12 22 31 41 52 58 64 69 77 89 1

WHO 2020 2016 9 30 2 3

郭壽雄 4 5

1-3 徐世達 6 7

GINA GOLD / / / / / / / / / / QR cord 8 9

HFA hydrofluoroalkane ICS LABA inhaled corticosteroid long-acting β 2 -agonists LAMA long-acting muscarinic antagonists NIV non-invasive ventilation MMAD pmdi SABA mass medium aerodynamic diameter pressurized metered-dose inhaler short-acting β2 agonist SAMA short-acting muscarinic antagonist SMI SVN soft mist inhaler small volume nebulizer CFC chlorofluorocarbons VMN CFC vibration chlorofluorocarbons mesh nebulizer COPD chronic obstructive pulmonary disease COPD accuhaler chronic obstructive pulmonary disease DPI dry powder inhaler DPI ambu dry powder inhaler ETS environmental tobacco smoke ETS asthma environmental tobacco smoke FEV 1 forced expiratory volume in one second FEV 1 chronic forced expiratory bronchitisvolume in one second FPF fine particle fraction FPF dual fine particle bronchodilator fraction FVC forced vital capacity FVC emphysema forced vital capacity GINA global initiative for asthma GINA nebulizer global initiative for asthma HFA hydrofluoroalkane HFA spacer hydrofluoroalkane ICS inhaled corticosteroid ICS turbuhaler inhaled corticosteroid LABA long-acting β 2 -agonists LABA long-acting β 2 -agonists LAMA long-acting muscarinic antagonists LAMA long-acting muscarinic antagonists NIV non-invasive ventilation NIV non-invasive ventilation MMAD mass medium aerodynamic diameter MMAD mass medium aerodynamic diameter pmdi pressurized metered-dose inhaler pmdi pressurized metered-dose inhaler SABA short-acting β2 agonist SABA short-acting β2 agonist SAMA short-acting muscarinic antagonist SAMA short-acting muscarinic antagonist SMI soft mist inhaler SMI soft mist inhaler SVN small volume nebulizer SVN small volume nebulizer VMN vibration mesh nebulizer VMN vibration mesh nebulizer accuhaler accuhaler ambu ambu 10 asthma asthma 11 chronic bronchitis chronic bronchitis

(mast cell) (eosinophils) T (T lymphocytes) (predisposing factors ) (causal factors ) (Contributing factors ) ( 1-1) 12 13

1-1. ( 1-2) 1-2. 1991 (Global Initiative for Asthma Guideline, GINA Guideline) ( 1-3) 14 15

1 2 3 4 1-3. 103 2020 5 6 - - - (chronic obstructive pulmonary disease, COPD) (chronic bronchitis) (emphysema) (COPD) 16 17

(cor pulmonale) 30 ( 1-1) (FEV1) (Environmental Tobacco Smoke ETS) NHANES III 30 75 19.2% 31.1% COPD 1-1. 18 19

1-4 1-4. ( / ) (AHR) 20 21

asthma (Homer) (Iliad) 460 (Hippocrates) 100 130 1892 (William Osler) 1940 B.C A.D (COPD) Theophile Bonet 1821 René Laennec (emphysema) 1959 CIBA 1965 (MRC-British Medical Research Council) (adrenergic agents) -- 19 1899 Abel 22 23

epinephrine 1948 (receptor) (α) (β) β isoproterenol (β 1 ) (β 2 ) Salbutamol (β 2 agonist) 1969 David Jack isoproterenol β 2 fenoterol terbutaline 4 6 Salmeterol (LABA) 1988 salmeterol salbuterol 10,000 12 salmeterol formoterol 12 (ultra-laba) 2,000 ultra-laba indacaterol olodaterol vilanterol β 2 (intrinsic activity) (anti-cholinergic agents) 2,000 M 1 M 3 M 3 Atropine 1974 ipratropium bromide oxitropium bromide (SAMA) 6-8 1980 (LAMA) Tiotropium ipratropium M 3 6 20 LAMA SAMA Glycopyrronium (NVA237) M 3 M 1 M 2 M 3 tiotropium umeclidinium 1950 1951 1972 Beclomethasone dipropionate (BDP) 1993 Fluticasone propionate 1997 Budesonide ICS LABA 2000 Fluticasone propionate / Salmeterol xinafoate (Seretide ) 2001 Budesonide / Formoterol Fumarate (Symbicort ) (dual) 2012 ultra-laba LAMA (dual bronchodilator) QVA149 (Ultibro ) (indacaterol + glycopyrronium) Anoro (vilanterol + umeclidinium) Spiolto (olodaterol + tiotropium) ICS 24 25

