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SUYN TR EM

MC TIU Y61. Hiu c nh ngha suyn2. Vn dng c sinh l bnh hc gii thch triu chng suyn v iu tr suyn 3. Nu c cc nguy c nhp vin v t vong ca suyn4. Chn on c bnh suyn, nng cn, nng ca bnh v mc kim sot suyn 5. So snh c cc thuc thit yu trong iu tr suyntheo hai nhm ct cn v d phng6. Nu c iu tr thch hp ct mt cn suyn cp7. Trnh by c iu tr d phng suyn

1. NH NGHA

Suyn l tnh trng vim mn tnh ca ng h hp vi s tham gia ca nhiu t bo vim. Vim mn tnh thng i i vi tng kch ng ng th v dn n nhng t kh kh, khth, au ngc v ho ti i ti li c bit thng xy ra v m hay sng sm. Nhng t biuhin triu chng thng do tc nghnphn ln ng th trong phi v thng hi phc tnhin hoc sau iu tr. [5]2. DCH T- c tnh trn ton th gii, theo WHO c khong 300 triu bnh nhn suyn (c ngi ln vtr em). Tuy nhin tn sut hin mcdao ng ng k gia cc quc gia t 1% - 18% dn s[5].- T vong tr em t 5 -14 tui ti M nm 2000 l 0,3/1000 tr, chim < 2% t vong chung tui ny [2]- Tn sut suyn thnh th cao hn nng thn.- Suyn l gnh nng kinh t v x hi. Suynkhng ch gy hao tn tin bc cho cha tr mcn gy hao tn do nhng nguyn nhn ngoi iu tr bao gmngh hc, ngh lm, tn tt sm v

t vong.[5]- Kh kh ti i ti li tui nh nhi c nguy c din tin thnh suyn cao hn tui thanh thiunin. [3]

2.1. Nhngyu t nh hng n s hnh thnh v khi phtsuyn[2,3,5]Gm 2 nhm: nhm nh hng hnh thnh suyn v nhm khi pht triu chng suyn. Mt syu t thuc c 2 nhm.

Nhm gy ra bnh suynL nhng yu t bnh ch gm:- Di truyn(ch yu)

Gen qui nh d ng Gen qui nh tng kch ng ng thTin cn d ng ca gia nh l mt trong nhng yu t nguy cquan trng nht ca

suyn ko di tr em v tr cng d b suyn nng hn.[2,9] Mi quan h gia m b suynhoc vim mi d ng vi suyn con l mnh nht. [9]Tr c m b suyn c nguy c bsuyn cao hn tr c cha b suyn. Gia cc tr song sinh, mt tr b suyn th nguy c 36 75% tr cn li cng b suyn. [2]

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Nu tr c biu hin ca c a d ng (nh test ly da (+), tng esinophil mu) th clin quan n suyn nng vko di tui nh nhng mi tng quan ny khng r rng khitr qua tui trng thnh.[2]- Bo ph- Gii tnh: trc 14 tui nam b suyn gn gp i n. T l ny gim dn v khi n tui

trng thnh n b nhiu hn nam

Nhm khi pht cc triu chng suyn (cn suyn)Yu t mi trng: thng gp nht

D ng nguyn- Trong nh: con mt, th c lng (ch, mo, chut), gin, nm, mc meo. - Ngoi nh: phn hoa, nm, mc meo. tr nh nhi, d ng thc n vi nhng biu hin ngoi da, ng tiu ha hay ngh hp thng gp hn d ng nguyn ng ht[3]. Nhim trng

- Nhim siu vi ng h hp l yu t khi pht cn thng gp nht tr em, trong RSV l tc nhn hng u tr di 3 tui v Rhinovirus nhm tui ln. Tuy nhin,nhng virus ny ch khi pht suyn trn nhng tr c c a d ng m thi[2]. Khong40% tr nh nhim RSV b kh kh ko di hoc din tin thnh suyn sau ny.[5,6]

- Mt s nhim trng sm nh si, vim gan A hoc thm ch mt s chng RSV c thlm gim nguy c mc bnh suyn.

- Cc chng vi khun rut cng l ngun tip xc thng xuyn nht ca tr em. S dngcc probiotic lm thay i thnh phn vi khun ng rut cng c xut l mtphng php ngn nga suyn. Tuy nhin, d mt s probiotic c hiu qu ngn ngavim da d ng, tc ngtrn suyn cha c ghi nhn[6].

- S dng khng sinh cng lm thay i chng vi khun rut nhng dng nh vic sdng khng sinh khi tr cn nh lm tng tn sut suyn khi tr ln ln. [6]

Cht kch thch tr em thng gp nc hoa,thuc xt phng,bi, chlorine Khi thuc l

- Ht thuc lch ng hay th ngul mt trong nhng yu t nguy c mi trngmnh m nht gy ho, kh kh ti pht hoc suyn triu chng v lm suy gim chcnng h hp bt k la tui nongay c t trc sanh.[2,3,5]

- Khi thuc l lm tng tnh oxy ha v kch thch vim c ng th trn v di. Trcng nh, nh hng bt li cng cao hn do ng th ca tr cn nh [3]. Tr nh nhic m ht thuc l c nguy c b bnh l kh kh tng gp 4 ln trong nm u i [5]

- Ht thuc l lm suyn kh kim sot hn, lm tng tn sut ln cn suyn, tng s lnnhp vin. Ht thuc l cn lm gim chc nng phi nhanh hn v gy tng nguy c t

vong [5] nhim mi trng nhim mi trng gy suy gim chc nng h hp, tuy nhin mi lin h vi suyncha c tm thyr rng. [5] Thi titThi tit dng nh c nh hng n suyn tr em[2]. Ngi ta nhn thy khi nhit khc nghit hay m cao hoc khi tri ma bo c sm st, tr gia tng nguy c lncn suyn.[3]

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Ch n- Tr b sa cng thc hay sa u nnh c tn sut b kh kh cao hn tr b m .[5]- Ch n phng Ty vi nhiu thc n ch bin sn, nhiu acid bo khng bo ha

chui di n-6 (c trong b v du thc vt); t thc n c cht chng oxi ha (c trong rauv tri cy), t acid bo khng bo ha chui n-3 (trong duc) lm tng tn sutbnh

suyn v d ng [2,5]

Gng scGng sc c th gy khi pht cn suyn trong phn ln tr b suyn.[ 3] C ch c th do

tnh thm thu ca ng th b thay i do mt nc, thay i nhit dn n co tht phqun.Tuy nhin, cc bi tp th dc u n hoc nhng bi tp th lc nh nhng rt tt chosc khe v c th cithin tnh trang suyn [3]

Sang chn tm lNhng ri lon tm l ko di c th nh hng n bnh suyn. Ngi ta nhn thy chc nngphi v hot tnh suyn tr em c th b nh hng bi sang chn tm l ca cha m.[3] Mi

lin quan gia stress trong gia nh v biu hin kh kh hay d ng tr nh nhi cng nhsuyn khi tr ln 6-8 tui cng c ghi nhn.[6]

