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CM medication

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									胸內常用藥品介紹


  胸腔內科
     Classification
1. Drugs for obstructive lung
   disease
2. Drugs for infectious disease
3. Drugs for chemotherapy
4. Drugs for symptomatic relief
     Drugs for obstructive lung
              disease
 COPD and asthma ( including stable
  condition and acute exacrbation
 Inhaled medication: prefer medicine
  oral medication
  IV and IM medication
GINA (Global Initiative for Asthma)
        Guidelines 2002
                                            Severe
                  Mild       Moderate      persistent
Intermittent   persistent    persistent

                                 Short-acting ß2 p.r.n
                              Inhaled Corticosteroid

                       Sustained-release theophylline

                                Leukotriene Modifier

                              Long-acting ß2 agonist

                                          Oral steroid
             GOLD guideline (2003)

0: at risk    I: mild    II: moderate     III: severe   IV: very severe


Aviodance of risk factors; influenza vaccination

             Add short acting bronchodilator when needed
                        Add regular one or more long acting
                        bronchodilator; Add rehabilitation
                                        Add inhaled steroid
                                                        Add long
                                                        term O2
   Inhalation Therapy

  液態或固態的粒子懸浮在氣體中便稱
為氣霧(aerosol).經由氣霧粒子攜帶藥
物,水或食鹽水進入呼吸道達到治療的效
果稱為吸入治療.
  1. 藥物吸入治療
  2. 非藥性(blind)吸入治療(含水或
     食鹽水粒子)
Indication and goal of inhaled therapy


 1. 呼吸道給藥
 2. 稀釋肺部分分泌物與誘發取痰
   (hydration of pulmonary secretions
    and sputum induction)
 3. 吸入氣體的濕化
    (humidification of inspired gases)
Devices of inhaled therapy
 1. 噴嘴式噴霧器
   jet nebeulizer
 2. 超音波噴霧器
  ultrasonic nebeulizer
 3. 定量吸入器
  metered dose inhaler (MDI)
 4. 乾粉吸入器
  dry power inhaler (DPI), including rotadisk,
  turbuhaler, accuhaler & easyhaler
Jet nebeulizer
Spacer as adjuvant therapy
    Dry power inhaler (DPI)
 Rotadisk
 Easyhaler
 Accuhaler
 Turbuhaler
Easyhaler
Accuhaler ( 胖胖魚)
Turbuhaler ( 都保)
     Reliever                  Controller
Short acting b 2-agonists   Inhaled corticosteroids
      (cold color)                (warm color)
            各種器具之優缺點比較
                 優點                缺點
Nebulizer   吸入率8-12%且不需病人配合    不 經濟藥品易浪費
            可用於人工氣道與呼吸器患者      耗時長易污染
            可作高劑量與持續性治療        需高流量氣體作動力來源
            不含氟氯化碳不污染環境


MDI         可用於人工氣道與呼吸器患者      吸入率9-12%且須病人高度配合
            方便便宜不易污染           人工氣道與呼吸器患者吸入率只有4-6%
                               氟氯化碳會破壞環保


DPI         吸入率12-16%且不需病人配合   需較高之吸氣流速
            不含氟氯化碳不污染環境        無法使用於人工氣道與呼吸器患者
            攜帶方便便宜不易污染         易受濕氣影響
Inhaled Medication


1. b2-agonist
2. Anti-cholinergic agent
3. Steroid
       Short acting b2 agonist
1. Ventolin (Salbutamol),
   nebeulizer, 1 amp
  (5mg/2.5 ml), q30 min –
  q6h prn; MDI 2 puff prn

2. Bricanyl (Terbutaline
   hydrochloride),
  Turbuhaler, 200mg/100
  dose, 1-2 puff qid prn
  Long acting b2 agonist
Serevent
(Salmeterol xinafoate),
 Accuhaler, 50mg/60
 1-2 puff bid



Oxis (formoterol),
9 ug / dose.
Turbuhaler 1 puff bid
        Anticholinergic Agent

