01CPG Uravej 1-50 - thoracicsocietythai.org · 5 ¢âÕ·π–π”°“√¥ Ÿ·≈√...

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ISBN: 978-616-8134-00-9

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¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560-- °√ÿß‡∑æœ : ¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å, 2560.112 Àπâ“

1. ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß. I. ™◊ËÕ‡√◊ËÕß

616.244ISBN: 978-616-8134-00-9

¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560

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μ“√“ß∑’Ë 2 ¬“∑’Ë„™â„π°“√√—°…“‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß 25

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√“¬π“¡§≥–∑”ß“πæ—≤π“¢âÕ·π–π”°“√¥Ÿ·≈√—°…“

ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 111

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‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2553 ·μà„πªí®®ÿ∫—π‰¥â¡’«‘«—≤π“°“√„π°“√¥Ÿ·≈√—°…“

‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß‡æ‘Ë¡¡“°¢÷Èπ ´÷Ëß®–¡’º≈∑”„Àâ§ÿ≥¿“æ™’«‘μ¢ÕßºŸâªÉ«¬¥’¢÷Èπ

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2560 ©∫—∫π’È¢÷Èπ ‚¥¬§«“¡√à«¡¡◊Õ®“°°√–∑√«ß “∏“√≥ ÿ¢ ·≈– ”π—°ß“π

À≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘

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©∫—∫π’È„Àâ ”‡√Á®≈ÿ≈à«ß‰ª¥â«¬¥’ ·≈–À«—ß‡ªìπÕ¬à“ß¬‘Ëß«à“·π«∑“ß©∫—∫π’È®–‡ªìπ‡§√◊ËÕß¡◊Õ

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ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

§«“¡·μ°μà“ß√–À«à“ß¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ». 2560

·≈– GOLD guideline 2017

·π«∑“ß°“√«‘π‘®©—¬‰¡à¡’§«“¡·μ°μà“ß°—π√–À«à“ß¢âÕ·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

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2. „π¢âÕ·π–π”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 °“√

√—°…“®–‡ªìπ·∫∫¢—Èπ∫—π‰¥μ“¡§«“¡√ÿπ·√ß¢Õß‚√§´÷Ëß„π GOLD guideline 2017

®–√—°…“μ“¡°“√·∫àß°≈ÿà¡ºŸâªÉ«¬

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

„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

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‰¡à¡’°“√®—¥·∫àß§«“¡√ÿπ·√ß¢Õß¿“«–°”‡√‘∫‡©’¬∫æ≈—π ·μà®–·∫àßºŸâªÉ«¬μ“¡°“√

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„Àâ ‡μ’¬√Õ¬¥å ¢π“¥·≈–√–¬–‡«≈“°“√„Àâ ¢÷ÈπÕ¬Ÿà°—∫§«“¡√ÿπ·√ß¢Õß°“√°”‡√‘∫

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14 «—π ¢≥–∑’Ë GOLD guideline 2017 ·π–π” prednisone 40 ¡°./«—π π“π

5 «—π ·≈–·π–π” nebulized budesonide ‡ªìπ∑“ß‡≈◊Õ°„πºŸâªÉ«¬∫“ß§π∑’Ë

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3. GOLD guideline 2017 „Àâ√“¬≈–‡Õ’¬¥∂÷ß°“√ª√–‡¡‘πºŸâªÉ«¬¿“¬„π

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√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß æ.». 2560 ‰¡à‰¥â≈ß√“¬≈–‡Õ’¬¥„π¥â“ππ’È ‰«â

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¢Õß°“√ªØ‘∫—μ‘ ºŸâ „™â “¡“√∂ªØ‘∫—μ‘·μ°μà“ß‰ª®“°¢âÕ·π–π”π’È ‰¥â „π°√≥’∑’Ë

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πÈ”Àπ—°§”·π–π” ++ ç§«√∑”é À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õß§”·π–π”„Àâ∑”Õ¬Ÿà„π

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√–¥—∫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„®¬—ß‰¡à‡æ’¬ßæÕ„π

°“√„Àâ§”·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„Àâ‡°‘¥

Õ—πμ√“¬μàÕºŸâªÉ«¬‡æ‘Ë¡¢÷Èπ ¥—ßπ—Èπ°“√μ—¥ ‘π„®°√–∑”¢÷ÈπÕ¬Ÿà

°—∫ªí®®—¬Õ◊Ëπ Ê

πÈ”Àπ—°§”·π–π” - ç‰¡àπà“∑”é À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õß§”·π–π”Àâ“¡∑”

Õ¬Ÿà„π√–¥—∫ª“π°≈“ß ‡π◊ËÕß®“°¡“μ√°“√¥—ß°≈à“«‰¡à¡’

ª√–‚¬™πåμàÕºŸâªÉ«¬·≈–‰¡à§ÿâ¡§à“

πÈ”Àπ—°§”·π–π” - - ç‰¡à§«√∑”é À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õß§”·π–π”Àâ“¡∑”

Õ¬Ÿà„π√–¥—∫ Ÿß ‡æ√“–¡“μ√°“√¥—ß°≈à“«Õ“®‡°‘¥‚∑…À√◊Õ

°àÕ„Àâ‡°‘¥Õ—πμ√“¬μàÕºŸâªÉ«¬

§ÿ≥¿“æÀ≈—°∞“π (Quality of Evidence)

§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1 À¡“¬∂÷ß À≈—°∞“π∑’Ë‰¥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“ß¥’

Õ¬à“ßπâÕ¬ 1 ©∫—∫ (a well-designed, randomize-controlled clinical

trial)

§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 2 À¡“¬∂÷ß À≈—°∞“π∑’Ë‰¥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“ß¥’ (well-designed, non-randomized, controlled clinical trial)

À√◊Õ

2.3 À≈—°∞“π®“°√“¬ß“π°“√»÷°…“μ“¡·ºπμ‘¥μ“¡‡Àμÿ‰ªÀ“º≈ (cohort)

À√◊Õ°“√»÷°…“ «‘‡§√“–Àå§«∫§ÿ¡°√≥’¬âÕπÀ≈—ß (case-control analytic

studies) ∑’Ë‰¥â√—∫°“√ÕÕ°·∫∫«‘®—¬ ‡ªìπÕ¬à“ß¥’ ´÷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∑’Ë‰¥â®“°°“√«‘®—¬∑“ß§≈‘π‘°√Ÿª·∫∫Õ◊ËπÀ√◊Õ∑¥≈Õß·∫∫

‰¡à¡’°≈ÿà¡§«∫§ÿ¡ ´÷Ëß¡’º≈ª√–®—°…å∂÷ßª√–‚¬™πåÀ√◊Õ‚∑…®“°°“√ªØ‘∫—μ‘

¡“μ√°“√∑’Ë‡¥àπ™—¥¡“° ‡™àπ º≈¢Õß°“√π”¬“‡æÁππ‘´‘≈‘π¡“„™â„π√“«

æ.». 2480 ®–‰¥â√—∫°“√®—¥Õ¬Ÿà„πÀ≈—°∞“πª√–‡¿∑π’È

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3 À¡“¬∂÷ß À≈—°∞“π∑’Ë‰¥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∑’Ë‰¥â®“°

4.1 √“¬ß“π¢Õß§≥–°√√¡°“√ºŸâ‡™’Ë¬«™“≠ ª√–°Õ∫°—∫§«“¡‡ÀÁπæâÕßÀ√◊Õ

©—π∑“¡μ‘ (consensus) ¢Õß§≥–ºŸâ‡™’Ë¬«™“≠ ∫πæ◊Èπ∞“πª√– ∫°“√≥å

∑“ß§≈‘π‘° À√◊Õ

4.2 √“¬ß“πÕπÿ°√¡ºŸâªÉ«¬®“°°“√»÷°…“„πª√–™“°√μà“ß°≈ÿà¡ ·≈–§≥–

ºŸâ»÷°…“μà“ß§≥– Õ¬à“ßπâÕ¬ 2 ©∫—∫√“¬ß“πÀ√◊Õ§«“¡‡ÀÁπ∑’Ë‰¡à‰¥âºà“π

°“√«‘‡§√“–Àå·∫∫¡’√–∫∫ ‡™àπ √“¬ß“πºŸâªÉ«¬‡©æ“–√“¬ (anecdotal

report) §«“¡‡ÀÁπ¢ÕßºŸâ‡™’Ë¬«™“≠‡©æ“–√“¬ ®–‰¡à‰¥â√—∫°“√æ‘®“√≥“

«à“‡ªìπÀ≈—°∞“π∑’Ë¡’§ÿ≥¿“æ„π°“√®—¥∑”·π«∑“ß‡«™ªØ‘∫—μ‘π’È

π‘¬“¡ (Definition)

‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß À√◊Õ COPD (Chronic Obstructive Pulmonary

Disease) ‡ªìπ‚√§∑’ËªÑÕß°—π‰¥â·≈–√—°…“‰¥â ‚¥¬¡’≈—°…≥–‡ªìπ progressive,

not fully reversible airflow limitation ´÷Ëß‡ªìπº≈®“°°“√√–§“¬‡§◊Õß‡√◊ÈÕ√—ßμàÕ

ªÕ¥ ®“°ΩÿÉπ ·≈–·°ä æ‘… ∑’Ë ”§—≠∑’Ë ÿ¥ ‰¥â·°à §«—π∫ÿÀ√’Ë ∑”„Àâ‡°‘¥ 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 ¡’π‘¬“¡®“°Õ“°“√∑“ß§≈‘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¡’æ¬“∏‘ ¿“æ°“√∑”≈“¬¢Õß∂ÿß≈¡ ·≈–

respiratory bronchiole ‚¥¬¡’°“√¢¬“¬μ—«‚ªÉßæÕßÕ¬à“ß∂“«√

ºŸâªÉ«¬ à«π„À≠à¡—°æ∫‚√§∑—Èß Õß¥—ß°≈à“«Õ¬Ÿà√à«¡°—π ·≈–·¬°ÕÕ°®“°°—π

‰¥â¬“°

æ¬“∏‘°”‡π‘¥ (Pathogenesis)

º≈®“°°“√√–§“¬‡§◊ÕßÕ¬à“ßμàÕ‡π◊ËÕß∑”„Àâ‡°‘¥°“√Õ—°‡ ∫‡√◊ÈÕ√—ß∑—Èß„πÀ≈Õ¥≈¡

‡π◊ÈÕªÕ¥ ·≈–À≈Õ¥‡≈◊Õ¥ªÕ¥ (pulmonary vasculature) ‚¥¬¡’‡´≈≈å ”§—≠∑’Ë

‡°’Ë¬«¢âÕß§◊Õ T-lymphocyte ( à«π„À≠à‡ªìπ CD8) neutrophil ·≈– macrophage

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

∑”„Àâ¡’°“√À≈—Ëß inflammatory mediators À≈“¬™π‘¥ ∑’Ë ”§—≠ ‰¥â·°à leukotriene

B4, interleukin 8 ·≈– tumor necrosis factor α ‡ªìπμâπ πÕ°®“°π’È¬—ß¡’

°√–∫«π°“√ ”§—≠∑’Ë¡“‡°’Ë¬«¢âÕß°—∫æ¬“∏‘°”‡π‘¥Õ’° 2 ª√–°“√ §◊Õ °“√‡æ‘Ë¡¢Õß

oxidative stress ·≈–§«“¡‰¡à ¡¥ÿ≈√–À«à“ß proteinase °—∫ antiproteinase

æ¬“∏‘«‘∑¬“ (Pathology)

æ∫°“√‡ª≈’Ë¬π·ª≈ß¢ÕßÀ≈Õ¥≈¡μ—Èß·μà¢π“¥„À≠à≈ß‰ª®π∂÷ß¢π“¥‡≈Á° ¡’

‡´≈≈å∑’Ë‡°’Ë¬«¢âÕß°—∫°“√Õ—°‡ ∫·∑√°„π‡¬◊ËÕ∫ÿ∑—Ë«‰ª ¡’ goblet cell ‡æ‘Ë¡¢÷Èπ ·≈–

mucous gland ¢¬“¬„À≠à¢÷Èπ ∑”„Àâ¡’°“√ √â“ß mucus ÕÕ°¡“¡“°·≈–‡Àπ’¬«

°«à“ª°μ‘ °“√Õ—°‡ ∫·≈–°“√∑”≈“¬∑’Ë‡°‘¥´È” Ê ®–∑”„Àâ‡°‘¥°“√‡ª≈’Ë¬π·ª≈ß‚§√ß

√â“ß¢Õßºπ—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

∑’Ë‡°’Ë¬«¢âÕß°—∫°“√Õ—°‡ ∫¡’®”π«π‡æ‘Ë¡¢÷Èπ

æ¬“∏‘ √’√«‘∑¬“ (Pathophysiology)

°“√‡ª≈’Ë¬π·ª≈ß∑“ßæ¬“∏‘«‘∑¬“¢ÕßªÕ¥ π”‰ª Ÿà°“√‡ª≈’Ë¬π·ª≈ß∑“ß

√’√«‘∑¬“„πºŸâªÉ«¬ ¥—ßπ’È

1. °“√ √â“ß mucus ¡“°°«à“ª°μ‘ √à«¡°—∫°“√∑”ß“πº‘¥ª°μ‘¢Õß cilia

∑”„ÀâºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß¡’‡ ¡À– ´÷ËßÕ“®‡ªìπÕ“°“√π”¢Õß‚√§°àÕπ∑’Ë®–¡’°“√‡ª≈’Ë¬π

·ª≈ß∑“ß √’√«‘∑¬“Õ◊Ëπ Ê

2. °“√μ’∫¢ÕßÀ≈Õ¥≈¡√à«¡°—∫°“√ Ÿ≠‡ ’¬ elastic recoil ¢Õß‡π◊ÈÕªÕ¥

∑”„Àâ‡°‘¥ airflow limitation ·≈– air trapping

3. °“√μ’∫¢ÕßÀ≈Õ¥≈¡ °“√∑”≈“¬¢Õß‡π◊ÈÕªÕ¥ ·≈–À≈Õ¥‡≈◊Õ¥ ®–¡’º≈

μàÕ°“√·≈°‡ª≈’Ë¬π°ä“´ ∑”„Àâ‡°‘¥¿“«– hypoxemia ·≈– hypercapnia μ“¡¡“

´÷ËßÕ“®∑”„Àâ‡°‘¥ 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«¬ ∑”„Àâ‡°‘¥‚√§√à«¡¢Õß COPD

¢÷Èπ„πÀ≈“¬√–∫∫ ‡™àπ muscle wasting, ischemic heart disease, heart

failure, type 2 diabetes, metabolic syndrome, osteoporosis, anemia ·≈–

depression

√–∫“¥«‘∑¬“ (Epidemiology)

¬—ß‰¡à¡’°“√ ”√«®√–¥—∫™“μ‘ ·μà®“°°“√§”π«≥‚¥¬„™â·∫∫®”≈ÕßÕ“»—¬

¢âÕ¡Ÿ≈§«“¡™ÿ°¢Õß°“√ Ÿ∫∫ÿÀ√’Ë ·≈–¡≈¿“«–„π ¿“æ·«¥≈âÕ¡„π∫â“π·≈–„π∑’Ë

“∏“√≥– ª√–¡“≥«à“√âÕ¬≈– 5 ¢Õßª√–™“°√‰∑¬ 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 ‚√ßæ¬“∫“≈

à«π„À≠à‡ªìπºŸâªÉ«¬√–¬–√ÿπ·√ß3

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

¢âÕ¡Ÿ≈°“√‡∫‘°®à“¬®“° ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘ ªï æ.». 25574

æ∫«à“ ºŸâªÉ«¬∑’ËπÕπ‚√ßæ¬“∫“≈¥â«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß¡’®”π«π 350 §πμàÕ

ª√–™“°√ 100,000 §π ¡’Õ—μ√“°“√‡ ’¬™’«‘μ √âÕ¬≈– 5.4 ¡’°“√„™â‡§√◊ËÕß™à«¬À“¬„®

À√◊Õ„ à∑àÕ™à«¬À“¬„® √âÕ¬≈– 9.8 ·≈–°≈—∫¡“πÕπ‚√ßæ¬“∫“≈ È”¿“¬„π 28 «—π

À≈—ß®”Àπà“¬ºŸâªÉ«¬ (re-admission) √âÕ¬≈– 28

·¡â«à“°“√√≥√ß§å‡æ◊ËÕ°“√≈¥°“√∫√‘‚¿§¬“ Ÿ∫¢Õßª√–‡∑»‰∑¬ ‰¥â¡’°“√¥”‡π‘π

°“√Õ¬à“ßμàÕ‡π◊ËÕß ·μà®”π«πºŸâ Ÿ∫∫ÿÀ√’Ë‰¡à ‰¥â≈¥≈ßμ“¡∑’Ë§«√®–‡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‡©≈’Ë¬∑’Ë‡√‘Ë¡ Ÿ∫∫ÿÀ√’Ë§√—Èß·√°πâÕ¬≈ß‡√◊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„Àâ‡°‘¥ºŸâ Ÿ∫√“¬„À¡à (primary

prevention) ÷Ëß®“°¢âÕ¡Ÿ≈„πªí®®ÿ∫—π¡’Õ“¬ÿ∑’Ë‡√‘Ë¡ Ÿ∫πâÕ¬≈ß ·≈–°“√™à«¬‡À≈◊Õ„Àâ

ºŸâ∑’Ë Ÿ∫∫ÿÀ√’Ë‡≈‘° Ÿ∫∫ÿÀ√’Ë (smoking cessation) ®÷ß¡’§«“¡ ”§—≠‡ªìπÕ¬à“ß¬‘Ëß∑’Ë®–

≈¥º≈°√–∑∫∑’Ë‡°‘¥®“°°“√ Ÿ∫∫ÿÀ√’Ë„πÕπ“§μ‰¥â

ªí®®—¬‡ ’Ë¬ß

·∫àß‰¥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 ‡ªìπ “‡Àμÿ ”§—≠∑’Ë ÿ¥¢Õß‚√§π’È æ∫«à“¡“°°«à“√âÕ¬≈–

