《课件马偕医院小儿科部李宏昌.ppt》由会员分享，可在线阅读，更多相关《课件马偕医院小儿科部李宏昌.ppt（45页珍藏版）》请在三一文库上搜索。
1、2019/3/12,1,馬偕醫院小兒科部 李宏昌,The role of bronchodilator in treating cough in children,2019/3/12,2,202A 依據病歷記載及病況，不足以支持實施本項 (門、急、住診療/手術/麻醉/處置/治療/檢 驗/檢查/藥品/特材) 324A 同時已投予同性質藥物，用藥種重複,2019/3/12,3,住院案例-1,5歲男童，診斷為464.4 Croup 病史：Fever with productive cough and hoarseness for 3 days. The cough sounds like barki
2、ng. Progressive hoarseness and rhinorrhea was also noted 理學檢查：nose: some discharge; throat: injected; tonsil: Gr.II/IV. No exudates. Chest: symmetric expansion; breath sounds: bilateral rhonchi Chest X-Ray: bilateral perihilar infiltration with peribronchial cuffing,2019/3/12,4,住院案例-1,核刪Pulmicort Ne
3、bulising suspension(IH) 核刪理由： 依所附文獻，IV form dexamethasone為首選，為何捨有效且便宜的療法 依據診斷/病況，無使用類固醇吸入劑治療之必要 申請理由：病童因Croup而入院，治療方法可用吸入性類固醇達到消腫、抗發炎的結果,Inhaled corticosteroids also have demonstrated efficacy, with most trials using budesonide. However, according to most authors, the relative ease, speed, and cost
4、of administration make systemic corticosteroids preferable to nebulized formulations,2019/3/12,5,Croup: Treatment Updated: Nov 21, 2008,A single dose of dexamethasone has been shown to be effective in reducing the overall severity of croup if administered within the first 4-24 hours after onset of i
5、llness. The long half-life of dexamethasone (54 h) often allows for a single injection. Dexamethasone (0.15 mg/kg) is as effective as 0.3 mg/kg or 0.6 mg/kg in relieving symptoms of mild-to-moderate croup. It has the same efficacy if administered intravenously, intramuscularly, or orally. A single o
6、ral dose of prednisolone (1 mg/kg) resulted in more return visits than a single oral dose of dexamethasone (0.15 mg/kg). Inhaled budesonide has also proven to be effective but is more expensive; in one study, oral dexamethasone resulted in better improvement than nebulized budesonide.,2019/3/12,6,Co
7、ugh is an important defense mechanism that plays a major role in maintaining the integrity of the airways and can be voluntary or involuntary. The pathophysiology of cough is incompletely understood. Cough is commonly triggered by mechanical or chemical stimulation of receptors in the pharynx, laryn
8、x, trachea and bronchi. Cough receptors also exist in the nose, paranasal sinuses, external auditory ear canals, tympanic membranes, parietal pleura, esophagus, stomach, pericardium and diaphragm.,. NLHEP (National Lung Health Education Program ),2019/3/12,7,Medicines commonly used in treating cough
9、: Acetaminophen or ibuprofen: Antibiotics: Antiviral medicine: Breathing treatments: Cough medicine: Expectorant: Coughing the phlegm out of the lungs can help your child breathe easier. Should drink plenty of liquids when taking this type of medicine. Suppressant : May need a cough suppressant at n
10、ight so he can rest. May not be used if caregivers think it may be dangerous to stop your childs cough. Bronchodilators: to help open the air passages in his lungs. Bronchodilators can be given during a breathing treatment or by using an inhaler. by mouth or through an IV. Steroids: Steroid medicine
11、 may help to open air passages in the lungs so that the child can breathe easier.,2019/3/12,8,夫街談巷說，必有可採；擊轅之歌，有應風雅，匹夫之思，未易輕棄也。” 文選曹植與楊德祖書,巷說百物語,街談,2019/3/12,9,公益法律扶助會想到要上法院，很多人就會腳軟。 感冒藥普拿疼伏冒加強錠感冒什麼藥也比不上我的醫生開的藥，不然你就要吃。 牙膏黑人超氟牙膏掛保證。人生有些東西就是剝離不了，黑人牙膏就是其中一味。 門號威寶電信你如果覺得有賺到可以笑出來沒關係。（企業形象篇、低費率篇）。 鞋類La new
12、DCS舒適動能氣墊鞋走快較不晃、走久較不累、走遠較不倦。 罐頭珍開味含是泡菜火鍋大家都我火鍋黨主席。（愛之味系列就有3款） 保健品引藻片有人說，它是藻中之王。 音響VEA家庭劇院數位時代，享受就要VEA 保健品鳥頭牌愛福好男人不要只剩一隻嘴。 全國電子足感心。 十八銅人好鐵貼吃老，吃東西掉滿地，肌肉痠痛都是你害的。,2019/3/12,10,Summary of important points: Asthma is a common condition but it is not always the diagnosis in a coughing child. A careful clin
