–¥—∫§«“¡√ÿπ·√ߢÕß‚√§À◊¥10, 13
√–¥—∫ Õ“°“√™à«ß°≈“ß«—π Õ“°“√™à«ß°≈“ߧ◊π
√–¥—∫ 1
¡’Õ“°“√π“πÊ §√—Èß
Intermittent
√–¥—∫ 2
À◊¥‡√◊ÈÕ√—ß
Õ“°“√√ÿπ·√ßπâÕ¬
Mild persistent
√–¥—∫ 3
À◊¥‡√◊ÈÕ√—ß
Õ“°“√√ÿπ·√ߪ“π°≈“ß
Moderate persistent
√–¥—∫ 4
À◊¥‡√◊ÈÕ√—ß
Õ“°“√√ÿπ·√ß¡“°
Severe persistent
- ¡’Õ“°“√ÀÕ∫À◊¥πâÕ¬
°«à“ —ª¥“Àå≈– 1 §√—Èß
- ¡’°“√®—∫À◊¥™à«ß —Èπ Ê
- ¡’§à“ PEF ª°μ‘ ™à«ßΣ’Ë
‰¡à¡’Õ“°“√®—∫À◊¥
- ¡’Õ“°“√ÀÕ∫À◊¥Õ¬à“ß
πâÕ¬ —ª¥“Àå≈– 1 §√—Èß
·μàπâÕ¬°«à“ 1 §√—Èß
μàÕ«—π
- ‡«≈“®—∫À◊¥Õ“®¡’º≈μàÕ
°“√Σ”°‘®°√√¡·≈–
°“√πÕπÀ≈—∫
- ¡’Õ“°“√ÀÕ∫Σÿ°«—π
- ‡«≈“®—∫À◊¥¡’º≈μàÕ°“√
Σ”°‘®°√√¡·≈–°“√
πÕπÀ≈—∫
- ¡’Õ“°“√ÀÕ∫μ≈Õ¥
‡«≈“
- ¡’°“√®—∫À◊¥∫àÕ¬·≈–
¡’¢âÕ®”°—¥„π°“√Σ”
°‘®°√√¡μà“ß Ê
- ¡’Õ“°“√ÀÕ∫‡«≈“
°≈“ߧ◊ππâÕ¬°«à“
2 §√—ÈßμàÕ‡¥◊Õπ
- ¡’Õ“°“√ÀÕ∫‡«≈“
°≈“ߧ◊π¡“°°«à“
2 §√—ÈßμàÕ‡¥◊Õπ
- ¡’Õ“°“√ÀÕ∫‡«≈“
°≈“ߧ◊π¡“°°«à“
1 §√—ÈßμàÕ —ª¥“Àå
- ¡’Õ“°“√ÀÕ∫‡«≈“
°≈“ߧ◊π∫àÕ¬ Ê
3.2 °“√ª√–‡¡‘πº≈°“√§«∫§ÿ¡‚√§À◊¥
°“√√—°…“‚√§À◊¥¡ÿà߇πâπ°“√≈¥°“√Õ—°‡ ∫¢ÕßÀ≈Õ¥≈¡¥â«¬¬“°≈ÿà¡
§«∫§¡ÿ (controller) ‡æÕË◊Σ”„ÀÕâ“°“√¢Õß‚√§À¥◊¥¢’πÈ÷ Õ¬“à߉√°μÁ“¡ °“√ª√–‡¡π‘º≈
Σ“ß¥â“π°“√Õ—°‡ ∫¢ÕßÀ≈Õ¥≈¡‚¥¬μ√ßΣ”‰¥â¬“°·≈–¡’¢âÕ®”°—¥ ‡π◊ËÕß®“°«‘Π’
μ√«®ππÈ—μÕâß°“√Σ°—…–¢ÕߺμâŸ√«® ߟ μÕâß„™Õâªÿ°√≥æ凑»…Σ¡Ë’√’“§“·æß ‡ ¬’‡«≈“
„π°“√μ√«®π“π ·≈–„πªí®®ÿ∫—πÀâÕߪؑ∫—μ‘°“√Σ’Ë “¡“√∂ª√–‡¡‘πº≈°“√§«∫§ÿ¡
‚√§À◊¥¥—ß°≈à“«¬—ß¡’®”π«π®”°—¥ ¥—ßπ—Èπ „πΣ“ßªØ‘∫—μ‘ºŸâ‡™’ˬ«™“≠®÷ß·π–π”„Àâ
ª√–‡¡‘πº≈°“√§«∫§ÿ¡‚√§À◊¥ ‚¥¬Õ“»—¬Õ“°“√Σ“ß§≈‘π‘° √à«¡°—∫°“√μ√«®
¡√√∂¿“æ°“√Σ”ß“π¢Õߪե À√◊Õ„™â·∫∫ Õ∫∂“¡‡æ◊ËÕª√–‡¡‘π°“√§«∫§ÿ¡
‚√§À◊¥ ‡™àπ Asthma Control Test (ACT)14 (§ÿ≥¿“æÀ≈—°∞“π √–¥—∫ 1, πÈ”Àπ—°
§”·π–π” ++) À√◊Õ Asthma Control Questionnaire (ACQ)15 (§ÿ≥¿“æ
À≈—°∞“π √–¥—∫ 1, πÈ”Àπ—°§”·π–π” ++) ¥Ÿ√“¬≈–‡Õ’¬¥„π¿“§ºπ«°
√–¥—∫°“√§«∫§ÿ¡‚√§À◊¥·∫àßÕÕ°®“°°—π‡ªìπ 3 °≈ÿà¡ (μ“√“ßΣ’Ë 3) ºŸâªÉ«¬
Σ’ËÕ¬Ÿà„π√–¬–ª≈Õ¥Õ“°“√À√◊ÕºŸâªÉ«¬Σ’Ë°”≈—߉¥â√—∫°“√√—°…“·≈– “¡“√∂§«∫§ÿ¡
Õ“°“√‰¥·â≈«â®¥—Õ¬àŸ„π°≈¡àÿΣ§Ë’«∫§¡ÿÕ“°“√‰¥ â(controlled) ºªâŸ«É¬„π°≈¡àÿπ®È’–μÕâß
‰¡à¡’Õ“°“√¢Õß‚√§À◊¥‡°‘¥¢÷Èπ Σ—Èß„π‡«≈“°≈“ß«—π ·≈–°≈“ߧ◊π ‰¡à¡’°“√°”‡√‘∫
¢Õß‚√§·≈–‰¡®à”‡ªπìμÕâß„™¬â“¢¬“¬À≈Õ¥≈¡ (relievers) „π¢≥–Σ¡Ë’ ’¡√√∂¿“æ
°“√Σ”ß“π¢ÕߪելŸà„π‡°≥±åª°μ‘ ·≈–‰¡à¡’º≈°√–Σ∫¢Õß‚√§μàÕ°‘®«—μ√
ª√–®”«π—16 «àπºªâŸ«É¬Σ¬Ë’ß—§«∫§¡ÿÕ“°“√‰¥â‰¡¥à ’(partly controlled) ·≈–ºªâŸ«É¬
Σ§Ë’«∫§¡ÿÕ“°“√¢Õß‚√§‰¡à‰¥ â(uncontrolled) ®–¡Õ’“°“√ °“√„™¬â“¢¬“¬À≈Õ¥≈¡
·≈–®”π«π§√—ÈߢÕß°“√°”‡√‘∫‡æ‘Ë¡¢÷Èπ √à«¡°—∫¡’°“√≈¥≈ߢÕß ¡√√∂¿“æ°“√
Σ”ß“π¢Õߪե ·≈–¡’º≈°√–Σ∫¢Õß‚√§μàÕ°‘®«—μ√ª√–®”«—π‡æ‘Ë¡¡“°¢÷Èπ
μ“¡≈”¥—∫
12 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 13

18. μ“√“ßΣ’Ë 3 √–¥—∫°“√§«∫§ÿ¡‚√§À◊¥
Controlled Partly Controlled
≈—°…≥–Σ“ß§≈‘π‘° (μâÕß¡’Σÿ°¢âÕ (¡’Õ¬à“ßπâÕ¬ 1 ¢âÕ Uncontrolled
