B Y T

------S: 979/Q-BYT

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
--------H Ni, ngy 24 thng 3 nm 2009

QUYT NH
V VIC BAN HNH HNG DN CHN ON, IU TR V PHNG BNH LAO

B TRNG B Y T
Cn c Ngh nh s 188/2007/N-CP ngy 27/12/2007 ca Chnh ph quy nh chc nng,
nhim v v c cu t chc B Y t;
Xt Bin bn hp Ban Bin son Hng dn chn on, iu tr v qun l bnh lao cc ngy 08
thng 06 nm 2008, 09 v 25 thng 12 nm 2008;
Theo ngh ca Cc trng Cc Qun l Khm, cha bnh-B Y t;

QUYT NH:
iu 1. Ban hnh km theo Quyt nh ny Hng dn chn on, iu tr v phng bnh lao.
iu 2. Hng dn chn on, iu tr v phng bnh lao p dng cho tt c cc c s khm,
cha bnh Nh nc v t nhn.
iu 3. Quyt nh ny c hiu lc sau 15 ngy, k t ngy k.
iu 4. Cc ng, B: Chnh Vn phng B, Cc trng Cc Qun l Khm, cha bnh- B Y t;
Gim c Bnh vin Lao v Bnh phi Trung ng, Gim c cc bnh vin, vin c ging
bnh trc thuc B Y t, Gim c S Y t cc tnh, thnh ph trc thuc Trung ng, Th
trng y t cc ngnh chu trch nhim thi hnh Quyt nh ny.

KT. B TRNG
TH TRNG

Nguyn Th Xuyn

HNG DN
CHN ON, IU TR V PHNG BNH LAO
(Ban hnh km theo Quyt nh s 979 /Q-BYT ngy 24 thng3 nm 2009 ca B trng B Y
t)

Lao l mt bnh nhim khun do vi khun lao (Mycobacterium tuberculosis) gy nn. Bnh lao c
th gp tt c cc b phn ca c th, trong lao phi l th lao ph bin nht (chim 80
85%) v l ngun ly chnh cho ngi xung quanh.
I. CHN ON BNH LAO
1. Xc nh ngi nghi lao phi
a) Ngi nghi lao phi c th c xc nh qua cc triu chng thng gp nh:
- Ho ko di trn 2 tun (ho khan, ho c m, ho ra mu) l triu chng nghi lao quan trng nht.
C th km theo:
- Gy st, km n, mt mi.
- St nh v chiu.
- Ra m hi trm ban m.
- au ngc, i khi kh th.
b) Nhm nguy c cao cn ch :
- Ngi nhim HIV/AIDS
- Ngi tip xc trc tip vi ngun ly, c bit tr em
- Ngi mc cc bnh mn tnh: lot d dy-t trng, i tho ng, ...
- Ngi nghin ma tu, ru, thuc l, thuc lo
- Ngi s dng cc thuc gim min dch ko di nh Corticoid, ho cht iu tr ung th
2. Chn on lao phi
a) Lm sng
- Ton thn: St nh v chiu, ra m hi m, chn n, mt mi, gy st cn.
- C nng: Ho, khc m, ho ra mu, au ngc, kh th.
- Thc th: Nghe phi c ting bnh l (ran m, ran n,....).
b) Cn lm sng
- Soi m trc tip tm AFB: Tt c nhng ngi c triu chng nghi lao phi c xt nghim
m t nht 2 mu, tt nht l 3 mu: 1 mu ti ch khi n khm, 1 mu bui sng sm sau ng
dy v mu th 3 ly ti ch khi em mu m bui sng n phng xt nghim.