75.4 ¢ÕßºŸâªÉ«¬ 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)

°“√«‘π‘®©—¬‚√§

Õ“»—¬Õß§åª√–°Õ∫À≈“¬Õ¬à“ß ‰¥â·°à ª√–«—μ‘ —¡º— ªí®®—¬‡ ’Ë¬ß¥—ß°≈à“«¢â“ß

μâπ √à«¡°—∫ Õ“°“√ º≈°“√μ√«®√à“ß°“¬ ¿“æ√—ß ’∑√«ßÕ° ·≈–¬◊π¬—π°“√«‘π‘®©—¬

‚¥¬°“√μ√«® spirometry

Õ“°“√

à«π„À≠àºŸâªÉ«¬®–¡’Õ“°“√‡¡◊ËÕæ¬“∏‘ ¿“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 «—≥‚√§ ¡–‡√ÁßªÕ¥ ·≈–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√–¬–∑â“¬¢Õß‚√§Õ“®μ√«®æ∫≈—°…≥–¢Õß§«“¡¥—π

À≈Õ¥‡≈◊Õ¥·¥ßªÕ¥ Ÿß·≈–/À√◊ÕÀ—«„®¥â“π¢«“≈â¡‡À≈« (cor pulmonale) ‰¡à§«√

μ√«®æ∫¿“«–π‘È«ªÿÑ¡ À“°æ∫§«√π÷°∂÷ß¿“«–Õ◊Ëπ ‡™àπ ¡–‡√ÁßªÕ¥, 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∫≈—°…≥–

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

hyperinflation §◊Õ °–∫—ß≈¡·∫π√“∫·≈–À—«„®¡’¢π“¥‡≈Á° „πºŸâªÉ«¬∑’Ë¡’ cor

pulmonale ®–æ∫«à“À—«„®ÀâÕß¢«“ ·≈– pulmonary trunk ¡’¢π“¥‚μ¢÷Èπ ·≈–

peripheral vascular marking ≈¥≈ß

°“√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√–¬–∑’ËºŸâªÉ«¬¬—ß‰¡à¡’Õ“°“√ ®–æ∫≈—°…≥–¢Õß airflow limitation ‚¥¬§à“

FEV1 / FVC À≈—ß„Àâ¬“¢¬“¬À≈Õ¥≈¡πâÕ¬°«à“√âÕ¬≈– 70 ·≈–·∫àß§«“¡√ÿπ·√ß

‡ªìπ 4 √–¥—∫ ‚¥¬„™â§à“ FEV1 À≈—ß„Àâ¬“¢¬“¬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„Àâ¬“¢¬“¬À≈Õ¥≈¡πâÕ¬°«à“√âÕ¬≈– 70

√ÿπ·√ßπâÕ¬ (GOLD 1) §à“ FEV1 > 80% ¢Õß§à“¡“μ√∞“π

√ÿπ·√ßª“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·√ß¢Õß‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ßμ“¡§à“ FEV1 À≈—ß„Àâ¬“¢¬“¬

À≈Õ¥≈¡

°“√«‘π‘®©—¬·¬°‚√§

∑’Ë ”§—≠§◊Õ ‚√§À◊¥ «—≥‚√§ ¡–‡√ÁßªÕ¥ ‚√§À≈Õ¥≈¡æÕß ‚√§ªÕ¥®“°

°“√ª√–°Õ∫Õ“™’æ ¿“«–À—«„®≈â¡‡À≈« ‡ªìπμâπ °“√«‘π‘®©—¬·¬°‚√§À◊¥ÕÕ°®“°

‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß∫“ß§√—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’È‡ªìπÀ≈—°„π°“√®—¥°≈ÿà¡ ‚¥¬æ‘®“√≥“μ“¡§«“¡

‡À¡“– ¡ ¡’°“√·∫àßºŸâªÉ«¬‡ªìπ 4 √–¥—∫ ¥—ßπ’È

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„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°°”≈—ßª“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°”‡√‘∫®πμâÕß‡¢â“√—∫°“√√—°…“

μ—«„π‚√ßæ¬“∫“≈Õ¬à“ßπâÕ¬ 1 §√—ÈßμàÕªï

ë º≈°“√μ√«® ¡√√∂¿“æªÕ¥ : FEV1 √âÕ¬≈– 30 ∂÷ß 49

°≈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°”‡√‘∫®πμâÕß‡¢â“√—∫°“√√—°…“

μ—«„π‚√ßæ¬“∫“≈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¡°“√√—°…“„Àâ¬“‚¥¬æ‘®“√≥“μ“¡§«“¡√ÿπ·√ß

¢Õß‚√§·∫∫¢—Èπ∫—π‰¥ (stepwise approach) ¥—ß·ºπ¿Ÿ¡‘∑’Ë 1 ‚¥¬‡√‘Ë¡μâπ®“°°“√

„Àâ¬“Àπ÷Ëß¢π“π ®“°π—Èπæ‘®“√≥“‡æ‘Ë¡¬“„ÀâºŸâªÉ«¬ À“°Õ“°“√ºŸâªÉ«¬‰¡à¥’¢÷Èπ À≈—ß

ª√–‡¡‘π«‘∏’°“√·≈–§«“¡ ¡Ë”‡ ¡Õ¢Õß°“√„™âÕÿª°√≥å Ÿ¥À√◊Õæàπ¬“Õ¬à“ß¥’·≈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” ++)

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

ë Õ“®æ‘®“√≥“‡≈◊Õ°„Àâ¬“¢¬“¬À≈Õ¥≈¡™π‘¥√—∫ª√–∑“π theophylline

™π‘¥ÕÕ°ƒ∑∏‘Ïπ“π„π¢π“¥μË” (sustained-release theophylline)

‡ªìπ¬“‡¥’Ë¬«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“°“√¢ÕßºŸâªÉ«¬ ·≈–ªÑÕß°—π°“√

°”‡√‘∫¢Õß‚√§ ·π–π”„Àâ‡æ‘Ë¡¬“¥—ßμàÕ‰ªπ’È

ë ¬“æàπ Ÿ¥¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï¬“«°≈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√◊ÕμâÕß‡¢â“√—∫°“√√—°…“μ—«„π‚√ßæ¬“∫“≈Õ¬à“ßπâÕ¬ 1 §√—ÈßμàÕªï) ·π–π”„Àâ‡æ‘Ë¡

¬“ ¥—ßμàÕ‰ªπ’È

ë ¬“æàπ Ÿ¥¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï¬“«°≈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” +)

·ºπ¿Ÿ¡‘∑’Ë 1 °“√√—°…“‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß·∫∫¢—Èπ∫—π‰¥

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

°“√√—°…“¥â«¬¬“ (μ“√“ß∑’Ë 2)

°“√„™â¬“¡’®ÿ¥ª√– ß§å‡æ◊ËÕ∫√√‡∑“Õ“°“√ ‡æ‘Ë¡§ÿ≥¿“æ™’«‘μ ≈¥°“√°”‡√‘∫

‡©’¬∫æ≈—π √«¡∂÷ß™–≈Õ°“√¥”‡π‘π‚√§ Õ¬à“ß‰√°Áμ“¡¬—ß‰¡à¡’¬“™π‘¥„¥∑’Ë¡’À≈—°∞“π

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¬“°≈ÿà¡ antimuscarinic ª√–°Õ∫¥â«¬¬“™π‘¥ÕÕ°ƒ∑∏‘Ï —Èπ À√◊Õ short

acting antimuscarinic (SAMA) ·≈–ÕÕ°ƒ∑∏‘Ï¬“« À√◊Õ long acting anti-

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SABA ¡“°π—° à«π¬“°≈ÿà¡ LAMA æ∫«à“‰¥âª√–‚¬™πå„π°“√∫√√‡∑“Õ“°“√ ≈¥

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(§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” ++)

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nebulizer ‡©æ“–„π√“¬∑’Ë ‰¡à “¡“√∂„™â¬“‚¥¬«‘∏’æàπ Ÿ¥™π‘¥Õ◊Ëπ Ê Õ¬à“ß¡’

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∑’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¢¿“æ¥’¢÷Èπ ·≈–≈¥Õ—μ√“°“√°”‡√‘∫¢Õß‚√§‰¥â¥’°«à“°“√„™â¬“ long acting

bronchodilator ‡¥’Ë¬«20-23

¬“°≈ÿà¡ beta2-agonist ¡’º≈¢â“ß‡§’¬ß∑’Ë ”§—≠ ‡™àπ À—«„®‡μâπ‡√Á«

(tachycardia) √–¥—∫‚ª·μ ‡´’¬¡„π‡≈◊Õ¥μË” ¡◊Õ —Ëπ ‡ªìπμâπ

¬“°≈ÿà¡ anticholinergic ¡’º≈¢â“ß‡§’¬ß∑’Ë ”§—≠ ‡™àπ ª“°·Àâß urinary

retention √ ¢¡À√◊Õ metallic taste „πª“° ∂â“„™â√Ÿª nebulizer Õ“®®–°√–μÿâπ

„Àâ‡°‘¥ acute glaucoma

¬“ ‡μ’¬√Õ¬¥å

¬“æàπ Ÿ¥ ‡μ’¬√Õ¬¥å (inhaled corticosteroids, ICS)

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∂÷ß≈¥°“√‡°‘¥°“√°”‡√‘∫ ‚¥¬‡©æ“–„πºŸâªÉ«¬∑’Ë¡’§à“ FEV1 < 60% predicted10,24-26

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‡¡◊ËÕ„™â„π¢π“¥ Ÿß ‡æ‘Ë¡§«“¡‡ ’Ë¬ß„π°“√‡°‘¥ªÕ¥Õ—°‡ ∫27-30 ‡¡◊ËÕ„™â„π√–¬–¬“«

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μâÕß√–«—ßº≈¢â“ß‡§’¬ß¢Õß¬“ ‡μ’¬√Õ¬¥å ®÷ß‰¡à·π–π”„™â¬“ ICS ‡ªìπ¬“‡¥’Ë¬«„π

°“√√—°…“‚¥¬‰¡à¡’¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï¬“«√à«¡¥â«¬

°“√À¬ÿ¥¬“ ICS Õ¬à“ß©—∫æ≈—π Õ“®¡’º≈∑”„ÀâÕ“°“√·¬à≈ß À√◊Õ‡°‘¥°“√

°”‡√‘∫‰¥â33 ·μà„πºŸâªÉ«¬°≈ÿà¡∑’Ë¡’§«“¡‡ ’Ë¬ß¢Õß°“√°”‡√‘∫μË” À“°μâÕß°“√À¬ÿ¥¬“

ICS ·π–π”„Àâ§àÕ¬Ê ≈¥¢π“¥¬“≈ß™â“ Ê √à«¡°—∫°“√„Àâ¬“¢¬“¬À≈Õ¥≈¡™π‘¥

ÕÕ°ƒ∑∏‘Ï¬“«Õ¬à“ß‡μÁ¡∑’Ë34,35 (§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” +/-)

º≈¢â“ß‡§’¬ß∑’Ë ”§—≠§◊Õ ‡™◊ÈÕ√“„πª“° ‡ ’¬ß·À∫ skin bruising ªÕ¥Õ—°‡ ∫

¬“ ‡μ’¬√Õ¬¥å™π‘¥√—∫ª√–∑“π (oral corticosteroids)

¡’ª√–‚¬™πå‡©æ“–„π°“√√—°…“°“√°”‡√‘∫‡©’¬∫æ≈—π‡∑à“π—Èπ36,37 ‰¡à§«√„™â

„π°“√√—°…“√–¬–¬“« (§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1, πÈ”Àπ—°§”·π–π” --) ‡π◊ËÕß®“°

¡’º≈¢â“ß‡§’¬ß¡“° ‡™àπ steroid myopathy, osteoporosis ‡æ‘Ë¡§«“¡‡ ’Ë¬ß„π

°“√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«¬

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Methylxanthines

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„™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“ß‰√°Áμ“¡‰¡à§«√„™â¬“°≈ÿà¡

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√–¥—∫ 1, πÈ”Àπ—°§”·π–π” +)

¢âÕ§«√√–«—ß∑’Ë ”§—≠§◊Õ drug interaction ‡¡◊ËÕ„™â√à«¡°—∫¬“Õ◊Ëπ∑’Ë metabolize

ºà“π cytochrome P450 ‡™àπ ¬“°≈ÿà¡ macrolide, quinolone ·≈– warfarin

‡ªìπμâπ ·≈–„™â¥â«¬§«“¡√–¡—¥√–«—ß„πºŸâ ŸßÕ“¬ÿ ‡π◊ËÕß®“°¡’‚Õ°“ ‡°‘¥º≈¢â“ß‡§’¬ß

‰¥âßà“¬°«à“

º≈¢â“ß‡§’¬ß∑’Ë ”§—≠§◊Õ À—«„®‡μâπº‘¥®—ßÀ«– ™—° ª«¥»’√…– πÕπ‰¡àÀ≈—∫

§≈◊Ëπ‰ â Õ“‡®’¬π heartburn

Phosphodiesterase-4 inhibitor (PDE-4 inhibitor)

‡ªìπ¬“∑’Ë‰¡à¡’ƒ∑∏‘Ï¢¬“¬À≈Õ¥≈¡‚¥¬μ√ß ·μàÕ“®„™â√à«¡°—∫¬“¢¬“¬À≈Õ¥≈¡

∑’ËÕÕ°ƒ∑∏‘Ï¬“« ‡æ◊ËÕ≈¥Õ—μ√“°“√°”‡√‘∫ ‰¥âª√–‚¬™πå‡©æ“–„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“ß‡§’¬ß∑’Ë ”§—≠‰¥â·°à §≈◊Ëπ‰ â

‡∫◊ËÕÕ“À“√ ª«¥∑âÕß ∑âÕß‡ ’¬ ª«¥»’√…– πÕπ‰¡àÀ≈—∫ πÈ”Àπ—°≈¥ ·≈–Àâ“¡„™â

√à«¡°—∫¬“ theophylline ‡æ√“–∑”„Àâ¡’º≈¢â“ß‡§’¬ß‡æ‘Ë¡¢÷Èπ

Mucolytic & Antioxidant‡™àπ ambroxol, carbocysteine, N-acetylcysteine, erdosteine Õ“®„™â

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

‡æ◊ËÕ∫√√‡∑“Õ“°“√‡ ¡À–‡Àπ’¬«‡ªìπ™à«ß —Èπ °“√„™â¬“≈–≈“¬‡ ¡À–‡æ◊ËÕ°“√√—°…“

√–¬–¬“« ¬—ß‰¡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‡ªìπ¬“‡ √‘¡√à«¡°—∫

°“√√—°…“Õ◊Ëπ‡æ◊ËÕ≈¥°“√°”‡√‘∫„πºŸâªÉ«¬∑’Ë¡’°“√°”‡√‘∫∫àÕ¬ (§ÿ≥¿“æÀ≈—°∞“π√–¥—∫

1, πÈ”Àπ—°§”·π–π” +)

¬“ªØ‘™’«π–

∫∑∫“∑À≈—°¢Õß¬“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≈°“√»÷°…“

¬—ß‰¡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√– ß§åπ’È®÷ß§«√„™â¥â«¬§«“¡√–¡—¥√–«—ß·≈–§”π÷ß∂÷ßº≈·∑√° âÕπ∑’Ë

‡°’Ë¬«¢âÕß¥â«¬ ‡™àπ º≈¢â“ß‡§’¬ß¢Õß¬“ °“√‡æ‘Ë¡®”π«π‡™◊ÈÕ¥◊ÈÕ¬“ ‡ªìπμâπ

¬“Õ◊Ëπ Ê

¬“·°â ‰Õ „™â‡æ◊ËÕ∫√√‡∑“Õ“°“√‡∑à“π—Èπ ‰¡à·π–π”„Àâ„™â‡ªìπª√–®”

¢—Èπ∑’Ë 3 °“√√—°…“Õ◊Ëπ Ê

§«√μâÕß„Àâ§”·π–π”§«∫§Ÿà‰ª°—∫°“√√—°…“¥â«¬¬“„πºŸâªÉ«¬∑ÿ°√“¬‡æ◊ËÕ‡æ‘Ë¡

§ÿ≥¿“æ™’«‘μ ≈¥°“√°”‡√‘∫ ·≈–«“ß·ºπ°“√√—°…“√à«¡°—∫ºŸâªÉ«¬‡ ¡Õ °“√√—°…“

Õ◊Ëπ Ê ∑’Ë‰¡à„™à¬“ ‰¥â·°à

ë „ÀâºŸâªÉ«¬√—∫«—§´’πªÑÕß°—π‰¢âÀ«—¥„À≠à (influenza vaccine) ªï≈–Õ¬à“ß

πâÕ¬ 1 §√—Èß ·≈–·π–π”ª√–‚¬™πå¢Õß°“√√—∫«—§´’πªÑÕß°—πªÕ¥Õ—°‡ ∫

(pneumococcal vaccine)

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‘®“√≥“„ÀâºŸâªÉ«¬„™âÕÕ°´‘‡®πÕ¬à“ßπâÕ¬«—π≈– 15 ™—Ë«‚¡ß (long term

oxygen therapy)

·π–π”∑“ß‡≈◊Õ°„π°“√√—°…“‚¥¬°“√ºà“μ—¥ (lung volume reduction

surgery - LVRS) „πºŸâªÉ«¬∑’Ë¡’¢âÕ∫àß™’È

·®âß°“√æ¬“°√≥å‚√§ §ÿ¬∂÷ß«“√– ÿ¥∑â“¬„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

√–¬–‡«≈“∑’Ë‡À¡“– ¡§◊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 ¢Õß§à“Õâ“ßÕ‘ß

