吸入性药物的使用方法永城市中心医院呼吸科主治医师张亚辉2020.04.22日支气管扩张剂支气管舒张剂是控制气流受限的中心药物松弛
支气管平滑肌使支气管扩张，缓解气流受限症状吸入治疗是最佳选择支气管扩张剂按需或规律给药以减轻症状规律吸入长效支气管扩张剂进行治疗较
短效支气管扩张剂更有效、安全支气管舒张剂的分类支气管扩张剂β2受体激动剂长效和短效抗胆碱能类药长效和短效糖皮质激素ICS其它：氨茶
碱等抗胆碱能类药机体受刺激（如吸烟）后，会产生化学“信使”-乙酰胆碱，致使呼吸道收缩抗胆碱能类药物能阻挡乙酰胆碱的作用，使肌肉组织
放松，呼吸道保持畅通状态抗胆碱能类药物作用于部分副交感神经，控制呼吸道松紧此外，抗胆碱能类药物还可降低COPD急性加重期的发病率抗
胆碱能类药物包括：长效：噻托溴铵短效：异丙托溴铵潜在副作用咳嗽口干恶心头痛噻托溴铵吸入β2受体激动剂短效心率加速；精神紧张震颤；口
干舌燥血压升高；肌肉力量减弱；血钾下降β2受体激动剂通过刺激交感神经系统相关的受体，松弛呼吸道周围组织中的肌肉而其作用。分长效和短
效两类：短效药多用于气短发作的急救药；长效药通过一天两次的使用，长期控制呼吸道畅通。短效：特布他林、沙丁胺醇长效：丙卡特罗等潜在副
作用咳嗽口干恶心头痛长效头痛上呼吸道感染鼻咽炎咳嗽β2受体激动剂必须学会科学使用β2受体激动剂三种状况使用β2受体激动剂1、出现
症状（不管咳痰喘的任何症状）2、不利的气候（风雨和雾霾、降温等）3、外出活动或身体锻炼（应随身携带）β2受体激动剂的使用限量
1、无心脏基础病的患者，可以使用12-20吸/天。2、有心脏基础病的患者，根据用药后的自我感受调整使用剂量，一般可使用6-12吸
/天。注：均以万托林气雾剂为例，一般每次2吸，最短15-30分钟可重复一次。β2受体激动剂：沙丁胺醇气雾剂ICS+LABA(信必
可都保)科学使用糖皮质激素吸入性的糖皮质激素是治疗支气管哮喘的核心药物，但并不作为COPD治疗的首选药物（但近年来有早期COPD就
使用此类药物的倾向）。全身使用糖皮质激素一般适用于重症哮喘和COPD患者以及急性加重的患者，全身使用激素不适宜长期使用。吸入使用糖
皮质激素的潜在危险是：鹅口疮（真菌感染）、舌痛、声嘶等，全身使用糖皮质激素的潜在危险是：免疫抑制、代谢紊乱、机会菌感染等。长效吸入
型支气管舒张剂联合吸入型皮质激素已经成为支气管哮喘和COPD治疗的共同首选。潜在副作用鹅口疮（真菌感染）舌痛声嘶价格噻托溴铵粉
气雾剂18um10粒60元/盒180元/月布地奈德福莫特罗粉吸入剂160ug,4.5ug224元/月丙卡特罗粉
吸入剂10ug200揿268元/月沙丁胺醇气雾剂100ug200揿19.8元/支ThankYou
!Bronchodilatorsareaclassofmedicationsthatrelaxthemuscle
saroundthebronchitoalloweasierbreathing.Theyaretypicall
yindicatedforthereliefofbronchospasm,whicharecontraction
softhesmoothmuscleinthewallsofthebronchiandbronchiole
sthatcausetheairwaystoconstrictornarrow.[8]Anticholinerg
icbronchodilatorsfallintothisclassofCOPDmedications,asd
oshort-actingbeta2-agonists,long-actingbeta2-agonists,methy
lxanthines(e.g.,theophylline),andacombinationofanantichol
inergicbronchodilatorandashort-actingbeta2-agonist.Allmajo
rguidelinesforCOPDmanagementrecommendbeginningtreatmentwi
thaerosolbronchodilators,whichareinhaleddirectlyintothel
ungsandhavefewsideeffects.[18,19,21,22]Anticholinergicbronc
hodilatorsInresponsetoirritantssuchascigarettesmoke,theb
odyproducesachemical"messenger"calledacetylcholinethatind
ucestheairwaystoconstrict.Anticholinergicsaretheonlymedi
cationsthatactbyblockingacetylcholine,therebyrelaxingthe
muscletissueandkeepingtheairwaysopen.[24]Anticholinergicm
edicationsworkviapartoftheparasympatheticnervoussystem,w
hichcontrolsairwaysize.InadditiontohelpingCOPDpatientst
akefullerbreaths,[24]maintenanceuseofanticholinergicmedica
tionmayalsohelplowertheincidenceofacuteexacerbationsin
COPDpatients.[25]TheAmericanThoracicSociety,aleadingmedic
alauthorityonrespiratoryillnesses,recommendsanticholinergic
sasthefirstlineofmaintenancetherapyforpatientswithdail
yCOPDsymptoms.[9]TheGlobalInitiativeforChronicObstructive
LungDiseasealsorecognizesanticholinergicsasanimportanttr
eatmentforCOPD.[19]Anticholinergicsaremostoftenadministere
dthroughmetered-doseinhalers,or"puffers,"astheyarecommon
lycalled.Theeffectsofthemedicationgenerallylastfromfour
tosixhours,sophysicianstypicallyprescribeusefourtimesa
day.[9]Inhaledanticholinergicsareminimallyabsorbed,resulti
nginrelativelyfewsideeffects.Somecommonsideeffectsofip
ratropiumbromide,aninhaledanticholinergictherapy,includeco
ughandnervousness.[24]Anticholinergicbronchodilators,asacl
ass,arethenumberoneprescribedbronchodilatorusedinthetre
atmentofCOPD.[26]Currently,theleadinganticholinergicmedica
tionprescribedbyphysiciansisipratropiumbromide.Itissold
aloneunderthebrandnameATROVENT,InhalationAerosolorincom
binationwithalbuterolsulfateunderthebrandnameCOMBIVENT,I
nhalationAerosol.抗胆碱类药物POSSIBLESIDEEFFECTS?C
oughing?Drymouth?Nausea?HeadachePOSSIBLESIDEEFF
