1. 1
ะเทศไทย
(The Thai National Guideline for Diagnosis and
Management of Childhood Asthma)
1. บทนำ
2.
3. (Treatment of
acute exacerbations)
4. (Chronic
therapy for childhood asthma)
5. (Prevention of asthma)
ร

2. 2
I บทนำ
-
)

3. 3
มำตรฐำนจำก NHLBI
(GINA)

4. 4

5. 5
(goal of therapy)
1.
2. กำร
3.
)
4.
และในโรงพยำบำล
5.
6.
1.
(educate patient and establish partnership)

6. 6
2.
ของปอด (assessment of
asthma severity)
3.
ของโรค (avoidance and control of triggers)
4.
กษำระยะยำว (establish medication plans for long-
term management)
5. กำรวำง (establish plans
for managing exacerbations)
6. (provide
regular follow-up care)

7. 7
II
1. Airway inflammation
2. Increased airway responsiveness to a variety of
stimuli
3. Reversible or partial reversible airway obstruction
1.
2.
กษำ (reversible airway
obstruction)
3.
ด (wheeze) โดย
1.1

8. 8
ยหลอดลม
1.2
ฯลฯ
1.3
(
2.1
(forced inspiratory/expiratory wheeze)
2.2 (increased A-P
diameter)
2.3
atopic
dermatitis

9. 9
recurrent wheezing (
3.1 (chest X-
pneumothorax, atelectasis

10. 10
3.2 (pulmonary
function test)
1
ของ FEV1
2
Peak flow variability = PEFmax - PEFmin x
100%
1/2 (PEFmax + PEFmin)
3.3
(allergy skin prick test)

11. 11
3.4
(bronchoprovocation test)
croup, foreign
body, vascular ring ฯลฯ
BPD
(bronchopulmonary dysplasia) ฯลฯ
3. gastroesophageal reflux (GER),
congestive heart failure ฯลฯ
(Classification of asthma
by severity)
NHLBI (National Heart Lung and Blood I
(intermitte
1)

12. 12
(Classification
of asthma severity)
4 : (Severe persistent)
อำกำรหอบตลอดเวลำ
(Exacerbation อยมำก
PEF FEV1
60%
> 30%
3 : (Moderate
persistent)
อำ (Exacerbation
2- agonist
PEF FEV1
>60% - <80%
>30%
2 : (mild persistent)
(Exacerbation
PEF FEV1
80%
20-30%
1:
(Intermittent)
(Exacerbation
exacerbation
PEF FEV1
80%
<20%

13. 13
I (Treatment of
acute asthmatic attacks)
1.
2.
FEV1, PEFR
3. as
- inhaled 2-agonist
-
- theophylline, anticholinergic drug ฯลฯ
-
4.
asthma exacerbations
1. asthma exacerbations

14. 14

15. 15
asthma exacerbations
Mild Moderate Severe วะ
Respiratory
arrest
อำกำร
(Symptoms
)
หำยใจลำบำก
อำกำรแสดง
(Signs)
จ
–
–
–
หำยใจ
wheeze
หำยใจออก
wheeze
)
< 100 100 – 120 > 120
–
–
–
Pulsus
paradoxus (< 10 mm Hg) (10–25 mm Hg)
–
ศษ
(Functional Assessment)
PEF
% predicted
or
% personal
best
> 80% ประมำณ 50–
80%
< 50%
PaO2 (on air) > 60 mm Hg < 60 mm Hg
PaCO2 < 42 mm Hg < 42 mm Hg > 42 mm Hg
SaO2% (on > 95% 91 – 95% < 91%

16. 16
air)
2. asthma
exacerbations
inhaled 2-agonist
และประ
1
asthma
exacerbations
PEF)
Inhaled short-acting 2– MDI*

17. 17
- 2-agonists
4 – 6 ชม
24 – 48 ชม.
-
–
- 2-
2 ชม.
น
- 2-
ม กษำ
MDI
MDI
3.

