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¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
™◊ËÕÀπ—ß ◊Õ ¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
ISBN: 978-616-8134-00-9
®—¥æ‘¡æå‚¥¬ ¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
æ‘¡æå§√—Èß∑’Ë 1 ‘ßÀ“§¡ 2560
®”π«πÀπâ“ 112 Àπâ“
®”π«πæ‘¡æå 3,000 ‡≈à¡
æ‘¡æå∑’Ë ∫√‘…—∑ ∫’¬Õπ¥å ‡ÕÁπ‡∑Õ√å‰æ√ å ®”°—¥
ß«π≈‘¢ ‘∑∏‘Ï
¢âÕ¡Ÿ≈∑“ß∫√√≥“πÿ°√¡¢ÕßÀÕ ¡ÿ¥·Ààß™“μ‘ ¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å.
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560-- °√ÿ߇∑æœ : ¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å, 2560.112 Àπâ“
1. ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß. I. ™◊ËÕ‡√◊ËÕß
616.244ISBN: 978-616-8134-00-9
3
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
“√∫—≠
§”π” 5
§«“¡·μ°μà“ß√–À«à“ߢâÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß
æ». 2560 ·≈– GOLD guideline 2017 6
§”™’È·®ßπÈ”Àπ—°§”·π–π”·≈–§ÿ≥¿“æÀ≈—°∞“π 10
𑬓¡ 13
欓∏‘°”‡π‘¥ 13
欓∏‘«‘∑¬“ 14
欓∏‘ √’√«‘∑¬“ 14
√–∫“¥«‘∑¬“ 15
ªí®®—¬‡ ’Ë¬ß 16
°“√«‘π‘®©—¬‚√§ 17
°“√«‘π‘®©—¬·¬°‚√§ 19
·π«∑“ß°“√√—°…“ 19
¢—Èπ∑’Ë 1 °“√ª√–‡¡‘πºŸâªÉ«¬‡æ◊ËÕ°“√√—°…“ 19
¢—Èπ∑’Ë 2 ·π«∑“ß°“√√—°…“¥â«¬¬“·∫∫¢—Èπ∫—π‰¥ 21
°“√√—°…“¥â«¬¬“ 24
¢—Èπ∑’Ë 3 °“√√—°…“Õ◊Ëπ Ê 32
4
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
°“√°”‡√‘∫‡©’¬∫æ≈—π¢Õß‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß 36
°“√ªÑÕß°—π°“√°”‡√‘∫‡©’¬∫æ≈—π¢Õß‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß 42
‡Õ° “√Õâ“ßÕ‘ß 42
¿“§ºπ«°
¿“§ºπ«° 1 °“√„™â¬“™π‘¥ Ÿ¥: ‡∑§π‘§·≈–Õÿª°√≥å™à«¬ Ÿ¥¬“ 51
¿“§ºπ«° 2 ·π«∑“ß°“√™à«¬‡À≈◊Õ„À⺟âªÉ«¬ COPD ‡≈‘° Ÿ∫∫ÿÀ√’Ë 78
¿“§ºπ«° 3 «—§´’π 86
¿“§ºπ«° 4 °“√øóôπøŸ ¡√√∂¿“æªÕ¥ 91
¿“§ºπ«° 5 °“√∫”∫—¥¥â«¬ÕÕ° ‘‡®π√–¬–¬“« 102
¿“§ºπ«° 6 °“√«“ß·ºπ™’«‘μ√–¬– ÿ¥∑⓬ 106
¿“§ºπ«° 7 °“√ª√–‡¡‘π·≈–μ‘¥μ“¡‚√§ 108
“√∫—≠μ“√“ß
μ“√“ß∑’Ë 1 √–¥—∫§«“¡√ÿπ·√ߢÕß‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ßμ“¡§à“ FEV1
À≈—ß„À⬓¢¬“¬À≈Õ¥≈¡ 18
μ“√“ß∑’Ë 2 ¬“∑’Ë„™â„π°“√√—°…“‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß 25
“√∫—≠·ºπ¿Ÿ¡‘
·ºπ¿Ÿ¡‘∑’Ë 1 °“√√—°…“‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß·∫∫¢—Èπ∫—π‰¥ 23
√“¬π“¡§≥–∑”ß“πæ—≤π“¢âÕ·π–π”°“√¥Ÿ·≈√—°…“
ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 111
5
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—߇ªìπ‚√§∑’Ë¡’§«“¡ ”§—≠¢Õߪ√–‡∑» ‚¥¬‡ªì𠓇Àμÿ
¢Õß°“√‡ ’¬™’«‘μ¢Õߪ√–™“°√‰∑¬„π√–¥—∫μâπ Ê ‡ªìπ‚√§∑’Ëæ∫∫àÕ¬„π‡«™ªØ‘∫—μ‘
∑—Ë«‰ª ·≈–‡¡◊ËÕμâÕß√—∫°“√√—°…“‡ªìπºŸâªÉ«¬„π¢Õß‚√ß欓∫“≈®–¡’Õ—μ√“°“√°≈—∫
‡¢â“√—∫°“√√—°…“ È”„π‚√ß欓∫“≈ Ÿß¢÷Èπ ¡’º≈°√–∑∫μàÕ ÿ¢¿“«–¢ÕߺŸâªÉ«¬·≈–
‡ªìπ¿“√–¢Õߧ√Õ∫§√—« √«¡∑—ÈßμâÕß„™âß∫ª√–¡“≥„π°“√¥Ÿ·≈ Ÿß ¡“§¡Õÿ√‡«™™å
·Ààߪ√–‡∑»‰∑¬ „πæ√–∫√¡√“™Ÿª∂—¡¿å ‰¥â®—¥∑” ·π«ªØ‘∫—μ‘∫√‘°“√ “∏“√≥ ÿ¢
‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2553 ·μà„πªí®®ÿ∫—π‰¥â¡’«‘«—≤π“°“√„π°“√¥Ÿ·≈√—°…“
‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—߇æ‘Ë¡¡“°¢÷Èπ ´÷Ëß®–¡’º≈∑”„Àâ§ÿ≥¿“æ™’«‘μ¢ÕߺŸâªÉ«¬¥’¢÷Èπ
Õ¬à“ß¡“° ®÷߉¥â®—¥∑”¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.».
2560 ©∫—∫π’È¢÷Èπ ‚¥¬§«“¡√à«¡¡◊Õ®“°°√–∑√«ß “∏“√≥ ÿ¢ ·≈– ”π—°ß“π
À≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘
„ππ“¡¢Õߪ√–∏“π§≥–∑”ß“πæ—≤π“·π«ªØ‘∫—μ‘∫√‘°“√ “∏“√≥ ÿ¢ ‚√§
ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ¢Õ¢Õ∫§ÿ≥§≥–∑”ß“π √«¡∑—ÈßΩÉ“¬‡≈¢“πÿ°“√ ·æ∑¬å ºŸâ‡™’ˬ«™“≠
·æ∑¬åºŸâ√à«¡∑”ª√–™“æ‘®“√≥å∑ÿ°∑à“π ·≈– ¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬ „π
æ√–∫√¡√“™Ÿª∂—¡¿å √«¡∂÷ß ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘∑’Ë„Àâ°“√ π—∫ πÿπ
°“√¥”‡π‘π°“√®—¥∑”¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
©∫—∫π’È„Àâ ”‡√Á®≈ÿ≈à«ß‰ª¥â«¬¥’ ·≈–À«—߇ªìπÕ¬à“߬‘Ëß«à“·π«∑“ß©∫—∫π’È®–‡ªìπ‡§√◊ËÕß¡◊Õ
à߇ √‘¡§ÿ≥¿“æ°“√„Àâ∫√‘°“√ ÷Ëß®–‡°‘¥ª√–‚¬™πå Ÿß ÿ¥μàÕºŸâªÉ«¬·≈–≠“μ‘ºŸâªÉ«¬
‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß„πª√–‡∑»‰∑¬
§”π”
æ≈μ√’ Õ¥‘»√ «ß…“ª√–∏“π§≥–°√√¡°“√®—¥∑”¢âÕ·π–π”°“√¥Ÿ·≈√—°…“
ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
6
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
§«“¡·μ°μà“ß√–À«à“ߢâÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ». 2560
·≈– GOLD guideline 2017
·π«∑“ß°“√«‘π‘®©—¬‰¡à¡’§«“¡·μ°μà“ß°—π√–À«à“ߢâÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥
Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 ·≈– GOLD guideline 2017
·π«∑“ß°“√√—°…“1. „π¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
·π«∑“ß°“√√—°…“®–ª√–‡¡‘π®“° Õ“°“√ °“√°”‡√‘∫‡©’¬∫æ≈—π¢Õß‚√§ªÕ¥Õÿ¥°—Èπ
‡√◊ÈÕ√—ß ¡√√∂¿“æªÕ¥·≈â«·∫àß°≈ÿࡺŸâªÉ«¬μ“¡§«“¡√ÿπ·√߇ªìπ mild, moderate
severe ·≈– very severe ´÷Ëß·μ°μà“ß®“° GOLD guideline 2017 ·∫àߺŸâªÉ«¬
‡ªìπ°≈ÿà¡ A B C ·≈– D ‚¥¬„™â‡©æ“–Õ“°“√·≈–°“√°”‡√‘∫‡©’¬∫æ≈—π¢Õß‚√§
ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—߉¡à‰¥â„™â ¡√√∂¿“æªÕ¥„π°“√®—¥°≈ÿࡺŸâªÉ«¬
2. „π¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 °“√
√—°…“®–‡ªìπ·∫∫¢—Èπ∫—π‰¥μ“¡§«“¡√ÿπ·√ߢÕß‚√§´÷Ëß„π GOLD guideline 2017
®–√—°…“μ“¡°“√·∫àß°≈ÿࡺŸâªÉ«¬
3. „π¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 ¡’
¢âÕ·π–π”„π°“√„™â sustained-release theophylline ¢π“¥μË”‡æ◊ËÕª√–‚¬™πå
7
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
„π°“√≈¥°“√Õ—°‡ ∫„πÀ≈Õ¥≈¡ ´÷Ëß„π GOLD guideline 2017 ‰¡à·π–π”°“√
„™â¬“¥—ß°≈à“«
4. „π¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
·π–π”°“√„™â inhaled corticosteroid (ICS) „πºŸâªÉ«¬∑’Ë¡’°“√°”‡√‘∫‡©’¬∫æ≈—π
∑’ËμâÕß„™â¬“ªØ‘™’«π–·≈–/À√◊Õ ‡μ’¬√Õ¬¥åÕ¬à“ßπâÕ¬ 2 §√—ÈßμàÕªï À√◊ÕμâÕß√—∫°“√
√—°…“μ—«∑’Ë‚√ß欓∫“≈Õ¬à“ßπâÕ¬ 1 §√—ÈßμàÕªï
5. „π¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 ‰¥â
‡¢’¬πÀ≈—°°“√„π°“√„™â¬“√—°…“‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ‚¥¬§”π÷ß∂÷߬“∑’Ë¡’®”Àπà“¬
„πª√–‡∑»‰∑¬‡ªìπÀ≈—° ·≈–‰¡à‰¥â≈ß„π√“¬≈–‡Õ’¬¥‡√◊ËÕߢÕß°≈‰°°“√ÕÕ°ƒ∑∏‘Ï
‡π◊ËÕß®“° “¡“√∂À“Õà“π‡æ‘Ë¡‡μ‘¡‰¥âμ“¡·À≈àßÕâ“ßÕ‘ß∑—Ë«‰ª
6. „π¢âÕ·π–π”°“√¥Ÿ·≈œ ©∫—∫π’È ‰¡à‰¥â‡πâπ„π‡√◊ËÕߢÕß°“√≈¥¬“„πºŸâªÉ«¬
‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß (step down treatment) √«¡∂÷ß°“√≈¥¬“ ICS À√◊ÕÀ¬ÿ¥
¬“‡æ◊ËÕ‡ª≈’ˬπ‡ªìπ¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ϭ“« ‡π◊ËÕß®“°ªí®®ÿ∫—πª√–‡∑»
‰∑¬¬—ß¡’¢âÕ®”°—¥‡√◊ËÕß°“√„™â¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ϭ“« ‡™àπ √“§“¬“
°“√‡¢â“∂÷߬“ °“√‡∫‘°®à“¬
°“√°”‡√‘∫‡©’¬∫æ≈—π¢Õß‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß1. „π¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
‰¡à¡’°“√®—¥·∫àߧ«“¡√ÿπ·√ߢÕß¿“«–°”‡√‘∫‡©’¬∫æ≈—π ·μà®–·∫àߺŸâªÉ«¬μ“¡°“√
√—°…“·∫∫ºŸâªÉ«¬πÕ°·≈–ºŸâªÉ«¬„π
2. „π¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 °“√
„Àâ ‡μ’¬√Õ¬¥å ¢π“¥·≈–√–¬–‡«≈“°“√„Àâ ¢÷ÈπÕ¬Ÿà°—∫§«“¡√ÿπ·√ߢÕß°“√°”‡√‘∫
‡©’¬∫æ≈—π ‚¥¬„Àâ prednisolone 30-40 ¡°./«—π π“π 5-10 «—π ·μà‰¡à§«√‡°‘π
8
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
14 «—π ¢≥–∑’Ë GOLD guideline 2017 ·π–π” prednisone 40 ¡°./«—π π“π
5 «—π ·≈–·π–π” nebulized budesonide ‡ªìπ∑“߇≈◊Õ°„πºŸâªÉ«¬∫“ߧπ∑’Ë
‰¡à “¡“√∂„Àâ ‡μ’¬√Õ¬¥å™π‘¥©’¥À√◊Õ√—∫ª√–∑“π‰¥â
3. GOLD guideline 2017 „Àâ√“¬≈–‡Õ’¬¥∂÷ß°“√ª√–‡¡‘πºŸâªÉ«¬¿“¬„π
‡¥◊Õπ·√°·≈– “¡‡¥◊ÕπÀ≈—ß®”Àπà“¬®“°‚√ß欓∫“≈ ·μà„π¢âÕ·π–π”°“√¥Ÿ·≈
√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 ‰¡à‰¥â≈ß√“¬≈–‡Õ’¬¥„π¥â“ππ’È ‰«â
9
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß©∫—∫π’È ‡ªìπ‡§√◊ËÕß¡◊Õ
à߇ √‘¡§ÿ≥¿“æ¢Õß°“√∫√‘°“√√—°…“‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ¡’«—μ∂ÿª√– ߧå∑’Ë®–
§«∫§ÿ¡Õ“°“√¢Õß‚√§·≈–∑”„À⺟âªÉ«¬¡’§ÿ≥¿“æ™’«‘μ∑’Ë¥’¢÷Èπ ‚¥¬„Àâ°“√√—°…“∑’Ë
¡’ª√– ‘∑∏‘¿“æ·≈–§ÿâ¡§à“ ¢âÕ·π–π”μà“ß Ê „π·π«∑“ß©∫—∫π’È ‰¡à„™à¢âÕ∫—ߧ—∫
¢Õß°“√ªØ‘∫—μ‘ ºŸâ „™â “¡“√∂ªØ‘∫—μ‘·μ°μà“߉ª®“°¢âÕ·π–π”π’È ‰¥â „π°√≥’∑’Ë
∂“π°“√≥å·μ°μà“ßÕÕ°‰ª À√◊Õ¡’¢âÕ®”°—¥¢Õß ∂“π∫√‘°“√·≈–∑√—欓°√À√◊Õ
¡’‡Àμÿº≈∑’Ë ¡§«√Õ◊Ëπ Ê ‚¥¬„™â«‘®“√≥≠“≥´÷Ë߇ªìπ∑’ˬա√—∫·≈–Õ¬Ÿà∫πæ◊Èπ∞“π
À≈—°«‘™“°“√·≈–®√√¬“∫√√≥
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
10
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
§”™’È·®ßπÈ”Àπ—°§”·π–π”·≈–§ÿ≥¿“æÀ≈—°∞“π
πÈ”Àπ—°§”·π–π” (Strength of Recommendation)
πÈ”Àπ—°§”·π–π” ++ 秫√∑”é À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õߧ”·π–π”„Àâ∑”Õ¬Ÿà„π
√–¥—∫ Ÿß ‡æ√“–¡“μ√°“√¥—ß°≈à“«¡’ª√–‚¬™πåÕ¬à“߬‘ËßμàÕ
ºŸâªÉ«¬
πÈ”Àπ—°§”·π–π” + çπà“∑”é À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õߧ”·π–π”„Àâ∑”Õ¬Ÿà„π
√–¥—∫ª“π°≈“ß ‡π◊ËÕß®“°¡“μ√°“√¥—ß°≈à“«Õ“®¡’ª√–‚¬™πå
μàÕºŸâªÉ«¬·≈–Õ“®§ÿâ¡§à“„π¿“«–®”‡æ“–
πÈ”Àπ—°§”·π–π” +/- çÕ“®∑”À√◊Õ‰¡à∑”é À¡“¬∂÷ß §«“¡¡—Ëπ„®¬—߉¡à‡æ’¬ßæÕ„π
°“√„À⧔·π–π” ‡π◊ËÕß®“°¡“μ√°“√¥—ß°≈à“«¬—ß¡’À≈—°∞“π
‰¡à‡æ’¬ßæÕ„π°“√ π—∫ πÿπÀ√◊Õ§—¥§â“π«à“ Õ“®¡’À√◊ÕÕ“®
‰¡à¡’ª√–‚¬™πåμàÕºŸâªÉ«¬ ·≈–Õ“®‰¡à§ÿâ¡§à“ ·μà‰¡à°àÕ„À⇰‘¥
Õ—πμ√“¬μàÕºŸâªÉ«¬‡æ‘Ë¡¢÷Èπ ¥—ßπ—Èπ°“√μ—¥ ‘π„®°√–∑”¢÷ÈπÕ¬Ÿà
°—∫ªí®®—¬Õ◊Ëπ Ê
πÈ”Àπ—°§”·π–π” - 牡àπà“∑”é À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õߧ”·π–π”Àâ“¡∑”
Õ¬Ÿà„π√–¥—∫ª“π°≈“ß ‡π◊ËÕß®“°¡“μ√°“√¥—ß°≈à“«‰¡à¡’
ª√–‚¬™πåμàÕºŸâªÉ«¬·≈–‰¡à§ÿ⡧à“
πÈ”Àπ—°§”·π–π” - - 牡৫√∑”é À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õߧ”·π–π”Àâ“¡∑”
Õ¬Ÿà„π√–¥—∫ Ÿß ‡æ√“–¡“μ√°“√¥—ß°≈à“«Õ“®‡°‘¥‚∑…À√◊Õ
°àÕ„À⇰‘¥Õ—πμ√“¬μàÕºŸâªÉ«¬
11
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
§ÿ≥¿“æÀ≈—°∞“π (Quality of Evidence)
§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1 À¡“¬∂÷ß À≈—°∞“π∑’ˉ¥â®“°
1.1 °“√∑∫∑«π·∫∫¡’√–∫∫ (systematic review) ®“°°“√»÷°…“·∫∫
ÿà¡°≈ÿà¡μ—«Õ¬à“ß-§«∫§ÿ¡ (randomize-controlled clinical trials) À√◊Õ
1.2 °“√»÷°…“·∫∫ ÿà¡°≈ÿà¡μ—«Õ¬à“ß-§«∫§ÿ¡ ∑’Ë¡’°“√ÕÕ°·∫∫«‘®—¬Õ¬à“ߥ’
Õ¬à“ßπâÕ¬ 1 ©∫—∫ (a well-designed, randomize-controlled clinical
trial)
§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 2 À¡“¬∂÷ß À≈—°∞“π∑’ˉ¥â®“°
2.1 °“√∑∫∑«π·∫∫¡’√–∫∫¢Õß°“√»÷°…“·∫∫‰¡à ‰¥â ÿà¡°≈ÿà¡μ—«Õ¬à“ß-
§«∫§ÿ¡ (non-randomized, controlled, clinical trials) À√◊Õ
2.2 °“√»÷°…“·∫∫‰¡à ‰¥â ÿà¡°≈ÿà¡μ—«Õ¬à“ß-§«∫§ÿ¡ ∑’Ë¡’°“√ÕÕ°·∫∫«‘®—¬
Õ¬à“ߥ’ (well-designed, non-randomized, controlled clinical trial)
À√◊Õ
2.3 À≈—°∞“π®“°√“¬ß“π°“√»÷°…“μ“¡·ºπμ‘¥μ“¡‡Àμÿ‰ªÀ“º≈ (cohort)
À√◊Õ°“√»÷°…“ «‘‡§√“–À姫∫§ÿ¡°√≥’¬âÕπÀ≈—ß (case-control analytic
studies) ∑’ˉ¥â√—∫°“√ÕÕ°·∫∫«‘®—¬ ‡ªìπÕ¬à“ߥ’ ´÷Ëß¡“®“° ∂“∫—πÀ√◊Õ
°≈ÿà¡«‘®—¬¡“°°«à“Àπ÷Ëß·Ààß / °≈ÿà¡ À√◊Õ
2.4 À≈—°∞“π®“° multiple time series ÷Ëß¡’À√◊Õ‰¡à¡’¡“μ√°“√¥”‡π‘π°“√
À√◊ÕÀ≈—°∞“π∑’ˉ¥â®“°°“√«‘®—¬∑“ߧ≈‘π‘°√Ÿª·∫∫Õ◊ËπÀ√◊Õ∑¥≈Õß·∫∫
‰¡à¡’°≈ÿࡧ«∫§ÿ¡ ´÷Ëß¡’º≈ª√–®—°…å∂÷ߪ√–‚¬™πåÀ√◊Õ‚∑…®“°°“√ªØ‘∫—μ‘
¡“μ√°“√∑’ˇ¥àπ™—¥¡“° ‡™àπ º≈¢Õß°“√𔬓‡æÁππ‘´‘≈‘π¡“„™â„π√“«
æ.». 2480 ®–‰¥â√—∫°“√®—¥Õ¬Ÿà„πÀ≈—°∞“πª√–‡¿∑π’È
12
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3 À¡“¬∂÷ß À≈—°∞“π∑’ˉ¥â®“°
3.1 °“√»÷°…“‡™‘ßæ√√≥π“ (descriptive studies) À√◊Õ
3.2 °“√»÷°…“·∫∫¡’°≈ÿà¡μ—«Õ¬à“ß-§«∫§ÿ¡ ∑’Ë¡’°“√ÕÕ°·∫∫«‘®—¬æÕ„™â (fair-
designed, controlled clinical trial)
§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 4 À¡“¬∂÷ß À≈—°∞“π∑’ˉ¥â®“°
4.1 √“¬ß“π¢Õߧ≥–°√√¡°“√ºŸâ‡™’ˬ«™“≠ ª√–°Õ∫°—∫§«“¡‡ÀÁπæâÕßÀ√◊Õ
©—π∑“¡μ‘ (consensus) ¢Õߧ≥–ºŸâ‡™’ˬ«™“≠ ∫πæ◊Èπ∞“πª√– ∫°“√≥å
∑“ߧ≈‘π‘° À√◊Õ
4.2 √“¬ß“πÕπÿ°√¡ºŸâªÉ«¬®“°°“√»÷°…“„πª√–™“°√μà“ß°≈ÿà¡ ·≈–§≥–
ºŸâ»÷°…“μà“ߧ≥– Õ¬à“ßπâÕ¬ 2 ©∫—∫√“¬ß“πÀ√◊Õ§«“¡‡ÀÁπ∑’ˉ¡à‰¥âºà“π
°“√«‘‡§√“–Àå·∫∫¡’√–∫∫ ‡™àπ √“¬ß“πºŸâªÉ«¬‡©æ“–√“¬ (anecdotal
report) §«“¡‡ÀÁπ¢ÕߺŸâ‡™’ˬ«™“≠‡©æ“–√“¬ ®–‰¡à‰¥â√—∫°“√æ‘®“√≥“
«à“‡ªìπÀ≈—°∞“π∑’Ë¡’§ÿ≥¿“æ„π°“√®—¥∑”·π«∑“߇«™ªØ‘∫—μ‘π’È
13
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
𑬓¡ (Definition)
‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß À√◊Õ COPD (Chronic Obstructive Pulmonary
Disease) ‡ªìπ‚√§∑’˪ÑÕß°—π‰¥â·≈–√—°…“‰¥â ‚¥¬¡’≈—°…≥–‡ªìπ progressive,
not fully reversible airflow limitation ´÷Ë߇ªìπº≈®“°°“√√–§“¬‡§◊Õ߇√◊ÈÕ√—ßμàÕ
ªÕ¥ ®“°ΩÿÉπ ·≈–·°ä æ‘… ∑’Ë ”§—≠∑’Ë ÿ¥ ‰¥â·°à §«—π∫ÿÀ√’Ë ∑”„À⇰‘¥ abnormal
inflammatory response ∑—Èß„πªÕ¥·≈–√–∫∫Õ◊ËπÊ ¢Õß√à“ß°“¬ (multicomponent
disease) ºŸâªÉ«¬∑’Ë¡’‚√§√à«¡À√◊ÕÕ“°“√°”‡√‘∫‡©’¬∫æ≈—π ®–¡’º≈μàÕ§«“¡√ÿπ·√ß
¢Õß‚√§
‚¥¬∑—Ë«‰ª¡—°À¡“¬√«¡∂÷ß‚√§ 2 ‚√§ §◊Õ ‚√§À≈Õ¥≈¡Õ—°‡ ∫‡√◊ÈÕ√—ß (chronic
bronchitis) ·≈–‚√§∂ÿß≈¡‚ªÉßæÕß (pulmonary emphysema)
‚√§À≈Õ¥≈¡Õ—°‡ ∫‡√◊ÈÕ√—ß ¡’𑬓¡®“°Õ“°“√∑“ߧ≈‘π‘° °≈à“«§◊Õ ºŸâªÉ«¬¡’
Õ“°“√‰Õ‡√◊ÈÕ√—ß ¡’‡ ¡À– ‚¥¬¡’Õ“°“√‡ªìπ Ê À“¬ Ê ªï≈–Õ¬à“ßπâÕ¬ 3 ‡¥◊Õπ ·≈–
‡ªìπμ‘¥μàÕ°—πÕ¬à“ßπâÕ¬ 2 ªï ‚¥¬‰¡à‰¥â‡°‘¥®“° “‡ÀμÿÕ◊Ëπ
‚√§∂ÿß≈¡‚ªÉßæÕß §◊Õ ‚√§∑’Ë¡’欓∏‘ ¿“æ°“√∑”≈“¬¢Õß∂ÿß≈¡ ·≈–
respiratory bronchiole ‚¥¬¡’°“√¢¬“¬μ—«‚ªÉßæÕßÕ¬à“ß∂“«√
ºŸâªÉ«¬ à«π„À≠à¡—°æ∫‚√§∑—Èß Õߥ—ß°≈à“«Õ¬Ÿà√à«¡°—π ·≈–·¬°ÕÕ°®“°°—π
‰¥â¬“°
欓∏‘°”‡π‘¥ (Pathogenesis)
º≈®“°°“√√–§“¬‡§◊ÕßÕ¬à“ßμàÕ‡π◊ËÕß∑”„À⇰‘¥°“√Õ—°‡ ∫‡√◊ÈÕ√—ß∑—Èß„πÀ≈Õ¥≈¡
‡π◊ÈÕªÕ¥ ·≈–À≈Õ¥‡≈◊Õ¥ªÕ¥ (pulmonary vasculature) ‚¥¬¡’‡´≈≈å ”§—≠∑’Ë
‡°’ˬ«¢âÕߧ◊Õ T-lymphocyte ( à«π„À≠à‡ªìπ CD8) neutrophil ·≈– macrophage
14
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
∑”„Àâ¡’°“√À≈—Ëß inflammatory mediators À≈“¬™π‘¥ ∑’Ë ”§—≠ ‰¥â·°à leukotriene
B4, interleukin 8 ·≈– tumor necrosis factor α ‡ªìπμâπ πÕ°®“°π’Ȭ—ß¡’
°√–∫«π°“√ ”§—≠∑’Ë¡“‡°’ˬ«¢âÕß°—∫欓∏‘°”‡π‘¥Õ’° 2 ª√–°“√ §◊Õ °“√‡æ‘Ë¡¢Õß
oxidative stress ·≈–§«“¡‰¡à ¡¥ÿ≈√–À«à“ß proteinase °—∫ antiproteinase
欓∏‘«‘∑¬“ (Pathology)
æ∫°“√‡ª≈’ˬπ·ª≈ߢÕßÀ≈Õ¥≈¡μ—Èß·μà¢π“¥„À≠à≈߉ª®π∂÷ß¢π“¥‡≈Á° ¡’
‡´≈≈å∑’ˇ°’ˬ«¢âÕß°—∫°“√Õ—°‡ ∫·∑√°„π‡¬◊ËÕ∫ÿ∑—Ë«‰ª ¡’ goblet cell ‡æ‘Ë¡¢÷Èπ ·≈–
mucous gland ¢¬“¬„À≠à¢÷Èπ ∑”„Àâ¡’°“√ √â“ß mucus ÕÕ°¡“¡“°·≈–‡À𒬫
°«à“ª°μ‘ °“√Õ—°‡ ∫·≈–°“√∑”≈“¬∑’ˇ°‘¥´È” Ê ®–∑”„À⇰‘¥°“√‡ª≈’ˬπ·ª≈ß‚§√ß
√â“ߢÕߺπ—ßÀ≈Õ¥≈¡ ‚¥¬‡©æ“–À≈Õ¥≈¡ à«πª≈“¬∑’Ë¡’¢π“¥‡ âπºà“»Ÿπ¬å°≈“ß
