Cough guideline 2016

2

™◊ËÕÀπ—ß ◊Õ ¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢°“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à

·Ààßª√–‡∑»‰∑¬ æ.». 2559

ISBN: 978-616-91693-1-4

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√“™«‘∑¬“≈—¬ ‚ μ »Õ π“ ‘°·æ∑¬å ·Ààßª√–‡∑»‰∑¬

¡“§¡·æ∑¬å√–∫∫∑“ß‡¥‘πÕ“À“√·Ààßª√–‡∑»‰∑¬

æ‘¡æå§√—Èß∑’Ë 1 2559

®”π«πæ‘¡æå 2,000 ‡≈à¡

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3¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ „À≠à·Ààßª√–‡∑»‰∑¬ æ.». 2559

“√∫—≠

§”π” _________________________ 4

√“¬π“¡§≥–°√√¡°“√ºŸâ∑√ß§ÿ≥«ÿ≤‘ ______________ 5

§”™’È·®ß§ÿ≥¿“æÀ≈—°∞“π·≈–πÈ”Àπ—°§”·π–π” _________ 7

∫∑π” _________________________ 10

§”®”°—¥§«“¡ ______________________ 10

“‡Àμÿ¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß _________________ 11

·π«∑“ß°“√ª√–‡¡‘πºŸâªÉ«¬ _________________ 12

æ¬“∏‘ √’√«‘∑¬“¢ÕßÕ“°“√‰Õ ________________ 18

°“√ª√–‡¡‘π§«“¡√ÿπ·√ß·≈–º≈°√–∑∫¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß _____ 19

°“√√—°…“‡∫◊ÈÕßμâπ ____________________ 20

“‡ÀμÿÕ“°“√‰Õ‡√◊ÈÕ√—ß„π¿“æ√—ß ’ªÕ¥ª°μ‘∑’Ëæ∫∫àÕ¬ ________ 21

¿“§ºπ«° 1 ·π«∑“ß°“√√—°…“ºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à ___ 37

¿“§ºπ«° 2 «‘∏’°“√ àÕßμ√«®®¡Ÿ° ·≈–μ√«®§Õ æ√âÕ¡¿“æª√–°Õ∫ _ 38

¿“§ºπ«° 3 °“√∑¥ Õ∫ ¡√√∂¿“æªÕ¥‚¥¬ ‰ª‚√‡¡μ√’¬å·≈–°“√∑¥ Õ∫§«“¡‰«À≈Õ¥≈¡ ___________ 41

¿“§ºπ«° 4 °≈‰°°“√‡°‘¥Õ“°“√‰Õ _____________ 43

¿“§ºπ«° 5 μ“√“ß· ¥ß§«“¡·μ°μà“ß√–À«à“ß‚√§eosinophilic airway ™π‘¥μà“ßÊ _________ 44

‡Õ° “√Õâ“ßÕ‘ß _____________________ 45

6

9) √».πæ.æß»°√ μ—πμ‘≈’ªî°√

10) √».æ≠.Õ√æ√√≥ ‚æ™πÿ°Ÿ≈

11) æ.Õ.æ≠.‡æ™√“ ∫ÿ≠¬ß √√§å™—¬

12) √».æ≠.ª√‘¬π—π∑å ®“√ÿ®‘π¥“

13) º».πæ.Œ‘‚√™‘ ®—π∑“¿“°ÿ≈

14) º».πæ.»‘«»—°¥‘Ï ®ÿ∑Õß

15) º».πæ.Õ¿‘™“μ‘ §≥‘μ∑√—æ¬å

16) º».πæ.¡π–æ≈ °ÿ≈ª√“≥’μ

17) º».æ≠.ª√–¿“æ√ æ√ ÿ√‘¬–»—°¥‘Ï

18) º».¥√.πæ.°√‡°’¬√μ‘ π‘∑«ß»å

19) º».¥√.æ≠.«‘¿“√—μπå ¡πÿ≠“°√

20) º».æ≠.∑‘™“ ƒ°…åæ—≤π“æ‘æ—≤πå

21) Õ.πæ.‡©≈’¬« æŸ≈»‘√‘ªí≠≠“

22) Õ.æ≠.‡ªïò¬¡≈“¿ · ß “¬—≥Àå

23) Õ.¥√.∑‘æ“æ√ æß…å‡¡…“

24) Õ.πæ.∏’√–»—°¥‘Ï ·°â«Õ¡μ«ß»å

25) Õ.æ≠.°—≈¬“ ªí≠®æ√æ≈

26) Õ.æ≠.¡π« ’ ª“®’π∫Ÿ√«√√≥å

27) Õ.πæ.∏π“ Õ—ß ÿ«√—ß…’

28) Õ.πæ.æ≈æß»å ™¬“ß»ÿ

29) Õ.πæ. —πμ‘ ‘≈—¬√—μπå

30) Õ.æ≠.«√«√√≥ »‘√‘™π–

31) º».æ≠.¡≥±‘√“ ¡≥’√—μπ–æ√

32) º».πæ. ¡∫Ÿ√≥å ®—π∑√å °ÿ≈æ√


§”™’È·®ß§ÿ≥¿“æÀ≈—°∞“π·≈–πÈ”Àπ—°§”·π–π”

§ÿ≥¿“æÀ≈—°∞“π (Quality of evidence)

§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1

À¡“¬∂÷ßÀ≈—°∞“π∑’Ë‰¥â®“°

1.1 °“√∑∫∑«π·∫∫¡’√–∫∫ (systematic review) ®“°°“√»÷°…“·∫∫

°≈ÿà¡ ÿà¡μ—«Õ¬à“ß §«∫§ÿ¡ (randomized controlled clinical trials)

À√◊Õ

1.2 °“√»÷°…“·∫∫°≈ÿà¡ ÿà¡μ—«Õ¬à“ß §«∫§ÿ¡∑’Ë¡’§ÿ≥¿“æ¥’‡¬’Ë¬¡Õ¬à“ßπâÕ¬

1 ©∫—∫

§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 2

À¡“¬∂÷ßÀ≈—°∞“π∑’Ë‰¥â®“°

2.1 °“√∑∫∑«π·∫∫¡’√–∫∫¢Õß°“√»÷°…“§«∫§ÿ¡·μà‰¡à ‰¥â ÿà¡μ—«Õ¬à“ß

(non-randomized controlled clinical trials) À√◊Õ

2.2 °“√»÷°…“§«∫§ÿ¡·μà‰¡à‰¥â ÿà¡μ—«Õ¬à“ß∑’Ë¡’§ÿ≥¿“æ¥’‡¬’Ë¬¡ À√◊Õ

2.3 À≈—°∞“π®“°√“¬ß“π°“√»÷°…“∑’Ë„™â√Ÿª·∫∫«‘®—¬Õ◊ËπÊ (cohort, case-

control) ∑’Ë‰¥â√—∫°“√ÕÕ°·∫∫«‘®—¬‡ªìπÕ¬à“ß¥’ ÷Ëß¡“®“° ∂“∫—πÀ√◊Õ

°≈ÿà¡«‘®—¬¡“°°«à“Àπ÷Ëß·Ààß/°≈ÿà¡

2.4 À≈—°∞“π®“°æÀÿ°“≈“πÿ°√¡ (multiple time series)

2.5 º≈°“√«‘®—¬æ∫ª√–‚¬™πåÀ√◊Õ‚∑…®“°°“√ªØ‘∫—μ‘∑’Ë‡¥àπ™—¥¡“°

8

§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3

À¡“¬∂÷ßÀ≈—°∞“π∑’Ë‰¥â®“°

3.1 °“√»÷°…“‡™‘ßæ√√≥π“ (descriptive studies) À√◊Õ

3.2 °“√»÷°…“§«∫§ÿ¡∑’Ë¡’§ÿ≥¿“ææÕ„™â

§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 4

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

Õ¬à“ß¡’√–∫∫

πÈ”Àπ—°§”·π–π” (Strength of recommendation)

πÈ”Àπ—°§”·π–π” ++

À¡“¬∂÷ß§«“¡¡—Ëπ„®¢Õß§”·π–π”„Àâ∑”Õ¬Ÿà„π√–¥—∫ Ÿß ‡æ√“–¡“μ√°“√

¥—ß°≈à“«¡’ª√–‚¬™πåÕ¬à“ß¬‘ËßμàÕºŸâªÉ«¬ ·≈–§ÿâ¡§à“ (cost effective) ç§«√∑”é

πÈ”Àπ—°§”·π–π” +

À¡“¬∂÷ß§«“¡¡—Ëπ„®¢Õß§”·π–π”„Àâ∑”Õ¬Ÿà„π√–¥—∫ª“π°≈“ß ‡π◊ËÕß®“°

¡“μ√°“√¥—ß°≈à“«Õ“®¡’ª√–‚¬™πåμàÕºŸâªÉ«¬ ·≈–Õ“®§ÿâ¡§à“„π¿“«–®”‡æ“– çπà“∑”é


πÈ”Àπ—°§”·π–π” +/-

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◊ËπÊ çÕ“®∑”À√◊Õ‰¡à∑”é

πÈ”Àπ—°§”·π–π” -

À¡“¬∂÷ß§«“¡¡—Ëπ„®Àâ“¡∑”Õ¬Ÿà„π√–¥—∫ª“π°≈“ß‡π◊ËÕß®“°¡“μ√°“√¥—ß°≈à“«

Õ“®‰¡à¡’ª√–‚¬™πåμàÕºŸâªÉ«¬·≈–‰¡à§ÿâ¡§à“ çÀ“°‰¡à®”‡ªìπ‰¡àπà“∑”é

πÈ”Àπ—°§”·π–π” - -

À¡“¬∂÷ß§«“¡¡—Ëπ„®Àâ“¡∑”Õ¬Ÿà„π√–¥—∫ Ÿß ‡æ√“–¡“μ√°“√¥—ß°≈à“«Õ“®

‡°‘¥‚∑…À√◊Õ°àÕ„Àâ‡°‘¥Õ—πμ√“¬μàÕºŸâªÉ«¬ ç‰¡à§«√∑”é

10

∫∑π”

Õ“°“√‰Õ‡√◊ÈÕ√—ß‡ªìπÕ“°“√∑’Ëæ∫∫àÕ¬„π‡«™ªØ‘∫—μ‘·≈–Õ“®°àÕ„Àâ‡°‘¥ªí≠À“

μàÕºŸâªÉ«¬∑—Èß∑“ß°“¬ (physical) ∑“ß®‘μ„® (psychological) ·≈–∑“ß —ß§¡ (so-

cial) ¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢°“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à©∫—∫π’È‡ªìπ

¢âÕ·π–π” ”À√—∫·æ∑¬å‡«™ªØ‘∫—μ‘∑—Ë«‰ª„π°“√«‘π‘®©—¬·≈–°“√√—°…“‡∫◊ÈÕßμâπ°àÕπ

àßæ∫ºŸâ‡™’Ë¬«™“≠ Õπ÷Ëß ¢âÕ·π–π”μà“ßÊ „π·π«∑“ß©∫—∫π’È ‰¡à„™à¢âÕ∫—ß§—∫¢Õß°“√

ªØ‘∫—μ‘ ·≈–‰¡à¡’º≈∫—ß§—∫∑“ß°ÆÀ¡“¬ ºŸâ„™â “¡“√∂ªØ‘∫—μ‘·μ°μà“ß‰ª®“°¢âÕ·π–π”

„π°√≥’∑’Ë¡’¢âÕ®”°—¥¢Õß ∂“π∫√‘°“√·≈–∑√—æ¬“°√ À√◊Õ¡’‡Àμÿº≈Õ◊ËπÊ ‚¥¬„™â

«‘®“√≥≠“≥´÷Ëß‡ªìπ∑’Ë¬Õ¡√—∫·≈–Õ¬Ÿà∫πæ◊Èπ∞“πÀ≈—°«‘™“°“√ ·≈–®√√¬“∫√√≥

1) §”®”°—¥§«“¡

Õ“°“√‰Õ‡©’¬∫æ≈—π À¡“¬∂÷ßÕ“°“√‰Õ∑’Ë¡’√–¬–‡«≈“πâÕ¬°«à“ 3 —ª¥“Àå

Õ“°“√‰Õ°÷Ëß‡©’¬∫æ≈—π À¡“¬∂÷ßÕ“°“√‰Õ∑’Ë¡’√–¬–‡«≈“√–À«à“ß 3 ∂÷ß 8

—ª¥“Àå

Õ“°“√‰Õ‡√◊ÈÕ√—ß À¡“¬∂÷ßÕ“°“√‰Õ∑’Ë¡’√–¬–‡«≈“‡°‘π 8 —ª¥“Àå

·μà„π‡«™ªØ‘∫—μ‘√–¬–‡«≈“ 8 —ª¥“ÀåÕ“®π“π‡°‘π‰ª ºŸâªÉ«¬Õ“®¡“æ∫

·æ∑¬å‡√Á«°«à“ 8 —ª¥“Àå‰¥â (1-5) „π¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢°“√√—°…“ºŸâªÉ«¬

‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à©∫—∫π’È ®–°≈à“«∂÷ß “‡ÀμÿÕ“°“√‰Õ∑’Ë¡’√–¬–‡«≈“‡°‘π 3 —ª¥“Àå

¢÷Èπ‰ª „π∑“ßªØ‘∫—μ‘À“°ºŸâªÉ«¬¡’Õ“°“√‰Õ∑’Ë¡’√–¬–‡«≈“μ—Èß·μà 3 —ª¥“Àå¢÷Èπ‰ª‚¥¬∑’Ë

‰¡à¡’°“√μ‘¥‡™◊ÈÕ∑“ß‡¥‘πÀ“¬„® à«π∫ππ”¡“°àÕπ ·π–π”«à“§«√ª√–‡¡‘πÀ“ “‡Àμÿ

¢ÕßÕ“°“√‰Õμ“¡¢âÕ·π–π”©∫—∫π’È


2) “‡Àμÿ¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß

§«√·¬° “‡Àμÿ∑’Ë√ÿπ·√ßÕÕ°‰ª°àÕπ ‡™àπ ¡–‡√ÁßªÕ¥ «—≥‚√§ªÕ¥ ªÕ¥Õ—°‡ ∫

‡√◊ÈÕ√—ß ‚¥¬Õ“»—¬ª√–«—μ‘ μ√«®√à“ß°“¬ ·≈–¿“æ√—ß ’∑√«ßÕ° (chest x-ray) ‚¥¬

‡πâπÀ“Õ“°“√‡μ◊Õπ (alarming symptoms) ‰¥â·°à ‰Õ‡ªìπ‡≈◊Õ¥ ‡ ’¬ß·À∫ ‰¢â

πÈ”Àπ—°≈¥ Õ“°“√‡Àπ◊ËÕ¬‚¥¬‡©æ“–¢≥–æ—°À√◊Õ‡«≈“°≈“ß§◊π ª√–«—μ‘°“√‡ªìπ

ªÕ¥Õ—°‡ ∫∫àÕ¬Ê °≈◊π≈”∫“° °≈◊π‡®Á∫ ·≈– ”≈—°

„π‡∫◊ÈÕßμâπÀ“°¿“æ√—ß ’∑√«ßÕ°ª°μ‘ „πºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß “‡Àμÿ∑’Ë

æ∫∫àÕ¬ ‰¥â·°à

1) °≈ÿà¡‚√§À◊¥

1.1 Asthma

1.2 Cough variant asthma

1.3 Non-asthmatic eosinophilic bronchitis

2) Upper Airway Cough Syndrome (UACS)

2.1 Rhinitis

2.2 Sinusitis

2.3 Posterior nasal drip

3) Gastro-esophageal reflux disease (GERD)/laryngopharyngeal

reflux (LPR)

4) ¬“ angiotensin converting enzyme inhibitor (ACE-I)

5) °“√ Ÿ∫∫ÿÀ√’Ë

6) ‚√§¢ÕßÀ≈Õ¥≈¡ ‰¥â·°à À≈Õ¥≈¡Õ—°‡ ∫‡√◊ÈÕ√—ß (chronic bronchitis)