2.2. Nguy c nhp vin ca suyn[2] Tui v gii- Tui khi pht cng sm cng tng nguy c nhp vin- T 5 14 tui tr trai nhp vin nhiu hn tr gi, nhng t 15 24 tui tr gi nhp vin

gp i tr trai Chng tc M, tr M gc Phi nhp vin nhiu hn gp 3 ln tr M trng. Mc nng ca bnh-

Bnh suyn cng nngnguy c nhp vin cng tng. Mc nng ca bnh bao gm tnsut c triu chng h hp, s dng thuc, chc nng phi v tng kch ng ng th.- i vi nhng tr b suynnhng tr c c a d ng dng nh d b kh kh ko di

hn [3] v tng nguy c nm vin. Nguy c nhp Hi sctng cng- Nhiu ln nhp cp cu trong vng 12 thng qua- Cc triu chng ko di trc khi nhp vin- Thiu oxy- Tng IgE trong huyt thanh

2.3. Nguy c t vong ca tr b suyn nng [2] TuiTr di 10 tui t vong thp hn tr 15 24 tui GiiNam/N: 1,5 ln nng ca bnh- Suyn cng nng cng tng nguy c t vong.- Yu t tm l dng nh l nguy c quan trng dn n t vong. Ngho i v chng tcNguy c t vong cao nht nhm tr sngtrong nhng gia nh c kinh t x hi thp nht.

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3. C CH BNH SINH - SINH L BNH HCCch gy bnh ca suyn rt phc tp v cn nhiu iu kh hiu cn c nghin cu

thm. Tuy nhin tnh trng vim mn tnh ca ng th c xem l c ch gy bnh quantrng nht. Tnh trng vim din ra ngay c khi khng c biu hin lm sng. Ton bng

th, k c ng th trn v mi cng b nh hng nhng cc ph qun ng knh trung bnhb mnh m nht. Phn ng vim ny c gy ra bi cc t bo vim v cc ha cht trunggian.[3,5]

Gn y, nhng ghi nhn v tnh trng suy gim chc nng phi mn tnh bnh nhnsuyn lmngi ta ngh n nhng thay i sm v ko di cu trc ng th c gi l ticu trcng th [4]. Lp biu m ph qun l b mt phn cch gia mi trng bn ngoi vbn trong v ng vai tr ch o trong nhiu biu hin sinh l bnh ca suyn. Lp di nimbao gm phc hp ngoi bo, mch mu, tuynnhy, c trn cng b thay i. C ch thn kinhcng gp phn quan trng gy co tht ph qun.[4]

tr em, suyn cng phc tp hn v nhiu yu t min dch nh hin din khngnguyn, chc nng t bo T, sn xut khng th cn cha hon chnh do d dng gy ra p

ng d ng. Mi tng quan gia s trng thnh ca h thng min dch, chc nng ca phi vs pht trin trong nm u i dng nh quyt nhs pht trin ca suyn tr em. Ngoi ra,ng th ca tr em cng db tc nghn hn v ng knh ng th nh hn, xng snmm hn nn nng phi yu hn do phi d b co rt li gy tc ng th.[3]

T bo cu trc ng th trong bnh sinh suyn [4,5]T bo biu m ng th

T bo biu m ng th ng vai tr l mt hng ro sinh l v sinh ha hc ngn cchgia khng kh bn ngoi v mi trng bn trong. T bo ny c th b hot ha bi nhiu kchthch t nh nhng cht c, nhim trng, d ng nguyn, cht nhim khng kh v khi thucl. Mt khi b hot ha, t bo biu m sn xut ra nhiu ha cht trung gian nh cytokines,

chemokines, lipid mediators v hot ha cc bch cu khc. T bo c trn ng th- T bo c trn ng th gy vim cng tng t nh t bo biu m.- Ph i c trn v tng sinh c trn ph qun cng l c im ni bt ca ti to ng

thT bo ni mc

T bo ni mc mch mu ph qun li ko cc t bo vim t mch mu vo ng th. Nguyn bo si v nguyn bo si c

Cc t bo ny tng sinh s lng v sn xut ra cc thnh phn ca m lin kt nhcollagen, proteoglycans, c lin quan n qu trnh ti to ng th.T bo thn kinh ng th

Bnh thng cc cht c ch giao cm v ng vn i giao cm gy ra co tht ph qunv biu hin triu chng suyn. Tuy nhin, khi c hai con ng ny b ct t, ngi ta nhnthy ph qun vnc thb co tht. iu ny dn n s pht hin ra con ng thn kinh khnggiao cm khng ph giao cm (NANC) lin quan n nhng cht trung gian thn kinh mi nhbradykinin, neurokinin, vasoactive intestinal peptid (VIP) v cht P.Nhng cht ny gy ra cotht ph qun, dn mch v vim [4]

T bo vim ng th b suyn

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T bo mastT bo mast b hot ha bi nhng d ng nguyn gn vo cc th th IgE i lc cao hoc

nhng kch thch thm thu (osmotic stimuli) (gii thch cho tnh trng co tht ph qun do gngsc). Khi b hot ha, chng phng thch cc ha cht trung gian gy co tht ph qun(histamine, cysteinyl leukotrienes, prostaglandin D2). Tng s lng t bo mast trong c trn

ng th c lin quan n tng kch ng ng th.Bch cu i toanBch cu i toan i vo biu m ng th theo tn hiu ha hc ca cytokines,

chemokines v phn t kt dnh b mt t bo. Cc t bo i toan b hot ha phng thch ranhng cht trung gian tin vim v nhng protein c bn chnh (MBP) gy ph hy t bo bium, co tht c trn, tng tnh kch ng ph qun v tng tnh thm thnh mch lm ph n immc.Lympho T

S lng lympho thm nhp nim mc ng th tng ln v phng thch ra cccytokines c hiugm IL-4, -5, -9, -13 li ko t bo i toan vo ng th gy vim v kchthch t bo lympho B sn xut IgE. T bo Th2 tng hot tnh mt phn c th do gim t bo T

iu ha (bnh thng c tc dng c chTh2) v c th do tng t bo T gitlm phng thchmt lng ln cytokines ca Th1 v Th2.T bo nhiu chn

Trnh din khng nguynv di chuyn n hch bch huyt vng, chng tng tcvit bo T iu ha v kch thch sn xut Th2.i thc bo

Hin din nhiu trong ng th, c th b hot ha khi d nguyn gn vo th th IgE,lm phng thch cc ha cht trung gian v cc cytokin gy vim dn n khuch i p ngvim

T bo a nhn trung tnhGhi nhn c gia tng trong ng th ca bnh nhn suyn nhng c ch sinh bnh cha

r rng.Ha cht trung gianHa cht trung gianng vai tr quan trng trong sinh bnh suyn. Cc ha cht trung gian chnh gm: chemokines, cystelnyl leukotrienes, cytokines, histamine,nitric oxide, prostaglandin D2.

