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삼성서울병원 알레르기센터
간호사 최영란
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기도폐쇄에 따른 증상의 치료
기도 염증 치료
비가역적인 기도의 변화 방지
천식조절상태에 도달하고 이를 잘 유지 하는 것.
** 조절상태란? 주간증상 : 없음~2회/주,활동제한 없음
야간증상/수면방해 없음
증상완화제사용 : 없음~2회/주
폐기능 정상
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1. 증상 완화제(Reliever)
: 신속히 기도확장 증상 개선
2. 질병 조절제(Controller)
: 항염증효과 천식증상 조절
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속효성 베타2 항진제 - Salbutamol(벤토린),Terbutalin(브리카닐) Fenoterol(베로텍)
항콜린성 약제 - Ipratropium(Atrovent)
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장점
효과가 빠르다: 급성 천식 발작에 유용
환자들이 선호한다.
운동유발성 기관지수축의 예방에 매우 효과적
단점
기도염증 조절 효과는 전혀 없다.
약효시갂이 짧다.
장기갂 규칙적으로 사용 시 내성 발현
속효성 2-교감신경 항진제
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속효성 2-교감신경 항진제
약제 제형 용량/dose
Salbutamol MDI 100 mcg
(Ventolin® )
Fenoterol MDI 200 mcg
(Berotec® )
Terbutaline Turbuhaler 200 mcg
(Bricanyl® )
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흡입 스테로이드제
- Budesonide, Fluticason, Ciclesonide
지속형 β2 항진제
- Salmeterol, Formoterol
흡입 스테로이드 + 지속형 β2 항진제
- 세레타이드(Fluticason + Salmeterol)
- 심비코트(Budesonide + Formoterol)
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장점
- 항염증 약제중 가장 효과적.
- 기도염증 조절, 기도과민증 호전
폐기능 개선 QOL증가
단점
-부작용 (구인두 캔디다증, 목소리 변성,
상기도자극에 의한 기침)
-개인에 따른 다양한 반응도
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국내 시판중인 흡입 스테로이드제
약 제 제 형 용 량 (ug/dose)
Budesonide MDI 200
(Pulmicort® ) Turbuhaler 200
Fluticasone MDI 50
(Flixotide® ) Diskus 100 or 250
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장점
약효시갂이 길다: 12시갂 이상 지속
천식 발작, 특히 야갂 천식 증상의 예방에 유용
통상 용량의 흡입 스테로이드제에 추가하면 폐기능 및 증상의 호
전과 QOL가 증가: 흡입 스테로이드제 투여량 감소 효과
단점
기도염증 조절 효과가 뚜렷하지 않다: 단독 사용보다는 흡입 스테
로이드제와의 병용 투여가 바람직
지속성 2-교감신경
항진제
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장점
- 각각 단독사용보다 더 효과적
- 사용 갂편 치료숚응도 증가
- 증상 완화제와 유지치료 모두 가능
단점
- 가격이 비싸다.
Corticosteroid + Long acting
2-Agonist
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Corticosteroid + Long acting 2-Agonist
상 품 명 성 분
Seretide® fluticasone 100/250/500 mcg
+ salmeterol 50 mcg
Symbicort® budesonide 200 mcg
+ formoterol 4.5 mcg
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장 점
- 기도에 직접 작용
- 적은 양으로 최대효과
- 전싞적 부작용 최소화
단 점
- 사용자의 사용숙련도에 의존
- 지속적인 흡입교육 필요
- 약 값이 비싸다.
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흡입제의 선택 기준
기관지로 충분한 약이 투여 될 수 있어야 한다.
경제적이어야 한다.
쓰기 쉽고 간편해야 한다.
구강 내 침착 되는 양이 적고 전신 부작용이
적어야 한다.
환자가 선호하는 기구이어야 한다.
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Particle Size and Airway Deposition
Particle Size
No clinical benefit
Systemic absorption if swallowed
> 5 microns
Optimal size for
clinical benefit
Clinical benefit uncertain
Systemic absorption
2-5 microns
< 2 microns
Result
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Adapted from National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the
Diagnosis and Management of Asthma. 1997. NIH publication No. 97-4051.
Mouth and pharynx
Lung deposition (10% to 30%)
Systemic circulation
Inactivation in the liver “first pass”
Absorption from the gut
Lung
Absorption from the lung (A)
GI tract
Active drug from the gut
(B)
Systemic concentration = A + B
Liver
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Metered dose inhaler (MDI)
Dry powder inhaler (DPI)
Turbuhaler
Nebulizer
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흡입과 분사 시기를 맞추기 어렵다.
하부 기도에 들어가는 약제의 양이 적다.
흡입 보조기구(spacer)를 사용할 수 있다.
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정량식 분무흡입기
(MDI)
Metering Chamber
Propellant (CFC or HFA) and Drug
Canister
Efficient way of using MDI
Slow, deep inspiration
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- 사용이 힘들지 않고, 약물 전달이 효과적 - 에어로졸 입자가 추짂제 증발과 함께 작아져 폐에 침착되기 쉽다 - 구강과 인후부위에 침착되는 약물의 양 흡입약물 부작용이 최소화
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장점
Reduce the velocity of aerosol
Decrease bad taste
Reduce cold-Freon effect
적응증
Incorrect MDI using technique: esp. inhaled steroid
Children and olds
Acute exacerbation of asthma: inhaled bronchodilator
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-Diskhaler, Diskus, Turbuhaler - 하부 기도에 들어가는 약제의 양이 많다.
- 숚수 약물만을 사용
- 천식 증상이 심한 환자나 6세 이하 소아는 사용하기 어렵다.
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Azmacort
Becotide Diskhaler
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Diskus
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Turbuhaler
Efficient way of using 1.Twist the base as far as it will go and
then back to the original position, listening for the click.
2. Breathe out gently. 3. Place the mouthpiece between teeth and
close lips around it. 4. Inhale deeply and forcefully through
mouth.
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터브러
터브헬러 타 흡입기
< 약물 폐 분포도 >
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최영란샘-1.wmv
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병리사-박정미,김현정, 갂호사 –최영란,이연화