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胸內常用藥品介紹 PowerPoint Presentation
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胸內常用藥品介紹

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胸內常用藥品介紹

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  1. 胸內常用藥品介紹 胸腔內科

  2. Classification • 1. Drugs for obstructive lung • disease • 2. Drugs for infectious disease • 3. Drugs for chemotherapy • 4. Drugs for symptomatic relief

  3. Drugs for obstructive lung disease • COPD and asthma ( including stable condition and acute exacrbation • Inhaled medication: prefer medicine oral medication IV and IM medication

  4. Severe persistent Moderate persistent Intermittent Mild persistent Short-acting ß2 p.r.n Inhaled Corticosteroid Long-acting ß2agonist GINA (Global Initiative for Asthma) Guidelines 2002 Sustained-release theophylline Leukotriene Modifier Oral steroid

  5. GOLD guideline (2003)

  6. Inhalation Therapy • 液態或固態的粒子懸浮在氣體中便稱為氣霧(aerosol).經由氣霧粒子攜帶藥物,水或食鹽水進入呼吸道達到治療的效果稱為吸入治療. • 1. 藥物吸入治療 • 2. 非藥性(blind)吸入治療(含水或 • 食鹽水粒子)

  7. Indication and goal of inhaled therapy • 1.呼吸道給藥 • 2.稀釋肺部分分泌物與誘發取痰 • (hydration of pulmonary secretions • and sputum induction) • 3. 吸入氣體的濕化 • (humidification of inspired gases)

  8. Devices of inhaled therapy • 1.噴嘴式噴霧器 • jet nebeulizer • 2.超音波噴霧器 • ultrasonic nebeulizer • 3.定量吸入器 • metered dose inhaler (MDI) • 4.乾粉吸入器 • dry power inhaler (DPI), including rotadisk, • turbuhaler, accuhaler & easyhaler

  9. Jet nebeulizer

  10. Spacer as adjuvant therapy

  11. Dry power inhaler (DPI) • Rotadisk • Easyhaler • Accuhaler • Turbuhaler

  12. Easyhaler

  13. Accuhaler ( 胖胖魚)

  14. Turbuhaler ( 都保)

  15. Controller Inhaled corticosteroids (warm color) Reliever Short acting b2-agonists (cold color)

  16. 各種器具之優缺點比較 • 優點 缺點 • Nebulizer吸入率8-12%且不需病人配合 不經濟藥品易浪費 • 可用於人工氣道與呼吸器患者 耗時長易污染 • 可作高劑量與持續性治療 需高流量氣體作動力來源 • 不含氟氯化碳不污染環境 • MDI可用於人工氣道與呼吸器患者 吸入率9-12%且須病人高度配合 • 方便便宜不易污染 人工氣道與呼吸器患者吸入率只有4-6% 氟氯化碳會破壞環保 • DPI 吸入率12-16%且不需病人配合 需較高之吸氣流速 • 不含氟氯化碳不污染環境 無法使用於人工氣道與呼吸器患者 • 攜帶方便便宜不易污染 易受濕氣影響

  17. Inhaled Medication • 1. 2-agonist • 2. Anti-cholinergic agent • 3. Steroid

  18. Short acting 2 agonist • 1. Ventolin (Salbutamol), • nebeulizer, 1 amp • (5mg/2.5 ml), q30 min – • q6h prn; MDI 2 puff prn • 2. Bricanyl (Terbutaline • hydrochloride), • Turbuhaler, 200mg/100 • dose, 1-2 puff qid prn

  19. Long acting 2 agonist • Serevent(Salmeterol xinafoate), • Accuhaler, 50mg/60 • 1-2 puff bid • Oxis (formoterol), • 9 ug / dose. Turbuhaler 1 puff bid

  20. Anticholinergic Agent • Atrovent (Ipratropium bromide) • 1. MDI, 200 puffs/10 ml, • 2-3 puff qid • 2. Nebeulizer solution, • 0.5mg/2ml/vial, • 1 vial qid

  21. Combined β2 agonist and anticholinergic drug ( Combivent ) • Combivent (Ipratropium + albuterol) 2puff Qid

  22. Inhaled steroid • Pulmicort (Budesonide) Turbuhaler: 200ug/200dose/bot, 2-4 puff bid Nebeulizer:1000ug/2ml/vial, 0.5 -1 vial bid • Flixotide (Fluticasone propionate) Accuhaler, 250mg/puff/60dose, 1 puff bid MDI, 50mg/puff/200dose

  23. Combination therapy(Long acting β2 agonist + steroid) • Symbicort (Budesonide + formoterol ) Turbuhaler, 200 puff, 1~2 puff bid • Seretide(Fluticasone propionate + Salmeterol ) Accuhaler; 1 puff bid

  24. Oral Medication • 1. 2 agonist • inolin ( 1# tid-qid); meptin ( 1# bid), • bambec 1# qn • 2. Xanthine derivates • Phyllocontin 1# bid-tid(不可磨碎), • theophylline 2# qn or 1# q12h(可磨粉,適合 • NG feeding者) • 3. Steroid: prednisolone 0.5-1mg/kg qd • 4. Leukotrine modifier: • Accolate 1# bid • singulair 1# qd

  25. IM & IV medication • 1. Epiphephrine • IM: 0.5 ml sc • IV: 0.5-1 ml slowly IVD • 2. Ipradol (Hexoprenaline Sulfate) • 1 amp(5ug/2ml) IM or IV slowly • 3. Aminophylline(must add in saline) • Loading dose: 250 mg x 30 min •  250 x 8 hours •  6-15 mg/kg qd (serum level 10-20ug/dL)

