Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_2720_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

31.08.2026

Размер:

31 Мб

Скачать

☆

<<< < Предыдущая 18 19 20 21 22 23 24 25 26 27 28 2930 / 5030 31 32 33 34 35 36 37 38 39 40 41 42 > Следующая >>>

274

https://t.me/med1917

274

CHAPTER10 Respiratorymedicine

Table10.4 Predicted PEFR measurements inL/ min (EU scale)

Children Height is theonly determinant ofPEFR inchildren. With i age

thepattern ofadult values takes over.

Height: Feet 3ʹ 3ʹ4ʺ 3ʹ8ʺ 4ʹ 4ʹ4ʺ 4ʹ8ʺ 5ʹ 5ʹ4ʺ 5ʹ8ʺ 6ʹ

Metres 90cm 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8

PEFR L/ min 88 105 136 172 220 265 313 371 427 487

Women

Height:l

Feet

4ʹ10ʺ4ʹ11ʺ 5ʹ 5ʹ1ʺ 5ʹ2ʺ 5ʹ3ʺ 5ʹ4ʺ 5ʹ5ʺ 5ʹ6ʺ 5ʹ7ʺ 5ʹ8ʺ 5ʹ9ʺ 5ʹ10ʺ M 1.47 1.5 1.52 1.55 1.57 1.6 1.62 1.65 1.67 1.7 1.72 1.75 1.77 Age

15y 379 382 385 389 391 394 397 400 402 405 407 411 413 20y 402 406 409 413 416 419 422 425 428 431 434 437 439 25y 415 419 422 426 429 433 435 439 441 445 447 451 453 30y 419 424 427 431 433 437 440 444 446 450 452 456 458 35y 418 423 425 430 432 436 439 443 445 449 451 454 457 40y 413 417 420 424 427 431 433 437 439 443 445 449 451 45y 405 409 412 416 418 422 425 428 431 434 436 440 442 50y 394 399 401 405 407 411 414 417 419 423 425 428 430 55y 383 387 389 393 395 399 401 404 407 410 412 415 417 60y 370 373 376 379 382 385 387 391 393 396 398 401 403 65y 356 360 362 366 368 371 373 376 378 381 383 386 388 70y 343 346 348 351 353 356 358 361 363 366 368 371 372

Men

Height:l

Feet

5ʹ2ʺ 5ʹ3ʺ 5ʹ4ʺ 5ʹ5ʺ 5ʹ6ʺ 5ʹ7ʺ 5ʹ8ʺ 5ʹ9ʺ 5ʹ10ʺ5ʹ11ʺ 6ʹ 6ʹ1ʺ 6ʹ2ʺ M 1.57 1.6 1.62 1.65 1.67 1.7 1.72 1.75 1.77 1.8 1.82 1.85 1.87 Age

15y 479 485 489 494 498 503 506 511 515 520 523 528 531 20y 534 540 545 551 555 561 565 571 575 580 584 589 593 25y 568 575 580 587 591 598 602 608 612 618 622 628 632 30y 587 594 599 606 611 617 622 628 633 639 643 649 653 35y 594 601 606 613 618 625 629 636 640 646 650 657 661 40y 592 599 604 611 615 622 627 633 637 644 648 654 658 45y 582 590 594 601 606 612 617 623 627 634 638 644 647 50y 568 575 580 586 591 597 601 608 612 618 622 627 631 55y 550 557 561 568 572 578 582 588 592 598 602 607 611 60y 529 536 540 546 550 556 560 566 570 575 579 584 588 65y 507 513 517 523 527 533 536 542 545 551 554 559 562 70y 484 490 493 499 503 508 511 517 520 525 528 533 536

0 For normal values in age groups/ heights not represented on these charts or for conversion from the old Wright scale peak ow meters see M www.peakow.com

Source:data from Gregg I., Nunn AJ, BMJ 1989;298:1068– 70 and Godfrey S, etal. Br J Dis Chest 1970;64:15.