Atrovent (Ipratropium
bromide)

1. MDI, 200 puffs/10 ml,
   2-3 puff qid
2. Nebeulizer solution,
   0.5mg/2ml/vial,
   1 vial qid
          Combined β2 agonist and
      anticholinergic drug ( Combivent )


   Combivent
    (Ipratropium + albuterol)
    2puff Qid
                     Inhaled steroid
   Pulmicort (Budesonide)
    Turbuhaler: 200ug/200dose/bot,
      2-4 puff bid
    Nebeulizer: 1000ug/2ml/vial,
     0.5 -1 vial bid


   Flixotide
    (Fluticasone propionate)
     Accuhaler, 250mg/puff/60dose,
     1 puff bid
    MDI, 50mg/puff/200dose
          Combination therapy
    (Long acting β2 agonist + steroid)
   Symbicort
    (Budesonide + formoterol )
    Turbuhaler, 200 puff,
    1~2 puff bid

   Seretide (Fluticasone
    propionate + Salmeterol )
    Accuhaler; 1 puff bid
         Oral Medication
1. b 2 agonist
  inolin ( 1# tid-qid); meptin ( 1# bid),
  bambec 1# qn
2. Xanthine derivates
  Phyllocontin 1# bid-tid (不可磨碎),
  theophylline 2# qn or 1# q12h (可磨粉,適合
    NG feeding者)
3. Steroid: prednisolone 0.5-1mg/kg qd
4. Leukotrine modifier:
  Accolate 1# bid
  singulair 1# qd
     IM & IV medication
1. Epiphephrine
  IM: 0.5 ml sc
  IV: 0.5-1 ml slowly IVD
2. Ipradol (Hexoprenaline Sulfate)
  1 amp(5ug/2ml) IM or IV slowly
3. Aminophylline (must add in saline)
  Loading dose: 250 mg x 30 min
   250 x 8 hours
   6-15 mg/kg qd (serum level 10-20ug/dL)
 Drugs for infectious lung disease

1. Community acquired pneumonia( CAP)
   with and without parapneumonic effusion
2. Hospital acquired pneumonia (HAP)
3. Pulmonary TB
5. Empyema thoracis and lung abscess
6. COPD or asthma with 2nd infection
8. Bronchiectasis with 2nd infection
Community acquired pneumonia

 Pathogens: S. pneumoniae; H. influenza;
  atypical pathogen ( M. pneumoniae,
  C. pneumoniae ). Mixed infection, MSSA,
  and some G(-) bacillus…
 Mixed typical and atypical pathogen.
 Risks factor or host factor of specific
  pathogens in pneumonia
Community acquired pneumonia
   S. pneumonae: Penicilline, Rocephine or
    Vancomycin, fluroquinolone
   H. influenza, G(-) bacillus: Unasyn, Augmentin
    or 2nd and 3rd cephalosporin and fluroquinolone
   Atypical pathogens: Erythromicin, klaricid,
    Zithromax, tetracycline and fluroquinolone
   Mixed infection: Penicillin, Cleocin, Unasyn
   MSSA: Cefalosporin, Oxacilline
    Hospital acquired pneumonia
   Pathogens: G(-) bacillus, P. aeruginosa, MRSA,
    VRE, A. baummanii, Legionella..
   MRSA: Vancomycin, Targocid
   P. aeruginosa: Pipril/Tazocin, Fortum, Cravit,
    Ciprofloxacin, Tienam and maxipime
   G(-) bacillus: 3rd cephalosporin
   Legionella: Erythromycin, Klaricid, Zithromax
   A. baummanii: Tienam
Pulmonary TB and TB pleurisy
 First line: INH, RIF, EMB, PZA
 Secondary line: Fluroquinolone, Aminoglycoside,
  PAS, Ethionamide, and Cycloserine
 Standard therapy: 6 months
  Intensive therapy X 2months: HERZ
  Maintain therapy X 4 months HER
 If PZA is not used, Keep HER for 9 months
Pulmonary TB and TB pleurisy
   Side effect:
    INH: hepatitis, peripheral neuropathy
    RIF: hepatitis, jaundice, rash
    EMB: neuritis
    PZA: hepatiits, hyperuricemia, gouty
 Steroid & Vitamin B6
 Combination therapy:
    Rifater: INH 80 + RIF 100 + PZA 250
    Rifinah: INH 150 + RIF 30
   Thoracis Empyema and
       Lung Abscess
1. Treat as pneumonia
2. Adequate drainage
  Tube drainage
  Decortication
  Repeated lung aspiration (abscess)
3. At least 3-4 weeks IV antibiotics
   treatment and total duration
   around 6-8 weeks
     COPD /c 2nd Infection
Most caused agents
1. H. influenza, G (-) coccobacillus
   Tx: Ampicilline/Unasyn, Amoxicilline
        /augmentin; 2nd cephalosporin, Macrolidw
2. Moraxella catarrhalis, G (-) diplococcus
   Tx: Macrolide, Baktar, Augmentin or
       Fluroquinolone, 3rd generation cephalosporin
3. Streptococcus pneumoniae G(+) diplococcus
   Tx: Penicillin, Amoxicilin/ Augmentin,
        Ampicilline/ Unasyn
Bronchiectasis with
secondary Infection