πâÕ¬°«à“ 2 ¡‘≈≈‘‡¡μ√ ∑”„Àâ¡’°“√μ’∫¢ÕßÀ≈Õ¥≈¡
‡π◊ÈÕªÕ¥ à«π respiratory bronchiole ·≈–∂ÿß≈¡∑’Ë∂Ÿ°∑”≈“¬·≈–‚ªÉßæÕß
¡’≈—°…≥–®”‡æ“–√«¡‡√’¬°«à“ centrilobular emphysema ‚¥¬‡√‘Ë¡®“°ªÕ¥ à«π
∫π·≈â«≈ÿ°≈“¡‰ª à«πÕ◊Ëπ Ê „π√–¬–μàÕ¡“
”À√—∫∫√‘‡«≥À≈Õ¥‡≈◊Õ¥ªÕ¥ ¡’ºπ—ßÀπ“μ—«¢÷Èπ °≈â“¡‡π◊ÈÕ‡√’¬∫·≈–‡´≈≈å
∑’ˇ°’ˬ«¢âÕß°—∫°“√Õ—°‡ ∫¡’®”π«π‡æ‘Ë¡¢÷Èπ
欓∏‘ √’√«‘∑¬“ (Pathophysiology)
°“√‡ª≈’ˬπ·ª≈ß∑“ß欓∏‘«‘∑¬“¢Õߪե 𔉪 Ÿà°“√‡ª≈’ˬπ·ª≈ß∑“ß
√’√«‘∑¬“„πºŸâªÉ«¬ ¥—ßπ’È
1. °“√ √â“ß mucus ¡“°°«à“ª°μ‘ √à«¡°—∫°“√∑”ß“πº‘¥ª°μ‘¢Õß cilia
15
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
∑”„À⺟âªÉ«¬‰Õ‡√◊ÈÕ√—ß¡’‡ ¡À– ´÷ËßÕ“®‡ªìπÕ“°“√π”¢Õß‚√§°àÕπ∑’Ë®–¡’°“√‡ª≈’ˬπ
·ª≈ß∑“ß √’√«‘∑¬“Õ◊Ëπ Ê
2. °“√μ’∫¢ÕßÀ≈Õ¥≈¡√à«¡°—∫°“√ Ÿ≠‡ ’¬ elastic recoil ¢Õ߇π◊ÈÕªÕ¥
∑”„À⇰‘¥ airflow limitation ·≈– air trapping
3. °“√μ’∫¢ÕßÀ≈Õ¥≈¡ °“√∑”≈“¬¢Õ߇π◊ÈÕªÕ¥ ·≈–À≈Õ¥‡≈◊Õ¥ ®–¡’º≈
μàÕ°“√·≈°‡ª≈’ˬπ°ä“´ ∑”„À⇰‘¥¿“«– hypoxemia ·≈– hypercapnia μ“¡¡“
´÷ËßÕ“®∑”„À⇰‘¥ pulmonary hypertension ·≈– cor pulmonale „π∑’Ë ÿ¥
πÕ°®“°π’È °“√‡æ‘Ë¡¢÷Èπ¢Õß inflammatory mediators „π√–∫∫‰À≈‡«’¬π
‚≈À‘μ ®–¡’º≈μàÕÕ«—¬«–μà“ß Ê ¿“¬πÕ°ªÕ¥¥â«¬ ∑”„À⇰‘¥‚√§√à«¡¢Õß COPD
¢÷Èπ„πÀ≈“¬√–∫∫ ‡™àπ muscle wasting, ischemic heart disease, heart
failure, type 2 diabetes, metabolic syndrome, osteoporosis, anemia ·≈–
depression
√–∫“¥«‘∑¬“ (Epidemiology)
¬—߉¡à¡’°“√ ”√«®√–¥—∫™“μ‘ ·μஓ°°“√§”π«≥‚¥¬„™â·∫∫®”≈ÕßÕ“»—¬
¢âÕ¡Ÿ≈§«“¡™ÿ°¢Õß°“√ Ÿ∫∫ÿÀ√’Ë ·≈–¡≈¿“«–„π ¿“æ·«¥≈âÕ¡„π∫â“π·≈–„π∑’Ë
“∏“√≥– ª√–¡“≥«à“√âÕ¬≈– 5 ¢Õߪ√–™“°√‰∑¬ Õ“¬ÿ‡°‘π 30 ªï¢÷Èπ‰ªªÉ«¬‡ªìπ
‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß1 ·μà„π°“√ ”√«®®√‘ß„πæ◊Èπ∑’Ë ‚¥¬»÷°…“„π‡¢μ∏π∫ÿ√’ ºŸâ∑’Ë¡’
Õ“¬ÿ 60 ªï¢÷Èπ‰ª æ∫§«“¡™ÿ°·≈–Õÿ∫—μ‘°“√≥å√âÕ¬≈– 7.1 ·≈– 3.6 μ“¡≈”¥—∫2
à«π°“√ ”√«®ºŸâ∑’Ë¡’Õ“¬ÿ 40 ªï¢÷Èπ‰ª„π™ÿ¡™π‡¡◊Õß·≈–™ÿ¡™π√Õ∫πÕ°π§√
‡™’¬ß„À¡à æ∫§«“¡™ÿ°√âÕ¬≈– 3.7 ·≈– 7.1 μ“¡≈”¥—∫ ‚¥¬ºŸâªÉ«¬∑’Ë ”√«®æ∫„π
™ÿ¡™π à«π„À≠à‡ªìπºŸâªÉ«¬√–¬–·√° à«πºŸâªÉ«¬∑’Ë¡“√—∫°“√√—°…“∑’Ë ‚√ß欓∫“≈
à«π„À≠à‡ªìπºŸâªÉ«¬√–¬–√ÿπ·√ß3
16
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
¢âÕ¡Ÿ≈°“√‡∫‘°®à“¬®“° ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘ ªï æ.». 25574
æ∫«à“ ºŸâªÉ«¬∑’ËπÕπ‚√ß欓∫“≈¥â«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß¡’®”π«π 350 §πμàÕ
ª√–™“°√ 100,000 §π ¡’Õ—μ√“°“√‡ ’¬™’«‘μ √âÕ¬≈– 5.4 ¡’°“√„™â‡§√◊ËÕߙ૬À“¬„®
À√◊Õ„ à∑àՙ૬À“¬„® √âÕ¬≈– 9.8 ·≈–°≈—∫¡“πÕπ‚√ß欓∫“≈ È”¿“¬„π 28 «—π
À≈—ß®”Àπà“¬ºŸâªÉ«¬ (re-admission) √âÕ¬≈– 28
·¡â«à“°“√√≥√ߧå‡æ◊ËÕ°“√≈¥°“√∫√‘‚¿§¬“ Ÿ∫¢Õߪ√–‡∑»‰∑¬ ‰¥â¡’°“√¥”‡π‘π
°“√Õ¬à“ßμàÕ‡π◊ËÕß ·μà®”π«πºŸâ Ÿ∫∫ÿÀ√’ˉ¡à ‰¥â≈¥≈ßμ“¡∑’˧«√®–‡ªìπ ®“°º≈°“√
”√«®§√—Èß≈à“ ÿ¥„πªï æ.». 2557 æ∫Õ—μ√“°“√ Ÿ∫‡æ‘Ë¡¢÷Èπ‡ªìπ√âÕ¬≈– 20.7 (11.4
≈â“π§π) ‚¥¬¡’Õ“¬ÿ‡©≈’ˬ∑’ˇ√‘Ë¡ Ÿ∫∫ÿÀ√’˧√—Èß·√°πâÕ¬≈߇√◊ËÕ¬ Ê ®“°Õ“¬ÿ 16.8 ªï„π
æ.». 2550 ‡ªìπÕ“¬ÿ 15.6 ªï„π æ.». 25575 ®–‡ÀÁπ«à“ªí≠À“°“√∫√‘‚¿§¬“ Ÿ∫¬—ß
‡ªìπªí≠À“∑’Ë ”§—≠„πª√–‡∑»‰∑¬ °“√ªÑÕß°—π‰¡à„À⇰‘¥ºŸâ Ÿ∫√“¬„À¡à (primary
prevention) ÷Ëß®“°¢âÕ¡Ÿ≈„πªí®®ÿ∫—π¡’Õ“¬ÿ∑’ˇ√‘Ë¡ Ÿ∫πâÕ¬≈ß ·≈–°“√™à«¬‡À≈◊Õ„Àâ
ºŸâ∑’Ë Ÿ∫∫ÿÀ√’ˇ≈‘° Ÿ∫∫ÿÀ√’Ë (smoking cessation) ®÷ß¡’§«“¡ ”§—≠‡ªìπÕ¬à“߬‘Ëß∑’Ë®–
≈¥º≈°√–∑∫∑’ˇ°‘¥®“°°“√ Ÿ∫∫ÿÀ√’Ë„πÕπ“§μ‰¥â
ªí®®—¬‡ ’ˬß
·∫à߉¥â‡ªìπ 2 °≈ÿà¡ §◊Õ
1. ªí®®—¬¥â“πºŸâªÉ«¬ ‡™àπ ≈—°…≥–∑“ßæ—π∏ÿ°√√¡
2. ªí®®—¬¥â“π ¿“«–·«¥≈âÕ¡ ¡’§«“¡ ”§—≠¡“°∑’Ë ÿ¥ ‰¥â·°à
ë §«—π∫ÿÀ√’Ë ‡ªì𠓇Àμÿ ”§—≠∑’Ë ÿ¥¢Õß‚√§π’È æ∫«à“¡“°°«à“√âÕ¬≈–
75.4 ¢ÕߺŸâªÉ«¬ COPD ‡°‘¥®“°∫ÿÀ√’Ë6
ë ¡≈¿“«–∑—Èß„π∫√‘‡«≥∫â“π ∑’Ë∑”ß“π ·≈–∑’Ë “∏“√≥– ∑’Ë ”§—≠§◊Õ
°“√‡º“‰À¡â‡™◊ÈÕ‡æ≈‘ß„π°“√ª√–°Õ∫Õ“À“√ (biomass fuel) ·≈–
”À√—∫¢—∫‡§≈◊ËÕπ‡§√◊ËÕß®—°√μà“ß Ê (diesel exhaust)
17
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
°“√«‘π‘®©—¬‚√§
Õ“»—¬Õߧåª√–°Õ∫À≈“¬Õ¬à“ß ‰¥â·°à ª√–«—μ‘ —¡º— ªí®®—¬‡ ’ˬߥ—ß°≈à“«¢â“ß
μâπ √à«¡°—∫ Õ“°“√ º≈°“√μ√«®√à“ß°“¬ ¿“æ√—ß ’∑√«ßÕ° ·≈–¬◊π¬—π°“√«‘π‘®©—¬
‚¥¬°“√μ√«® spirometry
Õ“°“√
à«π„À≠ຟâªÉ«¬®–¡’Õ“°“√‡¡◊ËÕ欓∏‘ ¿“æ≈ÿ°≈“¡‰ª¡“°·≈â« Õ“°“√∑’Ëæ∫
‰¥â·°à ÀÕ∫‡Àπ◊ËÕ¬´÷Ëß®–‡ªìπ¡“°¢÷Èπ‡√◊ËÕ¬Ê ‰Õ‡√◊ÈÕ√—ßÀ√◊Õ¡’‡ ¡À–‚¥¬‡©æ“–„π
™à«ß‡™â“ Õ“°“√Õ◊Ëπ∑’Ëæ∫‰¥â §◊Õ ·πàπÀπâ“Õ° À√◊ÕÀ“¬„®¡’‡ ’¬ßÀ«’¥ „π°√≥’∑’Ë¡’
Õ“°“√Õ◊Ëπ Ê ‡™àπ ‰ÕÕÕ°‡≈◊Õ¥ À√◊Õ‡®Á∫Àπâ“Õ° ®–μâÕßÀ“‚√§√à«¡À√◊Õ°“√«‘π‘®©—¬
Õ◊Ëπ‡ ¡Õ ∑’Ë ”§—≠ §◊Õ «—≥‚√§ ¡–‡√Áߪե ·≈–À≈Õ¥≈¡æÕß (bronchiectasis)
Õ“°“√· ¥ß
°“√μ√«®√à“ß°“¬„π√–¬–·√°Õ“®‰¡àæ∫§«“¡º‘¥ª°μ‘ ‡¡◊ËÕ°“√Õÿ¥°—Èπ¢Õß
À≈Õ¥≈¡¡“°¢÷ÈπÕ“®μ√«®æ∫≈—°…≥–¢Õß airflow limitation ·≈– air trapping
‡™àπ prolonged expiratory phase, increased chest A-P diameter,
hyperresonance on percussion, diffuse wheeze/rhonchi, ·≈– accessory
muscles use ‡ªìπμâπ „π√–¬–∑⓬¢Õß‚√§Õ“®μ√«®æ∫≈—°…≥–¢Õߧ«“¡¥—π
À≈Õ¥‡≈◊Õ¥·¥ßªÕ¥ Ÿß·≈–/À√◊ÕÀ—«„®¥â“π¢«“≈⡇À≈« (cor pulmonale) ‰¡à§«√
μ√«®æ∫¿“«–π‘È«ªÿÑ¡ À“°æ∫§«√π÷°∂÷ß¿“«–Õ◊Ë𠇙àπ ¡–‡√Áߪե, À≈Õ¥≈¡æÕß
(bronchiectasis) ‡ªìπμâπ
°“√μ√«®∑“ß√—ß ’«‘∑¬“
¿“æ√—ß ’∑√«ßÕ°¡’§«“¡‰«πâÕ¬ ”À√—∫°“√«‘π‘®©—¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ·μà
¡’§«“¡ ”§—≠„π°“√·¬°‚√§Õ◊Ëπ à«π„πºŸâªÉ«¬ emphysema Õ“®æ∫≈—°…≥–
18
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
hyperinflation §◊Õ °–∫—ß≈¡·∫π√“∫·≈–À—«„®¡’¢π“¥‡≈Á° „πºŸâªÉ«¬∑’Ë¡’ cor
pulmonale ®–æ∫«à“À—«„®ÀâÕߢ«“ ·≈– pulmonary trunk ¡’¢π“¥‚μ¢÷Èπ ·≈–
peripheral vascular marking Ŵŧ
°“√μ√«® ¡√√∂¿“æªÕ¥
Spirometry ¡’§«“¡®”‡ªìπ„π°“√«‘π‘®©—¬‚√§ ·≈–®—¥√–¥—∫§«“¡√ÿπ·√ß
‚¥¬°“√μ√«® spirometry π’È®–μâÕßμ√«®‡¡◊ËÕºŸâªÉ«¬¡’Õ“°“√§ß∑’Ë (stable) ·≈–
‰¡à¡’Õ“°“√°”‡√‘∫¢Õß‚√§Õ¬à“ßπâÕ¬ 1 ‡¥◊Õπ °“√μ√«®π’È “¡“√∂«‘π‘®©—¬‚√§‰¥â
μ—Èß·μà√–¬–∑’˺ŸâªÉ«¬¬—߉¡à¡’Õ“°“√ ®–æ∫≈—°…≥–¢Õß airflow limitation ‚¥¬§à“
FEV1 / FVC À≈—ß„À⬓¢¬“¬À≈Õ¥≈¡πâÕ¬°«à“√âÕ¬≈– 70 ·≈–·∫àߧ«“¡√ÿπ·√ß
‡ªìπ 4 √–¥—∫ ‚¥¬„™â§à“ FEV1 À≈—ß„À⬓¢¬“¬À≈Õ¥≈¡ (μ“√“ß∑’Ë 1) °“√μ√«®
¡√√∂¿“æªÕ¥Õ◊Ëπ Ê Õ“®¡’ª√–‚¬™πå ·μà‰¡à¡’§«“¡®”‡ªìπ„π°“√«‘π‘®©—¬ ‡™àπ æ∫
§à“ residual volume (RV), total lung capacity (TLC), ·≈– RV/TLC ‡æ‘Ë¡¢÷Èπ
à«π§à“ diffusing capacity ¢Õß carbon monoxide (DLCO) Õ“®≈¥≈ß
ºŸâªÉ«¬∑ÿ°√“¬μâÕß¡’§à“ FEV1/FVC À≈—ß„À⬓¢¬“¬À≈Õ¥≈¡πâÕ¬°«à“√âÕ¬≈– 70
√ÿπ·√ßπâÕ¬ (GOLD 1) §à“ FEV1 > 80% ¢Õß§à“¡“μ√∞“π
√ÿπ·√ߪ“π°≈“ß (GOLD 2) §à“ FEV1 50-79% ¢Õß§à“¡“μ√∞“π
√ÿπ·√ß¡“° (GOLD 3) §à“ FEV1 30-49% ¢Õß§à“¡“μ√∞“π
√ÿπ·√ß¡“°∑’Ë ÿ¥ (GOLD 4) §à“ FEV1 < 30% ¢Õß§à“¡“μ√∞“π
μ“√“ß∑’Ë 1 √–¥—∫§«“¡√ÿπ·√ߢÕß‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ßμ“¡§à“ FEV1 À≈—ß„À⬓¢¬“¬
À≈Õ¥≈¡
19
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
°“√«‘π‘®©—¬·¬°‚√§
∑’Ë ”§—≠§◊Õ ‚√§À◊¥ «—≥‚√§ ¡–‡√Áߪե ‚√§À≈Õ¥≈¡æÕß ‚√§ªÕ¥®“°
°“√ª√–°Õ∫Õ“™’æ ¿“«–À—«„®≈⡇À≈« ‡ªìπμâπ °“√«‘π‘®©—¬·¬°‚√§À◊¥ÕÕ°®“°
‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß∫“ߧ√—Èß∑”‰¥â¬“° ‚¥¬‡©æ“–„πºŸâªÉ«¬ ŸßÕ“¬ÿ∑’Ë¡’≈—°…≥–‡ªìπ
persistent airflow limitation ·≈–¡’ª√–«—μ‘ Ÿ∫∫ÿÀ√’Ë ·μà¡’≈—°…≥–Õ“°“√∑“ß
§≈‘π‘°‡¢â“‰¥â°—∫∑—Èß‚√§À◊¥·≈–‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ‡√’¬°°≈ÿà¡Õ“°“√π’È«à“ Asthma-
COPD Overlap (ACO)7
·π«∑“ß°“√√—°…“ ª√–°Õ∫¥â«¬
¢—Èπ∑’Ë 1 °“√ª√–‡¡‘πºŸâªÉ«¬‡æ◊ËÕ°“√√—°…“
¢—Èπ∑’Ë 2 ·π«∑“ß°“√√—°…“¥â«¬¬“·∫∫¢—Èπ∫—π‰¥ (stepwise approach
to COPD treatment)
¢—Èπ∑’Ë 3 °“√√—°…“Õ◊Ëπ Ê
¢—Èπ∑’Ë 1 °“√ª√–‡¡‘πºŸâªÉ«¬‡æ◊ËÕ°“√√—°…“
À≈—ß„Àâ°“√«‘π‘®©—¬¥â«¬‡°≥±å°“√«‘π‘®©—¬‚√§ §«√∑”°“√ª√–‡¡‘πºŸâªÉ«¬
‡æ◊ËÕ®—¥°≈ÿà¡„π°“√√—°…“ ‚¥¬„™âÀ≈“¬ªí®®—¬√à«¡°—π (multimodality) ‰¥â·°à Õ“°“√
ÀÕ∫‡Àπ◊ËÕ¬ °“√«—¥ modified medical research council dyspnea scale
(mMRC) °“√‡°‘¥°“√°”‡√‘∫‡©’¬∫æ≈—π¢Õß‚√§ (acute exacerbation) ·≈–º≈
°“√μ√«® ¡√√∂¿“æªÕ¥ (FEV1) ‡ªìπªí®®—¬„π°“√ª√–‡¡‘π ‚¥¬∂◊Õ‡Õ“§«“¡
√ÿπ·√ß Ÿß ÿ¥®“°ªí®®—¬‡À≈à“π’ȇªìπÀ≈—°„π°“√®—¥°≈ÿà¡ ‚¥¬æ‘®“√≥“μ“¡§«“¡
‡À¡“– ¡ ¡’°“√·∫àߺŸâªÉ«¬‡ªìπ 4 √–¥—∫ ¥—ßπ’È
20
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
°≈ÿà¡∑’Ë 1 Õ“°“√πâÕ¬ (mild) ª√–°Õ∫¥â«¬
ë Õ“°“√ : ¡’Õ“°“√‡Àπ◊ËÕ¬‡¡◊ËÕ¡’°“√ÕÕ°°”≈—ßÕ¬à“ßÀπ—° ¡’Õ“°“√¢Õß
‚√§‡æ’¬ß‡≈Á°πâÕ¬ ‰¡à‡§¬¡’Õ“°“√ÀÕ∫°”‡√‘∫ ·≈–Õ“°“√‰¡à¡’º≈μàÕ°“√
ª√–°Õ∫°‘®«—μ√ª√–®”«—π
ë mMRC : 0 - 1
ë °“√°”‡√‘∫‡©’¬∫æ≈—π : ‰¡à¡’
ë º≈°“√μ√«® ¡√√∂¿“æªÕ¥ : FEV1 μ—Èß·μà√âÕ¬≈– 80 ¢÷Èπ‰ª
°≈ÿà¡∑’Ë 2 Õ“°“√ª“π°≈“ß (moderate) ª√–°Õ∫¥â«¬
ë Õ“°“√ : ¡’Õ“°“√‡Àπ◊ËÕ¬‡¡◊ËÕ¡’°“√ÕÕ°°”≈—ߪ“π°≈“ß ¡’°“√μ‘¥‡™◊ÈÕ∑“ß
√–∫∫°“√À“¬„®∫àÕ¬§√—Èß ·≈–Õ“°“√‰¡à¡’º≈μàÕ°“√ª√–°Õ∫°‘®«—μ√
ª√–®”«—πÀ√◊Õ¡’º≈‡≈Á°πâÕ¬
ë mMRC : 1 - 2
ë °“√°”‡√‘∫‡©’¬∫æ≈—π : ¡’·μà‰¡à¡’§«“¡®”‡ªìπ∑’Ë®–μâÕß„™â¬“ªØ‘™’«π–
À√◊Õ ‡μ’¬√Õ¬¥å
ë º≈°“√μ√«® ¡√√∂¿“æªÕ¥ : FEV1 √âÕ¬≈– 50 ∂÷ß 79
°≈ÿà¡∑’Ë 3 Õ“°“√√ÿπ·√ß (severe) ª√–°Õ∫¥â«¬
ë Õ“°“√ : ¡’Õ“°“√‡Àπ◊ËÕ¬‡¡◊ËÕ¡’°‘®°√√¡‡æ’¬ß‡≈Á°πâÕ¬ ‡Àπ◊ËÕ¬·¡â®–‡¥‘π
∫π∑“ß√“∫ ¡’Õ“°“√‰Õ·≈–‡ ¡À–∫àÕ¬§√—Èß ·≈–Õ“°“√‡Àπ◊ËÕ¬¡’º≈
μàÕ°“√ª√–°Õ∫°‘®«—μ√ª√–®”«—π
ë mMRC : 2 - 3
ë °“√°”‡√‘∫‡©’¬∫æ≈—π : ¡’Õ“°“√°”‡√‘∫∑’ËμâÕß„™â¬“ªØ‘™’«π–·≈–/À√◊Õ
‡μ’¬√Õ¬¥åÕ¬à“ßπâÕ¬ 2 §√—ÈßμàÕªï À√◊Õ°”‡√‘∫®πμâÕ߇¢â“√—∫°“√√—°…“
μ—«„π‚√ß欓∫“≈Õ¬à“ßπâÕ¬ 1 §√—ÈßμàÕªï
ë º≈°“√μ√«® ¡√√∂¿“æªÕ¥ : FEV1 √âÕ¬≈– 30 ∂÷ß 49
21
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
°≈ÿà¡∑’Ë 4 Õ“°“√√ÿπ·√ß¡“° (very severe) ª√–°Õ∫¥â«¬
ë Õ“°“√ : ¡’Õ“°“√‡Àπ◊ËÕ¬μ≈Õ¥‡«≈“·¡â„π¢≥–æ—° ¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß
ª√‘¡“≥‡ ¡À–¡“° Õ“°“√‡Àπ◊ËÕ¬¡’º≈μàÕ°“√ª√–°Õ∫°‘®«—μ√ª√–®”«—π
‡ªìπÕ¬à“ß¡“°
ë mMRC : 3 - 4
ë °“√°”‡√‘∫‡©’¬∫æ≈—π : ¡’Õ“°“√°”‡√‘∫∑’ËμâÕß„™â¬“ªØ‘™’«π–·≈–/À√◊Õ
‡μ’¬√Õ¬¥åÕ¬à“ßπâÕ¬ 2 §√—ÈßμàÕªï À√◊Õ°”‡√‘∫®πμâÕ߇¢â“√—∫°“√√—°…“
μ—«„π‚√ß欓∫“≈Õ¬à“ßπâÕ¬ 1 §√—ÈßμàÕªï
ë º≈°“√μ√«® ¡√√∂¿“æªÕ¥ : FEV1 πâÕ¬°«à“√âÕ¬≈– 30
¢—Èπ∑’Ë 2 ·π«∑“ß°“√√—°…“¥â«¬¬“·∫∫¢—Èπ∫—π‰¥ (stepwise approachto COPD treatment)
À≈—ß®“°ª√–‡¡‘π¢â“ßμâπ ‡√‘Ë¡°“√√—°…“„À⬓‚¥¬æ‘®“√≥“μ“¡§«“¡√ÿπ·√ß
¢Õß‚√§·∫∫¢—Èπ∫—π‰¥ (stepwise approach) ¥—ß·ºπ¿Ÿ¡‘∑’Ë 1 ‚¥¬‡√‘Ë¡μâπ®“°°“√
„À⬓Àπ÷Ëߢπ“π ®“°π—Èπæ‘®“√≥“‡æ‘Ë¡¬“„À⺟âªÉ«¬ À“°Õ“°“√ºŸâªÉ«¬‰¡à¥’¢÷Èπ À≈—ß
ª√–‡¡‘π«‘∏’°“√·≈–§«“¡ ¡Ë”‡ ¡Õ¢Õß°“√„™âÕÿª°√≥å Ÿ¥À√◊Õæàπ¬“Õ¬à“ߥ’·≈â«
(¿“§ºπ«° 1) ‚¥¬æ‘®“√≥“°“√√—°…“¥—ßπ’È
°≈ÿà¡∑’Ë 1 Õ“°“√πâÕ¬ (mild)
ë ‡√‘Ë¡°“√√—°…“¥â«¬¬“æàπ Ÿ¥¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï —Èπ‰¡à«à“®–
‡ªìπ°≈ÿà¡ beta2 agonist (SABA) À√◊Õ°≈ÿà¡ anticholinergic (SAMA)
À√◊Õ¬“·∫∫º ¡∑—Èß 2 °≈ÿà¡ (SABA+SAMA) ‡æ◊ËÕ∫√√‡∑“Õ“°“√‡Àπ◊ËÕ¬
(§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” ++)
22
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
ë Õ“®æ‘®“√≥“‡≈◊Õ°„À⬓¢¬“¬À≈Õ¥≈¡™π‘¥√—∫ª√–∑“π theophylline
™π‘¥ÕÕ°ƒ∑∏‘Ïπ“π„π¢π“¥μË” (sustained-release theophylline)
‡ªì𬓇¥’ˬ«À√◊Õ„Àâ√à«¡°—∫¬“æàπ Ÿ¥¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï —Èπ
(§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” +)
°≈ÿà¡∑’Ë 2, 3, 4 Õ“°“√ª“π°≈“ß (moderate) Õ“°“√√ÿπ·√ß (severe)
·≈–Õ“°“√√ÿπ·√ß¡“° (very severe) ‡æ◊ËÕ≈¥Õ“°“√¢ÕߺŸâªÉ«¬ ·≈–ªÑÕß°—π°“√
°”‡√‘∫¢Õß‚√§ ·π–π”„Àâ‡æ‘Ë¡¬“¥—ßμàÕ‰ªπ’È
ë ¬“æàπ Ÿ¥¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ϭ“«°≈ÿà¡ anticholinergic
(LAMA) ·≈–/À√◊Õ°≈ÿà¡ beta2 agonist (LABA)
(§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” ++)
ºŸâªÉ«¬∑’Ë¡’Õ“°“√°”‡√‘∫∫àÕ¬ (¡’°“√°”‡√‘∫¡“°°«à“À√◊Õ‡∑à“°—∫ 2 §√—ÈßμàÕªï
À√◊ÕμâÕ߇¢â“√—∫°“√√—°…“μ—«„π‚√ß欓∫“≈Õ¬à“ßπâÕ¬ 1 §√—ÈßμàÕªï) ·π–π”„Àâ‡æ‘Ë¡
¬“ ¥—ßμàÕ‰ªπ’È
ë ¬“æàπ Ÿ¥¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ϭ“«°≈ÿà¡ beta2 agonist º ¡
‡μ’¬√Õ¬¥å (LABA/ICS) ·≈–/À√◊Õ°≈ÿà¡ anticholinergic (LAMA)
(§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” ++)
ë æ‘®“√≥“‡æ‘Ë¡¬“°≈ÿà¡ phosphodiesterase-4 (PDE-4) inhibitor
(roflumilast) „πºŸâªÉ«¬°≈ÿà¡À≈Õ¥≈¡Õ—°‡ ∫‡√◊ÈÕ√—ß (chronic bronchitis)
·≈–¡’§à“ FEV1 πâÕ¬°«à“√âÕ¬≈– 50
(§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” +)
ë æ‘®“√≥“‡æ‘Ë¡¬“ azithromycin „π√–¬–¬“« (§ÿ≥¿“æÀ≈—°∞“π√–¥—∫
1, πÈ”Àπ—°§”·π–π” +) À√◊Õ¬“ mucolytics ∑’Ë¡’ƒ∑∏‘Ïμâ“π°“√Õ—°‡ ∫
‡™àπ N-acetylcysteine, carbocysteine „πºŸâªÉ«¬∑’Ë¡’‡ ¡À–¡“°
(§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 2, πÈ”Àπ—°§”·π–π” +)
23
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
·ºπ¿Ÿ¡‘∑’Ë 1 °“√√—°…“‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß·∫∫¢—Èπ∫—π‰¥
24
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
°“√√—°…“¥â«¬¬“ (μ“√“ß∑’Ë 2)
°“√„™â¬“¡’®ÿ¥ª√– ߧå‡æ◊ËÕ∫√√‡∑“Õ“°“√ ‡æ‘Ë¡§ÿ≥¿“æ™’«‘μ ≈¥°“√°”‡√‘∫
‡©’¬∫æ≈—π √«¡∂÷ß™–≈Õ°“√¥”‡π‘π‚√§ Õ¬à“߉√°Áμ“¡¬—߉¡à¡’¬“™π‘¥„¥∑’Ë¡’À≈—°∞“π
™—¥‡®π«à“ “¡“√∂™–≈ÕÕ—μ√“°“√‡ ◊ËÕ¡¢Õß ¡√√∂¿“æªÕ¥‰¥â À≈—°°“√„π°“√
‡≈◊Õ°„™â¬“μ—«„¥°—∫ºŸâªÉ«¬ §«√æ‘®“√≥“∂÷ßªí®®—¬μàÕ‰ªπ’ȧ◊Õ
1. §«“¡√ÿπ·√ߢÕßÕ“°“√·≈–¿“«– airflow limitation
2. §«“¡∂’Ë·≈–§«“¡√ÿπ·√ߢÕß°“√‡°‘¥°“√°”‡√‘∫¢Õß‚√§
3. ‚√§∑’Ëæ∫√à«¡
4. √“§“¬“ ·≈–°“√‡¢â“∂÷߬“¢ÕߺŸâªÉ«¬
5. §«“¡ “¡“√∂„π°“√„™â¬“¢ÕߺŸâªÉ«¬ ‚¥¬‡©æ“–°“√„™âÕÿª°√≥嬓æàπ Ÿ¥
6. °“√μÕ∫ πÕߢÕߺŸâªÉ«¬ ·≈–º≈¢â“߇§’¬ß∑’ˇ°‘¥¢÷Èπ
πÕ°®“°π’ȧ«√¡’°“√ª√–‡¡‘π ·≈–ª√—∫¬“„Àâ‡À¡“– ¡°—∫ ¿“«–¢ÕߺŸâªÉ«¬
‡ªìπ√–¬– ‚¥¬ª√–‡¡‘π∑—Èߧÿ≥ª√–‚¬™πå∑’ˉ¥â·≈–º≈¢â“߇§’¬ß¢Õ߬“ ¬“À≈—°∑’Ë„™â
„π°“√√—°…“‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ߪ√–°Õ∫¥â«¬ ¬“¢¬“¬À≈Õ¥≈¡ ¬“μâ“π°“√Õ—°‡ ∫
‡™àπ ‡μ’¬√Õ¬¥å ¬“∫√√‡∑“Õ“°“√ ‡™à𠬓·°â ‰Õ ¬“¢—∫‡ ¡À– ¬“ªØ‘™’«π–·≈–
Õ◊Ëπ Ê ¥—ß√“¬≈–‡Õ’¬¥μàÕ‰ªπ’È
¬“¢¬“¬À≈Õ¥≈¡
¬“¢¬“¬À≈Õ¥≈¡¡’ª√–‚¬™πå‡æ◊ËÕ∫√√‡∑“Õ“°“√ ‡æ‘Ë¡ exercise capacity
·≈–‡æ‘Ë¡§ÿ≥¿“æ™’«‘μ¢ÕߺŸâªÉ«¬8 (§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1) ·¡â«à“ºŸâªÉ«¬∫“ß√“¬
Õ“®®–‰¡àæ∫°“√μÕ∫ πÕßμàÕ¬“¢¬“¬À≈Õ¥≈¡μ“¡‡°≥±å°“√μ√«® ¡√√∂¿“æ
ªÕ¥°Áμ“¡ ¬“¢¬“¬À≈Õ¥≈¡·∫à߉¥â‡ªìπ 3 °≈ÿà¡À≈—° §◊Õ beta2 agonist, anti-
cholinergics ·≈– xanthine derivatives À√◊Õ·∫àßμ“¡√–¬–‡«≈“°“√ÕÕ°ƒ∑∏‘Ï
‡ªìπ™π‘¥ÕÕ°ƒ∑∏‘Ï —Èπ ·≈–ÕÕ°ƒ∑∏‘Ϭ“«
25
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
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Antic
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c
26
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holin