- Nui cy tm vi khun lao: Nui cy trong mi trng c cho kt qu sau 6-8 tun. Nui cy
trong mi trng lng (MGIT, BATEC) cho kt qu khong 10 ngy.
- Xquang phi chun: Hnh nh trn phim Xquang gi lao phi tin trin l thm nhim, nt, x
hang, c th co ko 1/2 trn ca ph trng, c th 1 bn hoc 2 bn. ngi c HIV, hnh
nh Xquang phi t thy hnh hang, tn thng khong k nhiu hn v c th vng thp ca
phi.
- Phn ng Tuberculin (Mantoux): Phn ng Mantoux ch c ngha h tr trong chn on, nht
l chn on lao tr em khi phn ng dng tnh mnh ( 15 mm ng knh cc phn ng
vi Tuberculin PPD).
c) Chn on xc nh
- Lao phi AFB(+):
Tho mn 1 trong 3 tiu chun sau:
+ Ti thiu c 2 tiu bn AFB(+) t 2 mu m khc nhau.
+ Mt tiu bn m AFB(+) v c hnh nh lao tin trin trn phim Xquang phi.
+ Mt tiu bn m AFB(+) v nui cy dng tnh.
Ring i vi ngi bnh HIV(+) cn c t nht 1 tiu bn xt nghim m AFB(+) c coi l
lao phi AFB(+).
- Lao phi AFB(-):
Tho mn 1 trong 2 tiu chun sau:
+ Kt qu xt nghim m AFB m tnh qua 2 ln khm mi ln xt nghim 03 mu m cch
nhau khong 2 tun v c tn thng nghi lao tin trin trn phim Xquang phi v c hi chn
vi bc s chuyn khoa lao.
+ Kt qu xt nghim m AFB m tnh nhng nui cy dng tnh.
Ring i vi ngi bnh HIV(+) ch cn 2 tiu bn m AFB(-), iu tr khng sinh ph rng
khng thuyn gim, c hnh nh Xquang phi nghi lao v bc s chuyn khoa quyt nh l lao
phi AFB (-).
(S chn on lao phi AFB (-) xem Ph lc 1)
d) Chn on phn bit vi mt s bnh: Gin ph qun, ung th phi, vim phi, p xe phi,
bnh phi tc nghn mn tnh. ngi c HIV cn phn bit ch yu vi vim phi, nht l vim
phi do Pneumocystis jiroveci (PCP).
3. Chn on lao ngoi phi
Chn on da trn cc triu chng, du hiu tn thng lao c quan ngoi phi, km theo
xt nghim soi m trc tip, nui cy tm thy vi khun lao trong bnh phm ly t tn thng

ca c quan tng ng, hoc chn on m bnh t bo thuc cc c quan tng ng v c

cc thy thuc chuyn khoa lao chn on.
a) Lao hch
Lm sng: V tr thng gp nht l hch c, in hnh l dc c c n chm, nhng cng c
th cc v tr khc. Hch sng to, lc u hch chc, ring r, di ng t do, sau cc hch
nhuyn ha, dnh vo nhau v t chc di da, km di ng, chuyn thnh p xe, r m mn
tnh v c th khi v li so xu.
Chn on xc nh: Tiu bn xc nh thy cht hoi t b u, t bo bn lin, nang lao,
nhum soi tm thy AFB, nui cy tm vi khun lao.
b) Lao k
L th lao kh chn on, thng nhm vi mt s bnh khc.
Lm sng: Triu chng lm sng thng rm r vi triu chng ton thn nhiu hn l triu
chng h hp, st cao lin tc, ko di khng r nguyn nhn. C th gp bnh cnh lm sng
khng rm r.
Chn on xc nh: Th in hnh c bnh cnh lm sng nng, cp tnh, Xquang phi c nhiu
nt m kch thc nh m u v lan to phn b khp 2 phi. Xt nghim vi khun lao ti
cc mu bnh phm (m, nc tiu, mu) c th dng tnh.
c) Trn dch mng phi (TDMP )do lao
Lm sng: au ngc, kh th tng dn, khm phi c hi chng 3 gim.
Cn lm sng: Xquang phi thy hnh m m thun nht, mt gc sn honh. Siu m mng
phi c dch.
Chn on xc nh: Chc ht khoang mng phi thy dch mu vng chanh, rt him khi dch
mu hng, l dch tit, protein > 30g/l, nhiu t bo lymph, c th tm thy AFB trong dch mng
phi. Sinh thit mng phi chn on m bnh hc thy nang lao hoc nhum soi thy AFB, nui
cy tm thy vi khun lao.
d) Trn dch mng tim (TDMT) do lao
Lm sng: au ngc, kh th, ph chi di. Khm c tim nhp nhanh, huyt p thp, mch o
ngc, nghe ting c mng tim hoc ting tim m.
Cn lm sng: Xquang ngc thy bng tim to, hnh git nc, hnh i b. in tim c in th
thp cc chuyn o, sng T m v ST chnh. Siu m mng tim c dch.
Chn on xc nh: Chc ht dch mng tim l dch tit, protein>30g/l, t bo lympho chim u
th. C th tm thy vi khun lao (nhum soi, nui cy).
) Trn dch mng bng (TDMB) do lao

