马偕医院小儿科部李宏昌ppt课件

1、馬偕醫院小兒科部馬偕醫院小兒科部 李宏昌李宏昌The role of bronchodilator in treating cough in children202A 202A 依據病歷記載及病況，缺乏以支持實施本項依據病歷記載及病況，缺乏以支持實施本項 ( (門、急、住診療門、急、住診療/ /手術手術/ /麻醉麻醉/ /處置處置/ /治療治療/ /檢檢 驗驗/ /檢查檢查/ /藥品藥品/ /特材特材) )324A 324A 同時已投予同性質藥物，用藥種重複同時已投予同性質藥物，用藥種重複住院案例-1 5歲男童，診斷為464.4 Croup 病史：Fever with productive c

2、ough and hoarseness for 3 days. The cough sounds like barking. 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 w

3、ith peribronchial cuffing住院案例-1 核刪Pulmicort Nebulising suspension(IH) 核刪理由： 依所附文獻，IV form dexamethasone為首選，為何捨有效且廉价的療法 依據診斷/病況，無运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

4、 authors, the relative ease, speed, and cost of administration make systemic corticosteroids preferable to nebulized formulations Croup: Treatment & MedicationAuthor: Antonio Muiz, MD, Associate Professor of Emergency Medicine and Pediatrics, University of Texas Medical School at Houston; Update

5、d: Nov 21, 2019A 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 illness. The long half-life of dexamethasone (54 h) often allows for a single injection. Dexamethasone (0.15 mg/kg) is as

6、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 oral dose of prednisolone (1 mg/kg) resulted in more return visits than a single oral dose of dexamethasone (0.15 mg/kg).I

7、nhaled budesonide has also proven to be effective but is more expensive; in one study, oral dexamethasone resulted in better improvement than nebulized budesonide. Cough is an important defense mechanism that plays a major role in maintaining the integrity of the airways and can be voluntary or invo

8、luntary. The pathophysiology of cough is incompletely understood. Cough is commonly triggered by mechanical or chemical stimulation of receptors in the pharynx, larynx, trachea and bronchi. Cough receptors also exist in the nose, paranasal sinuses, external auditory ear canals, tympanic membranes, p

9、arietal pleura, esophagus, stomach, pericardium and diaphragm. NLHEP(National Lung Health Education Program )Medicines commonly used in treating cough:Acetaminophen or ibuprofen:Antibiotics:Antiviral medicine:Breathing treatments: Cough medicine:Expectorant: Coughing the phlegm out of the lungs can

10、help your child breathe easier. Should drink plenty of liquids when taking this type of medicine.Suppressant : May need a cough suppressant at night 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 hi

11、s lungs.Bronchodilators can be given during a breathing treatment or by using an inhaler. by mouth or through an IV.Steroids: Steroid medicine may help to open air passages in the lungs so that the child can breathe easier. 夫街談巷說，必有可採；擊轅之歌，有夫街談巷說，必有可採；擊轅之歌，有應風雅，匹夫之思，未易輕棄也。應風雅，匹夫之思，未易輕棄也。巷說百物語 街談街談公益

12、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，不然他就要吃。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。門號威寶電信他假设覺得有賺到可以笑出來沒關係。企業笼统篇、低費率篇。鞋類La newDCS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，享用就要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，肌肉痠痛都是他害的。 Summary of impo

13、rtant points: Asthma is a common condition but it is not always the diagnosis in a coughing child. A careful clinical 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 rhi

14、nitis, makes a diagnosis of asthma more likely. Physical examination may be normal in a child with asthma between 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 as

15、thma is suspected. Diagnosing asthma in young children is difficult because children often: cough and 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 Mar

16、ch.It is important not to over-diagnose asthma in children who in fact have a chronic 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 airf

17、low obstruction and response to bronchodilator has been demonstrated physiologically. 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

18、dose inhaled corticosteroids, and relapse on stopping medications with second response to recommencing them. Bush A; Pulm Pharmacol Ther. 2019;15(3):309-15 Pulm Pharmacol Ther. 2019;15(3):309-15 In a child with isolated (chronic) cough.One of five diagnostic categories: Normal child; A serious illne

19、ss such as cystic fibrosis, tuberculosis etc. Non-serious, 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. Bronchitis can be

20、 caused by viruses, bacteria, or allergies, and 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 produce

21、s thick mucous or sputum, usually lasts about 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 fo

22、r one week; no fever; night sleep: 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門診案例-1 用藥 C

23、ough Mixturel 4cc 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，缺乏以支持實施本項(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 Bronchodilators may be endogenous (originating naturally within the body), or they may

24、 be 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.