18. 18

19. 19
asthma exacerbations
ในโรงพยำบำล ( )
-
- SaO2, PEFR, EFV1
- Inhaled short-acting 2-agonist
3 doses
- oxygen SaO2 > 95%
- systemic corticosteroid
- อำกำร,
อำกำรแสดง
- SaO2,
PEFR, FEV1
- inhaled short-acting 2-
agonist
- systemic corticosteroid
- -
- inhaled short-acting 2-agonist
continuous
nebulization inhaled
anticholinergic
- oxygen
- systemic corticosteroid
-
distress
- SaO2 > 95%
- PEF > 70%
ง
-
- SaO2 < 95%
- PEF 50% -
70%
-
- PEF < 30%
- PCO2 > 45 mm
Hg
- SaO2 < 90%
- PaO2 < 60 mm
Hg
Discharge
- inhaled 2-
agonist
systemic
corticoste
short
course
-
กษำ
-
ล
- inhaled 2-agonist
- oxygen
- systemic
corticosteroid
- anticholinergic
-
theophylline
intensive care
- inhaled 2-agonist
- systemic
corticosteroid
- oxygen
- systemic
2-agonist: SC, IV, IM
- continuous
2-agonist IV
theophylline
- anticholinergic
-

20. 20
– Oxygen
– Bronchodilators: 2-agonist, anticholinergics,
adrenaline
– Corticosteroids
–
Oxygen
–
FEV1 PEFR
SaO2 > 95%
– face mask
– SaO2

21. 21
–
water nebulizer
2 - Agonists
– inhaled short-acting 2 -
Nebulizers
– -
PEFR
– nebulization oxygen flow
6-8 L/min
–
Metered-dose inhaler (MDI) with spacer
– -
bronchodilatation nebulizers
Injection

22. 22
–
0.01
mg/kg/dose 0.3 mg

23. 23
3 ขนำดของยำแ 2-agonist ในภำวะ
asthma exacerbations
ขนำดของยำ
Inhaled short – acting
2-gonist.
- Salbutamol nebulizer
solution
-
-
-
continuous
nebulization
selective 2-
2.5
– 4
6-8 L/min
- Salbutamol MDI
(100 g/puff)
-
-
Systemic (injected) 2-
agonists
- Terbutaline
-
aerosol therapy

24. 24
Epinephrine
–
angioedema
– 2-
– epinephrine 0.01 mg/kg 0.01
ml/kg 0.5 mL
3 doses
Anticholinergics
– inhaled 2-
acute
exacerbation
– inhaled 2-
severe airflow obstruction
(Ipratropium bromide -
Atroven Beta2-
salbutamol)

25. 25
Ipratropium bromide
2-agonist
ipratropium bromide nebulizer solution (0.25
mg/ml) initial
-
Combivent unit dose 2.5 cc
½ unit dose/ 10 kgs
anticholinergics
(hypertrophic
subaortic stenosi
atropine
Corticosteroids
acute asthmatic a
–
inhaled 2-agonists
– inhaled 2-
3-4
inhaled 2-

26. 26
– Severe acute episode
corticos
-
5
asthma
exacerbations
Steroid Anti-
inflammator
y
Effect
Growth
Suppre
ssion
Effect
Salt-
retaining
Effect
Plasma
Half-life
(min)
Biologi
cal
Half-life
(hr)
Hydrocortison
e
1.0 1.0 1.0 80-120 8
Prednisolone 4 7.5 0.8 120-300 16-36
Methylprednis
olone
5 7.5 0.5 120-300 16-36
Dexamethaso
ne
30 80 0 150-300 36-54

27. 27
5 ขนำดของยำ corticosteroids
อยำ ขนำดยำ
Methylprednisolon
e (IV)
loading dose 2 มก./กก.
-
6 ชม.
Methylprednisolone
succinate
(Solu-Medrol )
40 mg/1 ml = 159 บำท
125 mg/ 2 ml = 336 บำท
Hydrocortisone
(IV)
loading dose 5-7 มก./กก.
4-6
ชม.
Hydrocortisone succinate
(Solu-Cortef )
100 mg/2 ml = 50 บำท
Prednisolone (oral) -
-
1 tablet = 5 mg
Other treatments
– Theophylline first line drug
acute asthmatic attack therapeutic
index side effect
inhaled 2-
asthmatic attack

28. 28
initial bolus dose 5 mg/kg infusion 0.5-0.9
mg/kg/hr 10-20 g/dL
– Antibiotics
sinusitis, otitis media และ pneumonia
– I
– C
– S
4. asthma
exacerbations
–
–

