<Case>
A 61-year-old woman visited ER with dyspnea and productive
cough for 3-4 days.
The patient has been diagnosed as
having DM, glaucoma and old pulmonary tuberculosis. She
suffered from urticaria off-and-on since eight years old.
After that, episodic attacks of wheezes and dyspnea developed,
especially in the winter and nighttime. She was treated at OPD
and was hospitalized several times due to exacerbation.
Inhaled bronchodilators were prescribed.
She suffered from rhinorrhea, sore
throat and productive cough with scanty sputum 4 days prior to
this admission. Progressive dyspnea developed later. There was
neither fever nor chills complained.
At ER, the patient had clear
consciousness. Moderate respiratory distress with prolonged
expiratory phase were observed. The respiratory rate was
24/min, BP 124/76 mmHg and HR 116/min. Physical examination
revealed diffuse wheezes at lung. Leukocytosis with left
shifting was documented by lab exam. CXR showed bilateral
hyperinflation, collapse of RUL and bronchiectasis over lower
lung fields. Under the impression of upper respiratory tract
infection and asthma attack, she was admitted to the ward.
After admission, bronchodilators
with terbutaline (Bricanyl) and ipratropium (Atrovent)
nebulization were administered. Simultaneously, intravenous
steroid was started. The dyspnea and wheezes improved
gradually. Steroid was shifted to oral form and was tapered
then. Inhaled bronchodilators were changed into metered-dose
inhaler (MDI) and she was discharged smoothly.
<Discussion>
氣喘病是一種反覆發作的氣流阻滯病變,會自行緩解或是經過適當的治療而恢復。其症狀可有呼吸困難、喘鳴音、胸悶和咳嗽等,但並非每位病人都有全部的症狀。氣喘的病因及致病機轉尚未完全明瞭,主要是過敏造成氣道的發炎細胞增加,產生氣道過度反應(bronchial
hyperresponsiveness)並引起急性支氣管收縮,造成氣流阻滯,引發各項臨床症狀。
氣喘的診斷,除了典型臨床症狀,如間歇性呼吸困難、咳嗽、喘鳴等,還可以輔以肺功能測量、支氣管激發試驗或擴張劑試驗,或是尖峰吐氣流速之變異度。此病須與慢性阻塞性肺病作鑑別。由於氣喘是一過敏性疾病,病患也常伴有鼻炎、蕁麻疹等疾病。
近年來,氣喘病已有標準化之治療方式,目前的診療指引有GINA
(Global Initiative for Asthma) (http://www.ginasthma.com)及國內之各醫學會及國民健康局所編寫之指引。在治療氣喘前須對其嚴重性分級(此處是指長期之病患狀況,而非發作至醫院急診的特殊情形):輕度間歇性為每週低於一次的日間症狀,輕度持續性為每週多於一次但小於每日一次症狀,中度持續性為每天大於等於一次症狀,重度持續性為連續性的症狀。治療用藥包括緩解藥物及控制藥物:前者為短效(速效)之支氣管擴張劑(如fenoterol、terbutaline、salbutamol、ipratropium);後者包含類固醇(吸入型為主)、緩釋型茶鹼、長效型擴張劑(如salmeterol、formoterol)等。所需藥物的種類及劑量,依照病患氣喘嚴重性而有不同,此乃所謂階梯式的治療原則。重點為,輕度持續性的氣喘(含)以上,皆須使用吸入型類固醇治療。若只用短效型擴張劑,只能夠治標,但無法治本—控制其氣道過敏及發炎的反應,這也是某些病人長期症狀起伏而無法根治的主因。
若是病患氣喘急速惡化送至醫院急診時,則不適用前述之處置。此時應以穩定生命徵象為優先,注意是否發生呼吸衰竭或其他合併症。最直接有效的是使用速效乙二型交感神經興奮劑氣霧吸入,必要時須每20分鐘一劑。此時可同時給予類固醇(注射或口服)。反應良好者且療效持續者,在急診觀察後可返家;療效不良者須住院持續治療;更嚴重者會發生呼吸衰竭,就必須施行氣管插管、使用呼吸器及送入加護病房治療。
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