Nhng thay i cu ng th b suyn[5]Di tc ng ca phn ng vim mn tnh ko di, ng th ca bnh nhn suyn b thay icu trc, cn gi l ti cu trc ng th. Mt vi thay i lin quan n mc nng ca bnhv lm ng th hp tng i, ko di v khng th hi phc.Nhng thay i cu trc c ghi nhn:

-

Lng ng si collagen v proteogycan di mng y c thy nhn thy tt c bnhnhn suyn kc tr em. Hin tng ny thm ch c trc khi triu chng suyn ckhi pht nhng b tc ng bi iu tr.

- C trn ng thtng sinh v s lng v khi lng, gp phn lm dy thnh ngth. Tin trnh ny do cc ha cht trung gian gy vim gy ra (chng hn nh yu ttng trng) v nh hng n nng ca bnh.

- Mch muca ng th cng b tng sinh di tc ng ca cc yu t tng trng vgp phn lm dy thnh ng th.

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- Tng tit nhyhu qu ca tng sinh t bo tuyn nhy di nim

SINH L BNH HCSinh l bnh hc ch yu ca suyn l do hp lng ng th. Ba thnh t quan trng gy tc

nghn ng th lphn ng vimng th cp v mn tnh, co tht c trn ph qun c hiphc v tng kch ng ng th. Hu qu cui cng l ng th b hp li gy ra cc triuchng ca suyn.(hnh 1)ng th b hp li do:

- Co thtc trn ng thdo p ng vi cc ha cht trung gian v cc cht dn truynthn kinh. y l c ch chnh gy hp ng th v hi phc rt tt vi thuc dn phqun.

- Ph ng thdo thot mch trong phn ng vim, thng gp trong cn kch pht- Dy ng thdo thay i cu trc ng th ni trn, nh hng n nng ca bnh

v khng hi phc hon ton vi iu tr cp- Tng tit nhyto ra cc nt nhy lm tt nghn lng ph qun

Hnh 1: Sinh l bnh hc ca suyn

Tng kch ng ng th l c tnh quan trng trong sinh l bnh ca suyn. yl hu qu

ca phn ng vim ko div ti cu trc ng th, do ch hi phc mt phn vi iutr. Tng kch ng ng th c nh ngha l mc ng th hp li khi tip xc vicc cht kch thch khng c hiu nh methacholine, histamineChnh tnh tng kch ngng th lm ng th bnh nhn suyn b hp li khitip xc vimt nng thp chtkch thch trong khi ngi bnh thng khng b tc ng bi cng nng ny (hnh 2).Tng kch ng ng th khng nhng ng vai tr quan trng trong cn suyn cp m cnlm suy chc nng h hp khi tr suyn ln ln.[5]

Yu t gy suyn

Tng kchng ng

th

Triu chng

Yu t khipht cn

Hp ngth

VIM

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C ch cn suyn cp (cn kch pht)Tnh trng bnh suyn nng ln thong qua khi bnh nhn tip xc vi cc yu t nguy c hocyu t khi pht suyn v d nh gng sc, thay i thi tit Triu chng thng ko di hn,c th vi ngy n vi tun khi suyn b khi pht bi nhim siu vi h hp trn hoc tip xc dnguyn.

Cn mC ch chnh xc cha c bit r nhng c th b nh hng bi nhp sinh hc ca cchormone nh epinephrine, cortisonePhn ng vim ng th tng ln v m c nhn thyv th hin c chkhng vim ni sinh b yu i.Hp ng th khng hi phcMt vi bnh nhn b bnh suyn nng b hp ng th nng dn v khng th hi phc honton vi iu tr hin hnh. iu ny th hin tnh trng thay i cu trc ng th ca bnhsuyn mn tnhSuyn kh iu trMt vi bnh nhn tip tc b suyn nng ln hoc rt kh kim sot d c iu tr bngcorticoids. C th yu t di truyn hoc nhng ri lon tm l, tm thn c lin quan n tnhtrng ny. Nhng bnhnhn ny thng b suyn kh iu trngay t ban u hn l tng dn tnh n nng.

4. LM SNGTriu chng suyn tr em ch yu l ho, kh kh, kh th, au ngc do tc nghn ng thgy ra trong ho, kh kh ti i ti li l triu chng thng gp nht. Cc triu chng nythng khng c hiu cho bnh suyn nn vic hi bnh s, tin s t m l iu rt quan trng thc hin chn on suyn tr em.

%c

hcnnghhpbg

im

Hnh 2 : Thay i chc nng h hp khitng kch ng ng th

Nng cht co tht ng th

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Hi bnh s[5,6,7,9]1. Triu chng: ho, kh kh, kh th, au ngc, khc m? 2. c tnh ca triu chng:

Ti din, theo ma hay c hai?Lin tc hay tng t?

Cch khi pht, thi gian ko di, tn sut (theo ngy/m hoc theo tun/thng)?Thay i trong ngy, nht l vo ban m hay gn sng?3. Yu t khi pht?4. Tin trin ca bnh v iutr

Tui bt u c triu chng v tui c chn on?Tin s c tn thng phi trc y (vd: lon sn phi, vim phi)?Din tin tt hn hay t i?Thuc ang s dng v p ng vi iu tr, c bit l corticoids ung?Tin s nm hi sc v suyn cn nng hoc da ngng th? Bnh phi hp?

5. Tin cn gia nh:suyn (c bit l m), d ng, vim mi, vim xoanggi suynnhiu hn

Kh khc tnh kh kh trong suyn thng l ti pht nhiu ln, thng xy ra trong lc ng v b khipht bicc yu t gng sc, ci, khcTuy nhin tr nh khi b nhim siu vi ng hhp cng rt d kh kh. Nn lu khng phi kh kh no cng l suyn v khng phi bnhsuyn no cng c kh kh.Kh kh tr em c phn loi theo tui khi phtsmhay mun,thong qua hay ko di v c c a d ng hay khng d ng.- Kh kh thong qua l tr c kh kh khi phtsmtrc 3 tui nhng ht kh kh trc 6tui.- Kh kh khi pht mun l sau 6 tui.

- Nu kh kh khi pht sm v ko di n sau 6 tui vn cn kh kh c gi l kh kh daidng.Tnh trng kh kh thong qua thng lin quan n nhim siu vi h hp hn l suyn.Mt syu t lm kh kh khi pht sm c nguy c ko di dai dng hoc suyn(API) gm:

- C triu chng thng xuyn trong nm u i- Th trng chm- Tng bch cu i toan, tng IgE- C m b suyn- C m ht thuc l-N,bo ph

Trong bnh suyn kh kh thng nghe c th th ra. Tuy nhin nu suyn nng, kh kh cth nghe c trong chai th.Phi im lngl mt du hiu cp cu ca suyn v lc ny ng th b hp qu mc khngth gy kh kh.HoHo do bnh suyn thng ti pht hoc ko di v thng i km vi nhng t kh kh, khth. Ho v m (khi tr ng) hoc ho theo ma, ho khi gng sc, khi ci, khi khcm khng do

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bnh nhim trng h hp no hoc khi tip xc vi cht kch thch c hiugi suyn mnhm.Cn ho in hnh thng l ho khan v ho kch ng. Nu ho c m, m thng trng trong .