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62.5 m
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1.25
/0.5 m
g/UDV
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0.5m
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12/3
40 m
cg
110/
50 m
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2.5
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2.5/
2.5
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27
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ler, S
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unit
dos
e via
l
28
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
¬“°≈ÿà¡ beta2-agonist ¡’ƒ∑∏‘Ï¢¬“¬À≈Õ¥≈¡ ‚¥¬¬“°≈ÿà¡ short acting
beta2-agonist (SABA) ¡’º≈≈¥Õ“°“√‡Àπ◊ËÕ¬·≈–‡æ‘Ë¡§à“ FEV1 ·μàÕÕ°ƒ∑∏‘Ï —Èπ
ª√–¡“≥ 4-6 ™—Ë«‚¡ß à«π¬“°≈ÿà¡ long acting beta2-agonist (LABA) ¡’¢âÕ¡Ÿ≈
«à“ “¡“√∂‡æ‘Ë¡ FEV1 ≈¥Õ“°“√‡Àπ◊ËÕ¬ ≈¥°“√°”‡√‘∫ ·≈–≈¥°“√πÕπ‚√ß欓∫“≈
‰¥â ·μàº≈„π¥â“π°“√≈¥Õ—μ√“쓬 À√◊Õ™–≈Õ°“√‡ ◊ËÕ¡¢Õß ¡√√∂¿“æªÕ¥¬—ß
‰¡à™—¥‡®π ¬“°≈ÿà¡ LABA ·π–π”„Àℙ⫗π≈– 1-2 §√—Èß μ“¡√–¬–‡«≈“∑’ËÕÕ°ƒ∑∏‘Ï
‡æ◊ËÕ§«∫§ÿ¡Õ“°“√
¬“°≈ÿà¡ antimuscarinic ª√–°Õ∫¥â«¬¬“™π‘¥ÕÕ°ƒ∑∏‘Ï —Èπ À√◊Õ short
acting antimuscarinic (SAMA) ·≈–ÕÕ°ƒ∑∏‘Ϭ“« À√◊Õ long acting anti-
muscarinic (LAMA) ‚¥¬¬“°≈ÿà¡ SAMA ‰¥âº≈„π°“√∫√√‡∑“Õ“°“√‰¡àμà“ß°—∫
SABA ¡“°π—° à«π¬“°≈ÿà¡ LAMA æ∫«à“‰¥âª√–‚¬™πå„π°“√∫√√‡∑“Õ“°“√ ≈¥
°“√°”‡√‘∫ ·≈–≈¥°“√πÕπ‚√ß欓∫“≈ ·μàº≈„π¥â“π°“√™–≈Õ°“√‡ ◊ËÕ¡¢Õß
¡√√∂¿“æªÕ¥‰¡à™—¥‡®π
§«√„™â¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï —Èπ ‡æ◊ËÕ∫√√‡∑“Õ“°“√ ‡π◊ËÕß®“°
“¡“√∂≈¥Õ“°“√‡Àπ◊ËÕ¬‰¥â¥’8,9 (§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” ++)
·μà‰¡à·π–π”„Àℙ⇪ì𬓧«∫§ÿ¡Õ“°“√√–¬–¬“« ·π–π”„Àℙ⬓¢¬“¬À≈Õ¥≈¡
™π‘¥ÕÕ°ƒ∑∏‘Ϭ“«„π°“√§«∫§ÿ¡‚√§¡“°°«à“¬“™π‘¥ÕÕ°ƒ∑∏‘Ï —Èπ ‡π◊ËÕß®“° “¡“√∂
‡æ‘Ë¡ ¡√√∂¿“æªÕ¥‰¥â¥’°«à“ √«¡∂÷ß≈¥Õ“°“√·≈–‡æ‘Ë¡§ÿ≥¿“æ™’«‘μ¥â«¬9-15
(§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” ++)
°“√∫√‘À“√¬“¢¬“¬À≈Õ¥≈¡ ·π–π”„Àℙ⫑∏’æàπ Ÿ¥ (¿“§ºπ«° 1) ‚¥¬
Õ“®®– Ÿ¥ºà“πÕÿª°√≥å metered dose inhaler (MDI) (‚¥¬„™âÀ√◊Õ‰¡à„™â spacer
√à«¡¥â«¬), dry powder inhaler (DPI), soft mist inhaler (SMI) ‡ªìπμâπ
‰¡à·π–π”„Àℙ⬓¢¬“¬À≈Õ¥≈¡™π‘¥°‘πÀ√◊Õ©’¥„π°“√√—°…“‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß
‡π◊ËÕß®“°¡’º≈¢â“߇§’¬ß¡“°°«à“ ¬°‡«âπ„π°√≥’‰¡à¡’¬“™π‘¥æàπ Ÿ¥„™â πÕ°®“°π’Ȭ—ß
29
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
‰¡à¡’¢âÕ¡Ÿ≈∑’Ë™—¥‡®π«à“°“√„™â¬“æàπ Ÿ¥ºà“π nebulizer ¢≥–∑’˺ŸâªÉ«¬‰¡à‰¥â¡’Õ“°“√
°”‡√‘∫‰¥âª√–‚¬™πå¡“°°«à“°“√„™â¬“‚¥¬«‘∏’æàπ Ÿ¥·∫∫Õ◊Ëπ ®÷ߧ«√æ‘®“√≥“„™â
nebulizer ‡©æ“–„π√“¬∑’Ë ‰¡à “¡“√∂„™â¬“‚¥¬«‘∏’æàπ Ÿ¥™π‘¥Õ◊Ëπ Ê Õ¬à“ß¡’
ª√– ‘∑∏‘¿“æ‡∑à“π—Èπ16,17 (§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” +)
°“√„™â¬“¢¬“¬À≈Õ¥≈¡ Õß™π‘¥∑’Ë¡’°≈‰°·≈–√–¬–‡«≈“°“√ÕÕ°ƒ∑∏‘Ïμà“ß
°—π Õ“®™à«¬‡ √‘¡ƒ∑∏‘Ï´÷Ëß°—π·≈–°—π„π¥â“π°“√¢¬“¬À≈Õ¥≈¡·≈–≈¥º≈¢â“߇§’¬ß
∑’Ë®–‡°‘¥®“°°“√‡æ‘Ë¡¢π“¥¬“¢¬“¬À≈Õ¥≈¡ ‡™àπ °“√„™â¬“°≈ÿà¡ beta2 agonist
√à«¡°—∫¬“°≈ÿà¡ anticholinergic ‰¥âº≈¥’„π°“√‡æ‘Ë¡§à“ FEV1 ¡“°°«à“°“√‡æ‘Ë¡¢π“¥
¬“·μà≈–™π‘¥18,19 (§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” +) πÕ°®“°π’È
°“√„™â¬“°≈ÿà¡ LABA √à«¡°—∫ LAMA ¬—ß¡’º≈™à«¬∫√√‡∑“Õ“°“√ ∑”„Àâ ¿“«–
ÿ¢¿“楒¢÷Èπ ·≈–≈¥Õ—μ√“°“√°”‡√‘∫¢Õß‚√§‰¥â¥’°«à“°“√„™â¬“ long acting
bronchodilator ‡¥’ˬ«20-23
¬“°≈ÿà¡ beta2-agonist ¡’º≈¢â“߇§’¬ß∑’Ë ”§—≠ ‡™àπ À—«„®‡μâπ‡√Á«
(tachycardia) √–¥—∫‚ª·μ ‡´’¬¡„π‡≈◊Õ¥μË” ¡◊Õ —Ë𠇪ìπμâπ
¬“°≈ÿà¡ anticholinergic ¡’º≈¢â“߇§’¬ß∑’Ë ”§—≠ ‡™à𠪓°·Àâß urinary
retention √ ¢¡À√◊Õ metallic taste „𪓰 ∂â“„™â√Ÿª nebulizer Õ“®®–°√–μÿâπ
„À⇰‘¥ acute glaucoma
¬“ ‡μ’¬√Õ¬¥å
¬“æàπ Ÿ¥ ‡μ’¬√Õ¬¥å (inhaled corticosteroids, ICS)
¡’º≈°“√»÷°…“æ∫«à“°“√„™â ICS ∑”„ÀâÕ“°“√¥’¢÷Èπ ‡æ‘Ë¡§ÿ≥¿“æ™’«‘μ √«¡
∂÷ß≈¥°“√‡°‘¥°“√°”‡√‘∫ ‚¥¬‡©æ“–„πºŸâªÉ«¬∑’Ë¡’§à“ FEV1 < 60% predicted10,24-26
(§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1) Õ¬à“߉√°Áμ“¡¡’À≈—°∞“π«à“°“√„™â¬“ Ÿ¥ ICS ‚¥¬‡©æ“–
‡¡◊ËÕ„™â„π¢π“¥ Ÿß ‡æ‘Ë¡§«“¡‡ ’ˬ߄π°“√‡°‘¥ªÕ¥Õ—°‡ ∫27-30 ‡¡◊ËÕ„™â„π√–¬–¬“«
30
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
Õ“®∑”„Àâ¡«≈°√–¥Ÿ°≈¥≈ß31,32 ‡π◊ËÕß®“°¬—߉¡à¡’¢âÕ¡Ÿ≈¢Õß¢π“¥¬“∑’ˇÀ¡“– ¡ ·≈–
μâÕß√–«—ߺ≈¢â“߇§’¬ß¢Õ߬“ ‡μ’¬√Õ¬¥å ®÷߉¡à·π–π”„™â¬“ ICS ‡ªì𬓇¥’ˬ«„π
°“√√—°…“‚¥¬‰¡à¡’¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ϭ“«√à«¡¥â«¬
°“√À¬ÿ¥¬“ ICS Õ¬à“ß©—∫æ≈—π Õ“®¡’º≈∑”„ÀâÕ“°“√·¬à≈ß À√◊Õ‡°‘¥°“√
°”‡√‘∫‰¥â33 ·μà„πºŸâªÉ«¬°≈ÿà¡∑’Ë¡’§«“¡‡ ’ˬߢÕß°“√°”‡√‘∫μË” À“°μâÕß°“√À¬ÿ¥¬“
ICS ·π–π”„Àâ§àÕ¬Ê ≈¥¢π“¥¬“≈ß™â“ Ê √à«¡°—∫°“√„À⬓¢¬“¬À≈Õ¥≈¡™π‘¥
ÕÕ°ƒ∑∏‘Ϭ“«Õ¬à“߇μÁ¡∑’Ë34,35 (§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” +/-)
º≈¢â“߇§’¬ß∑’Ë ”§—≠§◊Õ ‡™◊ÈÕ√“„𪓰 ‡ ’¬ß·À∫ skin bruising ªÕ¥Õ—°‡ ∫
¬“ ‡μ’¬√Õ¬¥å™π‘¥√—∫ª√–∑“π (oral corticosteroids)
¡’ª√–‚¬™π凩擖„π°“√√—°…“°“√°”‡√‘∫‡©’¬∫æ≈—π‡∑à“π—Èπ36,37 ‰¡à§«√„™â
„π°“√√—°…“√–¬–¬“« (§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” --) ‡π◊ËÕß®“°
¡’º≈¢â“߇§’¬ß¡“° ‡™àπ steroid myopathy, osteoporosis ‡æ‘Ë¡§«“¡‡ ’ˬ߄π
°“√μ‘¥‡™◊ÈÕ πÈ”μ“≈„π‡≈◊Õ¥ Ÿß38,39
Combination Inhaled corticosteroids/ bronchodilator
æ∫«à“°“√„™â¬“º ¡√–À«à“ß ICS °—∫ LABA (ICS/LABA) ¡’ª√– ‘∑∏‘¿“æ
‡Àπ◊Õ°«à“¬“ LABA À√◊Õ¬“ ICS ™π‘¥æàπ Ÿ¥‡æ’¬ß™π‘¥‡¥’¬« ‚¥¬ “¡“√∂∑”„Àâ
health status ·≈– ¡√√∂¿“æªÕ¥¥’¢÷Èπ ·≈–≈¥°“√‡°‘¥°“√°”‡√‘∫‚¥¬‡©æ“–ºŸâªÉ«¬
°≈ÿà¡∑’Ë¡’§«“¡√ÿπ·√ߪ“π°≈“ߢ÷Èπ‰ª (FEV1 < 80% predicted)10,26,40,41 (§ÿ≥¿“æ
À≈—°∞“π√–¥—∫ 1)
Methylxanthines
‡ªìπ¬“∑’Ë¡’ƒ∑∏‘Ï„π°“√¢¬“¬À≈Õ¥≈¡ ·μàª√– ‘∑∏‘¿“æ„π°“√¢¬“¬À≈Õ¥≈¡
‰¡à¥’¡“°‡¡◊ËÕ‡∑’¬∫°—∫¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ϭ“«™π‘¥Õ◊Ëπ °“√»÷°…“
31
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
ª√– ‘∑∏‘¿“æ¢Õ߬“°≈ÿà¡π’È ¡’‡©æ“–√Ÿª·∫∫ sustained-release ‡∑à“π—Èπ æ∫«à“°“√
„™â¬“ theophylline „π¢π“¥μË” (‡™àπ sustained-release theophylline
¢π“¥ 200 ¡°.μàÕ«—π) Õ“®™à«¬∑”„ÀâÀ≈Õ¥≈¡μÕ∫ πÕßμàÕ ICS ‰¥â¥’¢÷Èπ42,43
(§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” +/-) Õ¬à“߉√°Áμ“¡‰¡à§«√„™â¬“°≈ÿà¡
methylxanthines ‡ªìπ¬“√—°…“‡¥’ˬ« ‡æ◊ËÕÀ«—߃∑∏‘Ï¢¬“¬À≈Õ¥≈¡‡ªìπÀ≈—°
‡π◊ËÕß®“°¡’‚Õ°“ ‡°‘¥º≈¢â“߇§’¬ß‰¥âßà“¬‚¥¬‡©æ“–„πºŸâªÉ«¬ ŸßÕ“¬ÿ Õ“®„™â¬“°≈ÿà¡
π’È√à«¡°—∫¬“¢¬“¬À≈Õ¥≈¡Õ◊Ëπ‡æ◊ËÕ‡ √‘¡ƒ∑∏‘Ï¢¬“¬À≈Õ¥≈¡44-46 (§ÿ≥¿“æÀ≈—°∞“π
√–¥—∫ 1, πÈ”Àπ—°§”·π–π” +)
¢âÕ§«√√–«—ß∑’Ë ”§—≠§◊Õ drug interaction ‡¡◊ËÕ„™â√à«¡°—∫¬“Õ◊Ëπ∑’Ë metabolize
ºà“π cytochrome P450 ‡™à𠬓°≈ÿà¡ macrolide, quinolone ·≈– warfarin
‡ªìπμâπ ·≈–„™â¥â«¬§«“¡√–¡—¥√–«—ß„πºŸâ ŸßÕ“¬ÿ ‡π◊ËÕß®“°¡’‚Õ°“ ‡°‘¥º≈¢â“߇§’¬ß
‰¥âßà“¬°«à“
º≈¢â“߇§’¬ß∑’Ë ”§—≠§◊Õ À—«„®‡μâπº‘¥®—ßÀ«– ™—° ª«¥»’√…– πÕπ‰¡àÀ≈—∫
§≈◊Ëπ‰ â Õ“‡®’¬π heartburn
Phosphodiesterase-4 inhibitor (PDE-4 inhibitor)
‡ªìπ¬“∑’ˉ¡à¡’ƒ∑∏‘Ï¢¬“¬À≈Õ¥≈¡‚¥¬μ√ß ·μàÕ“®„™â√à«¡°—∫¬“¢¬“¬À≈Õ¥≈¡
∑’ËÕÕ°ƒ∑∏‘Ϭ“« ‡æ◊ËÕ≈¥Õ—μ√“°“√°”‡√‘∫ ‰¥âª√–‚¬™π凩擖„πºŸâªÉ«¬°≈ÿà¡ chronic
bronchitis ∑’Ë¡’ FEV1 < 50% ·≈–¡’ª√–«—μ‘°“√°”‡√‘∫Õ¬à“ßπâÕ¬ 2 §√—ÈßμàÕªï47,48
(§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” +) º≈¢â“߇§’¬ß∑’Ë ”§—≠‰¥â·°à §≈◊Ëπ‰ â
‡∫◊ËÕÕ“À“√ ª«¥∑âÕß ∑âÕ߇ ’¬ ª«¥»’√…– πÕπ‰¡àÀ≈—∫ πÈ”Àπ—°≈¥ ·≈–Àâ“¡„™â
√à«¡°—∫¬“ theophylline ‡æ√“–∑”„Àâ¡’º≈¢â“߇§’¬ß‡æ‘Ë¡¢÷Èπ
Mucolytic & Antioxidant‡™àπ ambroxol, carbocysteine, N-acetylcysteine, erdosteine Õ“®„™â
32
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
‡æ◊ËÕ∫√√‡∑“Õ“°“√‡ ¡À–‡À𒬫‡ªìπ™à«ß —Èπ °“√„™â¬“≈–≈“¬‡ ¡À–‡æ◊ËÕ°“√√—°…“
√–¬–¬“« ¬—߉¡à¡’ª√–‚¬™πå∑’Ë™—¥‡®π (πÈ”Àπ—°§”·π–π” +/-) ·μà¡’À≈—°∞“π°“√„™â
¬“ N-acetylcysteine „π¢π“¥ Ÿß (1,200 ¡°.μàÕ«—π) ‡ªìπ anti-oxidant ´÷ËßÕ“®
≈¥Õ—μ√“°“√°”‡√‘∫ „πºŸâªÉ«¬ GOLD stage 249 “¡“√∂„™â‡ªì𬓇 √‘¡√à«¡°—∫
°“√√—°…“Õ◊Ëπ‡æ◊ËÕ≈¥°“√°”‡√‘∫„πºŸâªÉ«¬∑’Ë¡’°“√°”‡√‘∫∫àÕ¬ (§ÿ≥¿“æÀ≈—°∞“π√–¥—∫
1, πÈ”Àπ—°§”·π–π” +)
¬“ªØ‘™’«π–
∫∑∫“∑À≈—°¢Õ߬“ªØ‘™’«π–§◊Õ „™â√—°…“Õ“°“√μ‘¥‡™◊ÈÕ„π™à«ß∑’Ë¡’°“√°”‡√‘∫
¢Õß‚√§ à«π°“√„™â¬“ªØ‘™’«π–‡æ◊ËÕ≈¥Õ—μ√“°“√°”‡√‘∫¢Õß‚√§π—Èπ º≈°“√»÷°…“
¬—߉¡à‰¥â¢âÕ √ÿª∑’Ë™—¥‡®π ¬“∑’Ë¡’°“√»÷°…“«à“Õ“®™à«¬≈¥Õ—μ√“°“√°”‡√‘∫‰¥â ‡™àπ
erythromycin50, azithromycin51, moxifloxacin52 ‡ªìπμâπ °“√„™â¬“ªØ‘™’«π–
‡æ◊ËÕ«—μ∂ÿª√– ߧåπ’È®÷ߧ«√„™â¥â«¬§«“¡√–¡—¥√–«—ß·≈–§”π÷ß∂÷ߺ≈·∑√° âÕπ∑’Ë
‡°’ˬ«¢âÕߥ⫬ ‡™àπ º≈¢â“߇§’¬ß¢Õ߬“ °“√‡æ‘Ë¡®”π«π‡™◊ÈÕ¥◊ÈÕ¬“ ‡ªìπμâπ
¬“Õ◊Ëπ Ê
¬“·°â ‰Õ „™â‡æ◊ËÕ∫√√‡∑“Õ“°“√‡∑à“π—Èπ ‰¡à·π–π”„Àℙ⇪ìπª√–®”
¢—Èπ∑’Ë 3 °“√√—°…“Õ◊Ëπ Ê
§«√μâÕß„À⧔·π–𔧫∫§Ÿà‰ª°—∫°“√√—°…“¥â«¬¬“„πºŸâªÉ«¬∑ÿ°√“¬‡æ◊ËÕ‡æ‘Ë¡
§ÿ≥¿“æ™’«‘μ ≈¥°“√°”‡√‘∫ ·≈–«“ß·ºπ°“√√—°…“√à«¡°—∫ºŸâªÉ«¬‡ ¡Õ °“√√—°…“
Õ◊Ëπ Ê ∑’ˉ¡à„™à¬“ ‰¥â·°à
ë „À⺟âªÉ«¬√—∫«—§´’πªÑÕß°—π‰¢âÀ«—¥„À≠à (influenza vaccine) ªï≈–Õ¬à“ß
πâÕ¬ 1 §√—Èß ·≈–·π–π”ª√–‚¬™πå¢Õß°“√√—∫«—§´’πªÑÕß°—πªÕ¥Õ—°‡ ∫
(pneumococcal vaccine)
33
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
ë μ√«® Õ∫‡√◊ËÕß°“√ Ÿ∫∫ÿÀ√’Ë ·π–π”«‘∏’·≈–„Àâ°“√ π—∫ πÿπ°“√‡≈‘° Ÿ∫
∫ÿÀ√’Ë (¿“§ºπ«° 2)
ë ‡√‘Ë¡‚ª√·°√¡øóôπøŸ ¡√√∂¿“æªÕ¥ (pulmonary rehabilitation) „π
ºŸâªÉ«¬°≈ÿà¡∑’Ë¡’Õ“°“√
ë „πºŸâªÉ«¬°≈ÿà¡Õ“°“√√ÿπ·√ß (severe) ¢÷Èπ‰ª ·π–π”„Àâ
æ‘®“√≥“„À⺟âªÉ«¬„™âÕÕ°´‘‡®πÕ¬à“ßπâÕ¬«—π≈– 15 ™—Ë«‚¡ß (long term
oxygen therapy)
·π–π”∑“߇≈◊Õ°„π°“√√—°…“‚¥¬°“√ºà“μ—¥ (lung volume reduction
surgery - LVRS) „πºŸâªÉ«¬∑’Ë¡’¢âÕ∫àß™’È
·®âß°“√欓°√≥å‚√§ §ÿ¬∂÷ß«“√– ÿ¥∑⓬„π™’«‘μ°—∫ºŸâªÉ«¬·≈–≠“μ‘
‡æ◊ËÕ«“ß·ºπ™’«‘μ„πÕπ“§μ
«—§´’π53 (¿“§ºπ«° 3)
1. Inactivated influenza vaccine
·π–π”„Àâ«—§´’π‰¢âÀ«—¥„À≠à∑ÿ°ªï ªï≈– 1 §√—Èß „Àâ ‰¥âμ≈Õ¥∑—Èßªï ·μà
√–¬–‡«≈“∑’ˇÀ¡“– ¡§◊Õ ‡¥◊Õπ¡’π“§¡ - ‡¡…“¬π (§ÿ≥¿“æÀ≈—°∞“π 1, πÈ”Àπ—°
§”·π–π” ++)
2. Pneumococcal vaccine
Õ“®æ‘®“√≥“©’¥„πºŸâªÉ«¬∑’ËÕ“¬ÿ¡“°°«à“ 65 ªï À√◊ÕºŸâªÉ«¬∑’ËÕ“¬ÿπâÕ¬°«à“
65 ªï∑’Ë¡’§à“¢Õß FEV1 πâÕ¬°«à“√âÕ¬≈– 40 ¢Õߧà“Õâ“ßÕ‘ß
°“√øóôπøŸ ¡√√∂¿“æªÕ¥ (pulmonary rehabilitation) (¿“§ºπ«° 4)
¡’«—μ∂ÿª√– ߧå‡æ◊ËÕ≈¥Õ“°“√¢Õß‚√§ ‡æ‘Ë¡§ÿ≥¿“æ™’«‘μ ·≈–‡æ‘Ë¡§«“¡
“¡“√∂„π°“√∑”°‘®«—μ√ª√–®”«—π ´÷Ëß°“√øóôπøŸ ¡√√∂¿“æªÕ¥π’È ¡’Õߧåª√–°Õ∫
34
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
À≈“¬Õ¬à“ß §◊Õ°“√„À⧫“¡√Ÿâ °“√ª√—∫‡ª≈’ˬπæƒμ‘°√√¡ ‡∑§π‘§°“√¢—∫‡ ¡À–„Àâ
∂Ÿ°«‘∏’ °“√„™â¬“ °“√ª√–‡¡‘π·≈–øóôπøŸ ¿“æ¢Õß°≈â“¡‡π◊ÈÕ ¿“æÕ“√¡≥å·≈–
®‘μ„® ¿“«–‚¿™π“°“√ ·≈–°“√Ωñ°°“√ÕÕ°°”≈—ß°“¬ Õ—π®–𔉪 Ÿà°“√¥Ÿ·≈μπ‡Õß
∑’ˇÀ¡“– ¡ °“√Ωñ°ÕÕ°°”≈—ß°“¬‡ªìπªí®®—¬∑’Ë ”§—≠∑’Ë ÿ¥∑’Ë®–°”Àπ¥º≈≈—æ∏å¢Õß
°“√øóôπøŸ ¡√√∂¿“æªÕ¥ °“√øóôπøŸ ¡√√∂¿“æªÕ¥¡’¢âÕ∫àß™’È„πºŸâªÉ«¬∑ÿ°√–¥—∫
§«“¡√ÿπ·√ß∑’Ë¡’Õ“°“√ ‚¥¬‡√‘Ë¡μâπ®“°°“√®—¥°‘®°√√¡ºŸâªÉ«¬„π·≈–ºŸâªÉ«¬πÕ°
·≈–Õ“®¢¬“¬‰ª∂÷ß°“√®—¥°‘®°√√¡„π™ÿ¡™π·≈–§√—«‡√◊Õπ¥â«¬ ‚ª√·°√¡°“√
ÕÕ°°”≈—ß°“¬ §«√∑”Õ¬à“ßπâÕ¬ 6 —ª¥“Àå¢÷Èπ‰ª ‚¥¬¬‘Ëß∑”μàÕ‡π◊ËÕßπ“𠬑Ë߉¥â
ª√– ‘∑∏‘º≈ ·≈–‚ª√·°√¡¢ÕߺŸâªÉ«¬·μà≈–√“¬‰¡à®”‡ªìπμâÕ߇À¡◊Õπ°—π “¡“√∂
ª√—∫‡ª≈’ˬπ‰¥â ‚¥¬¢÷ÈπÕ¬Ÿà°—∫ ¿“«–¢Õß‚√§ √–¥—∫°“√√—∫√ŸâÀ√◊Õ§«“¡‡¢â“„® ¿“æ
—ߧ¡ À√◊Õ‡»√…∞“π–¢ÕߺŸâªÉ«¬·μà≈–√“¬
°“√øóôπøŸ ¡√√∂¿“æªÕ¥®–μâÕß¡’°“√ª√–‡¡‘πºŸâªÉ«¬∑—Èß°àÕπ·≈–À≈—ß°“√
‡¢â“√à«¡°‘®°√√¡ ‡æ◊ËÕ„™â‡ªìπμ—«™’È«—¥∂÷ߪ√–‚¬™πå∑’ˉ¥â√—∫·≈–‡ªÑ“À¡“¬∑’ËμâÕß°“√
„πºŸâªÉ«¬·μà≈–√“¬ ‚¥¬°“√ª√–‡¡‘π§«√ª√–°Õ∫¥â«¬¥—™π’À≈—° ¥—ßμàÕ‰ªπ’È
1) √–¥—∫§«“¡√ÿπ·√ߢÕßÕ“°“√‡Àπ◊ËÕ¬ ‡™àπ mMRC
2) §«“¡ “¡“√∂„π°“√ÕÕ°°”≈—ß°“¬ ‡™àπ 6 minute walk distance test
(6MWT)
3) §ÿ≥¿“æ™’«‘μ (quality of life) ‡™àπ COPD assessment test (CAT)
4) §«“¡·¢Áß·√ߢÕß°≈â“¡‡π◊ÈÕ∑’Ë„™â„π°“√À“¬„®·≈–°≈â“¡‡π◊ÈÕ·¢π¢“
(muscle strength) ‚¥¬‡©æ“–„πºŸâªÉ«¬√“¬∑’Ë¡’°≈â“¡‡π◊ÈÕ≈’∫ À√◊Õ
°≈â“¡‡π◊ÈÕÕàÕπ·√ß
5) °“√æ÷Ëßæ“∫√‘°“√∑“ß “∏“√≥ ÿ¢ ‡™àπ Õ—μ√“°“√°”‡√‘∫¢Õß‚√§
(exacerbation rate) Õ—μ√“°“√πÕπ‚√ß欓∫“≈ (admission rate) ‡ªìπμâπ
∑—Èßπ’È ¥—™π’∑’Ë„™â„π°“√ª√–‡¡‘π ¢÷ÈπÕ¬Ÿà°—∫»—°¬¿“æ¢Õß ∂“π∫√‘°“√
35
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
°“√∫”∫—¥¥â«¬ÕÕ°´‘‡®π√–¬–¬“« (¿“§ºπ«° 5)
°“√√—°…“‚¥¬°“√ºà“μ—¥ ·≈–/À√◊Õ À—μ∂°“√摇»…
”À√—∫ºŸâªÉ«¬∫“ß√“¬∑’ˉ¥â√—∫°“√√—°…“¥â«¬¬“ ·≈–°“√øóôπøŸ ¡√√∂¿“æ
ªÕ¥Õ¬à“߇μÁ¡∑’Ë·≈â« ¬—ߧ«∫§ÿ¡Õ“°“√‰¡à‰¥â¥’ Õ“®æ‘®“√≥“°“√√—°…“¥â«¬°“√ºà“μ—¥
‡™àπ
1) Bullectomy Õ“®æ‘®“√≥“„πºŸâªÉ«¬∑’Ë¡’ bleb À√◊Õ bullae ¢π“¥„À≠à
2) °“√ºà“μ—¥‡æ◊ËÕ≈¥ª√‘¡“μ√ªÕ¥ (lung volume reduction surgery) ¡’
ª√–‚¬™π凩擖„π°≈ÿࡺŸâªÉ«¬∑’Ë¡’≈—°…≥–∂ÿß≈¡‚ªÉßæÕ߇¥àπ∑’˪ե°≈’∫∫π (upper-
lobe predominant emphysema) ·≈–¡’§«“¡ “¡“√∂„π°“√ÕÕ°°”≈—ß°“¬„π
√–¥—∫μË”
3) °“√ àÕß°≈âÕß„ àÕÿª°√≥å ‡™àπ endobronchial valve „πÀ≈Õ¥≈¡‡æ◊ËÕ
≈¥ª√‘¡“μ√ªÕ¥
4) °“√ºà“μ—¥‡ª≈’ˬπªÕ¥ (lung transplantation)
Õ¬à“߉√°Á¥’ μâÕߧ”π÷ß∂÷ߪ√–‚¬™πå∑’˺ŸâªÉ«¬®–‰¥â√—∫°—∫§«“¡‡ ’ˬ߮“°°“√
ºà“μ—¥·≈–§à“„™â®à“¬®“°°“√ºà“μ—¥√à«¡¥â«¬ ¥—ßπ—È𠧫√ àßμàÕºŸâªÉ«¬‡À≈à“π’È ‰ª
¬—ßÕ“¬ÿ√·æ∑¬åºŸâ‡™’ˬ«™“≠‚√§√–∫∫°“√À“¬„® ‡æ◊ËÕª√–‡¡‘π°“√√—°…“‚¥¬≈–‡Õ’¬¥
μàÕ‰ª
°“√«“ß·ºπ™’«‘μ√–¬– ÿ¥∑⓬ (end of life plan) (¿“§ºπ«° 6)
°“√ª√–‡¡‘π·≈–°“√μ‘¥μ“¡‚√§ (¿“§ºπ«° 7)
36
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
°“√°”‡√‘∫‡©’¬∫æ≈—π¢Õß‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß(acute exacerbation of COPD)
°“√°”‡√‘∫‡©’¬∫æ≈—π¢Õß‚√§À¡“¬∂÷ß °“√∑√ÿ¥≈ߢÕßÕ“°“√Õ¬à“߇©’¬∫
æ≈—π¿“¬„π 3 «—π ®π∑”„ÀâμâÕ߇æ‘Ë¡À√◊Õª√—∫‡ª≈’ˬπ°“√√—°…“ Õ“°“√¥—ß°≈à“«‰¥â·°à
1. ‡Àπ◊ËÕ¬‡æ‘Ë¡¢÷Èπ
2. ‰Õ¡“°¢÷Èπ
3. ª√‘¡“≥‡ ¡À–‡æ‘Ë¡¢÷Èπ
4. ‡ ¡À–‡ª≈’ˬπ ’
‚¥¬Õ“°“√¥—ß°≈à“«μâÕ߉¡à‰¥â‡°‘¥®“°‚√§À√◊Õ¿“«–Õ◊Ëπ Ê ∑’Ë¡’≈—°…≥–Õ“°“√
§≈⓬§≈÷ß°—𠇙àπ À—«„®≈⡇À≈« ≈¡√—Ë«„π™àÕ߇¬◊ËÕÀÿ⡪ե ªÕ¥Õ—°‡ ∫ ≈‘Ë¡‡≈◊Õ¥
Õÿ¥μ—πÀ≈Õ¥‡≈◊Õ¥·¥ßªÕ¥‡©’¬∫æ≈—𠇪ìπμâπ37,54-58
°“√ª√–‡¡‘πºŸâªÉ«¬37,58-61
1. ª√–«—μ‘ √–¥—∫§«“¡√ÿπ·√ߢÕß‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ‚√§ª√–®”μ—«√à«¡
ª√–«—μ‘°“√°”‡√‘∫‡©’¬∫æ≈—π¢Õß‚√§§√—Èß°àÕπ∑—Èߧ«“¡∂’Ë·≈–§«“¡√ÿπ·√ß °“√‡§¬
‰¥â√—∫°“√„™â‡§√◊ËÕߙ૬À“¬„®
2. °“√μ√«®√à“ß°“¬ ¡’°“√„™â°≈â“¡‡π◊Èՙ૬À“¬„®¡“°¢÷Èπ ‡¢’¬« ¢“∫«¡
√–¥—∫§«“¡√Ÿâ ÷°μ—«≈¥≈ß —≠≠“≥™’溑¥ª°μ‘
3. °“√ª√–‡¡‘π gas exchange „™â pulse oximetry ‡æ◊ËÕª√–‡¡‘π μ‘¥μ“¡
°“√√—°…“ ·≈–ª√—∫°“√„ÀâÕÕ°´‘‡®π∑’ˇÀ¡“– ¡ ‡®“– arterial blood gases ‡¡◊ËÕ
ºŸâªÉ«¬¡’°“√À“¬„®≈⡇À≈«·≈–„™âμ‘¥μ“¡‡¡◊ËÕºŸâªÉ«¬‰¥â√—∫°“√„™â‡§√◊ËÕߙ૬À“¬„®