12

„π°≈ÿà¡ºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ°÷Ëß‡©’¬∫æ≈—π °≈à“«§◊Õμ—Èß·μà 3 —ª¥“Àå¢÷Èπ‰ª ·μà

‰¡à‡°‘π 8 —ª¥“Àå “‡Àμÿ∑’Ëæ∫∫àÕ¬Õ’°Õ¬à“ßÀπ÷Ëß‰¥â·°à Õ“°“√‰ÕÀ≈—ß®“°°“√μ‘¥‡™◊ÈÕ

∑“ß‡¥‘πÀ“¬„® (post-infectious cough)

Õ—μ√“°“√‡°‘¥Õ“°“√‰Õ‡√◊ÈÕ√—ß®“° “‡Àμÿμà“ßÊ ¢â“ßμâπ·μ°μà“ß°—π√–À«à“ß

ª√–‡∑»∑“ßμ–«—πμ°·≈–ª√–‡∑»∑“ßμ–«—πÕÕ° ‚¥¬ “‡Àμÿ®“° GERD ¡’

√“¬ß“πæ∫∫àÕ¬„πª√–‡∑»∑“ßμ–«—πμ°(2, 3) ·μàæ∫πâÕ¬°«à“¡“°„πª√–‡∑»∑“ß

μ–«—πÕÕ°(1, 5, 6) ¢âÕ¡Ÿ≈¢Õßª√–‡∑»‰∑¬„πªï æ.». 2540 æ∫«à“ “‡ÀμÿÕ“°“√‰Õ

‡√◊ÈÕ√—ß‚¥¬∑’Ë¿“æ√—ß ’∑√«ßÕ°ª°μ‘ ‰¥â·°à postnasal drip ·≈– post-infectious

cough æ∫ª√–¡“≥√âÕ¬≈– 45 asthma æ∫√âÕ¬≈– 26 postnasal drip √à«¡°—∫

asthma æ∫√âÕ¬≈– 13 ¬“ ACE-I æ∫√âÕ¬≈– 4 bronchiectasis æ∫√âÕ¬≈– 4

idiopathic æ∫√âÕ¬≈– 3 ·≈–æ∫ GERD ‡æ’¬ß√âÕ¬≈– 1.6(6)

„πª√–‡∑»·∂∫‡Õ‡™’¬ æ∫«à“¡’°≈ÿà¡Õ“°“√‰Õ‡√◊ÈÕ√—ß™π‘¥¡’‡ ¡À–∑’Ë„Àâ

§”®”°—¥§«“¡·μ°μà“ß®“°„πª√–‡∑»∑“ßμ–«—πμ° ‰¥â·°à sinobronchial syn-

drome(1)

3) ·π«∑“ß°“√ª√–‡¡‘πºŸâªÉ«¬

3.1 °“√ —°ª√–«—μ‘

3.1.1 ≈—°…≥–Õ“°“√‰Õ (characteristics) §«√ —°ª√–«—μ‘μà“ßÊ ¥—ß

μàÕ‰ªπ’È

1) √–¬–‡«≈“∑’Ë¡’Õ“°“√‰Õ·≈–°“√¥”‡π‘π¢Õß‚√§

2) Õ“°“√‰Õ‡ªìπ·∫∫¡’‡ ¡À– (productive) À√◊Õ‰¡à¡’‡ ¡À–

(nonproductive)


3) Õ“°“√‰Õ¡’‡ ¡À–‡√◊ÈÕ√—ß∑’Ë‡ªìπ¡“π“πÀ√◊Õ‡ªìπÊ À“¬Ê ∫“ß§√—Èß

¡’‡ ¡À–‡À≈◊Õß‡¢’¬«À√◊Õªπ‡≈◊Õ¥ æ∫‰¥â„πÀ≈Õ¥≈¡‚ªÉßæÕß

(bronchiectasis)

4) Õ“°“√‰Õ¡’°“√‡ª≈’Ë¬π·ª≈ßμ“¡™à«ß‡«≈“√–À«à“ß«—π (diurnal

variation)

5) ªí®®—¬∑’Ë°√–μÿâπÕ“°“√‰Õ ‡™àπ Õÿ≥À¿Ÿ¡‘ °≈‘Ëπ ‡ª√¬å À√◊Õ aero-

sol °“√ÕÕ°°”≈—ß°“¬ À√◊ÕÀ≈—ß√—∫ª√–∑“πÕ“À“√¡◊ÈÕ„À≠à

6) Õ“°“√‰Õ¡’§«“¡ —¡æ—π∏å°—∫∑à“∑“ß ‡™àπ ·¬à≈ß‡¡◊ËÕ°â¡μ—«À√◊Õ

πÕπ√“∫ Õ“°“√‰ÕÀ≈—ß°‘πÕ“À“√ ¡—°‡°‘¥„π™à«ß 10 π“∑’À≈—ß

°‘πÕ“À“√ À√◊ÕÕ“°“√‰Õ¡’§«“¡ —¡æ—π∏å°—∫°“√æŸ¥ °“√À—«‡√“–

°“√√âÕß‡æ≈ß ¡—°æ∫„π gastroesophageal reflux ‡π◊ËÕß®“°

¡’°“√≈¥≈ß¢Õß lower esophageal sphincter tone Õ“°“√

· ∫√âÕπ¬Õ¥Õ° (heartburn) ‡√Õ‡ª√’È¬« (regurgitation) æ∫

‰¥â·μà‰¡à∫àÕ¬„πºŸâªÉ«¬∑’Ë¡’Õ“°“√°√¥‰À≈¬âÕπ∑’Ë¡’Õ“°“√πÕ°

À≈Õ¥Õ“À“√ (extra-esophageal GERD)

7) Õ“°“√°√–·Õ¡ (throat clearing) æ∫„π postnasal drip

syndrome À√◊Õ‚æ√ß‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß

8) Õ“°“√‡μ◊Õπ (alarming symptoms) ¢Õß‚√§∑’ËÕ“®‡ªìπ “‡Àμÿ

√ÿπ·√ß¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß ‰¥â·°à ‰Õ‡ªìπ‡≈◊Õ¥ ‡ ’¬ß·À∫ ‰¢â

πÈ”Àπ—°≈¥ Õ“°“√‡Àπ◊ËÕ¬ ‚¥¬‡©æ“–¢≥–æ—°À√◊Õ‡«≈“°≈“ß§◊π

‡®Á∫Àπâ“Õ°‡«≈“À“¬„®‡¢â“≈÷°Ê ·≈–ª√–«—μ‘°“√‡ªìπªÕ¥Õ—°‡ ∫

∫àÕ¬Ê

3.1.2 ¬“∑’Ë„™âª√–®” ‰¥â·°à angiotensin converting enzyme inhibitor

(ACE-I)

14

3.1.3 ª√–«—μ‘‚√§ª√–®”μ—« ‡™àπ ‚√§¿Ÿ¡‘·æâ (atopic diseases) ‰¥â·°à ¿Ÿ¡‘·æâ

®¡Ÿ° ¿Ÿ¡‘·æâº‘«Àπ—ß ·≈–ª√–«—μ‘‚√§ autoimmune diseases

3.1.4 Õ“™’æ ß“πÕ¥‘‡√° —μ«å‡≈’È¬ß

Õ“™’æ∑’Ë¡’§«“¡‡ ’Ë¬ß‰¥â·°à §π∑”¢π¡ªíß ™à“ß∑”º¡ ∑”Õÿμ “À°√√¡

‡°’Ë¬«°—∫ºâ“ ‡°…μ√°√√¡ ·≈–‡≈’È¬ß —μ«å

3.1.5 ª√–«—μ‘°“√ Ÿ∫∫ÿÀ√’Ë

§«√´—°ª√–«—μ‘∑—Èß active ·≈– passive smoker À“°¡’ª√–«—μ‘°“√

Ÿ∫∫ÿÀ√’Ë „Àâª√–‡¡‘πμàÕ¥—ßπ’È „πºŸâªÉ«¬∑’Ë‡ªìπ active smoker ∂“¡ª√–«—μ‘®”π«π

·≈–√–¬–‡«≈“∑’Ë Ÿ∫ À“°¡’°“√‡ª≈’Ë¬π·ª≈ß§«“¡∂’Ë¢Õß°“√‰ÕÀ√◊Õ¡’Õ“°“√‰Õ‡ªìπ

‡≈◊Õ¥ §«√μ√«®§âπÀ“ “‡ÀμÿμàÕ °√≥’À¬ÿ¥ Ÿ∫∫ÿÀ√’Ë·≈â« ∫“ß§√—ÈßÕ“°“√‰ÕÕ“®¬—ß

‰¡àÀ¬ÿ¥‡æ√“–¡’°“√‡ª≈’Ë¬π·ª≈ß¢Õß cough reflex ‰ª·≈â« ·μà¡—°®–‰Õ≈¥≈ß

3.1.6 Õ“°“√‰Õ‡√‘Ë¡μâπ®“°Õ“°“√‡ªìπÀ«—¥À√◊Õ°“√μ‘¥‡™◊ÈÕ∑“ß‡¥‘πÀ“¬„®

à«π∫π (upper respiratory tract infection) π”¡“°àÕπÀ√◊Õ‰¡à ‚¥¬∂“¡Õ“°“√

‡√‘Ë¡¢Õß°“√‰Õ«à“¡’‡®Á∫§Õ À«—¥ πÈ”¡Ÿ°À√◊Õ‰¡à à«π„À≠àÀ“°‡ªìπ®“°°“√μ‘¥‡™◊ÈÕ

∑“ß‡¥‘πÀ“¬„® à«π∫πÕ“°“√¡—°¥’¢÷Èπ‡√◊ËÕ¬Ê ¿“¬„π√–¬–‡«≈“‰¡à‡°‘π 8 —ª¥“Àå

‚¥¬‡©æ“–Õ“°“√‰ÕμÕπ°≈“ß§◊π®–§àÕ¬Ê ≈¥≈ß°àÕπ ÷ËßºŸâªÉ«¬ à«π¡“°∂â“¬—ß‰¡à

À“¬ π‘∑ ·≈–∫“ß√“¬¡’Õ“°“√√ÿπ·√ß¡—°®–°—ß«≈·≈–¡“æ∫·æ∑¬å

3.1.7 ª√–«—μ‘ —¡º— °—∫‡¥Á°À√◊ÕºŸâªÉ«¬∑’Ë‡ªìπ‰Õ°√π

§«“¡·μ°μà“ß¢Õß‰Õ°√π°—∫°“√μ‘¥‡™◊ÈÕ∑“ß‡¥‘πÀ“¬„® à«π∫π®“°

‡™◊ÈÕ‰«√— (viral infection) §◊Õ ‰Õ°√π®–¡’§«“¡√ÿπ·√ß¢Õß°“√‰Õ¡“°¢÷Èπ ‰Õ¡“°

®πÕ“‡®’¬π ‚¥¬‰¡à¡’∑’∑à“«à“®–¥’¢÷Èπ ®π°«à“®– 2-3 —ª¥“Àå ·≈–¡—°‰Õ‰¥âπ“π∂÷ß

3 ‡¥◊Õπ „π§π∑’Ë‡ªìπ√ÿπ·√ßÕ“®π“π∂÷ß 7 ‡¥◊Õπ


3.1.8 „πºŸâ∑’Ë¡’ªí≠À“°“√°≈◊π ¡’‚√§∑“ß√–∫∫ª√– “∑ ·≈–ºŸâ ŸßÕ“¬ÿ Õ“®¡’

ª√–«—μ‘‰Õ·≈– ”≈—°™à«ß√–À«à“ß¥◊Ë¡πÈ”·≈–°‘πÕ“À“√ π”‰ª Ÿà¿“«– ”≈—° (chronic

silent aspiration) ‰¥â

3.2 °“√μ√«®√à“ß°“¬

3.2.1 °“√μ√«® ÀŸ §Õ ®¡Ÿ° ‚¥¬„™â ‰ø∑’Ë «à“ß‡æ’¬ßæÕ àÕß∑’Ë™àÕß®¡Ÿ°

·≈–§Õ ‡æ◊ËÕÀ“«à“¡’°“√Õ—°‡ ∫¢Õß‚æ√ß®¡Ÿ° à«π inferior turbinate √‘¥ ’¥«ß®¡Ÿ°

(nasal polyp) ¡’‡ ¡À–À≈—ß§Õ (postnasal drip ∑’Ë posterior pharynx) ≈—°…≥–

cobble stone ∫√‘‡«≥ posterior pharynx À√◊ÕμàÕ¡∑Õπ´‘≈¡’¢π“¥„À≠àÀ√◊Õ‰¡à

3.2.2 °“√μ√«®√à“ß°“¬Õ◊ËπÊ ‰¥â·°à √‘¡Ωïª“°·μ°Õ—°‡ ∫ (cheilitis)

Õ“®¡’°“√·¥ßÕ—°‡ ∫√Õ∫√‘¡Ωïª“°‰¥â ¢Õ∫μ“≈à“ß§≈È”¥” (allergic shiner) ‡°‘¥®“°

‡¬◊ËÕ®¡Ÿ°∑’Ë∫«¡∑”„Àâ¡’ chronic congestion ¢Õß lower eyelid venous plexus

À√◊Õº◊Ëπ·¥ß§—π∑’ËÀ—«μ“À√◊Õ‡ª≈◊Õ°μ“ Õ“°“√‡À≈à“π’È∫àß∫Õ°«à“ºŸâªÉ«¬¡’‡¬◊ËÕ®¡Ÿ°∫«¡

Õ—°‡ ∫‡√◊ÈÕ√—ß ´÷Ëß¡“°°«à“√âÕ¬≈– 80 ‡ªìπ‡¬◊ËÕ∫ÿ‚æ√ß®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ

3.2.3 °“√μ√«®ªÕ¥ ‡æ◊ËÕμ√«®À“‡ ’¬ßªÕ¥∑’Ëº‘¥ª°μ‘ ‰¥â·°à wheeze,

expiratory rhonchi ∫àß™’È∂÷ß¿“«–À≈Õ¥≈¡μ’∫ ·≈– coarse crepitation ∫àß™’È

∂÷ß°“√¡’‡ ¡À–„πÀ≈Õ¥≈¡ ¡—°æ∫„π bronchiectasis

3.3 °“√ ◊∫§âπÀ“ “‡Àμÿ (Investigations)

3.3.1 √–¥—∫ª∞¡¿Ÿ¡‘ (Primary care) ‰¥â·°à

3.3.1.1 ¿“æ√—ß ’∑√«ßÕ° (Chest X-ray) ·π–π”„Àâ∑”(1-5, 7) ‡æ◊ËÕ

§âπÀ“ “‡Àμÿ¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß ‡™àπ «—≥‚√§ªÕ¥ ¡–‡√ÁßªÕ¥ ∂â“æ∫§«“¡

º‘¥ª°μ‘„Àâ ◊∫§âπ‰ªμ“¡§«“¡º‘¥ª°μ‘π—Èπ (Level of evidence 1, Grade of

recommendation ++)

16

3.3.1.2 ¿“æ√—ß ’‰´π— (plain x-ray of paranasal sinus) §«√∑”

„π°√≥’∑’Ë ß —¬¿“«–‰´π— Õ—°‡ ∫ ·≈–„πºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß∑’Ë¡’‡ ¡À–¡“°

·μàμ√«®‚æ√ß®¡Ÿ°·≈â«‰¡àæ∫§«“¡º‘¥ª°μ‘(8, 9) ·π–π”„Àâ àß∂à“¬¿“æ√—ß ’¢Õß‰´π—

‡æ◊ËÕ™à«¬«‘π‘®©—¬‚√§ (Level of evidence 4, Grade of recommendation +)

„π°√≥’∑’Ëæ∫ maxillary sinus ¢ÿàπ∑÷∫ À√◊Õæ∫¡’√–¥—∫¢Õß‡À≈« ∫àß™’È«à“¡’‚Õ°“

‡ªìπ‚√§‰´π— Õ—°‡ ∫®“°‡™◊ÈÕ·∫§∑’‡√’¬ Ÿß¡“°(10)