μàÕ‰ªπ’È) μàÕ‰ªπ’È)
Õ“°“√™à«ß°≈“ß«—π ‰¡à¡’ (À√◊ÕπâÕ¬°«à“ ¡“°°«à“ 2 §√—Èß ¡’Õ“°“√„πÀ¡«¥
2 §√—Èß μàÕ —ª¥“Àå) μàÕ —ª¥“Àå partly controlled
¡’¢âÕ®”°—¥¢Õß°“√ ‰¡à¡’ ¡’ Õ¬à“ßπâÕ¬ 3 ¢âÕ
ÕÕ°°”≈—ß°“¬
Õ“°“√™à«ß°≈“ߧ◊π®π ‰¡à¡’ ¡’
√∫°«π°“√πÕπÀ≈—∫
μâÕß„™â¬“ reliever/ ‰¡à¡’ (À√◊ÕπâÕ¬°«à“ ¡“°°«à“ 2 §√—Èß
rescue treatment 2 §√—ÈßμàÕ —ª¥“Àå) μàÕ —ª¥“Àå
º≈°“√μ√«® ª°μ‘ πâÕ¬°«à“ 80%
¡√√∂¿“æªÕ¥ predicted or personal
(PEF or FEV1) best (if known)
°“√®—∫À◊¥‡©’¬∫æ≈—π ‰¡à¡’ Õ¬à“ßπâÕ¬ 1 §√—ÈßμàÕªï 1 §√—Èß„π™à«ß
(Exacerbation)* —ª¥“Àå‰Àπ°Á‰¥â
* Õ“°“√ÀÕ∫À◊¥√ÿπ·√ß®πμâÕ߉¥â√—∫°“√√—°…“·∫∫©ÿ°‡©‘π
4. °“√®—¥·ºπ°“√√—°…“ ”À√—∫ºŸâªÉ«¬‚√§À◊¥‡√◊ÈÕ√—ß
4.1 ¬“Σ’Ë„™â„π°“√√—°…“
¬“Σ’Ë„™â„π°“√√—°…“‚√§À◊¥®”·π°ÕÕ°®“°°—π‡ªìπ Õß°≈ÿà¡ §◊Õ ¬“Σ’Ë
„™â„π°“√§«∫§ÿ¡‚√§ (controller) ·≈–¬“∫√√‡Σ“Õ“°“√ (reliever) √“¬≈–‡Õ’¬¥
¢Õ߬“Σ—Èß Õß°≈ÿà¡π’ȉ¥â· ¥ß‰«â„π μ“√“ßΣ’Ë 4
μ“√“ßΣ’Ë 4 ¬“Σ’Ë„™â„π°“√√—°…“‚√§À◊¥13
°≈ÿ࡬“ ™◊ËÕ “¡—≠ °≈‰°°“√ÕÕ°ƒΣΠ‘Ï
CONTROLLER
MEDICATIONS
1. Corticosteroid
2. Long-acting
β2-agonist*
(LABA)
¬“ Ÿ¥
❍ beclomethasone
❍ budesonide
❍ fluticasone
¬“√—∫ª√–Σ“π
❍ prednisolone
¬“©’¥ (‡¢â“°≈â“¡‡π◊ÈÕ À√◊Õ
À≈Õ¥‡≈◊Õ¥)
❍ hydrocortisone
❍ dexamethasone
❍ methylprednisolone
¬“ Ÿ¥
❍ salmeterol**
❍ formoterol***
ANTI-INFLAMMATORY
AGENT
❍ ¢—¥¢«“ß·≈–°¥°“√Σ”ß“π¢Õß
inflammatory cell √«¡Σ—Èß
≈¥®”π«π¢Õß inflammatory
cell17 (§ÿ≥¿“æÀ≈—°∞“π√–¥—∫
1, πÈ”Àπ—°§”·π–π” ++)
❍ ≈¥°“√ √â“ß mucus „π
À≈Õ¥≈¡
❍ ‡æ‘Ë¡°“√Σ”ß“π¢Õß
β2-agonist Σ’Ë°≈â“¡‡π◊ÈÕ‡√’¬∫
¢ÕßÀ≈Õ¥≈¡
❍ Σ”„Àâ¿Ÿ¡‘μàÕμâ“π°“√Õ—°‡ ∫
¢ÕßÀ≈Õ¥≈¡ °≈—∫¡“Σ”ß“π
μ“¡ª°μ‘18 (§ÿ≥¿“æÀ≈—°∞“π
√–¥—∫ 2, πÈ”Àπ—°§”·π–π”
++)
❍ ‡ √‘¡ƒΣΠ‘Ï corticosteroid
™π‘¥ Ÿ¥„π°“√™à«¬≈¥°“√
Õ—°‡ ∫¢ÕßÀ≈Õ¥≈¡ ·≈–
ÕÕ°ƒΣΠ‘Ï≈¥°“√Õ—°‡ ∫™π‘¥
neutrophilic airway
inflammation ¢ÕߺŸâªÉ«¬‚√§
À◊¥19-20 (§ÿ≥¿“æÀ≈—°∞“π
√–¥—∫ 1, πÈ”Àπ—°§”·π–π”
++)
14 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 15

19. °≈àÿ¡¬“ ™Ë◊Õ “¡—≠ °≈‰°°“√ÕÕ°ƒΣΠ‘Ï°≈àÿ¡¬“ ™Ë◊Õ “¡—≠ °≈‰°°“√ÕÕ°ƒΣΠ‘Ï
2. Methylxanthine
3. Anticholinergic „π
√Ÿª¢Õ߬“º ¡°—∫
β2-agonist
❍ terbutaline
¬“√—∫ª√–Σ“π
❍ salbutamol
❍ terbutaline
❍ procaterol
¬“©’¥
❍ aminophylline
¬“ Ÿ¥
❍ ipratropium bromide
+ fenoterol À√◊Õ
salbutamol
❍ ÕÕ°ƒΣΠ‘Ï¢¬“¬À≈Õ¥≈¡
❍ ÕÕ°ƒΣΠ‘Ï¢¬“¬À≈Õ¥≈¡
3. ¬“ Ÿ¥„π√Ÿª¢Õ߬“º ¡
√–À«à“ß ICS ·≈–
LABA
4. Leukotriene
modifier
5. Xanthine
(sustained release)
6. Anti-IgE
❍ ≈¥°“√∫«¡¢ÕßÀ≈Õ¥≈¡ ‚¥¬
°“√≈¥ microvascular
leakage
❍ ¡’ª√– ‘ΣΠ‘¿“æ„π°“√√—°…“¥’
°«à“°“√„À⬓ ICS ·≈–
LABA ·¬°°—π
❍ ¬—∫¬—Èß°“√Σ”ß“π¢Õß
leukotriene·≈–ÕÕ°ƒΣΠ‘Ï
¢¬“¬À≈Õ¥≈¡
❍ ÕÕ°ƒΣΠ‘Ï¢¬“¬À≈Õ¥≈¡
❍ ‡ √‘¡ƒΣΠ‘Ï¢Õß corticosteroid
™π‘¥ Ÿ¥„π°“√™à«¬≈¥°“√
Õ—°‡ ∫
❍ μâ“π°“√ÕÕ°ƒΣΠ‘Ï IgE ‚¥¬