°“√øóôπøŸ ¡√√∂¿“æªÕ¥ (pulmonary rehabilitation) (¿“§ºπ«° 4)

¡’«—μ∂ÿª√– ß§å‡æ◊ËÕ≈¥Õ“°“√¢Õß‚√§ ‡æ‘Ë¡§ÿ≥¿“æ™’«‘μ ·≈–‡æ‘Ë¡§«“¡

“¡“√∂„π°“√∑”°‘®«—μ√ª√–®”«—π ´÷Ëß°“√øóôπøŸ ¡√√∂¿“æªÕ¥π’È ¡’Õß§åª√–°Õ∫

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

À≈“¬Õ¬à“ß §◊Õ°“√„Àâ§«“¡√Ÿâ °“√ª√—∫‡ª≈’Ë¬πæƒμ‘°√√¡ ‡∑§π‘§°“√¢—∫‡ ¡À–„Àâ

∂Ÿ°«‘∏’ °“√„™â¬“ °“√ª√–‡¡‘π·≈–øóôπøŸ ¿“æ¢Õß°≈â“¡‡π◊ÈÕ ¿“æÕ“√¡≥å·≈–

®‘μ„® ¿“«–‚¿™π“°“√ ·≈–°“√Ωñ°°“√ÕÕ°°”≈—ß°“¬ Õ—π®–π”‰ª Ÿà°“√¥Ÿ·≈μπ‡Õß

∑’Ë‡À¡“– ¡ °“√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“π ¬‘Ëß‰¥â

ª√– ‘∑∏‘º≈ ·≈–‚ª√·°√¡¢ÕßºŸâªÉ«¬·μà≈–√“¬‰¡à®”‡ªìπμâÕß‡À¡◊Õπ°—π “¡“√∂

ª√—∫‡ª≈’Ë¬π‰¥â ‚¥¬¢÷ÈπÕ¬Ÿà°—∫ ¿“«–¢Õß‚√§ √–¥—∫°“√√—∫√ŸâÀ√◊Õ§«“¡‡¢â“„® ¿“æ

—ß§¡ À√◊Õ‡»√…∞“π–¢ÕßºŸâªÉ«¬·μà≈–√“¬

°“√øóôπøŸ ¡√√∂¿“æªÕ¥®–μâÕß¡’°“√ª√–‡¡‘πºŸâªÉ«¬∑—Èß°àÕπ·≈–À≈—ß°“√

‡¢â“√à«¡°‘®°√√¡ ‡æ◊ËÕ„™â‡ªìπμ—«™’È«—¥∂÷ßª√–‚¬™πå∑’Ë‰¥â√—∫·≈–‡ªÑ“À¡“¬∑’ËμâÕß°“√

„πºŸâªÉ«¬·μà≈–√“¬ ‚¥¬°“√ª√–‡¡‘π§«√ª√–°Õ∫¥â«¬¥—™π’À≈—° ¥—ßμàÕ‰ªπ’È

1) √–¥—∫§«“¡√ÿπ·√ß¢ÕßÕ“°“√‡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·√ß¢Õß°≈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‚√ßæ¬“∫“≈ (admission rate) ‡ªìπμâπ

∑—Èßπ’È ¥—™π’∑’Ë„™â„π°“√ª√–‡¡‘π ¢÷ÈπÕ¬Ÿà°—∫»—°¬¿“æ¢Õß ∂“π∫√‘°“√

°“√∫”∫—¥¥â«¬ÕÕ°´‘‡®π√–¬–¬“« (¿“§ºπ«° 5)

°“√√—°…“‚¥¬°“√ºà“μ—¥ ·≈–/À√◊Õ À—μ∂°“√æ‘‡»…

”À√—∫ºŸâªÉ«¬∫“ß√“¬∑’Ë‰¥â√—∫°“√√—°…“¥â«¬¬“ ·≈–°“√øóôπøŸ ¡√√∂¿“æ

ªÕ¥Õ¬à“ß‡μÁ¡∑’Ë·≈â« ¬—ß§«∫§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√–‚¬™πå‡©æ“–„π°≈ÿà¡ºŸâªÉ«¬∑’Ë¡’≈—°…≥–∂ÿß≈¡‚ªÉßæÕß‡¥àπ∑’ËªÕ¥°≈’∫∫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≈’Ë¬πªÕ¥ (lung transplantation)

Õ¬à“ß‰√°Á¥’ μâÕß§”π÷ß∂÷ßª√–‚¬™πå∑’ËºŸâªÉ«¬®–‰¥â√—∫°—∫§«“¡‡ ’Ë¬ß®“°°“√

ºà“μ—¥·≈–§à“„™â®à“¬®“°°“√ºà“μ—¥√à«¡¥â«¬ ¥—ßπ—Èπ §«√ àßμàÕºŸâªÉ«¬‡À≈à“π’È ‰ª

¬—ßÕ“¬ÿ√·æ∑¬åºŸâ‡™’Ë¬«™“≠‚√§√–∫∫°“√À“¬„® ‡æ◊ËÕª√–‡¡‘π°“√√—°…“‚¥¬≈–‡Õ’¬¥

μàÕ‰ª

°“√«“ß·ºπ™’«‘μ√–¬– ÿ¥∑â“¬ (end of life plan) (¿“§ºπ«° 6)

°“√ª√–‡¡‘π·≈–°“√μ‘¥μ“¡‚√§ (¿“§ºπ«° 7)

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

°“√°”‡√‘∫‡©’¬∫æ≈—π¢Õß‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß(acute exacerbation of COPD)

°“√°”‡√‘∫‡©’¬∫æ≈—π¢Õß‚√§À¡“¬∂÷ß °“√∑√ÿ¥≈ß¢ÕßÕ“°“√Õ¬à“ß‡©’¬∫

æ≈—π¿“¬„π 3 «—π ®π∑”„ÀâμâÕß‡æ‘Ë¡À√◊Õª√—∫‡ª≈’Ë¬π°“√√—°…“ Õ“°“√¥—ß°≈à“«‰¥â·°à

1. ‡Àπ◊ËÕ¬‡æ‘Ë¡¢÷Èπ

2. ‰Õ¡“°¢÷Èπ

3. ª√‘¡“≥‡ ¡À–‡æ‘Ë¡¢÷Èπ

4. ‡ ¡À–‡ª≈’Ë¬π ’

‚¥¬Õ“°“√¥—ß°≈à“«μâÕß‰¡à‰¥â‡°‘¥®“°‚√§À√◊Õ¿“«–Õ◊Ëπ Ê ∑’Ë¡’≈—°…≥–Õ“°“√

§≈â“¬§≈÷ß°—π ‡™àπ À—«„®≈â¡‡À≈« ≈¡√—Ë«„π™àÕß‡¬◊ËÕÀÿâ¡ªÕ¥ ªÕ¥Õ—°‡ ∫ ≈‘Ë¡‡≈◊Õ¥

Õÿ¥μ—πÀ≈Õ¥‡≈◊Õ¥·¥ßªÕ¥‡©’¬∫æ≈—π ‡ªìπμâπ37,54-58

°“√ª√–‡¡‘πºŸâªÉ«¬37,58-61

1. ª√–«—μ‘ √–¥—∫§«“¡√ÿπ·√ß¢Õß‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ‚√§ª√–®”μ—«√à«¡

ª√–«—μ‘°“√°”‡√‘∫‡©’¬∫æ≈—π¢Õß‚√§§√—Èß°àÕπ∑—Èß§«“¡∂’Ë·≈–§«“¡√ÿπ·√ß °“√‡§¬

‰¥â√—∫°“√„™â‡§√◊ËÕß™à«¬À“¬„®

2. °“√μ√«®√à“ß°“¬ ¡’°“√„™â°≈â“¡‡π◊ÈÕ™à«¬À“¬„®¡“°¢÷Èπ ‡¢’¬« ¢“∫«¡

√–¥—∫§«“¡√Ÿâ ÷°μ—«≈¥≈ß —≠≠“≥™’æº‘¥ª°μ‘

3. °“√ª√–‡¡‘π gas exchange „™â pulse oximetry ‡æ◊ËÕª√–‡¡‘π μ‘¥μ“¡

°“√√—°…“ ·≈–ª√—∫°“√„ÀâÕÕ°´‘‡®π∑’Ë‡À¡“– ¡ ‡®“– arterial blood gases ‡¡◊ËÕ

ºŸâªÉ«¬¡’°“√À“¬„®≈â¡‡À≈«·≈–„™âμ‘¥μ“¡‡¡◊ËÕºŸâªÉ«¬‰¥â√—∫°“√„™â‡§√◊ËÕß™à«¬À“¬„®

4. ¿“æ√—ß ’∑√«ßÕ° §«√ àßμ√«®°√≥’ºŸâªÉ«¬¡’Õ“°“√°”‡√‘∫√ÿπ·√ß ‡æ◊ËÕ

™à«¬«‘π‘®©—¬·¬°‚√§‡™àπ À—«„®≈â¡‡À≈« ≈¡√—Ë«„π™àÕß‡¬◊ËÕÀÿâ¡ªÕ¥ ªÕ¥μ‘¥‡™◊ÈÕ

5. àßμ√«®‡ ¡À–‡æ“–‡™◊ÈÕ „πºŸâªÉ«¬∑’Ë¡’¢âÕ∫àß™’È¢Õß°“√„Àâ¬“μâ“π®ÿ≈™’æ

·≈–¡’‚√§°”‡√‘∫√ÿπ·√ß ¡’ª√–«—μ‘‚√§°”‡√‘∫∫àÕ¬ ºŸâªÉ«¬∑’ËμâÕß„™â‡§√◊ËÕß™à«¬À“¬„®

6. °“√μ√«®§≈◊Ëπ‰øøÑ“À—«„® °√≥’ ß —¬‚√§À—«„®√à«¡¥â«¬

7. °“√μ√«® CBC ·≈– blood chemistry °√≥’∑’Ë¡’Õ“°“√√ÿπ·√ß·≈–

æ‘®“√≥“√—∫‰«â„π‚√ßæ¬“∫“≈

·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¢Õß¬“æàπ Ÿ¥¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï —Èπ

‡ªìπ∑ÿ° 4-6 ™—Ë«‚¡ß °√≥’„™â¬“√Ÿª·∫∫ MDI §«√æàπºà“π spacer

2. „Àâ¬“ ‡μ’¬√Õ¬¥å™π‘¥√—∫ª√–∑“π ‡™àπ prednisolone 30-40 ¡°./«—π

π“π 5 «—π æ‘®“√≥“·≈â«·μà°√≥’μ“¡Õ“°“√∑’Ë°”‡√‘∫63-68

3. „Àâ¬“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‚√ßæ¬“∫“≈

¢âÕ∫àß™’È¢Õß°“√√—∫ºŸâªÉ«¬‰«â√—°…“„π‚√ßæ¬“∫“≈ ‰¥â·°à

1. ¡’Õ“°“√°”‡√‘∫√ÿπ·√ß ‰¥â·°à

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

- ¡’°“√„™â°≈â“¡‡π◊ÈÕ™à«¬À“¬„® (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—«„®ÀâÕß¢«“≈â¡‡À≈«∑’Ë‡°‘¥¢÷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—«„®≈â¡‡À≈«

À—«„®‡μâπº‘¥®—ßÀ«– (cardiac arrhythmia) ‡ªìπμâπ

4. ‰¡àμÕ∫ πÕßμàÕ°“√√—°…“·∫∫ºŸâªÉ«¬πÕ°

5. ºŸâªÉ«¬‰¡à “¡“√∂√—∫°“√¥Ÿ·≈Õ¬à“ß‡À¡“– ¡∑’Ë∫â“π‰¥â

6. ¬—ß„Àâ°“√«‘π‘®©—¬‰¡à·πà™—¥

·π«∑“ß°“√√—°…“„π‚√ßæ¬“∫“≈ 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

§—Ëß‰¥â (CO2 narcosis)73,74 (§ÿ≥¿“æÀ≈—°∞“π 1, πÈ”Àπ—°§”·π–π” ++)

2. °“√„Àâ¬“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

¢÷Èπ°—∫Õ“°“√ºŸâªÉ«¬ ∂â“Õ“°“√‰¡à¥’¢÷ÈπÀ≈—ß®“°æàπ¬“„π 1 ™—Ë«‚¡ß·√° æ‘®“√≥“„Àâ

°“√√—°…“‡æ‘Ë¡‡μ‘¡¥â“πÕ◊Ëπ75,76

3. °“√„Àâ¬“ ‡μ’¬√Õ¬¥å ™à«¬≈¥√–¬–‡«≈“°“√πÕπ‚√ßæ¬“∫“≈ ∑”„Àâ

Õ“°“√‡Àπ◊ËÕ¬·≈– ¡√√∂¿“æªÕ¥¥’¢÷Èπ ≈¥§«“¡‡ ’Ë¬ß¢Õß°“√‡°‘¥‚√§°”‡√‘∫´È”

·≈–°“√√—°…“≈â¡‡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≈’Ë¬π‡ªìπ¬“√—∫ª√–∑“π

‡™àπ prednisolone ¢π“¥ 30-40 ¡°./«—π √–¬–‡«≈“ 5-10 «—π ∂â“Õ“°“√‰¡à¥’¢÷Èπ

æ‘®“√≥“„Àâπ“π¢÷Èπ·μà‰¡à§«√‡°‘π 14 «—π §«√√–«—ßº≈¢â“ß‡§’¬ß∑’Ë ”§—≠ ‡™àπ ¿“«–

πÈ”μ“≈„π‡≈◊Õ¥ Ÿß ·≈–‡≈◊Õ¥ÕÕ°®“°∑“ß‡¥‘πÕ“À“√ à«π∫π ‚¥¬‡©æ“–„πºŸâªÉ«¬

ŸßÕ“¬ÿ63-68

4. °“√„Àâ¬“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‡§√◊ËÕß™à«¬À“¬„® æ∫«à“°“√„Àâ¬“ªØ‘™’«π– “¡“√∂™à«¬≈¥Õ—μ√“°“√

‡ ’¬™’«‘μ‰¥â (§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‘®“√≥“°“√„Àâ¬“μâ“π‰«√— (oseltamivir) °√≥’ºŸâªÉ«¬¡’Õ“°“√ ß —¬μ‘¥‡™◊ÈÕ

‰¢âÀ«—¥„À≠à√à«¡¥â«¬69-72

5. °“√„™â‡§√◊ËÕß™à«¬À“¬„® §«√æ‘®“√≥“„™â noninvasive ventilation (NIV)

°àÕπ ‡¡◊ËÕ‰¡à¡’¢âÕÀâ“¡ ‡π◊ËÕß®“° “¡“√∂≈¥Õ“°“√‡Àπ◊ËÕ¬ ·°â ‰¢§«“¡º‘¥ª°μ‘¢Õß

arterial blood gases ≈¥√–¬–‡«≈“°“√πÕπ‚√ßæ¬“∫“≈ ≈¥Õ—μ√“°“√μ“¬ ·≈–

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

≈¥¿“«–·∑√° âÕπ∑’Ë‡°‘¥®“°°“√„ à∑àÕ™à«¬À“¬„®‰¥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◊ÈÕ™à«¬À“¬„® (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. ¡’‚§√ßÀπâ“º‘¥ª°μ‘ À√◊Õ‰¡à “¡“√∂À“Àπâ“°“°∑’Ë‡À¡“– ¡‰¥â

3. ‡ ¡À–ª√‘¡“≥¡“°‰¡à “¡“√∂·°â ‰¢‰¥â¥â«¬ secretion clearance

techniques

4. ‡æ‘Ëß‰¥â√—∫°“√ºà“μ—¥„∫Àπâ“ ∑“ß‡¥‘πÀ“¬„® à«π∫π À√◊Õ∑“ß‡¥‘πÕ“À“√

à«π∫π

5. ¡’‡≈◊Õ¥ÕÕ°®“°∑“ß‡¥‘πÕ“À“√ à«π∫π∑’Ë¬—ß§«∫§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

πÕ°®“°π’È NIV “¡“√∂π”¡“„™â™à«¬„π°“√∂Õπ‡§√◊ËÕß™à«¬À“¬„® (NIV

facilitates weaning) æ∫«à“≈¥°“√„ à∑àÕ™à«¬À“¬„®„À¡à ·≈–≈¥Õ—μ√“°“√μ“¬

¢âÕ∫àß™’È¢Õß°“√„ à∑àÕ™à«¬À“¬„®·≈–„™â‡§√◊ËÕß™à«¬À“¬„® (invasive

mechanical ventilation)

1. À¬ÿ¥À“¬„® À√◊ÕÀ—«„®À¬ÿ¥‡μâπ

2. ¡’§«“¡º‘¥ª°μ‘„π√–∫∫À—«„® ‡™àπ §«“¡¥—π‚≈À‘μμË” °≈â“¡‡π◊ÈÕ

À—«„®¢“¥‡≈◊Õ¥ À—«„®‡μâπº‘¥®—ßÀ«–∑’Ë‰¡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

8. ¡’°“√ ”≈—°ª√‘¡“≥¡“° (massive aspiration)

6. °“√¥Ÿ·≈√—°…“‡ √‘¡ ‰¥â·°à °“√√—°…“‚√§√à«¡ °“√¥Ÿ·≈ ¡¥ÿ≈ “√πÈ”

·≈–‡°≈◊Õ·√à °“√¥Ÿ·≈¥â“π‚¿™π“°“√ °“√∑∫∑«π°“√„™â¬“·≈–«‘∏’°“√∫√‘À“√¬“

°“√ª√–‡¡‘π°“√‡≈‘°∫ÿÀ√’Ë °“√„Àâ§«“¡√Ÿâ‡°’Ë¬«°—∫‚√§·≈–·π«∑“ßªØ‘∫—μ‘ Õ“®

æ‘®“√≥“‚ª√·°√¡øóôπøŸ ¡√√∂¿“æªÕ¥‡¡◊ËÕºŸâªÉ«¬Õ“°“√¥’¢÷Èπ78,79

‡°≥±å°“√®”Àπà“¬ºŸâªÉ«¬ÕÕ°®“°‚√ßæ¬“∫“≈1. Õ“°“√‡Àπ◊ËÕ¬≈¥≈ß®π„°≈â‡§’¬ß°—∫°àÕπ√—∫‰«â„π‚√ßæ¬“∫“≈