https://t.me/med1917

RESPIRATORYINVESTIGATIONS

Table10.5 Predicted FEV1 and FVC measurements (in L) 0 These values apply forCaucasians. d values by7% forAsians and 13% forpeople ofAfro- Caribbean origin

Height Feet 4ʹ11ʺ 5ʹ1ʺ 5ʹ3ʺ 5ʹ5ʺ 5ʹ7ʺ 5ʹ9ʺ 5ʹ11ʺ

Metres 1.5 1.55 1.6 1.65 1.7 1.75 1.8

Age (y) Women

38– 41 FEV12.3 2.5 2.7 2.89 3.09 3.29 3.49

42– 45 FEV12.2 2.4 2.6 2.79 2.99 3.19 3.39

46– 49 FEV12.1 2.3 2.5 2.69 2.89 3.09 3.29

50– 53 FEV12 2.2 2.4 2.59 2.79 2.99 3.19

54– 57 FEV11.9 2.1 2.3 2.49 2.69 2.89 3.09

58– 61 FEV11.8 2 2.2 2.39 2.59 2.79 2.99

62– 65 FEV11.7 1.9 2.1 2.29 2.49 2.69 2.89

66– 69 FEV11.6 1.8 2 2.19 2.39 2.59 2.79

For women ≤70y use the formulae:

• FEV

• FVC=(0.0443 × height in m × 100)− (0.026 × age in y) − 2.89

Height

Age (y) Men 38– 41 FEV13.2 3.42 3.63 3.85 4.06 4.28 4.49

42– 45 FEV13.09 3.3 3.52 3.73 3.95 4.16 4.38

46– 49 FEV12.97 3.18 3.4 3.61 3.83 4.04 4.26

50– 53 FEV12.85 3.07 3.28 3.5 3.71 3.93 4.14

54– 57 FEV12.74 2.95 3.17 3.38 3.6 3.81 4.03

58– 61 FEV12.62 2.84 3.05 3.27 3.48 3.7 3.91

62– 65 FEV12.51 2.72 2.94 3.15 3.37 3.58 3.8

66– 69 FEV12.39 2.6 2.82 3.03 3.25 3.46 3.68

For men ≤70y use the formulae:

• FEV

• FVC=(0.0576 × height in m × 100)− (0.026 × age in y) − 4.34

Source:data from the British Thoracic Society.

FVC 2.69 2.91 3.13 3.35 3.58 3.80 4.02

FVC 2.59 2.81 3.03 3.25 3.47 3.69 3.91

FVC 2.48 2.7 2.92 3.15 3.37 3.59 3.81

FVC 2.38 2.6 2.82 3.04 3.26 3.48 3.71

FVC 2.27 2.49 2.72 2.94 3.16 3.38 3.6

FVC 2.17 2.39 2.61 2.83 3.06 3.28 3.5

FVC 2.07 2.29 2.51 2.73 2.95 3.17 3.39

FVC 1.96 2.18 2.4 2.63 2.85 3.07 3.29

=(0.0395 × height in m × 100)− (0.025 × age in y) − 2.6

Feet

5ʹ3ʺ 5ʹ5ʺ 5ʹ7ʺ 5ʹ9ʺ 5ʹ11ʺ 6ʹ1ʺ 6ʹ3ʺ

Metres 1.6 1.65 1.7 1.75 1.8 1.85 1.9

FVC 3.81 4.1 4.39 4.67 4.96 5.25 5.54

FVC 3.71 3.99 4.28 4.57 4.86 5.15 5.43

FVC 3.6 3.89 4.18 4.47 4.75 5.04 5.33

FVC 3.5 3.79 4.07 4.36 4.65 4.94 5.23

FVC 3.39 3.68 3.97 4.26 4.55 4.83 5.12

FVC 3.29 3.58 3.87 4.15 4.44 4.73 5.02

FVC 3.19 3.47 3.76 4.05 4.34 4.63 4.91

FVC 3.08 3.37 3.66 3.95 4.23 4.52 4.81

=(0.043 × height in m × 100)− (0.029 × age in y) − 2.49

275

ALGRAWANY

276

https://t.me/med1917

276

CHAPTER10 Respiratorymedicine

Bronchodilators andsteroids

Bronchodilators Cause relaxation of bronchial smooth muscle.