ultra-laba LAMA (inhaler) 2000 inhaler 1778 A.Turbuhaler Turbuhaler ( ) 1987 Turbuhaler (pressurized metered-dose inhaler, pmdi) 1955 3M G. Maison 1956 5 20 pmdi (chlorofluorocarbon, CFC) (hydrofluoroalkane, HFA) pmdi 1995 B.Accuhaler Accuhaler (Diskus) ( ) Diskhaler 1990 Accuhaler 60 (dry powder inhaler, DPI) 1971 C.ELLIPTA ELLIPTA 2003 2013 Accuhaler 26 27

D.Breezhaler Breezhaler 2012 2001 Aerolizer 3kPa 90 L/min (dosing confirmation) Breezhaler (nebulizer) 1895 1920 (aerosol) 1930 (jet nebulizer) (nebulizer) 1960 (mesh nebulizer) 1980 (static) (180 khz) (vibrating mesh nebulizer) 1900 Adaptive Aerosol Delivery (AAD ) AAD 1997 2002 (jet nebulizer) I-neb AAD (soft mist inhaler) ( Respimat) 1991 1992 Uniblock 50 1994 Respimat Uniblock Respimat 5.8 μm Respimat 28 29

( 2-1) SABA SAMA LABA ICS/LABA LAMA 2-1. 30 31

3-1 QR code 3-1. (SABA) Berotec (Fenoterol) Ventolin (Salbutamol) Combivent (Salbutamol + Ipratropium) Berodual (Fenoterol+ Ipratropium) Onbrez (Indacaterol) Striverdi (Olodaterol) Incruse (Umeclidinium) Seebri (Glycopyrronium) Spiriva (Tiotropium) Flutiform (Fluticasone propionate + Formoterol) Foster (Beclomethasone + Formoterol) Relvar (Fluticasone furoate + Vilanterol) Seretide (Fluticasone propionate + Salmeterol) Symbicort (Budesonide + Formoterol) Anoro (Vilanterol + Umeclidinium) Spiolto (Olodaterol + Tiotropium) Ultibro (Indacaterol + Glycopyrronium) Alvesco (Ciclesonide) Duasma (Budesonide) Flixotide (Fluticasone propionate) Pulmicort (Budesonide) (SABA) : Berotec MDI : Fenoterol : : 100 μg/ : 32 33

(SABA) : Ventolin MDI : Salbutamol : : 100 μg/ : (Ultra-LABA) : Striverdi Respimat : Olodaterol : : 2.5 μg / : 2 + (SABA+SAMA) : Berodual : Fenoterol + Ipratropium : : 50/20 μg / : 6-8 (LAMA) : Incruse Ellipta : Umeclidinium : : 55 mcg/ : (Ultra-LABA) : Onbrez Breezhaler : Indacaterol : : 150 μg / : (LAMA) : Seebri Breezhaler : Glycopyrronium : : 50 μg / : 34 35

(LAMA) : Spiriva Respimat : Tiotropium : : 2.5 μg / : 2 (ICS+LABA) : Relvar Ellipta : Fluticasone furoate + Vilanterol : : 92/22 μg / : (ICS+LABA) : Flutiform MDI : Fluticasone propionate + Formoterol : : 25/5 μg / : 12 1-2 (ICS+LABA) : Seretide Accuhaler : Fluticasone propionate + Salmeterol : ( ) : 100/50; 250/50; 500/50 μg / : 12 1 (ICS+LABA) : Foster MDI : Beclomethasone dipropionate + Formoterol : : 100/6 μg / : 12 1-2 (ICS+LABA) : Seretide Evohaler MDI : Fluticasone propionate + Salmeterol : : 50/25, 125/25, 250/25 μg / : 12 1-2 36 37