13、ical history is the key to diagnosis in asthma. Cough as the sole symptom of asthma is unusual. A family history of asthma, and family or personal history of atopy, eczema or allergic rhinitis, makes a diagnosis of asthma more likely. Physical examination may be normal in a child with asthma between
14、 episodes. The age at which children can perform spirometry is variable. In younger children, a trial of bronchodilator therapy with formal assessment of response may be appropriate if asthma is suspected.,2019/3/12,11,Diagnosing asthma in young children is difficult because children often: cough an
15、d wheeze with colds and chest infections but this is not necessarily asthma. Young children have very small, narrow airways and on average have a 6 -8 colds per year, usually between September and March.,2019/3/12,12,It is important not to over-diagnose asthma in children who in fact have a chronic
16、non-specific cough. Such children require no treatment, get better with time, and have normal long-term lung function“. The diagnosis of cough variant asthma should only be made in older children after variable airflow obstruction and response to bronchodilator has been demonstrated physiologically.
17、 In younger children, rational diagnostic criteria are an abnormally increased cough, with no evidence of any non-asthma diagnosis, a clear-cut response to a therapeutic trial of asthma medication, usually moderate dose inhaled corticosteroids, and relapse on stopping medications with second respons
18、e to recommencing them.,Bush A; Pulm Pharmacol Ther. 2002;15(3):309-15,2019/3/12,13,2019/3/12,14,Pulm Pharmacol Ther. 2002;15(3):309-15,In a child with isolated (chronic) cough,One of five diagnostic categories: Normal child; A serious illness such as cystic fibrosis, tuberculosis etc. Non-serious,
19、but treatable causes of cough and wheeze, for example gastro-oesophageal reflux or postnasal drip; 4. Asthma syndrome 5. An overestimation of symptoms for psychological or other reasons by either or both of child or family.,2019/3/12,15,Bronchitis can be caused by viruses, bacteria, or allergies, an
20、d it occurs in both acute and chronic forms Acute bronchitis is a common childhood disease, especially before the age of four. Bronchitis begins with a dry, hacking cough that usually lasts two or three days and then turns into a loose cough that produces thick mucous or sputum, usually lasts about
21、two weeks Breathing through the congested airway often produces a wheezing sound and may also cause pain below the sternum, or breastbone.,coughing can last over a month.,usually gets worse at night,2019/3/12,16,門診案例-1,3歲男童，14公斤，診斷為急性支氣管炎 主訴：Husky cough intermittent for one week; no fever; night sle
22、ep: not disturbed; no hoarseness 理學檢查：activity: fair; conjunctiva: no hyperemia or discharge; throat: not injected; chest: no tachypnea; breath sound: coarse, no rhonchi, wheezing or rales; RHB: no murmur; abdomen: soft, not distended; no tenderness; no rash,2019/3/12,17,門診案例-1,用藥 Cough Mixturel 4cc
23、 tid Dex-CTM 1/3# tid Mucosolvan 1/3# tid Meptin liquid 3cc bid 核刪理由： 病歷記載並無wheezing之情形 依據病歷記載及病況，不足以支持實施本項(門、急、住診療/手術/麻醉/處置/治療/檢驗/檢查/藥品/特材) 爭審理由：急性支氣管炎主要以症狀治療，聽診當時無明顯wheezing，口服支氣管擴張劑仍有一定療效,核刪本項藥品,2019/3/12,18,Bronchodilators may be endogenous (originating naturally within the body), or they may be
24、 medications administered for the treatment of breathing difficulties. They are most useful in obstructive lung diseases, of which asthma and chronic obstructive pulmonary disease are the most common conditions. Although this remains somewhat controversial, they might be useful in bronchiolitis.,201
25、9/3/12,19,Pneumonia and bronchiolitis , an inflammation of the bronchioles . If the cause of the bronchial inflammation can be identified as a bacterial infection, antibiotics such as erythromycin can be prescribed. Sometimes bronchodilators are prescribed to open congested airways and stop wheezing