2. —≠≠“≥™’æ‡ªìπª°μ‘ ·≈–Õ“°“√§ß∑’Ë·≈â«Õ¬à“ßπâÕ¬ 12-24 ™—Ë«‚¡ß

3. °“√„™â¬“æàπ¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï —Èπ‰¡à∂’Ë‰ª°«à“∑ÿ° 4 ™—Ë«‚¡ß

4. ºŸâªÉ«¬ “¡“√∂∫√‘À“√¬“™π‘¥ Ÿ¥‰¥âÕ¬à“ß∂Ÿ°«‘∏’ ·≈–√—∫∑√“∫·ºπ°“√

√—°…“μàÕ‡π◊ËÕßæ√âÕ¡°“√π—¥μ√«®μ‘¥μ“¡∑’Ë 2-4 —ª¥“Àå

§«√ª√–‡¡‘π¢âÕ∫àß™’È¢Õß°“√∫”∫—¥¥â«¬ÕÕ°´‘‡®π√–¬–¬“« (Long term

oxygen therapy) ∑’Ë 3 ‡¥◊ÕπÀ≈—ß°“√°”‡√‘∫‡©’¬∫æ≈—π

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

°“√ªÑÕß°—π°“√°”‡√‘∫‡©’¬∫æ≈—π¢Õß‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß°“√°”‡√‘∫‡©’¬∫æ≈—π¢Õß‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß¡’º≈‡ ’¬μàÕºŸâªÉ«¬ ∑”„Àâ

§ÿ≥¿“æ™’«‘μ‡≈«≈ß ‡√àß°“√‡ ◊ËÕ¡ ¡√√∂¿“æ¢ÕßªÕ¥ ‡æ‘Ë¡Õ—μ√“°“√∑ÿæ≈¿“æ

·≈–‡ ’¬™’«‘μ ‡æ‘Ë¡§à“„™â®à“¬„π°“√¥Ÿ·≈√—°…“‡ªìπÕ¬à“ß¡“°80 °“√ªÑÕß°—π°“√°”‡√‘∫

‡©’¬∫æ≈—π¢Õß‚√§®÷ß¡’§«“¡ ”§—≠ ·π«∑“ß°“√√—°…“∑’Ë¡’À≈—°∞“π π—∫ πÿπ«à“

≈¥°“√°”‡√‘∫¢Õß‚√§37,78,79,81 ‰¥â·°à

1. °“√‡≈‘°∫ÿÀ√’Ë (§ÿ≥¿“æÀ≈—°∞“π 2, πÈ”Àπ—°§”·π–π” ++)

2. °“√©’¥«—§´’π‰¢âÀ«—¥„À≠à (§ÿ≥¿“æÀ≈—°∞“π 2, πÈ”Àπ—°§”·π–π” ++)

3. ‚ª√·°√¡øóôπøŸ ¡√√∂¿“æªÕ¥¿“¬„π 4 —ª¥“ÀåÀ≈—ß°“√°”‡√‘∫‡©’¬∫

æ≈—π (§ÿ≥¿“æÀ≈—°∞“π 2, πÈ”Àπ—°§”·π–π” ++)

4. °“√„™â¬“μ“¡·π«∑“ß°“√√—°…“¥â«¬¬“

‡Õ° “√Õâ“ßÕ‘ß1. Regional CWG. COPD prevalence in 12 Asia-Pacific countries and regions:

projections based on the COPD prevalence estimation model. Respirology.2003;8(2):192-8.

2. Maranetra KN, Chuaychoo B, Dejsomritrutai W, Chierakul N, Nana A, LertakyamaneeJ, et al. The prevalence and incidence of COPD among urban older persons ofBangkok Metropolis. J Med Assoc Thai. 2002;85(11):1147-55.

3. Pothirat C, Petchsuk N, Pisanthanaphan S, et al, editors. Prevalence, smoking riskfactor, and severity of COPD in community: a comparative study between anurban and a rural area in Chiang Mai. Annual meeting of Thoracic Society ofThailand 2007; Pang Saunkaew Hotel, Chiang Mai

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√“¢Õßª√–™“°√ æ.». 2557 æ.». 2557. Available from: http://www.m-society.go.th/ewt_news.php?nid=13207.

6. Pothirat C, Phetsuk N, Deesomchok A, Theerakittikul T, Bumroongkit C, LiwsrisakunC, et al. Clinical characteristics, management in real world practice and long-termsurvival among COPD patients of Northern Thailand COPD club members. J MedAssoc Thai. 2007;90(4):653-62.

7. Diagnosis of Chronic Airflow Limitation: Asthma, COPD and Asthma-COPDOverlap Syndrome (ACOS). Available from: http://ginasthma.org.

8. Sestini P, Renzoni E, Robinson S, Poole P, Ram FS. Short-acting beta 2 agonistsfor stable chronic obstructive pulmonary disease. The Cochrane database ofsystematic reviews. 2002(4):CD001495.

9. Appleton S, Jones T, Poole P, Pilotto L, Adams R, Lasserson TJ, et al. Ipratropiumbromide versus short acting beta-2 agonists for stable chronic obstructivepulmonary disease. The Cochrane database of systematic reviews. 2006(2):CD001387.

10. Calverley PM, Anderson JA, Celli B, Ferguson GT, Jenkins C, Jones PW, et al.Salmeterol and fluticasone propionate and survival in chronic obstructivepulmonary disease. The New England journal of medicine. 2007;356(8):775-89.

11. Boyd G, Morice AH, Pounsford JC, Siebert M, Peslis N, Crawford C. An evaluationof salmeterol in the treatment of chronic obstructive pulmonary disease (COPD).The European respiratory journal. 1997;10(4):815-21.

12. Cazzola M, Matera MG, Santangelo G, Vinciguerra A, Rossi F, DûAmato G. Salmeteroland formoterol in partially reversible severe chronic obstructive pulmonarydisease: a dose-response study. Respiratory medicine. 1995;89(5):357-62.

13. Rossi A, Kristufek P, Levine BE, Thomson MH, Till D, Kottakis J, et al. Comparisonof the efficacy, tolerability, and safety of formoterol dry powder and oral, slow-release theophylline in the treatment of COPD. Chest. 2002;121(4):1058-69.

14. Tashkin D, Celli B, Kesten S, Lystig T, Decramer M. Effect of tiotropium in menand women with COPD: results of the 4-year UPLIFT trial. Respiratory medicine.2010;104(10):1495-504.

15. Tashkin DP, Fabbri LM. Long-acting beta-agonists in the management of chronicobstructive pulmonary disease: current and future agents. Respiratory research.2010;11:149.

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

16. Jenkins SC, Heaton RW, Fulton TJ, Moxham J. Comparison of domiciliary nebulizedsalbutamol and salbutamol from a metered-dose inhaler in stable chronic airflowlimitation. Chest. 1987;91(6):804-7.

17. Datta D, Vitale A, Lahiri B, ZuWallack R. An evaluation of nebulized levalbuterol instable COPD. Chest. 2003;124(3):844-9.

18. In chronic obstructive pulmonary disease, a combination of ipratropium andalbuterol is more effective than either agent alone. An 85-day multicenter trial.COMBIVENT Inhalation Aerosol Study Group. Chest. 1994;105(5):1411-9.

19. Gross N, Tashkin D, Miller R, Oren J, Coleman W, Linberg S. Inhalation bynebulization of albuterol-ipratropium combination (Dey combination) is superiorto either agent alone in the treatment of chronic obstructive pulmonary disease.Dey Combination Solution Study Group. Respiration; international review ofthoracic diseases. 1998;65(5):354-62.

20. Farne HA, Cates CJ. Long-acting beta2-agonist in addition to tiotropium versuseither tiotropium or long-acting beta2-agonist alone for chronic obstructivepulmonary disease. The Cochrane database of systematic reviews. 2015(10):CD008989.

21. Mahler DA, Decramer M, DûUrzo A, Worth H, White T, Alagappan VK, et al. Dualbronchodilation with QVA149 reduces patient-reported dyspnoea in COPD: theBLAZE study. The European respiratory journal. 2014;43(6):1599-609.

22. Mahler DA, Kerwin E, Ayers T, Fowler Taylor A, Maitra S, Thach C, et al. FLIGHT1and FLIGHT2: Efficacy and Safety of QVA149 (Indacaterol/Glycopyrrolate) versusIts Monocomponents and Placebo in Patients with Chronic Obstructive PulmonaryDisease. American journal of respiratory and critical care medicine. 2015;192(9):1068-79.

23. Wedzicha JA, Banerji D, Chapman KR, Vestbo J, Roche N, Ayers RT, et al.Indacaterol-Glycopyrronium versus Salmeterol-Fluticasone for COPD. The NewEngland journal of medicine. 2016;374(23):2222-34.

24. Calverley P, Pauwels R, Vestbo J, Jones P, Pride N, Gulsvik A, et al. Combinedsalmeterol and fluticasone in the treatment of chronic obstructive pulmonarydisease: a randomised controlled trial. Lancet. 2003;361(9356):449-56.

25. Jones PW, Willits LR, Burge PS, Calverley PM, Inhaled Steroids in ObstructiveLung Disease in Europe study i. Disease severity and the effect of fluticasonepropionate on chronic obstructive pulmonary disease exacerbations. The Europeanrespiratory journal. 2003;21(1):68-73.

26. Kardos P, Wencker M, Glaab T, Vogelmeier C. Impact of salmeterol/fluticasonepropionate versus salmeterol on exacerbations in severe chronic obstructivepulmonary disease. American journal of respiratory and critical care medicine.2007;175(2):144-9.

27. Kew KM, Dias S, Cates CJ. Long-acting inhaled therapy (beta-agonists, anti-cholinergics and steroids) for COPD: a network meta-analysis. The Cochranedatabase of systematic reviews. 2014;3:CD010844.

28. Crim C, Calverley PM, Anderson JA, Celli B, Ferguson GT, Jenkins C, et al.Pneumonia risk in COPD patients receiving inhaled corticosteroids alone or incombination: TORCH study results. The European respiratory journal. 2009;34(3):641-7.

29. Calverley PM, Stockley RA, Seemungal TA, Hagan G, Willits LR, Riley JH, et al.Reported pneumonia in patients with COPD: findings from the INSPIRE study.Chest. 2011;139(3):505-12.

30. Drummond MB, Dasenbrook EC, Pitz MW, Murphy DJ, Fan E. Inhaled cortico-steroids in patients with stable chronic obstructive pulmonary disease: a systematicreview and meta-analysis. Jama. 2008;300(20):2407-16.

31. Romme EA, McAllister DA, Murchison JT, Van Beek EJ, Petrides GS, Price CO,et al. Associations between COPD related manifestations: a cross-sectionalstudy. Respiratory research. 2013;14:129.

32. Rittayamai N, Chuaychoo B, Sriwijitkamol A. Prevalence of osteoporosis andosteopenia in Thai COPD patients. J Med Assoc Thai. 2012;95(8):1021-7.

33. van der Valk P, Monninkhof E, van der Palen J, Zielhuis G, van Herwaarden C.Effect of discontinuation of inhaled corticosteroids in patients with chronicobstructive pulmonary disease: the COPE study. American journal of respiratoryand critical care medicine. 2002;166(10):1358-63.

34. Rossi A, Guerriero M, Corrado A, Group OAS. Withdrawal of inhaled cortico-steroids can be safe in COPD patients at low risk of exacerbation: a real-life

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

study on the appropriateness of treatment in moderate COPD patients (OPTIMO).Respiratory research. 2014;15:77.

35. Magnussen H, Disse B, Rodriguez-Roisin R, Kirsten A, Watz H, Tetzlaff K, et al.Withdrawal of inhaled glucocorticoids and exacerbations of COPD. The NewEngland journal of medicine. 2014;371(14):1285-94.

36. Niewoehner DE. The role of systemic corticosteroids in acute exacerbation ofchronic obstructive pulmonary disease. American journal of respiratory medicine:drugs, devices, and other interventions. 2002;1(4):243-8.

37. Global strategiey for diagnosis, management and prevention of COPD 2016:GLobal Initiative for chronic obstructive pulmonary disease (GLOD) 2016; 2016[cited 2016]. Available from: http://www.goldcopd.org/.

38. Wood-Baker R, Walters J, Walters EH. Systemic corticosteroids in chronicobstructive pulmonary disease: an overview of Cochrane systematic reviews.Respiratory medicine. 2007;101(3):371-7.

39. Decramer M, Lacquet LM, Fagard R, Rogiers P. Corticosteroids contribute tomuscle weakness in chronic airflow obstruction. American journal of respiratoryand critical care medicine. 1994;150(1):11-6.

40. Ferguson GT, Anzueto A, Fei R, Emmett A, Knobil K, Kalberg C. Effect of fluticasonepropionate/salmeterol (250/50 microg) or salmeterol (50 microg) on COPDexacerbations. Respiratory medicine. 2008;102(8):1099-108.

41. Rennard SI, Tashkin DP, McElhattan J, Goldman M, Ramachandran S, Martin UJ,et al. Efficacy and tolerability of budesonide/formoterol in one hydrofluoroalkanepressurized metered-dose inhaler in patients with chronic obstructive pulmonarydisease: results from a 1-year randomized controlled clinical trial. Drugs. 2009;69(5):549-65.

42. Cosio BG, Iglesias A, Rios A, Noguera A, Sala E, Ito K, et al. Low-dose theophyllineenhances the anti-inflammatory effects of steroids during exacerbations of COPD.Thorax. 2009;64(5):424-9.

43. Ford PA, Durham AL, Russell RE, Gordon F, Adcock IM, Barnes PJ. Treatmenteffects of low-dose theophylline combined with an inhaled corticosteroid in COPD.Chest. 2010;137(6):1338-44.

44. Voduc N, Alvarez GG, Amjadi K, Tessier C, Sabri E, Aaron SD. Effect of theophyl-line on exercise capacity in COPD patients treated with combination long-actingbronchodilator therapy: a pilot study. International journal of chronic obstructivepulmonary disease. 2012;7:245-52.

45. Thomas P, Pugsley JA, Stewart JH. Theophylline and salbutamol improve pulmonaryfunction in patients with irreversible chronic obstructive pulmonary disease. Chest.1992;101(1):160-5.

46. Molfino NA, Zhang P. A meta-analysis on the efficacy of oral theophylline inpatients with stable COPD. International journal of chronic obstructive pulmonarydisease. 2006;1(3):261-6.

47. Fabbri LM, Calverley PM, Izquierdo-Alonso JL, Bundschuh DS, Brose M, MartinezFJ, et al. Roflumilast in moderate-to-severe chronic obstructive pulmonarydisease treated with longacting bronchodilators: two randomised clinical trials.Lancet. 2009;374(9691):695-703.

48. Calverley PM, Rabe KF, Goehring UM, Kristiansen S, Fabbri LM, Martinez FJ,et al. Roflumilast in symptomatic chronic obstructive pulmonary disease: tworandomised clinical trials. Lancet. 2009;374(9691):685-94.

49. Tse HN, Raiteri L, Wong KY, Yee KS, Ng LY, Wai KY, et al. High-dose N-acetylcysteinein stable COPD: the 1-year, double-blind, randomized, placebo-controlled HIACEstudy. Chest. 2013;144(1):106-18.

50. Seemungal TA, Wilkinson TM, Hurst JR, Perera WR, Sapsford RJ, Wedzicha JA.Long-term erythromycin therapy is associated with decreased chronic obstructivepulmonary disease exacerbations. American journal of respiratory and criticalcare medicine. 2008;178(11):1139-47.

51. Albert RK, Connett J, Bailey WC, Casaburi R, Cooper JA, Jr., Criner GJ, et al.Azithromycin for prevention of exacerbations of COPD. The New England journalof medicine. 2011;365(8):689-98.

52. Sethi S, Jones PW, Theron MS, Miravitlles M, Rubinstein E, Wedzicha JA, et al.Pulsed moxifloxacin for the prevention of exacerbations of chronic obstructivepulmonary disease: a randomized controlled trial. Respiratory research. 2010;11:10.

53. √“™«‘∑¬“≈—¬Õ“¬ÿ√·æ∑¬å·Ààßª√–‡∑»‰∑¬. §”·π–π”°“√„Àâ«—§´’πªÑÕß°—π‚√§ ”À√—∫ºŸâ„À≠à·≈–ºŸâ ŸßÕ“¬ÿ (Recommended Adult and Elderly Immunization Schedule) æ.». 2557.

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Available from: http://www.rcpt.org/index.php/2012-10-03-16-53-39/category/6-2013-02-02-09-02-52.html.

54. Rodriguez-Roisin R. Toward a consensus definition for COPD exacerbations.Chest. 2000;117(5 Suppl 2):398S-401S.

55. Celli BR, Barnes PJ. Exacerbations of chronic obstructive pulmonary disease.The European respiratory journal. 2007;29(6):1224-38.

56. Burge S, Wedzicha JA. COPD exacerbations: definitions and classifications. EurRespir J Suppl. 2003;41:46s-53s.

57. Pauwels R, Calverley P, Buist AS, Rennard S, Fukuchi Y, Stahl E, et al. COPDexacerbations: the importance of a standard definition. Respiratory medicine.2004;98(2):99-107.

58. Celli BR, MacNee W, Force AET. Standards for the diagnosis and treatment ofpatients with COPD: a summary of the ATS/ERS position paper. The Europeanrespiratory journal. 2004;23(6):932-46.