  26. Drugs for infectious lung disease • 1. Community acquired pneumonia( CAP) • with and without parapneumonic effusion • 2. Hospital acquired pneumonia (HAP) • 3. Pulmonary TB • 5. Empyema thoracis and lung abscess • 6. COPD or asthma with 2nd infection • 8. Bronchiectasis with 2nd infection

  27. Community acquired pneumonia • Pathogens: S. pneumoniae; H. influenza; atypical pathogen ( M. pneumoniae, C. pneumoniae ). Mixed infection, MSSA, and some G(-) bacillus… • Mixed typical and atypical pathogen. • Risks factor or host factor of specific pathogens in pneumonia

  28. Community acquired pneumonia • S. pneumonae: Penicilline, Rocephine or Vancomycin, fluroquinolone • H. influenza, G(-) bacillus: Unasyn, Augmentin or 2nd and 3rd cephalosporin and fluroquinolone • Atypical pathogens: Erythromicin, klaricid, Zithromax, tetracycline and fluroquinolone • Mixed infection: Penicillin, Cleocin, Unasyn • MSSA: Cefalosporin, Oxacilline

  29. Hospital acquired pneumonia • Pathogens: G(-) bacillus, P. aeruginosa, MRSA, VRE, A. baummanii, Legionella.. • MRSA: Vancomycin, Targocid • P. aeruginosa: Pipril/Tazocin, Fortum, Cravit, Ciprofloxacin, Tienam and maxipime • G(-) bacillus: 3rd cephalosporin • Legionella: Erythromycin, Klaricid, Zithromax • A. baummanii: Tienam

  30. Pulmonary TB and TB pleurisy • First line: INH, RIF, EMB, PZA • Secondary line: Fluroquinolone, Aminoglycoside, PAS, Ethionamide, and Cycloserine • Standard therapy: 6 months Intensive therapy X 2months: HERZ Maintain therapy X 4 months HER • If PZA is not used, Keep HER for 9 months

  31. Pulmonary TB and TB pleurisy • Side effect: INH: hepatitis, peripheral neuropathy RIF: hepatitis, jaundice, rash EMB: neuritis PZA: hepatiits, hyperuricemia, gouty • Steroid & Vitamin B6 • Combination therapy: Rifater: INH 80 + RIF 100 + PZA 250 • Rifinah: INH 150 + RIF 30

  32. Thoracis Empyema and Lung Abscess • 1. Treat as pneumonia • 2. Adequate drainage • Tube drainage • Decortication • Repeated lung aspiration (abscess) • 3. At least 3-4 weeks IV antibiotics • treatment and total duration • around 6-8 weeks

  33. COPD /c 2nd Infection • Most caused agents • 1. H. influenza, G (-) coccobacillus • Tx: Ampicilline/Unasyn, Amoxicilline • /augmentin; 2nd cephalosporin, Macrolidw • 2. Moraxella catarrhalis, G (-) diplococcus • Tx: Macrolide, Baktar, Augmentin or • Fluroquinolone, 3rd generation cephalosporin • 3. Streptococcus pneumoniae G(+) diplococcus • Tx: Penicillin, Amoxicilin/ Augmentin, • Ampicilline/ Unasyn

  34. Bronchiectasis with secondary Infection • 1. Initial: G(+) coccus + GNB: • Tx as COPD with 2nd infection • 2. Later: GNB, especially P.spp • Floroquinolone: • 3rd generation cephalosporins • Beta-lactam PCN + aminoglycoside • Tineam + aminoglycoside

  35. Drugs for chemotherapy • 1. Small cell lung cancer • (SCLC) • 2. Non-small cell lung cancer • (NSCLC)

  36. Small cell lung cancer • First choice • Cisplatin 75 mg/m² x 1 day • V-P 16 100 mg/ m² x 3 days • every 28 days • Second line • Topotecan 1.5-2.5 mg/m2 • Taxol 135 mg/m2 (自費) • every 21 or 28 days

  37. Non small cell lung cancer First line • 1. Gemzar 1000 mg/m² + Cisplatin • 100 mg/m² + x I • 2. Taxol 135 mg/m² + Cisplatin • 75 mg/m² x I • 3. Navelbine 25 mg/m² + Cispaltin • 75 mg/m² x I • Second line • 1. Taxotere 75 mg/m² x I /C or /S Cisplatin

  38. Drugs for symptomatic relief • Insomnia • Cough • Pain • Shortness of breath

  39. Insomnia • 看病人 • Haldol • Type I receptor : Zopiclone , Zolpidem • Type II receptor : Ativan , Valuim

  40. Antitussive & Expectorants • 1. Solution • 2. Tablet or capsule • 3. Nebular

  41. Solution • 1. Brown mixture (B.M) • 含opium, 5-10 ml tid – qid • 2. Guaifenesin (Unitussin or G.P) • reduce the visicosity of sputum • antihistamine effect (+) • 5-10 ml q4h - q6h • 3. Fusoco • 限小兒科使用,成人需自費

  42. Tablet • 1. Brown mixture (B.M), 1-2# tid - qid • 2. Bensau (Benzonatate) 1-2# tid - qid • 3. Codeine 1# q6h prn • 4. Bisco (Bisolvon) 1# qid • 5. Danzen 1-2 # tid - qid • 6. Mucora 1# qid • 7. Medicon 1# tid –qid • # 以上藥品不得同時開立三項 (含) 以上

  43. Nebulizer • 1. Bisolvon • aerosol + mucolytic agent •  help to expectorate • 2. Lidocaine • for refractory cough, 2mg/5ml IH • 3. Gentamycin • 40 mg IH q8h, as immunomodulater

  44. Pain • Acetaminophen • NSAID • Tramadol (50mg) & Tramadol-SR (100mg) • Morphine (10mg PO, IM, IV) • Fentanyl (25μg, 50μg)