4. ¿“æ√—ß ’∑√«ßÕ° §«√ àßμ√«®°√≥’ºŸâªÉ«¬¡’Õ“°“√°”‡√‘∫√ÿπ·√ß ‡æ◊ËÕ
™à«¬«‘π‘®©—¬·¬°‚√§‡™àπ À—«„®≈⡇À≈« ≈¡√—Ë«„π™àÕ߇¬◊ËÕÀÿ⡪ե ªÕ¥μ‘¥‡™◊ÈÕ
37
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
5. àßμ√«®‡ ¡À–‡æ“–‡™◊ÈÕ „πºŸâªÉ«¬∑’Ë¡’¢âÕ∫àß™’È¢Õß°“√„À⬓μâ“π®ÿ≈™’æ
·≈–¡’‚√§°”‡√‘∫√ÿπ·√ß ¡’ª√–«—μ‘‚√§°”‡√‘∫∫àÕ¬ ºŸâªÉ«¬∑’ËμâÕß„™â‡§√◊ËÕߙ૬À“¬„®
6. °“√μ√«®§≈◊Ëπ‰øøÑ“À—«„® °√≥’ ß —¬‚√§À—«„®√à«¡¥â«¬
7. °“√μ√«® CBC ·≈– blood chemistry °√≥’∑’Ë¡’Õ“°“√√ÿπ·√ß·≈–
æ‘®“√≥“√—∫‰«â„π‚√ß欓∫“≈
·π«∑“ß°“√√—°…“¿“«–°”‡√‘∫‡©’¬∫æ≈—π¢Õß‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß37,55,58,59,62
°“√√—°…“·∫∫ºŸâªÉ«¬πÕ°
°√≥’ºŸâªÉ«¬¡’Õ“°“√ÀÕ∫‰¡à¡“° ¬—ßæÕ∑”°‘®«—μ√ª√–®”«—π‰¥â ·≈–¡’§«“¡
æ√âÕ¡„π°“√¥Ÿ·≈∑’Ë∫â“π
1. ‡æ‘Ë¡¢π“¥·≈–§«“¡∂’Ë¢Õ߬“æàπ Ÿ¥¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï —Èπ
‡ªìπ∑ÿ° 4-6 ™—Ë«‚¡ß °√≥’„™â¬“√Ÿª·∫∫ MDI §«√æàπºà“π spacer
2. „À⬓ ‡μ’¬√Õ¬¥å™π‘¥√—∫ª√–∑“𠇙àπ prednisolone 30-40 ¡°./«—π
π“π 5 «—π æ‘®“√≥“·≈â«·μà°√≥’μ“¡Õ“°“√∑’Ë°”‡√‘∫63-68
3. „À⬓ªØ‘™’«π– ‡©æ“–°√≥’∑’Ë ß —¬°“√μ‘¥‡™◊ÈÕ·∫§∑’‡√’¬ ‡™àπ ¡’‡ ¡À–
¡“°¢÷ÈπÀ√◊Õ‡ª≈’Ë¬π ’ ¡’‰¢â (§ÿ≥¿“æÀ≈—°∞“π 3, πÈ”Àπ—°§”·π–π” +) §«√‡≈◊Õ°¬“
„Àâ§√Õ∫§≈ÿ¡‡™◊ÈÕ∑’Ë¡—° —¡æ—π∏å°—∫°“√°”‡√‘∫‡©’¬∫æ≈—π¢Õß‚√§ ‡™àπ Hemophilus
influenza, Streptococcus pneumonia, Moraxella catarrhalis69-72
4. ∑∫∑«π«‘∏’°“√„™â¬“ §«“¡ ¡Ë”‡ ¡Õ¢Õß°“√„™â¬“ ªí®®—¬°√–μÿâπ ·≈–
°“√‡≈‘°∫ÿÀ√’Ë
°“√√—°…“„π‚√ß欓∫“≈
¢âÕ∫àß™’È¢Õß°“√√—∫ºŸâªÉ«¬‰«â√—°…“„π‚√ß欓∫“≈ ‰¥â·°à
1. ¡’Õ“°“√°”‡√‘∫√ÿπ·√ß ‰¥â·°à
38
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
- ¡’°“√„™â°≈â“¡‡π◊Èՙ૬À“¬„® (accessory muscle) ¡“°¢÷Èπ À√◊Õ¡’
Õ“°“√· ¥ß¢Õß°≈â“¡‡π◊ÈÕÀ“¬„®ÕàÕπ·√ß ‡™àπ abdominal paradox
À√◊Õ respiratory alternans
- À“¬„®‡√Á«À√◊Õ‡°‘¥¿“«– cyanosis
- Hemodynamic instability
- ´÷¡ —∫ π À√◊ÕÀ¡¥ μ‘
- ¡’Õ“°“√· ¥ß¢ÕßÀ—«„®ÀâÕߢ«“≈⡇À≈«∑’ˇ°‘¥¢÷Èπ„À¡à ‡™àπ ¢“∫«¡
2. ¡’‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß√–¥—∫√ÿπ·√ß À√◊Õ¡’ª√–«—μ‘°“√°”‡√‘∫‡©’¬∫æ≈—π
¢Õß‚√§∫àÕ¬·≈–√ÿπ·√ß
3. ¡’‚√§À√◊Õ¿“«–Õ◊Ëπ∑’Ë√ÿπ·√ß√à«¡ ‡™àπ ªÕ¥μ‘¥‡™◊ÈÕ ¿“«–À—«„®≈⡇À≈«
À—«„®‡μâπº‘¥®—ßÀ«– (cardiac arrhythmia) ‡ªìπμâπ
4. ‰¡àμÕ∫ πÕßμàÕ°“√√—°…“·∫∫ºŸâªÉ«¬πÕ°
5. ºŸâªÉ«¬‰¡à “¡“√∂√—∫°“√¥Ÿ·≈Õ¬à“߇À¡“– ¡∑’Ë∫â“π‰¥â
6. ¬—ß„Àâ°“√«‘π‘®©—¬‰¡à·πà™—¥
·π«∑“ß°“√√—°…“„π‚√ß欓∫“≈ ª√–°Õ∫¥â«¬
1. °“√„ÀâÕÕ° ‘‡®π §«√ª√—∫Õ—μ√“°“√‰À≈¢ÕßÕÕ° ‘‡®π‡æ◊ËÕ„Àâ ‰¥â√–¥—∫
oxygen saturation Õ¬Ÿà√–À«à“ß 88-92% À√◊Õ PaO2 Õ¬Ÿà√–À«à“ß 60-70 mmHg
°“√„ÀâÕÕ°´‘‡®π∑’Ë¡“°‡°‘π‰ªÕ“®‡ªìπÕ—πμ√“¬ ‡™àπ ¿“«–´÷¡®“°§“√å∫Õπ‰¥ÕÕ°‰´¥å
§—Ë߉¥â (CO2 narcosis)73,74 (§ÿ≥¿“æÀ≈—°∞“π 1, πÈ”Àπ—°§”·π–π” ++)
2. °“√„À⬓æàπ Ÿ¥¢¬“¬À≈Õ¥≈¡ „™â inhaled SABA À√◊Õ inhaled
SABA √à«¡°—∫ SAMA æàπºà“π nebulizer æ‘®“√≥“„Àâ∑ÿ° 20 π“∑’„π 1 ™—Ë«‚¡ß
·√° ª√–‡¡‘π°“√μÕ∫ πÕßμàÕ°“√√—°…“ À≈—ß®“°π—Èπ„Àâæàπ¬“∑ÿ° 4-6 ™—Ë«‚¡ß
39
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
¢÷Èπ°—∫Õ“°“√ºŸâªÉ«¬ ∂â“Õ“°“√‰¡à¥’¢÷ÈπÀ≈—ß®“°æà𬓄π 1 ™—Ë«‚¡ß·√° æ‘®“√≥“„Àâ
°“√√—°…“‡æ‘Ë¡‡μ‘¡¥â“πÕ◊Ëπ75,76
3. °“√„À⬓ ‡μ’¬√Õ¬¥å ™à«¬≈¥√–¬–‡«≈“°“√πÕπ‚√ß欓∫“≈ ∑”„Àâ
Õ“°“√‡Àπ◊ËÕ¬·≈– ¡√√∂¿“æªÕ¥¥’¢÷Èπ ≈¥§«“¡‡ ’ˬߢÕß°“√‡°‘¥‚√§°”‡√‘∫´È”
·≈–°“√√—°…“≈⡇À≈« (§ÿ≥¿“æÀ≈—°∞“π 1, πÈ”Àπ—°§”·π–π” ++) „π√–¬–·√°
∑’ËÕ“°“√√ÿπ·√ßÕ“®„Àâ„π√Ÿª¬“©’¥ ‡™àπ hydrocortisone 100-200 ¡°. À√◊Õ
dexamethasone 5-10 ¡°.∑ÿ° 6 ™—Ë«‚¡ß ‡¡◊ËÕ¥’¢÷Èπ§«√‡ª≈’ˬπ‡ªìπ¬“√—∫ª√–∑“π
‡™àπ prednisolone ¢π“¥ 30-40 ¡°./«—π √–¬–‡«≈“ 5-10 «—π ∂â“Õ“°“√‰¡à¥’¢÷Èπ
æ‘®“√≥“„Àâπ“π¢÷Èπ·μà‰¡à§«√‡°‘π 14 «—𠧫√√–«—ߺ≈¢â“߇§’¬ß∑’Ë ”§—≠ ‡™àπ ¿“«–
πÈ”μ“≈„π‡≈◊Õ¥ Ÿß ·≈–‡≈◊Õ¥ÕÕ°®“°∑“߇¥‘πÕ“À“√ à«π∫π ‚¥¬‡©æ“–„πºŸâªÉ«¬
ŸßÕ“¬ÿ63-68
4. °“√„À⬓ªØ‘™’«π– æ‘®“√≥“„Àâ°√≥’∑’Ë ß —¬°“√μ‘¥‡™◊ÈÕ·∫§∑’‡√’¬ ‡™àπ
¡’‡ ¡À–‡æ‘Ë¡¢÷ÈπÀ√◊Õ‡ª≈’Ë¬π ’ ¡’‰¢â ·≈–ºŸâªÉ«¬∑’Ë¡’°“√°”‡√‘∫√ÿπ·√ß‚¥¬‡©æ“–
ºŸâªÉ«¬∑’ËμâÕß„™â‡§√◊ËÕߙ૬À“¬„® æ∫«à“°“√„À⬓ªØ‘™’«π– “¡“√∂™à«¬≈¥Õ—μ√“°“√
‡ ’¬™’«‘쉥â (§ÿ≥¿“æÀ≈—°∞“π 2, πÈ”Àπ—°§”·π–π” ++) ‚¥¬§«√§√Õ∫§≈ÿ¡‡™◊ÈÕ
∑’Ë —¡æ—π∏å°—∫°“√°”‡√‘∫‡©’¬∫æ≈—π¢Õß‚√§ ‰¥â·°à Hemophilus influenza,
Streptococcus pneumonia, Moraxella catarrhalis °√≥’ºŸâªÉ«¬¡’√–¥—∫‚√§√ÿπ·√ß
(FEV1 < 50% predicted) ¡’‚√§°”‡√‘∫∫àÕ¬ ·≈–‰¥â√—∫¬“μâ“π®ÿ≈™’æ∫àÕ¬ (¡“°
°«à“ 4 §√—Èß/ªï) §«√§√Õ∫§≈ÿ¡‡™◊ÈÕ Pseudomonas aeruginosa √à«¡¥â«¬ ·≈–
æ‘®“√≥“°“√„À⬓μâ“π‰«√— (oseltamivir) °√≥’ºŸâªÉ«¬¡’Õ“°“√ ß —¬μ‘¥‡™◊ÈÕ
‰¢âÀ«—¥„À≠à√à«¡¥â«¬69-72
5. °“√„™â‡§√◊ËÕߙ૬À“¬„® §«√æ‘®“√≥“„™â noninvasive ventilation (NIV)
°àÕπ ‡¡◊ËÕ‰¡à¡’¢âÕÀâ“¡ ‡π◊ËÕß®“° “¡“√∂≈¥Õ“°“√‡Àπ◊ËÕ¬ ·°â ‰¢§«“¡º‘¥ª°μ‘¢Õß
arterial blood gases ≈¥√–¬–‡«≈“°“√πÕπ‚√ß欓∫“≈ ≈¥Õ—μ√“°“√쓬 ·≈–
40
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
≈¥¿“«–·∑√° âÕπ∑’ˇ°‘¥®“°°“√„ à∑àՙ૬À“¬„®‰¥â77 (§ÿ≥¿“æÀ≈—°∞“π 1, πÈ”Àπ—°
§”·π–π” ++)
æ‘®“√≥“„™â NIV ‡¡◊ËÕ¡’≈—°…≥–§≈‘π‘° ¥—ßμàÕ‰ªπ’È
1. Acute respiratory acidosis (pH √–À«à“ß 7.25-7.35 ·≈– PCO2
> 45 mmHg )
2. ¡’°“√„™â°≈â“¡‡π◊Èՙ૬À“¬„® (accessory muscle) ¡“°¢÷Èπ À√◊Õ¡’
Õ“°“√· ¥ß¢Õß°≈â“¡‡π◊ÈÕÀ“¬„®ÕàÕπ·√ß
¢âÕÀâ“¡„™â NIV
1. ¡’¢âÕ∫àß™’È„π°“√„™â invasive mechanical ventilation
2. ¡’‚§√ßÀπ⓺‘¥ª°μ‘ À√◊Õ‰¡à “¡“√∂À“Àπâ“°“°∑’ˇÀ¡“– ¡‰¥â
3. ‡ ¡À–ª√‘¡“≥¡“°‰¡à “¡“√∂·°â ‰¢‰¥â¥â«¬ secretion clearance
techniques
4. ‡æ‘Ë߉¥â√—∫°“√ºà“μ—¥„∫Àπâ“ ∑“߇¥‘πÀ“¬„® à«π∫π À√◊Õ∑“߇¥‘πÕ“À“√
à«π∫π
5. ¡’‡≈◊Õ¥ÕÕ°®“°∑“߇¥‘πÕ“À“√ à«π∫π∑’ˬ—ߧ«∫§ÿ¡‰¡à‰¥â
À≈—ß°“√„™â NIV §«√ª√–‡¡‘π°“√μÕ∫ πÕß∑’Ë 30-60 π“∑’ ‚¥¬¥Ÿ®“°
√–¥—∫§«“¡√Ÿâ ÷°μ—« Õ“°“√‡Àπ◊ËÕ¬ Õ—μ√“°“√À“¬„® ·≈–º≈«‘‡§√“–Àå arterial blood
gases
πÕ°®“°π’È NIV “¡“√∂π”¡“„™â™à«¬„π°“√∂Õπ‡§√◊ËÕߙ૬À“¬„® (NIV
facilitates weaning) æ∫«à“≈¥°“√„ à∑àՙ૬À“¬„®„À¡à ·≈–≈¥Õ—μ√“°“√쓬
¢âÕ∫àß™’È¢Õß°“√„ à∑àՙ૬À“¬„®·≈–„™â‡§√◊ËÕߙ૬À“¬„® (invasive
mechanical ventilation)
41
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
1. À¬ÿ¥À“¬„® À√◊ÕÀ—«„®À¬ÿ¥‡μâπ
2. ¡’§«“¡º‘¥ª°μ‘„π√–∫∫À—«„® ‡™à𠧫“¡¥—π‚≈À‘μμË” °≈â“¡‡π◊ÈÕ
À—«„®¢“¥‡≈◊Õ¥ À—«„®‡μâπº‘¥®—ßÀ«–∑’ˉ¡à “¡“√∂·°â ‰¢‰¥â
3. ¡’√–¥—∫§«“¡√Ÿâ ÷°μ—«‰¡à¥’ À√◊Õ‰¡à√à«¡¡◊Õ
4. √–¥—∫ pH < 7.25
5. ‰¡àμÕ∫ πÕßμàÕ°“√„™â NIV (Õ“°“√À√◊Õ arterial blood gases
‡≈«≈ß∑’Ë 1-2 ™—Ë«‚¡ß)
6. ºŸâªÉ«¬‰¡à “¡“√∂∑πμàÕ°“√„™â NIV ‰¥â
7. ‡ ¡À–ª√‘¡“≥¡“°‰¡à “¡“√∂·°â ‰¢‰¥â¥â«¬ secretion clearance
techniques
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2. °“√©’¥«—§´’π‰¢âÀ«—¥„À≠à (§ÿ≥¿“æÀ≈—°∞“π 2, πÈ”Àπ—°§”·π–π” ++)
3. ‚ª√·°√¡øóôπøŸ ¡√√∂¿“æªÕ¥¿“¬„π 4 —ª¥“ÀåÀ≈—ß°“√°”‡√‘∫‡©’¬∫
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4. °“√„™â¬“μ“¡·π«∑“ß°“√√—°…“¥â«¬¬“
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4. ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘. μ—«™’È«—¥∫√‘°“√ ÿ¢¿“æ ª ™. (NHSO HealthService Indicator). æ.». 2557.
5. ”π—°ß“π ∂‘μ‘·Ààß™“μ‘. √ÿª ”À√—∫ºŸâ∫√‘À“√ °“√ ”√«® æƒμ‘°√√¡°“√ Ÿ∫∫ÿÀ√’Ë·≈–°“√¥◊Ë¡ ÿ√“¢Õߪ√–™“°√ æ.». 2557 æ.». 2557. Available from: http://www.m-society.go.th/ewt_news.php?nid=13207.
43
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48
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with spacer, Dry powder inhaler (DPI), Nebulizer (NB)·≈– Respimat˙
Soft mistTM inhaler
2. «‘∏’°“√∫√‘À“√¬“ : ∑’ˇÀ¡“–°—∫Õ“¬ÿ ‚√§√à«¡∑’Ë¡’Õ¬Ÿà §«“¡∂π—¥¢ÕߺŸâªÉ«¬
·≈–·æ∑¬å ∂â“¡’¬“¡“°°«à“ 1 ¢π“𠧫√„™â™π‘¥¢ÕßÕÿª°√≥å∫√‘À“√¬“‡ªìπ·∫∫
‡¥’¬«°—π‡æ◊ËÕ≈¥§«“¡ —∫ π·≈–ßà“¬μàÕ°“√„™â
3. √“§“¬“ ·≈–°“√‡¢â“∂÷߬“ (accessibility)
™π‘¥¢Õ߬“ Ÿ¥√—°…“‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß∑’Ë¡’„™â°—π ‰¥â·°à ™π‘¥°¥ Ÿ¥ (MDI)
™π‘¥°¥ Ÿ¥·≈–Õÿª°√≥å™à«¬ Ÿ¥ (MDI with spacer) ™π‘¥ºß (DPI) ™π‘¥æàπΩÕ¬
≈–ÕÕß (NB) ·≈– Respimat˙ Soft MistTM inhaler
52
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
™π‘¥°¥ Ÿ¥ (MDI) π—Èπ¡’¢âÕ¥’À≈“¬ª√–°“√§◊Õ·æ√àÀ≈“¬°«à“™π‘¥Õ◊ËπÊ
æ°æ“ßà“¬ à«π„À≠à¡’√“§“∂Ÿ° °“√ Ÿ¥‰¡àμâÕß„™â·√ß Ÿ¥ Ÿß·μà¡’¢âÕ®”°—¥§◊ÕμâÕß
Õ“»—¬®—ßÀ«–∑’Ë —¡æ—π∏å„π¢≥–°”≈—ß°¥¬“·≈–À“¬„®‡¢â“ (coordination) ºŸâªÉ«¬
∫“ß√“¬·≈–ºŸâªÉ«¬Õ“¬ÿπâÕ¬Ê √«¡∑—ÈߺŸâ ŸßÕ“¬ÿ¡—°‰¡à “¡“√∂„™â ‰¥âÕ¬à“ß∂Ÿ°«‘∏’
°“√∫√‘À“√¬“ “¡“√∂ Ÿ¥‰¥â‚¥¬
1. Ÿ¥∑“ߪ“°‚¥¬°“√Àÿ∫ª“°„Àâ π‘∑ (close mouth technique)
2. Ÿ¥‚¥¬°“√Õ⓪“°§â“ß (open mouth technique)
3. Ÿ¥‚¥¬„™âÕÿª°√≥å°√–∫Õ°™à«¬ Ÿ¥ (MDI with spacer)
°“√ Ÿ¥¬“Õ¬à“ß∂Ÿ°«‘∏’¬“®–‡¢â“∂÷ßÀ≈Õ¥≈¡‡ªÑ“À¡“¬ (drug deposition)
10-20% ·≈–°“√ Ÿ¥‚¥¬°“√Õ⓪“°§â“߉«âÕ“®®–™à«¬„À⬓‡¢â“∂÷ßÀ≈Õ¥≈¡ à«π
ª≈“¬ (distal airways) ‰¥â¡“°¢÷Èπ ·μà®–∑”‰¥â¬“°°«à“°“√ Ÿ¥‚¥¬°“√Àÿ∫ª“°„Àâ
π‘∑
°“√„™â°√–∫Õ°™à«¬ Ÿ¥®–™à«¬≈¥ªí≠À“§«“¡ —¡æ—π∏å¢Õß®—ßÀ«–°“√°¥¬“
·≈–°“√À“¬„®‡¢â“∑”„Àâ°“√ Ÿ¥ –¥«°¢÷Èπ πÕ°®“°π’Ȭ—ߙ૬≈¥Õ“°“√·∑√° âÕπ
‡©æ“–∑’ˉ¥â·°à oral candidiasis and dysphonia ¢âÕ¥’Õ’°ª√–°“√Àπ÷ËߢÕß°“√
„™â¬“ Ÿ¥™π‘¥°¥√à«¡°—∫°√–∫Õ°™à«¬ Ÿ¥§◊Õ “¡“√∂„™â ‰¥â°—∫ºŸâ∑’Ë¡’À≈Õ¥≈¡À¥‡°√Áß
∑’ËÀâÕß©ÿ°‡©‘π‰¥â °“√„™â¬“°¥ Ÿ¥π’È√à«¡°—∫°√–∫Õ° Ÿ¥∫“ß™π‘¥ “¡“√∂„™â°—∫ºŸâªÉ«¬
∑’Ë„™â‡§√◊ËÕߙ૬À“¬„®‰¥â
™π‘¥ºß (DPI) ¢âÕ¥’¢Õ߬“ Ÿ¥™π‘¥π’ȧ◊Õ‰¡àμâÕßÕ“»—¬®—ßÀ«–„π°“√ Ÿ¥¬“
¡“°‡À¡◊Õπ™π‘¥°¥ Ÿ¥ ·μà¡’¢âÕ®”°—¥§◊Õ μâÕß°“√·√ß Ÿ¥ Ÿß°«à“ 30-60 ≈‘μ√/π“∑’
¢÷Èπ‰ª À“°·√ß≈¡ Ÿ¥‡¢â“‰¡à·√ßæÕ®–≈¥ª√– ‘∑∏‘¿“æ¢Õ߬“ ´÷Ëß®–‡ªìπ¢âÕ®”°—¥
„π‡¥Á°‡≈Á°·≈–‰¡à·π–π”„ÀℙⰗ∫ºŸâªÉ«¬ª√–‡¿∑∑’Ë¡’°“√À¥μ—«¢ÕßÀ≈Õ¥≈¡√ÿπ·√ß
53
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 1)
‚¥¬∑—Ë«‰ª¡—°¡’√“§“ Ÿß°«à“™π‘¥°¥ Ÿ¥ ª√‘¡“≥¬“∑’ˇ¢â“∂÷ßÀ≈Õ¥≈¡‡ªÑ“À¡“¬‰¥â
ª√–¡“≥ 14%
™π‘¥ΩÕ¬≈–ÕÕß (NB) ¡’¢âÕ®”°—¥§◊Õ §à“„™â®à“¬μàÕ§√—Èß¡“°°«à“·≈–¢—ÈπμÕπ
∑’Ë¡“°°«à“™π‘¥Õ◊Ëπʪ√– ‘∑∏‘¿“æ¢Õß°“√√—°…“Õ“®·μ°μà“ß°—π‰¥â∂÷ß 10 ‡∑à“3 ‚¥¬
¢÷Èπ°—∫ª√– ‘∑∏‘¿“æ¢Õ߇§√◊ËÕß (driving gas flow) ª√‘¡“μ√¬“∑’Ë∫√‘À“√¬“‡¢â“∂÷ß
À≈Õ¥≈¡‡ªÑ“À¡“¬ª√–¡“≥ 10% ‰¡à “¡“√∂æ°æ“‰¥âÕ¬à“ß –¥«°°“√∫√‘À“√
·μà≈–§√—Èß„™â‡«≈“π“π°«à“ ¢âÕ¥’§◊Õ„™â ‰¥â°—∫ºŸâªÉ«¬∑’Ë¡’À≈Õ¥≈¡À¥‡°√Áß√ÿπ·√߉¥â
‚¥¬°“√À“¬„®μ“¡ª°μ‘ (tidal breathing) À√◊ÕºŸâ∑’Ë„™â‡§√◊ËÕߙ૬À“¬„®·≈–„π
‡¥Á°‡≈Á°Ê À√◊ÕºŸâ∑’ˉ¡à “¡“√∂„™â¬“ Ÿ¥™π‘¥Õ◊ËπÊ ‰¥â
°“√„™â‡§√◊ËÕßæàπΩÕ¬≈–ÕÕß ”À√—∫¬“Õ◊ËπÊ ∑’ËπÕ°‡Àπ◊Õ‰ª®“°¢¬“¬À≈Õ¥≈¡
ª°μ‘ ‡™à𠬓 ‡μ’¬√Õ¬¥åπ—Èπ§«√‡≈◊Õ°™π‘¥∑’ËÕÕ°·∫∫·≈–‰¥â√—∫°“√∑¥ Õ∫
ª√– ‘∑∏‘¿“æ°—∫ “√™π‘¥π—Èπ¡“°àÕπ °“√∑”§«“¡ –Õ“¥Õÿª°√≥å∑’Ë∫√√®ÿπÈ”¬“·≈–
”À√—∫ Ÿ¥ΩÕ¬≈–ÕÕß (nebulizing chamber, mouth piece and face mask)
§«√≈â“ߥ⫬πÈ” ∫ŸàÕàÕπÊ (mild soap/detergent and water) ≈â“ߥ⫬πÈ”‡ª≈à“
®π –Õ“¥ (rinse) ·≈–ª≈àÕ¬‰«â„Àâ·Àâß (air dry) ∑ÿ°§√—ÈßÀ≈—ß°“√„™âß“π
54
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
√“¬≈–‡Õ’¬¥¢Õß°“√„™â¬“ Ÿ¥‡∑§π‘§·≈–°“√„™âÕÿª°√≥å™à«¬ Ÿ¥·μà≈–™π‘¥∑’Ë· ¥ß¥—ßμàÕ‰ªπ’ȇªìπμ—«Õ¬à“ß
∫“ß à«π¢ÕßÕÿª°√≥å∑’Ë¡’°“√„™âÕ¬Ÿà„π‡«™ªØ‘∫—μ‘
°“√ Ÿ¥¬“™π‘¥ metered dose inhaler (MDI)
1. ∂Õ¥Ω“§√Õ∫ÕÕ°
2. ‡¢¬à“À≈Õ¥¬“„π·π«μ—Èß 3-5 §√—Èß‚¥¬ª“°°√–∫Õ°¬“Õ¬Ÿà¥â“π≈à“ß
3. À“¬„®ÕÕ°®π ÿ¥
4. Õ¡ª“°°√–∫Õ°¬“‚¥¬ªî¥ª“°„Àâ π‘∑‡√‘Ë¡À“¬„®‡¢â“∑“ߪ“°™â“Ê ·≈–
°¥À≈Õ¥¬“ Ÿ¥À“¬„®‡¢â“μàÕ™â“Ê ®π ÿ¥
5. °≈—Èπ≈¡À“¬„®‰«â 10 «‘π“∑’À√◊Õπ“π°«à“π—Èπ·≈â«À“¬„®ÕÕ°μ“¡ª°μ‘
55
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 1)
À“°®– Ÿ¥¬“§√—Èß∑’Ë 2 „Àâ√Õ‡«≈“ 30-60 «‘π“∑’·≈â«∑”´È”μ“¡¢—ÈπμÕπ∑’Ë
2-5
À¡“¬‡Àμÿ „π¢—ÈπμÕπ∑’Ë 2 ”À√—∫ºŸâ Ÿ¥∑’Ë¡’§«“¡™”π“≠¥’·≈â« Õ“®„™â«‘∏’
‡ªî¥ª“° Ÿ¥¬“ (open mouth technique) ‚¥¬„Àâ à«π mouth piece Àà“ß®“°
ª“°ºŸâ Ÿ¥ª√–¡“≥ 2 π‘È«¡◊Õ‡√‘Ë¡À“¬„®‡¢â“°àÕπ°¥À≈Õ¥¬“≈ß ·≈– Ÿ¥À“¬„®μàÕ„π
≈—°…≥–‡¥’¬«°—π∑ÿ°ª√–°“√·μà„À⇪î¥√‘¡Ω望°§â“߉«â„π¢≥– Ÿ¥Õ“®®–∑”„À⬓
‡¢â“∂÷ß∑“߇¥‘πÀ“¬„® à«π≈à“ß (drug deposition) ‰¥â¡“°¢÷Èπ
¢âÕº‘¥æ≈“¥∑’Ëæ∫‰¥â ‰¥â·°à 1) ‰¡à‡¢¬à“À≈Õ¥¬“ 2) ª“°°√–∫Õ°¬“Õ¬Ÿà¥â“π
∫π 3) ‰¡àÀ“¬„®ÕÕ°„Àâ ÿ¥°àÕπ Ÿ¥¬“ 4) °¥À≈Õ¥¬“‰¡à —¡æ—π∏å°—∫°“√À“¬„®‡¢â“
(‡√Á«À√◊ՙⓇ°‘π‰ª) 5) Ÿ¥¬“‡√Á«À√◊Õ·√߉ª 6) ‰¡àÀ“¬„®≈÷°μàÕ‡π◊ËÕß®π ÿ¥À≈—ß
°“√°¥À≈Õ¥¬“ 7) ‰¡à°≈—Èπ≈¡À“¬„®À≈—ßÀ“¬„®‡¢â“ ÿ¥ 8) °¥¬“ Õߧ√—Èßμ‘¥°—π
°“√ Ÿ¥¬“™π‘¥·Õ§§‘«‡Œ≈‡≈Õ√å (Accuhaler)
56
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
1. ‡ªî¥‡§√◊ËÕß‚¥¬®—∫μ—«‡§√◊ËÕߥâ“ππÕ°·≈–„™âπ‘È«À—«·¡à¡◊ÕÕ’°¢â“ß«“ß„π
√àÕß ”À√—∫‡ªî¥‡§√◊ËÕߥ—ππ‘È«À—«·¡à¡◊Õ‰ª®π ÿ¥μ“¡≈Ÿ°»√
2. ‡≈◊ËÕ𬓄ÀâÕ¬Ÿà„πμ”·Àπàßæ√âÕ¡ Ÿ¥ ‚¥¬®—∫μ—«‡§√◊ËÕß„ÀâÕ¬Ÿà„π·π«¢π“π
À—π¥â“𪓰°√–∫Õ° ”À√—∫ Ÿ¥‡¢â“À“μ—«¥—π·°π‡≈◊ËÕπ‰ª®π ÿ¥´÷Ëß®–
‰¥â¬‘π‡ ’¬ß ç§≈‘°é· ¥ß«à“¬“Õ¬Ÿà„πμ”·Àπàßæ√âÕ¡ Ÿ¥
3. À“¬„®ÕÕ°®π ÿ¥‚¥¬√–«—߉¡à„Àâ≈¡À“¬„®‡¢â“‰ª„π‡§√◊ËÕß
4. Õ¡ª“°°√–∫Õ°„Àâ π‘∑ Ÿ¥¬“‡¢â“∑“ߪ“°„Àâ·√ß·≈– ¡Ë”‡ ¡Õ®π ÿ¥
5. π”Õÿª°√≥å Ÿ¥¬“ÕÕ°®“°ª“°·≈â«°≈—Èπ≈¡À“¬„®‰«âª√–¡“≥ 10 «‘π“∑’
À≈—ß®“°π—ÈπÀ“¬„®ÕÕ°™â“Ê
À“°μâÕß Ÿ¥¬“§√—Èß∑’Ë 2 „Àâ√Õ 30-60 «‘π“∑’ ·≈â«∑”´È”μ“¡¢—ÈπμÕπ∑’Ë 2-5
6. ªî¥‡§√◊ËÕß‚¥¬«“ßπ‘È«À—«·¡à¡◊Õ≈ß„π√àÕߥ—πÀ—«·¡à¡◊Õ°≈—∫„πμ”·Àπàߪî¥
´÷Ëß®–‰¥â¬‘π‡ ’¬ß ç§≈‘°é ·°π‡≈◊ËÕπ®–°≈—∫§◊π Ÿàμ”·Àπà߇¥‘¡·≈–æ√âÕ¡
„™âß“π„π§√—ÈßμàÕ‰ª
¢âÕ§«√√–«—ß ¢≥–·≈–À≈—߇≈◊ËÕ𬓄ÀâÕ¬Ÿà„πμ”·Àπàßæ√âÕ¡ Ÿ¥ §«√«“ßμ—«
‡§√◊ËÕß„ÀâÕ¬Ÿà„π·π«¢π“π ‰¡à‡Õ“ª“°°√–∫Õ°≈ß ¬“®–‡§≈◊ËÕπÕÕ°®“°μ”·Àπà߉¥â
¢âÕº‘¥æ≈“¥∑’Ëæ∫‰¥â ‰¥â·°à 1) ‰¡à¥—π·°π‡≈◊ËÕπ„À⬓¡“Õ¬Ÿà„πμ”·Àπàßæ√âÕ¡
Ÿ¥ 2) ‰¡àÀ“¬„®ÕÕ°„Àâ ÿ¥°àÕπ Ÿ¥¬“ 3) À“¬„®æàπ‡¢â“‰ª„π‡§√◊ËÕß 4) Ÿ¥‡¢â“
‰¡à·√ßæÕ 5) ‰¡à°≈—ÈπÀ“¬„®À≈—ß Ÿ¥¬“
57
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 1)
°“√ Ÿ¥¬“™π‘¥‡∑Õ√å∫Ÿ‡Œ‡≈Õ√å (Turbuhaler)
58
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
1. ‡ªî¥‡§√◊ËÕß‚¥¬À¡ÿπΩ“§√Õ∫ÕÕ°∑‘»∑«π‡¢Á¡π“Ãî°“
2. ‡≈◊ËÕ𬓄ÀâÕ¬Ÿà„πμ”·Àπàßæ√âÕ¡ Ÿ¥‚¥¬®—∫À≈Õ¥¬“„ÀâÕ¬Ÿà„π·π«μ—Èßμ√ß
„™â¡◊ÕÕ’°¢â“ß®—∫ à«π∞“π¢Õ߇§√◊ËÕßÀ¡ÿπ∞“π°√–∫Õ°¬“‰ª·≈–°≈—∫®π
ÿ¥∑—Èß 2 ∑‘»∑“ß®π‰¥â¬‘π‡ ’¬ßç§≈‘°é · ¥ß«à“¬“Õ¬Ÿà„πμ”·Àπàßæ√âÕ¡
Ÿ¥À≈—ß®“°‰¥â¬‘π‡ ’¬ß ç§≈‘°é Àâ“¡‡¢¬à“À≈Õ¥¬“
3. À“¬„®ÕÕ°®π ÿ¥‚¥¬√–«—߉¡à„Àâ≈¡À“¬„®‡¢â“‰ª„π‡§√◊ËÕß
4. Õ¡ª“°°√–∫Õ°„Àâ π‘∑ ¢≥– Ÿ¥μâÕß∂◊Õ°√–∫Õ°¬“‰¡à„Àâ‡Õ’¬ß‡°‘π 45
Õß»“ Ÿ¥¬“‡¢â“∑“ߪ“°„Àâ·√ß·≈– ¡Ë”‡ ¡Õ®π ÿ¥
5. π”Õÿª°√≥å Ÿ¥¬“ÕÕ°®“°ª“°·≈â«°≈—Èπ≈¡À“¬„®‰«âª√–¡“≥ 10 «‘π“∑’
À≈—ß®“°π—Èπ§àÕ¬ÊÀ“¬„®ÕÕ°™â“Ê
À“°μâÕß Ÿ¥¬“§√—Èß∑’Ë 2 „Àâ√Õ 30-60 «‘π“∑’ ·≈â«∑”´È”μ“¡¢—ÈπμÕπ∑’Ë 2-5
6. ªî¥‡§√◊ËÕß‚¥¬π”Ω“§√Õ∫ªî¥μ—«‡§√◊ËÕß·≈–À¡ÿπΩ“§√Õ∫μ“¡‡¢Á¡π“Ãî°“
¢âÕ§«√√–«—ß À≈Õ¥¬“μâÕßμ—Èßμ√ߢ≥–À¡ÿπ∞“π°√–∫Õ°¬“‡æ◊ËÕ„Àâ ‰¥â¢π“¥
¬“∂Ÿ°μâÕß
¢âÕº‘¥æ≈“¥∑’Ëæ∫‰¥â ‰¥â·°à 1) ‰¡à®—∫À≈Õ¥¬“„ÀâÕ¬Ÿà„π·π«μ—Èß°àÕπÀ¡ÿπ