·¬àß IgE Σ’Ë®–¡“®—∫°—∫μ—«√—∫
Σ’Ëº‘«¢Õß mast cells ·≈–
basophils
❍ salmeterol °—∫
fluticasone
❍ formoterol °—∫
budesonide
❍ montelukast
❍ theophylline
❍ doxofylline
¬“©’¥
(omalizumab)
°≈ÿ࡬“ ™◊ËÕ “¡—≠ °≈‰°°“√ÕÕ°ƒΣΠ‘Ï
RELIEVER
MEDICATION
1. Short-acting
β2-agonist
❍ ÕÕ°ƒΣΠ‘Ï¢¬“¬À≈Õ¥≈¡
¬“ Ÿ¥
❍ salbutamol
❍ terbutaline
❍ procaterol
❍ fenoterol
¬“©’¥
❍ salbutamol
* °“√„™â¬“ long-acting β2-agonist Σ—Èß™π‘¥√—∫ª√–Σ“π·≈– Ÿ¥„π√–¬–¬“«
μâÕß„™â √à«¡°—∫ inhaled corticosteroid ‡ ¡Õ (πÈ”Àπ—°§”·π–π” ++)
** ¬“π’ȉ¡à·π–π”„Àâ„™â√—°…“ acute asthma ‡æ√“–ÕÕ°ƒΣΠ‘Ï™â“ ·≈–Õ“®¡’º≈
¢â“߇§’¬ß (πÈ”Àπ—°§”·π–π” -)
*** ÕÕ°ƒΣΠ‘Ï„π°“√¢¬“¬À≈Õ¥≈¡‰¥â‡√Á«Σ—¥‡Σ’¬¡°—∫¬“„π°≈ÿà¡ short-acting
β2-agonist
4.1.1 ¬“Σ’Ë„™â„π°“√§«∫§ÿ¡‚√§ (controller)
ƒΣΠμÏ‘Õàμ“âπ°“√Õ°—‡ ∫¢Õ߬“¡º’≈Σ”„À°â“√Õ°—‡ ∫„πºπß—À≈Õ¥≈¡≈¥≈ß
°“√„™â¬“„π°≈ÿà¡π’Èμ‘¥μàÕ°—π‡ªìπ‡«≈“π“π®–Σ”„Àâ°“√°”‡√‘∫¢Õß‚√§À◊¥≈¥≈ß
1. Corticosteroid
Corticosteroid ™π¥‘ ¥Ÿ‡ªπì¬“Σ¡Ë’ª’√– Σ‘Π¿‘“æ ߟ ¥ÿ·≈–
‡ªìπ¬“À≈—°„π°“√√—°…“‚√§À◊¥ (πÈ”Àπ—°§”·π–π” ++) ¬“ÕÕ°ƒΣΠ‘Ï‚¥¬°“√®—∫
°—∫ glucocorticoid receptor ¢Õß inflammatory cell Σ”„À⇰‘¥°“√
‡ª≈’ˬπ·ª≈ß°“√Σ”ß“π„π√–¥—∫™’«‚¡‡≈°ÿ≈¢Õ߬’π å¿“¬„π‡´≈≈套߰≈à“« ®÷ß¡’
º≈≈¥°“√ √â“ß cytokine Σ’Ë‡°’ˬ«¢âÕß°—∫°“√Σ”„À⇰‘¥°“√Õ—°‡ ∫ ¢≥–
16 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 17

20. ‡¥¬’«°π—Σ”„À¡â°’“√‡æ¡Ë‘¢πÈ÷¢Õß cytokine Σ‡Ë’°¬Ë’«¢Õâß°∫—°“√μÕàμ“âπ°“√Õ°—‡ ∫
√«¡Σ—È߬“ corticosteroid ¬—ß à߇ √‘¡Σ”„Àâ¿Ÿ¡‘μàÕμâ“π°“√Õ—°‡ ∫„πÀ≈Õ¥≈¡
¢ÕߺŸâªÉ«¬À◊¥°≈—∫¡“Σ”ß“πμ“¡ª°μ‘18 πÕ°®“°π’Ȭ—ߙ૬≈¥ microvascular
leakage ·≈–Σ”„Àâ β2-receptor „πÀ≈Õ¥≈¡Σ”ß“π¥’¢÷Èπ ª√– ‘ΣΠ‘¿“æ¢Õß
corticosteroid „π°“√√—°…“‚√§À◊¥ §◊Õ ™à«¬Σ”„ÀâÕ“°“√·≈–¿“«–À≈Õ¥≈¡
‰«μàÕ ‘Ëß°√–μÿâπ≈¥≈ß ¡√√∂¿“æ°“√Σ”ß“π¢Õߪե¢ÕߺŸâªÉ«¬¥’¢÷Èπ √«¡Σ—Èß
™«à¬≈¥Õμ—√“°“√μ“¬Σ‡Ë’°¥‘®“°‚√§À¥◊ ·≈–≈¥§«“¡∂¢Ë’ÕßÕ“°“√ÀÕ∫À¥◊°”‡√∫‘
Õ¬“à߉√°μÁ“¡¬“π®È’–‰¡Σà”„Àâ‚√§À¥◊À“¬¢“¥ ‡æ√“–æ∫«“à‡¡ÕË◊ºªâŸ«É¬À¬¥ÿ°“√√°—…“
Õ“°“√ÀÕ∫À◊¥Õ“®°≈—∫¡“Õ’°¿“¬„π‡«≈“‡ªìπ —ª¥“ÀåÀ√◊Õ‡ªìπ‡¥◊Õπ °“√„™â¬“
corticosteroid ™π‘¥ Ÿ¥ Õ“®æ∫º≈¢â“߇§’¬ß ‡™àπ ‡ ’¬ß·À∫ ‡™◊ÈÕ√“„π™àÕߪ“°
À“°„™â¬“„π¢π“¥ Ÿßμ‘¥μàÕ°—π‡ªìπ√–¬–‡«≈“π“π Õ“®‡°‘¥ ®È”‡¢’¬«μ“¡º‘«Àπ—ß
°“√Σ”ß“π¢ÕßμàÕ¡À¡«°‰μ≈¥≈ß §«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ°≈¥≈ß
μâÕ°√–®°·≈–μâÕÀ‘π
Corticosteroid ™π‘¥√—∫ª√–Σ“π„π¢π“¥πâÕ¬Σ’Ë ÿ¥ „™â„π
°“√√°—…“ºªâŸ«É¬‚√§À¥◊‡√ÕÈ◊√ß—Σ¡Ë’Õ’“°“√√πÿ·√ß ·≈–‰¥√â∫—°“√√°—…“¥«â¬¬“¢π“πÕπË◊
Õ¬“à߇μ¡ÁΣ·Ë’≈«â (μ“√“ßΣ Ë’6 step 5) ·μ¬àß—§«∫§¡ÿÕ“°“√‰¡à‰¥ â(π”ÈÀπ°—§”·π–π”
+) „π¢≥–Σ’Ë corticosteroid ™π‘¥©’¥¡’Σ’Ë„™â„πºŸâªÉ«¬Σ’Ë¡’Õ“°“√°”‡√‘∫¢Õß‚√§
‡©’¬∫æ≈—π·≈–√ÿπ·√ß (πÈ”Àπ—°§”·π–π” ++)
μ“√“ßΣ’Ë 5 ‡ª√’¬∫‡Σ’¬∫¢π“¥μà“ßÊ ¢Õ߬“ ICS ¢Õ߬“·μà≈–™π‘¥13
ICS Low daily Medium daily High daily