3.3.1.3 °“√μ√«® ¡√√∂¿“æªÕ¥

1) ·π–π”„Àâ∑” ‰ª‚√‡¡μ√’¬å (spirometry) „π√“¬∑’Ë ß —¬

‚√§À≈Õ¥≈¡(2) ‡æ◊ËÕ§âπÀ“¿“«–À≈Õ¥≈¡μ’∫ (airway obstruction)(3) (Level of

evidence 2, Grade of recommendation ++) [√“¬≈–‡Õ’¬¥„π¿“§ºπ«°] „π

°√≥’∑’ËÕ¬Ÿà„π ∂“π∑’Ë∑’Ë∑”°“√μ√«®‰¡à‰¥â ·π–π”„Àâ¡’°“√ àßμàÕºŸâ‡™’Ë¬«™“≠

2) °“√«—¥§à“ peak expiratory flow rate (PEFR) °àÕπ·≈–

¿“¬À≈—ß°“√„Àâ Ÿ¥¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï —Èπ‡æ’¬ß§√—Èß‡¥’¬« ‰¡à·π–π”

„Àâ∑”‡π◊ËÕß®“°‰¡à‡∑’Ë¬ßμ√ß‡¡◊ËÕ‡∑’¬∫°—∫§à“ forced expiratory volume „π‡«≈“

1 «‘π“∑’ (FEV1) „π°“√«‘π‘®©—¬¿“«–À≈Õ¥≈¡μ’∫(11) (Level of evidence 2, Grade

of recommendation +/-) ·μà°“√„™â serial PEFR „π°√≥’∑’Ë ß —¬‚√§À◊¥

¬—ß‰¡à¡’°“√»÷°…“‡æ’¬ßæÕ∑’Ë®–·π–π”„Àâ∑”„πºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß (Level of

evidence 4, Grade of recommendation +/-)

3.3.2 √–¥—∫∑ÿμ‘¬¿Ÿ¡‘ (Secondary care) ·π–π”„Àâ∑”„π°√≥’∑’Ë¡’ºŸâ‡™’Ë¬«™“≠

‰¥â·°à

3.3.2.1 Indirect laryngoscopy ‡æ◊ËÕ§âπÀ“À≈—°∞“π¢Õß laryngopha-

ryngeal reflux ·π–π”„Àâ∑”„π°√≥’∑’Ë¡’ºŸâ‡™’Ë¬«™“≠∑“ßÀŸ §Õ ®¡Ÿ° (ENT)(3) (Level

of evidence 1, Grade of recommendation ++)


3.3.2.2 Bronchoprovocative test ‡ªìπ°“√∑¥ Õ∫§«“¡‰«À≈Õ¥≈¡

(airway hyperresponsiveness, AHR) [√“¬≈–‡Õ’¬¥„π¿“§ºπ«°] ·π–π”„Àâ

∑”„π°√≥’∑’Ëº≈°“√μ√«® ‰ª‚√‡¡μ√’¬åª°μ‘·≈– ß —¬¿“«–À≈Õ¥≈¡‰«‡°‘π ‡π◊ËÕß®“°

º≈ ‰ª‚√‡¡μ√’¬å∑’Ëª°μ‘¬—ß‰¡à “¡“√∂μ—¥ “‡ÀμÿÕ“°“√‰Õ∑’Ë‡°‘¥®“° asthma ‰¥â(2, 12)

°“√∑¥ Õ∫§«“¡‰«À≈Õ¥≈¡∑”‰¥â‚¥¬«‘∏’ methacholine challenge test À“°

º≈°“√μ√«® methacholine challenge test ‡ªìπº≈≈∫ “¡“√∂μ—¥°“√«‘π‘®©—¬

‚√§À◊¥ÕÕ°‰ª‰¥â∂â“ºŸâªÉ«¬‰¡à‡§¬‰¥â√—∫¬“ Ÿ¥§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å¡“°àÕπ(13) (Level of

evidence 2, Grade of recommendation +)

3.3.2.3 ‡Õ°´‡√¬å§Õ¡æ‘«‡μÕ√åªÕ¥ (High-resolution computed

tomography, HRCT) „π°√≥’∑’Ë ß —¬‚√§À≈Õ¥≈¡‚ªÉßæÕß (bronchiectasis) ‚√§

interstitial lung diseases À√◊ÕÀ≈Õ¥≈¡¢π“¥‡≈Á°Õ—°‡ ∫ (bronchiolitis) ∑’Ëº≈

°“√μ√«®¿“æ√—ß ’∑√«ßÕ°ª°μ‘(3) (Level of evidence 3, Grade of recommen-

dation +)

3.3.2.4 ‡Õ°´‡√¬å§Õ¡æ‘«‡μÕ√å‰´π— (Computerized tomography

of paranasal sinus) ‰¡à·π–π”„Àâ àßμ√«®‡Õ°´‡√¬å§Õ¡æ‘«‡μÕ√å‰´π— „π°“√

μ√«®‡∫◊ÈÕßμâπ(9) (Level of evidence 2, Grade of recommendation -) ·π–π”

„Àâ∑”‡©æ“–„π√“¬∑’Ë®–‰¥â∑”°“√ºà“μ—¥‰´π— À√◊Õ¡’¿“«–·∑√° âÕπ™π‘¥√â“¬·√ß

‡™àπ¿“«–·∑√° âÕπ∑“ßμ“·≈– ¡Õß ·≈–„πºŸâ∑’Ë ‰¡àμÕ∫ πÕßμàÕ°“√√—°…“¥â«¬

¬“(4) (Level of evidence 3, Grade of recommendation ++)

3.3.2.5 °“√μ√«®‡æ◊ËÕ ◊∫§âπ¿“«–°√¥‰À≈¬âÕπ ¡’°“√μ√«®‰¥âÀ≈“¬«‘∏’ ‰¥â·°à

1) 24-hour esophageal pH monitoring2) Esophageal manometry/impedance testing

(Level of evidence 2, Grade of recommendation +/-)

18

3.3.2.6 °“√μ√«®π—∫®”π«πÕ‘‚Õ ‘‚πøî≈„π‡ ¡À– (sputum eosi-

nophil) ∑”‰¥â¬“°„π∑“ßªØ‘∫—μ‘ ª√‘¡“≥Õ‘‚Õ ‘‚πøî≈„π‡ ¡À–¡’§«“¡ —¡æ—π∏å°—∫

√–¥—∫‰πμ√‘°ÕÕ°‰´¥å„π≈¡À“¬„®ÕÕ° (fractional exhaled nitric oxide, FeNO)

°“√«—¥√–¥—∫ FeNO ‡æ◊ËÕ„™â·¬° “‡ÀμÿÕ“°“√‰Õ®“° eosinophilic inflammation

√–¥—∫ FeNO ¡’§à“ Ÿß¢÷Èπ„πÕ“°“√‰Õ∑’Ë‡°‘¥®“° asthma, cough variant asthma

·≈– non-asthmatic eosinophilic bronchitis(14) ·≈–„™â∑”π“¬°“√μÕ∫ πÕß

μàÕ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥„πºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß(15) ·π–π”„Àâ∑”À“°∑”‰¥â„π

°√≥’∑’Ë≈Õß„Àâ°“√√—°…“¥â«¬¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥·≈â«¬—ß‰¡à‰¥âº≈ ‡æ◊ËÕ™à«¬

„π°“√ª√—∫¬“μàÕ‰ª (Level of evidence 2, Grade of recommendation +)

3.3.2.7 √–¥—∫ specific IgE „π‡≈◊Õ¥ À√◊Õ skin prick test μàÕ

aeroallergen ¡’ª√–‚¬™πå„π°“√¬◊π¬—π°“√«‘π‘®©—¬¿“«–‚æ√ß®¡Ÿ°Õ—°‡ ∫®“°

¿Ÿ¡‘·æâ(4) (Level of evidence 2, Grade of recommendation ++)

4) æ¬“∏‘ √’√«‘∑¬“¢ÕßÕ“°“√‰Õ

‡°‘¥®“°‡ âπª√– “∑‡«°— ∂Ÿ°°√–μÿâπºà“πμ—«√—∫ —≠≠“≥∑’Ë‡≈’È¬ß„πÕ«—¬«–

μà“ßÊ ´÷Ëß„π√–∫∫°“√À“¬„®ª√–°Õ∫¥â«¬

1. C-fibers (nociceptor cough) Õ¬Ÿà∫√‘‡«≥ mucosa ¢ÕßÀ≈Õ¥≈¡

∂Ÿ°°√–μÿâπ‚¥¬ “√§—¥À≈—Ëß®“°‡´≈≈åÕ—°‡ ∫ (inflammatory mediators) À√◊Õ “√

∑’Ë°àÕ„Àâ‡°‘¥°“√√–§“¬‡§◊Õß (irritants)

2. Cough receptors (mechanoreceptor cough) Õ¬Ÿà„μâμàÕ epi-

thelium ¢Õß larynx, trachea ·≈– mainstem bronchus ∂Ÿ°°√–μÿâπ‚¥¬°“√

—¡º— (punctuate mechanical) ·≈–‰¡àμÕ∫ πÕßμàÕ “√‡§¡’¬°‡«âπ “√∑’Ë‡ªìπ°√¥


Õ“°“√‰Õ¬—ß‡°‘¥®“°°“√°√–μÿâπ∑’ËÕ«—¬«–Õ◊Ëπ∑’Ë‡≈’È¬ß¥â«¬‡ âπª√– “∑‡«°—

‰¥â·°à À≈Õ¥Õ“À“√ °√–‡æ“–Õ“À“√ À—«„® ·≈–ÀŸ™—ÈππÕ° ‡ªìπμâπ —≠≠“≥®“°

μ—«√—∫®– àßºà“π‰ª¬—ß nucleus tractus solitarius (nTS) „π brainstem ∑”„Àâ

‡°‘¥ çreflex coughé ‚¥¬°“√ àß —≠≠“≥‰ª¬—ß°≈â“¡‡π◊ÈÕ∑’Ë‡°’Ë¬«¢âÕß°—∫°“√‰Õ

πÕ°®“°π’ÈÕ“°“√‰Õ¬—ß “¡“√∂§«∫§ÿ¡‰¥â‚¥¬ ¡Õß à«π cortex çurge to coughé

À√◊Õ çbehavioral coughé ‚¥¬¡’§«“¡√Ÿâ ÷°·≈–Õ“√¡≥å‡¢â“¡“‡°’Ë¬«¢âÕß ‚¥¬

‡©æ“–°≈ÿà¡Õ“°“√‰Õ‡√◊ÈÕ√—ß ‡™àπ √Ÿâ ÷°§—π„π§ÕμâÕß°“√‰Õ‡Õ“‡ ¡À–ÕÕ°¡“ Õ“°“√

‰Õ‡√◊ÈÕ√—ß à«πÀπ÷Ëß‡ªìπº≈®“°°“√∑’Ë cough reflex ¡’§«“¡‰«‡°‘πμàÕμ—«°√–μÿâπ

·¡âμ—«°√–μÿâππ—Èπ‰¡à√ÿπ·√ß ´÷ËßÕ“®‡ªìπº≈®“°°“√μ‘¥‡™◊ÈÕ‚¥¬‡©æ“–‡™◊ÈÕ‰«√— °“√

Õ—°‡ ∫ (inflammation) ‡ªìπμâπ À≈—°°“√√—°…“Õ“°“√‰Õ§◊Õ √—°…“ “‡Àμÿ∑’Ë∑”„Àâ

‡°‘¥μ—«°√–μÿâπ ·≈–Õ“®„Àâ¬“À√◊Õ “√∑’Ë¬—∫¬—ÈßÕ“°“√‰Õ

5) °“√ª√–‡¡‘π§«“¡√ÿπ·√ß·≈–º≈°√–∑∫¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß

5.1) °“√ª√–‡¡‘π·∫∫ subjective ‰¥â·°à cough severity score, cough

diary ‚¥¬§«“¡√ÿπ·√ß¡“°¢÷Èπ„πºŸâ∑’Ë¡’Õ“°“√‰Õ°≈“ß§◊π √∫°«π°“√πÕπÀ≈—∫ °“√

ª√–‡¡‘π¥â«¬«‘∏’π’È„™â¥Ÿ°“√‡ª≈’Ë¬π·ª≈ß„π§π‡¥‘¡«à“‡ªìπÕ¬à“ß‰√ ·μà„™â ‰¡à‰¥â‡¡◊ËÕ

‡ª√’¬∫‡∑’¬∫√–À«à“ß∫ÿ§§≈ „πμà“ßª√–‡∑»„™â·∫∫ Õ∫∂“¡ Leicester ∑’Ë‰¥â√—∫

°“√ validation „πºŸâ∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß‚¥¬ª√–‡¡‘πº≈°√–∑∫®“°Õ“°“√‰Õ„π

3 ¡‘μ‘ ‰¥â·°à ∑“ß°“¬ (physical) ∑“ß®‘μ„® (psychological) ·≈–∑“ß —ß§¡

(social) ·≈–§ÿ≥¿“æ™’«‘μ °“√ª√–‡¡‘π¥â«¬«‘∏’π’È „™â ‰¥â¥’∑—Èß„π§π‡¥’¬«°—π·≈–

√–À«à“ß∫ÿ§§≈ ·≈–¬—ß¡’°“√»÷°…“À“§à“ minimal clinical importance diffe-

rence ¢Õß°“√‡ª≈’Ë¬π·ª≈ß∑’Ë¡’π—¬ ”§—≠∑“ß§≈‘π‘°(16) „πª√–‡∑»‰∑¬‰¥â¡’°“√·ª≈

·∫∫ Õ∫∂“¡ Leicester ‡ªìπ©∫—∫¿“…“‰∑¬·≈–∑¥ Õ∫§«“¡‡∑’Ë¬ßμ√ß·≈â«„π

ºŸâªÉ«¬ºŸâ„À≠à∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß(17)

20

5.2) °“√ª√–‡¡‘π·∫∫ objective ‚¥¬°“√„™â‡§√◊ËÕß¡◊Õπ—∫§«“¡∂’Ë¢Õß°“√

‰Õ ´÷Ëß¬—ß‰¡à‡ªìπ∑’Ë·æ√àÀ≈“¬·≈–¡’√“§“·æß

6) °“√√—°…“‡∫◊ÈÕßμâπÕ“°“√‰Õ°÷Ëß‡©’¬∫æ≈—πÀ√◊Õ‰Õ‡√◊ÈÕ√—ßÕ“®‡°‘¥®“° “‡ÀμÿÀπ÷ËßÀ√◊ÕÀ≈“¬ “‡Àμÿ

„π‡«≈“‡¥’¬«°—π “‡Àμÿ∑’Ëæ∫‰¥â∫àÕ¬„π°√≥’∑’Ë¿“æ√—ß ’∑√«ßÕ°ª°μ‘ ‰¥â·°à ¬“ ACE

inhibitor, UACS, cough variant asthma ·≈– GERD ¿“¬À≈—ß®“°À¬ÿ¥¬“

ACE-I À“°¡’°“√„™â¬“π’È·≈–À¬ÿ¥°“√ Ÿ∫∫ÿÀ√’Ë·≈â«

°“√√—°…“‡∫◊ÈÕßμâπ„π°√≥’∑’Ë ß —¬ UACS §«√‡√‘Ë¡®“° ¬“μâ“πŒ’ μ“¡’π

(antihistamine) ·≈–/À√◊Õ¬“ decongestant (Level of evidence 3, Grade of

recommendation +) ∂â“μÕ∫ πÕß¥’Õ“°“√‰Õ¡—°¥’¢÷Èπ¿“¬„π 2 —ª¥“Àå

„π°√≥’∑’Ë¡’ª√–«—μ‘‡¢â“‰¥â°—∫‚√§À◊¥ ·π–π”„Àâ‡æ‘Ë¡°“√√—°…“¥â«¬¬“¢¬“¬

À≈Õ¥≈¡ (beta-2 agonist bronchodilator) ·≈–/À√◊Õ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å

™π‘¥ Ÿ¥ (inhaled corticosteroid À√◊Õ ICS) (Level of evidence 1, Grade

of recommendation ++) ·≈–/À√◊Õ§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥√—∫ª√–∑“π‰¡à‡°‘π