∞“πÀ≈Õ¥¬“ 2) ‰¡àÀ“¬„®ÕÕ°„Àâ ÿ¥°àÕπ Ÿ¥¬“ 3) À“¬„®æàπ‡¢â“‰ª„πÀ≈Õ¥¬“
4) „™âπ‘È«ªî¥√Ÿ√–∫“¬Õ“°“»∑’Ë¢Õ∫∫π¢Õß∞“π‡§√◊ËÕß 5) Õ¡À≈Õ¥¬“≈÷°‡°‘π‰ª 6)
À¡ÿπ∞“π¬“Õ’°§√—Èß°àÕπªî¥Ω“§√Õ∫ (‡æ√“–‡¢â“„®«à“‡ªìπ°“√ªî¥À≈Õ¥¬“) 7) ‡¢¬à“
À≈Õ¥¬“‡æ◊ËÕ¥Ÿ«à“¬“À¡¥À√◊Õ‰¡à ‡ ’¬ß∑’Ë¥—߇«≈“‡¢¬à“À≈Õ¥¬“‡ªìπ “√¥Ÿ¥§«“¡™◊Èπ
¥—ßπ—ÈπÀ≈—߬“À¡¥®–¬—߉¥â¬‘π‡ ’¬ßπ’ÈÕ¬Ÿà „À⇪≈’ˬπ°√–∫Õ°„À¡à‡¡◊ËÕμ—«™’È∫Õ°®”π«π
¬“ (dose counter) ¢÷Èπ·∂∫·¥ß‡μÁ¡
59
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 1)
1. ∂Õ¥Ω“§√Õ∫À≈Õ¥¬“·≈–‡¢¬à“À≈Õ¥¬“„π·π«μ—Èß 3-5 §√—Èß Õ¥À≈Õ¥
¬“‡¢â“„π°√–∫Õ°™à«¬ Ÿ¥¥—ß¿“æ
2. À“¬„®ÕÕ°®π ÿ¥·≈–Õ¡ à«πª≈“¬°√–∫Õ°∑’ˇªìπ∑“ß„Àâ≈–ÕÕ߬“ÕÕ°
(mouth piece)
3. °¥À≈Õ¥¬“„Àâ≈–ÕÕ߬“‡¢â“‰ªÕ¬Ÿà„π°√–∫Õ°
4. Ÿ¥À“¬„®‡¢â“™â“Ê·≈–≈÷° ÿ¥
5. °≈—Èπ≈¡À“¬„®‡ªìπ‡«≈“ 10 «‘π“∑’À√◊Õ°«à“π—Èπ®“°π—ÈπÀ“¬„®ÕÕ°∑“ß
mouth piece
6. Ÿ¥À“¬„®‡¢â“´È”Õ’°§√—Èß‚¥¬‰¡àμâÕß°¥À≈Õ¥¬“À≈—ß®“°π—Èπ‡Õ“°√–∫Õ°
ÕÕ°®“°ª“°‰¥â
7. À“°μâÕß Ÿ¥¬“´È”„Àâ√Õ‡«≈“ª√–¡“≥ 30-60 «‘π“∑’·≈–∑” È”¢—ÈπμÕπ
∑’Ë 1-6
°√≥’°≈—ÈπÀ“¬„®‰¡à‰¥â„ÀâÀ“¬„®„π°√–∫Õ° 5 §√—Èß ·∑π¢—ÈπμÕπ∑’Ë 4-6
°“√ Ÿ¥¬“™π‘¥ MDI ºà“π°√–∫Õ°™à«¬ Ÿ¥¢π“¥„À≠à
60
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
°“√∑”§«“¡ –Õ“¥ ≈â“ߥ⫬πÈ”‡ª≈à“À√◊ÕπÈ” ∫ŸàÕàÕπ·≈â«®÷ß≈â“ßÕÕ°¥â«¬
πÈ”‡ª≈à“À≈—ß®“°π—Èπº÷Ëß„Àâ·Àâß (air dry) ‰¡à§«√‡™Á¥ºπ—ߥâ“π„π¢ÕßÕÿª°√≥å ·≈–
„Àâ°¥À≈Õ¥¬“ 2 §√—È߇æ◊ËÕ‡§≈◊Õ∫º‘«¥â“π„π°√–∫Õ°°àÕπ„™â§√—ÈßμàÕ‰ª
°“√ Ÿ¥¬“™π‘¥ MDI ºà“π°√–∫Õ°™à«¬ Ÿ¥ Aerochamber
1. ∂Õ¥Ω“§√Õ∫ÕÕ°·≈–‡¢¬à“À≈Õ¥¬“„π·π«μ—Èß 3-5 §√—Èß Õ¥À≈Õ¥¬“
‡¢â“„π°√–∫Õ°™à«¬ Ÿ¥¥—ß¿“æ
2. À“¬„®ÕÕ°®π ÿ¥·≈–Õ¡ à«πª≈“¬°√–∫Õ°∑’ˇªìπ∑“ß„Àâ≈–ÕÕ߬“ÕÕ°
(mouth piece) ∑’ˇªìπ™π‘¥∑àÕμàÕÀ√◊ÕÀ“°‡ªìπ™π‘¥™π‘¥Ω“§√Õ∫ (face
mask) „Àâ§√Õ∫√‘¡Ω望°·≈–®¡Ÿ°
3. „Àâ Ÿ¥À“¬„®‡¢â“·≈–ÕÕ°‡∫“Ê·≈–™â“Ê∑“ߪ“°À“°‰¥â¬‘π‡ ’¬ß§≈⓬
π°À«’¥¥—ߢ÷Èπ„À⺟⠟¥≈¥§«“¡‡√Á«„π°“√ Ÿ¥≈ß
4. ‡¡◊ËÕ°“√À“¬„®‰¥â®—ßÀ«–¥’·≈â«„Àâ°¥À≈Õ¥¬“ MDI ‚¥¬∑’˺Ÿâ Ÿ¥¬—ߧß
À“¬„®‡¢â“·≈–ÕÕ°¥â«¬ tidal breathing μ‘¥μàÕ°—π 5 §√—Èß
5. À≈—ß®“°π—Èπ„Àâπ”°√–∫Õ°ÕÕ°®“°ª“°ºŸâ Ÿ¥‰¥â
6. À“°μâÕß°“√ Ÿ¥¬“´È”„Àâ√ÕÕ’° 2-3 «‘π“∑’®÷ß∑”μ“¡¢—ÈπμÕπ∑’Ë 2-5
61
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 1)
°“√ Ÿ¥¬“™π‘¥ MDI ºà“π°√–∫Õ°™à«¬ Ÿ¥ Integra
1. ∂Õ¥Ω“§√Õ∫°√–∫Õ°™à«¬ Ÿ¥·≈–∫√√®ÿÀ≈Õ¥¬“ (canister) ¥—ß¿“æ
2. ‡¢¬à“·≈–®—∫°√–∫Õ°„Àâ ‰¥â√–¥—∫
3. À“¬„®ÕÕ°„Àâ ÿ¥·≈–πÿà¡π«≈
4. Õ¡ mouth piece ‰«â„𪓰
5. °¥À≈Õ¥¬“‡æ◊ËÕ„Àâ≈–ÕÕ߬“‡¢â“„π°√–∫Õ°
6. À“¬„®‡¢â“≈÷°·≈–™â“Ê
7. °≈—Èπ≈¡À“¬„®‰«â„Àâπ“π‡∑à“∑’Ë®–°√–∑”‰¥â
8. ‡Õ“°√–∫Õ°¬“ÕÕ°®“°ª“°·≈–À“¬„®μ“¡ª°μ‘
9. À“°μâÕß Ÿ¥¬“´È”„Àâ√Õ 2-3 «‘π“∑’®÷ß∑”¢—ÈπμÕπ∑’Ë 2-7
10. ∂Õ¥Õÿª°√≥åÕÕ°·≈–‡°Á∫μ“¡‡¥‘¡
62
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
°“√ Ÿ¥¬“™π‘¥ MDI ºà“π°√–∫Õ°™à«¬ Ÿ¥ Jet inhaler
1. °√–∫Õ° Ÿ¥æ√âÕ¡À≈Õ¥¬“ (canister) ∫√√®ÿ¥—ß„π¿“æ
2. ∂Õ¥Ω“§√Õ∫°√–∫Õ° à«π∑’ˇªìπ mouth piece ¢Õß jet inhaler ÕÕ°
3. ‡¢¬à“À≈Õ¥¬“‚¥¬·√ß‚¥¬∑’ˬ—߉¡àμâÕß°¥ canister
4. À“¬„®ÕÕ°„Àâ ÿ¥·≈–Õ¡ à«π mouth piece
5. °¥ canister ·≈– Ÿ¥À“¬„®‡¢â“„Àâ≈÷° 2-3 «‘π“∑’ ( “¡“√∂ Ÿ¥À“¬„®
‡¢â“‰¥â¡“°°«à“Àπ÷Ëߧ√—Èß)
6. ‡¡◊ËÕÀ“¬„®‡¢â“ ÿ¥„Àâ°≈—Èπ≈¡À“¬„®‰«â„Àâπ“π‡∑à“∑’Ë®–∑”‰¥â
7. ‡Õ“°√–∫Õ°¬“ÕÕ°®“°ª“°·≈â«À“¬„®μ“¡ª°μ‘·≈–ªî¥ jet inhaler
¥â«¬Ω“ªî¥
Õÿª°√≥å™à«¬ Ÿ¥¬“™π‘¥π’ȧ«√ –Õ“¥Õ¬Ÿà‡ ¡Õ·≈–À“°®–∑”§«“¡ –Õ“¥„Àâ
„™âπÈ”ÕÿàπÀ≈—ß®“°π” canister ÕÕ°·≈â«
63
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 1)
°“√ Ÿ¥¬“¢¬“¬À≈Õ¥≈¡·§ª Ÿ≈¥â«¬‡§√◊ËÕß Ÿ¥·Œπ¥å¥‘‡Œ‡≈Õ√ å(Handihaler˙)
1. ¥÷ßΩ“ªî¥¢÷Èπ·≈–‡ªî¥ª“°°√–∫Õ°
2. ·°–·§ª´Ÿ≈¬“ÕÕ°§√—Èß≈– 1 ‡¡Á¥
3. ∫√√®ÿ·§ª´Ÿ≈¬“≈ß„π™àÕß ”À√—∫„ à
4. ªî¥ª“°°√–∫Õ°≈ß®π‰¥â¬‘π‡ ’¬ß ç§≈‘°é
64
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
5. ®—∫‡§√◊ËÕßμ—Èßμ√ß·≈–°¥ªÿÉ¡¥â“π¢â“߇æ◊ËÕ‡®“–·§ª´Ÿ≈¬“‚¥¬°¥‡æ’¬ß
§√—È߇¥’¬«·≈⫪≈àÕ¬
6. À“¬„®ÕÕ°„Àâ ÿ¥√–«—߉¡à„Àâ≈¡À“¬„®‡¢â“‰ª„π‡§√◊ËÕß
7. Õ¡ª“°°√–∫Õ°¬“„Àâ π‘∑ Ÿ¥≈¡À“¬„®‡¢â“∑“ߪ“°™â“Ê≈÷°Ê®π ÿ¥¥â«¬
§«“¡‡√Á«æÕ∑’ˉ¥â¬‘π‡ ’¬ß —Ëπ¢Õß·§ª´Ÿ≈
8. ¥÷ß°√–∫Õ°¬“ÕÕ°®“°ª“° °≈—Èπ≈¡À“¬„®‰«âÕ¬à“ßπâÕ¬ 5-10 «‘π“∑’À√◊Õ
‡∑à“∑’Ë®–∑”‰¥â·≈â«À“¬„®ÕÕ°μ“¡ª°μ‘ (Õ¬à“‡ªÉ“≈¡À“¬„®‡¢â“Õÿª°√≥å)
®“°π—Èπ∑” È”μ“¡¢—ÈπμÕπ∑’Ë 6-8 ‡æ◊ËÕ„Àâ·πà„®«à“ Ÿ¥¬“ÕÕ°®“°·§ª´Ÿ≈®πÀ¡¥
9. ‡ªî¥ª“°°√–∫Õ°‡∑·§ª´Ÿ≈‡ª≈à“∑‘Èß·≈⫪“°°√–∫Õ°·≈–ªî¥Ω“‡°Á∫
¢âÕ§«√√–«—ß ‰¡à·°–·§ª´Ÿ≈¬“‰«â≈à«ßÀπâ“ ·≈–À“°¡◊Õ‡ªï¬°πÈ”§«√‡™Á¥¡◊Õ
„Àâ·Àâß°àÕπ·°–·§ª´Ÿ≈¬“ ‡æ√“–§«“¡™◊Èπ®–∑”„À⬓·μ°μ—«‰¡à¥’
¢âÕº‘¥æ≈“¥∑’Ëæ∫‰¥â ‰¥â·°à 1) ‰¡à‰¥â‡®“–·§ª´Ÿ≈¬“ 2) ‡®“–·§ª Ÿ≈¬“¡“°
°«à“ 1 §√—Èß 3) À≈—߇®“–·§ª Ÿ≈¬“·≈⫉¡àª≈àÕ¬‡¢Á¡‡®“– 4) À“¬„®‡¢â“‰ª„π‡§√◊ËÕß
5) À“¬„®‰¡à·√ßæÕ∑’Ë∑”„Àâ·§ª´Ÿ≈ —Ëπ 6) ‰¡à∑‘Èß·§ª´Ÿ≈¬“À≈—ß Ÿ¥ 7) π”·§ª´Ÿ≈
¬“‰ª√—∫ª√–∑“π·∑π°“√ Ÿ¥
65
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 1)
°“√ Ÿ¥¬“¢¬“¬À≈Õ¥≈¡·§ª Ÿ≈¥â«¬‡§√◊ËÕß Ÿ¥∫√‘ ‡Œ‡≈Õ√å (Breezhaler˙)
1. ‡ªî¥Ω“§√Õ∫¬“ÕÕ°
2. ‡ªî¥Ω“„πÕ’°™—Èπ ‡æ◊ËÕ‡μ√’¬¡∫√√®ÿ·§ª´Ÿ≈
3. ·°–·§ª´Ÿ≈¬“ ÕÕ°®“°·ºß¬“
4. ∫√√®ÿ·§ª Ÿ≈≈ß„π™àÕß ”À√—∫„ ଓ (Àâ“¡„ à·§ª Ÿ≈≈ߪ“°°√–∫Õ°‚¥¬
‰¡à‡ªî¥Ω“„π)
5. ªî¥Ω“„π ®π‰¥â¬‘π‡ ’¬ß ç§≈‘°é
66
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
6. ®—∫Õÿª°√≥åμ—Èߢ÷Èπ ·≈–°¥ªÿÉ¡¥â“π¢â“ß∑—Èß 2 ¢â“ßæ√âÕ¡°—π§√—È߇¥’¬«·≈â«
ª≈àÕ¬ ‡æ◊ËÕ‡®“–·§ª´Ÿ≈¬“
7. À“¬„®ÕÕ°„Àâ ÿ¥√–«—߉¡à„Àâ≈¡À“¬„®‡¢â“‰ª„πÕÿª°√≥å Ÿ¥¬“
8. Õ¡ª“°°√–∫Õ°¬“„Àâ π‘∑‚¥¬∂◊ÕÕÿª°√≥å Ÿ¥¬“„π·π«¢π“πæ◊Èπ „Àâ
ªÿÉ¡‡®“–¬“Õ¬Ÿà„π·π«´â“¬¢«“ (‰¡àμâÕß°¥ªÿÉ¡‡®“–¬“´È”) Ÿ¥≈¡À“¬„®
‡¢â“∑“ߪ“°™â“Ê≈÷°Ê®π ÿ¥¥â«¬§«“¡‡√Á«æÕ∑’ˉ¥â¬‘π‡ ’¬ß —Ëπ¢Õß·§ª´Ÿ≈
9. ¥÷ß°√–∫Õ°¬“ÕÕ°®“°ª“° °≈—Èπ≈¡À“¬„®‰«âÕ¬à“ßπâÕ¬ 5-10 «‘π“∑’
À√◊Õ‡∑à“∑’Ë®–∑”‰¥â·≈â«À“¬„®ÕÕ°μ“¡ª°μ‘ (Õ¬à“‡ªÉ“≈¡À“¬„®‡¢â“
Õÿª°√≥å)
10. ‡ªî¥Ω“„πÕÕ° ‡æ◊ËÕ¥Ÿ«à“¬—ß¡’ºß¬“§â“ß„π·§ª´Ÿ≈À√◊Õ‰¡à∂â“¡’¬“‡À≈◊Õ
∑”´È”¢—ÈπμÕπ∑’Ë 7-9 (‚¥¬‰¡àμâÕ߇®“–·§ª´Ÿ≈¬“ ȔՒ°) ∂Ⓣ¡à¡’¬“§â“ß
„𷧪´Ÿ≈·≈â« „Àâ∑‘Èß·§ª´Ÿ≈ ªî¥Ω“‡°Á∫
¢âÕ§«√√–«—ß 1) ‰¡à·°–·§ª Ÿ≈¬“‰«â≈à«ßÀπâ“ ·≈–À“°¡◊Õ‡ªï¬°πÈ”§«√
‡™Á¥¡◊Õ„Àâ·Àâß°àÕπ·°–·§ª´Ÿ≈¬“ ‡æ√“–§«“¡™◊Èπ®–∑”„À⬓·μ°μ—«‰¡à¥’ 2) °√≥’
Ÿ¥¬“·≈⫉¡à‰¥â¬‘π‡ ’¬ß·§ª Ÿ≈ —Ëπ∑—Èß∑’Ë Ÿ¥·√ß „À⇪î¥Ω“§√Õ∫¬“¥Ÿ«à“·§ª´Ÿ≈ÕÕ°
¡“πÕ°™àÕß∫√√®ÿ·§ª´Ÿ≈À√◊Õ‰¡à ‡æ√“–Õ“® Ÿ¥·√߉ª „Àâπ”·§ª Ÿ≈„ à≈ß„π™àÕß
∫√√®ÿ·§ª´Ÿ≈·≈â« Ÿ¥‡∫“≈ßæÕ‰¥â¬‘π‡ ’¬ß —Ëπ
¢âÕº‘¥æ≈“¥∑’Ëæ∫‰¥â ‰¥â·°à 1) ‰¡à‰¥â‡®“–·§ª´Ÿ≈¬“ 2) ‡®“–·§ª´Ÿ≈¬“¡“°
°«à“ 1 §√—Èß 3) À≈—߇®“–·§ª Ÿ≈¬“·≈⫉¡àª≈àÕ¬‡¢Á¡‡®“– 4) À“¬„®‡¢â“‰ª„π‡§√◊ËÕß
5) À“¬„®‰¡à·√ßæÕ∑’Ë∑”„Àâ·§ª´Ÿ≈ —Ëπ 6) Ÿ¥·√߇°‘π‰ª®π¬“ÕÕ°¡“πÕ°™àÕß
∫√√®ÿ·§ª´Ÿ≈¬“ 7) ‰¡à∑‘Èß·§ª´Ÿ≈¬“À≈—ß Ÿ¥ 8) π”·§ª Ÿ≈¬“‰ª√—∫ª√–∑“π·∑π
°“√ Ÿ¥
°“√∑”§«“¡ –Õ“¥ Õ“®∑” —ª¥“Àå≈– 1 §√—Èß ∑”‚¥¬„™âºâ“·Àâß –Õ“¥
67
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 1)
‡™Á¥Õÿª°√≥å Ÿ¥¬“∑—Èߥâ“π„π·≈–¥â“ππÕ° Àâ“¡π”‰ª≈â“ßπÈ” ·≈–‰¡à§«√·°–·¬°
Õÿª°√≥å Ÿ¥¬“ÕÕ°‡ªìπ à«πÊ
°“√ Ÿ¥¬“Õ‘´’‡Œ≈‡≈Õ√å (Easyhaler)
1. ∂Õ¥Ω“§√Õ∫ÕÕ°
2. ®—∫À≈Õ¥¬“„ÀâÕ¬Ÿà„π·π«μ—È߇¢¬à“À≈Õ¥¬“¢÷Èπ≈ß 3-5 §√—Èß
3. °¥À≈Õ¥¬“¥â“π∫π¢Õßμ—«‡§√◊ËÕß≈ß®π‰¥â¬‘π‡ ’¬ß ç§≈‘°é (¬“®–¡“Õ¬Ÿà
„πμ”·Àπàßæ√âÕ¡ Ÿ¥) ·≈⫧≈“¬π‘È«∑’Ë°¥
4. À“¬„®ÕÕ°®π ÿ¥√–«—߉¡àÀ“¬„®‡¢â“‰ª„π‡§√◊ËÕß
5. Õ¡ à«π ”À√—∫ Ÿ¥¬“·≈–À“¬„®‡¢â“∑“ߪ“°„Àâ·√ß≈÷°·≈– ¡Ë”‡ ¡Õ
6. À≈—ß®“°π—Èπ‡Õ“°√–∫Õ°¬“ÕÕ°®“°ª“°·≈–°≈—Èπ≈¡À“¬„®‰«âÕ¬à“ßπâÕ¬
5 «‘π“∑’·≈â«À“¬„®ÕÕ°μ“¡ª°μ‘ Õ¬à“À“¬„®‡¢â“‰ª„π‡§√◊ËÕß
68
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
°“√∫√‘À“√¬“ Ÿ¥ «‘߇Œ‡≈Õ√å (Swinghaler)
1. ‡ªî¥°√–∫Õ°¬“‡Õ“Ω“§√Õ∫ÕÕ°‚¥¬°“√°¥≈ß∑’˪≈“¬‡§√◊ËÕß¡◊Õ∑—Èß 2 ¢â“ß
2. ®—∫∑’Ë∞“π°√–∫Õ°¬“„Àâ°√–∫Õ°¬“Õ¬Ÿà„π·π«¢π“π°—∫æ◊Èπ ‡¢¬à“„π·π«
¢÷Èπ≈ß
3. Àß“¬‡§√◊ËÕß Ÿ¥¬“‡Õ“¥â“π∑’Ë¡’μ—«‡≈¢®”π«π¬“¢÷Èπ®—¥„À⇧√◊ËÕßÕ¬Ÿà„π·π«
¢π“π°—∫æ◊Èπ·≈â«¥—π∞“π°√–∫Õ°¬“‰ª∑“ߪ≈“¬°√–∫Õ°¬“ 1 §√—Èß
4. À“¬„®ÕÕ°„Àâ ÿ¥·≈–°≈—Èπ≈¡À“¬„®‰«â
5. Õ¡ª≈“¬°√–∫Õ°¬“„ÀâÕ¬Ÿà√–À«à“ß√‘¡Ω望°∫π·≈–≈à“ßÀ“¬„®‡¢â“∑“ß
ª“°„Àâ‡√Á«·≈–≈÷°®π ÿ¥·≈–°≈—Èπ≈¡À“¬„®‰«â 2-3 «‘π“∑’‡Õ“°√–∫Õ°
¬“ÕÕ°®“°ª“°·≈â«À“¬„®μ“¡ª°μ‘
6. ¥—π∞“π°√–∫Õ°¬“‰ª∑“ߪ≈“¬°√–∫Õ°¬“Õ’°§√—È߇æ◊ËÕªî¥√–∫∫°“√
ªÑÕπ¬“
7. ªî¥Ω“§√Õ∫¬“À≈—ß°“√„™â¬“
69
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 1)
°“√∫√‘À“√¬“ Ÿ¥‡Õ≈≈‘ªμâ“ (Ellipta)
1. ¬“∂Ÿ°∫√√®ÿ„π∂“¥øÕ¬≈å ≈Õ°Ω“ÕÕ° π”´Õß„ à “√¥Ÿ¥§«“¡™◊Èπ∑‘È߉ª
(Àâ“¡°≈◊π)
2. °àÕπ‡√‘Ë¡„™â¬“: ¥Ÿ„Àâ·πà„®«à“ μ—«‡≈¢π—∫®”π«π¬“ ‡√‘Ë¡μâπ∑’ˇ≈¢ 30 („π
°√–∫Õ°¬“ 1 °√–∫Õ° ®– Ÿ¥¬“‰¥â 30 §√—Èß) ∑ÿ°§√—Èß∑’ˇªî¥Ω“ §◊Õ°“√
‡μ√’¬¡¬“ 1 ¢π“¥ μ—«‡≈¢∑’Ë°√–∫Õ°¬“®–∂Õ¬≈ß∑’≈– 1
70
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
3. ‡μ√’¬¡ Ÿ¥¬“: ∫‘¥Ω“ªî¥≈ߥâ“π¢â“ß ®–‡ÀÁ𪓰°√–∫Õ°¬“ „Àâ∫‘¥®π
‰¥â¬‘π‡ ’¬ß ç§≈‘°é μ—«‡≈¢®–∂Õ¬≈ß 1 ·μâ¡ (‡™àπ ®“° 30 ‡ªìπ 29)
4. À“¬„®ÕÕ°®π ÿ¥ √–«—߉¡à‡ªÉ“≈¡À“¬„®‡¢â“„π°√–∫Õ°¬“
5. Õ¡ª“°°√–∫Õ°¬“„Àâ π‘∑ Ÿ¥≈¡À“¬„®‡¢â“∑“ߪ“°≈÷°Ê ™â“Ê „Àâ≈÷°
∑’Ë ÿ¥∑’Ë®–∑”‰¥â
* √–«—ßÕ¬à“‡Õ“¡◊Õ¡“ªî¥À√◊Õ∫—ß™àÕß≈¡¢Õßμ—«°√–∫Õ°¬“
6. °≈—Èπ≈¡À“¬„®‰«âÕ¬à“ßπâÕ¬ 5 - 10 «‘π“∑’ æ√âÕ¡°—∫¥÷ß°√–∫Õ°¬“ÕÕ°
®“°ª“° √–«—ßÕ¬à“‡ªÉ“≈¡À“¬„®≈ß„π°√–∫Õ°¬“
7. À“¬„®ÕÕ°™â“Ê ¬“™π‘¥π’È®–‰¡à¡’°≈‘Ëπ ‰¡à¡’√ ™“μ‘ ¥—ßπ—ÈπÕ¬à“ Ÿ¥¬“ È”
·¡â®–‰¡à√Ÿâ ÷°«à“¡’¬“‡¢â“‰ª
8. ‡¡◊ËÕ Ÿ¥¬“‡ √Á®·≈â« Õ“®π”°√–¥“…·Àâß¡“‡™Á¥ª“°°√–∫Õ°‰¥â ‡ √Á®
·≈â«∫‘¥Ω“°≈—∫¢÷Èπ‰ª„Àâ ÿ¥
9. ‡¡◊ËÕ„™â¬“®π‡À≈◊Õ¬“πâÕ¬°«à“ 10 §√—Èß ∫√‘‡«≥μ—«‡≈¢∑’Ë· ¥ß®”π«π¬“
‡À≈◊Õ ®–¡’·∂∫ ’·¥ß¢÷Èπ
‡¡◊ËÕ„™â¬“®πÀ¡¥°√–∫Õ° μ—«‡≈¢®–· ¥ß‡≈¢ ç0é §◊Õ∑‘Èß°√–∫Õ°¬“‰¥â ·≈–
‡μ√’¬¡°√–∫Õ°¬“„À¡à‡æ◊ËÕ„™â„π«—π∂—¥‰ª
¢âÕ —߇°μ ¬“ Ÿ¥™π‘¥π’È ‰¡àμâÕ߇¢¬à“°àÕπ Ÿ¥
∂â“∫‘¥Ω“®π‰¥â¬‘π‡ ’¬ß ç§≈‘°é ·≈â« ·μàμ—«‡≈¢‰¡à∂Õ¬≈ß ·ª≈«à“‰¡à¡’¬“
ÕÕ°¡“ μâÕߢՇª≈’ˬπ°√–∫Õ°¬“„À¡à
71
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 1)
°“√ Ÿ¥¬“™π‘¥ ‡√ ‰ª·¡∑ (Respimat˙ Soft MistTM inhaler)
°“√ª√–°Õ∫¬“ ‡æ◊ËÕ„™â¬“„π§√—Èß·√°
1. °¥ªÿÉ¡‡≈Á°Ê ¥â“π¢â“ß°√–∫Õ°¬“ ‡æ◊ËÕ∂Õ¥∞“πæ≈“ μ‘°„ ÕÕ°
2. π”À≈Õ¥¬“„ à‡¢â“‰ª„π°√–∫Õ°¬“ ‚¥¬À—π¥â“π‡≈Á°°«à“‡¢â“ §àÕ¬Ê °¥
À≈Õ¥¬“≈ß®π ÿ¥∫πæ◊Èπ·¢Áß
3. «¡∞“πæ≈“ μ‘°„ °≈—∫‡¢â“‰ª„Àâ π‘∑
¢âÕ§«√√–«—ß À≈—ß®“°„ àÀ≈Õ¥¬“ ·≈–∞“πæ≈“ μ‘°‡¢â“μ”·Àπàß·≈â« Àâ“¡
∂Õ¥À≈Õ¥¬“ À√◊Õ∞“πæ≈“ μ‘°ÕÕ°¡“Õ’°
4. ∫‘¥∞“π°√–∫Õ°¬“ μ“¡‡§√◊ËÕßÀ¡“¬∑’Ë°√–∫Õ°¬“ ®π‰¥â¬‘π‡ ’¬ß ç§≈‘°é
Õ¬à“‡æ‘Ë߇ªî¥Ω“§√Õ∫°√–∫Õ°¬“„π®—ßÀ«–π’È
5. ‡ªî¥Ω“ÕÕ°
72
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
6. °¥ªÿÉ¡ª≈àÕ¬¬“ ‚¥¬À—𪓰°√–∫Õ°≈ßæ◊Èπ ∑”´È”¢—ÈπμÕπ∑’Ë 4-6 ®π°«à“
®–‡ÀÁπ≈–ÕÕßΩÕ¬¬“ ®÷߇√‘Ë¡°√–∫«π°“√ Ÿ¥¬“‰¥â
¢—ÈπμÕπ°“√ Ÿ¥¬“ ª√–°Õ∫‰ª¥â«¬ 3 ¢—ÈπμÕπÀ≈—° §◊Õ
1. ∫‘¥°√–∫Õ°¬“
2. ‡ªî¥Ω“ªî¥§√Õ∫°√–∫Õ° (Ω“ ’‡¢’¬«)
3. Õ¡ª“°°√–∫Õ°¬“‚¥¬ªî¥ª“°„Àâ π‘∑ ‡√‘Ë¡À“¬„®‡¢â“∑“ߪ“°™â“Ê·≈–
°¥ªÿÉ¡ª≈àÕ¬¬“ (ªÿÉ¡ ’‡∑“) æ√âÕ¡°—∫ Ÿ¥¬“‡¢â“μàÕ ™â“Ê®π ÿ¥ °≈—ÈπÀ“¬„®
5 - 10 «‘π“∑’ ·≈⫪î¥Ω“§√Õ∫°√–∫Õ°¬“ ∂â“μâÕß°“√ Ÿ¥¬“§√—Èß∑’Ë 2
∑”´È”¢—ÈπμÕπ∑’Ë 1 - 3
73
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 1)
°“√∫√‘À“√¬“ºà“π‡§√◊ËÕß Ÿ¥ Aerosol Cloud Enhancer (ACE) Spacer
1. ‡μ√’¬¡ ACE spacer, valved mouth piece, coaching adapter
(whistle) ·≈–À≈Õ¥¬“ Ÿ¥
2. ª√–°Õ∫Õÿª°√≥å∑—ÈßÀ¡¥‡¢â“°—π‚¥¬„ à valved mouthpiece, coaching
adapter (whistle) ∑’˪≈“¬∑—Èß 2 ¥â“π·≈–μàÕÀ≈Õ¥¬“ Ÿ¥‡¢â“∑“ߥâ“π
∫π¥—ß„π√Ÿª
3. °“√ Ÿ¥¬“°√–∑”‰¥â‚¥¬
1) ‡¢¬à“À≈Õ¥¬“
2) À“¬„®ÕÕ°®π ÿ¥·≈–°¥À≈Õ¥¬“≈߇æ◊ËÕ„Àâ≈–ÕÕ߬“‡¢â“‰ªÕ¬Ÿà„π
spacer
3) Õ¡ mouth piece ‰«â√–À«à“ß√‘¡Ω望°·≈–À“¬„®‡¢â“™â“Ê À“°
‰¥â¬‘π‡ ’¬ßπ°À«’¥¥—ߢ÷Èπ„Àâ≈¥§«“¡‡√Á«„π°“√ Ÿ¥≈ß
4) °≈—Èπ≈¡À“¬„®‰«âª√–¡“≥ 10 «‘π“∑’·≈–À“¬„®ÕÕ°
5) Ÿ¥À“¬„®´È”‡™àπ‡¥‘¡Õ’°§√—Èß‚¥¬¬—߉¡àμâÕß°¥¬“„À¡à‡æ◊ËÕ„Àâ ‰¥â¬“∑’Ë
Õ“®À≈߇À≈◊ÕÕ¬Ÿà„π chamber
6) À“°μâÕß Ÿ¥¬“‡æ‘Ë¡„Àâ∑”´È”μ“¡¢—ÈπμÕπ∑’Ë 1) - 5)
74
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
°“√∫√‘À“√¬“ Ÿ¥„πºŸâªÉ«¬∑’ËÀ“¬„®∑“ß∑àÕ‡®“–§Õ (Tracheostomy tube)
„π°√≥’∑’˺ŸâªÉ«¬À“¬„®ºà“π tracheostomy ·≈–μâÕß∫√‘À“√¬“ Ÿ¥ Õ“®
„™âÕÿª°√≥å‡ √‘¡
1. ACE (aerosol cloud enhancer) spacer μàÕ°—∫
2. T-piece adapter ·≈–
3. extension tube ¥—ß√Ÿª
°“√∫√‘À“√¬“°√–∑”‰¥â‚¥¬
(1) μàÕ T-piece adapter ‡¢â“°—∫ tracheostomy tube
(2) ‡¢¬à“·≈–°¥À≈Õ¥¬“„π™à«ß‡√‘Ë¡À“¬„®‡¢â“‡æ◊ËÕ„Àâ≈–ÕÕ߬“‡¢â“‰ª„π
spacer
75
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 1)
Device
Metered-dose
inhaler (MDI)
Easyhaler
Swinghaler
μ“√“ß √ÿª√«¡™π‘¥¢Õ߬“ Ÿ¥ (inhaler)
Drug available
Salbutamol
Ipratropium/
fenoterol
Budesonide
Salmeterol/
fluticasone
Salbutamol
Budesonide
Advantages
- ¡’¬“À≈“°À≈“¬™π‘¥
„Àâ‡≈◊Õ°„™â
- à«π„À≠à√“§“
‰¡à·æß
- ¡’¬“ generic
ÕÕ°¡“
- „™â°—∫ spacer ‰¥â
- „™â°—∫ºŸâªÉ«¬‡®“–§Õ
À√◊ÕºŸâªÉ«¬∑’Ë„ à
‡§√◊ËÕߙ૬À“¬„®‰¥â
- æ°æ“ –¥«°
- °¥„™â ‰¥â¬“‡√Á«
- ®”π«π dose μàÕ
°√–∫Õ°¡“°
- ‰¡àμâÕßÕ“»—¬
co-ordination
- æ°æ“ –¥«°
- „™âßà“¬
- ‰¡àμâÕßÕ“»—¬
co-ordination
- æ°æ“ –¥«°
- „™âßà“¬
Disadvantages
- μâÕßÕ“»—¬®—ßÀ«–∑’Ë
—¡æ—π∏å„π°“√°¥¬“
·≈–°“√À“¬„®‡¢â“
(co-ordination)
- à«π„À≠à‰¡à¡’ dose
counter
- μâÕß°“√·√ß Ÿ¥∑’Ë¡“°¢÷Èπ
- μâÕß√–«—߇√◊ËÕߧ«“¡™◊Èπ
- μâÕß°“√·√ß Ÿ¥∑’Ë¡“°¢÷Èπ
- Õ“® —∫ π√–À«à“ß√–∫∫
‡ªî¥ªî¥°“√ªÑÕπ¬“
( Ÿ¥¬“μÕπ√–∫∫ªî¥)
- √“§“ Ÿß
- μâÕß√–«—߇√◊ËÕߧ«“¡™◊Èπ
76
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
Device
Turbuhaler
Accuhaler
Breezhaler
Handihaler
Soft mist
inhaler
μ“√“ß √ÿª√«¡™π‘¥¢Õ߬“ Ÿ¥ (inhaler) (μàÕ)
Drug available
Budesonide
Formoterol/
budesonide
Salmeterol/
fluticasone
Indacaterol
Glycopyrronium
Tiotopium
Tiotropium
Advantages
- ‰¡àμâÕßÕ“»—¬
co-ordination
- æ°æ“ –¥«°
- „™âßà“¬
- ‰¡à¡’°≈‘Ëπ
- ‰¡àμâÕßÕ“»—¬
co-ordination
- æ°æ“ –¥«°
- „™âßà“¬
- æ°æ“‰¥â –¥«°
- „™â‡æ’¬ß«—π≈–
1 §√—Èß
- æ°æ“‰¥â –¥«°
- „™â‡æ’¬ß«—π≈–
1 §√—Èß
- æ°æ“‰¥â –¥«°
- „™â‡æ’¬ß«—π≈–
1 §√—Èß
- μâÕß°“√·√ß Ÿ¥
‰¡à¡“°
Disadvantages
- μâÕß°“√·√ß Ÿ¥∑’Ë¡“°¢÷Èπ
- √“§“ Ÿß
- μâÕß√–«—߇√◊ËÕߧ«“¡™◊Èπ
- μâÕß°“√·√ß Ÿ¥∑’Ë¡“°¢÷Èπ
- √“§“ Ÿß
- μâÕß√–«—߇√◊ËÕߧ«“¡™◊Èπ
- μâÕß°“√·√ß Ÿ¥∑’Ë¡“°¢÷Èπ
- √“§“ Ÿß
- μâÕß√–«—߇√◊ËÕߧ«“¡™◊Èπ
- «‘∏’°“√´—∫´âÕπ
- μâÕß°“√·√ß Ÿ¥∑’Ë¡“°¢÷Èπ
- √“§“ Ÿß
- μâÕß√–«—߇√◊ËÕߧ«“¡™◊Èπ
- «‘∏’°“√´—∫´âÕπ
- √“§“ Ÿß
- «‘∏’°“√´—∫´âÕπ ‚¥¬
‡©æ“–μÕπ‡√‘Ë¡‚À≈¥
°√–∫Õ°„À¡à
77
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 1)
‡Õ° “√Õâ“ßÕ‘ß1. Dolovich MB, Ahren RC, Hess DR, et al. Device selection and outcomes of
aerosol therapy: evidence based guideline. American College of Chest Physi-cians/American College of Asthma, Allergy, and Immunology. Chest 2005; 127:335-71.
