임신과 호흡기 질환
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임신과 호흡기 질환. 고려대학교 안암병원 이은주 2013.6.11. Asthma Pulmonary embolism Infection (CAP, TBc). Asthma. F/29 CC: Dyspnea, wheezing(+). Special consideration - Pregnancy. Severity : 1/3 은 호전 , 1/3 은 악화 , 1/3 은 unchanged Tx : theophylline, ICS, BA, leukotriene modifier(montelukast) - PowerPoint PPT PresentationTRANSCRIPT
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임신과 호흡기 질환
고려대학교 안암병원 이은주 2013.6.11
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AsthmaPulmonary embolismInfection (CAP, TBc)
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Asthma
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F/29
CC: Dyspnea, wheezing(+)
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Special consideration - Pregnancy
Severity : 1/3 은 호전 , 1/3 은 악화 , 1/3 은 unchanged
Tx: theophylline, ICS, BA, leukotriene modifier(montelukast)
Exacerbation : to avoid fetal hypoxia
BA, O2, systemic steroid
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Definition
Chronic inflammatory disorder of the airway.
Airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning.
Variable, airflow obstruction within the lung that is often reversible either spontaneously or with Tx.
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Diagnosis – test for Dx & monitoring
Airflow limitation : spirometry (FEV1, FVC), peak expiratory flow(PEF)
PFT : severity of airflow limitation, reversibility, variability
Reversibility : improvement of FEV1(or PEF) after bronchodilator
or controller (ICS..) ≥ 12% & 200mL
Variability : Sx / lung function 의 improvement or deterioration
예 > diurnal variability
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Diagnosis – test for Dx & monitoring
Peak expiratory flow (PEF) diurnal PEF variability =
or
≥ 20% 시 Dx 에 도움 Dx, monitoring 에 도움
( 밤 PEF)- ( 아침 PEF)
{( 밤 PEF)+ ( 아침 PEF)} /2
1 주일 중 최저의 아침 PEF
1 주일 중 최고의 PEF
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Medication - Controller Medications
Inhaled / systemic glucocorticosteroids (ICS)
Leukotriene modifiers
Long-acting inhaled / oral β2-agonists (LABA)
Theophylline ( sustained-release)
Anti-IgE
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Medication - Reliever Medications
Rapid-acting inhaled β2-agonists
Inhaled anticholinergics
Systemic glucocorticosteroids
Theophylline (short-acting)
Short-acting oral β2-agonists
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Medications
Ventolin / Atrovent (MDI)
Foster (MDI)Seretide (Diskus, MDI) Symbicort (Turbuhaler)
Oral steroid/ theophylline
Oral long acting β2-
agonist
Leukotriene modifiers
기 타
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12Ref) 세레타이드 에보할러 , 벤토린 에보할러 제품 설명서
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Spacer
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14※ 사용법은 보조흡입기의 종류에 따라 다를 수 있으며 , 정확한 사항은 보조흡입기 사용법을 참고해주십시오 .
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환자 자신의 들여 마시는 힘에 의해 약물이 비산되어 흡입 흡입기를 입에 물고 숨을 내쉬지 않도록 교육 빠르고 세게 흡입
터부헬러 (Turbuhaler)디스커스 (DisKus)
DPI : Dry Powder Inhaler
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16
숨을 끝까지 내쉰다 . 한번에 강하고 깊게 들이 마신다 .
5~10 초간 숨을 참은 후 코로 숨을 천천히 내쉰다 .
손잡이를 돌려 한번에 닫는다 .
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물로 입안을 깨끗이 헹군다 .
Ref) 세레타이드 디스커스 제품 설명서
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Pulmonary embolism
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Case M/ 20 CC: dyspnea (onset: 내원 전날 ) PI : 약 10 일 전부터 Rt leg swelling, pain 있어 local OS 에서 치료 중 내원 3 일 전부터 blood tinged sputum 있고 내원 전날부터 dyspnea 있으면서 내원 당일 갑자기 dizziness 발생하여 내원
대학생 , never smoker
PHx : DM/HTN/TBc/DM(-/+/-/-)
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ROS : C/S(+/+-): blood tinged(+) F/C(+/-) dyspnea, NYHA IV pleuritic chest pain(+): Rt., 2-3 일 전부터 발생 LOC(+): 5 분 정도
P/Ex : V/S 100/60-140/min-24/min-37.5C mental alert, acute ill looking, cyanotic SBS without c/w extremity: Rt. Leg swelling(+)
Lab : ABGA(NP O2 2L): 7.447-33.6-94.3-25-97.5% AST/ALT : 74/113 troponin I : 0.14 (0-0.2)
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2D echo : EF 55-60% Estimated PA systolic pr.>30mmHg interventicular septal flattening d/t Rt pr.