(ICS+LABA) : Symbicort Turbuhaler : Budesonide + Formoterol : : 160/4.5 μg / : 12 1-2 (Ultra-LABA+LAMA) : Spiolto Respimat : Olodaterol + Tiotropium : : 2.5/2.5 μg / : 2 (ICS+LABA) : Symbicort Rapihaler MDI : Budesonide + Formoterol : : 160/4.5 μg / : 12 1-2 (Ultra-LABA+LAMA) : Ultibro Breezhaler : Indacaterol + Glycopyrronium : : 110/50 μg / : (Ultra-LABA+LAMA) : Anoro Ellipta : Vilanterol + Umeclidinium : : 55/22 μg / : (ICS) : Alvesco MDI : Ciclesonide : : 160 μg / : 1 38 39

(ICS) : Duasma MDI : Budesonide : : 200 μg / : 12 1-2 (ICS) : Flixotide Evohaler MDI : Fluticasone propionate : : 50 μg / : 12 1-2 (ICS) : Pulmicort Turbuhaler : Budesonide : : 200 μg / : 12 1-2 40 41

4-1. ( Berotec ) 1 3 1 2 3 2 4 :. ( 4-1 ) 1 4-5 2 3 4 (spacer) 5 6 ( ) ( 3 4-5 ) 7 ( 10 ) 8 9 6 9 30-60 10 11 4 5 6. Accuhaler Breezhaler Ellipta Turbuhaler A. Accuhaler ( ) ( 4-2 ) 1 2 " " 42 43

3 ( ) 4 ( 10 ) 5 6 30-60 7 ( ) 8 4-2. Accuhaler 1 2 B. Breezhaler ( 4-3 ) 1 2 3 ( " " ) 4 ( ) 5 ( ) ( ) 6 ( 10 ) 7 8 30-60 9 10 3 4 44 45

4-3. Breezhaler 4-4. Ellipta 1 2 3 1 2 3 4 5 6 4 5 6 C. Ellipta ( 4-4 ) 1 2 ( ) 3 ( 10 ) 4 5 6 D. Turbuhaler ( 4-5 ) 1 2 " " 3 ( ) 4 ( 10 ) 5 46 47

6 30-60 7 8 4-5. Turbuhaler 3 4 5 1 2 1 2 3 4 3 4. ( Spiriva Respimat ) A. 1 2 B. 1, 2 48 49

3 4 ( 10 ) 5 6 30-60 4-6. ( Spiriva Respimat ) 1 2. (SVN) : 1 4 6 ml 2 6-8 L/min 3 (mouth piece) 4 5 ( ) ( 30 L/min) 6 ( ) ( 10 ) 7 8 4-6. nebulizer kit 3 4 50 51

pmdi pmdi spacer (ICS) AeroChamber ( 5.1 ) 52 53

5-1. ( ) AeroChamber : A. (spacer) ( AeroChamber ) : 1 (pmdi) 2 3 pmdi 8-10 4 pmdi 1-2 5 5-10 6-10 5-6 30 6 pmdi 30 3 5 5-1. AeroChamber : 0-18 B. ( 5-1) ( 5-2) ( 5-3) ( 5-4) pmdi pmdi 5-2. AeroChamber : 1-5 54 55

4 5 6 7 5-3. AeroChamber : 5 QR code 5-1. (AeroChamber) 5-4. AeroTrach : C. AeroChamber 1 ( ) 2 3 15-30 D. pmdi 1 4-5 2 puffs 30~60 2 ( 4-5 ) 3 4 ( ) 56 57

: ( ) 31-85% 6-1 58 59

(checklist) 10% 100% : 6-1. (pmdi+spacer) 60 61

Symbicort Respimat Turbuhaler 5-10 Accuhaler Ellipta Breezhaler 62 63

. 1~5 μm 1.5 μm 2.8 μm 5 μm 2.8 μm (mass medium aerodynamic diameter, MMAD) (mass medium diameter, MMD) 50% MMD 50% MMD (cascade impactor) MMAD 64 65

1. 4 / 6-8 / 8 / 2. 4~6 ml 2 ml. (inertial deposition) 10.. 1 2 3 4 5 6 7 8 66 67