59. Snow V, Lascher S, Mottur-Pilson C, Joint Expert Panel on CotACoCP, theAmerican College of Physicians-Amercian Society of Internal M. The evidencebase for management of acute exacerbations of COPD: clinical practice guide-line, part 1. Chest. 2001;119(4):1185-9.

60. Emerman CL, Cydulka RK. Evaluation of high-yield criteria for chest radiographyin acute exacerbation of chronic obstructive pulmonary disease. Ann Emerg Med.1993;22(4):680-4.

61. Sherman S, Skoney JA, Ravikrishnan KP. Routine chest radiographs in exacerba-tions of chronic obstructive pulmonary disease. Diagnostic value. Arch InternMed. 1989;149(11):2493-6.

62. Quon BS, Gan WQ, Sin DD. Contemporary management of acute exacerbationsof COPD: a systematic review and metaanalysis. Chest. 2008;133(3):756-66.

63. Walters JA, Tan DJ, White CJ, Gibson PG, Wood-Baker R, Walters EH. Systemiccorticosteroids for acute exacerbations of chronic obstructive pulmonarydisease. The Cochrane database of systematic reviews. 2014(9):CD001288.

64. Walters JA, Tan DJ, White CJ, Wood-Baker R. Different durations of cortico-steroid therapy for exacerbations of chronic obstructive pulmonary disease. TheCochrane database of systematic reviews. 2014(12):CD006897.

65. Lindenauer PK, Pekow PS, Lahti MC, Lee Y, Benjamin EM, Rothberg MB. Asso-ciation of corticosteroid dose and route of administration with risk of treatmentfailure in acute exacerbation of chronic obstructive pulmonary disease. Jama.2010;303(23):2359-67.

66. Leuppi JD, Schuetz P, Bingisser R, Bodmer M, Briel M, Drescher T, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronicobstructive pulmonary disease: the REDUCE randomized clinical trial. Jama.2013;309(21):2223-31.

67. Niewoehner DE, Erbland ML, Deupree RH, Collins D, Gross NJ, Light RW, et al.Effect of systemic glucocorticoids on exacerbations of chronic obstructivepulmonary disease. Department of Veterans Affairs Cooperative Study Group.The New England journal of medicine. 1999;340(25):1941-7.

68. Schweiger TA, Zdanowicz M. Systemic corticosteroids in the treatment of acuteexacerbations of chronic obstructive pulmonary disease. Am J Health Syst Pharm.2010;67(13):1061-9.

69. Vollenweider DJ, Jarrett H, Steurer-Stey CA, Garcia-Aymerich J, Puhan MA. Anti-biotics for exacerbations of chronic obstructive pulmonary disease. The Cochranedatabase of systematic reviews. 2012;12:CD010257.

70. Stefan MS, Rothberg MB, Shieh MS, Pekow PS, Lindenauer PK. Associationbetween antibiotic treatment and outcomes in patients hospitalized with acuteexacerbation of COPD treated with systemic steroids. Chest. 2013;143(1):82-90.

71. Puhan MA, Vollenweider D, Latshang T, Steurer J, Steurer-Stey C. Exacerbationsof chronic obstructive pulmonary disease: when are antibiotics indicated?A systematic review. Respiratory research. 2007;8:30.

72. El Moussaoui R, Roede BM, Speelman P, Bresser P, Prins JM, Bossuyt PM.Short-course antibiotic treatment in acute exacerbations of chronic bronchitisand COPD: a meta-analysis of double-blind studies. Thorax. 2008;63(5):415-22.

73. Ntoumenopoulos G. Using titrated oxygen instead of high flow oxygen during anacute exacerbation of chronic obstructive pulmonary disease (COPD) saves lives.J Physiother. 2011;57(1):55.

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

74. Austin MA, Wills KE, Blizzard L, Walters EH, Wood-Baker R. Effect of high flowoxygen on mortality in chronic obstructive pulmonary disease patients in prehospitalsetting: randomised controlled trial. BMJ. 2010;341:c5462.

75. McCrory DC, Brown CD. Inhaled short-acting beta2-agonists versus ipratropiumfor acute exacerbations of chronic obstructive pulmonary disease. The Cochranedatabase of systematic reviews. 2001(2):CD002984.

76. McCrory DC, Brown CD. Anti-cholinergic bronchodilators versus beta2-sympatho-mimetic agents for acute exacerbations of chronic obstructive pulmonarydisease. The Cochrane database of systematic reviews. 2002(4):CD003900.

77. Ram FS, Picot J, Lightowler J, Wedzicha JA. Non-invasive positive pressureventilation for treatment of respiratory failure due to exacerbations of chronicobstructive pulmonary disease. The Cochrane database of systematic reviews.2004(3):CD004104.

78. Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J.Pulmonary rehabilitation following exacerbations of chronic obstructive pulmo-nary disease. The Cochrane database of systematic reviews. 2011(10):CD005305.

79. Puhan MA, Scharplatz M, Troosters T, Steurer J. Respiratory rehabilitation afteracute exacerbation of COPD may reduce risk for readmission and mortality --a systematic review. Respiratory research. 2005;6:54.

80. Soler-Cataluna JJ, Martinez-Garcia MA, Roman Sanchez P, Salcedo E, NavarroM, Ochando R. Severe acute exacerbations and mortality in patients with chronicobstructive pulmonary disease. Thorax. 2005;60(11):925-31.

81. Criner GJ, Bourbeau J, Diekemper RL, Ouellette DR, Goodridge D, Hernandez P,et al. Prevention of acute exacerbations of COPD: American College of ChestPhysicians and Canadian Thoracic Society Guideline. Chest. 2015;147(4):894-942.

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®π –Õ“¥ (rinse) ·≈–ª≈àÕ¬‰«â„Àâ·Àâß (air dry) ∑ÿ°§√—ÈßÀ≈—ß°“√„™âß“π

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

√“¬≈–‡Õ’¬¥¢Õß°“√„™â¬“ Ÿ¥‡∑§π‘§·≈–°“√„™âÕÿª°√≥å™à«¬ Ÿ¥·μà≈–™π‘¥∑’Ë· ¥ß¥—ßμàÕ‰ªπ’È‡ªìπμ—«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“∑“ßª“°™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‘

À“°®– Ÿ¥¬“§√—Èß∑’Ë 2 „Àâ√Õ‡«≈“ 30-60 «‘π“∑’·≈â«∑”´È”μ“¡¢—ÈπμÕπ∑’Ë

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„Àâ‡ªî¥√‘¡Ωïª“°§â“ß‰«â„π¢≥– Ÿ¥Õ“®®–∑”„Àâ¬“

‡¢â“∂÷ß∑“ß‡¥‘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√◊Õ™â“‡°‘π‰ª) 5) Ÿ¥¬“‡√Á«À√◊Õ·√ß‰ª 6) ‰¡àÀ“¬„®≈÷°μàÕ‡π◊ËÕß®π ÿ¥À≈—ß

°“√°¥À≈Õ¥¬“ 7) ‰¡à°≈—Èπ≈¡À“¬„®À≈—ßÀ“¬„®‡¢â“ ÿ¥ 8) °¥¬“ Õß§√—Èßμ‘¥°—π

°“√ Ÿ¥¬“™π‘¥·Õ§§‘«‡Œ≈‡≈Õ√å (Accuhaler)

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

1. ‡ªî¥‡§√◊ËÕß‚¥¬®—∫μ—«‡§√◊ËÕß¥â“ππÕ°·≈–„™âπ‘È«À—«·¡à¡◊ÕÕ’°¢â“ß«“ß„π

√àÕß ”À√—∫‡ªî¥‡§√◊ËÕß¥—ππ‘È«À—«·¡à¡◊Õ‰ª®π ÿ¥μ“¡≈Ÿ°»√

2. ‡≈◊ËÕπ¬“„ÀâÕ¬Ÿà„πμ”·Àπàßæ√âÕ¡ Ÿ¥ ‚¥¬®—∫μ—«‡§√◊ËÕß„ÀâÕ¬Ÿà„π·π«¢π“π

À—π¥â“πª“°°√–∫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¥‚¥¬√–«—ß‰¡à„Àâ≈¡À“¬„®‡¢â“‰ª„π‡§√◊ËÕß

4. Õ¡ª“°°√–∫Õ°„Àâ π‘∑ Ÿ¥¬“‡¢â“∑“ßª“°„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√àÕß¥—πÀ—«·¡à¡◊Õ°≈—∫„πμ”·Àπàßªî¥

´÷Ëß®–‰¥â¬‘π‡ ’¬ß ç§≈‘°é ·°π‡≈◊ËÕπ®–°≈—∫§◊π Ÿàμ”·Àπàß‡¥‘¡·≈–æ√âÕ¡

„™âß“π„π§√—ÈßμàÕ‰ª

¢âÕ§«√√–«—ß ¢≥–·≈–À≈—ß‡≈◊ËÕπ¬“„ÀâÕ¬Ÿà„πμ”·Àπàßæ√âÕ¡ Ÿ¥ §«√«“ßμ—«

‡§√◊ËÕß„ÀâÕ¬Ÿà„π·π«¢π“π ‰¡à‡Õ“ª“°°√–∫Õ°≈ß ¬“®–‡§≈◊ËÕπÕÕ°®“°μ”·Àπàß‰¥â

¢âÕº‘¥æ≈“¥∑’Ëæ∫‰¥â ‰¥â·°à 1) ‰¡à¥—π·°π‡≈◊ËÕπ„Àâ¬“¡“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¥¬“

°“√ Ÿ¥¬“™π‘¥‡∑Õ√å∫Ÿ‡Œ‡≈Õ√å (Turbuhaler)

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

1. ‡ªî¥‡§√◊ËÕß‚¥¬À¡ÿπΩ“§√Õ∫ÕÕ°∑‘»∑«π‡¢Á¡π“Ãî°“

2. ‡≈◊ËÕπ¬“„ÀâÕ¬Ÿà„πμ”·Àπàßæ√âÕ¡ Ÿ¥‚¥¬®—∫À≈Õ¥¬“„ÀâÕ¬Ÿà„π·π«μ—Èßμ√ß

„™â¡◊ÕÕ’°¢â“ß®—∫ à«π∞“π¢Õß‡§√◊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¥‚¥¬√–«—ß‰¡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“∑“ßª“°„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√ß¢≥–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¥—ß‡«≈“‡¢¬à“À≈Õ¥¬“‡ªìπ “√¥Ÿ¥§«“¡™◊Èπ

¥—ßπ—ÈπÀ≈—ß¬“À¡¥®–¬—ß‰¥â¬‘π‡ ’¬ßπ’ÈÕ¬Ÿà „Àâ‡ª≈’Ë¬π°√–∫Õ°„À¡à‡¡◊ËÕμ—«™’È∫Õ°®”π«π

¬“ (dose counter) ¢÷Èπ·∂∫·¥ß‡μÁ¡

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°∑’Ë‡ªìπ∑“ß„Àâ≈–ÕÕß¬“ÕÕ°

(mouth piece)

3. °¥À≈Õ¥¬“„Àâ≈–ÕÕß¬“‡¢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

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

°“√∑”§«“¡ –Õ“¥ ≈â“ß¥â«¬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—ß¥â“π„π¢ÕßÕÿª°√≥å ·≈–

„Àâ°¥À≈Õ¥¬“ 2 §√—Èß‡æ◊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°∑’Ë‡ªìπ∑“ß„Àâ≈–ÕÕß¬“ÕÕ°

(mouth piece) ∑’Ë‡ªìπ™π‘¥∑àÕμàÕÀ√◊ÕÀ“°‡ªìπ™π‘¥™π‘¥Ω“§√Õ∫ (face

mask) „Àâ§√Õ∫√‘¡Ωïª“°·≈–®¡Ÿ°

3. „Àâ Ÿ¥À“¬„®‡¢â“·≈–ÕÕ°‡∫“Ê·≈–™â“Ê∑“ßª“°À“°‰¥â¬‘π‡ ’¬ß§≈â“¬

π°À«’¥¥—ß¢÷Èπ„ÀâºŸâ Ÿ¥≈¥§«“¡‡√Á«„π°“√ Ÿ¥≈ß

4. ‡¡◊ËÕ°“√À“¬„®‰¥â®—ßÀ«–¥’·≈â«„Àâ°¥À≈Õ¥¬“ MDI ‚¥¬∑’ËºŸâ Ÿ¥¬—ß§ß

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

°“√ 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„πª“°

5. °¥À≈Õ¥¬“‡æ◊ËÕ„Àâ≈–ÕÕß¬“‡¢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“¡‡¥‘¡

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„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∑’Ë‡ªìπ mouth piece ¢Õß jet inhaler ÕÕ°

3. ‡¢¬à“À≈Õ¥¬“‚¥¬·√ß‚¥¬∑’Ë¬—ß‰¡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÷Ëß§√—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’È§«√ –Õ“¥Õ¬Ÿà‡ ¡Õ·≈–À“°®–∑”§«“¡ –Õ“¥„Àâ

„™âπÈ”ÕÿàπÀ≈—ß®“°π” canister ÕÕ°·≈â«

°“√ 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

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

5. ®—∫‡§√◊ËÕßμ—Èßμ√ß·≈–°¥ªÿÉ¡¥â“π¢â“ß‡æ◊ËÕ‡®“–·§ª´Ÿ≈¬“‚¥¬°¥‡æ’¬ß

§√—Èß‡¥’¬«·≈â«ª≈àÕ¬

6. À“¬„®ÕÕ°„Àâ ÿ¥√–«—ß‰¡à„Àâ≈¡À“¬„®‡¢â“‰ª„π‡§√◊ËÕß

7. Õ¡ª“°°√–∫Õ°¬“„Àâ π‘∑ Ÿ¥≈¡À“¬„®‡¢â“∑“ßª“°™â“Ê≈÷°Ê®π ÿ¥¥â«¬

§«“¡‡√Á«æÕ∑’Ë‰¥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·≈â«ªî¥ª“°°√–∫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®–∑”„Àâ¬“·μ°μ—«‰¡à¥’

¢âÕº‘¥æ≈“¥∑’Ëæ∫‰¥â ‰¥â·°à 1) ‰¡à‰¥â‡®“–·§ª´Ÿ≈¬“ 2) ‡®“–·§ª Ÿ≈¬“¡“°

°«à“ 1 §√—Èß 3) À≈—ß‡®“–·§ª Ÿ≈¬“·≈â«‰¡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¥

°“√ 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√—∫„ à¬“ (Àâ“¡„ à·§ª Ÿ≈≈ßª“°°√–∫Õ°‚¥¬

‰¡à‡ªî¥Ω“„π)

5. ªî¥Ω“„π ®π‰¥â¬‘π‡ ’¬ß ç§≈‘°é

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

6. ®—∫Õÿª°√≥åμ—Èß¢÷Èπ ·≈–°¥ªÿÉ¡¥â“π¢â“ß∑—Èß 2 ¢â“ßæ√âÕ¡°—π§√—Èß‡¥’¬«·≈â«

ª≈àÕ¬ ‡æ◊ËÕ‡®“–·§ª´Ÿ≈¬“

7. À“¬„®ÕÕ°„Àâ ÿ¥√–«—ß‰¡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“∑“ßª“°™â“Ê≈÷°Ê®π ÿ¥¥â«¬§«“¡‡√Á«æÕ∑’Ë‰¥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 (‚¥¬‰¡àμâÕß‡®“–·§ª´Ÿ≈¬“ È”Õ’°) ∂â“‰¡à¡’¬“§â“ß

„π·§ª´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®–∑”„Àâ¬“·μ°μ—«‰¡à¥’ 2) °√≥’

Ÿ¥¬“·≈â«‰¡à‰¥â¬‘π‡ ’¬ß·§ª Ÿ≈ —Ëπ∑—Èß∑’Ë Ÿ¥·√ß „Àâ‡ªî¥Ω“§√Õ∫¬“¥Ÿ«à“·§ª´Ÿ≈ÕÕ°

¡“πÕ°™àÕß∫√√®ÿ·§ª´Ÿ≈À√◊Õ‰¡à ‡æ√“–Õ“® Ÿ¥·√ß‰ª „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≈—ß‡®“–·§ª Ÿ≈¬“·≈â«‰¡àª≈àÕ¬‡¢Á¡‡®“– 4) À“¬„®‡¢â“‰ª„π‡§√◊ËÕß

5) À“¬„®‰¡à·√ßæÕ∑’Ë∑”„Àâ·§ª´Ÿ≈ —Ëπ 6) Ÿ¥·√ß‡°‘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“¥

‡™Á¥Õÿª°√≥å Ÿ¥¬“∑—Èß¥â“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—Èß‡¢¬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¥) ·≈â«§≈“¬π‘È«∑’Ë°¥

4. À“¬„®ÕÕ°®π ÿ¥√–«—ß‰¡àÀ“¬„®‡¢â“‰ª„π‡§√◊ËÕß

5. Õ¡ à«π ”À√—∫ Ÿ¥¬“·≈–À“¬„®‡¢â“∑“ßª“°„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

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

°“√∫√‘À“√¬“ Ÿ¥ «‘ß‡Œ‡≈Õ√å (Swinghaler)

1. ‡ªî¥°√–∫Õ°¬“‡Õ“Ω“§√Õ∫ÕÕ°‚¥¬°“√°¥≈ß∑’Ëª≈“¬‡§√◊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®—¥„Àâ‡§√◊ËÕßÕ¬Ÿà„π·π«

¢π“π°—∫æ◊Èπ·≈â«¥—π∞“π°√–∫Õ°¬“‰ª∑“ßª≈“¬°√–∫Õ°¬“ 1 §√—Èß

4. À“¬„®ÕÕ°„Àâ ÿ¥·≈–°≈—Èπ≈¡À“¬„®‰«â

5. Õ¡ª≈“¬°√–∫Õ°¬“„ÀâÕ¬Ÿà√–À«à“ß√‘¡Ωïª“°∫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∑“ßª≈“¬°√–∫Õ°¬“Õ’°§√—Èß‡æ◊ËÕªî¥√–∫∫°“√