ECTSYoumaynoticeafterafewdays:?Fluidretention?Increa
sedappetiteYoumayexperienceafterseveralmonthsofuse:?Adren
alsuppression(lessabletohandlestress)?Decreasedresistancet
oinfection(getinfectionsmoreeasily)Beta2-agonistsBeta2-agonis
tsworkviapartofthenervoussystemthatcontrolsmuscletissu
earoundtheairways.Theyworkbystimulatingreceptorsinthes
ympatheticnervoussystem,leadingtodilationofairpassages.[8
]Twotypesofbeta2-agonistsareavailable:short-actingbeta-a
gonistsandlong-actingbeta-agonists.Short-actingbeta2-agonist
sThesemedicationsarerecommendedbytheAmericanThoracicSocie
tyforpatientswithCOPDwhoexperienceintermittentsymptoms.[9
]Theyarealsousedasa"rescue"medicationtofendoffanimpe
ndingattackofshortnessofbreath.Short-actingbeta2-agonists
aretypicallyprescribedalongwithanticholinergicstoopenup
theairwaysofCOPDpatientswithcontinuingsymptoms.[9]Thesho
rt-actingbeta2-agonistmostcommonlyprescribedbyphysiciansis
albuterol.[26]Inclinicalstudies,themostcommonsideeffects
ofalbuterolincludedtremor,nausea,tachycardia,palpitations
andnervousness.[27]Long-actingbeta-agonistsThesebronchodilato
rsaretakentwiceadayand,likeshort-actingbeta-agonists,wo
rkviapartofthenervoussystemthatcontrolsmuscletissuearo
undtheairways.TheyarerecognizedasatreatmentforCOPDbyt
heGlobalInitiativeforChronicObstructiveLungDisease.[19]Lo
ng-actingbeta-agonistsareoftenprescribedfornighttimebreath
ingproblemsbecausetheyprovideupto12hoursofrelief.[19]P
atientsusinglong-actingbeta-agonistsneedtoberemindedtoco
ntinueusingtheirshort-actingbeta-agonistfor"rescue"therapy
,becauselong-actingbeta-agonistsdonotworkasquicklyandar
eindicatedforuseonlytwiceaday.[28]Themostcommonsideef
fectsseenwithuseoflong-actingbeta-agonistsbypatientswith
COPDincludeheadache,upperrespiratorytractinfection,nasoph
aryngitisandcough.[27](Veryuncommon)?Racingheart?Tremors(
shaking)?NervousnessPOSSIBLESIDEEFFECTS?Rapid
heartbeat?Nervousness?Tremorsandshakiness?Nausea?Drymouth
andthroat?Increasedbloodpressure?Muscleweakness?Decreased
bloodpotassiumlevelCorticosteroidsCurrently,inhaledcorticost
eroidsarenotindicatedforthetreatmentofCOPD.Theyarethe
cornerstoneofasthmatherapy,buthavealimitedroleinthemai
ntenanceoflungfunctioninpatientswithCOPD.Onlyabout10pe
rcentofpatientswithCOPDshowasignificantimprovementinlun
gfunctionwhentreatedwithcorticosteroids.[32]Thereasonist
hatdifferentmediatorscauseinflammationinasthmaandCOPD.[32
]ThemediatorsthatcauseinflammationinCOPDhaveonlylimited
responsivenesstocorticosteroids,whilethosemediatorsrespons
ibleforinflammationinasthmaaredramaticallyaffectedbyinha
ledcorticosteroids.[32]Surveysofclinicians''prescribinghabit
s,however,haveshownlittledifferenceintheuseofinhaledco
rticosteroidsforasthmapatientsandforCOPDpatients.[33],34]
GuidelinesforthetreatmentofCOPDsuggestthatbecauseinhaled
corticosteroidsplayonlyaminorroleinthemaintenancetreatm
entofCOPDandmayproducesystemicsideeffects,theyshouldbe
reservedforpatientswhosesymptomsarenotoptimallycontrolle
dwithbronchodilators.Thissubgroupofpatientsshouldreceive
inhaledororalcorticosteroidsforatrialperiod.Ifasignific
antobjectiveclinicalresponseisnotachieved,corticosteroidsshouldbediscontinued.Whenabenefitisobservedwithoralcorticosteroids,thedoseshouldbetaperedtothelowestpossibledose.Atthatpoint,atrialofaninhaledcorticosteroidshouldbeinitiated.[19,21]Themostcommonsideeffectsofinhaledcorticosteroidsincludeupperrespiratoryinfection,headacheandpharyngitis.POSSIBLESIDEEFFECTS?Oralthrush(yeastinfectionofthemouth)andsoretongue?Hoarseness |
|