2 —ª¥“Àå¢÷ÈπÕ¬Ÿà°—∫§«“¡√ÿπ·√ß¢ÕßÕ“°“√ °“√μ√«®‡æ‘Ë¡‡μ‘¡‚¥¬μ√«® metha-

choline ‡æ◊ËÕ·¬°‚√§À◊¥·≈–Õ“°“√‰Õ∑’Ë‡°‘¥®“°°“√Õ—°‡ ∫™π‘¥Õ‘‚Õ ‘‚πøî≈ (non-

asthmatic eosinophilic bronchitis) À“°μ√«®‰¡à‰¥â °“√„Àâ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å

™π‘¥ Ÿ¥ ·≈–/À√◊Õ ‡μ’¬√Õ¬¥å™π‘¥√—∫ª√–∑“π 2 —ª¥“Àå “¡“√∂√—°…“Õ“°“√‰Õ

∑’Ë‡°‘¥®“°°“√Õ—°‡ ∫™π‘¥Õ‘‚Õ ‘‚πøî≈·≈–‚√§À◊¥‰¥â (steroid-responsive cough)

(Level of evidence 3, Grade of recommendation +) ∂â“μÕ∫ πÕß¥’

Õ“°“√‰Õ¡—°¥’¢÷Èπ¿“¬„π 2-4 —ª¥“Àå „π°√≥’∑’Ë‰¡àμÕ∫ πÕßμàÕ°“√√—°…“¥â«¬¬“

§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å Õ“®μâÕßæ‘®“√≥“°“√μ√«®‡æ‘Ë¡‡μ‘¡‚¥¬μ√«® methacholine


·≈–°“√«—¥°“√Õ—°‡ ∫™π‘¥Õ‘‚Õ ‘‚πøî≈ ·μà ”À√—∫·æ∑¬å‡«™ªØ‘∫—μ‘ ∑—Ë«‰ª§«√

æ‘®“√≥“ àßª√÷°…“·æ∑¬åºŸâ‡™’Ë¬«™“≠

À“°ºŸâªÉ«¬¡’Õ“°“√‰Õ√à«¡°—∫Õ“°“√¢Õß¿“«–°√¥‰À≈¬âÕπ (GERD) ∑’Ë™—¥‡®π

À√◊Õ¡’Õ“°“√°√¥‰À≈¬âÕπ‰¡à™—¥‡®π ·μà‰¥âμ—¥ª√–‡¥Áπμà“ßÊ ¢â“ßμâπ·≈â« ‰¥â·°à

UACS ·≈–‚√§À◊¥ “¡“√∂æ‘®“√≥“„Àâ°“√√—°…“¥â«¬¬“≈¥°√¥‰¥â ·μàμâÕß¥Ÿº≈°“√

μÕ∫ πÕßμàÕ°“√√—°…“∑’ËÕ¬à“ßπâÕ¬ 4 —ª¥“Àå À“°‰¥â¬“‰ª 8-12 —ª¥“Àå·≈â«¬—ß

‰¡à¥’¢÷Èπ§«√À¬ÿ¥¬“ ·≈–æ‘®“√≥“ àßª√÷°…“·æ∑¬åºŸâ‡™’Ë¬«™“≠

7) “‡ÀμÿÕ“°“√‰Õ‡√◊ÈÕ√—ß„π¿“æ√—ß ’ªÕ¥ª°μ‘∑’Ëæ∫∫àÕ¬

7.1 ACE inhibitor induced cough

æ∫Õÿ∫—μ‘°“√≥åª√–¡“≥√âÕ¬≈– 10 ∂÷ß 30 Ÿß¢÷Èπ„π‡æ»À≠‘ß«—¬°≈“ß

§π Õ“°“√‰Õ¡—°‡ªìπÀ≈—ß®“°‰¥â¬“‡ªìπ√–¬–‡«≈“À≈“¬«—π®π∂÷ßÀ≈“¬ —ª¥“Àå „π

∫“ß°√≥’ºŸâªÉ«¬‰¥â¬“¡“π“πÀ≈“¬‡¥◊Õπ§àÕ¬¡“‡°‘¥Õ“°“√‰Õ‰¥â‡¡◊ËÕ¡’μ—«°√–μÿâπ ‡™àπ

°“√μ‘¥‡™◊ÈÕÀ«—¥ Õ“°“√‰Õ®“°¬“π’È¡—°‰¡àμÕ∫ πÕßμàÕ¬“¢¬“¬À≈Õ¥≈¡À√◊Õ¬“

°¥Õ“°“√‰Õ Õ“°“√‰ÕÀ“¬‰¥â‡ÕßÀ≈—ßÀ¬ÿ¥¬“¿“¬„π 1-4 —ª¥“Àå(18) À“°ºŸâªÉ«¬‰Õ

‡√◊ÈÕ√—ß§«√À¬ÿ¥¬“ (Level of evidence 3, Grade of recommendation +)

7.2 Cough variant asthma

≈—°…≥–∑’Ë ”§—≠∑“ß§≈‘π‘°§◊Õ ºŸâªÉ«¬¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß∑’Ë‡¢â“‰¥â°—∫‚√§À◊¥

‡™àπ ‰Õ‡«≈“°≈“ß§◊π ‰ÕÀ≈—ß®“°‰¥â√—∫°“√°√–μÿâπ À√◊Õ “√°àÕ¿Ÿ¡‘·æâ ‚¥¬∑’Ë‰¡à¡’

‡ ’¬ßÀ«’¥ À√◊Õ‰¡à¡’Õ“°“√‡Àπ◊ËÕ¬ ‰Õ à«π„À≠à‰¡à¡’‡ ¡À–À√◊Õ¡’‡æ’¬ß‡≈Á°πâÕ¬ ‚¥¬

‰¡à¡’¿“«–μ‘¥‡™◊ÈÕ∑“ß‡¥‘πÀ“¬„®π”¡“°àÕπ(19) ‚√§π’ÈμÕ∫ πÕß¥’μàÕ°“√√—°…“¥â«¬¬“

¢¬“¬À≈Õ¥≈¡ À“°ºŸâªÉ«¬μÕ∫ πÕß¥’μàÕ¬“¢¬“¬À≈Õ¥≈¡ §«√∑”°“√∑¥ Õ∫

‡æ◊ËÕ¬◊π¬—π°“√«‘π‘®©—¬‚√§À◊¥μ“¡·π«∑“ß°“√ªØ‘∫—μ‘ ”À√—∫ºŸâªÉ«¬‚√§À◊¥(12)

22

°“√√—°…“‚√§À◊¥

1. „π°√≥’∑’Ë¡’Õ“°“√‰Õ‡ªìπ§√—Èß§√“« (intermittent) Õ“®æ‘®“√≥“„Àâ¬“ β2-

agonist ™π‘¥√—∫ª√–∑“πÀ√◊Õ™π‘¥ Ÿ¥∑’ËÕÕ°ƒ∑∏‘Ï —Èπ(1) (Level of evidence 2,

Grade of recommendation ++) ‡æ◊ËÕ∫√√‡∑“Õ“°“√¢Õß‚√§À◊¥ (relievers)

®“°°“√À¥‡°√Áß¢Õß°≈â“¡‡π◊ÈÕ‡√’¬∫À≈Õ¥≈¡ °“√μÕ∫ πÕß¥Ÿ®“°Õ“°“√‰Õ¥’¢÷Èπ

„π 2-4 —ª¥“Àå

2. À“°Õ“°“√‰Õ‡ªìπμ≈Õ¥μàÕ‡π◊ËÕß (persistent) À√◊Õ‰¡àμÕ∫ πÕßμàÕ¬“

„π¢âÕ 1 æ‘®“√≥“„Àâ¬“∑’Ë„™â§«∫§ÿ¡‚√§À◊¥ (controllers) „™â‡æ◊ËÕ√—°…“°“√Õ—°‡ ∫

‡√◊ÈÕ√—ß¢ÕßÀ≈Õ¥≈¡ ¬“∑’Ë¡’ª√– ‘∑∏‘¿“æ¥’∑’Ë ÿ¥ §◊Õ ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥

(inhaled corticosteroid À√◊Õ ICS)(12) (Level of evidence 1, Grade of

recommendation ++) ‚¥¬¬—∫¬—Èß°“√ √â“ß “√∑’Ë‡°’Ë¬«¢âÕß°—∫°“√Õ—°‡ ∫®“°

‡¡Á¥‡≈◊Õ¥¢“« ·≈–¬—ß¡’¬“°≈ÿà¡Õ◊ËπÊ ∑’Ë “¡“√∂„™â ‰¥â‡™àπ ¬“μâ“π≈‘«‚§‰μ√Õ’π (leuko-

triene receptor antagonist, LTRA)(20) (Level of evidence 1, Grade of

recommendation ++) º≈°“√√—°…“¥â«¬¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥·≈–

¬“μâ“π≈‘«‚§‰μ√Õ’π„π¥â“πÕ“°“√‰ÕæÕÊ °—π·μà ICS ªÑÕß°—π°“√¥”‡π‘π‚√§‰ª Ÿà

classic asthma À√◊Õ wheezing ‰¥â¥’°«à“ LTRA(21) À“°¬—ß§«∫§ÿ¡‰¡à‰¥â “¡“√∂

„™â¬“¢¬“¬À≈Õ¥≈¡∑’ËÕÕ°ƒ∑∏‘Ï¬“« (long-acting β2-agonist, LABA) ∑’Ëº ¡°—∫

¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥ (ICS/LABA)(22) ‡æ◊ËÕ‡ √‘¡ƒ∑∏‘Ï°—π(23) (Level of

evidence 1, Grade of recommendation ++)

À“°„Àâ°“√√—°…“¥â«¬¬“¢â“ßμâπ·≈–μ‘¥μ“¡·≈â«‰¡à‰¥âº≈¿“¬„π‡«≈“ 4 —ª¥“Àå

§«√æ‘®“√≥“ àßμàÕ·æ∑¬åºŸâ‡™’Ë¬«™“≠

7.3 Upper airway cough syndrome

°≈ÿà¡Õ“°“√π’Èª√–°Õ∫¥â«¬ rhinitis, sinusitis ·≈– postnasal drip ∑’Ë


∑”„Àâ¡’Õ“°“√‰Õ ¡’¡Ÿ°‰À≈≈ß§Õ °√–·Õ¡∫àÕ¬Ê ‰´π— Õ—°‡ ∫ À¡“¬∂÷ß‚æ√ß

Õ“°“»¢â“ß®¡Ÿ° (À√◊Õ‡√’¬°«à“‰´π— ) ‡°‘¥°“√Õ—°‡ ∫ ´÷Ëß “‡Àμÿ à«π„À≠à∑’Ë∑”„Àâ

‚æ√ß‰´π— Õ—°‡ ∫®–‡°‘¥μ“¡À≈—ß®“°‚æ√ß®¡Ÿ°Õ—°‡ ∫ (rhinitis) ¥—ßπ—Èπ®÷ß®–‡√’¬°

√«¡«à“ çrhinosinusitisé

7.3.1 ‰´π— Õ—°‡ ∫ (sinusitis)

°“√·∫àß™π‘¥¢Õß‰´π— Õ—°‡ ∫ “¡“√∂·∫àß‰¥â‡ªìπ‰´π— Õ—°‡ ∫

‡©’¬∫æ≈—π (acute rhinosinusitis) ·≈–‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß (chronic rhinosinusitis,

CRS) ‚¥¬„™â√–¬–‡«≈“∑’ËπâÕ¬°«à“ 12 —ª¥“Àå À√◊Õ 12 —ª¥“Àå¢÷Èπ‰ª ‡ªìπμ—«·∫àß

‰´π— Õ—°‡ ∫∑’Ë∑”„Àâ‡°‘¥Õ“°“√‰Õ‡√◊ÈÕ√—ß¡—°‡°‘¥®“°‰´π— Õ—°‡ ∫·∫∫‡√◊ÈÕ√—ß ÷Ëß “¡“√∂

·∫àß¬àÕ¬‰¥âÕ’°‡ªìπ‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß∑’Ë¡’√‘¥ ’¥«ß®¡Ÿ° (CRS with nasal polyp)

À√◊Õ‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß∑’Ë‰¡à¡’√‘¥ ’¥«ß®¡Ÿ° (CRS without nasal polyp) ”À√—∫

‚√§∑“ß‰´π— ∑’Ë∑”„Àâ —¡æ—π∏å°—∫Õ“°“√‰Õ‡√◊ÈÕ√—ßπ—Èπ Õ“°“√‰Õ∑’Ë‡°‘¥¢÷ÈπÕ“®‡ªìπ

®“°¡Ÿ°∑’Ë‰À≈≈ß§Õ°√–μÿâπ∑“ß‡¥‘πÀ“¬„® à«π≈à“ß ·≈–/À√◊Õ °“√Õ—°‡ ∫∑’Ë‡°‘¥∑’Ë

∑“ß‡¥‘πÀ“¬„® à«π∫π‡°’Ë¬«¢âÕß‰ª Ÿà∑“ß‡¥‘πÀ“¬„® à«π≈à“ß (united airway

inflammation)

‡°≥±å°“√«‘π‘®©—¬‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß

1) Õ“°“√ ”§—≠ Õßª√–°“√§◊Õ Õ“°“√§—¥®¡Ÿ° ·≈–πÈ”¡Ÿ°‰À≈ ´÷Ëß

Õ“®®–‡ªìπ πÈ”¡Ÿ°‰À≈ÕÕ°¡“∑“ß√Ÿ®¡Ÿ° (anterior rhinorrhea) À√◊Õ¡Ÿ°‰À≈≈ß§Õ

(postnasal drip) √à«¡°—∫√–¬–‡«≈“∑’Ë‡ªìπ 12 —ª¥“Àå¢÷Èπ‰ª

2) °“√μ√«®√à“ß°“¬‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß ‚¥¬·æ∑¬å‡«™ªØ‘∫—μ‘∑—Ë«‰ª

“¡“√∂„™â ‰ø©“¬ À√◊Õ otoscope àÕß√Ÿ®¡Ÿ°‡æ◊ËÕª√–‡¡‘π«à“ ¡’°“√Õ—°‡ ∫¢Õß

‡¬◊ËÕ∫ÿ‚æ√ß®¡Ÿ° √‘¥ ’¥«ß®¡Ÿ° ·≈–„™â ‰¡â°¥≈‘Èπ‡æ◊ËÕμ√«®¥Ÿ«à“¡’¡Ÿ°‰À≈≈ß§ÕÀ√◊Õ‰¡à

24

°“√μ√«®∑“ß√—ß ’‚¥¬°“√‡ÕÁ°´å‡√¬å‰´π— (Plain-film of paranasal sinus)

¡’§«“¡·¡àπ¬”„π°“√«‘π‘®©—¬μË”(24) ∂â“æ∫§«“¡º‘¥ª°μ‘ °Á “¡“√∂„Àâ°“√«‘π‘®©—¬

À“°¬—ß ß —¬‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß®“°≈—°…≥–∑“ß§≈‘π‘° ·μà‡ÕÁ° å‡√¬åå‰´π— ª°μ‘°Á

¬—ß‰¡à “¡“√∂μ—¥°“√«‘π‘®©—¬ÕÕ°‰¥â

°“√√—°…“‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß

1.1 °“√√—°…“‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß„π°√≥’∑’Ë¡’°“√°”‡√‘∫‡©’¬∫æ≈—π(25) æ‘®“√≥“

„Àâ¬“μâ“π®ÿ≈™’æ‡ªìπ‡«≈“ 3-4 —ª¥“Àå

1.1.1 ¬“μâ“π®ÿ≈™’æ∑’Ë§«√‡≈◊Õ°„™âÕ—π¥—∫·√° (first-line antibiotics)

‰¥â·°à amoxicillin „π°√≥’∑’Ë·æâ penicillin „Àâ‡≈◊Õ° macrolides ‰¥â·°à clari-

thromycin À√◊Õ azithromycin

1.1.2 ¬“μâ“π®ÿ≈™’æ∑’Ë§«√‡≈◊Õ°„™âÕ—π¥—∫ Õß (second-line antibio-

tics)