ªÑÕπ¬“

7. ªî¥Ω“§√Õ∫¬“À≈—ß°“√„™â¬“

°“√∫√‘À“√¬“ Ÿ¥‡Õ≈≈‘ªμâ“ (Ellipta)

1. ¬“∂Ÿ°∫√√®ÿ„π∂“¥øÕ¬≈å ≈Õ°Ω“ÕÕ° π”´Õß„ à “√¥Ÿ¥§«“¡™◊Èπ∑‘Èß‰ª

(Àâ“¡°≈◊π)

2. °àÕπ‡√‘Ë¡„™â¬“: ¥Ÿ„Àâ·πà„®«à“ μ—«‡≈¢π—∫®”π«π¬“ ‡√‘Ë¡μâπ∑’Ë‡≈¢ 30 („π

°√–∫Õ°¬“ 1 °√–∫Õ° ®– Ÿ¥¬“‰¥â 30 §√—Èß) ∑ÿ°§√—Èß∑’Ë‡ªî¥Ω“ §◊Õ°“√

‡μ√’¬¡¬“ 1 ¢π“¥ μ—«‡≈¢∑’Ë°√–∫Õ°¬“®–∂Õ¬≈ß∑’≈– 1

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

3. ‡μ√’¬¡ Ÿ¥¬“: ∫‘¥Ω“ªî¥≈ß¥â“π¢â“ß ®–‡ÀÁπª“°°√–∫Õ°¬“ „Àâ∫‘¥®π

‰¥â¬‘π‡ ’¬ß ç§≈‘°é μ—«‡≈¢®–∂Õ¬≈ß 1 ·μâ¡ (‡™àπ ®“° 30 ‡ªìπ 29)

4. À“¬„®ÕÕ°®π ÿ¥ √–«—ß‰¡à‡ªÉ“≈¡À“¬„®‡¢â“„π°√–∫Õ°¬“

5. Õ¡ª“°°√–∫Õ°¬“„Àâ π‘∑ Ÿ¥≈¡À“¬„®‡¢â“∑“ßª“°≈÷°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 —ß‡°μ ¬“ Ÿ¥™π‘¥π’È ‰¡àμâÕß‡¢¬à“°àÕπ Ÿ¥

∂â“∫‘¥Ω“®π‰¥â¬‘π‡ ’¬ß ç§≈‘°é ·≈â« ·μàμ—«‡≈¢‰¡à∂Õ¬≈ß ·ª≈«à“‰¡à¡’¬“

ÕÕ°¡“ μâÕß¢Õ‡ª≈’Ë¬π°√–∫Õ°¬“„À¡à

°“√ 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‘Ëß‡ªî¥Ω“§√Õ∫°√–∫Õ°¬“„π®—ßÀ«–π’È

5. ‡ªî¥Ω“ÕÕ°

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

6. °¥ªÿÉ¡ª≈àÕ¬¬“ ‚¥¬À—πª“°°√–∫Õ°≈ßæ◊Èπ ∑”´È”¢—ÈπμÕπ∑’Ë 4-6 ®π°«à“

®–‡ÀÁπ≈–ÕÕßΩÕ¬¬“ ®÷ß‡√‘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“∑“ßª“°™â“Ê·≈–

°¥ªÿÉ¡ª≈àÕ¬¬“ (ªÿÉ¡ ’‡∑“) æ√âÕ¡°—∫ Ÿ¥¬“‡¢â“μàÕ ™â“Ê®π ÿ¥ °≈—ÈπÀ“¬„®

5 - 10 «‘π“∑’ ·≈â«ªî¥Ω“§√Õ∫°√–∫Õ°¬“ ∂â“μâÕß°“√ Ÿ¥¬“§√—Èß∑’Ë 2

∑”´È”¢—ÈπμÕπ∑’Ë 1 - 3

°“√∫√‘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) ∑’Ëª≈“¬∑—Èß 2 ¥â“π·≈–μàÕÀ≈Õ¥¬“ Ÿ¥‡¢â“∑“ß¥â“π

∫π¥—ß„π√Ÿª

3. °“√ Ÿ¥¬“°√–∑”‰¥â‚¥¬

1) ‡¢¬à“À≈Õ¥¬“

2) À“¬„®ÕÕ°®π ÿ¥·≈–°¥À≈Õ¥¬“≈ß‡æ◊ËÕ„Àâ≈–ÕÕß¬“‡¢â“‰ªÕ¬Ÿà„π

spacer

3) Õ¡ mouth piece ‰«â√–À«à“ß√‘¡Ωïª“°·≈–À“¬„®‡¢â“™â“Ê À“°

‰¥â¬‘π‡ ’¬ßπ°À«’¥¥—ß¢÷Èπ„Àâ≈¥§«“¡‡√Á«„π°“√ Ÿ¥≈ß

4) °≈—Èπ≈¡À“¬„®‰«âª√–¡“≥ 10 «‘π“∑’·≈–À“¬„®ÕÕ°

5) Ÿ¥À“¬„®´È”‡™àπ‡¥‘¡Õ’°§√—Èß‚¥¬¬—ß‰¡àμâÕß°¥¬“„À¡à‡æ◊ËÕ„Àâ ‰¥â¬“∑’Ë

Õ“®À≈ß‡À≈◊ÕÕ¬Ÿà„π chamber

6) À“°μâÕß Ÿ¥¬“‡æ‘Ë¡„Àâ∑”´È”μ“¡¢—ÈπμÕπ∑’Ë 1) - 5)

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

°“√∫√‘À“√¬“ Ÿ¥„πºŸâªÉ«¬∑’ËÀ“¬„®∑“ß∑àÕ‡®“–§Õ (Tracheostomy tube)

„π°√≥’∑’ËºŸâªÉ«¬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≈–ÕÕß¬“‡¢â“‰ª„π

spacer

Device

Metered-dose

inhaler (MDI)

Easyhaler

Swinghaler

μ“√“ß √ÿª√«¡™π‘¥¢Õß¬“ 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

‡§√◊ËÕß™à«¬À“¬„®‰¥â

- æ°æ“ –¥«°

- °¥„™â ‰¥â¬“‡√Á«

- ®”π«π dose μàÕ

°√–∫Õ°¡“°

- ‰¡àμâÕßÕ“»—¬

co-ordination

- æ°æ“ –¥«°

- „™âßà“¬

co-ordination

- æ°æ“ –¥«°

- „™âßà“¬

Disadvantages

- μâÕßÕ“»—¬®—ßÀ«–∑’Ë

—¡æ—π∏å„π°“√°¥¬“

·≈–°“√À“¬„®‡¢â“

(co-ordination)

- à«π„À≠à‰¡à¡’ dose

counter

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- μâÕß√–«—ß‡√◊ËÕß§«“¡™◊Èπ

- μâÕß°“√·√ß Ÿ¥∑’Ë¡“°¢÷Èπ

- Õ“® —∫ π√–À«à“ß√–∫∫

‡ªî¥ªî¥°“√ªÑÕπ¬“

( Ÿ¥¬“μÕπ√–∫∫ªî¥)

- √“§“ Ÿß

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

Device

Turbuhaler

Accuhaler

Breezhaler

Handihaler

Soft mist

inhaler

μ“√“ß √ÿª√«¡™π‘¥¢Õß¬“ Ÿ¥ (inhaler) (μàÕ)

Drug available

Budesonide

Formoterol/

budesonide

Salmeterol/

fluticasone

Indacaterol

Glycopyrronium

Tiotopium

Tiotropium

Advantages

co-ordination

- æ°æ“ –¥«°

- „™âßà“¬

- ‰¡à¡’°≈‘Ëπ

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°“√·√ß Ÿ¥∑’Ë¡“°¢÷Èπ

- √“§“ Ÿß

- μâÕß°“√·√ß Ÿ¥∑’Ë¡“°¢÷Èπ

- √“§“ Ÿß

- «‘∏’°“√´—∫´âÕπ

- μâÕß°“√·√ß Ÿ¥∑’Ë¡“°¢÷Èπ

- √“§“ Ÿß

- «‘∏’°“√´—∫´âÕπ

- √“§“ Ÿß

- «‘∏’°“√´—∫´âÕπ ‚¥¬

‡©æ“–μÕπ‡√‘Ë¡‚À≈¥

°√–∫Õ°„À¡à

‡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

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

¿“§ºπ«° 2

·π«∑“ß°“√™à«¬‡À≈◊Õ„ÀâºŸâªÉ«¬ 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“ “¡“√∂∑”„ÀâºŸâªÉ«¬¡’‚Õ°“ ‡≈‘° Ÿ∫∫ÿÀ√’Ë‰¥â¡“°¢÷Èπ ª√–°Õ∫

¥â«¬·π«∑“ß ”§—≠ 2 ·π«∑“ß§◊Õ

1. °“√„Àâ§”ª√÷°…“‡æ◊ËÕª√—∫‡ª≈’Ë¬πæƒμ‘°√√¡ (education and knowledge

management) ‡ªìπ°“√√—°…“∑’Ë ”§—≠·≈–ª√– ∫º≈ ”‡√Á®¡“°∑’Ë ÿ¥ æ∫«à“°“√

„Àâ§”ª√÷°…“·¡â„™â√–¬–‡«≈“ —ÈπÊ (brief counselling) “¡“√∂®–‡æ‘Ë¡‚Õ°“ „π

°“√‡≈‘° Ÿ∫∫ÿÀ√’Ë„Àâ ”‡√Á®‰¥â¡“° °“√„Àâ§”ª√÷°…“∑’Ë„™â‡«≈“¡“°¢÷Èπ À√◊Õ‡ªìπ°≈ÿà¡

°“√„ÀâºŸâªÉ«¬‚∑√»—æ∑å√—∫§”ª√÷°…“Õ¬à“ßμàÕ‡π◊ËÕß®“°»Ÿπ¬å‡≈‘°∫ÿÀ√’Ë∑“ß‚∑√»—æ∑å

(À¡“¬‡≈¢ 1600) ≈â«π∑”„ÀâºŸâªÉ«¬¡’ ‚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°≈ÿà¡ºŸâªÉ«¬ COPD æ∫«à“ Odd ratio

®“°°“√‰¥â√—∫°“√ª√÷°…“‡≈‘°∫ÿÀ√’Ë ‡∑à“°—∫ 1.82 ‡∑à“ (95% confidence interval

0.96-3.44) ‡ª√’¬∫‡∑’¬∫°—∫°≈ÿà¡ºŸâªÉ«¬∑’Ë‰¡à‰¥â√—∫§”ª√÷°…“‡√◊ËÕß‡≈‘°∫ÿÀ√’Ë (usual

√“¬≈–‡Õ’¬¥°“√„Àâ§”ª√÷°…“Õ¬à“ß —Èπ (brief counselling)

¡’¢—ÈπμÕπ ”§—≠ ç5Aé ¥—ßμ“√“ß

¢—ÈπμÕπ 5A

ADVISE

ASSESSMENT

ASSIST

§«“¡ ”§—≠

- °“√ Ÿ∫∫ÿÀ√’ËÕ¬à“ßμàÕ‡π◊ËÕß

®—¥‡ªìπ‚√§‡√◊ÈÕ√—ß „Àâ∂◊Õ

«à“°“√ Ÿ∫∫ÿÀ√’Ë‡ªìπ active

problem „π°“√¥Ÿ·≈

ºŸâªÉ«¬‡ ¡Õ®π°«à“®–

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- ·æ∑¬å„Àâ¢âÕ¡Ÿ≈‡°’Ë¬«°—∫

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„ÀâºŸâªÉ«¬

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·π«ªØ‘∫—μ‘

- ∂“¡ª√–«—μ‘°“√ Ÿ∫∫ÿÀ√’Ë ‡™àπ Ÿ∫¡“

π“π‡∑à“‰À√à ª√‘¡“≥°“√ Ÿ∫μàÕ«—π

- ·æ∑¬å§«√∂“¡ºŸâªÉ«¬∑ÿ°§π‡°’Ë¬«°—∫

ª√–«—μ‘°“√ Ÿ∫∫ÿÀ√’Ë ·≈–∫—π∑÷°≈ß„π

ª√–«—μ‘ºŸâªÉ«¬

- „Àâ§”·π–π”ºŸâªÉ«¬‡°’Ë¬«°—∫‡√◊ËÕß

æ‘…¿—¬∫ÿÀ√’Ë ·≈–°“√‡≈‘° Ÿ∫∫ÿÀ√’Ë À√◊Õ

“¡“√∂ àßμàÕºŸâªÉ«¬‰ª√—∫°“√¥Ÿ·≈∑’Ë

‡À¡“– ¡‰¥â

- „Àâ§”·π–π”∑’Ë‡À¡“– ¡‡æ◊ËÕ™à«¬„Àâ

ºŸâªÉ«¬≈ß¡◊Õ‡≈‘° Ÿ∫∫ÿÀ√’Ë

- „πºŸâ Ÿ∫∑’Ë¬—ß‰¡àμâÕß°“√‡≈‘°∫ÿÀ√’Ë §«√¡’

°“√„Àâ§”·π–π”‡æ◊ËÕ°√–μÿâπºŸâ Ÿ∫„Àâ

‡√‘Ë¡§‘¥‡≈‘° Ÿ∫∫ÿÀ√’Ë∑ÿ°§√—Èß∑’Ë¡’‚Õ°“

(motivation counselling)

- Õ∏‘∫“¬∂÷ß¢—ÈπμÕπ°“√‡≈‘°∫ÿÀ√’Ë

- §«√°”Àπ¥«—π‡≈‘°∫ÿÀ√’Ë¿“¬„π 1 ‡¥◊Õπ

- ·π–π”·π«∑“ßªØ‘∫—μ‘μ—«„π™à«ß°àÕπ

®–‡≈‘° ·≈–„π«—π∑’Ë‡≈‘°∫ÿÀ√’Ë

- ∂â“®”‡ªìπμâÕß„™â¬“™à«¬‡≈‘°∫ÿÀ√’Ë “¡“√∂

®à“¬¬“ ·≈–·π–π”«‘∏’„™â∑’Ë∂Ÿ°μâÕß‰¥â

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„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≈°“√√—°…“ ·≈–„Àâ§”·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√’Ë‰¥â ª√–°Õ∫

¥â«¬¬“ 2 °≈ÿà¡ (μ“√“ß∑’Ë 1) §◊Õ

1) °≈ÿà¡¬“ 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) °≈ÿà¡¬“ 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 ∑”„ÀâºŸâ‡≈‘°∫ÿÀ√’Ëª√– ∫§«“¡ ”‡√Á®

¡“°¢÷Èπ à«π¬“°≈ÿà¡ antidepressant §◊Õ bupropion SR ·≈– nortriptyline ¡’

ƒ∑∏‘Ï™à«¬≈¥Õ“°“√Õ¬“°∫ÿÀ√’Ë‰¥â

„πª√–‡∑»‰∑¬ ¡’°“√π”°≈ÿà¡¬“ ¡ÿπ‰æ√ À√◊Õ¬“·ºπ‰∑¬ ¡“„™â ‡™àπ ™“

À≠â“¥Õ°¢“« (Vernonia cinerea Less) ÕÕ°ƒ∑∏‘Ï‚¥¬∑”„Àâ≈‘Èπ™“ ·≈–‰¡àÕ¬“°

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‡Õ° “√Õâ“ßÕ‘ß1. ÿ∑—»πå √ÿàß‡√◊ÕßÀ‘√—≠≠“ ·≈– ÿ√®‘μ ÿπ∑√∏√√¡. ·π«∑“ß‡«™ªØ‘∫—μ‘Õ‘ßÀ≈—°∞“π °“√∫”∫—¥

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.

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

¿“§ºπ«° 3

«—§ ’π

°“√μ‘¥‡™◊ÈÕ√–∫∫°“√À“¬„®∑’Ë‡°‘¥®“°‡™◊ÈÕ‰¢âÀ«—¥„À≠à ·≈–≈¥°“√‡°‘¥°“√°”‡√‘∫

‰ª Ÿà°≈ÿà¡‡ ’Ë¬ßπ’È ‡™àπ ∫ÿ§≈“°√∑“ß°“√·æ∑¬å·≈–ÀâÕßªØ‘∫—μ‘°“√ ∫ÿ§§≈∑’Ëæ—°Õ¬Ÿà„π

∫â“π‡¥’¬«°—∫ª√–™“°√∑’Ë¡’§«“¡‡ ’Ë¬ß Ÿß

«—§´’πªÑÕß°—π‰¢âÀ«—¥„À≠à∑’Ë„™â„πª√–‡∑»‰∑¬ „™â«—§´’π™π‘¥‡™◊ÈÕμ“¬ ÷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“ß‡§’¬ß

influenza B virus ‰¥â¡“°¢÷Èπ

°“√„Àâ«—§´’π‡æ◊ËÕªÑÕß°—π°“√μ‘¥‡™◊ÈÕ‰¢âÀ«—¥„À≠à μâÕß‡ª≈’Ë¬π·ª≈ß‰ªμ“¡

™π‘¥¢Õß‰«√— ‰¢âÀ«—¥„À≠à∑’Ë§“¥«à“®–√–∫“¥„πªïπ—Èπ (seasonal influenza) ¥—ßπ—Èπ

®÷ß·π–π”„Àâ«—§´’π‰¢âÀ«—¥„À≠à∑ÿ°ªï ªï≈– 1 §√—Èß √–¬–‡«≈“∑’Ë‡À¡“– ¡§◊Õ ‡¥◊Õπ

¡’π“§¡-‡¡…“¬π ·μàÕ“®„Àâ ‰¥âμ≈Õ¥∑—Èßªï (§ÿ≥¿“æÀ≈—°∞“π 1, πÈ”Àπ—°§”·π–π” ++)

«—§´’π‰¢âÀ«—¥„À≠à‰¡à§«√„Àâ·°àºŸâ∑’Ë¡’ª√–«—μ‘·æâ ‰¢à√ÿπ·√ß À√◊ÕºŸâ∑’Ë¡’ª√–«—μ‘

‡ªìπ Guillain-Barre syndrome “¡“√∂„Àâ«—§´’πªÑÕß°—π‚√§‰¢âÀ«—¥„À≠à √à«¡

§π≈–¢â“ß¢Õßμâπ·¢π

∑’Ë¡’‚√§√à«¡ ‡™àπ ‚√§À—«„® ‚√§ªÕ¥‡√◊ÈÕ√—ßÕ◊Ëπ æ∫«à“≈¥Õ—μ√“°“√‡°‘¥ community-

acquired pneumonia ‰¥â

«—§´’π¡’ 2 ™π‘¥ §◊Õ ™π‘¥‚æ≈’·´§§“‰√¥å (23-valent pneumococcal

polysaccharide vaccine: PPV-23) ·≈–™π‘¥§Õπ®Ÿ‡°μ (13-valent pneumococcal

«—§´’π™π‘¥‚æ≈’·´§§“‰√¥å (PPV-23) (PCV13-PPV23 sequence) ÷Ëß§√Õ∫§≈ÿ¡

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

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·Ààßª√–‡∑»‰∑¬ ªï 2557

μ“√“ß∑’Ë 2 §”·π–π”„π°“√„À«—§´’πªÑÕß°—π‚√§ ”À√—∫ºŸâ„À≠à ·≈–ºŸâ ŸßÕ“¬ÿ∑’Ë¡’‚√§

ª√–®”μ—« À≠‘ßμ—Èß§√√¿å ·≈–∫ÿ§≈“°√∑“ß°“√·æ∑¬å ¥—¥·ª≈ß®“°§”

·π–π”¢Õß√“™«‘∑¬“≈—¬Õ“¬ÿ√·æ∑¬å·Ààßª√–‡∑»‰∑¬ ªï 2557

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„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·Ààßª√–‡∑»‰∑¬ 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.