2. Newman SP, Clark SW. Inhalation devices and techniques. In Asthma 3rd ed.Clark TJH, Godfrey S, Lee TH. editers. 1992 Chapman & Hall, London 469-505.
3. Canadian Asthma Consensus Group. Inhalation devices and propellants. JAMC1999;161 s44-s52.
4. ACCP: Inhaled Medications and Devices: American College of Chest Physicians2003. Tips and Techniques. www.chestnet.org.
5. Laube BL., Janssens HM, de Jongh FHC, et al. What the pulmonary specialistshould know about the new inhalation therapies. Eur Respir J 2011; 37: 1308-31
6. Capstick TG, Clifton IJ. Inhaler technique and training in people with chronicobstructive pulmonary disease and asthma. Expert Rev Respir Med. 2012 Feb;6(1):91-101.
7. National Asthma Council Australia. Inhaler technique in adults with asthma orCOPD. Available from www.nationalasthma.org.au
78
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
¿“§ºπ«° 2
·π«∑“ß°“√™à«¬‡À≈◊Õ„À⺟âªÉ«¬ COPD ‡≈‘° Ÿ∫∫ÿÀ√’Ë
(Smoking cessation)
°“√‡≈‘°∫ÿÀ√’Ë ‡ªìπ°“√√—°…“∑’Ë¥’∑’Ë ÿ¥ ∑’Ë®–™–≈Õ§«“¡‡ ◊ËÕ¡¢Õß ¡√√∂¿“æ
ªÕ¥ ·≈–≈¥Õ—μ√“°“√‡ ’¬™’«‘μ ®÷ß·π–π”„Àâ™à«¬‡À≈◊ÕºŸâªÉ«¬ COPD „π°“√‡≈‘°
∫ÿÀ√’ËÕ¬à“ß®√‘ß®—ß ·≈–μàÕ‡π◊ËÕß §«∫§Ÿà‰ª°—∫°“√√—°…“‚√§ COPD ·≈–‚√§√à«¡Õ◊ËπÊ
·π«∑“ß°“√√—°…“ºŸâ∑’ËμâÕß°“√‡≈‘° Ÿ∫∫ÿÀ√’Ë°“√√—°…“∑’Ëæ∫«à“ “¡“√∂∑”„À⺟âªÉ«¬¡’‚Õ°“ ‡≈‘° Ÿ∫∫ÿÀ√’ˉ¥â¡“°¢÷Èπ ª√–°Õ∫
¥â«¬·π«∑“ß ”§—≠ 2 ·π«∑“ߧ◊Õ
1. °“√„À⧔ª√÷°…“‡æ◊ËÕª√—∫‡ª≈’ˬπæƒμ‘°√√¡ (education and knowledge
management) ‡ªìπ°“√√—°…“∑’Ë ”§—≠·≈–ª√– ∫º≈ ”‡√Á®¡“°∑’Ë ÿ¥ æ∫«à“°“√
„À⧔ª√÷°…“·¡â„™â√–¬–‡«≈“ —ÈπÊ (brief counselling) “¡“√∂®–‡æ‘Ë¡‚Õ°“ „π
°“√‡≈‘° Ÿ∫∫ÿÀ√’Ë„Àâ ”‡√Á®‰¥â¡“° °“√„À⧔ª√÷°…“∑’Ë„™â‡«≈“¡“°¢÷Èπ À√◊Õ‡ªìπ°≈ÿà¡
°“√„À⺟âªÉ«¬‚∑√»—æ∑å√—∫§”ª√÷°…“Õ¬à“ßμàÕ‡π◊ËÕß®“°»Ÿπ¬å‡≈‘°∫ÿÀ√’Ë∑“ß‚∑√»—æ∑å
(À¡“¬‡≈¢ 1600) ≈â«π∑”„À⺟âªÉ«¬¡’ ‚Õ°“ ‡≈‘°∫ÿÀ√’Ë ‰¥â¡“°¢÷Èπ À“°¡’°“√„Àâ
§”ª√÷°…“√à«¡°—∫°“√„™â¬“™à«¬‡≈‘°∫ÿÀ√’Ë ®–‡æ‘Ë¡‚Õ°“ °“√‡≈‘°∫ÿÀ√’Ë ”‡√Á®
Õ—μ√“°“√‡≈‘° Ÿ∫∫ÿÀ√’Ë„π√–¬–¬“«„π°≈ÿࡺŸâªÉ«¬ COPD æ∫«à“ Odd ratio
®“°°“√‰¥â√—∫°“√ª√÷°…“‡≈‘°∫ÿÀ√’Ë ‡∑à“°—∫ 1.82 ‡∑à“ (95% confidence interval
0.96-3.44) ‡ª√’¬∫‡∑’¬∫°—∫°≈ÿࡺŸâªÉ«¬∑’ˉ¡à‰¥â√—∫§”ª√÷°…“‡√◊ËÕ߇≈‘°∫ÿÀ√’Ë (usual
care)
79
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 2)
√“¬≈–‡Õ’¬¥°“√„À⧔ª√÷°…“Õ¬à“ß —Èπ (brief counselling)
¡’¢—ÈπμÕ𠔧—≠ ç5Aé ¥—ßμ“√“ß
¢—ÈπμÕπ 5A
ASK
ADVISE
ASSESSMENT
ASSIST
§«“¡ ”§—≠
- °“√ Ÿ∫∫ÿÀ√’ËÕ¬à“ßμàÕ‡π◊ËÕß
®—¥‡ªìπ‚√§‡√◊ÈÕ√—ß „Àâ∂◊Õ
«à“°“√ Ÿ∫∫ÿÀ√’ˇªìπ active
problem „π°“√¥Ÿ·≈
ºŸâªÉ«¬‡ ¡Õ®π°«à“®–
‡≈‘°‰¥â
- ·æ∑¬å„Àâ¢âÕ¡Ÿ≈‡°’ˬ«°—∫
º≈‡ ’¬¢Õß°“√ Ÿ∫∫ÿÀ√’Ë
·≈–ª√–‚¬™πå¢Õß°“√
‡≈‘°∫ÿÀ√’Ë
- ‡ πÕ§«“¡™à«¬‡À≈◊Õ∑ÿ°
§√—Èß∑’Ë¡’‚Õ°“
- °“√ª√–‡¡‘π«à“ºŸâªÉ«¬¡’
§«“¡μâÕß°“√∑’Ë®–‡≈‘°
∫ÿÀ√’ËÀ√◊Õ‰¡à
- °“√™à«¬‡À≈◊Õ„À⺟âªÉ«¬
“¡“√∂À¬ÿ¥∫ÿÀ√’ˉ¥â
·π«ªØ‘∫—μ‘
- ∂“¡ª√–«—μ‘°“√ Ÿ∫∫ÿÀ√’Ë ‡™àπ Ÿ∫¡“
π“π‡∑à“‰À√à ª√‘¡“≥°“√ Ÿ∫μàÕ«—π
- ·æ∑¬å§«√∂“¡ºŸâªÉ«¬∑ÿ°§π‡°’ˬ«°—∫
ª√–«—μ‘°“√ Ÿ∫∫ÿÀ√’Ë ·≈–∫—π∑÷°≈ß„π
ª√–«—μ‘ºŸâªÉ«¬
- „À⧔·π–π”ºŸâªÉ«¬‡°’ˬ«°—∫‡√◊ËÕß
æ‘…¿—¬∫ÿÀ√’Ë ·≈–°“√‡≈‘° Ÿ∫∫ÿÀ√’Ë À√◊Õ
“¡“√∂ àßμàÕºŸâªÉ«¬‰ª√—∫°“√¥Ÿ·≈∑’Ë
‡À¡“– ¡‰¥â
- „À⧔·π–π”∑’ˇÀ¡“– ¡‡æ◊Ëՙ૬„Àâ
ºŸâªÉ«¬≈ß¡◊Õ‡≈‘° Ÿ∫∫ÿÀ√’Ë
- „πºŸâ Ÿ∫∑’ˬ—߉¡àμâÕß°“√‡≈‘°∫ÿÀ√’Ë §«√¡’
°“√„À⧔·π–π”‡æ◊ËÕ°√–μÿâπºŸâ Ÿ∫„Àâ
‡√‘Ë¡§‘¥‡≈‘° Ÿ∫∫ÿÀ√’Ë∑ÿ°§√—Èß∑’Ë¡’‚Õ°“
(motivation counselling)
- Õ∏‘∫“¬∂÷ߢ—ÈπμÕπ°“√‡≈‘°∫ÿÀ√’Ë
- §«√°”À𥫗π‡≈‘°∫ÿÀ√’Ë¿“¬„π 1 ‡¥◊Õπ
- ·π–π”·π«∑“ߪؑ∫—μ‘μ—«„π™à«ß°àÕπ
®–‡≈‘° ·≈–„π«—π∑’ˇ≈‘°∫ÿÀ√’Ë
- ∂â“®”‡ªìπμâÕß„™â¬“™à«¬‡≈‘°∫ÿÀ√’Ë “¡“√∂
®à“¬¬“ ·≈–·π–π”«‘∏’„™â∑’Ë∂Ÿ°μâÕ߉¥â
80
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
¢—ÈπμÕπ 5A
ARRANGE
§«“¡ ”§—≠
- °“√μ‘¥μ“¡ºŸâªÉ«¬
(follow up) ¿“¬À≈—ß
®“°°“√≈ß¡◊Õ‡≈‘°∫ÿÀ√’Ë
·π«ªØ‘∫—μ‘
- §«√¡’°“√π—¥ºŸâªÉ«¬¡“‡æ◊ËÕμ‘¥μ“¡
º≈°“√√—°…“ ·≈–„À⧔·π–π”∑’Ë
‡À¡“– ¡μàÕ‰ª
2. °“√„™â¬“„π°“√‡≈‘°∫ÿÀ√’Ë (smoking cessation medications) ªí®®ÿ∫—π
¬“∑’Ë„™â™à«¬„π°“√‡≈‘°∫ÿÀ√’Ë ∑’Ëæ∫«à“ “¡“√∂‡æ‘Ë¡‚Õ°“ „π°“√‡≈‘°∫ÿÀ√’ˉ¥â ª√–°Õ∫
¥â«¬¬“ 2 °≈ÿà¡ (μ“√“ß∑’Ë 1) §◊Õ
1) °≈ÿ࡬“ nicotine supplement ‡ªìπ°“√„Àâ nicotine ‡ √‘¡„πºŸâªÉ«¬
‡æ◊ËÕ≈¥Õ“°“√¢Õß nicotine withdrawal ªí®®ÿ∫—π„πª√–‡∑»‰∑¬¡’Õ¬Ÿà 2 √Ÿª·∫∫
‰¥â·°à nicotine patch ·≈– nicotine gum
2) °≈ÿ࡬“ non-nicotine medication „πªí®®ÿ∫—π∑’Ë„™â°—π§◊Õ ¬“
varenicline ÕÕ°ƒ∑∏‘Ï‚¥¬‡ªìπ partial agonist ·≈– partial antagonist ¢Õß
nicotine receptor „π√–∫∫ª√– “∑ à«π°≈“ß ∑”„À⺟â‡≈‘°∫ÿÀ√’˪√– ∫§«“¡ ”‡√Á®
¡“°¢÷Èπ à«π¬“°≈ÿà¡ antidepressant §◊Õ bupropion SR ·≈– nortriptyline ¡’
ƒ∑∏‘ϙ૬≈¥Õ“°“√Õ¬“°∫ÿÀ√’ˉ¥â
„πª√–‡∑»‰∑¬ ¡’°“√π”°≈ÿ࡬“ ¡ÿπ‰æ√ À√◊Õ¬“·ºπ‰∑¬ ¡“„™â ‡™àπ ™“
À≠â“¥Õ°¢“« (Vernonia cinerea Less) ÕÕ°ƒ∑∏‘Ï‚¥¬∑”„Àâ≈‘Èπ™“ ·≈–‰¡àÕ¬“°
Ÿ∫∫ÿÀ√’Ë (§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3, πÈ”Àπ—°§”·π–π” ++) ·μଗ߉¡à¡’°“√»÷°…“
¥â“πª√– ‘∑∏‘¿“æ·≈–º≈¢â“߇§’¬ß¡“°æÕ
¢âÕ§«√√–«—ß„π°“√„™â¬“™à«¬‡≈‘°∫ÿÀ√’Ë §◊Õ‰¡à§«√„™â„πºŸâ∑’Ë Ÿ∫∫ÿÀ√’˪√‘¡“≥
‰¡à¡“° (<10 ¡«πμàÕ«—π) ºŸâ∑’Ëμ—Èߧ√√¿å À√◊Õ„Àâπ¡∫ÿμ√ ·≈–ºŸâ∑’Ë¡’¢âÕÀâ“¡„π°“√
„™â¬“·μà≈–™π‘¥
81
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 2)
¬“™à«
¬
‡≈‘°∫
ÿÀ√’Ë
𑂧μ
‘π™π‘¥
·ºàπ·
ª–
(Nico
tine
patc
h)
À¡“°
Ω√—Ëß
𑂧μ
‘π
(Nico
tine
gum
)
¢π“¥
¬“
- > 1
0 ¡«
π/«—π
: „™ â¢
π“¥
21 ¡
°./«—π
x 6
-8
—ª¥“
Àå ®“
°π—Èπ≈
¥‡ªìπ
14 ¡
°./« —π
·≈–
7 ¡
°./
«—π ∑
ÿ°Ê 2
-4
—ª¥“À
å
- < 1
0 ¡«
π/« —π
: „™â¢
π“¥
14 ¡
°./« —π
x 6
—ª¥
“Àå
·≈â«≈
¥≈߇
ªìπ 7
¡°./
«—π
x 2-
4 —ª
¥“Àå
- > 2
5 ¡«
π/« —π
: „™â¢
π“¥
4 ¡°
. ‚¥¬
—ª¥“
Àå∑’Ë 0
-6
„Àâ 1
™‘Èπ
∑ÿ° 1
-2 ™
¡.
(Õ¬à“
ßπâÕ¬
9 ™
‘ÈπμàÕ«
—π)
—ª¥“
Àå∑’Ë 7
-9 „À
â 1 ™
‘Èπ
∑ÿ° 2
-4 ™
¡.
√–¬–
‡«≈“
( —ª¥
“Àå)
6-16
6-14
Estim
ated
Odds
Rat
io
(95%
CI)*
1.9
(1.7-
2.2)
1.5
(1.2-
1.7)
Odds
Rat
io
(95%
CI)
„π C
OPD
√«¡
NRT
5.1
(4.3-
6.0)
¢âÕ¥ ’
ÕÕ°ƒ
∑∏‘Ï
¬“«
- „™âß
à“¬
- ≈¥Õ
“°“√
‡ ’Ȭπ
¬“
‰¥â¥’
-™–
≈ÕπÈ”
Àπ—°
‡æ‘Ë¡‰
¥â
¢âÕ‡
’¬
- ÕÕ°
ƒ∑∏ ‘Ï™
â“
‰¡à‡À
¡“–°
—∫
ºŸâ∑’Ë¡’Õ
“°“√
‡ ’Ȭπ
¬“
(cra
ving)
∫àÕ¬Ê
- º‘«À
π—ßÕ—°
‡ ∫
(50%
)
μâÕ߇
§’Ȭ«„
Àâ∂Ÿ°
«‘∏’ (c
hew
and
park
tech
nique
)
‡æ◊ËÕ„
ˉ 䴉
ª√–
‘∑∏‘¿“
æ·≈–
≈¥º≈
¢â“߇
§’¬ß
¢âÕ§«
√
√–«—ß
À≈’°‡
≈’ˬ߄
π μ√
’
μ—Èߧ√
√¿å
(pre
gnan
cy
cate
gory
D)
À√◊Õ
μ√’„À
â
π¡∫ÿμ
√
- ºŸâ∑’Ë¡
’ tem
poro
-
man
dibu
lar
joint
(TM
J)
dise
ase
À√◊Õ„
™â
øíπª≈
Õ¡
πÈ”Àπ
—°
§”
·π–π
”
+ +
82
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
√–¬–
‡«≈“
( —ª¥
“Àå)
12-2
4
Estim
ated
Odds
Rat
io
(95%
CI)*
2.0
(1.8-
2.2)
Odds
Rat
io
(95%
CI)
„π C
OPD
3.3
(1.5-
7.2)
¢âÕ¥ ’
- „™â„
πºŸâªÉ«
¬
‚√§À
—«„®‰
¥â
- ™–≈
ÕπÈ”À
π—°
‡æ‘Ë¡‰
¥â
- „™â ‰
¥â¥’„π
ºŸâªÉ«¬
∑ ’Ë¡’
¿“«–
´÷¡‡»
√â“
√à«¡¥
⫬
¢âÕ‡
’¬
- Õ“°
“√™—°
(1:1,
000)
- eat
ing
diso
rder
s
- πÕπ
‰¡àÀ≈
—∫
(35-
40%
)
πÈ”Àπ
—°
§”
·π–π
”
+
¬“™à«
¬
‡≈‘°∫
ÿÀ√’Ë
À¡“°
Ω√—Ëß
𑂧μ
‘π
(Nico
tine
gum
) (μàÕ
)
Bupr
opion
SR
¢π“¥
¬“
—ª¥“
Àå∑’Ë 1
0-12
„Àâ
1 ™‘Èπ
∑ÿ°
4-8
™¡.
- < 2
5 ¡«
π/«—π
: 㪉
¢π“¥
2 ¡
°. μ“
¡
·π«∑
“ߢâ“
ßμâπ
‡√‘Ë¡¬
“Õ¬à“
ßπâÕ¬
1-2
—ª¥“
Àå°àÕπ
À¬ÿ¥∫
ÿÀ√’Ë
‚¥¬„
Àâ¢π“
¥ 15
0 ¡°
.
√—∫ª√
зҹ
«—π≈–
§√—Èß„
π
3 «—π
·√°
·≈⫇
æ ‘Ë¡‡ª
ìπ
150
¡°. √
—∫ª√–
∑“π
«—π≈–
2 §
√—Èß (‡
™â“-‡¬
Áπ)
¢âÕ§«
√
√–«—ß
- μ
√’μ—Èߧ
√√¿ å
(pre
gnan
cy
cate
gory
C)
- ºŸâªÉ«
¬‚√§
≈¡™—°
- ºŸâªÉ«
¬„™â
À√◊Õ
‡§¬„
™â¬“°
≈ ÿà¡
MAO
I
- μ
√’μ—Èߧ
√√¿å
(pre
gnan
cy
cate
gory
C)
83
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 2)
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¬
‡≈‘°∫
ÿÀ√’Ë
Var
enicl
ine
¢π“¥
¬“
‡√‘Ë¡¬
“Õ¬à“
ßπâÕ¬
1-2
—ª¥“
Àå°àÕπ
À¬ÿ¥∫
ÿÀ√’Ë
‚¥¬„
Àâ¢π“
¥ 0.5
¡°.
√—∫ª√
зҹ
# «—π
≈–§√
—Èß„π
3 «—π
·√°
®“°π
—Èπ 0.5
¡°.
«—π≈–
2 §
√—Èß (‡
™â“-‡¬
Áπ)
„π«—π
∑’Ë 4-
7 ·≈
– 1
¡°.
«—π≈–
2 §
√—Èß (‡
™â“-‡¬
Áπ)
„π«—π
∑’Ë 8
‡ªìπμ
âπ‰ª
(·π–
π”√ —∫
ª√–∑
“π
æ√âÕ¡
Õ“À“
√ ‡æ
◊ËÕ≈¥
Õ“°“
√§≈◊Ëπ
‰ âÕ“
‡®’¬π
)
√–¬–
‡«≈“
( —ª¥
“Àå)
12-2
4
Estim
ated
Odds
Rat
io
(95%
CI)*
3.1
(2.5-
3.8)
Odds
Rat
io
(95%
CI)
„π C
OPD
4.0
(2.1-
7.7)
¢âÕ¥ ’
- ‰¥âº
≈ Ÿß
ÿ¥
- ≈¥
posit
ive
reinf
orce
-
men
t 䴉
- „™â ‰
¥â„π
ºŸâªÉ«¬
‚√§
À—«„®
¢âÕ‡
’¬
- §≈◊Ëπ
‰ â
(30%
)
- abn
orm
al
drea
ms
(5%
)
¢âÕ§«
√
√–«—ß
- μ√
’μ—Èߧ√
√¿å
(pre
gnan
cy
cate
gory
C)
- ºŸâªÉ«
¬‰μ«
“¬
√–¬–
ÿ¥∑â“
¬
- ºŸâªÉ«
¬‚√§
≈¡™—°
À√◊Õ
¡’
psyc
hiatri
c
diso
rder
s
πÈ”Àπ
—°
§”
·π–π
”
+
84
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
¬“™à«
¬
‡≈‘°∫
ÿÀ√’Ë
Nortr
ipty
line
¢π“¥
¬“
‡√‘Ë¡¬
“Õ¬à“
ßπâÕ¬
10-2
8 «—π
°àÕπ
À¬ÿ¥∫
ÿÀ√’Ë ‚¥
¬„Àâ¢
π“¥
25 ¡
°. √—∫
ª√–∑
“π
«—π≈–
§√—Èß
·≈⫇
æ ‘Ë¡
¢π“¥
¢ ÷Èπ‡√
◊ËÕ¬Ê
∑ÿ° 3
-5 «
—π ®π
∂÷ß
75-1
00 ¡
°.
«—π≈–
§√—Èß
√–¬–
‡«≈“
( —ª¥
“Àå)
12
Estim
ated
Odds
Rat
io
(95%
CI)*
1.8
(1.3-
2.6)
Odds
Rat
io
(95%
CI)
„π C
OPD
¢âÕ¥ ’
√“§“
∂Ÿ°
¢âÕ‡
’¬
- ª“°
·Àâß
§Õ·À
âß
- ßà«ß
πÕπ
¢âÕ§«
√
√–«—ß
- μ√
’μ—Èߧ√
√¿å
(pre
gnan
cy
cate
gory
D)
- ºŸâªÉ«
¬‚√§
À—«„®
∑ÿ°
ª√–‡
¿∑
- ºŸâ∑’ˇ
§¬„™
⬓
°≈ÿà¡
MAO
I
¿“¬„
π
2 —ª
¥“Àå
πÈ”Àπ
—°
§”
·π–π
”
++
ª√—∫ª
√ÿß®“
°Àπ —ß
◊Õ ·
π«∑“
߇«™
ªØ‘∫—μ
‘Õ‘ßÀ≈
—°∞“π
°“√
∫”∫ —¥
‚√§‡
欓
Ÿ∫„π
ª√–‡
∑»‰∑
¬ ªï
æ.».
255
5* ·
¥ßª
√– ‘∑
∏‘¿“æ
¢Õ߬
“∑’Ë „™
â ‡¡◊ËÕ‡
∑’¬∫°
—∫°≈ÿà¡
∑’ˉ¡à‰
¥â¬“
85
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 2)
‡Õ° “√Õâ“ßÕ‘ß1. ÿ∑—»πå √ÿà߇√◊ÕßÀ‘√—≠≠“ ·≈– ÿ√®‘μ ÿπ∑√∏√√¡. ·π«∑“߇«™ªØ‘∫—μ‘Õ‘ßÀ≈—°∞“π °“√∫”∫—¥
‚√§‡ 欓 Ÿ∫„πª√–‡∑»‰∑¬ ©∫—∫ª√—∫ª√ÿß æ.». 2555
2. Tonnesen P. Clinical year in review - Smoking cessation and COPD. Eur RespirRev 2013;22:127, 37-43.
3. Strassmann R, Bausch B, Spaar A, et al. Smoking cessation interventions inCOPD: a network meta-analysis of randomized trials. Eur Respir J 2009;34:634-40.
86
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¿“§ºπ«° 3
«—§ ’π
1. Inactivated influenza vaccine°“√©’¥«—§´’πªÑÕß°—π‰¢âÀ«—¥„À≠à„πºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ™à«¬≈¥
°“√μ‘¥‡™◊ÈÕ√–∫∫°“√À“¬„®∑’ˇ°‘¥®“°‡™◊ÈÕ‰¢âÀ«—¥„À≠à ·≈–≈¥°“√‡°‘¥°“√°”‡√‘∫
‡©’¬∫æ≈—π¢Õß‚√§ (exacerbation) ®÷ß·π–π”„Àâ©’¥„π°≈ÿࡇ ’Ë¬ß §◊Õ ºŸâªÉ«¬‚√§
ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß∑ÿ°√“¬ ·≈–¬—ß·π–π”©’¥„π°≈ÿà¡∑’Ë “¡“√∂·æ√à‚√§‰¢âÀ«—¥„À≠à
‰ª Ÿà°≈ÿࡇ ’ˬßπ’È ‡™àπ ∫ÿ§≈“°√∑“ß°“√·æ∑¬å·≈–ÀâÕߪؑ∫—μ‘°“√ ∫ÿ§§≈∑’Ëæ—°Õ¬Ÿà„π
∫â“π‡¥’¬«°—∫ª√–™“°√∑’Ë¡’§«“¡‡ ’Ë¬ß Ÿß
«—§´’πªÑÕß°—π‰¢âÀ«—¥„À≠à∑’Ë„™â„πª√–‡∑»‰∑¬ „™â«—§´’π™π‘¥‡™◊ÈÕ쓬 ÷Ëß
ªí®®ÿ∫—π¡’∑—Èß™π‘¥ 3 “¬æ—π∏ÿå ·≈–™π‘¥ 4 “¬æ—π∏ÿå «—§´’π™π‘¥ 3 “¬æ—π∏ÿå §◊Õ
influenza A (H1N1), influenza A (H3N2) ·≈– influenza B à«π™π‘¥ 4 “¬
æ—π∏ÿå‡æ‘Ë¡ influenza B ‡ªìπ 2 “¬æ—π∏ÿå º≈°“√°√–μÿâπ¿Ÿ¡‘§ÿâ¡°—π·≈–º≈¢â“߇§’¬ß
‰¡à·μ°μà“ß®“°°“√©’¥™π‘¥ 3 “¬æ—π∏ÿå ·μà™π‘¥ 4 “¬æ—π∏ÿå§√Õ∫§≈ÿ¡°“√μ‘¥‡™◊ÈÕ
influenza B virus ‰¥â¡“°¢÷Èπ
°“√„Àâ«—§´’π‡æ◊ËÕªÑÕß°—π°“√μ‘¥‡™◊ÈÕ‰¢âÀ«—¥„À≠à μâÕ߇ª≈’ˬπ·ª≈߉ªμ“¡
™π‘¥¢Õ߉«√— ‰¢âÀ«—¥„À≠à∑’˧“¥«à“®–√–∫“¥„πªïπ—Èπ (seasonal influenza) ¥—ßπ—Èπ
®÷ß·π–π”„Àâ«—§´’π‰¢âÀ«—¥„À≠à∑ÿ°ªï ªï≈– 1 §√—Èß √–¬–‡«≈“∑’ˇÀ¡“– ¡§◊Õ ‡¥◊Õπ
¡’π“§¡-‡¡…“¬π ·μàÕ“®„Àâ ‰¥âμ≈Õ¥∑—Èߪï (§ÿ≥¿“æÀ≈—°∞“π 1, πÈ”Àπ—°§”·π–π” ++)
87
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 3)
·π–π”„ÀℙⰓ√©’¥‡¢â“°≈â“¡∫√‘‡«≥μâπ·¢π ªí®®ÿ∫—π¡’«—§´’π™π‘¥ 3 “¬æ—π∏ÿå ©’¥
‡¢â“„πÀπ—ß (intradermal route) æ∫«à“°“√©’¥‡¢â“„πÀπ—ß „Àâ¿Ÿ¡‘§ÿâ¡°—π∑’Ë¥’
„πºŸâ ŸßÕ“¬ÿ ·μàÕ“®æ∫«à“º≈¢â“߇§’¬ß‡©æ“–∑’Ë ‡™àπ §—π ·¥ß μ√ßμ”·Àπàß∑’Ë©’¥
¡“°°«à“°“√©’¥«—§´’π‡¢â“°≈â“¡
«—§´’π‰¢âÀ«—¥„À≠à‰¡à§«√„Àⷰຟâ∑’Ë¡’ª√–«—μ‘·æâ ‰¢à√ÿπ·√ß À√◊ÕºŸâ∑’Ë¡’ª√–«—μ‘
‡ªìπ Guillain-Barre syndrome “¡“√∂„Àâ«—§´’πªÑÕß°—π‚√§‰¢âÀ«—¥„À≠à √à«¡
°—∫«—§´’πÕ◊ËπÊ ‰¥â „π‡«≈“‡¥’¬«°—𠇙àπ pneumococcal vaccine ‚¥¬©’¥«—§´’π
§π≈–¢â“ߢÕßμâπ·¢π
2. Pneumococcal vaccineæ‘®“√≥“©’¥„πºŸâªÉ«¬∑’ËÕ“¬ÿ¡“°°«à“ 65 ªï À√◊ÕºŸâªÉ«¬∑’ËÕ“¬ÿπâÕ¬°«à“ 65 ªï
∑’Ë¡’‚√§√à«¡ ‡™àπ ‚√§À—«„® ‚√§ªÕ¥‡√◊ÈÕ√—ßÕ◊Ëπ æ∫«à“≈¥Õ—μ√“°“√‡°‘¥ community-
acquired pneumonia 䴉
«—§´’π¡’ 2 ™π‘¥ §◊Õ ™π‘¥‚æ≈’·´§§“‰√¥å (23-valent pneumococcal
polysaccharide vaccine: PPV-23) ·≈–™π‘¥§Õπ®Ÿ‡°μ (13-valent pneumococcal
conjugate vaccine: PCV-13) ·π–π”©’¥∑—Èß Õß™π‘¥ ·μà¢âÕ®”°—¥§◊Õ√“§“ Ÿß Õ“®
©’¥‡©æ“– PPV-23 Õ¬à“߇¥’¬«°Á‰¥â ·μà¿Ÿ¡‘§ÿâ¡°—π®–¥âÕ¬°«à“
ªí®®ÿ∫—π·π–π”„Àâ©’¥‡¢â“°≈â“¡ 1 ‡¢Á¡ ‚¥¬‡√‘Ë¡¥â«¬°“√©’¥«—§´’π™π‘¥
§Õπ®Ÿ‡°μ (PCV-13) ´÷Ëß«—§´’ππ’È®–°√–μÿâπ¿Ÿ¡‘§ÿâ¡°—π‰¥â¥’ ·≈â«μ“¡¥â«¬°“√©’¥
«—§´’π™π‘¥‚æ≈’·´§§“‰√¥å (PPV-23) (PCV13-PPV23 sequence) ÷Ëߧ√Õ∫§≈ÿ¡
‡™◊ÈÕ‰¥â¡“°°«à“ (§ÿ≥¿“æÀ≈—°∞“π 1, πÈ”Àπ—°§”·π–π” +) ·μàÀ“°©’¥‡¢Á¡·√°
‡ªìπ PPV-23 „Àâ©’¥«—§´’π‡¢Á¡°√–μÿâπ‚¥¬„™â«—§´’π PCV-13 (PPV23-PCV13
sequence) ‚¥¬©’¥Àà“ß°—π‡ªìπ√–¬–‡«≈“‰¡àπâÕ¬°«à“ 1 ªï
88
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
°“√©’¥«—§´’π™π‘¥§Õπ®Ÿ‡°μ (PCV-13) °àÕπ™π‘¥‚æ≈’·´§§“‰√¥å (PPV-23)
®–∑”„À⇰‘¥¿Ÿ¡‘§ÿâ¡°—π‰¥â¥’°«à“ (PCV13-PPV23 sequence) °“√æ‘®“√≥“„Àâ©’¥´È”
1 §√—Èß (re-vaccination) ¡’¢âÕ∫àß™’ȧ◊Õ ©’¥«—§´’π´È”À≈—ß®“°‡¢Á¡·√° 5 ªï„π°√≥’
ºŸâªÉ«¬∑’ˉ¡à¡’¡â“¡ À√◊Õ©’¥«—§´’π´È”„πÕ“¬ÿ 65 ªï„π°√≥’ºŸâªÉ«¬∑’ˇ§¬‰¥â√—∫«—§´’π
‡¢Á¡·√°°àÕπÕ“¬ÿ 65 ªï ªí®®ÿ∫—π¬—߉¡à·π–π”„Àâ©’¥«—§´’π PPV-23 ¡“°°«à“ 2 §√—Èß
Õ“°“√¢â“߇§’¬ß∑’Ëæ∫‰¥â∫àÕ¬ ‡ªìπÕ“°“√¢â“߇§’¬ß‡©æ“–∑’Ëμ√ßμ”·Àπàß∑’Ë©’¥
«—§´’π (√âÕ¬≈– 30-50) ‡™àπ Õ“°“√∫«¡ ·¥ß ‡®Á∫„πμ”·Àπàß∑’Ë©’¥¬“ À√◊Õ¡’‰¢â
·≈–æ∫«à“Õ“°“√¢â“߇§’¬ßæ∫∫àÕ¬¢÷Èπ „π°“√©’¥«—§´’π PPV-23 ´È”
μ“√“ß∑’Ë 1 §”·π–π”°“√„Àâ«—§´’πªÑÕß°—π‚√§ ”À√—∫ºŸâ„À≠à ·≈–ºŸâ ŸßÕ“¬ÿ ¥—¥·ª≈ß®“°
§”·π–π”¢Õß√“™«‘∑¬“≈—¬Õ“¬ÿ√·æ∑¬å·Ààߪ√–‡∑»‰∑¬ ªï 2557
89
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 3)
μ“√“ß∑’Ë 2 §”·π–π”„π°“√„À«—§´’πªÑÕß°—π‚√§ ”À√—∫ºŸâ„À≠à ·≈–ºŸâ ŸßÕ“¬ÿ∑’Ë¡’‚√§
ª√–®”μ—« À≠‘ßμ—Èߧ√√¿å ·≈–∫ÿ§≈“°√∑“ß°“√·æ∑¬å ¥—¥·ª≈ß®“°§”
·π–π”¢Õß√“™«‘∑¬“≈—¬Õ“¬ÿ√·æ∑¬å·Ààߪ√–‡∑»‰∑¬ ªï 2557
90
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
‡Õ° “√Õâ“ßÕ‘ß1. Jefferson T, Di Pietrantonj C, Al-Ansary LA, Ferroni E, Thorning S, Thomas RE.