Short- acting β2 agonists e.g. salbutamol, terbutaline. Safest, most eective β2 agonists for use as quick relievers in asthma and COPD.

• Duration of action:~3– 5h. Oral preparations are less eective than

inhaled preparations. Prescribe as 1– 2 pus prn

• Warn patients to seek medical advice if usual dose does not relieve

symptoms or relieves symptoms for <3h

• Regular treatment with bronchodilators alone may be linked with

worsening of asthma and asthma deaths. If the patient has asthma and is using a β2 agonist inhaler >3×/ wk, consider prophylaxis— E p. 282

Longer- acting β2 agonists e.g. salmeterol, formoterol.

• Asthma e.g. salmeterol 50– 100mcg bd as an adjunct to existing corticosteroid treatment— E p. 282. Particularly useful for night- time asthma. Duration of action is 712h. Due to its rapid onset of action, formoterol can also be used for relief of acute attacks, usually in combined steroid/LABA inhaler, as part of a maintenance and reliever therapy (MART) regime.

• COPD E p. 286

0 Always prescribe as combination inhaler with inhaled steroid.

Steroids Short- and long- term treatment of inammatory conditions.

• Oral steroids Prescribe as a single dose in the morning. Often started at high dose (e.g.40– 50mg od) to suppress disease process and then stopped after improvement. If used as maintenance therapy, use the minimum dose that controls disease. Supply with a ‘steroid card’

• Inhaled steroids Use regularly to obtain maximum benet. Alleviation of symptoms occurs 3– 7d after initiation. If causes coughing, try a short- acting β2 agonist before use. Common unwanted eects are oral candidiasis (5%) and hoarseness— d by use of a large volume spacer or mouth washing after use

0 Beclometasone inhalers should always be prescribed by brand name.

Side eects oforal and high- dose inhaledsteroids

• i BP

• Osteoporosis ± fracture

• Proximal muscle wasting

• Euphoria

• Paranoid states/ depression— especially if PMH

• Peptic ulceration— po soluble or EC preparations may d risk

• Suppression of clinical signs— may allow diseases, e.g. septicaemia, to reach advanced stage before being recognized

Steroid cards Should be carried by patients on oral/ high doses of inhaled steroids. The card informs other practitioners that the patient is on steroids and gives the patient advice on use of steroids and risk of infection. Steroid cards can be obtained from:F 0161 6832189 Email:nhsforms@spsl.uk.com

• Spread of infection, e.g. chickenpox

• DM/ worsening of diabetic control

• Cushing’s syndrome— moon face,

striae, and acne

• Adrenal atrophy— can persist years

after stopping long- term steroids— illness/ surgical emergencies may need to be covered with steroid supplements

• Growth suppression in children

• Na+ and water retention; K+ loss

https://t.me/med1917

BRONCHODILATORS ANDSTEROIDS

Withdrawal ofsteroids Stop abruptly if disease is unlikely to relapse, the patient has received treatment for ≤3wk and is not included in the following patient groups. Withdraw gradually if disease is unlikely to relapse and the patient has:

• Recently had repeated steroid courses (particularly if taken for >3wk)

• Taken a short course <1y after stopping long- term therapy

• Other possible causes of adrenal suppression

• Received >40mg od of prednisolone (or equivalent) for >1wk

• Been given repeat doses in the evening

• Received treatment with steroids for >3wk During corticosteroid withdrawal, d dose rapidly to physiological levels

(~prednisolone 7.5mg od)— thereafter d more slowly. Assess the disease during withdrawal to ensure relapse does not occur.