dose µg dose µg dose µg
Beclomethasone dipropionate 200 › 500 > 500 › 1000 > 1000 › 2000
Budesonide 200 › 400 > 400 › 800 > 800 › 1600
Fluticasone propionate 100 › 250 > 250 › 500 > 500 › 1000
Ciclesonide 80 › 160 > 160 › 320 > 320 › 1280
Mometasone furoate 200 › 400 > 400 › 800 > 800 › 1200
2. β2-agonist ™π¥‘ÕÕ°ƒΣΠ¬Ï‘“« (inhaled long-acting
β2-agonist, LABA)
πÕ°®“°¡ƒ’ΣΠÏ‘„π°“√¢¬“¬À≈Õ¥≈¡ ¬“π¬È’ß—ÕÕ°ƒΣΠ‡Ï‘æ¡Ë‘
mucociliary clearance ≈¥ vascular permeability ¬—∫¬—Èß°“√À≈—Ëß mediator
®“° mast cell ·≈– basophil ·≈–≈¥°“√Õ—°‡ ∫‚¥¬Σ”„Àâ®”π«π neutrophil
„πÀ≈Õ¥≈¡≈¥≈ß19-20 ´ßË÷Õ“®¡º’≈¥μ’Õà°“√ªÕÑß°π—°“√‡°¥‘Õ“°“√ÀÕ∫À¥◊°”‡√∫‘
Σ‡Ë’°¬Ë’«¢Õâß°∫— neutrophil21 Õ¬“à߉√°μÁ“¡°“√„™¬â“πÈ’„π√–¬–¬“«®”‡ªπìμÕâß
„™â√à«¡°—∫ ICS ‡ ¡Õ (πÈ”Àπ—°§”·π–π” ++)
3. ¬“ Ÿ¥„π√Ÿª¢Õ߬“º ¡√–À«à“ß ICS ·≈– LABA
¬“ Ÿ¥„π√Ÿª¢Õ߬“º ¡√–À«à“ß ICS ·≈– LABA ‡™àπ
salmeterol °—∫ fluticasone À√◊Õ formoterol °—∫ budesonide Σ’Ë∫√√®ÿ„π
‡§√ÕË◊ßæπଓ‡¥¬’«°π— πÕ°®“°‡æ¡Ë‘§«“¡ –¥«°„π°“√∫√À‘“√¬“„À·â°ºàªâŸ«É¬·≈«â
¬ß—¡ª’√– Σ‘Π¿‘“æ„π°“√§«∫§¡ÿÕ“°“√¥°’«“à°“√∫√À‘“√¬“·μ≈à–¢π“πº“àπ‡§√ÕË◊ß
æàπ·¬°°—π¥â«¬ °“√„™â formoterol °—∫ budesonide ‡ªìπ maintenance ·≈–
reliever πÕ°®“° “¡“√∂§«∫§ÿ¡Õ“°“√¢Õß‚√§À◊¥‰¥â¥’·≈â« °“√√—°…“·∫∫π’È
¬—ßΣ”„Àâ®”π«π ICS Σ’Ë„™âπâÕ¬°«à“°“√√—°…“·∫∫‡¥‘¡22-23 (§ÿ≥¿“æÀ≈—°∞“π
√–¥—∫ 1, πÈ”Àπ—°§”·π–π” ++)
4. Leukotriene modifier
ÕÕ°ƒΣΠ‘Ïμâ“π°“√ —߇§√“–Àå leukotriene À√◊Õμâ“π°“√
ÕÕ°ƒΣΠ¢Ï‘Õß leukotriene Σ Ë’leukotriene receptor ¡°’“√»°÷…“À≈“¬°“√»°÷…“
Σ’Ëæ∫«à“ª√– ‘ΣΠ‘¿“æ¢Õ߬“ leukotriene modifier ¥âÕ¬°«à“ corticosteroid
™π‘¥ Ÿ¥ ®÷߇À¡“–Σ’Ë®–„™â¬“π’ȇªì𬓇 √‘¡°—∫ ICS „π°“√√—°…“ºŸâªÉ«¬À◊¥™π‘¥
√ÿπ·√ß À√◊Õ„™â‡ªì𬓇¥’ˬ« Ê „π°“√√—°…“ºŸâªÉ«¬À◊¥«—¬‡¥Á°À√◊ÕºŸâªÉ«¬‚√§À◊¥
√πÿ·√ßπÕâ¬Σ¬Ë’ß—‰¡‡à§¬√°—…“¡“°Õàπ ‚¥¬‡©æ“–„π√“¬ΣμË’Õâß°“√À≈°’‡≈¬Ë’ß°“√„™â
corticosteroid ™π‘¥ Ÿ¥ ¥—ß„πμ“√“ßΣ’Ë 6 step 2 (πÈ”Àπ—°§”·π–π” ++) ¢âÕ¥’
§◊Õ ‡ªì𬓇¡Á¥Σ”„Àâ°‘πßà“¬ ¢âÕ‡ ’¬§◊Õ√“§“·æß ¢âÕ∫àß„™â摇»…§◊Õ„™â„π√“¬Σ’Ë
‡°‘¥Õ“°“√ÀÕ∫À◊¥®“°¬“°≈ÿà¡ NSAID ·≈–ºŸâªÉ«¬‚√§À◊¥Σ’Ë¡’ allergic rhinitis
√à«¡¥â«¬ (πÈ”Àπ—°§”·π–π” ++)
18 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 19

21. 5. Xanthine
¡’ª√– ‘ΣΠ‘¿“æπâÕ¬°«à“ LABA ·≈–¡’ªí≠À“„π°“√„™â
‡πÕË◊ß®“°μÕâߪ√∫—¢π“¥¬“„π‡≈Õ◊¥„À≥√â–¥∫—‡À¡“– ¡ ·≈–‡°¥‘Õ“°“√¢“â߇§¬’ß
‰¥âßà“¬ º≈¢Õ߬“„π√–¥—∫μË”¡’ƒΣΠ‘Ï¢¬“¬À≈Õ¥≈¡·≈–Õ“®¡’ƒΣΠ‘Ïμâ“π°“√
Õ—°‡ ∫‰¥â¥â«¬ ·π–π”„Àâ‡≈◊Õ°„™â™π‘¥ sustained released theophylline
(πÈ”Àπ—°§”·π–π” +)
6. Anti-IgE
Anti-IgE (omalizumab) ÕÕ°ƒΣΠ‘Ï‚¥¬°“√®—∫°—∫ free
IgE Σ’Ëμ”·ÀπàߢÕß Ce3 domain ¢Õß Fc fragment ‡°‘¥‡ªìπ immune complex
®÷ßΣ”„Àâ√–¥—∫¢Õß IgE ≈¥≈ß·≈–‰¡à “¡“√∂®—∫°—∫ high affinity receptor