1) ¬“μâ“π®ÿ≈™’æ™π‘¥ Beta-lactam/ beta-lactamase inhibi-

tor ‰¥â·°à amoxicillin/clavulanate

2) Second À√◊Õ third generation cephalosporin ‰¥â·°à

cefuroxime, cefpodoxime proxetil À√◊Õ cefdinir

3) Respiratory fluoroquinolones ‰¥â·°à levofloxacin À√◊Õ

moxifloxacin

1.2 °“√√—°…“¥â«¬¬“Õ◊ËπÊ(26)

1.2.1 °“√√—°…“¿“«–°“√Õ—°‡ ∫ ‰¥â·°à ¬“ ‡μ’¬√Õ¬¥å™π‘¥æàπ®¡Ÿ°

(nasal steroid) ‡ªìπÕ—π¥—∫·√° ‡ªìπ‡«≈“ 12 —ª¥“Àå (Level of evidence 1,

Grade of recommendation ++)


1.2.2 °“√‡æ‘Ë¡°“√√–∫“¬¡Ÿ°ÀπÕß∑’Ë§â“ß„π‰´π— „Àâ√–∫“¬‰¥â¥’¢÷Èπ

(promoting drainage from paranasal sinuses) ‚¥¬≈â“ß®¡Ÿ°¥â«¬πÈ”‡°≈◊Õ (Level

of evidence 1, Grade of recommendation ++)

1.2.3 ¬“ decongestant ™π‘¥æàπÀ√◊Õ°‘π ·π–π”„Àâ„™â ”À√—∫

ºŸâ∑’Ë¡’Õ“°“√§—¥®¡Ÿ° ·μà¬—ß‰¡à¡’À≈—°∞“π«à“∑”„Àâ‚√§‰´π— Õ—°‡ ∫À“¬‰¥â‡√Á«·≈–

¡“°°«à“ºŸâªÉ«¬∑’Ë‰¡à‰¥â√—∫¬“ ∂â“„™â™π‘¥æàπ·π–π”„™â ‰¡à‡°‘π 5 «—π à«π™π‘¥°‘π

·π–π”„™â ‰¡à‡°‘π 10 -14 «—π (Level of evidence 3, Grade of recommenda-

tion +)

1.2.4 ¬“μâ“πŒ‘ μ“¡’π ·π–π”„Àâ„™â„π√“¬∑’Ë¡’ª√–«—μ‘/Õ“°“√¢Õß

‚√§¿Ÿ¡‘·æâ‡∑à“π—Èπ „π°√≥’∑’Ë®–„™â¬“„π°≈ÿà¡π’È ‰¡à·π–π”„Àâ„™â™π‘¥ first genera-

tion ‡™àπ chlorpheniramine ‡æ√“–∑”„Àâ¡Ÿ°‡Àπ’¬« ·≈–‡°‘¥Õ“°“√ßà«ß´÷¡

“¡“√∂„Àâ°“√√—°…“‡∫◊ÈÕßμâπ (Empirical treatment) ¥—ß°≈à“«¢â“ß

μâπ°àÕπ°“√μ√«®‡æ◊ËÕ§âπÀ“ “‡Àμÿ™π‘¥Õ◊ËπÊ „π°√≥’∑’ËºŸâªÉ«¬‰¥â√—∫°“√¥Ÿ·≈√—°…“

‡∫◊ÈÕßμâπ·≈â« 4 —ª¥“Àå ºŸâªÉ«¬¬—ß‰¡à¡’°“√μÕ∫ πÕßÕ¬à“ß¡’π—¬ ”§—≠§«√ àß„Àâ

·æ∑¬å‡©æ“–∑“ß‡æ◊ËÕμ√«®„π‚æ√ß®¡Ÿ°‚¥¬≈–‡Õ’¬¥‚¥¬°“√„™â°≈âÕß‡∑‡≈ ‚§ª

(nasal telescopy) ‚¥¬‡©æ“–Õ¬à“ß¬‘Ëß∑’Ë∫√‘‡«≥™àÕß∑“ß√–∫“¬¡Ÿ°À√◊ÕÀπÕß®“°

‚æ√ß‰´π— ¡“∑’Ë‚æ√ß®¡Ÿ° (middle meatus)

7.3.2 ‚æ√ß®¡Ÿ°Õ—°‡ ∫ (Rhinitis)

‚æ√ß®¡Ÿ°Õ—°‡ ∫ (rhinitis) ‡°‘¥®“°°“√Õ—°‡ ∫¢Õß‡¬◊ËÕ∫ÿ‚æ√ß®¡Ÿ°

´÷Ëß‡°‘¥‰¥â®“°À≈“¬ “‡Àμÿ À“°‡°‘¥®“°¿Ÿ¡‘·æâ ‡√’¬°«à“ allergic rhinitis (AR) À“°

‰¡à‰¥â‡°‘¥®“°¿Ÿ¡‘·æâ ‡√’¬°«à“ non-allergic rhinitis (NAR) ÷Ëß¡’‰¥âÀ≈“¬æ¬“∏‘

°”‡π‘¥ ‡™àπ vasomotor rhinitis, drug-induced, hormonal-induced, environ-

26

ment/irritant-induced, gustatory reflex À√◊Õ°“√Õ—°‡ ∫™π‘¥Õ’‚Õ ‘‚πøî≈‚¥¬

‰¡à‰¥â‡°‘¥®“°¿Ÿ¡‘·æâ (non-allergic rhinitis with eosinophilia syndrome, NARES)

°“√«‘π‘®©—¬‚æ√ß®¡Ÿ°Õ—°‡ ∫

ª√–°Õ∫¥â«¬Õ“°“√¡“°°«à“ 1 „π 3 Õ“°“√¥—ßμàÕ‰ªπ’È 1) §—πÀ√◊Õ®“¡

(sneezing) 2) πÈ”¡Ÿ°‰À≈ (rhinorrhea) À√◊Õ 3) §—¥®¡Ÿ° (congestion) Õ¬à“ß‰√

°Áμ“¡ 1 „π 3 ¢ÕßºŸâªÉ«¬Õ“®¡’Õ“°“√∑’Ë‰¡à®”‡æ“– (unrecognized form) ‡™àπ

Õ“°“√°√–·Õ¡ (throat clearing), ª“°·ÀâßÀ√◊Õ§Õ·ÀâßÀ≈—ßμ◊ËππÕπ ´÷ËßÕ“®‡°‘¥

®“°§—¥®¡Ÿ°‡√◊ÈÕ√—ß®πÕâ“ª“°À“¬„® (mouth breathing), ª«¥¡÷π»’√…–®“°§—¥®¡Ÿ°

(headache), ÀŸÕ◊ÈÕ®“°°“√∫«¡¢Õß‡¬◊ËÕ∫ÿ‚æ√ß®¡Ÿ°®π∑”„Àâ Eustachian tube

dysfunction, ·≈–Õ“°“√§—π∫√‘‡«≥‡¬◊ËÕ‡¡◊Õ°„°≈â‡§’¬ß ‡™àπ §—π‡æ¥“πª“° §—πÀŸ

§—πμ“ ·≈–§—π„π§Õ ‡ªìπμâπ Õ¬à“ß‰√°Áμ“¡Õ“°“√‰Õπ—Èπ “¡“√∂æ∫„π‚√§‚æ√ß®¡Ÿ°

Õ—°‡ ∫‰¥â‚¥¬‰¡à‰¥â™à«¬·¬°·¬–«à“‡°‘¥®“° AR À√◊Õ NAR(27) ‚¥¬Õ“°“√‰ÕÕ“®‡°‘¥

®“°°“√‡æ‘Ë¡ capsaicin cough sensitivity ®“°°“√Õ—°‡ ∫¢Õß∑“ß‡¥‘πÀ“¬„®

®“°°“√ —¡º— “√°àÕ¿Ÿ¡‘·æâ(28) Õ“°“√∑’Ë∑”„Àâ ß —¬‚æ√ß®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ

¡“°¢÷Èπ ‰¥â·°à §—π ®“¡ ·≈–Õ“°“√∑“ßμ“ „π¢≥–∑’ËÕ“°“√πÈ”¡Ÿ°‰À≈·≈–§—¥®¡Ÿ°

æ∫‰¥â„π‚æ√ß®¡Ÿ°Õ—°‡ ∫‡°◊Õ∫∑ÿ° “‡Àμÿ °“√μ√«®√à“ß°“¬Õ“®æ∫§«“¡º‘¥ª°μ‘

„π‚æ√ß®¡Ÿ°À√◊Õ‰¡à°Á‰¥â

°“√√—°…“‚æ√ß®¡Ÿ°Õ—°‡ ∫

1. °“√√—°…“‚æ√ß®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ

‡πâπ°“√≈¥°“√Õ—°‡ ∫¢Õß‡¬◊ËÕ∫ÿ®¡Ÿ°∑’Ë‡°‘¥®“°°“√ —¡º— “√°àÕ¿Ÿ¡‘·æâ

¥â«¬¬“ ‡μ’¬√Õ¬¥å™π‘¥æàπ®¡Ÿ° (Level of evidence 1, Grade of recommen-

dation ++) ¬“Õ◊ËπÊ ∑’ËÕ“®æ‘®“√≥“„™â√—°…“Õ“°“√§—π ®“¡ À√◊Õ√—°…“‡ªìπ¬“À≈—°


À“°¡’Õ“°“√‰¡à√ÿπ·√ß ‰¥â·°à ¬“μâ“πŒ’ μ“¡’π·∫∫√—∫ª√–∑“π™π‘¥‰¡àßà«ß (Level

of evidence 1, Grade of recommendation ++) ·≈–°“√√—°…“μ“¡Õ“°“√ ‡™àπ

°“√≈â“ß®¡Ÿ°¥â«¬πÈ”‡°≈◊Õ (Level of evidence 3, Grade of recommendation

+) °“√‡æ‘Ë¡¬“μâ“π≈‘«‚§‰μ√Õ’π (Leukotriene receptor antagonist, LTRA) ‡¡◊ËÕ

√—°…“¥â«¬¬“μâ“πŒ’ μ“¡’πÀ√◊Õ¬“ ‡μ’¬√Õ¬¥å™π‘¥æàπ®¡Ÿ°·≈â«‰¡à‰¥âº≈ ‰¡à¡’ª√–‚¬™πå

„π°“√√—°…“‚æ√ß®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ (Level of evidence 2, Grade of

recommendation -) ¬°‡«âπ„π°√≥’∑’Ë¡’‚√§À◊¥√à«¡¥â«¬ (Level of evidence 2,

Grade of recommendation ++)(29) Õ¬à“ß‰√°Áμ“¡‚√§‚æ√ß®¡Ÿ°Õ—°‡ ∫®“° “‡Àμÿ

Õ◊ËπÊ Õ“®‰¡àμÕ∫ πÕßμàÕ°“√√—°…“¥—ß°≈à“«¢â“ßμâπ À“° ß —¬¿“«–π’È·μà‰¡àμÕ∫ πÕß

μàÕ°“√√—°…“¿“¬„π 4 —ª¥“Àå §«√æ‘®“√≥“ àßμàÕºŸâ‡™’Ë¬«™“≠ (¥Ÿ®“°·π«∑“ß°“√

μ√«®√—°…“‚√§®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâ„π§π‰∑¬ ©∫—∫ª√—∫ª√ÿß æ.». 2554)

2. °“√√—°…“¿“«–¡Ÿ°‰À≈≈ß§Õ (postnasal drip) ∑’Ë‰¡à¡’¿“«–

‰´π— Õ—°‡ ∫

„™â¬“μâ“πŒ’ μ“¡’π√ÿàπ∑’Ë 1 ‰¥â·°à dexbrompheniramine ·≈–/À√◊Õ

pseudoephedrine „π¿“«–‰Õ‡√◊ÈÕ√—ß·π–π”„Àâ√—°…“π“π 3 —ª¥“Àå·≈â«ª√–‡¡‘π

º≈ (Level of evidence 4, grade of recommendation +) à«π¬“ ipratropium

™π‘¥æàπ®¡Ÿ° Õ“®‰¥âª√–‚¬™πå„π°“√≈¥Õ“°“√πÈ”¡Ÿ°‰À≈®“°‚æ√ß®¡Ÿ°Õ—°‡ ∫ (Level

of evidence 4, Grade of recommendation +/-) ·μà¢âÕ¡Ÿ≈°“√≈¥Õ“°“√‰Õ¬—ß

‰¡à™—¥‡®π(30-32)

7.4 Nonasthmatic eosinophilic bronchitis

‚√§π’È‡°‘¥®“°°“√Õ—°‡ ∫™π‘¥Õ‘‚Õ ‘‚πøî≈∫√‘‡«≥∑“ß‡¥‘πÀ“¬„® à«π≈à“ß

ºŸâªÉ«¬¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß·∫∫¡’‡ ¡À–À√◊Õ‰¡à¡’‡ ¡À–°Á‰¥â √âÕ¬≈– 60 ¡’ rhinitis √à«¡

¥â«¬‚¥¬¡—°‡ªìπ allergic rhinitis √âÕ¬≈– 10 ¢ÕßºŸâªÉ«¬¡’ peripheral eosino-

28

philia ·≈–√âÕ¬≈– 20 ¡’ specific IgE antibodies „Àâº≈∫«°(33) °“√μ√«®

¡√√∂¿“æªÕ¥¡—°‰¡àæ∫°“√μÕ∫ πÕßμàÕ°“√∑¥ Õ∫¥â«¬¬“¢¬“¬À≈Õ¥≈¡ ¡’

‡æ’¬ß√âÕ¬≈– 12 ∑’ËÕ“®μÕ∫ πÕßμàÕ°“√∑¥ Õ∫¥â«¬¬“¢¬“¬À≈Õ¥≈¡ °“√μ√«®

methacholine º≈ª°μ‘ °“√μ√«® serial peak flow æ∫ diurnal variation ‰¥â

æÕÊ °—∫ cough variant asthma °“√Õ—°‡ ∫„πÀ≈Õ¥≈¡ “¡“√∂μ√«®æ∫‡´≈≈å

Õ—°‡ ∫™π‘¥Õ‘‚Õ ‘‚πøî≈‰¥â®“°‡ ¡À– πÈ”≈â“ßªÕ¥ ·≈–™‘Èπ‡π◊ÈÕ‰¥â‡™àπ‡¥’¬«°—∫‚√§À◊¥

Õ¬à“ß‰√°Áμ“¡ √–¥—∫ fractional exhaled nitric oxide (FeNO) „πºŸâªÉ«¬ eosino-

philic bronchitis ‰¡à Ÿß‡À¡◊Õπ„πºŸâªÉ«¬ asthma À√◊Õ cough variant asthma(14)

°“√√—°…“ Nonasthmatic eosinophilic bronchitis

¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥„π¢π“¥ Ÿß (budesonide 800 mcg

μàÕ«—π À√◊Õ‡∑’¬∫‡∑à“) (Level of evidence 4, Grade of recommendation ++)

º≈°“√μÕ∫ πÕß¥’„π 2-4 —ª¥“Àå (34) ‚√§π’È ‰¡àμÕ∫ πÕßμàÕ¬“¢¬“¬À≈Õ¥≈¡ √–¬–

‡«≈“„π°“√√—°…“¬—ß‰¡à·πàπÕπ ·π–π”„ÀâÀ≈’°‡≈’Ë¬ß “√°àÕ¿Ÿ¡‘·æâ·≈– “√√–§“¬‡§◊Õß

À“°¡’ª√–«—μ‘ —¡º— ™—¥‡®π À“°‰¡àμÕ∫ πÕßμàÕ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥„π

¢π“¥ Ÿß Õ“®æ‘®“√≥“¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥°‘π(2) (Level of evidence 4,

Grade of recommendation +)

7.5 Õ“°“√‰Õ®“°¿“«–°√¥‰À≈¬âÕπ (Cough related reflux disease)

