..

2547

1 2547
10,000

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. --. I. .
.
ISBN 974-92592-9-7

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:

1281
10400
. 0-2619-8907 0-2619-8907

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6

(bronchial hyperresponsiveness, BHR)

1
..

()

()

25441 12,219 20-44

25452 3,454 20-44

(%)
(%)

6.8
16.4

4.0
3.25

BHR
(%)

(%)

3.31

2.91

.. 2547


.. 2545
102,245 1,000,000


.. 25373 2 .. 25404

corticosteroid

1 15%
21%

6.7% corticosteroid 5


1.

2.

3.

4. allergic rhinitis, allergic
conjunctivitis allergic dermatitis
5.

6.

wheeze

- COPD
- acute pulmonary edema
- foreign body aspiration
- gastro-esophageal reflux
- bronchiectasis
.. 2547



FEV1 (forced expiratory volume
in one second) PEF (peak
expiratory flow) peak flow meter
reversible airflow obstructiion FEV1
12 PEF 15
corticosteroid

(variable) PEF
1-2
20

PEF - PEF 100

1/2 (PEF + PEF )

bronchial hyperresponsiveness
FEV1
(pharmacologic challenge)
methacholine
osmolarity
(osmotic challenge)
10

corticosteroid

1.
2.
3.

4.
5.

6. chronic irreversible airway

obstruction
7.


1.

.. 2547

11

2.

3.

4. (chronic
asthma)
5. (acute
asthma)
6.

1.
2.
3.

4. peak flow meter

5.

12

1. (allergen)


2.

3. NSAID -blocker
4.
5.
6.





indoor pollutant

.. 2547

13


6
extrinsic
allergic intrinsic non-allergic asthma


1

1. (intermittent asthma)
1
2
exacerbation exacerbation PEF FEV1
80 20
2.
(mild persistent asthma)
1
1
2 excerbation
exacerbation
PEF FEV1 80
20-30
3.
(moderate persistent asthma)

1 exacerbation
2-agonist
14

 exacerbation PEF FEV1

60-80 30
4.
(severe persistent asthma)

exacerbation
exacerbation PEF FEV1 60
30

1. (controller)

exacerbation
2. (reliever)



bronchial
hyperresponsiveness
2
.. 2547

15

1. Corticosteroid

 beclomethasone
 budesonide
 fluticasone

 prednisolone
(
)
 hydrocortisone
 dexamethasone
 methylprednisolone

Anti-inflammatory
agent


inflammatory cell


microvascular leakage

2-agonist

2. Leukotriene modifier

leukotriene

3. 2- agonist
3.1 short-acting

16

zafirlukast
montelukast

 salbutamol
 terbutaline
 procaterol

 salbutamol
 terbutaline
 procaterol
 fenoterol

 salbutamol
 terbutaline

 mucociliary
clearance
vascular permeability


3.2 long-acting

4. Anticholinergic

 salmeterol
 formoterol

 bambuterol
Sustained-release tablet
 salbutamol
 terbutaline
Ipratropium bromide

vagal tone

2-agonist

5. Methylxanthine
 Short-acting
 Sustained-release

6.
 epinephrine
 adrenaline

1. Corticosteroid

arachidonic acid metabolism
prostaglandin microvascular leakage
cytokine -receptor
corticosteroid 3
corticosteroid acute attack
.. 2547

17

 dexamethasone 5-10 mg hydrocortisone

100-200 mg 6
corticosteroid
systemic corticosteroid acute attack
7-10 acute attack

corticosteroid corticosteroid
(> 1,000 g beclomethasone
dipropionate, BDP 800 g budesonide
500 g fluticasone)

2. 2-agonist
(long acting 2-agonist, LABA)

12 mucociliary
clearance vascular permeability
mediator mast cell basophil
3. Sustained-release theophylline
LABA

4. Leukotriene modifier
leukotriene
receptor corticosteroid

18


1.