26、, but care should be taken when using them with children because they have a tendency to speed up the heart rate.,2019/3/12,20,In chronic cough , majority of patients are suffering from one of three conditions: a form of asthma, gastro-esophageal reflux, or Rhinitis/postnasal drip.,2019/3/12,21,A st
27、udy of children ages 5 to 10.5 years,2019/3/12,22,ACAAI 2008: Gastroesophageal Reflux Disease Treatment Improves Asthma in Children,After 2 years of treatment, 22% of children in group A (medical treatment) showed a greater than 20% improvement in forced expiratory flow (FEF)25%-75%, 25% of children
28、 in group B (surgical treatment) showed a similar improvement, as did 11% of children in group C. FEF25%-75% in groups A and B was significantly higher than in group C (P .05). “In a select group of patients who are non-allergic, GERD is an important factor to consider in terms of therapy.“,.lead in
29、vestigator Aaron Kobernick, MD, MPH, from the Tulane University School of Medicine, in New Orleans, Louisiana, told Medscape Allergy & Clinical Immunology.,62 children, between 6 and 11 years old,2019/3/12,23,Three types of prescription bronchodilating drugs : 2-agonists (short- and long-acting), An
30、ticholinergics (short-acting) Theophylline (long-acting).,2019/3/12,24,A bronchodilator Short-acting bronchodilators are used only as needed as asthma “rescue” medications, Long-acting bronchodilators are used every day to control asthma.,2019/3/12,25,門診案例-1,10歲男童，47公斤，診斷：Asthma(493.9)、Acute sinusit
31、is(461.9)、 Bronchopneumonia(485)及Allergic rhinitis(477.9) 主訴：frequently night cough everyday, itching eyes and nose every morning. Clear rhinorrhea every morning, severe nasal obstruction; rhinitis attack every day, asthma attack 1 times/ month/ admission 理學檢查：breath sound: diffuse wheezing and rale
32、,2019/3/12,26,門診案例-2,用藥 Symbicort turbuhaler Xanthium Polaramin Medicon-A Psubity Ventolin 核刪理由： Symbicor含類固醇及formoterol(支氣管擴張劑)，再重覆使用Ventolin 同時已投予同性質藥物，用藥種類重複 申請理由：Symbicor的bronchodilator是low dose的，預防Asthma病人的夜咳，病人有URI及Bronchopneumonin的症狀應該加上Ventolin,核刪本項藥品,a long-acting 2-agonist,short-acting 2-a
33、drenergic receptor agonist,2019/3/12,27,門診案例-3,3歲男童，17公斤，診斷：Extrinsic Asthma(493)、 Acute bronchiolitis(46619) 、Allergic rhinitis(477.9)及Other atopic dermatitis(6918) 主訴：nasal obstruction, cough with sputum, severe; day time cough(每天一次) ; night time cough(一週一次) 理學檢查： sneezing nose(+); itching eye(+);
34、 breath sound: rhonchi and rale, throat: injected with enlarged; conjunctivitis,2019/3/12,28,門診案例-3,用藥 Acetaminophen syrup Ventolin Periactin Polaramin Vistaril Asverin Zyrtec syrup Meptin liquid Medicon-A 核刪理由： Ventolin與Meptin重複用藥，Medicon-A與Asverin為同類祛痰劑Zyrtec 與Periactin為重複用藥 同時已投予同性質藥物，用藥種類重複 申請理由
35、：Meptin及Zyrtec是為控制Asthma、過敏性鼻炎及URI用藥,核刪3項藥品,beta-2 adrenergic receptor agonist,short-acting 2-adrenergic receptor agonist,2019/3/12,29,2019/3/12,30,2019/3/12,31,There is very limited evidence in regards to the benefit of inhaled bronchodilators for improving symptoms of acute bronchitis. A few of th
36、e observations taken from these studies are: 1) Both studies had at least a trend towards improving various symptoms of acute bronchitis, although the sample sizes in both studies were small and statistical significance was rarely achieved; 2) The side effects from the bronchodilators (e.g.albuterol
37、) are mild; 3) Both studies excluded patients with known bronchoconstrictive lung disease and other historical factors, who, likely, would have a greater benefit with brochodilators in acute cough/acute bronchitis.,2019/3/12,32,2019/3/12,33,Objectives To determine the efficacy of inhaled anti-cholin
