a regular basis even the individual is taking an anti-inflammatory drug. 哮喘病的處理 Combined Medication 簡介 Combination of inhaled steroids and long acting

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1 哮喘病的處理 ASTHMA MANAGEMENT

2 a regular basis even the individual is taking an anti-inflammatory drug. 哮喘病的處理 Combined Medication 簡介 Combination of inhaled steroids and long acting 哮喘是非常普遍的慢性疾病 bronchodilators, for example:, 可於任何年紀發病香港現約 Seretide (containing both 有 10-15% Salmeterol 的兒童和 and Fluticasone) 6-8% 的成年人患有哮喘, 兒童的發病率以男孩子較高, 而成年女性則比男性為高 They 本港每年因哮喘病致死平均約有 They are usually are usually prescribed prescribed twice twice daily 80 至 daily 100 人病人不單只經常需要往診所或急症室求診 Combination of inhaled, short-acting 甚至需要住院過往二十年 ß2 - agonists and 內, anticholinergic 全世界因哮喘住院的紀錄有顯著的飆升 drugs, for example: Combivent, 對病者 (containing, 家庭和社會都是一項沉重的經濟負擔 Salbutamol and Ipratropium) They are usually for patients with chronic obstructive lung disease rather 什麼是哮喘病 than asthma.? As inhalant drugs are available in different strengths, 哮喘病是慢性氣管發炎 it is important, for 部分來自遺傳哮喘病人的氣管比 patients with asthma to ask their doctors 一般人敏感 or pharmacists, 當遇到可引起氣管敏感的物質 carefully how many times, they 氣管便會收 have to use 窄, the 主要是因為 inhaler on each : occasion in order to obtain the appropriate dose. 平滑肌緊縮痰液滯留在氣道引致堵塞 Inhalation techniques and devices: 氣管內壁發炎和水腫 Metered dose inhalers Spacer devices 哮喘病的病徵喘鳴 Autohalers 氣促 Powdered inhalers 胸口緊翳 Nebulisers 咳嗽哮喘的徵狀可以是陣發性或持續性發生, 清晨時份較普遍, 持續性咳嗽可以是唯一的症狀 17 1

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4 2. 誘發原誘發原本身是不會引起氣管發炎或氣管敏感, 已有哮喘病的人, 其氣管過敏, 一但接觸誘發原, 可能誘使哮喘病發作常見的誘發原有 : 二手煙空氣污染物上呼吸道感染冷空氣運動情緒緊張強烈氣味和香水天氣轉變診斷哮喘病的診斷包括 : 詳盡病歷臨床檢查肺功能檢查量度最高呼氣流速率 : 可評估氣管的寬緊情況氣管激發測試 : 可用氣管激發劑刺激輕微哮喘發作, 以確定診斷胸腔 X 光檢查 : 可排除其他疾病的存在性有些時候可能需要驗血皮膚測試 : 可確定對何種物質過敏最高呼氣流速計哮喘病人最高流速表正常人最高流速表時間時間

5 治療目標 - 晚上可以安睡 - 減少使用氣管舒張藥物的次數 - 肺功能回復正常或提升至最好狀態 - 可以正常地生活 - 副作用減至最少甚至沒有處理方法長期處理需注意藥物, 教育及環境的控制這三方面的因素藥物 : 哮喘病藥物包括兩大類 : 預防性藥物抗炎藥物用作治理氣管因接觸到致敏原而引發的炎症, 必需每天定時定量使用, 沒有即時的功效, 因此不應在病發作時作為舒緩氣管之用 1. 吸入性類固醇是安全和有效的藥物, 常用的包括 : - 倍氯米松 (Beclomethasone) -- 例如 : Becotide, Becloforte, Vanceril - 布地奈德 (Budesonide) -- 例如 : Pulmicort - 輔舒酮 (Fluticasone) -- 例如 : Flixotide 吸入性類固醇是最安全和有效的抗炎藥物, 用作防治和控制哮喘使用低劑量時, 其副作用不多, 若長時期使用高劑量, 孩子的生長速度可能暫時會被壓仰但另一方面, 若孩子的哮喘病控制不當, 其生長速度也一定比不上同年齡的兒童一般副作用包括聲音沙啞喉嚨痛和口腔炎, 若使用霧 4