KHM LM SNG

Khi ngoi cn suyn, khm lm sng tr suyn thng bnh thng. Nu khm thy bt thngkhi tr khng ln cn suyn thng gi bnh suyn nng, khng kim sot ko di hoc c linquan n tng d ng. Nhng triu chng c th gp l:

Tng ng knh trc sau ca lng ngc do kh Nghe phi c kh kh hoc gim kh vo Thi gian th ra ko di Cc du hiu ca vim mi d ng, vim xoang, hi th hi Chm da

Cc du hiu khi tr ln cn suyn cp:xem bng phn nng ca cn Dau hieu sinh ton: nhp th, mach, huyet ap, nhiet o. Mc o kho th: kho khe, th nhanh, co lom ngc, ngoi th, tm tai. SaO2la phng

phap tot nhat e theo doi mc o suy ho hap. Kham phoi: phe am, ran phoi o lu lng nh neu tre tren 7 tuoi

Bo ph cng l yu t lin quan n nng ca bnh suyn

5. CN LM SNGChn on suyn tr nh phn ln da vo lm sng. Ngoi tr nh gi chc nng h hp, ccxt nghim thngkhong can thiet, ngoai tr cac trng hp nang hay khong ap ng ieu trban au hoac can chan oan phan biet.

- Cng thc mu: Eosinophil tang, cong thc BC chuyen trai khi co boi nhiem.-

Xquang phoi: thng c ch nh trong chn on phan biet vi viem phoi, d vat ngth, bt thng ng th bm sinh hoc khi nghi ng bin chng vim phi, trn khmng phi, xp phi, trn kh trung thtHnh anh kh phe nang: phoi tang sang, c hoanh det, h thp, khoang lin sn dnrng,trung that nh li.

- Kh mau: khi c cn doa ngng th hoc khilam sang xau hn. Cn suyen nhe va trungbnh giai oan au: PaO2con bnh thng, co the kem kiem ho hap (giam PaCO2).Cn nang: PaO2 giam va toan ho hap (tang PaCO2)

- nh lng Theophyline va duy tr nong o 10-20 g/mL.- Test trong da tm d nguyen-

o tnh kch ng ng th- FEV1 hoc PEF (xem phn chn on xc nh)5. CHN ON

5.1. Chn on xc nhChn on xc nh suyn tr em tht s rt kh khn, i hi phi hi bnh s, tin s t m,khm lm sng cn thn. Mt s cu hi gi nchn on suyn [11]

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Cu tr li C cho bt k cu hi no di y u gi c th l suyn Trong vng 12 thng quaCon c nhng t ho, kh kh, kh th, au ngc xy ra t ngt hay ti i ti li khng?Con c tng c nhng t cm lnh n v phi hoc ko di hn 10 ngy mi ht khng?

Con c tng c nhng t ho, kh kh, kh th ch xy ra theo ma hoc vo mt thi im cnh trong nm khng?Con c tng c nhng t ho, kh kh, kh th xy ra ni no hoc khi tip xc vi th no (chng hn nh sc vt, khi thuc l, mi hng)? Con c s dng thuc g gip con th tt hn? Bao lu mt ln?Cc triu chng c ci thin khi con s dng thuc khng? Trong 4 tun va qua con cnhng t ho, kh kh, kh thVo ban m, nh thc con dy?Ngay lc thc gic?Sau khi chy chi, tp th dc va phi hoc cc hot ng th lc khc?

p ng vi iu tr dn ph qun cng rt quan trng chn on suyn .

O CHC NNG H HPTin s, bnh s v khm lm sng gi chn on suyn nhng o chc nng h hp xc nhchn on v nh gi nng ca suyn do c th cung cp thng tin v nng ca hp ngth cng nh kh nng hi phc v thay i ca hp ng th.

H hp kTcnghn ng th khith tch th ra gng sc trong giy u tin (FEV1Forced ExpiratoryVolume in the first second) < 80% d on vt sFEV1/FVC < 70% hoc.Tc nghn ng th c p ng vi dn ph qun khi FEV1 tng > 12% sau s dng thuc dnph qun tr ln hoc ngi ln v tng > 9% tr em < 12 tui.

Gi tr tham chiuca cc thng s trnda vo tui, gii, chiu cao v chng tc.Lu lng nhLu lng nh (PEFPeek Expiratory Flow) c a chung s dng trong theo di v nhgi suyn v kh n gin, r tin, d s dng v sn c hn h hp k. Tuy nhin, tnh chnh xcca PEF khng cao nn mt mnh tr s PEF khng dng chn on suyn. Ngi ta thngdng PEF theo di p ngtrn cng mt bnh nhn trc v sau mt thi gian iu tr so vigi tr PEF tt nht ca bnh nhn.[3,4]Hp ng th khi PEF < 80% tr s d onhoc vi gi tr cao nht ca bn thn.p ng vi dn ph qun khi PEF tng > 20% so vi trc phun thucTham kho tr s PEF bnh thng ca tr em bng 1

Bng 1: Gia tr bnh thng lu lng nh tre em

Chieu cao (cm) Lu lng nh (lt/phut)110 150120 200130 250140 300150 350160 400

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170 450

Dao ng xung k (IOS)L mt phng php o chc nng h hp khng xm ln v khng cn hp tc gng sc do rt d dng s dng cho tr em t 2 tui tr ln. Tuy nhin, hin nay IOS cha sn c v cha

c s dng rng ri trong chn on suyn. Cn lu nu chc nng h hp th hin tc nghn ng thc hi phc, xc nh chn onsuyn mnh m. Nhng nu chc nng h hp bnh thng hoc khng r p ng dn ph quntrong cn cp cng khng th loi tr chn on suyn khi lm sng c p ng.[ 3,4]

Chn on suyn tr di 5 tui thng gp nhiu kh khn v rt kh phn bit cc triuchng ho, kh kh do suyn hay do nhim siu vi. Hn na o chc nng h hp la tui nycng kh thc hin. Do , chn on ch yu vn da vo bnh s, tin s v khm lm sng nh cp trn. Nu trc t 3 t ho, kh kh tr ln nn c xem xt chn on suyn.Nu tr c p ng vi iu tr th suyn v nng hn khi ngng iu tr l im gi chn onsuyn quan trng.[5]

5.2.Chn on nng cn suyn cpCn suyn kch pht hay cn suyn cp l nhng tcc triu chngho, kh kh, kh th, aungc nng hnt ngt hay t t, v thnggy ra suy h hp. c tnh ca ng th trongcn suyn l b hp li nhiu hn, lm gim lu lng kh th ra ng k. Thi iu tr s tythuc vo mc nng ca cn suyn cp theo bng 2 v bng3