29. 29
–
–
–
signs, symptoms และ
functional assessment
–
–
–
–
pulse oxim
–

30. 30
กษำในโรงพยำบำ
ล
– blood
gases โดยเฉพำะ PaCO2
5.
2
impending
respiratory failure ค
-
-
-

31. 31
-
retraction ของ paradoxical
thoracoabdominal movement
-
ง wheeze เลย (silent chest)
-
- Pulsus paradoxus 20 mmHg
- PEF 50% ของ predicted/personal base value
- PaO2
- PaCO2 42 mmHg
- SaO2 room air 90%
- pneumomediastinum
6. emergency department
Criteria
-
- peak expiratory flow
personal base value
Medications
- -

32. 32
7.
-
- inhaler และ peak flow meter
-
-
-

33. 33
IV แนวทำงก (Chronic
therapy for childhood asthma)
1 ยำขยำยหลอดลม (Bronchodilator)
acute asthma
2 (Anti-inflamma
(Preventer, Controller)
-
6)

34. 34
1
-
2-
2

35. 35
FEV1 (
(variability) ประมำณ 20-30%
: inhaled low-dose corticostero
leukotriene receptor
antagonists
-
-
oral long-acting
2-
3
FEV1 -
30%

36. 36
-
-
sustained-release
theophylline, long-acting inhaled 2-
long acting oral 2-agonist
leukotriene-receptor antagonist
4
FEV1 ≤
30 %
- -
inhaled long-acting 2-agonist,
sustained-release theophylline, long-acting oral 2-agonist,
leukotriene-receptor antagonist
ตลอดเวลำ อ

37. 37
รงของโรค
-
high-dose inhaled corticosteroid
low-dose inhaled steroid
peak flow meter
peak flow meter

38. 38
(life-threatening asthma)
6
(long-term preventive
medications for asthma in children)
ำ
1. Inhaled
corticoster
oid
-
และคว
2)
-
-
-
-
ดม
-
)
2.
Cromolyn
sodium
- nebulized (20
mg/2ml)
-
- MDI (1และ 5
mg/puff)
- -
-
-
ก
-
กกำร
- รำคำแพง
- -
3.
Leukotrie
ne
-
-
-
- รำคำแพง
-

39. 39
receptor
antagoni
st
กกำร
4.
Ketotifen
- (1 mg/5
ml)
- (1
mg/tab)
ขนำด
0.5 mg
bid
1 mg bid
-
-
-
-
-
-
1-3

40. 40
3
องโรค
ยะยำว
(Long-term Preventive) (Quick-Relief)
4   short acting 2- ลดลง (Step
down)
 inhaled medium-to-
high dose
มำก (severe corticosteroid
persistent)
- long-acting inhaled 2--agonist
จำรณำลด
- sustained-release theophylline
ขนำดและจำนวนยำลง
- long-acting oral 2-
agonist
- leukotriene-receptor
antagonist
 prednisolone
3  inhaled medium-dose corticosteroid  short acting 2-
(Step up)
ปำนกลำง  inhaled low-dose corticosteroid -
(moderate
persistent) - long-acting inhaled 2- agonist

41. 41
- sustained-release theophylline
- long-acting oral 2- agonist
- leukotriene-receptor antagonist
2  inhaled low dose corticosteroid  short acting 2
(mild  inhaled cromolyn sodium -
persistent)
 sustained-release theophylline
 leukotriene-receptor antagonist
 ketotifen
1   short acting 2-
-
(intermittent inhaled 2- inhaled
asthma)

42. 42
7 ขนำดของ corticosteroid
Types of corticosteroids Low dose
(g)
Medium
dose
(g)
High
dose
(g)
Beclomethasone
-MDI (50,250 g)
-Diskhaler (100,200,400
g)
100-400 400-600 >600
Budesonide
-Turbuhaler (100,200 g)
-MDI (50, 100,200 g)
-Nebulized solution
(500,1000 g)
100-200
100-400
-
200-400
400-600
1,000-2000
>400
>600
>2,000
Fluticasone (MDI
25,125,250 g)
50-200 200-300 >300
8
nebulizer
MDI with spacer (with
mask)

43. 43
-
MDI with spacer
DPI
MDI with or without spacer
DPI
MDI = metered-dose inhaler
DPI = dry powder inhaler
IV
1. Primary prevention

44. 44
ก. มำ
25-30
ข. และ
1.2.1. (Indoor environment)
1.2.2. (Outdoor environment)
1.2.3.
1.2.4.