38、ergic medications in the management of prolonged non-specific cough in children. Search strategy The Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register and Cochrane Airways Group, MEDLINE and EMBASE databases were searched. Relevant pharmaceutical compa
39、nies were contacted. The latest searches were performed in April 2004.,Main results No randomised-controlled trials that examined the efficacy of inhaled anti-cholinergic medications in the management of prolonged non-specific cough in children were found. An additional search in April 2005 did not
40、identify any further studies. Authors conclusions There is currently no evidence to support the use of inhaled anti-cholinergics for symptomatic control of non-specific cough in children. Further research examining the effects of this intervention is needed.,2019/3/12,34,Anticholinergics,Only availa
41、ble as an inhalant, ipratropium bromide relieves acute or new asthma symptoms. Because it has no effect on asthma symptoms when used alone, it is most often paired with a short-acting 2-agonist. While it is considered a relief or rescue medication, it can take a full hour to begin working. For this
42、reason, it plays a minor role in asthma treatment. Dry throat is the most common side-effect. If the medication gets in contact with the eyes, it may cause blurred vision for a brief time.,2019/3/12,35,誰說Berodual MDI不能用在哮喘病人身上？,這次我的一個哮喘病人，用了一支噴霧劑Berodual MDI被刪，加上倒扣回推，被罰款一萬六千四百六十二元！看到這筆數字委實令人心痛，更不甘願的
43、是審查委員在上面的眉批與指教，他寫道：B.A(案:Bronchial Asthma)病人，anticholinergic drug沒有學理及臨床使用的適應性！夠了！我實在受夠了！由於申覆時再審查的是不同人；換句話說，敵暗我明，我永遠沒辦法和那位大員溝通，只好跳出來講清楚說明白，也兼發表一點個人行醫以來的委屈吧！,並不是只有 anticholinergic （ipratropium）而已，尚有 fenoterol (Berotec)，,2019/3/12,36,Methylxanthines: including caffeine, theobromine and theophylline,20
44、19/3/12,37,relaxing bronchial smooth muscle increasing heart muscle contractility and efficiency: positive inotropic increasing heart rate: positive chronotropic increasing blood pressure increasing renal blood flow some anti-inflammatory effects central nervous system stimulatory effect mainly on t
45、he medullary respiratory center.,Theophylline,2019/3/12,38,2019/3/12,39,Methylxanthines for prolonged non-specific cough in children published online: 20 April 2005 in Issue 2, 2005. Last assessed as up-to-date: 31 December 2007. (Chang AB, Halstead RAP, Petsky HL),This review examined whether there
46、 was any evidence for using methylxanthines in children with non-specific cough. There were no randomised controlled trials that assessed methylxanthines for prolonged non-specific cough in children. In four non-randomised controlled studies, the researchers described that dramatic improvements in c
47、ough were seen within 2-14 days of taking oral theophylline. However, this is possibly a placebo and/or time period effect. There is no RCT evidence to support the routine use of methylxanthines for the symptom of non-specific cough in children.,2019/3/12,40,Authors conclusions (Chang AB, Halstead R
48、AP, Petsky HL),There is currently an absence of reliable evidence to support the routine use of methylxanthines for symptomatic control of non-specific cough in children. If methylxanthines were to be trialled in children with prolonged non-specific cough, cohort data (thus limited) suggest a clinic
49、al response (subjective cough severity) would be seen within 2-5 days (and certainly within 14 days) of therapy. However methylxanthine use has to be balanced against the well known risk of toxicity and its low therapeutic range in children. Further research examining the efficacy of this intervention is needed.,2019/3/12,41,anticholinergic bronchodilator,2019/3/12,42,Some patients have a dry or irritated throat or a dry mouth after using bronchodilators. To help prevent these problems, gar