25、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, but care

26、 should be taken when using them with children because they have a tendency to speed up the heart rate. In chronic cough , majority of patients are suffering from oneof three conditions:a form of asthma, gastro-esophageal reflux, or Rhinitis/postnasal drip. A study of children ages 5 to 10.5 yearsAC

27、AAI 2019: 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 in group B (surgical treatment) showed a similar im

28、provement, 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 investigator Aaron Kobernick, MD, MPH, from the Tulane U

29、niversity School of Medicine, in New Orleans, Louisiana, told Medscape Allergy & Clinical Immunology.62 children, between 6 and 11 years old, Three types of prescription bronchodilating drugs :2-agonists (short- and long-acting),Anticholinergics (short-acting) Theophylline (long-acting). A bronc

30、hodilator. Short-acting bronchodilators are used only as needed as asthma “rescue medications, Long-acting bronchodilators are used every day to control asthma. 門診案例-1 10歲男童，47公斤，診斷：Asthma(493.9)、Acute sinusitis(461.9)、 Bronchopneumonia(485)及Allergic rhinitis(477.9) 主訴：frequently night cough everyda

31、y, 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, 門診案例-2用藥Symbicort turbuhalerXanthiumPolaraminMedicon-APsubityVentolin核刪理由：Symbicor含類固醇及fo

32、rmoterol(支氣管擴張劑)，再重覆运用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核刪本項藥品核刪本項藥品a long-acting 2-agonist short-acting 2-adrenergic receptor agonist 門診案例-3 3歲男童，17公斤，診斷：Extrinsic Asthma(493)、 Acute bronchiolitis(46619) 、Allergic rh

33、initis(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(+); breath sound: rhonchi and rale, throat: injected with enlarged; conjunctivitis門診案例-3用藥用藥Acetaminophen syrupVentolinPeriac

34、tin PolaraminVistarilAsverinZyrtec syrupMeptin liquidMedicon-A核刪理由：核刪理由：Ventolin與與Meptin重複用藥，重複用藥，Medicon-A與與Asverin為同類祛痰劑為同類祛痰劑Zyrtec 與與Periactin為重複用藥為重複用藥同時已投予同性質藥物，用藥種類重複同時已投予同性質藥物，用藥種類重複 申請理由：申請理由：Meptin及及Zyrtec是為控制是為控制Asthma、過敏性鼻炎及、過敏性鼻炎及URI用藥用藥核刪核刪3項藥品項藥品beta-2 adrenergic receptor agonist shor

35、t-acting 2-adrenergic receptor agonist There is very limited evidence in regards to the benefit of inhaled bronchodilators for improving symptoms of acute bronchitis. A few of the observations taken from these studies are: 1) Both studies had at least a trend towards improving various symptoms of ac

36、ute 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) are mild; 3) Both studies excluded patients with known bronchoconstrictive lung disease and other historical factors, wh

37、o, likely, would have a greater benefit with brochodilators in acute cough/acute bronchitis. ObjectivesTo determine the efficacy of inhaled anti-cholinergic medications in the management of prolonged non-specific cough in children.Search strategyThe Cochrane Register of Controlled Trials (CENTRAL),

38、the Cochrane Airways Group Specialised Register and Cochrane Airways Group, MEDLINE and EMBASE databases were searched. Relevant pharmaceutical companies were contacted. The latest searches were performed in April 2019.Main resultsNo randomised-controlled trials that examined the efficacy of inhaled

39、 anti-cholinergic medications in the management of prolonged non-specific cough in children were found. An additional search in April 2019 did not identify any further studies.Authors conclusionsThere is currently no evidence to support the use of inhaled anti-cholinergics for symptomatic control of

40、 non-specific cough in children. Further research examining the effects of this intervention is needed.Anticholinergics Only available 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

41、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 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 visio

42、n for a brief time. 誰說誰說Berodual MDI不能用在哮喘病人身上？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沒有學理及臨床运用的適應性！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冤枉吧！並不是只需並不是只需 ant

43、icholinergic ipratropium而已，尚有而已，尚有 fenoterol (Berotec)， Methylxanthines: including caffeine, theobromine and theophylline relaxing bronchial smooth muscle increasing heart muscle contractility and efficiency: positive inotropic increasing heart rate: positive chronotropic increasing blood pressure i

44、ncreasing renal blood flow some anti-inflammatory effects central nervous system stimulatory effect mainly on the medullary respiratory center. TheophyllineMethylxanthines for prolonged non-specific cough in children published online: 20 April 2019 in Issue 2, 2019. Last assessed as up-to-date: 31 D

45、ecember 2019. (Chang AB, Halstead RAP, Petsky HL) This review examined whether there 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-rand

46、omised controlled studies, the researchers described that dramatic improvements in cough 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 no

47、n-specific cough in children. Authors conclusions (Chang AB, Halstead RAP, 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 pr

48、olonged non-specific cough, cohort data (thus limited) suggest a clinical 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

49、in children. Further research examining the efficacy of this intervention is needed. anticholinergic bronchodilator Some patients have a dry or irritated throat or a dry mouth after using bronchodilators. To help prevent these problems, gargle and rinse the mouth or take a sip of water after each dose.The most common side effects are nervous