(pmdi) 1 (HFA) (CFC) 2 3 4 5 7-1. 30 / < 30 / 30 / < 30 / 68 69

In-Check DIAL ( Alliance Tech Medical, Inc. ) 8-1A 15 L/min 120 L/ min Turbuhaler, Flexhaler, Twisthaler, Aerolizer, Handihaler Diskus ( 8-2) 8-2. (Ellipta, Accuhaler Respimat) 8-1A. In-Check DIAL 8-1B. Turbuhaler Turbuhaler whistle ( 8-1B) Turbuhaler Turbuhaler whistle Turbuhaler Turbuhaler ( ) 70 71

: : ( 8-1 ) 1 2 8-1. 3 4 5 6 72 73

: 1 2 : 1 2 3 4 5 : 1 2 3 : 4 5 74 75

: 76 77

A. 1 1 2 T 3 Y ( 9-1) 1 9-2 2 Y-piece 4 ( ) 6-10 / 5 6 B. 1 2 AeroChamber MV ( 9-3 ) 1 : ( 9-4) 2 : 3 pmdi AeroChamber 4 5 30 6 4~5 7 AeroChamber 8 9-3. 9-4. 9-1. 9-2 C. AeroTrach 78 79

第一次使用 氣喘與慢性阻塞性 肺病吸入治療 吸入器就上手 始緩慢吸氣 助器 它有幾個不同型式如下 a AeroTrach-Plus 防靜電閥保持室 (anti-static VHC) 專為壓力定量吸 5 入器 pmdi 藥物的運送到自主呼吸的氣管切開術患者 ( 圖 9-5) 若有第二劑量時 休息 30 秒後再重複步驟 4 確保每一劑量能完全進 入肺部 6 若病人有呼吸困難的跡象 請將本裝置移開 b AeroChamber-Mini 氣霧室高效裝置 設計成可維持 PEEP 並可用於 使用正壓呼吸器之病患 體積小 可以保留氣霧劑劑量和減少死腔的 空間 也可用於手壓式甦醒球 (Ambu) ( 圖 9-7) 圖 9-5. 吸藥輔助器 AeroTrach-Plus 1 MDI 2 3 圖 9-7. 吸藥輔助器 AeroChamber-Mini 4 5 c AeroVent 可折疊儲存室設計成可留置於吸氣管路中使用 並且不會影 響到機械通氣使用 ( 圖 9-8) 圖 9-6. 吸藥輔助器 AeroTrach-Plus 連接及使用步驟 1-5 80 1 打開壓力定量吸入器的護蓋 2 檢查 AeroTrach 內是否有異物 3 將噴霧劑大約搖 10 下 將壓力定量吸入器卡入 AeroTrach 的後方 4 再將 AeroTrach 連到氣管開口管連接件接上 按壓噴霧劑一下劑量 開 圖 9-8. 吸藥輔助器 AeroVent 81

d AeroChamber * MV ( 9-9) ) 4 AeroChamber MV Ambu ( 9-11) 9-9. AeroChamber * MV 1 2 1 2 3 3 4 4 5 6 9-10. AeroChamber * MV 1-4 1 AeroChamber MV 2 AeroChamber MV 3 ( 15 9-11. AeroChamber * MV Ambu 1-6 1 AeroChamber MV 2 Ambu 82 83

3 4 Ambu Bag AeroChamber MV 5 Ambu Bag ( 15 ) 6 AeroChamber MV D. (vibration mesh nebulizer, VMN) ( 9-12) ( 9-13) 1 10 ml 2 Y 3 4 9-13. (GE Engstrom) 9-12. (VMN) E. : 84 85

2009 Lenney B. I. II. ( 9-1) 3 ( ) (mouthpiece) A. 3 6 6 + 6 3 3-6 3-6 6 6 9-1. 3-4 3-4 1 1 86 87

88 89

QR code 郭炳宏 : Mitchell JP. What the pulmonary specialist should know about the new inhalation therapies. Eur Respir J. 2011 Jun;37(6):1308-31 90 91

10048 02-2314-4089 02-2314-1289 tspccm.t6237@msa.hinet.net http://www.tspccm.org.tw 105 11 ISBN 978-986-92595-3-8 ( ) 92