‚√§À√◊Õ¿“«–°√¥‰À≈¬âÕπ ‡ªìπ¿“«–∑’Ë¡’°“√¬âÕπ°≈—∫¢Õß¡«≈ “√„π

°√–‡æ“–Õ“À“√ (gastric content) ¢÷Èπ¡“ ŸàÀ≈Õ¥Õ“À“√ ª√–°Õ∫¥â«¬∑—Èß°√¥∑’Ë

‡°‘¥®“°πÈ”¬àÕ¬®“°°√–‡æ“–Õ“À“√ À√◊ÕÕ“®‡ªìπ¥à“ß∑’Ë‡°‘¥®“°πÈ”¬àÕ¬∑’ËÀ≈—Ëß®“°

≈”‰ â‡≈Á°À√◊Õ·°ä (35)

Õ“°“√¢Õß¿“«–°√¥‰À≈¬âÕπ¡’À≈“°À≈“¬ ‚¥¬Õ“°“√∫“ßÕ¬à“ß°Á‰¡à¡’


§«“¡‡©æ“–‡®“–®ßμàÕ‚√§ °“√ —°ª√–«—μ‘‡ªìπ ‘Ëß ”§—≠ πÕ°®“°®”‡ªìπ„π°“√

«‘π‘®©—¬·≈â« ¬—ß™à«¬„π°“√‡≈◊Õ°„Àâ°“√√—°…“‰¥âÕ¬à“ß‡À¡“– ¡¬‘Ëß¢÷Èπ¥â«¬

‚¥¬∑—Ë«‰ªÕ“°“√¢ÕßºŸâªÉ«¬∑’Ë¡’‚√§¥—ß°≈à“« Õ“®¡’Õ“°“√∑“ß§≈‘π‘°∑’Ë

·∫àß‰¥â‡ªìπ°≈ÿà¡„À≠àÊ ª√–°Õ∫¥â«¬

1) Õ“°“√¢ÕßÀ≈Õ¥Õ“À“√ (esophageal symptoms) ¡’Õ“°“√‡¥àπ

2 Õ“°“√ ‰¥â·°à Õ“°“√· ∫√âÕπ¬Õ¥Õ° (heartburn) ·≈–Õ“°“√‡√Õ‡ª√’È¬« (re-

gurgitation) Õ’°Õ“°“√∑’Ëæ∫‰¥â ‰¡à∫àÕ¬π—°§◊ÕÕ“°“√‡®Á∫Àπâ“Õ° (chest pain) „π

°≈ÿà¡Õ“°“√¢ÕßÀ≈Õ¥Õ“À“√π’È‡Õß¬—ß¡’°“√·∫àß¬àÕ¬ÕÕ°‡ªìπ¿“«–·∑√°´âÕπ∑’Ë‡°‘¥

®“°°√¥‰À≈¬âÕπ ‚¥¬‡ªìπ≈—°…≥–∑’Ëæ∫‰¥â®“°°“√ àÕß°≈âÕßμ√«®∑“ß‡¥‘πÕ“À“√‡ªìπ

4 ≈—°…≥– §◊Õ ·º≈Õ—°‡ ∫¢ÕßÀ≈Õ¥Õ“À“√ (erosive esophagitis) À≈Õ¥Õ“À“√

μ’∫®“°·º≈Õ—°‡ ∫¢ÕßÀ≈Õ¥Õ“À“√ (esophageal stricture) Baretteûs esopha-

gus ·≈–¡–‡√ÁßÀ≈Õ¥Õ“À“√ (esophageal cancer) ™π‘¥ adenocarcinoma

2) Õ“°“√πÕ°À≈Õ¥Õ“À“√ (extraesophageal symptoms) ª√–°Õ∫

¥â«¬ Õ“°“√μà“ßÊ ∑’Ë‰¡à —¡æ—π∏å°—∫À≈Õ¥Õ“À“√‚¥¬μ√ß ‰¥â·°à Õ“°“√‰Õ ·≈–°≈àÕß

‡ ’¬ßÕ—°‡ ∫®“°¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ¢÷ÈπÀ≈Õ¥§Õ (laryngopharyngeal reflux

À√◊Õ LPR) ÀÕ∫À◊¥ ·≈–øíπºÿ πÕ°®“°π’È¬—ß¡’Õ“°“√∑’Ë§“¥«à“Õ“®‡ªìπº≈®“°¿“«–

°√¥‰À≈¬âÕπ ∑’Ë∂Ÿ°®—¥Õ¬Ÿà„π°≈ÿà¡π’È ‰¥â·°à ‰´π— Õ—°‡ ∫ §ÕÀÕ¬Õ—°‡ ∫ ÀŸ™—Èπ°≈“ß

Õ—°‡ ∫‡√◊ÈÕ√—ß ·≈–ªÕ¥‡ªìπæ—ßº◊¥(35, 36)

®–‡ÀÁπ‰¥â«à“ Õ“°“√‰Õ‡√◊ÈÕ√—ß ‰´π— Õ—°‡ ∫ À√◊Õ¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ

¢÷ÈπÀ≈Õ¥§Õ (laryngopharyngeal reflux À√◊Õ LPR) ∑’Ë‡°‘¥®“°¿“«–°√¥‰À≈¬âÕπ

≈â«π‡ªìπÕ“°“√πÕ°À≈Õ¥Õ“À“√∑—Èß ‘Èπ ÷Ëß§«“¡·μ°μà“ß√–À«à“ßÕ“°“√πÕ°À≈Õ¥

Õ“À“√·≈–Õ“°“√¢ÕßÀ≈Õ¥Õ“À“√ §◊Õ æ¬“∏‘ √’√«‘∑¬“°“√‡°‘¥‚√§ √«¡∂÷ß°“√

μÕ∫ πÕßμàÕ°“√√—°…“

30

Õ“°“√‰Õ®“°¿“«–πÈ”¬àÕ¬‰À≈¬âÕππ’È “¡“√∂°√–μÿâπ„Àâ‡°‘¥¿“«–‰Õ‡√◊ÈÕ√—ß‰¥â

‚¥¬ºà“π°≈‰°Õ—π„¥Õ—πÀπ÷Ëß À√◊ÕÀ≈“¬°≈‰° ¥—ßπ’È

1) Esophagopharyngeal reflux (microaspiration theory)(37) °“√

°√–μÿâπÀ≈Õ¥§Õ‚¥¬μ√ß®“°¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ

2) Laryngeal chemoreflex (reflex pathway ª√–°Õ∫¥â«¬ afferent limb

§◊Õ stimulated superior laryngeal nerve ·≈– efferent limb ‚¥¬ recurrent

laryngeal nerve)

3) Vagally mediated reflex (¡’ sensory stimulation ¢Õß distal eso-

phagus ‚¥¬‰¡à¡’ laryngeal stimulation ÷Ëß∑”„Àâ‡°‘¥ laryngospasm À√◊ÕÕ“°“√

‰Õ ºà“π∑“ß afferent limb of vagus nerve)

4) ¿“«–πÈ”¬àÕ¬°√–μÿâπ√–∫∫ª√– “∑Õ—μ‚π¡—μ‘°“√‡°‘¥°“√‰Õ„Àâ‡æ‘Ë¡¢÷Èπ

(Increased cough reflex)

5) ¿“«–°“√‰Õ °àÕ„Àâ‡°‘¥¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ®“°°“√‰Õπ—Èπ‡ªìπ«ß®√(38-41)

°“√«‘π‘®©—¬‰Õ‡√◊ÈÕ√—ß®“°¿“«–°√¥‰À≈¬âÕπ

°“√«‘π‘®©—¬∑”‰¥â ‰¡àßà“¬π—° ‚¥¬æ∫«à“ √âÕ¬≈– 43-75 ¢ÕßºŸâªÉ«¬°≈ÿà¡π’È ‰¡à¡’

Õ“°“√∑“ßÀ≈Õ¥Õ“À“√√à«¡¥â«¬(42, 43) ·μà°Á¡’¢âÕ¡Ÿ≈«à“ ¿“«–°√¥‰À≈¬âÕπÕ“®‡ªìπ

‡Àμÿ¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß‰¥â∂÷ß√âÕ¬≈– 10 ‚¥¬∑—Ë«‰ª§«√π÷°∂÷ß¿“«–°√¥‰À≈¬âÕπ„π

ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß∑’Ë¡’≈—°…≥–¥—ßμàÕ‰ªπ’È ‰Õ‰¡à¡’‡ ¡À– ºŸâªÉ«¬∑’Ë¡’Õ“°“√°”‡√‘∫À≈—ß

√—∫ª√–∑“πÕ“À“√¡◊ÈÕ„À≠àÀ√◊Õ ¡’Õ“°“√∫àÕ¬„π∑à“πÕπ(44) °“√«‘π‘®©—¬¿“«–πÈ”¬àÕ¬

‰À≈¬âÕπ∑’Ë∑”„Àâ‡°‘¥Õ“°“√‰Õπ—Èπ §«√«‘π‘®©—¬μ“¡¢—ÈπμÕπ∑’Ë∂Ÿ°μâÕß ‡æ√“–„π∫“ß§√—Èß

Õ“°“√πÈ”¬àÕ¬‰À≈¬âÕπ ‡™àπ · ∫√âÕπ∑√«ßÕ° À√◊Õ‡√Õ‡ª√’È¬« ‰¡à¡’Õ“°“√‡¥àπ™—¥

„πºŸâªÉ«¬‡À≈à“π’È ·≈–Õ“®∑”„Àâ‡°‘¥°“√«‘π‘®©—¬º‘¥æ≈“¥‰¥â ¥—ßπ—Èπ°“√«‘π‘®©—¬Õ“°“√


‰Õ‡√◊ÈÕ√—ß®“°¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ ®÷ß§«√§”π÷ß·≈–μ—¥ª√–‡¥Áπ∑’ËÕ“®‡ªìπ “‡Àμÿ

Õ◊ËπÊ μ“¡¢—ÈπμÕπ°àÕπ„Àâ°“√«‘π‘®©—¬ ¥—ßπ’È (45) (Level of evidence 4, Grade of

recommendation ++)

1. ºŸâªÉ«¬ —¡º— ¡≈¿“«–∑“ßÕ“°“» À√◊Õ “√√–§“¬‡§◊Õß À√◊Õ‡ªìπºŸâ Ÿ∫

∫ÿÀ√’ËÕ¬ŸàÀ√◊Õ‰¡à

2. ºŸâªÉ«¬‰¥â√—∫¬“ ACE-I Õ¬ŸàÀ√◊Õ‰¡à

3. ¿“æ∂à“¬√—ß ’ªÕ¥§«√ª°μ‘ À√◊Õ‡ªìπ√Õ¬‚√§‡°à“∑’Ë‰¡à°àÕ„Àâ‡°‘¥Õ“°“√

4. ‰¡à¡’¿“«–ÀÕ∫À◊¥„πªí®®ÿ∫—π ‚¥¬Õ“°“√‰Õπ—Èπ‰¡à¥’¢÷ÈπÀ≈—ß√—°…“ÀÕ∫À◊¥

À√◊Õ°“√«‘π‘®©—¬¿“«–ÀÕ∫À◊¥¥â«¬°“√°√–μÿâπ¥â«¬ methacholine ‰¥âº≈≈∫

5. ‰¡à¡’¿“«–Õ“°“√‰Õ®“°‚√§¥â“π®¡Ÿ°À√◊Õ‰´π—

6. ‰¡à¡’Õ“°“√‰Õ®“°¿“«– nonasthmatic eosinophilic bronchitis ‚¥¬

«‘π‘®©—¬®“°°“√μ√«® eosinophil „π‡ ¡À–‡ªìπ≈∫·≈–Õ“°“√‰Õπ—Èπ‰¡à¥’¢÷Èπ®“°

°“√„™â inhaled À√◊Õ systemic corticosteroids

à«π„À≠à·≈â«°“√«‘π‘®©—¬‰Õ‡√◊ÈÕ√—ß®“°¿“«–°√¥‰À≈¬âÕπ ‰¡à‰¥â àß ◊∫§âπ

‡æ‘Ë¡‡μ‘¡‡æ◊ËÕ¬◊π¬—π°“√«‘π‘®©—¬‚√§‚¥¬∑—π∑’ ‡π◊ËÕß®“°°“√μ√«®æ‘‡»…∑—ÈßÀ≈“¬¡’

¢—ÈπμÕπ∑’Ë§àÕπ¢â“ß¬ÿàß¬“° ·≈–Õ“®°àÕ„Àâ‡°‘¥§«“¡‰¡à ÿ¢ ∫“¬·°àºŸâ‡¢â“√—∫°“√μ√«®

∫â“ß πÕ°®“°π’È¬—ß¡’¢âÕ®”°—¥À≈“¬ª√–°“√„π°“√·ª≈º≈ ¥—ßπ—ÈπÀ“°¡’Õ“°“√

∑’Ë‡¢â“‰¥â°—∫‰Õ‡√◊ÈÕ√—ß®“°¿“«–°√¥‰À≈¬âÕπ ·≈–‰¥âμ—¥ª√–‡¥Áπ¢âÕ 1-6 ¢â“ßμâπ·≈â«

„π∑“ßªØ‘∫—μ‘®÷ß„Àâ°“√√—°…“‰ª‡≈¬·≈â«¥Ÿ°“√μÕ∫ πÕßμàÕ°“√√—°…“(44)

°√≥’ºŸâªÉ«¬‰¡àμÕ∫ πÕßμàÕ proton pump inhibitor °“√ ◊∫§âπ‡æ‘Ë¡‡μ‘¡

¬—ßÕ“®‰¥âª√–‚¬™πå„π∫“ß°√≥’ Õ¬à“ß‰√°Á¥’·æ∑¬åºŸâ àß§«√√Ÿâª√–‚¬™πå·≈–¢âÕ®”°—¥

¢Õß°“√μ√«®·μà≈–«‘∏’ ¥—ßμàÕ‰ªπ’È

32

1. °“√ àÕß°≈âÕßμ√«®∑“ß‡¥‘πÕ“À“√ à«πμâπ (Esophagogastroduo-

denoscopy) Õ“®‰¥âª√–‚¬™πå °√≥’∑’Ëμ√«®æ∫«à“¡’°“√Õ—°‡ ∫ (erosive esopha-

gitis) ∫√‘‡«≥ÀŸ√Ÿ¥À≈Õ¥Õ“À“√ à«π≈à“ß À√◊Õæ∫≈—°…≥–¢Õß Barrettûs esopha-

gus °Á “¡“√∂¬◊π¬—π«à“¡’°“√‰À≈¬âÕπ¢Õß “√®“°°√–‡æ“–Õ“À“√®√‘ß ·μà‡π◊ËÕß®“°

¡’§«“¡‰«„π°“√μ√«®μË” ¡’°“√»÷°…“¢π“¥‡≈Á°æ∫«à“ „πºŸâ∑’Ë¡’Õ“°“√¢Õß°√¥‰À≈

¬âÕπ„πÀ≈Õ¥Õ“À“√ æ∫≈—°…≥–¥—ß°≈à“«‰¥â∂÷ß√âÕ¬≈– 55 ·μà„πºŸâ∑’Ë¡’Õ“°“√‰Õ

‡√◊ÈÕ√—ß‚¥¬∑’Ë‰¡à¡’Õ“°“√¢ÕßÀ≈Õ¥Õ“À“√ ®–æ∫≈—°…≥–¥—ß°≈à“«‰¥â‡æ’¬ß√âÕ¬≈– 16

‡∑à“π—Èπ(46)

2. °“√«—¥§à“§«“¡‡ªìπ°√¥-¥à“ß„πÀ≈Õ¥Õ“À“√ 24 ™—Ë«‚¡ß °“√μ√«®π’È

∂◊Õ«à“‡ªìπ°“√μ√«®¡“μ√∞“π (gold standard) „π°“√«‘π‘®©—¬°√¥‰À≈¬âÕπ ‚¥¬

°“√»÷°…“¢π“¥‡≈Á°À≈“¬°“√»÷°…“∫àß™’È«à“°“√μ√«®«‘∏’π’È ™à«¬¬◊π¬—π°“√«‘π‘®©—¬«à“

ºŸâªÉ«¬¡’°√¥‰À≈¬âÕπ‰¥â μ—Èß·μà√âÕ¬≈– 60-100(47) à«π§«“¡®”‡æ“–μË”§◊Õ‡æ’¬ß√âÕ¬≈–

66(48) ∑—Èßπ’È°“√μ√«®æ∫«à“¡’°“√‰À≈¬âÕπ ‰¡à‰¥â¬◊π¬—π«à“°“√‰À≈¬âÕπ‡ªìπμâπ‡Àμÿ

¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß ·μàμâÕß¥Ÿ§«“¡ —¡æ—π∏å√–À«à“ß°“√‡°‘¥°√¥‰À≈¬âÕπ°—∫Õ“°“√