6 化器及能夠使用後漱口, 這些副作用可以避免或減少 2. 口服類固醇醫生可處方口服類固醇予哮喘病急性發作的病人長期服用類固醇的副作用包括有水腫體重增加容易有瘀痕胃口增加及骨質疏鬆等由於吸入類固醇極為安全及有效, 以往大部份需要長期服用口服類固醇的情況己被取代, 目前仍然有少數病人仍需長期服用口服類固醇 3. 非類固醇的預防性藥物 - 色甘酸鈉 (Sodium Cromoglycate) -- 例如 : Intal - 尼多克羅 (Nedocromil Sodium) -- 例如 : Tilade 非類固醇預防性藥物的功效不及吸入類固醇 4. 白三烯受體阻斷劑 (Leukotriene receptor antagonists) 是新一代的口服哮喘藥物主要是針對可引致慢性氣管發炎 ( 即哮喘病 ) 的其中一種物質稱為白三烯若在運動前接觸致敏原或冷空氣前使用, 更可保護氣管例如 : - 孟魯司特鈉 (Montelukast) -- 例如 : Singulair - 扎魯司特 (Zafirlukast) -- 例如 : Accolate 舒緩性藥物氣管舒張劑是舒緩性的藥物 - 能幫助放鬆氣管璧周圍的肌肉, 使呼吸較暢順 - 快速舒緩哮喘病病徵, 可用於因運動時引發性哮喘病 - 是急需時用的藥物, 通常不是定時定量用 - 不是抗炎藥物 - 通常是藍色的 5

7 氣管舒張劑的種類 1. 吸入性 ß2 促效劑, 常見的包括 : 舒喘靈 (Salbutamol) -- 例如 :Ventolin 特布他林 (Terbutaline Sulphate) -- 例如 :Brincanyl 吸入性 ß2 促效劑是常用的舒緩性藥物, 通常在需要時使用, 若定時定量使用舒張藥, 可導致更嚴重哮喘病, 故此切勿過量使用副作用包括 : - 手震 - 精神緊張 - 心跳加快若需頻頻使用氣管舒張劑, 顯示可能需要增加抗炎藥物 2. 抗膽鹼能的吸入劑 (Anticholinergic Inhalers) 異丙托溴銨 (Ipratropium) -- 例如 :Atrovent 有些病人可加用此藥, 但這不能代替氣管舒張劑 3. 口服氣管舒張藥茶鹼 (Xanthines, Theophylline) -- 例如 :Nuelin 可用作放鬆氣道周圍的肌肉, 請遵醫囑服用正確的劑量副作用包括 : - 肚瀉 - 作悶 - 胃部不適 - 頭痛 - 心跳加速 6

8 4. 長效吸入性 ß2 促效劑 Infection Some 沙美特羅 viral (Salmeterol) infections can -- cause 例如 :Severent asthma while others can only trigger an attack in people already with asthma 富馬酸福莫特羅 (Formoterol) -- 例如 :Oxis 長效氣管舒張藥需要較長時間才達到最佳的舒張效果 Occupational agents, 可持續十二小時或以上如哮喘病人已經使用抗炎藥及需要定時 There are over 300 agents in the workplace known to give rise 使用短效舒張藥 to asthma. About, 醫生便會考慮處方長效的舒張氣管藥 5-15% of adult onset asthma is due to occupational exposure 合拼藥物治療 Second hand smoke 吸入性類固醇與長效氣管舒張藥的合拼藥物包括有 Children whose mothers smoke are at a greater : risk for developing 舒悅泰 (Seretide)( asthma 含有沙美特羅及輔舒酮 than those whose mothers ) 通常每天使用 do not smoke. The 兩次短效氣管舒張藥與抗膽鹼能吸入劑的合拼藥物包 risk is even higher when both parents smoke 括有 : Allergy 可必特 (Combivent), to food and certain 含有喘樂寧及異丙托溴銨 drugs such as aspirin, and 通常適 other nonsteroidal 用於慢性氣管阻塞病人吸入性藥物的劑量度數各異 anti-inflammatory drugs can also give rise, to asthma 每個病人需用的份量皆不同 They are the less common, 因此 causes., 請注意醫生或藥劑 2. Triggers 師的處方及份量 Exposure to triggers may lead to an attack of asthma in people who 吸入器物 already have asthma. However, exposure to triggers does not lead 請向醫護人員查詢吸入器的模樣及所使用技巧 to airway inflammation or hyperresponsiveness., 產品包括 Common : triggers 壓力型定量吸入器 are : (Metered dose inhalers) Second 霧化器 hand (Spacer smoke Devices) or environmental tobacco smoke (ETS) Air 自動吸入器 pollutants(autohalers) Upper 粉末型吸入器 respiratory (Powered tract infection inhalers) Cold 化霧器 air (Nebulisers) Exercise Emotional upsets 117

9 各式霧化器各式吸入器教育及環境控制每一位哮喘病人或家長都需要了解他們周邊環境有沒有致敏原或誘發原和懂得怎樣避免接觸它 : 如有任何查詢, 請聯絡你的主診醫生以上資料由瑪麗醫院內科部提供 8