(FceRI) Σ’ËÕ¬Ÿà∫πº‘«¢Õß mast cell ·≈– basophil ¥—ßπ—Èπ ®÷߉¡à¡’°“√À≈—Ëß
“√‡§¡Õ’Õ°¡“®“°‡´≈≈¥åß—°≈“à«¡“Σ”„ÀÕâ“°“√À¥◊°”‡√∫‘ ¬“π‡È’À¡“– ”À√∫—ºªâŸ«É¬
‚√§À¥◊Σ¡Ë’Õ’“°“√√πÿ·√ß¡“° ·≈–‰¡ à“¡“√∂§«∫§¡ÿÕ“°“√‰¥¥â«â¬ corticosteroid
™π‘¥ Ÿ¥¢π“¥ Ÿß √à«¡°—∫¬“ controller ™π‘¥Õ◊Ëπ Ê À√◊ÕμâÕß√—∫ª√–Σ“π¬“
corticosteroid „π¢π“¥ Ÿß √à«¡¥â«¬‡ªìπ√–¬–‡«≈“π“π ·≈–ºŸâªÉ«¬√“¬π—Èπ
®–μâÕ߇ªìπ allergic asthma Σ’Ë¡’√–¥—∫¢Õß IgE „π‡≈◊Õ¥ Ÿßº‘¥ª°μ‘ (πÈ”Àπ—°
§”·π–π” ++) °“√„™¬â“π§È’«√Õ¬¿àŸ“¬„μ°â“√¥·Ÿ≈¢Õß·æΣ¬ºå‡âŸ™¬Ë’«™“≠‡Σ“àππÈ—
4.1.2 ¬“∫√√‡Σ“Õ“°“√ (reliever)
¡ƒ’ΣΠªÏ‘ÕÑß°π—·≈–√°—…“Õ“°“√À¥‡°√ßÁ¢ÕßÀ≈Õ¥≈¡Σ‡Ë’°¥‘¢πÈ÷ ·μà
®–‰¡à¡’º≈μàÕ°“√Õ—°‡ ∫Σ’Ë‡°‘¥¢÷Èπ„πºπ—ßÀ≈Õ¥≈¡ ‰¥â¡’°“√»÷°…“ºŸâªÉ«¬‚√§À◊¥Σ’Ë
‰¥â√—∫¬“¢¬“¬À≈Õ¥≈¡μ‘¥μàÕ°—π‡ªìπ‡«≈“π“π æ∫«à“‰¡à™à«¬„Àâ°“√Õ—°‡ ∫¢Õß
À≈Õ¥≈¡≈¥≈ß
1. β2-agonist ™π‘¥ÕÕ°ƒΣΠ‘Ï —Èπ (short-acting β2-
agonist) πÕ°®“°ÕÕ°ƒΣΠ‘Ï¢¬“¬À≈Õ¥≈¡·≈â« ¬—ßΣ”„Àâ mucociliary
clearance ¥’¢÷Èπ√«¡Σ—ÈßΣ”„Àâ vascular permeability ≈¥≈ß ¬“„π°≈ÿà¡π’È
à«π„À≠à¡’ƒΣΠ‘Ï¢¬“¬À≈Õ¥≈¡Õ¬Ÿà‰¥âπ“πª√–¡“≥ 4 › 6 ™—Ë«‚¡ß °“√∫√‘À“√
¬“„π°≈ÿà¡π’È„À≥âΣ—Èß°“√©’¥ √—∫ª√–Σ“π ·≈– Ÿ¥ Õ¬à“߉√°Á¥’°“√∫√‘À“√¬“Σ’Ë¡’
°“√©’¥μ‘¥μàÕ°—π ·æΣ¬åºŸâ√—°…“®–μâÕߥŸ·≈ ¡¥ÿ≈¢Õß electrolyte ‡æ√“–
¬“°≈ÿà¡π’ÈÕ“®Σ”„À⇰‘¥¿“«– hypokalemia ‰¥â (πÈ”Àπ—°§”·π–π” ++) à«π
β2-agonist ™π‘¥√—∫ª√–Σ“π‰¡à‡ªìπΣ’Ëπ‘¬¡‡æ√“–ºŸâªÉ«¬¡—°®–¡’Õ“°“√¢â“߇§’¬ß
‰¥â·°à ¡◊Õ —Ëπ „® —Ëπ oe≈oe ¢π“¥¢Õ߬“Σ’Ë„™â„π°“√√—°…“ ®“° metered-dose
inhaler (MDI) §◊Õ 200 › 500 ¡°. ·≈–®“° nebulizer §◊Õ 2.5 › 5 ¡°.
‡¡◊ËÕ¡’Õ“°“√ÀÕ∫‡Àπ◊ËÕ¬ °“√„À⬓ β2-agonist Ÿ¥„π¢π“¥ Ÿß°«à“π’È¡’¢âÕ∫àß„™â
„π°“√√—°…“ºŸâªÉ«¬‚√§À◊¥Σ’Ë¡’ acute severe attack ´÷Ëß°“√√—°…“„π≈—°…≥–π’È
‰¥âº≈¥’Σ—¥‡Σ’¬¡°—∫°“√©’¥¬“ adrenaline ‡¢â“„μ⺑«Àπ—ß24 (πÈ”Àπ—°§”·π–π” ++)
2. Methylxanthine ª®í®∫ÿπ—¡Σ’Ë’„™πâÕâ¬≈ß ‡πÕË◊ß®“°¬“ÕÕ°
ƒΣΠ‘Ï™â“ ‰¡à·π–π”„Àâ„™â methylxanthine ‡ªìπª√–®” aminophylline ™π‘¥©’¥
¡’¢âÕ∫àß„™â‡©æ“–„π°“√√—°…“ºŸâªÉ«¬ acute severe asthma À√◊Õ status
asthmaticus Σ’Ë„™â¬“ β2-agonist ·≈⫉¡à‰¥âº≈
3. Anticholinergic/β2-agonist ¬“„π°≈¡àÿπΣÈ’πË’¬‘¡„™√â°—…“
‚√§À◊¥„πªí®®ÿ∫—π ‰¥â·°à ¬“ Ÿ¥„π√Ÿª¢Õ߬“º ¡√–À«à“ß ipratropium bromide
°—∫ fenoterol À√◊Õ salbutamol ‚¥¬‡©æ“–„π√“¬Σ’Ë¡’Õ“°“√ÀÕ∫À◊¥°”‡√‘∫
·≈â«„™â¬“„π°≈ÿà¡ β2-agonist ¡“°àÕπ·μà‰¡à‰¥âº≈ (πÈ”Àπ—°§”·π–π” ++)
4.2 °“√√—°…“ºŸâªÉ«¬‚√§À◊¥‡√◊ÈÕ√—ß (persistent asthma)
4.2.1 ¢—ÈπμÕπ°“√√—°…“ºŸâªÉ«¬‚√§À◊¥‡√◊ÈÕ√—ß
ºŸâªÉ«¬‚√§À◊¥‡√◊ÈÕ√—ß (persistent asthma) Σ’Ë‰¡à‡§¬‰¥â√—∫
corticosteroid ™π‘¥ Ÿ¥¡“°àÕπ ·≈–Õ“°“√√ÿπ·√߉¡à¡“° §«√‡√‘Ë¡μâπ°“√√—°…“
¥â«¬ corticosteroid ™π‘¥ Ÿ¥„π¢π“¥πâÕ¬25-26 (§ÿ≥¿“æÀ≈—°∞“π √–¥—∫ 1,
πÈ”Àπ—°§”·π–π” ++) μ“¡ step 2 (μ“√“ßΣ’Ë 6) „π¢≥–Σ’ËºŸâªÉ«¬¡’Õ“°“√√ÿπ·√ß