¿“§ºπ«° 4

°“√øóôπøŸ ¡√√∂¿“æªÕ¥(Pulmonary rehabilitation)

π‘¬“¡ °“√øóôπøŸ ¡√√∂¿“æªÕ¥ §◊Õ ‚ª√·°√¡°“√¥Ÿ·≈ºŸâªÉ«¬∑’Ë∑ÿææ≈¿“æ

®“°‚√§√–∫∫°“√À“¬„®‡√◊ÈÕ√—ß ‚¥¬∑’¡∫ÿ§≈“°√®“° À “¢“ ‚ª√·°√¡¥—ß°≈à“«

“¡“√∂ÕÕ°·∫∫À√◊Õª√—∫‡ª≈’Ë¬π‰¥â‡æ◊ËÕ„Àâ‡À¡“– ¡°—∫ ¿“æ —ß§¡ ·≈– ∂“π∑’Ë

μ≈Õ¥®π¡’§«“¡§≈àÕßμ—«„π°“√ªØ‘∫—μ‘

°“√øóôπøŸ ¡√√∂¿“æªÕ¥ ‡ªìπ°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬·∫∫Õß§å√«¡ ∑’Ë‡ √‘¡

‡æ‘Ë¡‡μ‘¡º≈®“°°“√√—°…“¥â«¬¬“ ‚ª√·°√¡øóôπøŸ ¡√√∂¿“æªÕ¥∑’Ë¡’§ÿ≥¿“æ ®–¡’

º≈∑”„ÀâºŸâªÉ«¬¡’Õ“°“√‡Àπ◊ËÕ¬≈¥≈ß §«“¡ “¡“√∂„π°“√ÕÕ°°”≈—ß°“¬‡æ‘Ë¡¢÷Èπ

§ÿ≥¿“æ™’«‘μ¥’¢÷Èπ ·≈–°“√°”‡√‘∫¢Õß‚√§≈¥≈ß ‚¥¬º≈¥’¥—ß°≈à“«∑—ÈßÀ¡¥®– àßº≈

‚¥¬∑“ßÕâÕ¡ ∑”„Àâ§à“„™â®à“¬„π°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬≈¥≈ß (μ“√“ß∑’Ë 1)

∫ÿ§≈“°√ À “¢“∑’Ë‡°’Ë¬«¢âÕß„π°“√¥”‡π‘π‚ª√·°√¡øóôπøŸ ¡√√∂¿“æªÕ¥

‰¥â·°à ·æ∑¬å æ¬“∫“≈ π—°‡∑§π‘§¥â“π°“√∑¥ Õ∫ ¡√√∂¿“æªÕ¥ ‡¿ —™°√ π—°

°“¬¿“æ∫”∫—¥ ‚¿™π“°√ π—° —ß§¡«‘∑¬“ μ≈Õ¥®πºŸâªÉ«¬∑’Ë‡§¬‰¥â√—∫°“√√—°…“

μ“¡‚ª√·°√¡øóôπøŸ ¡√√∂¿“æªÕ¥¡“·≈â« ‡ªìπμâπ À√◊ÕÕ“®®–‡ªìπ∫ÿ§≈“°√Õ◊Ëπ∑’Ë

‰¥â√—∫°“√Ωñ°Ωπμ“¡§«“¡‡À¡“– ¡

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

¢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‚√ßæ¬“∫“≈¥â«¬¿“«–°”‡√‘∫

≈¥Õ—μ√“°“√πÕπ‚√ßæ¬“∫“≈ ·≈–≈¥®”π«π«—π∑’ËμâÕßπÕπ„π

‚√ßæ¬“∫“≈

≈¥§«“¡«‘μ°°—ß«≈ ·≈–¿“«–´÷¡‡»√â“∑’Ë‡°’Ë¬«¢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√–‚¬™πå®“°°“√øóôπøŸœ ¬—ß§ß‰¥â√—∫·¡âæâπ™à«ßΩñ°œ

Ωñ°ÕÕ°°”≈—ß°“¬∑—Ë«‰ª

§ÿ≥¿“æÀ≈—°∞“π

√–¥—∫

3. Program content

- Patient education

- Exercise training

- Psychosocial and behavioral intervention

- Nutritional assessment

- Outcome assessment

1. °“√ª√–‡¡‘π§«“¡√ÿπ·√ß¢Õß‚√§ ·≈–°“√§—¥‡≈◊Õ°ºŸâªÉ«¬‡æ◊ËÕ‡¢â“‚ª√·°√¡

(patient selection and assessment)

ºŸâªÉ«¬∑’Ë§«√‰¥â√—∫°“√øóôπøŸ ¡√√∂¿“æªÕ¥ ‰¥â·°à ºŸâªÉ«¬∑’Ë¡’Õ“°“√‡Àπ◊ËÕ¬

‡√◊ÈÕ√—ß ®π§ÿ°§“¡°“√¥”‡π‘π™’«‘μª°μ‘ª√–®”«—π °àÕ„Àâ‡°‘¥¢âÕ®”°—¥μà“ßÊ ∑—Èß¥â“π

°“√ÕÕ°°”≈—ß°“¬ °“√ª√–°Õ∫°‘®°√√¡πÕ°∫â“π À√◊Õ°‘®°√√¡æ◊Èπ∞“π∑“ß —ß§¡

‡°‘¥§«“¡«‘μ°°—ß«≈ ·≈–§«“¡°≈—«∑’Ë®–Õ¬Ÿà§π‡¥’¬« ®”‡ªìπμâÕßæ÷Ëßæ“ºŸâÕ◊Ëπ

°“√§—¥‡≈◊Õ°ºŸâªÉ«¬‡æ◊ËÕ„Àâ‡¢â“‚ª√·°√¡øóôπøŸ ¡√√∂¿“æªÕ¥ ‚¥¬∑—Ë«‰ª®–

ª√–‡¡‘πμ“¡Õ“°“√À√◊Õ§«“¡∑ÿææ≈¿“æ®“°‚√§ §«“¡√ÿπ·√ß¢Õß‚√§ ÷Ëßª√–‡¡‘π

®“° pulmonary function tests À√◊Õ arterial blood gases

πÕ°®“°π’È „πºŸâªÉ«¬∑’Ë‡æ‘Ëßøóôπ®“°°“√°”‡√‘∫ (COPD exacerbation) ¡’

§«“¡®”‡ªìπ∑’Ë®–μâÕß‡√‘Ë¡°“√øóôπøŸ ¡√√∂¿“æªÕ¥„Àâ‡√Á«¢÷Èπ ·π–π”‡√‘Ë¡∑—π∑’À≈—ß

®“°À“¬®“°Õ“°“√°”‡√‘∫ À√◊ÕÕ¬à“ß™â“‡√‘Ë¡¿“¬„π 4 —ª¥“Àå ‚¥¬ “¡“√∂∑”‰¥â

μ—Èß·μà™à«ß∑’Ë¬—ßπÕπ‚√ßæ¬“∫“≈ ‡™àπ °“√Ωñ° early mobilization °“√Ωñ°°”≈—ß¢Õß

°≈â“¡‡π◊ÈÕ¡—¥‡≈Á°Ê (resistance exercises for small muscle groups) °“√

‡§≈◊ËÕπ¬â“¬ °“√∑√ßμ—« °“√‡¥‘π (gait and transfer) „π°≈ÿà¡ºŸâªÉ«¬∑’Ë¡’ªí≠À“

‡ ¡À–¡“° ·π–π”∑” √’√–∫”∫—¥À≈Õ¥≈¡ (bronchial hygiene therapy) ·≈–

Ωñ°°“√À“¬„® (breathing exercises) ·≈–§«√¡’ª√–‡¡‘π´È”°àÕπ°≈—∫∫â“π‡æ◊ËÕ

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

ª√—∫‚ª√·°√¡°“√øóôπøŸ ¡√√∂¿“æªÕ¥„Àâ‡ªìπ‰ªÕ¬à“ßμàÕ‡π◊ËÕß‡¡◊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‚√ßæ¬“∫“≈ (hos-

pital-based) „π™ÿ¡™π (community-based) À√◊Õ∑’Ë∫â“π (home-based)

∑—Èßπ’È¢÷ÈπÕ¬Ÿà°—∫§«“¡‡À¡“– ¡ ·≈–§«“¡§≈àÕßμ—« Õ¬à“ß‰√°Áμ“¡ ‚ª√·°√¡∑’Ë¡’

ª√– ‘∑∏‘¿“æ ·≈–‡ªìπ∑’Ëπ‘¬¡¡“°∑’Ë ÿ¥ §◊Õ‚ª√·°√¡øóôπøŸ ¡√√∂¿“æªÕ¥∑’Ë„™â„π

‚√ßæ¬“∫“≈·∫∫ºŸâªÉ«¬πÕ°

°“√‡≈◊Õ°‚ª√·°√¡°“√øóôπøŸœ ®–μâÕßª√—∫„Àâ‡¢â“°—∫§«“¡ –¥«°¢ÕßºŸâªÉ«¬

·≈–∫ÿ§≈“°√ ®”μâÕß§”π÷ß∂÷ß»—°¬¿“æ ·≈–§à“„™â®à“¬∑’Ë®–‡°‘¥¢÷Èπ¢Õß·μà≈– ∂“∫—π

¥â«¬

3. Õß§åª√–°Õ∫¢Õß‚ª√·°√¡ (program content) ‰¥â·°à

3.1 °“√„Àâ°“√»÷°…“·°àºŸâªÉ«¬ (patient education)

‰¥â·°à §«“¡√Ÿâ‡°’Ë¬«°—∫‚√§ §«“¡√Ÿâ‡√◊ËÕß¬“ ·≈–«‘∏’°“√„™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“°“√∑’Ë‡À¡“– ¡

μ≈Õ¥®π°“√§«∫§ÿ¡¿“«–Õ“√¡≥å·≈–®‘μ„® ‡ªìπμâπ πÕ°®“°π—Èπ¬—ß§√Õ∫§≈ÿ¡∂÷ß

°“√«“ß·ºπ™’«‘μμπ‡Õß‡¡◊ËÕ‚√§‡¢â“ Ÿà√–¬– ÿ¥∑â“¬

3.2 Ωñ°°“√À“¬„® (breathing exercise) ‡™àπ pursed-lip breathing,

diaphragmatic breathing ‡ªìπμâπ

3.3 °“√Ωñ°ΩπÕÕ°°”≈—ß°“¬ (exercise training)

°“√Ωñ°Ωπ°“√ÕÕ°°”≈—ß°“¬ ‡ªìπÕß§åª√–°Õ∫∑’Ë ”§—≠∑’Ë ÿ¥¢Õß°“√

øóôπøŸ ¡√√∂¿“æªÕ¥ ∑’Ë “¡“√∂‡ª≈’Ë¬πº≈≈—æ∏å¢Õß‚ª√·°√¡‰¥â ‚ª√·°√¡°“√

ÕÕ°°”≈—ß°“¬∑’Ë¡’ª√– ‘∑∏‘¿“æ ®”‡ªìπμâÕß‡πâπ°“√Ωñ°Ωπ∑—Èß¥â“π strength training

§«∫§Ÿà‰ª°—∫ endurance training ·≈–∑”°“√Ωñ°ΩπÕ¬à“ßμàÕ‡π◊ËÕß‡ªìπ√–¬–‡«≈“

∑’Ëπ“πæÕ º≈≈—æ∏å®“°°“√Ωñ°ΩπÕÕ°°”≈—ß°“¬π’È®–∑”„ÀâºŸâªÉ«¬¡’§«“¡ “¡“√∂„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 àßº≈„ÀâÕ—μ√“°“√À“¬„® ·≈–§ÿ≥¿“æ™’«‘μ‚¥¬Õß§å√«¡

(health-related quality of life, HRQoL) ¥’¢÷Èπ

°“√øóôπøŸ ¡√√∂¿“æªÕ¥ §«√∑”Õ¬à“ßπâÕ¬ 6 —ª¥“Àå ‚¥¬¬‘Ëß∑”μàÕ‡π◊ËÕß

π“π ¬‘Ëß‰¥âª√– ‘∑∏‘º≈¡“° º≈ª√–‚¬™πå®“°°“√øóôπøŸœ ∑’ËºŸâªÉ«¬‰¥â√—∫ ®–¬—ß§ßÕ¬Ÿà

„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“®°”Àπ¥®“°√–¥—∫§«“¡Àπ—°‡∫“¢Õß°“√ÕÕ°°”≈—ß°“¬

(intensity) ¥—ßμ“√“ß∑’Ë 2

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

°“√»÷°…“®“°‚√ßæ¬“∫“≈√“¡“∏‘∫¥’ æ∫«à“ °“√Ωñ°ΩπÕÕ°°”≈—ß°“¬‚¥¬

ª√–¬ÿ°μå„™â∑à“√”¡«¬®’π Tai Chi Qigong (´÷Ëß‡ªìπ moderate intensity exercise)

§«∫§Ÿà°—∫°“√§«∫§ÿ¡°“√À“¬„®·∫∫ pursed-lip §√—Èß≈– 30 π“∑’ —ª¥“Àå≈– > 5

§√—Èß ‡ªìπ‡«≈“π“π 6 —ª¥“Àå¢÷Èπ‰ª ®–¡’º≈∑”„ÀâºŸâªÉ«¬¡’§«“¡ “¡“√∂„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·√ß¢÷Èπ §ÿ≥¿“æ™’«‘μ (HRQoL) ¥’¢÷Èπ ·≈–§«“¡

‡Àπ◊ËÕ¬≈¥≈ß ∑—Èßπ’È√–¥—∫º≈∑’Ë¥’¢÷Èπ Õ¬Ÿà„π‡°≥±å∑’Ë‡∑’¬∫‡§’¬ß‰¥â ·≈–‰¡àπâÕ¬°«à“°“√

Ωñ°Ωπ‚¥¬«‘∏’ cycling À√◊Õ walking ·μà¡’¢âÕ¥’μ√ß∑’ËªØ‘∫—μ‘‰¥âæ√âÕ¡°—π‡ªìπ°≈ÿà¡

μ“√“ß∑’Ë 2 °“√°”Àπ¥§«“¡∂’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

·≈–Ωñ°Ωπ‡Õß∑’Ë™ÿ¡™π À√◊Õ∑’Ë∫â“π‰¥â ‚¥¬‰¡àμâÕß„™âÕÿª°√≥å√“§“ Ÿß πÕ°®“°π’È¬—ß

°“√»÷°…“„πμà“ßª√–‡∑» æ∫«à“ °“√ÕÕ°°”≈—ß°“¬¥â«¬ Tai Chi Qigong

¬—ß‰¥âª√–‚¬™πå„πºŸâ ŸßÕ“¬ÿÀ≈“¬¥â“π ‡™àπ ¥â“π°“√∑√ßμ—« (balance) §«“¡¬◊¥À¬ÿàπ

(flexibility) §«“¡·¢Áß·√ß¢Õß°≈â“¡‡π◊ÈÕ (muscle strength) √–∫∫‰À≈‡«’¬π‚≈À‘μ

(cardiovascular fitness) °“√√—∫√Ÿâ (cognition) §ÿ≥¿“æ°“√πÕπÀ≈—∫ (sleep

quality) °“√ª√—∫Õ“√¡≥å (emotional functioning) ´÷ËßºŸâªÉ«¬ 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)

°“√»÷°…“®“°‚√ßæ¬“∫“≈¡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·√ß¢÷Èπ §«“¡§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∫π “¬æ“π (treadmill) À√◊ÕÕ“®ª√–¬ÿ°μå„™âÕÿª°√≥å∑’Ë “¡“√∂

À“‰¥âßà“¬ ·≈–√“§“∂Ÿ° ‡™àπ dumbbell ∂ÿß∑√“¬ ·≈–¬“ß¬◊¥ (theraband) ÷Ëß

“¡“√∂„ÀâºŸâªÉ«¬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§≈“°√‚√ßæ¬“∫“≈„Àâ