Bng 2: nh gi nng ca cn suyn tr 5 tui

Triu chng Nh NngTri gic Bnh thng Bt rt, l hoc l m

Ni chuyn Thnh cu Tng tNhp tim (l/ph) < 100 03 tui: > 20045 tui: > 180

Tm Khng CCng kh kh Thay i C th im lngSaO2 94% < 90%

Bng 3: nh gi nng cn suyncho tr trn 5 tui v ngi ln

Nhe Trung bnh Nang Doa ngng thKho th Khi i bo

Co the nam

Khi noi

Tre nhu nhi-khocyeu va ngan hn,kho bu

Thch ngoi hn

Luc ngh ngi

Bo bu

Ngoi cui ra trce th

C ong ngc bung

ngc chieu

Noi chuyen Thanh cau Tng oan Tng t

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Nhp th(lan/phut)

Tang Tang < 5 tuoi: > 50> 5 tuoi: > 40

Cn ngng th

Nhp th bnh thng theo tuoi:< 2 thang: < 602 12 thang: < 501-5 tuoi: < 406 -8 tuoi: < 30

Mach (l/p) Bnh thng Nhanh Nhanh ChamGii han mach bnh thng tre em

2 12 thang: < 1601 2 tuoi: < 1202 8 tuoi: 95% 91 95% < 90%PEF > 80% 60-80% < 60%PaO2 bnh thng > 60 mmHg < 60 mmHgPaCO2 < 45 mmHg < 45 mmHg > 45 mmHgCh cn c vi du hiu trn l c th xp loi vo nng tng ng.

Trn lm sng, d dng phn nng cn, ta c th da vo cc du hiu n gin di y1

Cn nhe: kho khe, khong hoac kho th nhe, SaO2 > 95% Cn trung bnh: kho khe, kho th, th nhanh, rut lom ngc, SaO2 91-95% Cn nang: kho khe, ngoi th, co keo c c on chum, khong an uong c, noi tng t,

SaO2 < 91% Cn doa ngng th: tm tai, vat va, hon me5.3.Chn on nng bnh suyn

nh gi nng ca bnh suyn da vo triu chng v mc tc nghn ng th. Trcy, cch nh gi ny c s dng rng ri. Tuy nhin mc nng ca bnh thay i theothng, nm v cchphn nng bnh suyn c gi tr d on km trong vic chn iu tr cn

thit cng nh nh gi bnh nhn p ng iu tr vi ci g [5]. Do hin nay khuynh hngs dng phng php nh gi mc kim sot suyn (trnh by mc k tip) c achung hn.Bang 4: anh gia o nang cua benh suyen (bac suyen)

PHAN LOAI O NANG BENH SUYENTrieu chng Trieu chng ve em

BAC 4 Lien tuc, gii han hoat ong the lc Thng xuyen

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Nang, keo dai FEV1 hay PEF < 60% d oanPEF hay FEV1 thay oi > 30%

BAC 3Va, keo dai

Moi ngayS dung 2 giao cam moi ngayCn anh hng en hoat ong

FEV1 hay PEF 60-80% d oanPEF hay FEV1 thay oi > 30%

> 1 lan/tuan

BAC 2Nhe, keo dai

Cn 1 lan/tuan nhng < 1 lan/ngayFEV1 hay PEF bnh thng

PEF hay FEV1 thay oi < 20-30%

> 2 lan/thang

BAC 1Tng cn

Cn < 1 lan/tuanFEV1 hay PEF bnh thng

PEF hay FEV1 thay oi < 20%

2 lan/thang

Ch can co mot trong cac bieu hien tren la u e xep benh nhan vao bac tng ng.

Hau het suyen tre em la bac 1 va 2, a so la bac 1.5.4.nh gi mc kim sot suyn

Bang 5: Mc o kiem soat suyen (GINA 2010)

A. nh gi mc kim sot lm sng hin ti (tt nht trn 4 tun) ac iem c kiem soat

(Tat ca ac iem)Kiem soat mot phan(Bat ky ac iem nao)

Khong kiemsoat

Trieu chng ngay Khng ( 2 lan/tuan) > 2 lan/tuan 3ac iemcua suyenkiem soat motphan trong batc tuan nao

Gii han hoat ong Khong Bat kyTrieu chng em Khong Bat ky

S dung thuoc catcn

Khng ( 2 lan/tuan) > 2 lan/tuan

Chc nang phoi Bnh thng < 80% d on

B. nh gi nguy c tng lai (nguy c cn kch pht, suyn khng n nh, gimchc nng phi, tc dng ph)

Tng nguy c nu: kim sot lm sng km, ln cn kch pht* thng xuyn trong nm qua,

tng nhp hi sc v suyn, FEV1 thp, tip xc khi thuc l, dng thuc liu cao.

*Khi co t kch phat suyen can xem lai ngay ieu tr phong nga ay u cha. Tr < 5 tuico nguy c xuat hien t kch phat suyen khi co viem ng ho hap tren do sieu vi.

anh gia kiem soat suyen cho tre di 5 tuoi cung s dung bang tren nhng khong co tieuchuan chc nang phoi.

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5.5.Chn on phn bitChn on phn bitch yu da vo triu chng kh kh ti i ti li ca tr, ty thuc vonhm tui: tr nh di 5 tui hay tr ln trn 5 tuiTr di 5 tui[6,10]

Do nhim trngo

Nhim trng ng h hp ti dino Vim xoang mi mn tnho Laoo Ho g

Do bt thng bm sinho Mm sn kh quno Lon sn ph qun phio Chnng th do bt thng bm sinho Suy gim min dcho Bt thng tim bm sinh

Do bt thng c hco

D vt ng tho D vt thc quno Tro ngc d dy thc qun

Tr trn 5 tuio Hi chng tng thng kh v cn hong lono Tc ng th trn, d vt ng tho Ri lon chc nng dy thanho Cc bnh phi khng gy tc nghno Nguyn nhn khng thuc ng h hp (vd: suy tim tri)

6. THUOC IEU TR CAT CN SUYEN Co hai loai thuoc giup kiem soat benh suyen: Thuoc cat cn:tac dung nhanh cat cn, kho th Thuoc phong nga lau dai: tranh tai phat cn suyen

6.1. Thuc ct cn6.1.1. Thuoc giao cam:Thuoc chon loc 2 giao cam tac dung nhanh:

- Salbutamol (Albuterol, Ventoline), Terbutaline (Bricanyl) kch thch thu the 2, tangAMP vong lam dan phe quan. Thuoc c chon la au tien: nhanh, manh, t tacdung phu ac biet la dang kh dung (KD), bnh xt liu nh chun (MDIMetered

dose inhaler)- tre nho < 1 tuoi kem ap ng vi giao cam- Salbutamol va Terbutaline TM qua bm tiem: cn suyen nang that bai vi 2 giao

camkh dungThuoc 2 giao cam khong chon loc:

- Isoproterenol: nhieu tac dung phu, khong s dung.

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- Adrenaline TDD: cn suyen nguy kch hoac khong san 2 giao cam kh dung

6.1.2. Thuoc khang oi giao cam- Ipratropium (Atrovent): tac dung yeu va cham hn so vi 2 giao cam

Ipratropium n thuan khong la thuoc chon la au tien trong cat cn suyen.- Ipratropium cong hng vi 2 giao cam phoi hp vi 2 trong cn suyen nang

hoac that bai vi 2 giao cam.