Use ofspacers withmetered dose inhalers (MDIs)

Advantages ofusing a spacer Allows more time for evaporation of propellant so a larger proportion of active drug is deposited in the lungs; there is no need to coordinate actuation with inhalation; results in less oropharyngeal side eects (e.g. thrush, hoarseness with inhaled steroids).

Use ofspacers Both large- volume spacers (e.g. Volumatic™) and mediumvolume devices (e.g. Aerochamber™) are widely available, acceptable, and portable. Inhale the drug from the spacer immediately after actuation as eect of the drugs is short- lived. Spacers should be washed and air dried monthly to prevent build- up of electrostatic charge aecting drug delivery, and replaced every 6– 12mo.

Home nebulizer therapy In England and Wales nebulizers are not

available via the NHS (but are free of VAT). Some nebulizers are available in Scotland on form GP10A. Nebulizers convert a solution of drug into an aerosol for inhalation. They are used to deliver a higher dosage of drug than is usual with inhalers over a short period of time (5– 10min). Indications:

• Acute exacerbations ± regular treatment of asthma/ COPD

• Antibiotic treatment— for patients with chronic purulent infection,

e.g. CF; bronchiectasis; prophylaxis and treatment of pneumocystis pneumonia with pentamidine in patients with AIDS

• Palliative care— palliation of breathlessness and cough, e.g.

bronchodilators, lidocaine, or bupivacaine for dry, persistent cough

Use inasthma/ COPD Before suggesting long- term use:

• Review diagnosis, technique using hand- held device ± spacer, and

compliance

• Try i dose of bronchodilator via a hand- held device for at least 2wk

• Perform a 2wk trial of nebulizer therapy and monitor therapeutic eect

(e.g. with PEFR in asthma, or dyspnoea score with COPD)

• Provide clear instructions on the use of the nebulizer, monitoring, and

when to seek help. Follow up regularly

Further information

European Respiratory Society (2001) Guidelines on the use of nebulizers. Eur Respir J 18:228– 42.

277

ALGRAWANY

278

https://t.me/med1917

278

CHAPTER10 Respiratorymedicine

Asthma inadults

Symptoms/ signs ofa severe asthmaattack

• PEFR 33– 50% predicted or

best

• Oxygen saturation ≥92%

• Unable to talk in sentences

Life- threateningsigns

• PEFR <33% predicted or best

• Oxygen saturation <92%

• Poor respiratory eort

• Silent chest (inaudible wheeze)

Management of an acute asthma attack E p. 1072

 There are two competing national asthma guidelines in the UK which dier signicantly from each other. The guidance in this section is based on BTS/ SIGN guidance; links to both the BTS/ SIGN guidance and parallel NICE guidance are provided on E p. 281.

Asthma is a condition of paroxysmal, reversible airways obstruction that

aects 1 in 12 adults in the UK. It has 3 characteristic features:

• Airow limitation— usually reversible spontaneously or with treatment

• Airway hyper- responsiveness to a wide range of stimuli

• Inammation of the bronchi

Asthma inspecialgroups

• Children E p. 860

• Occupational asthma E p. 306

Diagnosis of asthma Characteristic pattern of symptoms/ signs and

tests without another explanation. Determine probability of asthma:

• High Recurrent, episodic asthma symptoms (>1 of wheeze, breathlessness, chest tightness, cough), diurnal variability, audible expiratory wheeze, documented variable airow obstruction (e.g. PEFR variability), atopic history, absence of features to suggest another diagnosis

• Intermediate Some features of asthma; poor treatment response

• Low No typical asthma features; symptoms suggest another diagnosis

0 Always consider the possibility of occupational asthmaN. Ask:‘Are symptoms better on days away from work?’ and ‘Are symptoms better on holiday?’ If

yes to either/ both, consider referral.

Clinical features that d probability ofasthma

• Normal chest examination and/ or PEFR/ spirometry when symptomatic

• Chronic productive cough without wheeze/ breathlessness

• Prominent dizziness, light- headedness, peripheral tingling

• Voice disturbance

• Symptoms with colds only

0 Normal spirometry when asymptomatic does not exclude asthma.

Tes t s Spirometry + reversibility is the preferred initial test; consider CXR with atypical/ additional symptoms; eosinophil counts. 0 NICE advocates initial use of fractional exhaled nitric oxide (FeNO) testing.