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

§”·π–π” (supervised) μ≈Õ¥ ¡’°“√«Õ√å¡Õ—æ 10-15 π“∑’°àÕπ‡√‘Ë¡ ‡√‘Ë¡∑”°“√

ÕÕ°°”≈—ß°“¬√–¬–‡«≈“ —ÈπÊ °àÕπ ·≈â«§àÕ¬Ê ‡æ‘Ë¡¢÷Èπ∑ÿ° 2 —ª¥“Àå ®π‰¥â√–¬–

‡«≈“ 35-40 π“∑’μàÕ§√—Èß ‚¥¬∑” 2 §√—ÈßμàÕ —ª¥“Àå‡ªìπ‡«≈“ 8 —ª¥“Àå æ∫«à“

ª√–‚¬™πå∑’Ë‰¥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∑”„ÀâºŸâªÉ«¬‡Àπ◊ËÕ¬‡°‘π‰ª °“√ª√—∫

‚ª√·°√¡§«“¡Àπ—°‡∫“ √–¬–‡«≈“∑’ËÕÕ°°”≈—ß°“¬ √–¬–‡«≈“æ—° ‰¡àμ“¬μ—« ·μà

¡’À≈—°∞“π«à“‰¥âª√–‚¬™πå∑—Èß„π·ßà‡æ‘Ë¡§«“¡ “¡“√∂„π°“√ÕÕ°°”≈—ß°“¬ ∑”„Àâ

§ÿ≥¿“æ™’«‘μ¥’¢÷Èπ ·≈–Õ“®‰¥âª√–‚¬™πå®“°°“√ÕÕ°°”≈—ß°“¬ßà“¬Ê ‡™àπ °“√°“ß

·¢π ‡À«’Ë¬ß·¢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∑’Ë™à«¬‡ √‘¡ √â“ß§«“¡¡—Ëπ§ß∑“ßÕ“√¡≥å ·≈–®‘μ„®

μ≈Õ¥®π°“√ª√—∫‡ª≈’Ë¬πæƒμ‘°√√¡°“√¥”‡π‘π™’«‘μ„Àâ‡À¡“– ¡ ‡™àπ °“√·π–π”

Õ“™’æ °“√·π–π”°“√ªØ‘∫—μ‘μ—«‡æ◊ËÕÀ≈’°‡≈’Ë¬ß§«“¡‡Àπ◊ËÕ¬ (energy conservation

technique) °“√ √â“ß‡§√◊Õ¢à“¬ À√◊Õ√«¡°≈ÿà¡ºŸâªÉ«¬∑’Ë¡’‚√§§≈â“¬§≈÷ß°—π„Àâ¡’°‘®°√√¡

∑’Ë√à«¡°—π À√◊Õ·≈°‡ª≈’Ë¬π§«“¡§‘¥‡ÀÁπª√– ∫°“√≥å°—π μ≈Õ¥®π°“√¡’∑’Ëª√÷°…“

¬“¡ºŸâªÉ«¬¡’ªí≠À“ ‘Ëßμà“ßÊ ‡À≈à“π’È≈â«π¡’º≈ ”§—≠μàÕ ÿ¢¿“æ∑“ß°“¬·≈–„®‚¥¬

Õß§å√«¡ Õ—π®–∑”„ÀâºŸâªÉ«¬μàÕ Ÿâ°—∫‚√§ ·≈–¡’™’«‘μ„π —ß§¡‰¥â¥’¢÷Èπ

3.5 °“√ª√–‡¡‘π¥â“π‚¿™π“°“√ (nutritional assessment)

ºŸâªÉ«¬ COPD ∑’Ë¡’πÈ”Àπ—°πâÕ¬ ¡’§«“¡ —¡æ—π∏å°—∫Õ—μ√“μ“¬∑’Ë Ÿß¢÷Èπ

§«√ª√–‡¡‘π¿“«–‚¿™π“°“√¢ÕßºŸâªÉ«¬ ‡™àπ «—¥πÈ”Àπ—°μ—« §à“ body mass

index (BMI) ª√‘¡“≥‰¢¡—π ¡«≈°≈â“¡‡π◊ÈÕ °àÕπ°“√øóôπøŸ ¡√√∂¿“æ§«√„Àâ°“√

·π–π”¥â“π‚¿™π“°“√§«∫§Ÿà°—∫°“√ÕÕ°°”≈—ß°“¬‡æ◊ËÕª√—∫ ¡¥ÿ≈¬å¢ÕßπÈ”Àπ—°μ—«

·≈–¿“«–‚¿™π“°“√„ÀâÕ¬Ÿà„π‡°≥±å„°≈â‡§’¬ßª°μ‘¡“°∑’Ë ÿ¥

3.6 °“√ª√–‡¡‘πº≈≈—æ∏å¢Õß°“√øóôπøŸ ¡√√∂¿“æªÕ¥ (outcome assess-

°“√ª√–‡¡‘πº≈≈—æ∏å®“°°“√øóôπøŸ ¡√√∂¿“æªÕ¥π’È ®”‡ªìπÕ¬à“ß¬‘Ëß

·≈–μâÕß∑”‡ª√’¬∫‡∑’¬∫ºŸâªÉ«¬ ‡¡◊ËÕ°àÕπ‡¢â“‚ª√·°√¡ ·≈– 6-12 —ª¥“ÀåÀ≈—ß‡¢â“

‚ª√·°√¡ ‡æ√“–‰¡à‡æ’¬ß·μà®–∑”„ÀâºŸâªÉ«¬‰¥â√—∫√Ÿâ§«“¡‡ª≈’Ë¬π·ª≈ß„π∑“ß∑’Ë¥’ ∑’Ë‡°‘¥

¢÷ÈπÀ≈—ß°“√øóôπøŸ ¡√√∂¿“æªÕ¥ ¬—ß‡ªìπ°“√ª√–‡¡‘π»—°¬¿“æ ·≈–ª√– ‘∑∏‘¿“æ

¢Õß‚ª√·°√¡∑’Ë„™â„π ∂“∫—ππ—ÈπÊ À≈—ß®“°π—Èπ§«√∑”°“√ª√–‡¡‘πÕ¬à“ßπâÕ¬∑ÿ°

1 ªï ∑—Èßπ’È‡æ◊ËÕ‡ªìπ°”≈—ß„®„ÀâºŸâªÉ«¬μ‘¥μ“¡‚ª√·°√¡μàÕ‰ª„Àâπ“π∑’Ë ÿ¥ ·≈– ∂“∫—π

‰¥â∑”°“√∑∫∑«πª√—∫‡ª≈’Ë¬π‚ª√·°√¡¢Õßμπ‡Õß„Àâ‡À¡“– ¡¬‘ËßÊ ¢÷Èπ Õß§å

ª√–°Õ∫ ”§—≠∑’Ë§«√ª√–‡¡‘π§◊Õ

°. §«“¡ “¡“√∂„π°“√ÕÕ°°”≈—ß°“¬ (exercise capacity) ‚¥¬°“√

«—¥ 6-minute walking distance (6-MWD, meters)

¢. ª√–‡¡‘π§«“¡‡Àπ◊ËÕ¬ °àÕπ·≈–À≈—ß°“√ÕÕ°°”≈—ß°“¬ ‚¥¬„™â borg

scale ·≈– modified medical research council (mMRC)

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„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‚√ßæ¬“∫“≈

À√◊Õ§à“„™â®à“¬„π°“√√—°…“‚√§

·π–π”„Àâª√–‡¡‘πÕß§åª√–°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.

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.

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

¿“§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 ∑’Ë‰¥â√—∫°“√ª√–‡¡‘π„π

¢≥–æ—° (resting) ¢≥–ÕÕ°°”≈—ß°“¬À√◊Õ¢≥–À≈—∫ ·≈â«æ∫«à“¡’§ÿ≥ ¡∫—μ‘¢âÕ„¥

¢âÕÀπ÷Ëß¥—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

«‘∏’°“√Õÿª°√≥å°“√„ÀâÕÕ°´‘‡®π π‘¬¡„™â nasal cannula ‚¥¬„Àâª√‘¡“≥ÕÕ° ‘‡®π

„πÕ—μ√“°“√‰À≈∑’Ë§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≈’Ë¬π·ª≈ß

∑“ß √’√«‘∑¬“„π∑“ß∑’Ë¥’¢÷Èπ °≈à“«§◊Õ ¿“«– erythrocytosis, pulmonary

hypertension ·≈–Õ—μ√“μ“¬≈¥≈ß πÕ°®“°π—Èπ¬—ß∑”„Àâ ¡√√∂π–·≈–§«“¡∑π∑“π

„π°“√ÕÕ°°”≈—ß°“¬‡æ‘Ë¡¢÷Èπ §ÿ≥¿“æ™’«‘μ·≈– cognitive function ¥’¢÷Èπ Õ’°∑—Èß

àßº≈„Àâ¿“«–´÷¡‡»√â“ Õ—μ√“‚√§°”‡√‘∫ ·≈–Õ—μ√“°“√πÕπ‚√ßæ¬“∫“≈≈¥≈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«¬‡§√◊ËÕß™à«¬À“¬„® non-invasive ventilator „πstable COPD

°“√∫”∫—¥¥â«¬‡§√◊ËÕß™à«¬À“¬„®™π‘¥‰¡à„ à∑àÕ™à«¬À“¬„® (noninvasive

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“°“»·√ß¥—π∫«°™π‘¥·√ß¥—π§ß∑’Ë

continuous positive airway pressure (CPAP) §◊Õ ®–™à«¬≈¥Õ—μ√“°“√πÕπ

‚√ßæ¬“∫“≈ ·≈–Õ—μ√“μ“¬

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

2. ºŸâªÉ«¬ COPD √–¬– ß∫∑’Ë¡’¿“«–°“√À“¬„®≈â¡‡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√–¬–¬“«¬—ß‰¡à “¡“√∂ √ÿª‰¥â™—¥‡®π Õ¬à“ß‰√

°Áμ“¡ °“√‡≈◊Õ°°≈ÿà¡ºŸâªÉ«¬∑’Ë‡À¡“– ¡·≈–¡’°“√ª√—∫‡§√◊ËÕß∑’Ë¡’‡ªÑ“À¡“¬„π°“√≈¥

PaCO2 Õ¬à“ß∂Ÿ°μâÕß Õ“®∑”„ÀâºŸâªÉ«¬Õ“°“√¥’¢÷Èπ ≈¥°“√°”‡√‘∫·≈–≈¥Õ—μ√“μ“¬

‰¥â

‡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.

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.

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

¿“§ºπ«° 6

°“√«“ß·ºπ™’«‘μ√–¬– ÿ¥∑â“¬(End of life plan)

‡π◊ËÕß®“°ºŸâªÉ«¬ COPD ®–¡’ progressive lung function decline ‚¥¬

·≈– LTOT Õ“®™à«¬™–≈Õ§«“¡‡ ◊ËÕ¡·≈–‡æ‘Ë¡Õ“¬ÿ¢—¬∫â“ß ·μà‚√§‡√◊ÈÕ√—ß¥—ß°≈à“«

¬—ß¥”‡π‘πμàÕ®π‚√§√ÿπ·√ß¡“°¢÷Èπ·≈–‡¢â“ Ÿà√–¬– ÿ¥∑â“¬„π∑’Ë ÿ¥ ‚¥¬ºŸâªÉ«¬Õ“®

‡ ’¬™’«‘μ®“° COPD ‡Õß ·≈–/À√◊Õ ¿“«–·∑√°´âÕπ∑’Ë‡°‘¥√à«¡°—π°Á‰¥â ¥—ßπ—Èπ

ºŸâªÉ«¬∑ÿ°√“¬§«√®–‰¥â√—∫§”·π–π”°“√‡μ√’¬¡μ—«·≈–‡μ√’¬¡„®„π°“√«“ß·ºπ™’«‘μ

„π√–¬– ÿ¥∑â“¬ ªí®®—¬À≈—°∑’Ë§«√§”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∑“ß§≈‘π‘° °“√μ√«® spirometry ·≈–‚√§√à«¡

2. ºŸâªÉ«¬∑ÿ°√“¬§«√®–‰¥âºà“π°“√√—°…“¥â«¬¬“Õ¬à“ß∂Ÿ°μâÕß·≈–¥’∑’Ë ÿ¥¡“

·≈â« ‰¥â√—∫°“√øóôπøŸ ¡√√∂¿“æªÕ¥·≈– LTOT ·μà¬—ßª√“°ØÕ“°“√∑“ß§≈‘π‘°∑’Ë

∑√ÿ¥≈ß‡√◊ËÕ¬Ê ·≈–‰¡à “¡“√∂øóôπ§◊π Ÿà ¡√√∂π–‡¥‘¡‰¥â

3. Õ“°“√∑“ß§≈‘π‘°∑’Ë™à«¬∫àß™’È«à“‚√§‡¢â“„°≈â√–¬– ÿ¥∑â“¬ ‰¥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

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¥∑â“¬ §«√‡ªìπ·æ∑¬å‡®â“¢Õß

‰¢â∑’Ë√Ÿâ®—°§ÿâπ‡§¬®π‡ªìπ∑’Ë‰«â«“ß„®¢ÕßºŸâªÉ«¬·≈–≠“μ‘ ∂â“ºŸâªÉ«¬¡’ μ‘ —¡ª™—≠≠–¥’

§«√®–·π–π”∑—ÈßºŸâªÉ«¬·≈–≠“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“ß‡™àπ °“√„Àâ§«“¡√Ÿâ‡°’Ë¬«°—∫§«“¡‡√◊ÈÕ√—ß·≈–≈—°…≥–

∑’Ë progressive ¢Õß‚√§ °“√≈Õß„ÀâºŸâªÉ«¬·≈–≠“μ‘π÷°∑∫∑«π‡ª√’¬∫‡∑’¬∫§«“¡

‡ªìπ‰ª¢ÕßÕ“°“√‚√§¢Õßμπ‡Õßμ—Èß·μà‡√‘Ë¡‡ªìπ®π∂÷ßªí®®ÿ∫—π °“√‡¢â“°≈ÿà¡ºŸâªÉ«¬

øóôπøŸ ¡√√∂¿“æªÕ¥®–∑”„ÀâºŸâªÉ«¬‰¥â‡¢â“ —ß§¡¢Õß§π∑’Ë‚√§§≈â“¬§≈÷ß°—π ‰¥âæ∫

‡ÀÁπºŸâªÉ«¬∑’Ë¡’§«“¡Àπ—°¢Õß‚√§∑’Ë·μ°μà“ß°—π √«¡∑—Èß‰¥â‡ÀÁπºŸâªÉ«¬∫“ß√“¬„π°≈ÿà¡

∑’Ë§àÕ¬Ê ‡ ’¬™’«‘μ‰ª ‡ªìπμâπ ‚¥¬∑—Ë«‰ª«‘∏’·≈–¢—ÈπμÕπ°“√·π–π”π—Èπ‰¡à¡’°Æ‡°≥±å

∑’Ë·πàπÕπμ“¬μ—« ∑—Èßπ’È¢÷ÈπÕ¬Ÿà°—∫§«“¡∂π—¥¢Õß·æ∑¬å §«“¡‡¢â“„® °“√√—∫√Ÿâ ·≈–

°“√¬Õ¡√—∫¢ÕßºŸâªÉ«¬·≈–≠“μ‘ ‚¥¬¡’«—μ∂ÿª√– ß§å„ÀâºŸâªÉ«¬·≈–≠“μ‘‰¥â‡μ√’¬¡μ—«

‡μ√’¬¡„®‡¡◊ËÕ«—ππ—Èπ¢Õß«“√– ÿ¥∑â“¬¡“∂÷ß ‡æ◊ËÕºŸâªÉ«¬®–‰¥â‡ ’¬™’«‘μÕ¬à“ß ß∫ ÿ¢

·≈–‰¡à∑√¡“π ∑—Èßπ’È°“√·π–π”§«√°√–∑”¥â«¬§«“¡‡¢â“„®∑’Ë¥’μàÕ°—π ¿“¬„μâ§«“¡

‡À¡“– ¡∑“ß‡»√…∞“π–·≈–‰¡à¢—¥μàÕ°“√¬Õ¡√—∫∑“ß«—≤π∏√√¡·≈– —ß§¡

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

¿“§ºπ«° 7

°“√ª√–‡¡‘π·≈–μ‘¥μ“¡‚√§

„π°“√ª√–‡¡‘πº≈°“√√—°…“§«√¡’°“√ª√–‡¡‘π∑—Èß Õ“°“√ºŸâªÉ«¬ (subjective)

·≈–º≈°“√μ√«® (objective) ª√–°Õ∫¥â«¬°“√ª√–‡¡‘π∑’Ë§«√∑”∑ÿ°§√—Èß∑’Ë¡“μ√«®

·≈–°“√ª√–‡¡‘π∑’Ë§«√∑”Õ¬à“ßπâÕ¬ªï≈– 1 §√—Èß

1. °“√ª√–‡¡‘π∑’Ë§«√∑”∑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≈’Ë¬π·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

¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬„πæ√–∫√¡√“™Ÿª∂—¡¿å

1.9 Õ“°“√À√◊ÕÕ“°“√· ¥ß¢Õß‚√§√à«¡ (co-morbid diseases) ∑’Ëæ∫

∫àÕ¬ ‡™àπ ‚√§‡∫“À«“π ‚√§À≈Õ¥‡≈◊Õ¥·≈–À—«„® ‚√§°√–¥Ÿ°·≈–‰¢¢âÕ ‚√§μàÕ¡

≈Ÿ°À¡“° ·≈–‚√§´÷¡‡»√â“ ‡ªìπμâπ

2. °“√ª√–‡¡‘π∑’Ë§«√∑”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%)

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

æ≈μ√’ Õ¥‘»√ «ß…“ π“¬° ¡“§¡·≈–ª√–∏“π

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