‰Õ (symptom association) ´÷Ëßº≈°“√»÷°…“μà“ßÊ ¬—ß¡’§«“¡À≈“°À≈“¬¡“°

3. Multichannel intraluminal impedance pH monitoring ‡æ◊ËÕ

«‘π‘®©—¬¿“«–°√¥ÕàÕπÀ√◊Õ¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ∑’Ë‰¡à„™à°√¥ À√◊Õ°√¥·°ä ‰À≈¬âÕπ

¢÷ÈπÀ≈Õ¥§Õ

°“√√—°…“Õ“°“√‰Õ®“°¿“«–°√¥‰À≈¬âÕπ

·π«∑“ß°“√√—°…“‚¥¬∑—Ë«‰ª ·π–π”„Àâ„™â¬“≈¥°“√À≈—Ëß°√¥ ∑—Èßπ’È proton

pump inhibitor ¡’ª√– ‘∑∏‘¿“æ„π°“√≈¥°“√À≈—Ëß°√¥‰¥â¥’°«à“ histamine receptor

2 antagonist ‚¥¬·π–π”„Àâ„™â¬“ proton pump inhibitor „π¢π“¥ Ÿß ·≈–


√–¬–‡«≈“π“π°«à“„π°≈ÿà¡ typical À√◊Õ esophageal GERD ‰¥â·°à omeprazole

¢π“¥ 20 mg 1 ‡¡Á¥ °àÕπÕ“À“√ ‡™â“·≈–‡¬Áπ À√◊Õ proton pump inhibitor

μ—«Õ◊Ëπ∑’Ë¡’¢π“¥‡∑’¬∫‡∑à“°—π ‡ªìπ‡«≈“Õ¬à“ßπâÕ¬ 4-8 —ª¥“Àå (Level of evidence

2, Grade of recommendation ++) ·≈â«¥Ÿº≈°“√μÕ∫ πÕßμàÕ°“√√—°…“∑’ËÕ¬à“ß

πâÕ¬ 4 —ª¥“Àå À“°‰¥â¬“‰ª 8-12 —ª¥“Àå·≈â«¬—ß‰¡à¥’¢÷Èπ§«√À¬ÿ¥¬“·≈– àßμàÕ

ºŸâ‡™’Ë¬«™“≠

‚¥¬ºŸâ‡™’Ë¬«™“≠ à«π„À≠à·π–π”„Àâ„™â¬“≈¥°“√À≈—Ëß°√¥‡ªìπ°“√√—°…“‡∫◊ÈÕß

μâπ ‡π◊ËÕß®“°¡’º≈®“°°“√»÷°…“∑¥≈Õß·∫∫‡ªî¥ (open-label trial)(49) ∫àß™’È«à“

ºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß∑’Ë ß —¬«à“‡ªìπº≈®“°°√¥‰À≈¬âÕπ μÕ∫ πÕßμàÕ°“√

√—°…“¥â«¬¬“≈¥°“√À≈—Ëß°√¥™π‘¥ proton pump inhibitors ∑—Èß¢π“¥¡“μ√∞“π

(«—π≈–§√—Èß) ·≈–¢π“¥ Ÿß («—π≈– 2 §√—Èß)(46) Õ¬à“ß‰√°Á¥’°“√»÷°…“·∫∫°“√«‘‡§√“–Àå

Õ¿‘¡“π ®“° 9 °“√»÷°…“ ‡ª√’¬∫‡∑’¬∫¬“≈¥°“√À≈—Ëß°√¥°—∫¬“À≈Õ° æ∫«à“‰¡à¡’

§«“¡·μ°μà“ß°—π (odds ratio, OR 0.46; 95% CI 0.19-1.15)(41) ÷Ëß°Á Õ¥§≈âÕß

°—∫°“√»÷°…“·∫∫ ÿà¡‡ª√’¬∫‡∑’¬∫Õ’° 2 °“√»÷°…“(50, 51) ∑—Èßπ’È ¡’°“√«‘‡§√“–Àå«à“ º≈

°“√»÷°…“∑’Ë·μ°μà“ß°—π¢â“ßμâπ πà“®–‡ªìπº≈®“°«‘∏’°“√«‘π‘®©—¬∑’ËÀ≈“°À≈“¬ ∑”„Àâ

‰¥âºŸâªÉ«¬„π°“√»÷°…“∑’Ë¡’§«“¡À≈“°À≈“¬¡“°(48) Õ¬à“ß‰√°Á¥’ °“√„Àâ¬“ proton pump

inhibitor °Á¬—ß·π–π”„Àâ„™â‡ªìπ¡“μ√∞“π‡∫◊ÈÕßμâπ ·μà„Àâμ‘¥μ“¡¥Ÿ°“√μÕ∫ πÕß

¿“¬„π 4-8 —ª¥“Àå ÷Ëß‡ªìπμ—«∫àß™’È∑’Ë¥’«à“ºŸâªÉ«¬πà“®–‰¥âª√–‚¬™πå®“° proton pump

inhibitor(46) À“°‰¡à¡’°“√μÕ∫ πÕß‡≈¬ §«√À¬ÿ¥¬“·≈â«∑”°“√ ◊∫§âπ‡æ‘Ë¡‡μ‘¡ ‡æ◊ËÕ

·¬°‚√§·≈–„Àâ°“√«‘π‘®©—¬

7.6 Post-infectious cough

Õ“°“√‰Õ¿“¬À≈—ß°“√μ‘¥‡™◊ÈÕ∑“ß‡¥‘πÀ“¬„® à«π∫π (upper respira-

tory tract infection, URI) æ∫‰¥â∫àÕ¬„π‡«™ªØ‘∫—μ‘ ¡—°¡’ª√–«—μ‘°“√μ‘¥‡™◊ÈÕ∑“ß

34

‡¥‘πÀ“¬„® à«π∫ππ”¡“°àÕπ à«π„À≠à‰¡à‡°‘π 2 —ª¥“Àå®“°‡™◊ÈÕ‰«√— Mycoplasma,

Chlamydia À√◊Õ Moraxella catarrhalis Õ“°“√Õ◊ËπÊ À“¬‰ª ‡À≈◊Õ·μàÕ“°“√‰Õ

Õ“°“√‰Õπ“π¢÷Èπ‰¥â„πºŸâªÉ«¬∑’Ë¡’‚√§À≈Õ¥≈¡Õ¬Ÿà¥â«¬ Õ¬à“ß‰√°Áμ“¡√–¬–‡«≈“‰Õ

®“°¿“«–π’È ‰¡à§«√‡°‘π 8 —ª¥“Àå À“°‡°‘π 8 —ª¥“Àå §«√ ◊∫§âπ “‡ÀμÿÕ◊Ëπ(2)

Õÿ∫—μ‘°“√≥å„πºŸâ„À≠àª√–¡“≥√âÕ¬≈– 10 ∂÷ß 25 ·≈–®–æ∫ Ÿß¢÷Èπ‡ªìπ√âÕ¬≈– 25

∂÷ß 50 ®“°°“√μ‘¥‡™◊ÈÕ Mycoplasma À√◊Õ Bordetella pertussis æ¬“∏‘°”‡π‘¥

¬—ß‰¡à™—¥‡®π °≈‰°∑’Ë∑”„Àâ‡°‘¥ cough hypersensitivity ‚¥¬ºà“π∑“ß airway

inflammation ·≈–°“√°√–μÿâπ airway sensory nerves ·≈– cholinergic motor

pathway ∑”„Àâ‡°‘¥ bronchoconstriction ·≈– airway hyperresponsiveness

μ“¡¡“(52) ‚¥¬ cough hypersensitivity π’È‡ªìπ‡æ’¬ß™—Ë«§√“« “¡“√∂À“¬‰¥â‡Õß

À“°‰¡à‰¥â‡°‘¥®“° Bordetella pertussis

Õ“°“√‰Õ®“° Pertussis

‡√‘Ë¡¥â«¬Õ“°“√π”§≈â“¬‰¢âÀ«—¥ 2 —ª¥“Àå°àÕπ μ“¡¥â«¬Õ“°“√‰Õ‡ªìπ™ÿ¥Ê

Õ“‡®’¬πÀ≈—ß‰Õ √à«¡°—∫ inspiratory whoop (æ∫‰¥â ‰¡à∫àÕ¬„πºŸâ„À≠à) °“√¬◊π¬—π

°“√«‘π‘®©—¬Õ“»—¬ polymerase chain reaction ®“° “√§—¥À≈—Ëß∫√‘‡«≥ naso-

pharynx (sensitivity 80-100%) (Level of evidence 3, Grade of recom-

mendation +/-) ‰¥âº≈¥’°«à“ culture (sensitivity 25-50%) (Level of evidence

3, Grade of recommendation +) À√◊Õ serology (pertussis IgG, IgA titer)

‚¥¬‡®“– 2 §√—Èß §√—Èß·√° 2 —ª¥“ÀåÀ≈—ß®“°¡’Õ“°“√‰Õ·≈–§√—ÈßμàÕ‰ª 3-4 —ª¥“Àå

(sensitivity 60%)(53) (Level of evidence 3, Grade of recommendation

+/-)


°“√√—°…“ Post-infectious cough

„π°√≥’∑’Ë‰¡à‰¥â‡°‘¥®“° pertussis

Õ“°“√‰Õ¿“¬À≈—ß°“√μ‘¥‡™◊ÈÕ∑“ß‡¥‘πÀ“¬„® à«π∫π¡—°®–À“¬‰¥â‡Õß ‰¡à‡°‘π

8 —ª¥“Àå °“√√—°…“∑’Ë¡’√“¬ß“π ‰¥â·°à §Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥(54, 55) (Level of

evidence 4, Grade of recommendation +), √“¬∑’Ë¡’Õ“°“√‰Õ¡“°Ê Õ“®®–„™â

inhaled ipratropium(56) (Level of evidence 2, Grade of recommendation

+) À√◊Õ¬“ ‡μ’¬√Õ¬¥å™π‘¥°‘π (prednisolone 30-40 mg μàÕ«—π) √–¬– —ÈπÊ 1-2

—ª¥“Àå (3) (Level of evidence 3, Grade of recommendation +/-) À“°‰¡à‰¥â

º≈ Õ“®æ‘®“√≥“°“√„™â¬“°¥Õ“°“√‰Õ (Level of evidence 4, Grade of

recommendation +) °“√√—°…“∑’Ë¡’√“¬ß“π«à“‰¡à‰¥âº≈‰¥â·°à montelukast(57)

(Level of evidence 1, Grade of recommendation -)

„π°√≥’∑’ËºŸâªÉ«¬‡ªìπ¿Ÿ¡‘·æâ®¡Ÿ°Õ¬Ÿà‡¥‘¡ °“√μ‘¥‡™◊ÈÕ∑“ß‡¥‘πÀ“¬„® à«π∫π

®–∑”„ÀâÕ“°“√¿Ÿ¡‘·æâ®¡Ÿ°°”‡√‘∫ ∫«¡·≈–º≈‘μ¡Ÿ°¡“°·≈–‡Àπ’¬«∑”„Àâ‡°‘¥°“√‰Õ

‡æ√“–¡’ postnasal drip ‰¥â „Àâ√—°…“·∫∫¿Ÿ¡‘·æâ®¡Ÿ°¥â«¬°“√æàπ≈â“ß®¡Ÿ°¥â«¬

πÈ”‡°≈◊Õ·≈–¬“ ‡μ’¬√Õ¬¥å™π‘¥æàπ®¡Ÿ°

°“√√—°…“Õ“°“√‰Õ®“° pertussis

„π√–¬–·√° „™â¬“ªØ‘™’«π– macrolide ‰¥â·°à erythromycin À√◊Õ tri-

methoprim/sulfamethoxazole ‡ªìπ‡«≈“ 2 —ª¥“Àå (52, 53) ·≈–·π–π”„Àâ isola-

tion ‡ªìπ‡«≈“ 5 «—πÀ≈—ß®“°‡√‘Ë¡°“√√—°…“ (Level of evidence 1, Grade of

recommendation ++) ‰¡à·π–π”„Àâ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å ¬“¢¬“¬À≈Õ¥≈¡∑’Ë

ÕÕ°ƒ∑∏‘Ï¬“« ·≈–¬“ pertussis immunoglobulin (Level of evidence 1, Grade

of recommendation -)

36

Sinobronchial syndrome

„πª√–‡∑»·∂∫‡Õ‡™’¬ æ∫«à“¡’°≈ÿà¡Õ“°“√‰Õ‡√◊ÈÕ√—ß™π‘¥¡’‡ ¡À–∑’Ë¡’¿“æ

√—ß ’∑√«ßÕ°·≈–‰´π— º‘¥ª°μ‘ ·≈–„Àâ™◊ËÕ‚√§«à“ sinobronchial syndrome ¿“«–

π’È ‰¡àæ∫À√◊Õæ∫‰¥âπâÕ¬¡“°„π™“«μ–«—πμ°·≈–‰¡à¡’·π«∑“ß°“√√—°…“∑’Ë√–∫ÿ‰«â„π

chronic cough guidelines ®“°∑“ßμ–«—πμ°·μàÕ“®æ∫‰¥â„π‡Õ‡™’¬(1) ºŸâªÉ«¬

¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß·∫∫¡’‡ ¡À–≈—°…≥– mucoid À√◊Õ mucopurulent Õ“°“√

∑“ß§≈‘π‘°∑’Ë∑”„Àâπ÷°∂÷ß§◊Õ°“√∑’Ë¡’Õ“°“√√à«¡°—π¢Õß‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß (chronic

sinusitis) √à«¡°—∫Õ“°“√Õ—°‡ ∫∑“ß‡¥‘πÀ“¬„® à«π≈à“ß (chronic lower airway

inflammation) ‰¥â·°à diffuse bronchiectasis À√◊Õ diffuse panbronchiolitis

(DBP) À√◊Õ chronic bronchitis

Õ“°“√∑’Ë∫àß∂÷ß‰´π— Õ—°‡ ∫‰¥â·°à postnasal drip, nasal discharge ·≈–

throat clearing Õ“°“√¡—°®–·¬à≈ß‡¡◊ËÕ¡’ upper respiratory tract infection

°“√μ√«®√à“ß°“¬æ∫ post nasal drip ·≈– cobble stone appearance ∫√‘‡«≥

oropharynx °“√‡æ“–‡™◊ÈÕ‡ ¡À–¡—°¢÷Èπ pneumococcus ·≈– H. influenzae

º≈°“√μ√«®√–¥—∫ serum IgA ·≈– cold agglutinins Ÿß¢÷Èπ °“√μ√«®∑“ß√—ß ’

æ∫¿“æ√—ß ’‰´π— À√◊Õ‡ÕÁ°´‡√¬å§Õ¡æ‘«‡μÕ√å (computed tomography) º‘¥ª°μ‘

∑’Ë‡¢â“‰¥â°—∫‰´π— Õ—°‡ ∫

°“√√—°…“ Sinobronchial syndrome

°√≥’Õ“°“√‰¡à√ÿπ·√ß expectorant ∑”„ÀâÕ“°“√¥’¢÷Èπ‰¥â ∂â“Õ“°“√√ÿπ·√ß

·π–π”„Àâ 14-membered ring macrolides ‰¥â·°à erythromycin 300-600 mg

μàÕ«—π clarithromycin 250-500 mg μàÕ«—π À√◊Õ roxithromycin 150-300 mg

μàÕ«—π ‡ªìπ‡«≈“ 2-12 —ª¥“Àå (Level of evidence 3, Grade of recommenda-

tion +)