45. 45
1.2.5
1.2.6
1)
2)
1.2.7. อำหำรและโภชนำกำร
-

46. 46
indo
2. Secondary prevention
1.
2.
1.
10
2.
3.
(identify and avoid triggers)
1. house dust mite)

47. 47
2. สำบ
3.
4.
5.
6.
7.
8.
9.

48. 48
19
550
ทำควำมส
)
(exterminator)

49. 49
HEPA (high efficiency
particulate air
สำมำรถก

50. 50
- long-acting
cromolyn
-
- -

51. 51
I. บทนำ
1. National Heart, Lung and Blood Institute, National
Institutes of Health. Global initiative for Asthma.
NIH/NHLBI publication no 95-3659. Washington
DC:NIH;1995.
2. National Heart, Lung and Blood Institute, National
Institutes of Health. Guidelines for the diagnosis and
management of asthma. Expert panel report 2.
NIH/NHLBI publication no. 97-4051. Washington
DC:NIH:1997.
3. Vichyanond P, Jirapongsananuruk O, Visitsuntorn N,
Tuchinda M. Prevalence of asthma, rhinitis, and eczema in
children from the Bangkok area using the ISAAC
(International study for asthma and allergy in children)
questionnaires. J Med Assoc Thai 1998;81:175-81.
4. Vichyanond P, et al. Guidelines on the diagnosis and
treatment of childhood asthma in Thailand. Thai J
Pediatrics 1995;34:3:194-211.
5. Sullivan SD. Cost and cost-effectiveness in asthma.
Immunol Allergy Clin N America 1996;16:819-38.
II.

52. 52
1. National Heart, Lung and Blood Institute, National
Institutes of Health. Global initiative for Asthma.
NIH/NHLBI publication No 96-3659. Washington
DC:NIH;1998.
2. National Heart, Lung and Blood Institute, National
Institutes of Health. Guidelines for the diagnosis and
management of asthma. Expert panel report 2.
NIH/NHLBI publication No. 97-4051. Washington
DC:NIH:1997.
III.
1. National Heart, Lung and Blood Institute, National
Institutes of Health. Guidelines for the diagnosis and
management of asthma. Expert panel report 2.
NIH/NHLBI publication No. 97-4051. Washington
DC:NIH:1997.
2. Global NHLBI/WHO Workshop Report: Global Strategy for
Asthma Management and Prevention. NIH Publication No.
96-3659A. December 1995

53. 53
Anticholinergic Agents in Acute Asthma
1. Brian J L. Treatment of acute asthma. Lancet
1997;350(suppl II):18-23.
2. O'Driscoll RB, Taylor RJ, Horsley MG, Chambers DK,
Bernstein A. Nebulised salbutamol with and without
ipratropium bromide in acute airflow obstruction. Lancet
1989;i:1418-20.
3. Schuh S, Johnson DW, Callahan S, Cally G, Levison H.
Effects of frequent nebulised ipratropium bromide added
to frequent high dose albuterol therapy in severe
childhood asthma. J Paediatr 1995;126:639-45.
4. Karpel JP, Schacter NE, Fanta C, et al. A comparison of
ipratropium and albuterol versus albuterol alone for the
treatment of acute asthma. Chest 1996;110:611-16.
5. Fitzgerald MK, Grunfeld A, Parae PD, et al. The clinical
efficacy of combination nebulised anticholinergic and
adrenergic bronchodilators versus nebulised adrenergic
bronchodilator alone in acute asthma. Chest
1997;111:311-15.
Intravenous bronchodilator therapy for acute asthmatic
attack