¡“°°«“à (moderate persistent ¥ß—μ“√“ßΣ Ë’2 À√Õ◊‡¢“≥°â∫— partly controlled
¥—ßμ“√“ßΣ’Ë 3) ·π–π”„Àℙ⬓„π step 3 (πÈ”Àπ—°§”·π–π” ++)
à«πºŸâªÉ«¬Σ’ˇ§¬‰¥â√—∫°“√√—°…“¥â«¬ corticosteroid ™π‘¥ Ÿ¥
Õ¬·àŸ≈«â „Àªâ√–‡¡π‘√–¥∫—°“√§«∫§¡ÿ‚√§À¥◊«“àÕ¬àŸ„π°≈¡àÿ partly À√Õ◊ uncontrolled
·≈–„À°â“√√°—…“‚¥¬ª√∫—¬“‡æ¡Ë‘¢πÈ÷‰ªÕ°’ 1 step ∂“âÕ“°“√¬ß—Õ¬àŸ„π√–¥∫— partly
20 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 21

22. controlled À√◊Õ uncontrolled ·μà∂â“°“√§«∫§ÿ¡Õ¬Ÿà„π√–¥—∫ controlled
Õ¬Ÿà·≈â«°Á„À⬓„π¢π“¥‡¥‘¡μàÕ‰ª „π·μà≈–¢—Èπ¢Õß°“√√—°…“ºŸâªÉ«¬®–‰¥â√—∫¬“
β2-agonist ™π¥‘æπà ¥ŸÕÕ°ƒΣΠ‡Ï‘√«Á‡æÕË◊∫√√‡Σ“Õ“°“√ÀÕ∫À¥◊Σ‡Ë’°¥‘¢πÈ÷ (π”ÈÀπ°—
§”·π–π” ++) „π°√≥’Σ’ËºŸâªÉ«¬μâÕß„™â¬“ β2-agonist ™π‘¥æàπ Ÿ¥À≈“¬§√—Èß
„πÀπ÷Ëß«—π · ¥ß«à“‚√§À◊¥¢ÕߺŸâªÉ«¬Õ¬Ÿà„π¢—Èπ§«∫§ÿ¡Õ“°“√‰¡à‰¥â ºŸâªÉ«¬§«√‰¥â
√—∫°“√ª√—∫‡æ‘Ë¡¢π“¥¢Õ߬“ ICS ¢÷Èπ À√◊Õ ‡æ‘Ë¡¬“ controller ™π‘¥Õ◊Ëπ‡¢â“¡“
√à«¡„π°“√√—°…“ ®π “¡“√∂§«∫§ÿ¡Õ“°“√¢Õß‚√§‰¥â (πÈ”Àπ—°§”·π–π” ++)
μ“√“ßΣ’Ë 6 ¢—ÈπμÕπ°“√√—°…“ºŸâªÉ«¬‚√§À◊¥‡√◊ÈÕ√—ß*
Reduce Treatment Steps Increase
Step 1 Step 2 Step 3 Step 4
Asthma education
Environmental control
As needed
rapid-acting
β2-agonist
Step 5
As needed rapid- acting β2-agonist
Select one Select one
Low-dose
inhaled
ICS*
Leukotriene
modifier
Low-dose ICS
plus
long-acting
β2-agonist
Medium-or-high-
dose ICS
Low-dose ICS
plus leukotriene
modifier
Low-dose ICS
plus sustained
release
theophylline
Add one or
more
Medium-or-high-
dose ICS
plus
long-acting
β2-agonist
Leukotriene
modifier
Sustained
release
theophylline
Controller
options
* ICS-inhaled glucocorticosteroid
Add one or
both
Oral glucocor-ticosteroid
(lowest dose)
Anti-lgE
treatment
* Σ’Ë¡“ Global Initiative Asthma 2006
°“√‡≈◊Õ°„™â¬“„π°“√√—°…“μ“¡≈”¥—∫°àÕπÀ≈—ß „Àâ‡≈◊Õ°„™â¬“Σ’ËÕ¬Ÿà„π·∂∫ ’‡¢â¡°àÕπ
22 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 23

23. °“√√—°…“¢—ÈπΣ’Ë 1 („Àâ„™â β2-agonist ™π‘¥ Ÿ¥ÕÕ°ƒΣΠ‘Ï‡√Á«)
·π–π”„Àâ√—°…“¥â«¬ β2-agonist ™π‘¥ Ÿ¥ÕÕ°ƒΣΠ‘Ï‡√Á« ‡©æ“–‡¡◊ËÕ¡’
Õ“°“√‡Σà“π—Èπ „πºŸâªÉ«¬‚√§À◊¥Σ’Ë¡’≈—°…≥–μàÕ‰ªπ’È (πÈ”Àπ—°§”·π–π” ++)
✧ ¬—߉¡à‡§¬√—°…“¡“°àÕπ
✧ ¡’Õ“°“√ÀÕ∫À◊¥ (‰Õ ‡Àπ◊ËÕ¬ À“¬„®¡’‡ ’¬ßÀ«’¥) ™à«ß°≈“ß«—π
✧ Õ“°“√ÀÕ∫À◊¥‡°‘¥¢÷Èπ < 2 §√—ÈßμàÕ —ª¥“Àå À√◊Õ‡°‘¥Õ“°“√™à«ß
°≈“ߧ◊ππ“π Ê §√—Èß
✧ ·μà≈–§√—Èß¡’Õ“°“√πâÕ¬°«à“ 2 - 3 ™—Ë«‚¡ß
✧ ™à«ßª°μ‘μâÕ߉¡à¡’Õ“°“√ÀÕ∫À◊¥‡≈¬·≈–μâÕ߉¡àμ◊Ëπ°≈“ߧ◊π
®“°Õ“°“√ÀÕ∫À◊¥ (nocturnal awakening) ‡≈¬
✧ ¡’ ¡√√∂¿“æ°“√Σ”ß“π¢Õߪեª°μ‘
✧ ¡’Õ“°“√ÀÕ∫À◊¥Σ’ˇ°‘¥®“°°“√ÕÕ°°”≈—ß°“¬ (exercised-induced
asthma)
°“√√—°…“¢—ÈπΣ’Ë 2 („Àâ‡≈◊Õ°„™â¬“§«∫§ÿ¡‚√§¢π“π„¥¢π“πÀπ÷Ë߇Σà“π—Èπ)
·π–π”„Àâ√—°…“¥â«¬ β2-agonist ™π‘¥ Ÿ¥ÕÕ°ƒΣΠ‘Ï‡√Á« ‡©æ“–‡¡◊ËÕ¡’