6.1. 3. Theophylline:Hieu qua kem, lieu ieu tr th rat gan vi lieu oc hay khong tac dung, o thanh thai tuythuoc theo tuoi, benh ly phoi hp, thuoc kem theo va nhieu tac dung phu t c dungtrong ieu tr cn suyen cap.

Nong o theophyllin trong huyet tng (g/ml)

6.1.4. Corticoides

Nong o ieu tr

Ngo oc20

10

Khong tac dung

Dan phe quan

AMP vongATP

Adenylate cyclase

kch thch

giao cam

Theophylline

c che

Phosphodiestera

5-AMP

Hien nay 2 chon loc dang kh dung la thuoc c chon la au tien trong ieu

tr cat cn suyen.

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Nen co ch nh phoi hp vi cac thuoc DPQ khac trong cn suyen nang, nguy kch,hoac cn suyen that bai vi 2 giao cam kh dung.6.1.5. MagnesiumMagnesium sulphate truyn tnh mch khng c khuyn co dng thng qui nhng c th sdng i vi cc trng hp tr trn 1 tui c suyn nng km p ng vi iu tr ban u phi

nm hi sc.

Bang 6: Lieu lng thuoc DPQ dung cho tre emThuoc Lieu lng

2 giao camdang kh dung

Nebulizer:. Salbutamol: 2,5-5 mg moi 20 phut, hoac moi 1-4 g. Terbutaline: 5-10 mg moi 20 phut, hoac moi 1-4 g

MDI: 2 nhat (Salbutamol 100 g/nhat,

Terbutaline 250 g/nhat) moi 20-30 phut2 giao camtoan than

Salbutamol TMTan cong: 4-6 g/kg TTM 10 phutDuy tr: 0,1-1 g/kg/phut

Terbutaline TMTan cong: 10 g/kg TTM 30 phutDuy tr: 0,1-4 g/kg/phut

Terbutaline TDD 0,01 mg/kg, toi a: 0,3 mg/lan/30 (LieuAdrenaline TDD # Lieu Terbutaline TDD )Salbutamol, Terbutaline uong: 0,15 mg/kg moi 6 gi

Ipratropium 125-250 g moi 6 gi

Theophylline Aminophylline TMTan cong: 5 mg/kg TTM 15 phutDuy tr: 1 mg/kg/gi

Theophylline uong: 3-5 mg/kg moi 6 giCorticoides toanthan

Prednisone: 2 mg/kg/ngay chia 2 lan trong 3 ngayToi a: 60 mg/ngay

Hydrocortisone: 5-7 mg/kg TM moi 8 giMagnesium

sulphate

25 -75mg/kg truyn TM trong 20 pht, nng truyn khngqu 5%

6.2. Thuoc phong nga lau dai6.2.1. Nhom khang viem:Corticoides- MDI c chon do khong hoac t tac dung phu. Vi lieu TB khong hoac t anh hng en

s tang trng cua tre.

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- Khong ap ng vi lieu corticoides TB th thay v dung lieu cao nen ket hp vi thuocDPQ tac dung keo dai

- Tranh tac dung phu: buong em va suc mieng- ng toan than khong c dung phong nga suyen.Cromolyn hoac Nedocromil:- An toan, khong anh hng ti tang trng cua tre6.2.2. 2 giao cam tac dung keo daiDang ht (Salmeterol, Formoterol) dang uong (Bambuterol) dung ngay 1 lan.

Phoi hp vi corticoides dang ht khi:- Suyen bac 3 hoac that bai vi corticoide lieu TB- Phong cn ve emNgoai ra con dung e nga cn khi gang sc, khong c dung e cat cn hay cap cu.

6.2.3. Theophyllin tac dung cham:- Chon phoi hp corticoides ht khi that bai vi lieu trung bnh, hoac phong nga cn

ve em.6.2.4. Khang Histamine: Ketotifene (Zaditen):- Hieu qua cha chac chan, de s dung v uong.

6.2.5. Khang Leukotrien: Montelukast, Zirfulukast- oi khang vi thu the Leukotrien

7. IU TRMc tiu iu tr ca iu tr suyn theo G INA 2010 l t c v duy tr kim sot lm sngsuyn. Ngha l bnh nhn

C triu chng ti thiu Khng cn cnm Khng b gii hn hot ng gng sc S dng thuc ti thiu Chc nang ho hap bnh thng Khng cn ln cn suyn kch pht

t c mc ch iu tr, cn c s phi hp cc yu t: Xy dng mi quan h bc s bnh nhn tt Xc nh v phng trnh tip xc yu t nguy c nh gi, iu tr v theo di suyn iu tr cn kch pht (iu tr ct cn)

7.1. iu tr ct cn suyn7.1.1. Suyen nhe va trung bnh ieu tr ban au- Kh dung 2giao camqua Jet nebulizer 3 lan lien tiep moi 20 neu cha cat c cn.

Salbutamol: 0,15 mg/kg/lan; toi thieu 1,25 mg/lan; toi a 5 mg/lan hocTerbutaline: 0,2 mg/kg/lan; toi thieu 2,5 mg/lan; toi a 5 mg/lan.

iu tr phng nga

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- Trong trng hp khong co Jet nebulizer hoac cn nhe co the dung bnh xt nh lieu(MDI):

MDI neu tre > 6 tuoi va hp tacMDI + buong em (tre 4 6 tuoi hoac khong hp tac)MDI + buong em + mask (tre di 4 tuoi)

- Ch nh corticoide uong Benh nhan ang ieu tr corticoide hoac co tien can cn nguy kch a nam Hoi sc. Neu sau lieu 2giao cam au tien khong ap ng hay ap ng khong hoan toan. Cn suyn nng

Lieu : Prednisone uong 1-2 mg/kg/ngay ieu tr tiep theo

ap ng tot:- Tiep tuc 2giao cam kh dung hoac MDI moi 4-6 gi, trong 24 gi au.- Prednisone ung, neu a dung, trong 5-7 ngay- ieu tr phong nga

ap ng khong hoan toan- Kh dung 2giao cam mi gi, 3 ln lin tip. Sau mi 2 6 gi.- Cn nhc phi hp phun kh dung Ipratropium 250g ti a c th 3 ln lin tip. Sau

o moi 4-6 gi.- Prednisone uong

Khong ap ng hocdien tien nang hn c xem nh cn nang.7.1.2. Suyen nang

ieu tr ban au- Oxy e duy tr SaO295% tt nht nn dng qua mask tr nh- Kh dung 2giao cam qua Jet nebulizer 3 lan lien tiep moi 20 phut cho en khi cat cn.

Nen phun di oxy, khong dung day kh nen. Nu khng c Jet nebulisez, dng MDI +bung m + mt n

- Anticholinergic: Ipratropium 250 g, phun kh dung moi 20 phut x 3 lan lien tiep, chungvi 2giao cam.