54. 54
1. Janson C. Plasma levels and effects of salbutamol after
inhaled or iv administration for stable asthma. Eur Respir
J 1991;4:544-50.
2. Swedish Society of Chest Medicine. High dose inhaled
versus intravenous salbutamol combined with theophylline
in severe acute asthma. Eur Respir J 1990;3:163-70.
3. Salmeron S, Brochard L, Mal H, et al. Nebulised versus
intravenous albuterol in hypercapnic acute asthma. Am J
Respir Crit Care Med 1994;149:1466-70.
4. Cheong B, Reynolds SR, Rajan G, Ward MJ. Intravenous
2-agonist in severe acute asthma. BMJ 1988;297:448-
50.
5. Browne GJ, Penna AS, Phung X, Soo M. Randomised
trial of intravenous salbutamol in early management of
acute severe asthma in children. Lancet 1997; 349: 301-
05.
6. Murphy DG, McDermott MF, Rydman RJ, Sloan EP,
Zalenski RJ. Aminophylline in the treatment of acute
asthma when -adrenergics and steroids are provided.
Arch Intern Med 1993;153:1784-88.
7. Huang D, O'Brien RG, Harman E, et al. Does
aminophylline benefit adults admitted to the hospital in

55. 55
acute exacerbation of asthma. Ann Intern Med 1993; 119:
1155-60.
8. DiGiulio G, Kercsmar C, Krug S, Alpert S, Marx C.
Hospital treatment of asthma: lack of benefit from
theophylline given in addition to nebulised albuterol and
intravenously administered corticosteroid. J Pediatr
1993;122:464-69.
9. Strauss ARE, Wertheim DL, Bonagura VR, Velacer DJ.
Aminophylline therapy does not improve outcome and
increases adverse effects in children hospitalised with
acute asthmatic exacerbations. Paediatrics 1994;93:205-
10.
Theophylline
1. Miles Weinberger, Leslie Hendeles. Drug Therapy:
Theophylline in Asthma. NEJM 1996;21:334.
2. DeNicola LK, GF Monem, MO Gayle, and N Kissoon.
Treatment of Critical Status Asthmaticus in Children.
Pediatr Clin N America 1994;41:1293-325.
3. Brian J Lipworth. Treatment of acute asthma. Lancet
1997;350(suppl II):18-23
4. Practice Parameters for the Diagnosis and Treatment of
Asthma: Joint Task Force on Practice Parameters; The

56. 56
American Academy of Allergy, Asthma, and Immunology,
The American College of Allergy, Asthma, and
Immunologyand the Joint Council of Allergy, Asthma, and
Immunology Editors: Sheldon L. Spector, MD; Richard A.
Nicklas, MD. J Allergy Clin Immunol 1995;96(5):2.
IV. (Chronic therapy for
childhood asthma)
1. National Heart, Lung and Blood Institutes of Health.
Global initiative for asthma. NIH/NHLBI publication no 95-
3659. Washington DC: NIH;1995.
2. National Heart, Lung and Blood Institutes of Health.
Guidelines for the diagnosis and management of asthma.
Expert panel report 2. NIH/NHLBI publication no. 97-4501.
Washington DC: NIH;1997.
3. Warner JO, Naspitz CK, Croup GJA. Third international
pediatric consensus statement on the management of
children asthma. Pediatr Pulmonol 1998;25:1-17.
4. De Jongste JC. Prophylactic drugs in asthma: their use
and abuse. Clinical Pediatr 1995;3:379-98.
5. Price JF. The management of chronic childhood asthma.
In: Silverman M, ed. Childhood asthma and other

57. 57
wheezing disorders. London: Chapman & Hill, 1995:357-
74.

58. 58
V. ด
1. National Heart, Lung and Blood Institute, National
Institutes of Health. Global initiative for Asthma.
NIH/NHLBI publication no 95-3659. Washington
DC:NIH;1995.
2. National Heart, Lung and Blood Institute, National
Institutes of Health. Guidelines for the diagnosis and
management of asthma. Expert panel report 2.
NIH/NHLBI publication no. 97-4051. Washington
DC:NIH:1997.
3. Warner JO, Naspitz CK, Croup GJA. Third international
pediatric consensus statement on the management of
childhood asthma. Pediatric Pulmonol 1998;25:1-17.
4. Warner JO, Warner JA. Preventing Asthma. In:
Silverman M, ed. Childhood asthma and other wheezing
disorders. London: Chapman & Hall; 1995;429-40.
5. Partridge MR. Education of patients, parent, health
professionals and other. In: Silverman M, ed. Childhood
asthma and other wheezing disorders. London: Chapman
& Hall; 1995:465-72.

59. 59
1.
2.
1.
2.
3.
4.
3.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

60. 60
13.
14.
15.