Vaccines for preventing influenza in the elderly (Review)Cochrane Database SystRev 2010 Feb 17;2: CD004876.
2. Wongsurakiat P, Maranetra KN, Wasi C, Kositanont U, Dejsomritrutai W,Charoenratanakul S. Acute respiratory illness in patients with COPD and theeffectiveness of influenza vaccination: a randomized controlled study. Chest2004;125:2011-20.
3. The Global Strategy for the Diagnosis, Management and Prevention of COPD,Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015. Availablefrom: http://www.goldcopd.org
4. §”·π–π”°“√„Àâ«—§´’πªÑÕß°—π‚√§ ”À√—∫ºŸâ„À≠à·≈–ºŸâ ŸßÕ“¬ÿ (Recommended Adult andElderly Immunization Schedule) √“™«‘∑¬“≈—∫Õ“¬ÿ√·æ∑¬å·Ààߪ√–‡∑»‰∑¬ ªï æ.». 2557.http://www.rcpt.org/index.php/2012-10-03-16-53-39/category/6-2013-02-02-09-02-52.html
5. Kobayashi M, Bennett NM, Gierke R, Almendares O, Moore MR, Whitney CG,Pilishvili T. Interval Between PCV13 and PPSV23 Vaccines: Recommendations ofthe Advisory Committee on Immunization Practices (ACIP). MMWR Morb MortalWkly Rep. 2015;64:944-7.
91
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¿“§ºπ«° 4
°“√øóôπøŸ ¡√√∂¿“æªÕ¥(Pulmonary rehabilitation)
𑬓¡ °“√øóôπøŸ ¡√√∂¿“æªÕ¥ §◊Õ ‚ª√·°√¡°“√¥Ÿ·≈ºŸâªÉ«¬∑’Ë∑ÿææ≈¿“æ
®“°‚√§√–∫∫°“√À“¬„®‡√◊ÈÕ√—ß ‚¥¬∑’¡∫ÿ§≈“°√®“° À “¢“ ‚ª√·°√¡¥—ß°≈à“«
“¡“√∂ÕÕ°·∫∫À√◊Õª√—∫‡ª≈’ˬπ‰¥â‡æ◊ËÕ„Àâ‡À¡“– ¡°—∫ ¿“æ —ß§¡ ·≈– ∂“π∑’Ë
μ≈Õ¥®π¡’§«“¡§≈àÕßμ—«„π°“√ªØ‘∫—μ‘
°“√øóôπøŸ ¡√√∂¿“æªÕ¥ ‡ªìπ°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬·∫∫Õߧå√«¡ ∑’ˇ √‘¡
‡æ‘Ë¡‡μ‘¡º≈®“°°“√√—°…“¥â«¬¬“ ‚ª√·°√¡øóôπøŸ ¡√√∂¿“æªÕ¥∑’Ë¡’§ÿ≥¿“æ ®–¡’
º≈∑”„À⺟âªÉ«¬¡’Õ“°“√‡Àπ◊ËÕ¬≈¥≈ß §«“¡ “¡“√∂„π°“√ÕÕ°°”≈—ß°“¬‡æ‘Ë¡¢÷Èπ
§ÿ≥¿“æ™’«‘μ¥’¢÷Èπ ·≈–°“√°”‡√‘∫¢Õß‚√§≈¥≈ß ‚¥¬º≈¥’¥—ß°≈à“«∑—ÈßÀ¡¥®– àߺ≈
‚¥¬∑“ßÕâÕ¡ ∑”„Àâ§à“„™â®à“¬„π°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬≈¥≈ß (μ“√“ß∑’Ë 1)
∫ÿ§≈“°√ À “¢“∑’ˇ°’ˬ«¢âÕß„π°“√¥”‡π‘π‚ª√·°√¡øóôπøŸ ¡√√∂¿“æªÕ¥
‰¥â·°à ·æ∑¬å 欓∫“≈ π—°‡∑§π‘§¥â“π°“√∑¥ Õ∫ ¡√√∂¿“æªÕ¥ ‡¿ —™°√ π—°
°“¬¿“æ∫”∫—¥ ‚¿™π“°√ π—° —ߧ¡«‘∑¬“ μ≈Õ¥®πºŸâªÉ«¬∑’ˇ§¬‰¥â√—∫°“√√—°…“
μ“¡‚ª√·°√¡øóôπøŸ ¡√√∂¿“æªÕ¥¡“·≈â« ‡ªìπμâπ À√◊ÕÕ“®®–‡ªìπ∫ÿ§≈“°√Õ◊Ëπ∑’Ë
‰¥â√—∫°“√Ωñ°Ωπμ“¡§«“¡‡À¡“– ¡
92
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¢Õ∫¢à“¬¢Õß°“√øóôπøŸ ¡√√∂¿“æªÕ¥
(Scopes of pulmonary rehabilitation) ª√–°Õ∫¥â«¬
1. Patient selection and assessment
2. Pulmonary rehabilitation setting
- Hospital-based (in-patient, out-patient)
- Community-based
- Home-based
μ“√“ß∑’Ë 1 ª√–‚¬™πå¢Õß°“√øóôπøŸ ¡√√∂¿“æªÕ¥„πºŸâªÉ«¬ COPD
ª√–‚¬™πå
≈¥Õ“°“√‡Àπ◊ËÕ¬
‡æ‘Ë¡§«“¡ “¡“√∂„π°“√ÕÕ°°”≈—ß°“¬
‡æ‘Ë¡§ÿ≥¿“æ™’«‘μ
°“√øóôπμ—«‡√Á«¢÷ÈπÀ≈—ß°“√πÕπ‚√ß欓∫“≈¥â«¬¿“«–°”‡√‘∫
≈¥Õ—μ√“°“√πÕπ‚√ß欓∫“≈ ·≈–≈¥®”π«π«—π∑’ËμâÕßπÕπ„π
‚√ß欓∫“≈
≈¥§«“¡«‘μ°°—ß«≈ ·≈–¿“«–´÷¡‡»√â“∑’ˇ°’ˬ«¢âÕß°—∫ COPD
‡æ‘Ë¡Õ—μ√“°“√√Õ¥™’«‘μ
‡ √‘¡ƒ∑∏‘Ï¢Õß long-acting bronchodilator
‡æ‘Ë¡§«“¡·¢Áß·√ß·≈–∑π∑“π¢Õß°≈â“¡‡π◊ÈÕ·¢π
ª√–‚¬™π宓°°“√øóôπøŸœ ¬—ߧ߉¥â√—∫·¡âæâπ™à«ßΩñ°œ
°“√Ωñ°°≈â“¡‡π◊ÈÕÀ“¬„®¡’ª√–‚¬™πå ‚¥¬‡©æ“–‡¡◊ËÕ∑”√à«¡°—∫°“√
Ωñ°ÕÕ°°”≈—ß°“¬∑—Ë«‰ª
§ÿ≥¿“æÀ≈—°∞“π
√–¥—∫
1
1
1
1
1
1
2
2
2
2
3
93
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3. Program content
- Patient education
- Exercise training
- Psychosocial and behavioral intervention
- Nutritional assessment
- Outcome assessment
1. °“√ª√–‡¡‘𧫓¡√ÿπ·√ߢÕß‚√§ ·≈–°“√§—¥‡≈◊Õ°ºŸâªÉ«¬‡æ◊ËÕ‡¢â“‚ª√·°√¡
(patient selection and assessment)
ºŸâªÉ«¬∑’˧«√‰¥â√—∫°“√øóôπøŸ ¡√√∂¿“æªÕ¥ ‰¥â·°à ºŸâªÉ«¬∑’Ë¡’Õ“°“√‡Àπ◊ËÕ¬
‡√◊ÈÕ√—ß ®π§ÿ°§“¡°“√¥”‡π‘π™’«‘쪰쑪√–®”«—π °àÕ„À⇰‘¥¢âÕ®”°—¥μà“ßÊ ∑—Èߥâ“π
°“√ÕÕ°°”≈—ß°“¬ °“√ª√–°Õ∫°‘®°√√¡πÕ°∫â“π À√◊Õ°‘®°√√¡æ◊Èπ∞“π∑“ß —ߧ¡
‡°‘¥§«“¡«‘μ°°—ß«≈ ·≈–§«“¡°≈—«∑’Ë®–Õ¬Ÿà§π‡¥’¬« ®”‡ªìπμâÕßæ÷Ëß擺ŸâÕ◊Ëπ
°“√§—¥‡≈◊Õ°ºŸâªÉ«¬‡æ◊ËÕ„À⇢Ⓜª√·°√¡øóôπøŸ ¡√√∂¿“æªÕ¥ ‚¥¬∑—Ë«‰ª®–
ª√–‡¡‘πμ“¡Õ“°“√À√◊Õ§«“¡∑ÿææ≈¿“殓°‚√§ §«“¡√ÿπ·√ߢÕß‚√§ ÷Ëߪ√–‡¡‘π
®“° pulmonary function tests À√◊Õ arterial blood gases
πÕ°®“°π’È „πºŸâªÉ«¬∑’ˇæ‘Ëßøóôπ®“°°“√°”‡√‘∫ (COPD exacerbation) ¡’
§«“¡®”‡ªìπ∑’Ë®–μâÕ߇√‘Ë¡°“√øóôπøŸ ¡√√∂¿“æªÕ¥„Àâ‡√Á«¢÷Èπ ·π–π”‡√‘Ë¡∑—π∑’À≈—ß
®“°À“¬®“°Õ“°“√°”‡√‘∫ À√◊ÕÕ¬à“ߙⓇ√‘Ë¡¿“¬„π 4 —ª¥“Àå ‚¥¬ “¡“√∂∑”‰¥â
μ—Èß·μà™à«ß∑’ˬ—ßπÕπ‚√ß欓∫“≈ ‡™àπ °“√Ωñ° early mobilization °“√Ωñ°°”≈—ߢÕß
°≈â“¡‡π◊ÈÕ¡—¥‡≈Á°Ê (resistance exercises for small muscle groups) °“√
‡§≈◊ËÕπ¬â“¬ °“√∑√ßμ—« °“√‡¥‘π (gait and transfer) „π°≈ÿࡺŸâªÉ«¬∑’Ë¡’ªí≠À“
‡ ¡À–¡“° ·π–π”∑” √’√–∫”∫—¥À≈Õ¥≈¡ (bronchial hygiene therapy) ·≈–
Ωñ°°“√À“¬„® (breathing exercises) ·≈–§«√¡’ª√–‡¡‘π´È”°àÕπ°≈—∫∫â“π‡æ◊ËÕ
94
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
ª√—∫‚ª√·°√¡°“√øóôπøŸ ¡√√∂¿“æªÕ¥„À⇪ìπ‰ªÕ¬à“ßμàÕ‡π◊ËÕ߇¡◊ËÕμ‘¥μ“¡°“√
√—°…“‡ªìπºŸâªÉ«¬πÕ° (§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” ++)
2. √Ÿª·∫∫¢Õß‚ª√·°√¡ (pulmonary rehabilitation setting)
‚ª√·°√¡°“√øóôπøŸ ¡√√∂¿“æªÕ¥ “¡“√∂„™â ‰¥â∑—Èß„π‚√ß欓∫“≈ (hos-
pital-based) „π™ÿ¡™π (community-based) À√◊Õ∑’Ë∫â“π (home-based)
∑—Èßπ’È¢÷ÈπÕ¬Ÿà°—∫§«“¡‡À¡“– ¡ ·≈–§«“¡§≈àÕßμ—« Õ¬à“߉√°Áμ“¡ ‚ª√·°√¡∑’Ë¡’
ª√– ‘∑∏‘¿“æ ·≈–‡ªìπ∑’Ëπ‘¬¡¡“°∑’Ë ÿ¥ §◊Õ‚ª√·°√¡øóôπøŸ ¡√√∂¿“æªÕ¥∑’Ë„™â„π
‚√ß欓∫“≈·∫∫ºŸâªÉ«¬πÕ°
°“√‡≈◊Õ°‚ª√·°√¡°“√øóôπøŸœ ®–μâÕߪ√—∫„À⇢⓰—∫§«“¡ –¥«°¢ÕߺŸâªÉ«¬
·≈–∫ÿ§≈“°√ ®”μâÕߧ”π÷ß∂÷ß»—°¬¿“æ ·≈–§à“„™â®à“¬∑’Ë®–‡°‘¥¢÷Èπ¢Õß·μà≈– ∂“∫—π
¥â«¬
3. Õߧåª√–°Õ∫¢Õß‚ª√·°√¡ (program content) ‰¥â·°à
3.1 °“√„Àâ°“√»÷°…“·°àºŸâªÉ«¬ (patient education)
‰¥â·°à §«“¡√Ÿâ‡°’ˬ«°—∫‚√§ §«“¡√Ÿâ‡√◊ËÕ߬“ ·≈–«‘∏’°“√„™â¬“ ª√–‚¬™πå
¢Õß°“√øóôπøŸ ¡√√∂¿“æªÕ¥ °“√À¬ÿ¥ Ÿ∫∫ÿÀ√’Ë °“√ªØ‘∫—μ‘μ—«‡¡◊ËÕ‡Àπ◊ËÕ¬ À√◊Õ
‡¡◊ËÕ‚√§°”‡√‘∫ °“√∫”∫—¥¥â«¬ÕÕ° ‘‡®π °“√¥Ÿ·≈√—°…“¿“«–‚¿™π“°“√∑’ˇÀ¡“– ¡
μ≈Õ¥®π°“√§«∫§ÿ¡¿“«–Õ“√¡≥å·≈–®‘μ„® ‡ªìπμâπ πÕ°®“°π—Èπ¬—ߧ√Õ∫§≈ÿ¡∂÷ß
°“√«“ß·ºπ™’«‘μμπ‡Õ߇¡◊ËÕ‚√§‡¢â“ Ÿà√–¬– ÿ¥∑⓬
3.2 Ωñ°°“√À“¬„® (breathing exercise) ‡™àπ pursed-lip breathing,
diaphragmatic breathing ‡ªìπμâπ
3.3 °“√Ωñ°ΩπÕÕ°°”≈—ß°“¬ (exercise training)
°“√Ωñ°Ωπ°“√ÕÕ°°”≈—ß°“¬ ‡ªìπÕߧåª√–°Õ∫∑’Ë ”§—≠∑’Ë ÿ¥¢Õß°“√
95
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 4)
øóôπøŸ ¡√√∂¿“æªÕ¥ ∑’Ë “¡“√∂‡ª≈’ˬπº≈≈—æ∏å¢Õß‚ª√·°√¡‰¥â ‚ª√·°√¡°“√
ÕÕ°°”≈—ß°“¬∑’Ë¡’ª√– ‘∑∏‘¿“æ ®”‡ªìπμâÕ߇πâπ°“√Ωñ°Ωπ∑—Èߥâ“π strength training
§«∫§Ÿà‰ª°—∫ endurance training ·≈–∑”°“√Ωñ°ΩπÕ¬à“ßμàÕ‡π◊ËÕ߇ªìπ√–¬–‡«≈“
∑’Ëπ“πæÕ º≈≈—æ∏宓°°“√Ωñ°ΩπÕÕ°°”≈—ß°“¬π’È®–∑”„À⺟âªÉ«¬¡’§«“¡ “¡“√∂„π
°“√ÕÕ°°”≈—ß°“¬‰¥âÀπ—°¢÷Èπ ·≈–∑π∑“π¢÷Èπ (increase maximum work rate
and exercise endurance time) §«“¡ “¡“√∂„π°“√À“¬„®‡¢â“ (inspiratory
capacity, IC) ‡æ‘Ë¡¢÷Èπ Õ—μ√“°“√À“¬„® ·≈–√–¥—∫§«“¡‡Àπ◊ËÕ¬ (dyspnea scale)
„π¢≥–ÕÕ°°”≈—ß°“¬≈¥≈ß àߺ≈„ÀâÕ—μ√“°“√À“¬„® ·≈–§ÿ≥¿“æ™’«‘μ‚¥¬Õߧå√«¡
(health-related quality of life, HRQoL) ¥’¢÷Èπ
°“√øóôπøŸ ¡√√∂¿“æªÕ¥ §«√∑”Õ¬à“ßπâÕ¬ 6 —ª¥“Àå ‚¥¬¬‘Ëß∑”μàÕ‡π◊ËÕß
π“𠬑Ë߉¥âª√– ‘∑∏‘º≈¡“° º≈ª√–‚¬™π宓°°“√øóôπøŸœ ∑’˺ŸâªÉ«¬‰¥â√—∫ ®–¬—ߧßÕ¬Ÿà
·¡â®∫‚ª√·°√¡°“√ÕÕ°°”≈—ß°“¬‰ª·≈â«π“π∂÷ß 12 ‡¥◊Õπ ‚¥¬‡©æ“– ª√–‚¬™πå
„π°“√‡æ‘Ë¡§«“¡ “¡“√∂„π°“√ÕÕ°°”≈—ß°“¬ ≈¥Õ“°“√ÀÕ∫‡Àπ◊ËÕ¬®“°°“√∑”
°‘®°√√¡ ‡æ‘Ë¡§ÿ≥¿“æ™’«‘μ ‡ªìπμâπ ºŸâªÉ«¬§πÀπ÷ËßÊ “¡“√∂‡¢â“‚ª√·°√¡°“√øóôπøŸœ
‰¥â´È” À“°ª√–‡¡‘π«à“πà“®–‰¥âª√–‚¬™πå‡æ‘Ë¡‡μ‘¡Õ’°
∫∑ √ÿª®“°°“√»÷°…“μà“ßÊ æ∫«à“ °“√Ωñ°ΩπÕÕ°°”≈—ß°“¬∑’Ë¡’ª√– ‘∑∏‘¿“æ
ª√–°Õ∫¥â«¬
°. °“√Ωñ°ΩπÕÕ°°”≈—ß°“¬·∫∫ endurance exercise training ‚¥¬«‘∏’
°“√¢’Ë®—°√¬“πÕ¬Ÿà°—∫∑’Ë (stationary cycling) À√◊Õ°“√‡¥‘π-«‘Ëß (treadmill or shuttle
walking)
¢. °“√ÕÕ°°”≈—ß°“¬μàÕ‡π◊ËÕß Õ¬à“ßπâÕ¬ 6 —ª¥“Àå¢÷Èπ‰ª ‚¥¬ÕÕ°°”≈—ß°“¬
—ª¥“Àå≈–Õ¬à“ßπâÕ¬ 3-5 §√—Èß §√—Èß≈– 20-60 π“∑’ ‚¥¬§«“¡∂’Ë·≈–√–¬–‡«≈“
¢Õß°“√ÕÕ°°”≈—ß°“¬Õ“®°”À𥮓°√–¥—∫§«“¡Àπ—°‡∫“¢Õß°“√ÕÕ°°”≈—ß°“¬
(intensity) ¥—ßμ“√“ß∑’Ë 2
96
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
°“√»÷°…“®“°‚√ß欓∫“≈√“¡“∏‘∫¥’ æ∫«à“ °“√Ωñ°ΩπÕÕ°°”≈—ß°“¬‚¥¬
ª√–¬ÿ°μå„™â∑à“√”¡«¬®’π Tai Chi Qigong (´÷Ë߇ªìπ moderate intensity exercise)
§«∫§Ÿà°—∫°“√§«∫§ÿ¡°“√À“¬„®·∫∫ pursed-lip §√—Èß≈– 30 π“∑’ —ª¥“Àå≈– > 5
§√—Èß ‡ªìπ‡«≈“π“π 6 —ª¥“Àå¢÷Èπ‰ª ®–¡’º≈∑”„À⺟âªÉ«¬¡’§«“¡ “¡“√∂„π°“√
ÕÕ°°”≈—ß°“¬‡æ‘Ë¡¢÷Èπ (increase maximum exercise capacities and functional
exercise capacities) §«“¡ “¡“√∂„π°“√À“¬„®‡¢â“ (IC) ¢≥–ÕÕ°°”≈—ß°“¬
‡æ‘Ë¡¢÷Èπ °≈â“¡‡π◊ÈÕÀ“¬„®·¢Áß·√ߢ÷Èπ §ÿ≥¿“æ™’«‘μ (HRQoL) ¥’¢÷Èπ ·≈–§«“¡
‡Àπ◊ËÕ¬≈¥≈ß ∑—Èßπ’È√–¥—∫º≈∑’Ë¥’¢÷Èπ Õ¬Ÿà„π‡°≥±å∑’ˇ∑’¬∫‡§’¬ß‰¥â ·≈–‰¡àπâÕ¬°«à“°“√
Ωñ°Ωπ‚¥¬«‘∏’ cycling À√◊Õ walking ·μà¡’¢âÕ¥’μ√ß∑’˪ؑ∫—쑉¥âæ√âÕ¡°—π‡ªìπ°≈ÿà¡
μ“√“ß∑’Ë 2 °“√°”À𥧫“¡∂’Ë¢Õß°“√ÕÕ°°”≈—ß°“¬μ“¡§«“¡Àπ—°‡∫“ ·≈–«‘∏’°“√ª√–‡¡‘π
§«“¡Àπ—°¢Õß
°“√ÕÕ°°”≈—ß°“¬
(intensity)
√–¥—∫ª“π°≈“ß
(moderate)
(recommend)
√–¥—∫μË” (low)
(*alternative)
μ—«Õ¬à“ß
°‘®°√√¡
°“√‡¥‘π‡√Á«
°“√«‘Ëß
°“√√”‰∑™‘
°“√¢’Ë®—°√¬“π
°“√‡μâπ√”
°“√∑”ß“π∫â“π
À√◊Õ∑” «π
°“√‡¥‘π
°“√·°«àß·¢π
§«“¡∂’Ë
> 5 §√—ÈßμàÕ
—ª¥“Àå
> 5 §√—ÈßμàÕ
—ª¥“Àå
√–¬–‡«≈“
20-60 π“∑’
μàÕ«—π
20-60 π“∑’
μàÕ«—π
°“√ª√–‡¡‘π‡æ◊ËÕ
‡∑’¬∫§«“¡Àπ—°‡∫“*
(‡≈◊Õ°)
- Borg scale ∂÷ß√–¥—∫ 4-6
- HR ‡æ‘Ë¡ 20-50 §√—ÈßμàÕ
π“∑’ ®“° baseline
- Borg scale ∂÷ß√–¥—∫ 3-4
- HR ‡æ‘Ë¡ 20 §√—ÈßμàÕπ“∑’
®“° baseline
*°√≥’‰¡à “¡“√∂ÕÕ°°”≈—ß°“¬√–¥—∫ moderate intensity
97
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 4)
·≈–Ωñ°Ωπ‡Õß∑’Ë™ÿ¡™π À√◊Õ∑’Ë∫â“π‰¥â ‚¥¬‰¡àμâÕß„™âÕÿª°√≥å√“§“ Ÿß πÕ°®“°π’Ȭ—ß
æ∫«à“ ¡’º≈≈¥°“√°”‡√‘∫‡©’¬∫æ≈—π°“√¡“√—°…“¥à«π∑’Ë·ºπ°©ÿ°‡©‘π
°“√»÷°…“„πμà“ߪ√–‡∑» æ∫«à“ °“√ÕÕ°°”≈—ß°“¬¥â«¬ Tai Chi Qigong
¬—߉¥âª√–‚¬™πå„πºŸâ ŸßÕ“¬ÿÀ≈“¬¥â“𠇙àπ ¥â“π°“√∑√ßμ—« (balance) §«“¡¬◊¥À¬ÿàπ
(flexibility) §«“¡·¢Áß·√ߢÕß°≈â“¡‡π◊ÈÕ (muscle strength) √–∫∫‰À≈‡«’¬π‚≈À‘μ
(cardiovascular fitness) °“√√—∫√Ÿâ (cognition) §ÿ≥¿“æ°“√πÕπÀ≈—∫ (sleep
quality) °“√ª√—∫Õ“√¡≥å (emotional functioning) ´÷ËߺŸâªÉ«¬ COPD Õ¬Ÿà„π
«—¬ ŸßÕ“¬ÿ‡ªìπ à«π„À≠à ®÷ßπà“®–‡À¡“–°—∫°“√ÕÕ°°”≈—ß°“¬™π‘¥π’ÈπÕ°®“°π’È
¢âÕ¡Ÿ≈°“√ÕÕ°°”≈—ß°“¬‰∑™‘„πºŸâªÉ«¬ COPD Õ¬à“ßπâÕ¬ 12 —ª¥“Àå æ∫«à“ “¡“√∂
‡æ‘Ë¡§«“¡ “¡“√∂„π°“√‡¥‘π («—¥‚¥¬ 6MWT) ‡æ‘Ë¡§ÿ≥¿“æ™’«‘μ («—¥‚¥¬ SGRQ)
≈¥Õ—μ√“°“√°”‡√‘∫‡©’¬∫æ≈—π
°“√»÷°…“®“°‚√ß欓∫“≈¡À“√“™π§√‡™’¬ß„À¡à ‚¥¬„™â‚ª√·°√¡ Suandok
Exercise Training (SET) æ∫«à“‰¥âº≈¥’∑—Èß„π√–¬– —Èπ ·≈–√–¬–¬“« ∑”„ÀâÕ“°“√
ÀÕ∫‡Àπ◊ËÕ¬≈¥≈ß °≈â“¡‡π◊ÈÕ·¢π - ¢“·¢Áß·√ߢ÷È𠧫“¡§ß∑π„π°“√ÕÕ°°”≈—ß
‡æ‘Ë¡¢÷Èπ ∑”°‘®°√√¡ª√–®”‰¥â¡“°¢÷Èπ §ÿ≥¿“æ™’«‘μ¥’¢÷Èπ ·≈–‚√§°”‡√‘∫‰¥â¬“°
Õÿª°√≥å∑’Ë„™â„π°“√Ωñ° „™â‡ªìπ®—°√¬“π¡◊Õ (arm ergometer) ®—°√¬“π‡∑â“ (leg
ergometer) ‡¥‘π∫𠓬æ“π (treadmill) À√◊ÕÕ“®ª√–¬ÿ°μå„™âÕÿª°√≥å∑’Ë “¡“√∂
À“‰¥âßà“¬ ·≈–√“§“∂Ÿ° ‡™àπ dumbbell ∂ÿß∑√“¬ ·≈–¬“߬◊¥ (theraband) ÷Ëß
“¡“√∂„À⺟âªÉ«¬π”‰ªΩñ°μàÕ‡π◊ËÕß∑’Ë∫â“πÀ≈—ß ‘Èπ ÿ¥‚ª√·°√¡‰¥â
à«π°“√„™â‚ª√·°√¡ modified Suandok exercise training (MSET)
‚¥¬„™âÕÿª°√≥å∑’ËÀ“‰¥âßà“¬ √“§“‰¡à·æß „π°“√Ωñ°°≈â“¡‡π◊ÈÕ·¢π¢“ ¥â«¬°“√¬°
πÈ”Àπ—° (weight lifting and resistive loading) Ωñ°§«“¡§ß∑π„π°“√ÕÕ°°”≈—ß°“¬
‚¥¬°“√‡¥‘π„πæ◊Èπ√“∫ (low to moderate intensity) ¡’∫ÿ§≈“°√‚√ß欓∫“≈„Àâ
98
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
§”·π–π” (supervised) μ≈Õ¥ ¡’°“√«Õ√å¡Õ—æ 10-15 π“∑’°àÕπ‡√‘Ë¡ ‡√‘Ë¡∑”°“√
ÕÕ°°”≈—ß°“¬√–¬–‡«≈“ —ÈπÊ °àÕπ ·≈⫧àÕ¬Ê ‡æ‘Ë¡¢÷Èπ∑ÿ° 2 —ª¥“Àå ®π‰¥â√–¬–
‡«≈“ 35-40 π“∑’μàÕ§√—Èß ‚¥¬∑” 2 §√—ÈßμàÕ —ª¥“À凪ìπ‡«≈“ 8 —ª¥“Àå æ∫«à“
ª√–‚¬™πå∑’ˉ¥â®“°°“√ÕÕ°°”≈—ß°“¬ §◊Õ ≈¥Õ“°“√ÀÕ∫‡Àπ◊ËÕ¬ ·¡âÀ¬ÿ¥‚ª√·°√¡
‰ª·≈â«∂÷ß 9 ‡¥◊Õπ ‡æ‘Ë¡§«“¡ “¡“√∂„π°“√ÕÕ°°”≈—ß°“¬ ·≈–‡æ‘Ë¡§ÿ≥¿“æ™’«‘μ
ºŸâªÉ«¬ ·¡âÀ¬ÿ¥‚ª√·°√¡‰ª∂÷ß 12 ‡¥◊Õπ
ºŸâªÉ«¬∑’Ë¡’¢âÕ®”°—¥„π°“√ÕÕ°°”≈—ß°“¬ ·≈–‰¡à “¡“√∂Ωñ°Ωπ√à“ß°“¬
μ“¡‚ª√·°√¡μà“ßÊ ‰¥â Õ“®Ωñ°‡ªìπ≈—°…≥– interval training §◊Õ ∑”°“√ÕÕ°
°”≈—ß°“¬ ≈—∫°—∫æ—°‡ªìπ√–¬–Ê ‚¥¬¢âÕ¥’§◊Õ‰¡à∑”„À⺟âªÉ«¬‡Àπ◊ËÕ¬‡°‘π‰ª °“√ª√—∫
‚ª√·°√¡§«“¡Àπ—°‡∫“ √–¬–‡«≈“∑’ËÕÕ°°”≈—ß°“¬ √–¬–‡«≈“æ—° ‰¡à쓬엫 ·μà
¡’À≈—°∞“π«à“‰¥âª√–‚¬™πå∑—Èß„π·ßà‡æ‘Ë¡§«“¡ “¡“√∂„π°“√ÕÕ°°”≈—ß°“¬ ∑”„Àâ
§ÿ≥¿“æ™’«‘μ¥’¢÷Èπ ·≈–Õ“®‰¥âª√–‚¬™π宓°°“√ÕÕ°°”≈—ß°“¬ßà“¬Ê ‡™àπ °“√°“ß
·¢π ‡À«’ˬ߷¢π¢÷Èπ≈ß °“√°√–¥°¢“ ·≈–°“√∫‘¥μ—« œ≈œ °‘®°√√¡ßà“¬Ê ‡À≈à“π’È
À“°∑”æ√âÕ¡°—∫°“√Ωñ°Ωπ°“√À“¬„®·∫∫ pursed-lip Õ¬à“ß ¡Ë”‡ ¡Õ®π‡§¬™‘π
Õ“®™à«¬∫√√‡∑“§«“¡‡Àπ◊ËÕ¬
„πºŸâªÉ«¬∑’Ë¡’ desaturation √–À«à“ßÕÕ°°”≈—ß°“¬ À√◊Õ‡ªìπºŸâªÉ«¬∑’Ë
‡¢â“‡°≥±å∑’Ë®–‰¥â√—∫ÕÕ°´‘‡®πÕ¬Ÿà·≈â« (long term oxygen therapy) ·π–π”„Àâ
ÕÕ°´‘‡®π‡ √‘¡ (supplemental oxygen) ∑”„Àâ°“√ÕÕ°°”≈—ß°“¬¥’¢÷Èπ
3.4 Psychosocial and behavioral intervention
§«“¡™à«¬‡À≈◊Õ∑’˙૬‡ √‘¡ √â“ߧ«“¡¡—Ëπ§ß∑“ßÕ“√¡≥å ·≈–®‘μ„®
μ≈Õ¥®π°“√ª√—∫‡ª≈’ˬπæƒμ‘°√√¡°“√¥”‡π‘π™’«‘μ„Àâ‡À¡“– ¡ ‡™àπ °“√·π–π”
Õ“™’æ °“√·π–π”°“√ªØ‘∫—μ‘μ—«‡æ◊ËÕÀ≈’°‡≈’ˬߧ«“¡‡Àπ◊ËÕ¬ (energy conservation
technique) °“√ √â“߇§√◊Õ¢à“¬ À√◊Õ√«¡°≈ÿࡺŸâªÉ«¬∑’Ë¡’‚√§§≈⓬§≈÷ß°—π„Àâ¡’°‘®°√√¡
99
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 4)
∑’Ë√à«¡°—π À√◊Õ·≈°‡ª≈’Ë¬π§«“¡§‘¥‡ÀÁπª√– ∫°“√≥å°—π μ≈Õ¥®π°“√¡’∑’˪√÷°…“
¬“¡ºŸâªÉ«¬¡’ªí≠À“ ‘Ëßμà“ßÊ ‡À≈à“π’È≈â«π¡’º≈ ”§—≠μàÕ ÿ¢¿“æ∑“ß°“¬·≈–„®‚¥¬
Õߧå√«¡ Õ—π®–∑”„À⺟âªÉ«¬μàÕ Ÿâ°—∫‚√§ ·≈–¡’™’«‘μ„π —ߧ¡‰¥â¥’¢÷Èπ
3.5 °“√ª√–‡¡‘π¥â“π‚¿™π“°“√ (nutritional assessment)
ºŸâªÉ«¬ COPD ∑’Ë¡’πÈ”Àπ—°πâÕ¬ ¡’§«“¡ —¡æ—π∏å°—∫Õ—μ√“쓬∑’Ë Ÿß¢÷Èπ
§«√ª√–‡¡‘π¿“«–‚¿™π“°“√¢ÕߺŸâªÉ«¬ ‡™àπ «—¥πÈ”Àπ—°μ—« §à“ body mass
index (BMI) ª√‘¡“≥‰¢¡—π ¡«≈°≈â“¡‡π◊ÈÕ °àÕπ°“√øóôπøŸ ¡√√∂¿“槫√„Àâ°“√
·π–π”¥â“π‚¿™π“°“√§«∫§Ÿà°—∫°“√ÕÕ°°”≈—ß°“¬‡æ◊ËÕª√—∫ ¡¥ÿ≈¬å¢ÕßπÈ”Àπ—°μ—«
·≈–¿“«–‚¿™π“°“√„ÀâÕ¬Ÿà„π‡°≥±å„°≈⇧’¬ßª°μ‘¡“°∑’Ë ÿ¥
3.6 °“√ª√–‡¡‘πº≈≈—æ∏å¢Õß°“√øóôπøŸ ¡√√∂¿“æªÕ¥ (outcome assess-
ment)
°“√ª√–‡¡‘πº≈≈—æ∏宓°°“√øóôπøŸ ¡√√∂¿“æªÕ¥π’È ®”‡ªìπÕ¬à“߬‘Ëß
·≈–μâÕß∑”‡ª√’¬∫‡∑’¬∫ºŸâªÉ«¬ ‡¡◊ËÕ°àÕπ‡¢â“‚ª√·°√¡ ·≈– 6-12 —ª¥“ÀåÀ≈—߇¢â“
‚ª√·°√¡ ‡æ√“–‰¡à‡æ’¬ß·μà®–∑”„À⺟âªÉ«¬‰¥â√—∫√Ÿâ§«“¡‡ª≈’ˬπ·ª≈ß„π∑“ß∑’Ë¥’ ∑’ˇ°‘¥
¢÷ÈπÀ≈—ß°“√øóôπøŸ ¡√√∂¿“æªÕ¥ ¬—߇ªìπ°“√ª√–‡¡‘π»—°¬¿“æ ·≈–ª√– ‘∑∏‘¿“æ
¢Õß‚ª√·°√¡∑’Ë„™â„π ∂“∫—ππ—ÈπÊ À≈—ß®“°π—Èπ§«√∑”°“√ª√–‡¡‘πÕ¬à“ßπâÕ¬∑ÿ°
1 ªï ∑—Èßπ’ȇæ◊ËÕ‡ªìπ°”≈—ß„®„À⺟âªÉ«¬μ‘¥μ“¡‚ª√·°√¡μàÕ‰ª„Àâπ“π∑’Ë ÿ¥ ·≈– ∂“∫—π
‰¥â∑”°“√∑∫∑«πª√—∫‡ª≈’ˬπ‚ª√·°√¡¢Õßμπ‡Õß„Àâ‡À¡“– ¡¬‘ËßÊ ¢÷Èπ Õߧå
ª√–°Õ∫ ”§—≠∑’˧«√ª√–‡¡‘π§◊Õ
°. §«“¡ “¡“√∂„π°“√ÕÕ°°”≈—ß°“¬ (exercise capacity) ‚¥¬°“√
«—¥ 6-minute walking distance (6-MWD, meters)
¢. ª√–‡¡‘𧫓¡‡Àπ◊ËÕ¬ °àÕπ·≈–À≈—ß°“√ÕÕ°°”≈—ß°“¬ ‚¥¬„™â borg
scale ·≈– modified medical research council (mMRC)
100
¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å
§. ª√–‡¡‘π§ÿ≥¿“æ™’«‘μ ‚¥¬„™â COPD assessment test (CAT) ·≈–/
À√◊Õ St. George Respiratory Questionnaires (SGRQ)
ß. °“√ª√–‡¡‘π¬àÕ¬Õ◊ËπÊ ‡™àπ Õ“°“√‰Õ ª√‘¡“≥‡ ¡À– §«“¡‡Àπ◊ËÕ¬≈â“
(fatigue) ¿“«–‚¿™π“°“√ Õ—μ√“°“√°”‡√‘∫¢Õß‚√§ Õ—μ√“°“√πÕπ‚√ß欓∫“≈
À√◊Õ§à“„™â®à“¬„π°“√√—°…“‚√§
·π–π”„Àâª√–‡¡‘πÕߧåª√–°Õ∫√à«¡°—πÀ≈“¬Õ¬à“ß ≈â«π™à«¬‡ √‘¡„Àâ‡ÀÁπ
ª√–‚¬™πå¢Õß°“√øóôπøŸ ¡√√∂¿“æªÕ¥¡“°¢÷Èπ
‡Õ° “√Õâ“ßÕ‘ß1. The Global Strategy for the Diagnosis, Management and Prevention of COPD,
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015. Availablefrom: http://www.goldcopd.org
2. Tang CY, Blackstock FC, Clarence M, Taylor NF. Early rehabilitation exerciseprogram for inpatients during an acute exacerbation of chronic obstructive pul-monary disease: a randomized controlled trial. J CardiopulmRehabil Prev. 2012;32:163-9.