10 ASTHMA MANAGEMENT Introduction Asthma is a very common disease and can develop at any age. In Hong Kong, about 10 to 15% of children and 6 to 8% of adults suffer from asthma. It is more common in boys than girls in childhood but more common in women than in men in adulthood. In Hong Kong, asthma causes about 80 to 100 deaths per year. The disease is also associated with considerable morbidity leading to hospitalizations, emergency room or out-patient consultation and treatment. In many countries around the world and in Hong Kong, hospitalization rate for asthma has increased during the past 2 decades. The economic burden of the disease to the individual, family and society is great. What is is asthma?? Asthma is is a a chronic lung condition characterized by by difficulty in in breathing. People with asthma have hyperresponsive or or irritable airways. The airways react by by narrowing when they become irritated. The narrowing is is caused by by : : Smooth muscle contraction in in the airways Mucus in in the airways Inflammation of of wall and swelling of of the lining of of the airway S T fo T fo ea in W A te E ca 1. In by hy 9

11 Symptoms of asthma The narrowing of the airways can give rise to one or more of the following symptoms : Wheezing Shortness of breath Chest tightness Cough These symptoms can occur in episodes and can frequently recur for prolonged periods. Symptoms often occur at night or in the early morning, waking the individual from sleep. In some individuals, persistent cough may be the main symptom. What can cause asthma Asthma occurs in genetically predisposed individuals. Thus, it tends to occur among first degree relatives of asthma patients. Environmental factors are very important in causing asthma. They can be divided into two groups, inducers and triggers : 1. Inducers Inducers can cause asthma in people who do not have it previously by inducing both airway inflammation and airway hyperresponsiveness. Allergens Exposure to indoor aeroallergens such as house dust mites, mold spores, animal dander and cockroaches is an important risk factor for the development of sensitization and asthma. Exposure to pollen is an uncommon cause of asthma especially in Hong Kong 10

12 Infection Some viral infections can cause asthma while others can only trigger an attack in people already with asthma Occupational agents There are over 300 agents in the workplace known to give rise to asthma. About 5-15% of adult onset asthma is due to occupational exposure Second hand smoke Children whose mothers smoke are at a greater risk for developing asthma than those whose mothers do not smoke. The risk is even higher when both parents smoke Allergy to food and certain drugs such as aspirin and other nonsteroidal anti-inflammatory drugs can also give rise to asthma They are the less common causes. 2. Triggers Exposure to triggers may lead to an attack of asthma in people who already have asthma. However, exposure to triggers does not lead to airway inflammation or hyperresponsiveness. Common triggers are : Second hand smoke or environmental tobacco smoke (ETS) Air pollutants Upper respiratory tract infection Cold air Exercise Emotional upsets 11

13 Strong fumes and odours Change in weather Diagnosis Many diseases can give rise to cough, wheeze and shortness of breath. The diagnoses of asthma includes : Detailed history Physical examination Measurement of lung function. Measurement of peak expiratory flow (PEF) using a small peak flow meter is useful for assessing the degree of narrowing of the airways Inhalation provocation tests may be needed to induce a mild attack of asthma to confirm the diagnosis in some patients Chest x-ray to exclude other possibilities Blood tests may be done Allergy skin prick tests. Useful to detect or confirm whether sensitization to common allergens has occurred Peak flow meter Peak flow rate of asthma patient Time Peak flow rate of normal adult Time

14 Treatment Goal of treatment - Freedom from night symptoms to enable undisturbed sleep - Reduction of the use of short acting bronchodilators - Normalize or optimize lung function - Normalize lifestyle - Achieve the above with minimal side effects of drugs and treatment Long-term Management - Medications - Education and environmental control Medications There are two groups of drugs for treatment of asthma : Drugs that prevent attacks of asthma (Preventers) and Drugs that relief an attack of asthma (Relievers) Preventers Drugs that prevent attacks of asthma should be taken regularly. They are anti-inflammatory drugs to treat airway inflammation caused by exposure to inducers. They do not have immediate effects and should not be used to relief an attack of asthma. 1. Inhaled corticosteroids - efficacious and safe - Beclomethasone (Becotide, Becloforte) - Budesonide (Pulmicort) - Fluticasone (Flixotide) 13

