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題名 | 急性氣喘發作的處理 |
---|---|
作者姓名(中文) | 謝炎堯; | 書刊名 | 內科學誌 |
卷期 | 5:1 1994.03[民83.03] |
頁次 | 頁57-68 |
分類號 | 415.425 |
關鍵詞 | 急性; 氣喘; 處理; 發作; |
語文 | 中文(Chinese) |
中文摘要 | 急性氣喘發作名列十大死亡原因之一,1970年代以後,對氣喘發作的 病態生理及病理變化有更深入明確的瞭解,各種治療氣喘藥品相繼問世,呼吸加 護發達,治療氣喘藥品銷售量大幅成長,各專科學會公佈氣喘的治療指引,可是 氣喘死亡率卻不降低反而上升,可能是新療法不妥所導致。近二十年來,專家們 強調炎症反應是氮喘病人的基本病因,使用抗炎症藥(腎上腺皮質類固醇、 cromolyn等),具有對症下藥、安全、而且有效的優點。一直認為氣道只有β��- 受體,心臟只有β��-受體,使用β��-選擇型激動藥的氣霧吸入療法,是局部療 法,可避免心臟及全身性副作用。Aminophylline的支氣管擴張藥效微弱,治療安 全指標狹窄,有許多藥品交互作用及毒性反應,不是治療急性氣喘發作的首選藥 品,甚至於是落伍可捨棄的藥品。事實上,氣道的β-受體有20-30是β��-受體, 心臟的β-受體也有13-35是β��-受體,而且經由氣霧吸入氣道能發揮局部藥效 的劑量,平均僅是給藥劑量的10左右,有80沉積於口腔,經黏膜及胃腸道吸收 而產生全身藥效。故認為氣霧吸入藥沒有心臟及全身性不良反應是錯誤的。由於 氣霧顆粒大小不一,所需要的有效劑量可相差12倍。氣喘嚴重發作時,氣道阻 力可增大土倍,需要較大劑量才能發揮療效,有效安全劑量難以掌握。所謂 aminophyllne的毒性大,危險性高,並不是經由良好設計的臨床試驗所獲得的結 論,而只是零星的病例報告而已。1988年Littenberg搜尋文獻,分析靜脈注射 aminophylline治療嚴重氣喘發作的價值,自I975-1985年共有13篇有對照的試驗 發表,其中有7篇表示與使用同-激動藥或其它支氣管擴張劑沒有差別,3篇報告 amInophylline的療效較佳,另外3篇則較差,把13篇的數據混合分析,結果顯 示沒有差別,可是單獨使用arninophylline不如與β-激動藥合用的療效。 Aminophylline除有良好的支氣管擴張藥效外,尚能增強呼吸肌收縮力,延後肌肉 疲乏時間,及具有兔疫調整作用。經由靜脈注射,可於10分鐘左右迅速緩解氣 喘症狀,仍然是急救氣喘急性發作的最佳選藥。 |
英文摘要 | In spite of advances in the understanding of pathophysiology of bronchia] asthma and the developmentof many new drugs for treatment, the mortality rate of acute asthmatic attack paradoxically increased in thepast two decades. Although the reason is not clear, inappropriate use of new therapy and over-reliance on/?-adrenergic agonists have been implicated.Use of β��- adrenergic agonists for the treatment of asthma has been advocated by chest physicians andrespiratory therapists in the 1 980s. The safety and efficacy ofβ��-adrenergic agonists have been emphasizedon the basis that this class of drugs has potent action at the bronchial β��- adrenergic receptor while spares theheart which contains only A-adrenergic receptors. Aerosol administration of β��-adrenergic agonists isstrongly recommended for the belief that it provides the greatest benefits with the fewest adverse effects. Those who enthusiastically recommended the use ofβ-adrenergic agonists maintained that methylxanthines such as theophylline and aminophylline are obsolete because of weak bronchodilatory effect withhigh toxicity. In 1985 the Drug Committee of American Academy of Allergy and Immunology published a positionstatement indicating thatβ-agonists have been over-used . The Committee pointed outthat β��-agonists couldparadoxically increase bronchial responsiveness, exaggerate arterial hypoxemia, and increase the mortalityrate of asthmatic patients. The notation that aerosol β��-adrenergic agonists exert only local action with minimal cardiac side effect isactually wrong. In fact, only approximately 10 of an aerosol dose can reach bronchioles and alveoli.Almost 80 of the dose deposits in the oral cavity and hypopharynx which is absorbed into the systemiccirculation. In addition, about 20-35 of the β- adrenergic receptors of the heart are As-adrenergic receptors. Thus, even aerosol delivery of β��- adrenergic agonists is not so safe as generally believed. On the other hand, some experts claim that theophylline is a safe and effective medication for the management of chronic asthma. Meta-analysis of thirteen well conducted clinical trials comparing the efficacyand safety of β��-adrenergic agonists and intravenous aminophyllines for the treatment of acute asthmaticattack revealed no statistically significant difference. In conclusion, intravenous aminophylline remains the first-line drug of choice for the treatment of acuteasthmatic attack. (J Intern Med ROC 1994; 5: 57-68.) |
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