3. Troosters T, Gosselink R, Decramer M. Short- and long-term effects of outpatientrehabilitation in patients with chronic obstructive pulmonary disease: a randomizedtrial. Am J Med 2000;109:207-12.
4. Griffiths T, Burr M, Campbell I, et al. Results at 1 year of outpatient multidisciplinarypulmonary rehabilitation: a randomised controlled trial. Lancet 2000;355:362-68.
5. WHO: Global strategy on diet, physical activity and health (Intensity of physicalactivity). Available from: http://www.who.int/dietphysicalactivity/physical_activity_intensity/en/
6. Kiatboonsri S, Vorakitvat K, Vongvivat K, Boonsarngsuk V. Effect of Tai Chi Qigongexercise training in stable COPD patients. ERS Meeting Abstracts 2006;28:3186a.
101
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7. Kiatboonsri, S., Amornputtisathaporn N, Siriket S, Boonsarngsuk V, Kiatboonsri C.Tai Chi Qigong exercise training in COPD. Chest Meeting Abstracts 2007;132:535a.
8. Learsanantrakul P, Kiatboonsri S. Outcome of Tai Chi Qigong exercise-basedpulmonary rehabilitation in COPD. Current Chest 2012: TST 2012 Annual MeetingAbstract.
9. Wu W, et al. Effects of Tai Chi on exercise capacity and health-related quality oflife in patient with chronic obstructive pulmonary disease: a systematic reviewand meta-analysis. International Journal of COPD. 2014;9:1253-63.
10. Chan A, et al. The sustaining effects of Tai chi Qigong on physiological healthfor COPD patients: A randomized controlled trial. Complementary Therapy inMedicine. 2013;21:585-94.
11. Pothirat C, Chaiwong W, Phetsuk N. Long-term efficacy of exercise programfor advanced COPD patients. Int J Chron Obstruct Pulmon Dis. 2015 Jan 12;10:133-44.
12. Pothirat C, Chaiwong W, Phetsuk N. Efficacy of a simple and inexpensive trainingprogram for advanced chronic obstructive pulmonary disease patients incommunity hospitals. J Thorac Dis 2015;7(4):637-43.
13. Vasileios A, Peter K, Frits F, Martijn S. Exercise training in pulmonary rehabilita-tion. Clin Chest Med 2014;35:313-22.
14. Kylie H, Anne EH. Strategies to enhance the benefits of exercise training in therespiratory patient. Clin Chest Med 2014;35:323-36.
15. Bolton CE, Bevan-Smith EF, Biakey JD. British Thoracic Society guideline onpulmonary rehabilitation in adults. Thorax 2013;68(suppl2):ii1-30.
16. Spruit MA, Singh S, Garvey C. An official American Thoracic Society/EuropeanRespiratory Society statement: key concepts and advances in pulmonary rehabi-litation-an executive summary. Am J Respir Crit Care Med 2013;188(8):e13-64.
102
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¿“§ºπ«° 5
°“√∫”∫—¥¥â«¬ÕÕ° ‘‡®π√–¬–¬“«(Oxygen therapy)
°“√∫”∫—¥¥â«¬ÕÕ°´‘‡®π ‡ªìπ°“√√—°…“·∫∫ non-pharmacological
treatment „πºŸâªÉ«¬ COPD stage III À√◊Õ IV ´÷Ëß‚√§¡’§«“¡√ÿπ·√ß¡“° ®π¡’
arterial desaturation „π¢≥–ª°μ‘ ‡ªìπ°“√∫”∫—¥¥â«¬ oxygen √–¬–¬“«À√◊Õ
long term oxygen therapy (LTOT)
¢âÕ∫àß™’È : LTOT „Àâ„πºŸâªÉ«¬ stable stage COPD ∑’ˉ¥â√—∫°“√ª√–‡¡‘π„π
¢≥–æ—° (resting) ¢≥–ÕÕ°°”≈—ß°“¬À√◊Õ¢≥–À≈—∫ ·≈â«æ∫«à“¡’§ÿ≥ ¡∫—μ‘¢âÕ„¥
¢âÕÀπ÷Ëߥ—ßμàÕ‰ªπ’È
1. PaO2 < 55 mmHg À√◊Õ SpO2 < 88%
2. PaO2 56-59 mmHg À√◊Õ SpO2 89% ·μàæ∫¡’¿“«–·∑√°´âÕπ
®“° long standing hypoxia ÷ËßÕ∏‘∫“¬®“° “‡ÀμÿÕ◊Ëπ‰¡à‰¥â ‡™àπ erythrocytosis
(Hct > 55%), pulmonary hypertension À√◊Õ right-sided heart failure ‡ªìπμâπ
°“√ª√–‡¡‘πºŸâªÉ«¬∑’ËμâÕß„Àâ LTOT §«√°√–∑”‡¡◊ËÕºŸâªÉ«¬Õ¬Ÿà„π¢≥–ª°μ‘
À√◊Õ¿“¬À≈—ß exacerbation Õ¬à“ßπâÕ¬ 4-6 —ª¥“Àå ‚¥¬∑”°“√ª√–‡¡‘π´È” 2 §√—Èß
Àà“ß°—π 3 —ª¥“Àå
103
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«‘∏’°“√Õÿª°√≥å°“√„ÀâÕÕ°´‘‡®π π‘¬¡„™â nasal cannula ‚¥¬„Àâª√‘¡“≥ÕÕ° ‘‡®π
„πÕ—μ√“°“√‰À≈∑’˧àÕπ¢â“ßμË” (low flow) ‡™àπ 2-3 ≈‘μ√μàÕπ“∑’ ‡æ’¬ßæÕ∑’Ë®–∑”„Àâ
PaO2 > 60 mmHg À√◊Õ SaO2 > 90% ‚¥¬‰¡à∑”„Àâ PaCO2 §—Ëß ‰¡à«à“„π¢≥–æ—°
¢≥–ÕÕ°°”≈—ß°“¬ À√◊Õ¢≥–À≈—∫ à«π√–¬–‡«≈“°“√„ÀâÕÕ° ‘‡®π ®”‡ªìπ®–μâÕß
‰¥â√—∫Õ¬à“ßπâÕ¬«—π≈– 15 ™—Ë«‚¡ß (15-24 ™—Ë«‚¡ß) ®÷ß®–¡’º≈°“√‡ª≈’ˬπ·ª≈ß
∑“ß √’√«‘∑¬“„π∑“ß∑’Ë¥’¢÷Èπ °≈à“«§◊Õ ¿“«– erythrocytosis, pulmonary
hypertension ·≈–Õ—μ√“쓬≈¥≈ß πÕ°®“°π—Èπ¬—ß∑”„Àâ ¡√√∂π–·≈–§«“¡∑π∑“π
„π°“√ÕÕ°°”≈—ß°“¬‡æ‘Ë¡¢÷Èπ §ÿ≥¿“æ™’«‘μ·≈– cognitive function ¥’¢÷Èπ Õ’°∑—Èß
àߺ≈„Àâ¿“«–´÷¡‡»√â“ Õ—μ√“‚√§°”‡√‘∫ ·≈–Õ—μ√“°“√πÕπ‚√ß欓∫“≈≈¥≈ß
·À≈àß°”‡π‘¥ÕÕ°´‘‡®π (oxygen source) Õ“®‡ªìπ compressed oxygen
®“° cylinder À√◊Õ®“°‡§√◊ËÕß °—¥ÕÕ° ‘‡®π (oxygen concentrator) À√◊Õ®“°
ÕÕ°´‘‡®π‡À≈« (liquid oxygen) ‡ªìπμâπ
°“√∫”∫—¥¥â«¬‡§√◊ËÕߙ૬À“¬„® non-invasive ventilator „πstable COPD
°“√∫”∫—¥¥â«¬‡§√◊ËÕߙ૬À“¬„®™π‘¥‰¡à„ à∑àՙ૬À“¬„® (noninvasive
ventilation, NIV) ¡’ª√–‚¬™πå„πºŸâªÉ«¬‡©æ“–°≈ÿà¡ ‰¥â·°à
1. ºŸâªÉ«¬ COPD √–¬– ß∫∑’Ë¡’¿“«–À¬ÿ¥À“¬„®¢≥–À≈—∫™π‘¥Õÿ¥°—Èπ
(obstructive sleep apnea) √à«¡¥â«¬ (COPD-OSA overlap syndrome)
‚¥¬ª√–‚¬™πå∑’Ë®–‰¥â®“°°“√„™â‡§√◊ËÕßÕ—¥Õ“°“»·√ߥ—π∫«°™π‘¥·√ߥ—π§ß∑’Ë
continuous positive airway pressure (CPAP) §◊Õ ®–™à«¬≈¥Õ—μ√“°“√πÕπ
‚√ß欓∫“≈ ·≈–Õ—μ√“쓬
104
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2. ºŸâªÉ«¬ COPD √–¬– ß∫∑’Ë¡’¿“«–°“√À“¬„®≈⡇À≈«‡√◊ÈÕ√—ß (chronic
respiratory failure) ·≈–¡’¿“«– hyperinflation ¡“° ®π∑”„Àâ°ä“´§“√å∫Õπ‰¥ÕÕ°‰´¥å
„π‡≈◊Õ¥·¥ß (PaCO2) Ÿß°«à“ª°μ‘ (PaCO2 > 45 mmHg) º≈¢Õß°“√„™â home-
NIV §«∫§Ÿà°—∫ LTOT „πºŸâªÉ«¬‡À≈à“π’È„π√–¬–¬“«¬—߉¡à “¡“√∂ √ÿª‰¥â™—¥‡®π Õ¬à“߉√
°Áμ“¡ °“√‡≈◊Õ°°≈ÿࡺŸâªÉ«¬∑’ˇÀ¡“– ¡·≈–¡’°“√ª√—∫‡§√◊ËÕß∑’Ë¡’‡ªÑ“À¡“¬„π°“√≈¥
PaCO2 Õ¬à“ß∂Ÿ°μâÕß Õ“®∑”„À⺟âªÉ«¬Õ“°“√¥’¢÷Èπ ≈¥°“√°”‡√‘∫·≈–≈¥Õ—μ√“쓬
䴉
‡Õ° “√Õâ“ßÕ‘ß1. Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy
in hypoxemic chronic obstructive lung disease: a clinical trial. Ann Intern Med1980;93:391-8.
2. Report of the Medical Research Council Working Party. Long term domiciliaryoxygen therapy in chronic hypoxic cor-pulmonale complicating chronic bronchitisand emphysema. Lancet 1981;1:681-6.
3. Eaton T, Lewis C, Young P, et al. Long-term oxygen therapy improves health-related quality of life. Respir Med 2004;98:285.
4. Heaton RK, Grant I, McSweeny AJ, et al. Psychologic effects of continuous andnocturnal oxygen therapy in hypoxemic chronic obstructive pulmonary disease.Arch Intern Med 1983;143:1941.
5. Ringbaek TJ, Viskum K, Lange P. Does long-term oxygen therapy reducehospitalisation in hypoxaemic chronic obstructive pulmonary disease? Eur RespirJ 2002;20:38.
6. Haidl P, Clement C, Wiese C, et al. Long-term oxygen therapy stops the naturaldecline of endurance in COPD patients with reversible hypercapnia. Respiration2004;71:342.
105
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7. Marin JM, Soriano JB, Carrizo SJ, et al. Outcomes in Patients with ChronicObstructive Pulmonary Disease and Obstructive Sleep Apnea. The OverlapSyndrome. Am J Respir Crit Care Med 2010;182:325-31.
8. Wijkstra PJ, Lacasse Y, Guyatt GH, et al. A Meta-analysis of Nocturnal NoninvasivePositive Pressure Ventilation in Patients With Stable COPD. Chest 2003;124:337-43.
9. Elliott MW. Domiciliary non-invasive ventilation in stable COPD? Thorax 2009;64:553-6.
10. Clini S, Sturani C, Rossi A, et al. The Italian multicentre study on noninvasiveventilation in chronic obstructive pulmonary disease patients. Eur Respir J2002;20:529-38.
11. McEvoy RD, Pierce RJ, Hillman D, et al. Nocturnal non-invasive nasal ventilationin stable hypercapnic COPD: a randomised controlled trial. Thorax 2009;64:561-6.
12. Köhnlein T, Windisch W, Köhler D. Non-invasive positive pressure ventilationfor the treatment of severe stable chronic obstructive pulmonary disease: aprospective, multicentre, randomised, controlled clinical trial. Lancet Respir Med2014;2: 698-705.
106
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¿“§ºπ«° 6
°“√«“ß·ºπ™’«‘μ√–¬– ÿ¥∑⓬(End of life plan)
‡π◊ËÕß®“°ºŸâªÉ«¬ COPD ®–¡’ progressive lung function decline ‚¥¬
‡©æ“– FEV1 π—Èπ≈¥¡“°°«à“§πª°μ‘Õ¬à“ßπâÕ¬ 3-4 ‡∑à“ °“√√—°…“¥â«¬¬“„πªí®®ÿ∫—π
·≈– LTOT Õ“®™à«¬™–≈Õ§«“¡‡ ◊ËÕ¡·≈–‡æ‘Ë¡Õ“¬ÿ¢—¬∫â“ß ·μà‚√§‡√◊ÈÕ√—ߥ—ß°≈à“«
¬—ߥ”‡π‘πμàÕ®π‚√§√ÿπ·√ß¡“°¢÷Èπ·≈–‡¢â“ Ÿà√–¬– ÿ¥∑⓬„π∑’Ë ÿ¥ ‚¥¬ºŸâªÉ«¬Õ“®
‡ ’¬™’«‘μ®“° COPD ‡Õß ·≈–/À√◊Õ ¿“«–·∑√°´âÕπ∑’ˇ°‘¥√à«¡°—π°Á‰¥â ¥—ßπ—Èπ
ºŸâªÉ«¬∑ÿ°√“¬§«√®–‰¥â√—∫§”·π–π”°“√‡μ√’¬¡μ—«·≈–‡μ√’¬¡„®„π°“√«“ß·ºπ™’«‘μ
„π√–¬– ÿ¥∑⓬ ªí®®—¬À≈—°∑’˧«√§”π÷ß∂÷ß„π°“√§—¥‡≈◊Õ°ºŸâªÉ«¬ ‰¥â·°à
1. ºŸâªÉ«¬ COPD „π¢—Èπ√ÿπ·√ß¡“° (√–¥—∫∑’Ë 3 ·≈– 4) ∑—Èßπ’È ‚¥¬¬◊π¬—π
®“°Õ“°“√ Õ“°“√· ¥ß∑“ߧ≈‘π‘° °“√μ√«® spirometry ·≈–‚√§√à«¡
2. ºŸâªÉ«¬∑ÿ°√“¬§«√®–‰¥âºà“π°“√√—°…“¥â«¬¬“Õ¬à“ß∂Ÿ°μâÕß·≈–¥’∑’Ë ÿ¥¡“
·≈â« ‰¥â√—∫°“√øóôπøŸ ¡√√∂¿“æªÕ¥·≈– LTOT ·μଗߪ√“°ØÕ“°“√∑“ߧ≈‘π‘°∑’Ë
∑√ÿ¥≈߇√◊ËÕ¬Ê ·≈–‰¡à “¡“√∂øóôπ§◊π Ÿà ¡√√∂𖇥‘¡‰¥â
3. Õ“°“√∑“ߧ≈‘π‘°∑’˙૬∫àß™’È«à“‚√§‡¢â“„°≈â√–¬– ÿ¥∑⓬ ‰¥â·°à
3.1 Frequent exacerbation ‚¥¬‰¡àæ∫ “‡Àμÿ°√–μÿâπ„Àâ™—¥‡®π À√◊Õ
exacerbation ∑’Ë√ÿπ·√ß¡“°®πμâÕßæ÷Ëß invasive ventilation > 2 §√—ÈßμàÕªï
·≈–·μà≈–§√—ÈßμâÕß„™â‡«≈“À¬à“‡§√◊ËÕßπ“π‡°‘π 10 «—π
107
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3.2 ºŸâªÉ«¬¡’ desaturation ¡“° ®πμâÕßæ÷ËßÕÕ°´‘‡®πμ≈Õ¥ 24 ™¡.
À√◊Õ bed ridden À√◊Õ‡Àπ◊ËÕ¬¡“°®πª√–°Õ∫°‘®«—μ√ à«πμ—«ª√–®”«—π‰¡à‰¥â
3.3 ºŸâªÉ«¬¡’‚√§·∑√°´âÕπ À√◊Õ‚√§√à«¡Õ◊ËπÊ „π√–¬–∑’Ë√ÿπ·√ß ·≈–‰¡à
“¡“√∂√—°…“„ÀâÀ“¬‰¥â ‡™àπ chronic congestive heart failure, uncontrolled
malignancy, end stage cirrhosis À√◊Õ end stage renal disease ∑’ËμâÕßæ÷Ëß
chronic dialysis ‡ªìπμâπ
ºŸâ∑’Ë¥”‡π‘π°“√·π–π”°“√«“ß·ºπ™’«‘μ√–¬– ÿ¥∑⓬ §«√‡ªìπ·æ∑¬å‡®â“¢Õß
‰¢â∑’Ë√Ÿâ®—°§ÿâπ‡§¬®π‡ªìπ∑’ˉ«â«“ß„®¢ÕߺŸâªÉ«¬·≈–≠“μ‘ ∂⓺ŸâªÉ«¬¡’ μ‘ —¡ª™—≠≠–¥’
§«√®–·π–π”∑—ÈߺŸâªÉ«¬·≈–≠“μ‘æ√âÕ¡Ê°—π ¢—ÈπμÕπ°“√·π–π”®”‡ªìπμâÕß∑”
À≈“¬Ê §√—Èß §àÕ¬‡ªìπ§àÕ¬‰ª ®“°πâÕ¬‰ªÀ“¡“° æ√âÕ¡ Õ¥·∑√°§«“¡√Ÿâ∑—Èß¿“§
∑ƒ…Æ’·≈–¿“§ªØ‘∫—μ‘ μ—«Õ¬à“߇™àπ °“√„À⧫“¡√Ÿâ‡°’ˬ«°—∫§«“¡‡√◊ÈÕ√—ß·≈–≈—°…≥–
∑’Ë progressive ¢Õß‚√§ °“√≈Õß„À⺟âªÉ«¬·≈–≠“μ‘π÷°∑∫∑«π‡ª√’¬∫‡∑’¬∫§«“¡
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øóôπøŸ ¡√√∂¿“æªÕ¥®–∑”„À⺟âªÉ«¬‰¥â‡¢â“ —ߧ¡¢Õߧπ∑’Ë‚√§§≈⓬§≈÷ß°—𠉥âæ∫
‡ÀÁπºŸâªÉ«¬∑’Ë¡’§«“¡Àπ—°¢Õß‚√§∑’Ë·μ°μà“ß°—π √«¡∑—È߉¥â‡ÀÁπºŸâªÉ«¬∫“ß√“¬„π°≈ÿà¡
∑’˧àÕ¬Ê ‡ ’¬™’«‘쉪 ‡ªìπμâπ ‚¥¬∑—Ë«‰ª«‘∏’·≈–¢—ÈπμÕπ°“√·π–π”π—Èπ‰¡à¡’°Æ‡°≥±å
∑’Ë·πàπÕπ쓬엫 ∑—Èßπ’È¢÷ÈπÕ¬Ÿà°—∫§«“¡∂π—¥¢Õß·æ∑¬å §«“¡‡¢â“„® °“√√—∫√Ÿâ ·≈–
°“√¬Õ¡√—∫¢ÕߺŸâªÉ«¬·≈–≠“μ‘ ‚¥¬¡’«—μ∂ÿª√– ߧå„À⺟âªÉ«¬·≈–≠“쑉¥â‡μ√’¬¡μ—«
‡μ√’¬¡„®‡¡◊ËÕ«—ππ—Èπ¢Õß«“√– ÿ¥∑⓬¡“∂÷ß ‡æ◊ËÕºŸâªÉ«¬®–‰¥â‡ ’¬™’«‘μÕ¬à“ß ß∫ ÿ¢
·≈–‰¡à∑√¡“π ∑—Èßπ’È°“√·π–𔧫√°√–∑”¥â«¬§«“¡‡¢â“„®∑’Ë¥’μàÕ°—π ¿“¬„μ⧫“¡
‡À¡“– ¡∑“߇»√…∞“π–·≈–‰¡à¢—¥μàÕ°“√¬Õ¡√—∫∑“ß«—≤π∏√√¡·≈– —ߧ¡
108
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°“√ª√–‡¡‘π·≈–μ‘¥μ“¡‚√§
„π°“√ª√–‡¡‘πº≈°“√√—°…“§«√¡’°“√ª√–‡¡‘π∑—Èß Õ“°“√ºŸâªÉ«¬ (subjective)
·≈–º≈°“√μ√«® (objective) ª√–°Õ∫¥â«¬°“√ª√–‡¡‘π∑’˧«√∑”∑ÿ°§√—Èß∑’Ë¡“μ√«®
·≈–°“√ª√–‡¡‘π∑’˧«√∑”Õ¬à“ßπâÕ¬ªï≈– 1 §√—Èß
1. °“√ª√–‡¡‘π∑’˧«√∑”∑ÿ°§√—Èß∑’Ë¡“μ√«®1.1 Õ“°“√‡Àπ◊ËÕ¬ÀÕ∫∑’Ë¡“°¢÷ÈπÀ√◊ÕπâÕ¬≈ß Õ“®„™â modified medical
research council (mMRC) scale À√◊Õ visual analogue scale À√◊Õ COPD
assessment test (CAT) ¥—ß√Ÿª
1.2 Õ“°“√‰Õ ·≈–/À√◊Õ ª√‘¡“≥‡ ¡À–¡“°¢÷ÈπÀ√◊ÕπâÕ¬≈ß
1.3 °“√‡ª≈’ˬπ·ª≈ß ’‡ ¡À–
1.4 §«“¡ “¡“√∂„π°“√∑”°‘®°√√¡ª√–®”«—π (actual daily activity) ·≈–
§«“¡ “¡“√∂„π°“√ÕÕ°°”≈—ß°“¬ (exercise capacity)
1.5 ∂“π–¢Õß°“√ Ÿ∫∫ÿÀ√’Ë„πªí®®ÿ∫—π
1.6 §«“¡ “¡“√∂·≈–§«“¡∂Ÿ°μâÕß„π°“√„™â¬“æàπ Ÿ¥
1.7 §«“¡ ¡Ë”‡ ¡Õ„π°“√„™â¬“æàπ Ÿ¥ (adherence)
1.8 ª√–‡¡‘π SpO2 «—¥πÈ”Àπ—° à«π Ÿß ‡æ◊ËÕª√–‡¡‘π§à“ BMI
109
¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 (¿“§ºπ«° 7)
110
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1.9 Õ“°“√À√◊ÕÕ“°“√· ¥ß¢Õß‚√§√à«¡ (co-morbid diseases) ∑’Ëæ∫
∫àÕ¬ ‡™àπ ‚√§‡∫“À«“π ‚√§À≈Õ¥‡≈◊Õ¥·≈–À—«„® ‚√§°√–¥Ÿ°·≈–‰¢¢âÕ ‚√§μàÕ¡
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2. °“√ª√–‡¡‘π∑’˧«√∑”Õ¬à“ßπâÕ¬ªï≈– 1 §√—Èß2.1 Spirometry, pre and post bronchodilator
2.2 §ÿ≥¿“æ™’«‘μ ‚¥¬ St. George Respiratory Questionnaires (SGRQ)
À√◊Õ CAT
„πºŸâªÉ«¬∑’Ë¡’Õ“°“√‡Àπ◊ËÕ¬®π§ÿ°§“¡°‘®«—μ√ª√–®”«—π§«√ª√–‡¡‘π‡æ‘Ë¡‡μ‘¡
§◊Õ
2.3 Six-minute walking distance (6MWD)
2.4 Arterial blood gases (°√≥’∑’Ë SpO2 < 92%)
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
111
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𓬷æ∑¬å‡®√‘≠ ™Ÿ‚™μ‘∂“«√ °√√¡°“√
»“ μ√“®“√¬å𓬷æ∑¬å°‘μμ‘æß»å ¡≥’‚™μ‘ ÿ«√√≥ °√√¡°“√
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ºŸâ™à«¬»“ μ√“®“√¬å𓬷æ∑¬åÕ¿‘™“μ‘ §≥‘μ∑√—æ¬å °√√¡°“√
√Õß»“ μ√“®“√¬å𓬷æ∑¬å™“¬™“≠ ‚æ∏‘√—μπå °√√¡°“√
ºŸâ™à«¬»“ μ√“®“√¬å𓬷æ∑¬å»‘«»—°¥‘Ï ®ÿ∑Õß °√√¡°“√
√Õß»“ μ√“®“√¬å·æ∑¬åÀ≠‘߇∫≠®¡“» ™à«¬™Ÿ °√√¡°“√
√Õß»“ μ√“®“√¬å𓬷æ∑¬å©—𙓬 ‘∑∏‘æ—π∏ÿå °√√¡°“√
·æ∑¬åÀ≠‘߇ªïò¬¡≈“¿ · ß “¬—≥Àå °√√¡°“√
𓬷æ∑¬å‰æ√—™ ‡°μÿ√—μπ°ÿ≈ °√√¡°“√
ºŸâ·∑π ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘ ( ª ™.) °√√¡°“√
√“¬π“¡§≥–∑”ß“πæ—≤π“¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560
112
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√Õß»“ μ√“®“√¬å·æ∑¬åÀ≠‘ß ÿ√’¬å ¡ª√–¥’°ÿ≈ °√√¡°“√·≈–‡≈¢“πÿ°“√
·æ∑¬åÀ≠‘ß«√«√√≥ »‘√‘™π– °√√¡°“√·≈–
ºŸâ™à«¬‡≈¢“πÿ°“√
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ºŸâ™à«¬‡≈¢“πÿ°“√
æ—π‚∑ «‘√‘ √ «ß»å»√’™π“≈—¬ °√√¡°“√·≈–
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ºŸâ™à«¬»“ μ√“®“√¬å𓬷æ∑¬å∏’√°√ ∏’√°‘μμ‘°ÿ≈ °√√¡°“√·≈–
ºŸâ™à«¬‡≈¢“πÿ°“√
√“¬π“¡§≥–∑”ß“πæ—≤π“¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560