- Hydrocortisone 5 mg/kg TM hay Methylprednisolone 1mg/kg moi 6 gi trong 24 gi au,sau o moi 12 gi ieu tr tiep theo ap ng tot

- Tiep tuc 2giao cam kh dung hoac MDI moi 4-6 gi, trong 24 gi au.- Iprtropium moi 4-6 gi cho en khi cat cn- Prednisone uong trong 5-7 ngay- ieu tr phong nga

Khong ap ng: Nam khoa hoi sc- Tiep tuc kh dung 2giao cam moi gi trong 3 gi, sau o moi 2-4 gi cho en khi

cat cn.- Ipratropium moi gi trong 3 gi, sau o moi 4-6 gi cho en khi cat cn.

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- Tiep tuc Hydrocortisone 5 mg/kg/lan TM moi 6 gi- Magnesium sulfat 25-75mg/kg, trung bnh 50mg/kg TTM trong 20 phtoi vi tre

1 tuoi- Aminophylline truyen TM oi vi tre < 1 tuoi. Lieu tan cong 5mg/kg truyen trong

20 phut (neu co dung theophylline trc o th dung lieu 3mg/kg). Duy tr1mg/kg/gi. Nen theo doi nong o Theophylline mau gi th 12 va sau o moi12 en 24 gi.

Neu that bai- 2giao cam truyen tnh mach

Salbutamol: lieu tan cong 15g/kg truyen trong 20 phut, sau o duy tr: 1 g/kg/phuthoac Terbutaline: lieu tan cong 15g/kg truyen trong 20-30 phut, sau o duy tr: 1g/kg/phutCan kiem tra kh mau va Kali moi 6 gi

- Hoac truyen TM Theophylline oi vi tre di1 tuoi.Lieu tan cong 5mg/kg truyen trong 20 phut (neu co dung theophylline trc o thdung lieu 3mg/kg). Duy tr 1mg/kg/gi

7.1.3. Doa ngng th ieu tr ban au- Oxy gi SaO292-96%- Terbutaline 1 hoac Adrenaline 1 0,01 mL/kg, toi a 0,3 mL/lan TDD moi 30 phut,

cho n khi ct cn,toi a 3 lan.- Kh dung 2 giao cam va Ipratropium qua Jet nebulizer giong suyen cn nang- Hydrocortisone 5-7 mg/kg TM moi 6 gi ieu tr tiep theo

Giong ieu tr tip theo ca suyen cn nang7.1.4. ieu tr khac- Truyen dch: theo nhu cau c ban e tranh thieu dch gay kho va tac am, nhng

khong truyen qua nhieu gay nguy c qua tai va tang tiet ADH khong thch hp.Dch truyen Dextrose 5% trong 0,2%/0,45% saline, pha them kali 40mEq/L (thngtruyn 2ml/kg/gi tr 1 9 tui, 1,5ml/kg/gi tr 10 15 tui). Theo di nghuyt mi 6 gi.

- Khang sinh khi co boi nhiem: sot, bach cau tang, am mu, X-quang co viem phoi.- at noi kh quan v th my khi ngng th hay that bai tat ca cac ieu tr tren

Phac o ieu tr cat cn suyen (hnh 5) [1]

7.2. iu tr phng ngaMuc tieu ieu tr phong nga va quan ly benh nhan suyen l t c mc tiu kim sotsuyn tt, giup benh nhan khong len cn suyen va co the sinh hoat va hoc tap nh tre bnhthng. y chnh l iu tr bnh suyn, iu tr theo bnh sinh v sinh l bnh ca suyn.ieu tr phong nga tuy thuoc vao mc o nang cua benh (bac suyen) (bang 3) va mc okiem soat suyen (bang 4).

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7.2.1. Giao duc benh nhan Tranh yeu to nguy c

- Tranh khoi thuoc la (ch ng v th ng), thuoc xt phong, cc hng nng mi- Trnh tip xc vi th vt c lng (ch, mo)- Don dep nha ca sach va thoang c bit phng ng- Hn ch tip xc cc yu t khc gy ra cn suyn - Xt 2giao cam trc khi gang sc

Biet x tr cn suyen tai nha va dau hieu nang can nhap vien Phn bit c thuc ct cn v thuc phng nga Hng dan s dung 2giao cam bnh xt nh lieu khi len cn suyen Biet dau hieu nang can a en benh vien: kho th nang, khong ap ng ba lieu kh

dung 2giao cam hoac xau hn. Ti khm nh k mi 1-3 thng ngay c khi bnh suyn c kim sot. Nu c cn kch

pht, ti khm trong vng 24 tun sau khi iu tr ct cn.7.2.2. nh gi, iu tr v theo di suynMc ch iu tr l t c kim sot suyn tt. Do nu suyn t c kim sot tt,iu trs c duy tr mc thp nht suyn vn c kim sot. Nu kim sot suyn chatt, cn tng bc iu tr dn n khi tr t c kim sot tt.

ieu tr phong nga suyen cho tre di 5 tuoi

- Khuyen cao s dung ICS lieu thap hn leucotrien modifier.- Tang lieu ICS hoac ket hp ICS liu thp vleucotrien modifier oi vi suyen khong kiem

soat.Hnh 3: S o ieu tr phong nga suyen cho tre t 5 tuoi tr len

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c kiem soat Duy tr va tm bckiem soat thap nhat

Kiem soat mot phan Xem xet tang bce at kiem soat

Khong kim sot Tang bccho en khi at c kiem soat

t kch phat ieu tr cn kch phat

Giao duc suyen

Kiem soat moi trng

Kch thch 2giao cam tac dung nhanh khi can

Chon lathuoc kiem

soat

Chon 1 Chon 1 Them 1 hoac

hn

Them 1 hoac

ca 2ICS lieu thap ICS lieu thap

+ LABAICS lieu vahoac cao +

LABA

Corticoid uong(lieu thap

nhat)

Leucotrienemodifier

ICS lieu vahoac cao

Leucotrienemodifier

ieu tr

anti-IgE

ICS lieu thap+ Leucotriene

modifier

Theophyllinephong thch

cham

ICS lieu thap+ theophylline

phong thchcham

ICS: Inhaled glucocorticosteroids Corticoides ng ht

O to nen: Chon la thuoc kiem soat c a chuong hn.