Õ“°“√ÀÕ∫À◊¥ √à«¡°—∫°“√„™â¬“ controller 1 ™π‘¥ ‡æ◊ËÕ§«∫§ÿ¡‚√§À◊¥ ¬“
controller ™π‘¥·√°Σ’Ë·π–π”§◊Õ ¬“ Ÿ¥corticosteroid ¢π“¥μË”25-26 (§ÿ≥¿“æ
À≈—°∞“π √–¥—∫ 1, πÈ”Àπ—°§”·π–π” ++) (μ“√“ßΣ’Ë 5, 6) À√◊Õ Õ’°Σ“߇≈◊Õ°Àπ÷Ëß
§◊Õ√—°…“¥â«¬¬“°≈ÿà¡ leukotriene modifier27-29 (§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1,
πÈ”Àπ—°§”·π–π” ++) ´÷Ë߇À¡“– ”À√—∫ºŸâªÉ«¬Σ’ˉ¡àÕ¬“°„™â À√◊Õ‰¡à∂𗥄™â¬“
corticosteroid ™π‘¥ Ÿ¥ À√◊Õ‡§¬‡°‘¥º≈¢â“߇§’¬ß®“°¬“ ‡™àπ ‡ ’¬ß·À∫‡√◊ÈÕ√—ß
À√◊Õ¡’Õ“°“√ allergic rhinitis30-31 (§ÿ≥¿“æÀ≈—°∞“π √–¥—∫ 3)
°“√√—°…“¢—ÈπΣ’Ë 3 („Àâ‡≈◊Õ°„™â¬“§«∫§ÿ¡‚√§‡¥’ˬ« Ê À√◊Õ‡≈◊Õ°§Ÿà„¥§ŸàÀπ÷Ë߇Σà“π—Èπ)
·π–π”„Àâ√—°…“¥â«¬ β2-agonist ™π‘¥ Ÿ¥ÕÕ°ƒΣΠ‘Ï‡√Á« ‡©æ“–‡¡◊ËÕ¡’
Õ“°“√ÀÕ∫À◊¥ (πÈ”Àπ—°§”·π–π” ++) √à«¡°—∫°“√„™â corticosteroid ™π‘¥ Ÿ¥
¢π“¥μË”·≈–¬“ long-acting β2-agonist ™π‘¥ Ÿ¥32-33 (§ÿ≥¿“æÀ≈—°∞“π √–¥—∫
1, πÈ”Àπ—°§”·π–π” ++) Σ“ß‡≈◊Õ°Õ◊Ëπ Ê §◊Õ
✧ ª√∫—‡æ¡Ë‘¢π“¥¬“ ¥Ÿ corticosteroid ™π¥‘ ¥Ÿ ΣË’„™Õâ¬®àŸ“°¢π“¥μ”Ë
‡ªìπ¢π“¥°≈“ß34-36 À√◊Õ Ÿß (§ÿ≥¿“æÀ≈—°∞“π √–¥—∫ 1, πÈ”Àπ—°§”·π–π” ++)
„π√Ÿª¢Õß pressurized metered-dose inhaler (pMDI) ºà“πΣ“ß spacer device
‡æ◊Ëՙ૬„À⬓°√–®“¬‡¢â“À≈Õ¥≈¡¡“°¢÷Èπ ´÷Ëß®–≈¥º≈¢â“߇§’¬ß„π™àÕߪ“°
·≈–™«à¬≈¥°“√¥¥Ÿ´¡÷¢Õ߬“‡¢“â √àŸ“àß°“¬ (systemic absorption)37-39 (§≥ÿ¿“æ
À≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” ++)
✧ „™â corticosteroid ™π‘¥ Ÿ¥ ¢π“¥μË” √à«¡°—∫°‘𬓠leukotriene
modifier40-47 (§ÿ≥¿“æÀ≈—°∞“π √–¥—∫ 1, πÈ”Àπ—°§”·π–π” +)
✧ „™â¬“ Ÿ¥ corticosteroid ™π‘¥ Ÿ¥ ¢π“¥μË” √à«¡°—∫°‘π¬“
sustained release theophylline48 (§ÿ≥¿“æÀ≈—°∞“π √–¥—∫ 2, πÈ”Àπ—°
§”·π–π” +)
°“√√—°…“¢—ÈπΣ’Ë 4 (ºŸâªÉ«¬Σ’ˉ¥â√—∫ ICS ·≈– LABA Õ¬Ÿà·≈â«„Àâ‡æ‘Ë¡¬“§«∫§ÿ¡‚√§
¢÷Èπ§√—Èß≈–¢π“π)
°“√‡≈◊Õ°„™â¬“√—°…“¢—ÈπΣ’Ë 4 ¢÷ÈπÕ¬Ÿà°—∫«à“‡§¬„™â¬“ª√–‡¿Σ„¥„π¢—ÈπΣ’Ë
2 ·≈– 3 ¡“°àÕπ Õ¬à“߉√°Áμ“¡ ≈”¥—∫°“√‡≈◊Õ°„™â¬“μâÕߧ”π÷ß∂÷ߪ√– ‘ΣΠ‘¿“æ
¢Õ߬“Σ’Ë®–‡≈◊Õ°„™â ‚¥¬Õ“»—¬¢âÕ¡Ÿ≈®“°°“√»÷°…“ ´÷Ë߇Σà“Σ’Ë¡’Õ¬Ÿà„πªí®®ÿ∫—π
·π–π”„Àâ„™â β2-agonist ™π‘¥ Ÿ¥ÕÕ°ƒΣΠ‘Ï‡√Á« ‡©æ“–‡¡◊ËÕ¡’Õ“°“√ÀÕ∫À◊¥
√à«¡°—∫°“√„™â¬“μàÕ‰ªπ’È
✧ ‡√¡Ë‘¥«â¬°“√„À âcorticosteroid ™π¥‘ ¥Ÿ ¢π“¥°≈“ß À√Õ◊¢π“¥
Ÿß √à«¡°—∫¬“ Ÿ¥ long-acting β2-agonist (§ÿ≥¿“æÀ≈—°∞“π √–¥—∫ 1,
πÈ”Àπ—°§”·π–π” ++)
✧ ‡æ‘Ë¡¬“ leukotriene modifier49 (§ÿ≥¿“æÀ≈—°∞“π √–¥—∫ 1,
πÈ”Àπ—°§”·π–π” +)
✧ ‡æ‘Ë¡¬“ sustained release theophylline50 (§ÿ≥¿“æÀ≈—°∞“π
√–¥—∫ 1, πÈ”Àπ—°§”·π–π” ++)
24 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 25

24. °“√√—°…“¢—ÈπΣ’Ë 5 („Àâ‡æ‘Ë¡¬“Σ’Ë‰¥â√—∫®“°°“√√—°…“¢—ÈπΣ’Ë 4 ¢÷Èπ§√—Èß≈– 1 ∂÷ß 2
¢π“π)
ºŸâªÉ«¬Σ’˧«√‰¥â√—∫°“√√—°…“¢—ÈπΣ’Ë 5 §◊Õ ºŸâªÉ«¬Σ’Ë¡’Õ“°“√√ÿπ·√ß·≈–
Õ¬Ÿà„π√–¥—∫Σ’Ë§«∫§ÿ¡‰¡à‰¥â ·≈–‰¥â√—∫°“√√—°…“¥â«¬¬“„π¢—ÈπΣ’Ë 4 ¡“·≈â«