• Tachypnoea (respiratory rate ≥25

breaths/ min)

• Tachycardia (heart rate ≥110bpm)

• Arrhythmia

• Hypotension

• Altered

consciousness

• Pregnancy E p. 800

• Smoking history (>20 pack y)

• Cardiac disease

• Cyanosis

• Exhaustion

https://t.me/med1917

ASTHMA INADULTS

Dierential diagnosis Airow obstruction=FEV

Airow obstruction No airow obstruction

• COPD

• Bronchiectasis*

• Inhaled foreign body*

• Obliterative bronchiolitis

• Large airway stenosis

• Lung cancer*

• Sarcoidosis*

*May also be associated with non- obstructive spirometry.

• Chronic cough syndromes

• Hyperventilation syndrome

• Vocal cord dysfunction

• Rhinitis

• Gastro- oesophageal reux

• Heart failure

• Pulmonary brosis

/ FVC <0.7

Action

High probability Give trial of treatment with inhaled beclometasone 200mcg bd (or equivalent) for 6wk. If response is poor despite adequate inhaler technique/ concordance, investigate further.

0 If signicant airow obstruction, there may be inhaled steroid resistance. Treat with oral prednisolone 30mg od for 2wk instead.

Intermediate probability Perform spirometry:

• If FEV1/ FVC <0.7 (i.e. airways obstruction present)— oer reversibility

testing and/ or trial of treatment. If signicant reversibility and/ or trial of treatment is benecial, treat as asthma. If insignicant reversibility and treatment trial is not benecial, consider tests for alternative diagnoses

• If FEV1/ FVC >0.7 (i.e. no evidence of airways obstruction), arrange

further investigations, e.g. challenge tests or FeNO testing to identify eosinophilic inammation (≥40 parts per billion is +ve indicating high likelihood of asthma), before commencing treatment ± refer

Low probability Consider alternative diagnoses and investigate/ manage accordingly. Reconsider asthma if no response.

Reversibility testing For patients with diagnostic uncertainty:

• If airow obstruction is present at the time of assessment— assess FEV1

(or PEFR) and/ or symptoms before and 20min after 400 mcg inhaled salbutamol via MDI and spacer

• If no airow obstruction is present, or response to inhaled salbutamol

is uncertain— assess FEV1 (or PEFR) and/ or symptoms after trial of treatment with inhaled beclometasone 200mcg bd or equivalent for 6wk, or oral steroids (prednisolone 30mg od for 14d)

>200mL i in FEV1 suggests (>400mL i strongly suggests) asthma. If smaller improvement, decide whether to continue treatment by assessment of symptoms. Trial of treatment withdrawal may be helpful if doubt.

Reasons forreferral E=Emergency; U=Urgent; S=Soon; R=Routine

• Severe asthma exacerbation E

• Monophonic wheeze/ stridor E/ U

• CXR shadowing U

• Prominent systemic features

(myalgia, fever, weight loss) U/ S

• Diagnosis unclear S/ R

• Unexpected clinical ndings (e.g.

crackles, clubbing, cyanosis) S/ R

• Constant breathlessness S/ R

• Poor response to treatment S/ R

• Unexplained restrictive spirometry R

• Suspected occupational asthma R

• Chronic sputum production R

• Eosinophilia (>1 × 109/ L) R

279

ALGRAWANY

280

https://t.me/med1917

280

CHAPTER10 Respiratorymedicine

Asthma management inpractice

 There are two competing national asthma guidelines in the UK which dier signicantly from each other. The guidance in this section is based on BTS/ SIGN guidance; a link to the parallel NICE guidance is provided.