overloding suggesting acute cor pulmonale
CUS : DVT(+) on Rt SFV, popliteal vein
그 외 FANA, ANCA, RF, protein C,S, antithombin III, prothrombin gene mutation .. 등등
: ok
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CXR
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Embolism CT
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F/U Tx
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Special problems –pregnancy 1
Hypercoagulable state : - fibrin, factor II, VII, VIII, X, resistance to activated prot. C - fibrinolytic activity, protein S, venous flow velocity Risk factors : inherited thrombophilia, antiphospholipid syndrome, Hx of thrombosis, DM, lupus, smoking, multiple pregnancy, age>35, obesity, C/S, heart dz, sickle cell dz
thrombophilia screening 은 임신 종결되고 , anticoagulation 중단 후 시행 ( 다음 임신에 대한 대비 )
Venous thromboembolic dz and pregnancy NEJM 2008;359:2025-33
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Special problems –pregnancy 2
D-dimer : 임신 내내 상승 가능 normal D-dimer : PE 거의 배제 ( 특히 1st & 2nd ∆)
D-dimer(+) lower limb CUS (+) 이면 heparin (-) 이면 다른 검사 고려
Radiation upper limit ( 태아 위험 고려시 ) : 50mSv chest CT< Lung scan ( 엄마의 경우는 반대 )
Guidelines on the Dx & Tx of acute PE European Heart Journal 2008;29:2276-2315
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Special problems –pregnancy 3 Sudden death 모든 의심되는 임산부는 바로 heparin 투여하고 w/u 진행
CUS : test of choice 주로 femoral v.
MRDTI : magnetic resonance
direct
thrombus imaging iliac v thrombosis not harmful to fetus
Venous thromboembolic dz and pregnancy NEJM 2008;359:2025-33
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Special problems –pregnancy 4
Tx heparin (UFH < LMWH)
- 최소 분만 후 3 개월까지 anti-Xa monitoring 은 extremes of BWt/RI 시에만 분만 가까운 시기엔 UFH 을 선호 cf. warfarin 은 2nd ∆ 에 조심스럽게 가능 , but not
recommend 수유시 - heparin, warfarin 가능 fondaparinux- ?
epidural analgesia 최소 12 시간 전에 LMWH 은 중단 epidural catheter 제거 12-24 시간 후 다시 시작 (d/t spinal hematoma)
Guidelines on the Dx & Tx of acute PE European Heart Journal 2008;29:2276-2315
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Special problems –pregnancy 5
Venous thromboembolic dz and pregnancy NEJM 2008;359:2025-33
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Infection(CAP, TBc )
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CXR- CAP
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CXR, bronchoscopy - Tbc
Endobronchial TBc
Active pul TBc
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Sputum study/ tissue Bx
Caseating necrotizing granulomaAFB(+)
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임신 : INH/RMP/EMB 는 안전 9 개월 요법 PZA 는 국제항결핵연맹에서는 추천하나 사용은 잘 안함
수유 : INH/RMP/EMB/PZA 모두 안전
Tuberculosis -1
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부작용 INH ( 말초 신경염 , 간독성 )
RIF ( 발진 , 용혈성 빈혈 / plt 감소 , ARF 중단 )
PZA ( 고요산혈증 , 관절통 , arthritis 중단 )
EMB ( 시신경염 중단 )
SM ( 이독성 , 신독성 중단 )
Hepatotoxicity
aSx & 5 배 이상 (≈200) / Sx(+) & 3 배 이상
INH/RIF/PZA 중단
INH or RIF 부터 시작
간 독성시 사용 가능 약 : SM/KM, CS, EMB, quinolone
Tuberculosis -2
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Skin rash
mild : anti-histamine
severe : 모든 약 끊고 원인 약 확인
GI trouble
분복 가능
한가지 약은 한 번에 복용 (RIF 을 제외하고는 식후 복용 가능 )
기타
CS: psychosis
PZA: arthragia 시 aspirin, allopurunol 투여 가능
Tuberculosis -3
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경청해 주셔서 감사합니다