¿“§ºπ«° 1·π«∑“ß°“√√—°…“ºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à

μ√«®¿“æ√—ß ’ªÕ¥ (CXR) ‡æ◊ËÕ§âπÀ“ “‡Àμÿ®“°ªÕ¥ ‡™àπ «—≥‚√§ ¡–‡√Áß ÷ËßÕ“®æ∫ “‡ÀμÿÕ“°“√‰Õ®“°À≈“¬‡Àμÿ√à«¡°—π À“° CXR ª°μ‘ „Àâ°“√√—°…“‡∫◊ÈÕßμâπμ“¡¢—ÈπμÕπ À“°Õ“°“√‡¢â“‰¥â°—∫

- Upper Airway Cough Syndrome (UACS)„Àâ°“√√—°…“‡∫◊ÈÕßμâπ·≈– ◊∫§âπÀ“ “‡Àμÿ∑’Ë®”‡æ“–

- Asthma„Àâ°“√√—°…“‡∫◊ÈÕßμâπ ·≈–æ‘®“√≥“∑” Spirometry, bronchodilator reversibility

- Non-asthmatic eosinophil bronchitis (NAEB)„Àâ°“√√—°…“‡∫◊ÈÕßμâπ

- Gastroesophageal Reflux Disease (GERD)„Àâ°“√√—°…“‡∫◊ÈÕßμâπ

°“√μ√«®«‘π‘®©—¬‡æ‘Ë¡‡μ‘¡- Spirometry or peak expiratory flow variability

(if not be evaluated)- Bronchial provocation test- Plain sinus imaging (if not be evaluated) + CT sinus- 24h esophageal pH monitoring

À√◊Õ 24 h-pH / impedance test- Endoscope (Nasal, larynx or Bronchoscope)- Swallowing Evaluation- “‡ÀμÿÕ◊ËπÊ

ª√–‡¥Áπæ‘®“√≥“∑’Ë ”§—≠- √—°…“μ“¡ “‡Àμÿ∑’Ë ß —¬Õ¬à“ß‡μÁ¡∑’Ë- μ‘¥μ“¡§«“¡ ¡Ë”‡ ¡Õ¢Õß°“√√—°…“- ‡π◊ËÕß®“° “‡Àμÿ°“√‰Õ‡√◊ÈÕ√—ßÕ“®¡’‰¥âÀ≈“¬ “‡Àμÿ„π

ºŸâªÉ«¬√“¬Àπ÷ËßÊ §«√„Àâ°“√μ√«®·≈–√—°…“‡æ‘Ë¡‡μ‘¡®“°°“√√—°…“‡¥‘¡∑’ËμÕ∫ πÕß‡æ’¬ß∫“ß à«π

38

¿“§ºπ«° 2

«‘∏’°“√ àÕßμ√«®®¡Ÿ°

1) μ√«®¥â«¬‰ø©“¬∑’Ë· ß «à“ß Ÿß „π¢≥–∑’Ë„ÀâºŸâªÉ«¬·Àßπ§Õ·≈–¥—π

ª≈“¬®¡Ÿ°¢÷Èπ‡æ◊ËÕ∑”„Àâ‡ÀÁπ√Ÿ®¡Ÿ°‰¥âßà“¬ ¢âÕ¥’§◊Õ –¥«°·≈–ßà“¬ ·μà¢âÕ®”°—¥ §◊Õ

®–μ√«®‰¡à‰¥âÀ“°¡’¢π®¡Ÿ°¡“° ·≈–‰¡à “¡“√∂‡ÀÁπ√“¬≈–‡Õ’¬¥«à“¡’¡Ÿ°¢â“ß„π

Õ¬à“ß‰√

2) °“√ àÕß®¡Ÿ°¥â«¬ Otoscope ∏√√¡¥“ ®–‡ÀÁπ‰¥â¥’¢÷Èπ°«à“«‘∏’·√°

3) °“√ àÕß®¡Ÿ°¥â«¬°≈âÕß digital otoscope ®–¡’°”≈—ß¢¬“¬ Ÿß ‡ÀÁπ‰¥â

™—¥‡®π


«‘∏’°“√μ√«®§Õ‡æ◊ËÕμ√«®À“Õ“°“√· ¥ß¢Õß postnasal drip syndrome ‡™àπ ¿“«– glan-

dular pharyngitis, tonsil enlargement ‚¥¬„™â ‰ø©“¬∑’Ë «à“ß Ÿß „π¢≥–„Àâ

ºŸâ≈ÕßÕâ“ª“°°«â“ß·≈–À“¬„®‡¢â“∑“ß§Õ≈÷°Ê ‚¥¬‰¡àμâÕß„™â ‰¡â°¥≈‘Èπ‰¥â À“°¡Õß

‰¡à‡ÀÁπ®÷ß§àÕ¬„™â ‰¡â°¥≈‘Èπ μ√«® àÕß™â“Ê √Ÿª· ¥ß¿“«– glandular pharyngitis

(≈Ÿ°»√™’È)

√Ÿª´â“¬·≈–¢«“∫π · ¥ß∂÷ß¿“«–®¡Ÿ°∫«¡ (complete nasal obstruction) √Ÿª´â“¬·≈–¢«“≈à“ß · ¥ß∂÷ß¿“«–∑’Ë¡’¡Ÿ°‡Àπ’¬«¡“° ∑”„Àâ‡°‘¥Õ“°“√ postnasal drip, °√–·Õ¡‰Õ

40

°“√μ√«®æ∫§«“¡º‘¥ª°μ‘∑’Ë∫àß™’È«à“¡’¿“«–‡¬◊ËÕ®¡Ÿ°∫«¡Õ—°‡ ∫‡√◊ÈÕ√—ß (chronic

rhinitis)

√Ÿª· ¥ß¿“«–√‘¡Ωïª“°·μ°Õ—°‡ ∫ (cheilitis) ‡°‘¥®“°®¡Ÿ°μ—π∑”„ÀâμâÕß

À“¬„®∑“ßª“°∫àÕ¬Ê

√Ÿª´â“¬· ¥ß¢Õ∫μ“≈à“ß§≈È”¥” (allergic shiner)

√Ÿª¢«“· ¥ßº◊Ëπ·¥ß§—π∑’ËÀ—«μ“À√◊Õ‡ª≈◊Õ°μ“ (periorbital dermatitis)

À¡“¬‡Àμÿ: √Ÿª¿“æ∑—ÈßÀ¡¥‰¥â√—∫Õπÿ≠“μ„Àâ‡º¬·æ√à®“°ºŸâªÉ«¬·≈–

». πæ. ‡°’¬√μ‘ √—°…å√ÿàß∏√√¡


¿“§ºπ«° 3°“√∑¥ Õ∫ ¡√√∂¿“æªÕ¥‚¥¬ ‰ª‚√‡¡μ√’¬å·≈–°“√∑¥ Õ∫§«“¡‰«À≈Õ¥≈¡

°“√∑¥ Õ∫ ¡√√∂¿“æªÕ¥‚¥¬ ‰ª‚√‡¡μ√’¬å™à«¬∫àß™’È«à“¡’°“√μ’∫¢ÕßÀ≈Õ¥≈¡ (airway obstruction) ·π–π”„Àâ∑”„π

ºŸâªÉ«¬∑’Ë¡’ª√–«—μ‘·≈–°“√μ√«®√à“ß°“¬∑’Ë ß —¬‚√§À◊¥ ‡æ◊ËÕ«—μ∂ÿª√– ß§å 1) ¬◊π¬—π

«à“¡’¿“«–À≈Õ¥≈¡μ’∫ ·≈–ª√–‡¡‘π§«“¡√ÿπ·√ß ·≈– 2) ª√–‡¡‘π«à“¡’°“√μÕ∫

πÕßμàÕ¬“ Ÿ¥¢¬“¬À≈Õ¥≈¡ (reversibility) °àÕπ°“√√—°…“ ·≈–/À√◊Õ ¡’°“√

μÕ∫ πÕßμàÕ°“√„™â¬“√—°…“‚√§À◊¥À√◊Õ‰¡à (variable airflow limitation) ‚¥¬°“√

¬◊π¬—π«à“¡’¿“«–À≈Õ¥≈¡μ’∫ æ‘®“√≥“®“°§à“ FEV1/FVC ¡’§à“πâÕ¬°«à“ 0.75-0.8

„πºŸâ„À≠à∑’Ë¡’Õ“¬ÿπâÕ¬°«à“ 60 ªï ·≈–°“√μÕ∫ πÕßμàÕ¬“ Ÿ¥¢¬“¬À≈Õ¥≈¡ æ‘®“√≥“

®“°§à“ ¡√√∂¿“æªÕ¥ FEV1 ‡æ‘Ë¡¢÷Èπ¡“°°«à“ 200 ml ·≈–¡“°°«à“√âÕ¬≈– 12

À≈—ß Ÿ¥¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï‡√Á« 20 π“∑’ ·≈–/À√◊Õ À≈—ß°“√‰¥â¬“

controller √—°…“‚√§À◊¥‡ªìπ‡«≈“Õ¬à“ßπâÕ¬ 4 —ª¥“Àå

¿“«–À≈Õ¥≈¡μ’∫∑’Ë¡’§«“¡º—πº«π (variable airflow obstruction) ¥—ß

°≈à“« “¡“√∂μ√«®‰¥â‚¥¬«‘∏’Õ◊ËπÊ ‰¥â·°à °“√«—¥ peak expiratory flow rate (PEFR)

°“√«—¥ peak expiratory flow rate (PEFR) ‚¥¬°“√μÕ∫ πÕßμàÕ¬“ Ÿ¥

¢¬“¬À≈Õ¥≈¡ æ‘®“√≥“®“°§à“ PEFR ∑’Ë‡æ‘Ë¡¢÷Èπ¡“°°«à“ 60 L/min À√◊Õ‡æ‘Ë¡¢÷Èπ

¡“°°«à“√âÕ¬≈– 20 À≈—ß Ÿ¥¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï‡√Á« ·μà°“√∑¥ Õ∫

¥â«¬°“√«—¥ PEFR ¡’§«“¡‡∑’Ë¬ßμ√ßπâÕ¬°«à“ ‰ª‚√‡¡μ√’¬å °“√„™â PEFR ‡æ◊ËÕ

μ√«®À“¿“«–À≈Õ¥≈¡μ’∫∑’Ë¡’§«“¡º—πº«π ‚¥¬°“√«—¥ PEFR „π™à«ß 1-2 —ª¥“Àå

42

“¡“√∂„™â„π°“√«‘π‘®©—¬·≈–ª√–‡¡‘π‚√§À◊¥‰¥â¥’°«à“ §π∑’Ë‡ªìπ‚√§À◊¥®–¡’§«“¡

º—πº«π¡“°°«à“§πª°μ‘ (¡“°°«à“√âÕ¬≈– 10) ‚¥¬°“√«—¥ PEFR «—π≈– 2 §√—Èß

„π¢≥–¬—ß‰¡à‰¥â‡√‘Ë¡°“√√—°…“ À√◊Õ PEFR ‡æ‘Ë¡¢÷Èπ¡“°°«à“√âÕ¬≈– 20 ¿“¬À≈—ß

°“√√—°…“¥â«¬¬“§«∫§ÿ¡‚√§À◊¥‡ªìπ‡«≈“ 4 —ª¥“Àå

°“√§”π«≥§à“§«“¡º—πº«π¢Õß PEFR (peal flow variability,PFV)

PFV (%) = (§à“ PEFR ¢Õß«—π∑’Ë Ÿß ÿ¥ - §à“ PEFR ¢Õß«—π∑’ËμË” ÿ¥) À“√

¥â«¬§à“‡©≈’Ë¬¢Õß PEFR (§à“ PEFR Ÿß ÿ¥¢Õß«—π + §à“ PEFR μË” ÿ¥¢Õß«—π/2)

·≈â«§Ÿ≥¥â«¬ 100%

°“√∑¥ Õ∫§«“¡‰«¢ÕßÀ≈Õ¥≈¡ (Bronchoprovocative test) “¡“√∂∑”‰¥â¥â«¬°“√„Àâ Ÿ¥ “√°√–μÿâπ “√ histamine À√◊Õ∑’Ëπ‘¬¡„πªí®®ÿ∫—π

‰¥â·°à methacholine ∑’Ë§«“¡‡¢â¡¢âπ‡√‘Ë¡®“°πâÕ¬‰ª¡“° ·≈–«—¥§à“ ¡√√∂¿“æªÕ¥

‚¥¬°“√μ√«® ‰ª‚√‡¡μ√’¬å¿“¬À≈—ß°“√ Ÿ¥¬“·μà≈–§«“¡‡¢â¡¢âπ«à“¡’°“√≈¥≈ß¢Õß

§à“ ¡√√∂¿“æªÕ¥ FEV1 ¡“°°«à“√âÕ¬≈– 20 ®“°§à“°àÕπ Ÿ¥¬“ methacholine

À“°§«“¡§«“¡‡¢â¡¢âπ¢Õß methacholine ∑’Ë„™â„π°“√°√–μÿâπ„Àâ‡°‘¥°“√≈¥≈ß

¢Õß FEV1 ¡“°°«à“√âÕ¬≈– 20 ®“°§à“°àÕπ Ÿ¥¬“ (PC20) μË”°«à“ 8 mg/dl ∂◊Õ«à“

¡’¿“«–À≈Õ¥≈¡‰« ∂â“ PC20 μË”°«à“ 1 mg/dl ∂◊Õ«à“¿“«–À≈Õ¥≈¡‰«√ÿπ·√ß

(severe AHR) à«π§à“ PC20 ∑’Ë¡“°°«à“ 16 mg/dl ∂◊Õ«à“º≈°“√∑¥ Õ∫‡ªìπ≈∫

°“√∑¥ Õ∫ methacholine challenge test „π°“√«‘π‘®©—¬‚√§À◊¥ ¡’§à“

positive predictive value √âÕ¬≈– 60-88


¿“§ºπ«° 4°≈‰°°“√‡°‘¥Õ“°“√‰Õ

44

¿“§ºπ«° 5μ“√“ß· ¥ß§«“¡·μ°μà“ß√–À«à“ß‚√§ eosinophilic airway ™π‘¥μà“ßÊ(1)

Classic asthma CVA NAEB AC

Õ“°“√ ‰Õ ‡Àπ◊ËÕ¬ «’È¥ ‰ÕÕ¬à“ß‡¥’¬« ‰Õ√à«¡°—∫Õ“°“√ ‰ÕÕ¬à“ß‡¥’¬«

∑“ß upper airway

Atopy 60-80% 40-80% 20-70% 40-50%

Variable airflow limitation + + - -

AHR + + - -

Cough hypersensitivity - - ‡æ‘Ë¡ ‡æ‘Ë¡

°“√μÕ∫ πÕßμàÕ + + ‰¡à∑√“∫ -

¬“¢¬“¬À≈Õ¥≈¡

°“√μÕ∫ πÕßμàÕ + + + +

‡μ’¬√Õ¬¥å

°“√μÕ∫ πÕßμàÕ + + ‰¡à∑√“∫ +

¬“μâ“πŒ‘ μ“¡’π

°“√≈¥≈ß¢Õß ¡√√∂¿“æªÕ¥ + + + -

°“√¥”‡π‘π‚√§‡ªìπ‚√§À◊¥ 30% 10% πâÕ¬¡“°

Sputum eosinophil >3% ∫àÕ¬ ∫àÕ¬ μâÕß¡’„π°“√«‘π‘®©—¬ ∫àÕ¬

FeNO ‡æ‘Ë¡ ‡æ‘Ë¡ ‡æ‘Ë¡ ‰¡à‡æ‘Ë¡

Submucosal eos ‡æ‘Ë¡ ‡æ‘Ë¡ ‡æ‘Ë¡ ‡æ‘Ë¡

Mast cell in ASM ‡æ‘Ë¡ ‰¡à‡æ‘Ë¡ ‰¡à‡æ‘Ë¡ ‰¡à∑√“∫

Subepithelial thickening + + + ‰¡à∑√“∫

Vascular proliferation + + + ‰¡à∑√“∫

CVA=cough variant asthma, NAEB=non-asthmatic eosinophilic bronchitis, AC=allergic cough,AHR= airway hyperresponsiveness, eos= eosinophil, FeNO= fractional exhaled nitric oxide,ASM= airway smooth muscle


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Cough guideline 2016

Health & Medicine

Transcript of Cough guideline 2016