Aims oftreatment To:

• d daytime symptoms and night- time waking due to asthma

• Minimize the need for reliever medication

• d impact on lifestyle, e.g. absences from work/ school, exercise

• Prevent severe attacks/ exacerbations

• Have normal lung function (FEV1 and/ or PEF >80% predicted or best)

• d side eects from medications

GP services Routine asthma care should be carried out in a specialized

primary care clinic. Doctors/ nurses involved need appropriate training and regular updates. Practices should keep an asthma register to ensure adequate follow- up and allow audit.

0 Not all patients want to attend a pre- arranged appointment. Telephone reviews may be as eective as face- to- face consultations.

Reviews and monitoring Frequency depends on needs. Aim to re-

view all patients with asthma at least annually (Figure 10.2).

• Check symptoms since last seen. Use objective measures, e.g. RCP 3 questions (E p. 273)

• Record smoking status and advise smokers to stop

Include objective measures

Symptoms

e.g. RCP 3 questions, ACQ, ACT

( p. 273)

Smoking status

Exacerbations

Medication

Examination

Education

Goals and next review

Figure10.2 Summary of the annual asthma review

Record/advise about smoking cessation

Numbers and circumstances

Use/concordance

Problems/side eects

Inhaler technique

Objective measures of lung function e.g.

PEFR, spirometry

Tailor to the individual:

Treatment Monitoring

Allergen avoidance

Action plan

https://t.me/med1917

ASTHMA MANAGEMENT INPRACTICE

• Record any exacerbations/ acute attacks since last seen

• Check medication— use, concordance (prescription count— E p. 116), inhaler technique, problems, side eects. 0 If >1 SABA inhaler/ mo, may have poor asthma control— consider stepping up treatment

• Check inuenza/ pneumococcal vaccination received

• Review objective measures of lung function, e.g. home PEFR chart, PEFR/ spirometry at review

• Address any problems or queries and educate about asthma

• Agree management goals and date for further review

Self- management All patients should receive:

• Self- management education Brief, simple education linked to patient goals is most likely to be successful. Include information about:nature of disease, nature of the treatment and how to use it, self- monitoring/ self- assessment, recognition of acute exacerbations, allergen/ trigger avoidance, patients’ own goals of treatment

• Written action plan Focus on individual needs. Include information about symptom triggers and peak ow levels that indicate when asthma is worsening, and guidance about what to do under those circumstances. Action plans d morbidity and health costs from asthma

• PEFR monitoring Record PEFR at asthma review and if acute exacerbation. Home monitoring + action plan can be useful especially for patients with severe asthma, brittle asthma (i.e. rapid development of acute asthma attacks), and/ or if poor perceivers of symptoms

Management ofacute asthma Ep. 1072

Non- pharmacologicalmeasures

• Smoking May i symptoms of asthma— advise to stop

• Weight There is some evidence that weight d in obese patients with asthma results in i asthma control

• Allergen avoidance

• House dust mite:there is little evidence that d house dust mite results in clinical improvement. Physical and chemical methods of reducing house dust mite levels are ineective and should not be recommended, e.g. acaricides, mattress covers, vacuum cleaning, heating, ventilation, freezing, washing, air ltration, and ionizers

• Pets:there is no evidence that removing pets from a home results in improved symptoms, but many experts still advise removal of the pet if patients with asthma also have an allergy to the pet

Drug therapy E p. 282

Further information

BTS/ SIGN (2019) British guideline to the management of asthma.

Mwww.sign.ac.uk/ sign- 158- british- guideline- on- the- management- ofasthma.html NICE (2017) Asthma:diagnosis, monitoring and chronic asthma management. M www.nice.org.uk/ guidance/ ng80

Patient information and support

Asthma UK F 0300 222 5800 M www.asthma.org.uk

281

ALGRAWANY

282

https://t.me/med1917

282

CHAPTER10 Respiratorymedicine

Drug treatment ofasthma

Management ofacute asthma E p. 1072

Exacerbations Treat early. In adult patients on 200mcg doses of

inhaled steroids, a 5× i in dose reduces severity of exacerbations. Alternatively, use prednisolone 30– 40mg od for 1– 2wk.

