過敏氣喘的治療藥物與噴霧療法 林應然小兒科診所 臺大醫學院小兒科兼任講師 林應然醫師

Transcription

1 過敏氣喘的治療藥物與噴霧療法 林應然小兒科診所 臺大醫學院小兒科兼任講師 林應然醫師

2 氣管擴張劑 茶鹼類 (theophyllin) 口服 aminophyllin, phyllocontin, theolan, theovent 乙型氣管擴張劑 (β-adrenergic agent) 口服 吸入,ventolin, berortec, bricanyl, meptin, salmeterol, formoterol 抗乙烯膽鹼 (anticholinergic) 吸入 iprtropium bromide, tiotropium bromide 抗白三烯接受器 ( 如欣流 singulair) 口服

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4 Long-acting inhaled 2 -agonist recommended use As regular bronchodilators in patients taking moderate/high dose inhaled steroids daily. Useful in nocturnal asthma (single night time dose sometimes useful) Prolonged protection against exercise-induced asthma. No anti-inflammatory effect alone, therefore always use in combination with an inhaled steroid.

5 Leukotriene antagonists Inhibitory effect in allergen, exercise, cold air and aspirin challenges. Reduce asthma symptoms and ß 2 -agonist use and improve lung function in clinical trials (but less effective than inhaled steroids). No significant side-effects. Orally active.

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9 Asthma The imprortance of adherence in treatment of chronic disease

10 Inhalation Therapy Direct to lung Fast onset Less side-effects

11 < 吸入器 > (1) 小容積噴霧器 Nebulizer 空氣壓縮機 超音波 (2) 固定劑量噴霧器 pmdi 輔助器 (Aerochamber) (3) 乾粉製劑吸入器 DPI 渦輪旋風式 (Turbuhaler) 喋 式 (Disk haler) (Accuhaler)

12 Metered dose inhaler (MDI) Advantages Disadvantages Small and portable Perfect technique essential Cheap Unsuitable for children < 5-6 years Quick to use Unsuitable for the elderly, arthritic Cold jet may irritate throat CFCs may damage ozone layer Limited amount of drug delivered per puff

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14 1 2 Remove cap and shake. Hold upright Breath out 3 4 Coordinate firing and slow inspiration. Hold breath for at least 10 seconds.

15 Delivery System

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17 New valve & baffle system Aerodynamic body design Improved performance New masks New instructions

18 Metered dose inhaler with spacer (MDI+spacer) Advantages Disadvantages Coordination unimportant Bulky and inconvenient Can be used by all ages Valves sometimes stick or May reduce systemic become incompetent absorption CFCs damage ozone layer May be effective even in severe asthma Relatively inexpensive

19 450million inhalers/year

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21 Nebulizer Advantages Disadvantages Coordination unimportant Cumbersome equipment Can be used for all ages Expensive Effective in severe asthma Noisy No CFCs Treatment takes a long time Disliked by someinfants, loathed by others

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24 Type of nebuliser Jet nebuliser Ultrasonic nebuliser Ultrasonic nebuliser is not suitable for use with drug suspension Dahlback,1994

25 The jet nebuliser Compressed air Therapeutic mist Therapeutic droplets Area of negative pressure Gas orifice Second orifice Baffle Suspension

26 Ultrasonic atomization ULTRASONIC FOUNTAIN IN THE AIR LIQUID HIGH FREQUENCU TRANSDUCER WITH PEIZOELECTRIC CRYSTAL

27 Fractional deposition Mouth Lung Apparatus Exhaled air Metered dose aerosol Nebuliser

28 10 ml

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31 ultrasonic

32 150 ml

33 Lin YZ, Hsieh KH. Metered dose inhaler and nebulizer in acute asthma. Arch Dis Child 1995;72: Aerosol treatment by MDI (with a valved holding chamber) proved to be superior to nebuliser treatment in terms of SaO 2 and some measurements of spirometry. Respiratory therapists working with children with severe asthma should be aware of the possibility of oxygen desaturation, especially when using room air as the driving gas for nebulization.

34 Figure 1. Rate of nebulization, volume change and dead volume of a compressed-air nebulizer Remaining volume (ml) L/min 4L/min 6L/min 8L/min 10L/min Min

35 Figure 2. Rate of nebulization, volume change and dead volume of a ultrasonic nebulizer, Remaining volume (ml) Dead volume 6 ml in conducting tube 2.5 ml in container Min

36 Figure 3. The osmolality change during nebulization Osmolality (mosm/l) C-Ter C-Fen U-Ter U-Fen Min

37 ph value C-Ter C-Fen U-Ter U-Fen Min Figure 4. The ph value change during nebulization.

38 Temperature (oc) degrees C-MP C-C U-MP U-C Min Figure 5. The temperature change during nebulization.

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40 Aeroeclipse 6L/min ml L/min(keep open) 6L/min(with breathing) Min

41 Which inhalation device for which patient? Infants < 5 y/o pmdi+spacer, Nebulizer Children > 5 y/o powdered form device Competent older children/ anykinds adults Incompetent older children/ pmdi+spacer, Nebulizer adults

42 The Fate of Inhaled Corticosteroids % Deposited in lung Complete absorption from the lung Mouth and pharynx Lung Orally bioavailable fraction Systemic Circulation Absorption from gut Liver % swallowed (reduced by spacer or mouth rinsing) GI tract First-pass inactivation Systemic side effects