1. Initial: G(+) coccus + GNB:
  Tx as COPD with 2nd infection
2. Later: GNB, especially P.spp
  Floroquinolone:
  3rd generation cephalosporins
  Beta-lactam PCN + aminoglycoside
  Tineam + aminoglycoside
Drugs for chemotherapy

 1. Small cell lung cancer
   (SCLC)


 2. Non-small cell lung cancer
   (NSCLC)
Small cell lung cancer
  First choice
   Cisplatin 75 mg/m² x 1 day
   V-P 16 100 mg/ m² x 3 days
   every 28 days
  Second line
   Topotecan 1.5-2.5 mg/m2
    Taxol 135 mg/m2 (自費)
   every 21 or 28 days
Non small cell lung cancer

  First line
  1. Gemzar 1000 mg/m² + Cisplatin
     100 mg/m² + x I
  2. Taxol 135 mg/m² + Cisplatin
     75 mg/m² x I
  3. Navelbine 25 mg/m² + Cispaltin
     75 mg/m² x I
  Second line
  1. Taxotere 75 mg/m² x I /C or /S Cisplatin
    Drugs for symptomatic relief

 Insomnia
 Cough
 Pain
 Shortness of breath
              Insomnia
 看病人
 Haldol
 Type I receptor : Zopiclone , Zolpidem
 Type II receptor : Ativan , Valuim
Antitussive & Expectorants


      1. Solution

       2. Tablet or capsule

       3. Nebular
        Solution
1. Brown mixture (B.M)
  含opium, 5-10 ml tid – qid
2. Guaifenesin (Unitussin or G.P)
  reduce the visicosity of sputum
  antihistamine effect (+)
  5-10 ml q4h - q6h
3. Fusoco
  限小兒科使用,成人需自費
            Tablet
1. Brown mixture (B.M), 1-2# tid - qid
2. Bensau (Benzonatate) 1-2# tid - qid
3. Codeine 1# q6h prn
4. Bisco (Bisolvon) 1# qid
5. Danzen 1-2 # tid - qid
6. Mucora 1# qid
7. Medicon 1# tid –qid
# 以上藥品不得同時開立三項 (含) 以上
       Nebulizer
1. Bisolvon
  aerosol + mucolytic agent
   help to expectorate
2. Lidocaine
  for refractory cough, 2mg/5ml IH
3. Gentamycin
  40 mg IH q8h, as immunomodulater
                Pain
 Acetaminophen
 NSAID
 Tramadol (50mg) & Tramadol-SR (100mg)
 Morphine (10mg PO, IM, IV)
 Fentanyl (25μg, 50μg)

								
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