Use a stepwise approach Figure10.3. Start at the step most appro-

priate to the initial severity of symptoms. Achieve early control. Maintain control by i treatment if needed and d treatment if good control.

Selection ofinhaler device If possible, use a MDI. Inadequate tech-

nique may result in drug failure. Patients must inhale slowly and hold their breath for 10sec after inhalation. Demonstrate inhaler technique before prescribing and check at follow- ups. Spacers/ breath- activated devices are useful if patients nd activation dicult. Dry powder inhalers are an alternative.

Short- acting β2 agonists E p. 276— e.g. salbutamol/ terbutaline.

Work more quickly and with fewer side eects than alternatives. Use prn unless shown to benet from regular dosing. Using ≥2 canisters/ mo or >10– 12 pus/ d is a marker of poorly controlled asthma.

0 Abudesonide/ formoterol combination inhaler is an alternative rescue medication as part of a MART regime.

Inhaled corticosteroids E p. 276— eective preventer. May be

benecial even for patients with mild asthma. Consider if:exacerbation of asthma in the last 2y requiring steroids; using inhaled β2 agonists ≥3×/ wk; or symptomatic ≥3×/ wk or ≥1 night/ wk.

Oral steroids E p. 276

Add on therapy Aims to improve lung function/ symptoms. Before

initiating a new drug, check compliance, inhaler technique, and eliminate trigger factors. Only continue if of demonstrable benet.

• Inhaled long- acting β2 agonists (LABA) E p. 276— e.g. salmeterol.

Although there is no dierence in ecacy, combination inhalers are recommended to improve inhaler concordance. A MART regime using a steroid/formoterol combined inhaler for both regular prevention and relief of acute symptoms is useful to d asthma attacks.

• Leukotriene receptor agonists e.g. montelukast. d exacerbations

• Theophylline Side eects are common e.g. nausea, gastric irritation

Complementary therapies Buteyko breathing technique d symp-

toms. No convincing evidence of eectiveness of any other therapies.

Monocloncal antibodies e.g. omalizumab, mepolizumab. May be

considered in patients with a high oral corticosteroid burden. Always specialist initiated. Side eects include local skin reactions and anaphylaxis.

https://t.me/med1917

DRUG TREATMENT OFASTHMA

283

Figure10.3 Summary of stepwise management in adults

Source:data from British Thoracic Society and Scottish Intercollegiate Guidelines Network, SIGN 158: British guideline on the management of asthma (revised 2019)https:// www.sign.ac.uk/ assets/ sign158.pdf

Stepping down Review and consider stepping down at intervals ≤3mo.

Maintain on the lowest dose of inhaled steroid controlling symptoms. When reducing steroids, cut dose by 25– 50% each time.

Dicult asthma Persistent symptoms and/ or frequent exacerbations

despite treatment at step 4/ 5. Check diagnosis and exacerbating factors. Assess adherence to medication. Find out about family, psychological, or social problems that may be interfering with eective management.

Further information

BTS/ SIGN (2019) British guideline to the management of asthma. Mwww. sign.ac.uk/ sign- 158- british- guideline- on- the- management- of- asthma.html NICE (2017) Asthma:diagnosis, monitoring and chronic asthma management. M www.nice.org.uk/ guidance/ ng80

ALGRAWANY

<<< < Предыдущая 18 19 20 21 22 23 24 25 26 27 28 2930 / 5030 31 32 33 34 35 36 37 38 39 40 41 42 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
31.08.202634 Мб0Книга_2710_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202633 Мб0Книга_2711_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202633 Мб0Книга_2713_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202632 Мб0Книга_2716_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202632 Мб0Книга_2717_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202631 Мб0Книга_2720_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202631 Мб0Книга_2721_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202631 Мб0Книга_2724_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202631 Мб0Книга_2725_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202631 Мб0Книга_2727_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202630 Мб0Книга_2729_Библиотеки_им_академика_М_И_Перельмана.pdf