15 Inhaled steroids are the most effective preventer. There are few side effects at low doses. At high doses, they may cause growth suppression. But children whose asthma is not well controlled do not grow as well as other children either. There are local side effects including hoarseness of voice, sore throat, and yeast infection or thrush. They can be prevented by the use of a spacer or by rinsing the mouth after taking the inhaler. 2. Systemic corticosteroids Indicated during severe acute episodes. There are many side effects if used long-term, including water retention, weight gain, easy bruising, puffy face, increased appetite, osteoporosis, diabetes and cataracts. With the development of inhaled steroids which is both efficacious and safe, the need for long term, systemic steroids has decreased dramatically although a few patients may still require it 3. Non-steroid preventers - Sodium Cromoglycate ( Intal ) - Nedocromil sodium ( Tilade ) Nonsteroidal preventers are not as effective as the inhaled steroids. They are mostly used in children with allergic type of asthma 4. Leukotriene receptor antagonists They are a new class of oral asthma medications. They act against one of the inflammatory components of asthma and provide protection against bronchoconstriction when taken before exercise or exposure to allergen or to cold air, for examples : 14

16 - Montelukast (Singulair) - Zafirlukast (Accolate) Relievers Bronchodilators are relievers. - They relax muscles around the bronchi and allow breathing to become easier - They provide quick relief of symptoms and are useful with exercise induced bronchoconstriction - They are rescue medications and should be used only when needed and not on a regular basis - They are not anti-inflammatory agents - Usually in blue colour devices Types of Bronchodilator Drugs 1. Inhaled ß2 - agonists, for example : Salbutamol (Ventolin) Terbutaline (Brincanyl) Inhaled ß2 - agonists are relievers and are used as rescue medications. They should be used only needed and not on a regular basis. Regular use of ß2 - agonists bronchodilators has been shown to lead to more severe asthma. Over use of ß2 - agonists should be avoided. Side effects of ß2 - agonists bronchodilators : Tremor Nervousness Increased heart rate 15

17 Frequent use of ß2-agonists bronchodilators means that the antiinflammatory medications should be stepped up. 2. Anticholinergic inhalers, for example : Iptropium (Atrovent) This medication can be used as adjunct therapy but cannot replace the conventional bronchodilators. 3. Xanthines or theophylline, for example : Nuelin Theophylline is an oral bronchodilator that works directly on the airway muscle and relax it. The right dose is important and should be determined by your physician.theophylline has side effects : Diarrhoea Nausea Upset stomach Headaches Rapid heart beat 4. Long acting ß2 - agonists, for examples: Salmeterol (Severent) Formoterol (Oxis) Long acting ß2 - agonists take longer to achieve bronchodilation, but the duration of action is longer which last 12 hours. They are usually pescribed when short-acting ß2 - agonists are required on 16

18 a regular basis even the individual is taking an anti-inflammatory drug. Combined Medication Combination of inhaled steroids and long acting bronchodilators, for example: Seretide (containing both Salmeterol and Fluticasone) They They are usually are usually prescribed prescribed twice twice daily daily Combination of inhaled short-acting ß2 - agonists and anticholinergic drugs, for example: Combivent (containing Salbutamol and Ipratropium) They are usually for patients with chronic obstructive lung disease rather than asthma. As inhalant drugs are available in different strengths, it is important for patients with asthma to ask their doctors or pharmacists carefully how many times they have to use the inhaler on each occasion in order to obtain the appropriate dose. Inhalation techniques and devices: Metered dose inhalers Spacer devices Autohalers Powdered inhalers Nebulisers 17

19 Various kinds of spacers Various kinds of inhalers Education and Environmental Control People with asthma or children's parents should be familiar with the following : Identify and avoid triggering factors It is important for each patient to identify his / her environmental triggers and avoid these triggers if possible - House dust mites: Dust mites are responsible for house dust allergy and they live off the dead skin that we shed. They are present in large quantities among bedding and carpets. The use of vinyl covers for mattresses, pillows and duvets and hot water(>55 o C) wash of bedding at least every two weeks will reduce mite allergen level. Removal of carpets, and furry toys are also recommended - - Pets: The only way to reduce exposure is to remove them from home Second hand smoke: Parents should give up smoking if their child has asthma 18

20 - High humidity: High humidity encourages the growth of house dust mites and moulds. The use of dehumidifier may be helpful during the humid season Recognize features of disease worsening, including use of home peak expiratory flow rate monitoring, know what to do when asthma gets worse Understand the action of different anti-asthma medications and their possible side effects or proper technique of using inhalation devices Should you have any queries, please consult your doctorin-charge Information provided by Department of Medicine, Queen Mary Hospital. 19

COPD Information Booklet

COPD Information Booklet 什麼是 COPD? (WHAT IS COPD?) COPD 代表慢性阻塞性胸腔疾病 (Chronic Obstructive Pulmonary Disease) 慢性意指它不會消失阻塞意指部份堵塞胸腔意指肺部疾病指生病 COPD 是一種長期性肺病, 它會減少進出肺的氣流, 使肺難以