·π–π”„Àâ„™â β2-agonist ™π‘¥ Ÿ¥ÕÕ°ƒΣΠ‘Ï‡√Á« ‡¡◊ËÕ¡’Õ“°“√ÀÕ∫À◊¥ √à«¡°—∫„Àâ
§ß¬“ controller ¢Õß°“√√—°…“¢—ÈπΣ’Ë 4 ‰«â ·≈–‡æ‘Ë¡¬“Õ◊Ëπ Ê √à«¡¥â«¬¥—ßμàÕ‰ªπ’È
✧ „À⬓ corticosteroid ™π‘¥√—∫ª√–Σ“π„π¢π“¥μË”51 (§ÿ≥¿“æ
À≈—°∞“π √–¥—∫ 4, πÈ”Àπ—°§”·π–π” +)
✧ °“√„À⬓ anti-IgE ®–™à«¬§«∫§ÿ¡Õ“°“√¢ÕߺŸâªÉ«¬ allergic
asthma Σ¡Ë’¢’Õâ∫ßà™®È’”‡æ“–52-57 (§≥ÿ¿“æÀ≈°—∞“π √–¥∫— 1, π”ÈÀπ°—§”·π–π” ++)
°“√√—°…“ºŸâªÉ«¬¢—ÈπΣ’Ë 4 À√◊Õ 5 §«√Õ¬Ÿà„𧫓¡¥Ÿ·≈¢Õß·æΣ¬å
ºŸâ™”π“≠‚√§π’È‚¥¬‡©æ“–
4.2.2 √–¬–‡«≈“Σ’Ë‡√‘Ë¡μÕ∫ πÕßμàÕ°“√√—°…“
À≈ß—√°—…“¥«â¬¬“ controller Õ“°“√ÀÕ∫À¥◊¢ÕߺªâŸ«É¬ «àπ„À≠à
®–‡√‘Ë¡¥’¢÷Èπ¿“¬„π‡«≈“π—∫‡ªìπ«—π‰¥â ·≈–¥’¢÷Èπ‡μÁ¡Σ’Ë¿“¬„π‡«≈“ 3 - 4 ‡¥◊ÕπÀ≈—ß
√—°…“16, 58
4.2.3 °“√ª√—∫‡ª≈’ˬπ°“√√—°…“10, 13
‚√§À◊¥‡ªìπ‚√§Σ’Ë¡’°“√‡ª≈’ˬπ·ª≈ߢÕßÕ“°“√‡°‘¥¢÷Èπ‰¥âμ≈Õ¥
‡«≈“ °“√√°—…“‚√§π®È’ß÷μÕâß¡°’“√ª√∫—‡ª≈¬Ë’π¬“ΣË’„™â„π°“√√°—…“„À‡âÀ¡“– ¡‡æÕË◊
Σ®Ë’–§«∫§¡ÿÕ“°“√¢Õß‚√§„À≥¥âΣ’ Ë’¥ÿ ‚¥¬·æΣ¬ºå√⟰—…“®–ª√–‡¡π‘º≈°“√§«∫§¡ÿ
‚√§¢ÕߺŸâªÉ«¬®“°°“√√—°…“ (assessing asthma control) Σ’Ë°”≈—߉¥â√—∫ (√ŸªΣ’Ë
1) ·≈–¡’°“√ª√—∫¬“Σ’Ë„™â„π°“√√—°…“¢÷ÈπÀ√◊Õ≈ßμ“¡√–¥—∫°“√§«∫§ÿ¡‚√§ ‚¥¬
¡’‡ªÑ“À¡“¬Σ’Ë®–§«∫§ÿ¡Õ“°“√¢Õß‚√§„À≥â (treating to achieve control)
À≈ß—®“°ππÈ—°®Á–¡°’“√ª√–‡¡π‘º≈°“√§«∫§¡ÿ‚√§À¥◊‡ªπì√–¬– Ê (monitoring to
maintain control) ·≈–¡’°“√ª√—∫‡ª≈’ˬπ°“√√—°…“μ“¡§«“¡®”‡ªìπ‡æ◊ËÕΣ’Ë®–
§«∫§ÿ¡Õ“°“√¢Õß‚√§‰¥âμ≈Õ¥‰ª (πÈ”Àπ—°§”·π–π” ++)
Assessing asthma control
Treating to
achieve control
Monitoring to
maintain control
√ŸªΣ’Ë 1 ·π«Σ“ß°“√ª√—∫‡ª≈’ˬπ°“√√—°…“
✧ °“√ª√—∫≈¥¬“≈߇¡◊ËÕ§«∫§ÿ¡Õ“°“√‰¥â (Stepping down treatment)
ª®í®∫ÿπ—¬ß—¢“¥¢Õâ¡≈Ÿ‡°¬Ë’«°∫—√–¬–‡«≈“¢Õß°“√√°—…“Σ‡Ë’À¡“– ¡°Õàπ
Σ’Ë®–‡√‘Ë¡ª√—∫≈¥¬“ ≈”¥—∫¢—ÈπμÕπ¢Õß°“√≈¥¬“ ·≈– ª√‘¡“≥¬“Σ’Ë§«√≈¥„π
·μ≈à–§√ßÈ—‚¥¬‰¡Σà”„ÀÕâ“°“√ÀÕ∫À¥◊°”‡√∫‘ Õ¬“à߉√°μÁ“¡®“°¢Õâ¡≈ŸΣ¡Ë’’„πª®í®∫ÿπ—
·π–π”„ÀâªØ‘∫—μ‘¥—ßπ’È
1. ºŸâªÉ«¬Σ’Ë√—°…“¥â«¬ corticosteroid ™π‘¥ Ÿ¥ ¢π“¥°≈“ßÀ√◊Õ Ÿß
Õ¬“à߇¥¬’«À≈ß—®“°§«∫§¡ÿÕ“°“√‰¥μ⥑μÕà°π—‡ªπ쇫≈“μßÈ—·μ à3 ‡¥Õ◊π „À≈⥢π“¥
corticosteroid ™π‘¥ Ÿ¥≈ߧ√—Èß≈– 50% Σÿ° 3 ‡¥◊Õπ ‚¥¬Σ’Ë°“√≈¥¢π“¥¬“≈ß
μâÕ߉¡àΣ”„ÀâÕ“°“√À◊¥°”‡√‘∫59-61 (§ÿ≥¿“æÀ≈—°∞“π √–¥—∫ 1, πÈ”Àπ—°§”·π–π”
++) ®π°√–Σ—Ëß “¡“√∂≈¥¬“ Ÿ¥ corticosteroid ™π‘¥ Ÿ¥≈ß¡“‡À≈◊Õ¢π“¥μË”
·≈⫧àÕ¬„À⇪≈’Ë¬π‰ª„™â corticosteroid ™π‘¥ Ÿ¥¢π“¥μË”π—Èπ·∫∫«—π≈–§√—Èß
(§ÿ≥¿“æÀ≈—°∞“π √–¥—∫ 1, πÈ”Àπ—°§”·π–π” ++)62-63
2. ºŸâªÉ«¬Σ’Ë√—°…“¥â«¬¬“ Ÿ¥ corticosteroid ™π‘¥ Ÿ¥ √à«¡°—∫¬“ Ÿ¥
long-acting β2-agonist À≈—ß®“°Õ“°“√§«∫§ÿ¡‰¥âμ‘¥μàÕ°—πÕ¬à“ßπâÕ¬ 3 ‡¥◊Õπ
°“√ª√—∫≈¥¬“Õ“®Σ”‰¥â¥—ßπ’ȧ◊Õ
- §Õà¬ Ê ≈¥¢π“¥¬“ corticosteroid ™π¥‘ ¥Ÿ≈ß°Õàπ§√ßÈ—≈– 50%
26 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 ·π«ªØ‘∫—μ‘∫√‘°“√ “Π“√≥ ÿ¢ °“√¥Ÿ·≈ºâŸªÉ«¬‚√§À◊¥ æ.». 2551 27