2-agonist

(short acting 2-agonist)

mucociliary
clearance vascular permeability
4-6

electrolyte
hypokalemia 2-agonist

metered-dose inhaler
(MDI) 200-500 g nebulizer 2.5-5 mg
2-agonist
acute severe attack
adrenaline
2. Methylxanthine
aminophylline
acute severe asthma status asthmaticus
2-agonist sustained-release
theophylline

therapeutic toxic level
5-15 g/ml
3. Aniticholinergic
cholinergic receptor

.. 2547

19

 2-agonist

anticholinergic

MDI 40 g nebulizer
250-500 g ipratropium bromide

3 6
4 : (severe persistent)

exacerbation

PEF FEV1 60%

> 30%

20

Corticosteroid
LABA

Sustained-release theophylline

Long-acting oral 2-agonist

Leukotriene modifier

Oral corticosteroid
2-agonist

 3 : (moderate persistent)

> 1

Exacerbation


2-agonist

PEF FEV1 60-80%

> 30%

Corticosteroid
(200-1,000 g BDP or
equivalent) LABA


corticosteroid

corticosteroid
sustainedrelease theophylline

corticosteroid

leukotriene modifier
2-agonist
3-4

2 : (mild persistent)

1
< 1

> 2
< 1

Exacerbation

PEF FEV1 80%

20-30%

Corticosteroid
(< 500 g BDP or equivalent)


Sustained-release theophylline

Leukotriene modifier
2-agonist
3-4

.. 2547

21

 1 : (intermittent)

< 1

< 2

exacerbation
(2-3 2-3 )


exacerbation

PEF FEV1 80%

< 20%

2-agonist
1

2-agonist

1-3

22

2-agonist

2-agonist

PEF

PEF FEV1

PEF < 20%

PEF FEV1 80%

3

corticosteroid 25
(< 500 g BDP
or equivalent)

1. oxygen
O2 saturation > 90%
2.
(PEF > 50%
) 2-agonist nebulizer
MDI spacer nebulizer 0.5-1 ml
(salbutamol 2.5-5 mg or terbutaline 5-10 mg)
MDI spacer 2 puff
16 puff 15-30
4-6
nebulizer 15-30
.. 2547

23


4-6
(PEF < 50%
accessory
muscle) anticholinergic 2-agonist

3. corticosteroid
corticosteroid
dexamethasone 5-10 mg
hydrocortisone 100-200 mg 6
prednisolone 30-60 mg 30-60
mg
4.
4.1

4.2

4.3 antihistamine

1. 1-2

PEF 50% 200 /
2.

24

3.
4.
5.
6.

1. oxygen
2.

3. corticosteroid (dexamethasone
5-10 mg hydrocortisone 100-200 mg 6
prednisolone 30-60 mg )
4. 2-agonist 4-6
nebulizer MDI spacer
5. anticholinergic 2agonist nebulizer
6. assisted ventilation

(monitoring)
1.

2. PEF 1-2
3. arterial blood gas
/

4. 2-agonist

.. 2547

25

5.

prednisolone
7

2-agonist
26

 corticosteroid
2-agonist theophylline
warm up

pre-eclampsia

.. 2547

27

bronchial
hyperresponsiveness




FEV1
80 prednisolone
systemic corticosteroid
6 corticosteroid

24

28

bronchial hyperresponsiveness


corticosteroid airway hyperresponsiveness



peak flow meter

.. 2547

29

1. Boonsawat W, Charoenphan P, Kaitboonsri S, et al. Prevalence

of asthma symptoms in adult in 4 cities of Thailand. Abstract
for Joint scientific meeting of the Thoracic Society of Thailand,
the Malaysia Thoracic Society, and the Singapore Thoracic
Society. Bangkok, Thailand 2002; 112.
2. Dejsomritrutai W, Nana A, Chierakul N, Sompradeekul S,
Tscheikuna J, Ruttanaumpawan P, Charoenratanakul S. Prevalence and risk factors of bronchial hyperresponsiveness
and asthma in an adult population in Thailand. Intern Med J
Thai 2004; 20(suppl):79.
3. . 2538; 24:
17-29.
4. .
().
. 2541; 19:179-93.
5. Boonsawat W, Charoenphan P, Kiatboonsri S, et al. Survey of
asthma control in Thailand. Respirology 2004; 9:373-8.
6. National Heart, Lung and Blood Institute/World Health
Organization. Global initiative for asthma. Publication No.
02-3659. Bethesda, MD. National Institute of Health, National
Heart, Lung and Blood Institute, 2002.
30

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