Bac ieu tr

Mc o kiem soat ieu tr

Gimb

c

Tngbc

Giam Tang

Bac 1 Bac 2 Bac 3 Bac 5Bac 4

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ieu tr phong nga cho tre t 5 tuoi tr xuong

Giao duc suyen, kiem soat moi trng va s dung 2 tac dung nhanh khi canKiem soat tot

vi 2 tac dung nhanh khi can

Kiem soat mot phan

vi 2 tac dung nhanh khi can

Khong kiem soat hoac ch

kiem soat mot phan vi ICSlieu thap

Chon la thuoc kiem soatTiep tuc 2 tac dung nhanh

khi canICS lieu thap Tang gap oi lieu thap ICS

Leukotriene modifier ICS lieu thap ket hp vileukotriene modifier

Corticoids uong ch s dung e ieu tr cat cn

7.2.3. Thuoc phong ngaBang 7: Lieu corticosteroids ht tre em (ICS)

Thuoc Lieu thap (g) Lieu trung bnh (g) Lieu cao (g)

Budesonide 100 - 200 > 200 - 400 > 400

Budesonide-Neb 250 - 500 > 500 - 1000 > 1000

Fluticasone 100 - 200 > 200 500 > 500

Dang phoi hp: ICS + LABA (long acting beta angonism)Budesonide + Formoterol: SymbicortFluticasone + Salmeterol: Seretide

Montelukast(Leucotrien modifier):Ch nh trong ieu tr phong nga suyen

- Thuc thay th iu tr bc 2, khi tr khng th s dng ICS hoc b d ng hoc tc dngph vi ICS.- Thuc thay th iu tr bc 2, khi tr c km theo vim mi d ng

- Thuc thm vo vi ICS iu tr bc 3 nhm gim liu corticoids ht.- Thuc thm vo vi ICS iu tr bc 3, 4 khi khng sn c dng phi hp 2 trong 1 hoc

khng dung np LABA.Liu dng: Tr 15 tui: 10mg

Tr 6 14 tui: 5mgTr < 6 tui: 4mg

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Hnh 4: Lu iu tr ct cn suyn

P NGKHNG HONTON/ KHNGP NG:KD 2giao cam moigiKD 2+ Ipratropiummi gi x 3 ln. Sau mi 2-6 gi.Prednisolone (u)

P NGXUiu tr nhsuyn cn nng

KHONG CAI THIEN

at noi kh quan th may

CN SUYN

KHONG CAI THIEN

Thm

- 2giao cam TTM hoc- Aminophyline TTM

AP NG TOT:KD 2giao cam moi 4-6 gitrong 24 giTiep tuc Prednisolone neu adung x 3-5 ngayieu tr phong nga

AP NG KHONGHOAN TOAN HOAC XAU:

Nam Hoi scKD 2giao cam + Ipratropium moi gitrong 3 gi

Hydrocortisone TMCan nhac truyen Magnesium Sulfate

Can nhac truyen Aminophylline (

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CU HI LNG GIChn mt cu ng nhtCu 1: Suyn c nh ngha nh l mt tnh trng:

a. Ri lon co tht c trn ph qunb. Kh kh ti i ti li nhiu ln, thng xy ra v m hoc khi gng scc. Tng kch ng ng th vi cc cht kch thchd. Vim mn tnh ng th vi s thm nhim ca cc t bo vime. Kh th th th ra do tc nghn ng th di

Cu 2: Cc yu t c ngh gy bnh suynl:a. Bo phb. Di truync. D ng nguynd. Cu a v b nge. Cu b v c ng

Cu 3: C ch hp ng th trong cn suyn cp do:a. Co tht c trn ph qunb. Tng xut tit ph qunc. Dy ng thd. Ph n lp nim mc v di nime. Tt c ng

Cu 4: Triu chng thng gp ca suyn c c im: a. Ting th rt trong th ht vob. Ting th rt th th rac. Ting kh kh th ht vod. Ting kh kh th th rae. Kh kh km phi c nhiu ran rt, ngy

Cu 5: Cc du hiu no sau y gi chn onsuynngoi tr:

a. Ho, kh kh khi tip xc cc cht kch thchb. Ho, kh kh v mc. Ho, kh kh khi nhim siu vi h hpd. Ho, kh kh khi gng sce. Gim kh kh khi phun thuc dn ph qun

Cu 6: Khi bnh nhn vo suyn cn nng, tr s SaO2 (SpO2) thng: a. > 100%b. > 95% - 100%c. > 9095%d. 90%e. SaO2 khng c gi tr trong chn on nng cn suyn.

Cu 7: Thuc u tay trong iu tr ct cn suyn l:a. 2giao cm tc dng ngn ng htb. 2giao cm tc dng di ng htc. 2giao cm ng ungd. corticoid ng hte. Corticoid ng ung

Cu: 8-9

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Cu 8: Bnh nhi A,18 thng tui, tin cn kh kh 3 ln, c m b suyn. B bnh 3 ngy, c ho,s mi nc trong v st nh, N3 b ho nhiu, kh kh, b km. B nhp vin trong tnh trngtnh, mch 130l/ph, nhp th 52 ln/pht, rt lm ngc, phi c ran rt, ran ngy, m 2 bn, SpO2:95%.Hy cho bit chn on ph hp nht lc nhp vin:

a. Vim tiu ph qun c bin chng suy h hpb. Vim phi nngc. Suyn cn nh, bc 1d. Suyn cn trung bnh, bc 1e. Suyn cn nng, bc 1

Cu 9: B A nn c x tr ban u vi:a. MDI 2giao cm tc dng ngn 1 nht mi 20 pht x 3 lnb. MDI 2giao cm tc dng ngn 2 nht mi20 pht x 3 lnc. MDI 2giao cm tc dng ngn 3 nht mi 20 pht x 3 lnd. Kh dung 2giao cm tc dng ngn 1mg mi 20 pht x 3 lne. Kh dung 2giao cm tc dng ko di 1mg mi 20 pht x 3 ln

Cu 10 - 17: Bt cp nhm thuc iu tr suyn

a. iu tr ct cnb. iu tr phng ngac. C hai nhmd. Khng thuc nhm no10.Prednisone11.Theophylline12.Ipratropium13.Magnesium sulfate14.Khng leucotrien15.Corticoid ht16.LABA17.Terbutaline

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TI LIU THAM KHOCHNH

1. Bch Vn Cam (2009).Phc iu tr nhi khoa 2009. Nh xut bn Y Hc, thnh ph HCh Minh, tr. 455466.

2. Asher M., Cameron Grant (2006). Epidemiology of asthma. Kendigs Disorders of therespiratory tract in children. Elsevier, seventh edition, pp. 762 779.

3. Bacharier L. et al. (2008). Diagnosis and treatment of asthma in childhood: a PRACTALLconsensus report. Allergy: 63, pp. 534.

4. Boyd J., Strunk R. (2008). What is Asthma? Clinical Asthma. Elsevier, pp. 4955.5. Global Strategy for Asthma Management and Prevention (update 2010): Global Initiative

for asthma (GINA). URL:http://www.ginasthma6. Global Strategy for the diagnosis and Management of Asthma in children 5 years and

younger (update 2010): Global Initiative for asthma (GINA). URL:http://www.ginasthma7. Guerra S., Wright A. (2008). The Natural History of Asthma into Adulthood. Clinical

Asthma. Elsevier, pp. 3544.

8.

Kercsmar C. Wheezing in older children: Asthma. Kendigs Disorders of the respiratorytract in children. Elsevier, seventh edition, pp. 810 846.9. Warner J. (2008). Development of Asthma in Early Life. Clinical Asthma. Elsevier, pp. 13

34.

10.Weinberger M., Abu Hasan M. Asthma in the preschool child. Kendigs Disorders of therespiratory tract in children. Elsevier, seventh edition, pp. 795 805.

11.National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for theDiagnosis and Management of Asthma.NIH Publication no. 08-4051, 2007.

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