Lm sng: C cc du hiu trn dch mng bng (g c vng thp thay i theo t th, sng
v, du hiu g c bn c giai on mun, ). C th s thy cc u cc, m cng trong
bng. C th c du hiu tc hoc bn tc rut do cc hch dnh vo rut.
Cn lm sng: Siu m bng c cc hnh nh gi lao mng bng: hch mc treo to, hch sau
mng bng, dch khu tr gia cc m dnh, ni soi bng thy cc ht lao. Dch mng bng l
dch tit: protein > 30g/l, t bo lympho chim u th. C th tm thy vi khun lao (nhum soi,
nui cy).
Chn on xc nh: Chc ht dch mng bng mu vng chanh, i khi c, t bo trong dch
mng bng do lao ch yu l bch cu lymph. Soi bng v sinh thit l k thut rt c gi tr
cho chn on trong hu ht cc trng hp. Trn tiu bn sinh thit thy hoi t b u, nang
lao.
e) Lao mng no
Lm sng: Bnh cnh vim mng no khi pht bng au u tng dn v ri lon tri gic. Khm
thng thy c du hiu c cng v du hiu Kernig(+). C th c du hiu tn thng dy thn
kinh s no v du hiu thn kinh kh tr. Cc tn thng tu sng c th gy ra lit 2 chi di
(lit cng hoc lit mm).
Cn lm sng: Xt nghim sinh ho, t bo v vi khun dch no tu. Dch no tu p lc tng,
dch c th trong, vng chanh, c khi vn c. Bch cu trong dch no tu tng v lympho chim
u th. Xt nghim sinh ho thy protein tng v ng gim. Xt nghim soi trc tip tm AFB
c th dng tnh trong mt s t trng hp.
Chn on xc nh: Da vo bnh cnh lm sng v xt nghim dch no tu, loi tr cc cn
nguyn khc
g) Lao ct sng
Lm sng: au lng, hn ch vn ng, au ti ch tng ng vi t sng b tn thng, giai
on mun gy bin dng g ct sng hoc c du hiu chn p tu, lit.
Cn lm sng: Chp Xquang ct sng thy hp khe t, c th thy mnh xng cht v hnh p
xe lnh cnh ct sng.
Chn on xc nh: Da vo lm sng v cc c im tn thng trn Xquang ct sng. Nu
c p xe lnh, xt nghim m p xe tm AFB cho t l dng tnh cao. Sinh thit t chc cho
php chn on m bnh t bo.
h) Cc th lao khc: Lao sinh dc-tit niu, lao da, lao lch, lao gan, v.v
4. Chn on bnh lao khng thuc
Lm sng: Khi ang iu tr lao nhng cc triu st, ho, khc m khng thuyn gim hoc
thuyn gim mt thi gian ri li xut hin tr li vi cc triu chng tng ln.
Cn lm sng: Hnh nh tn thng trn phim Xquang phi khng thay i hoc xut hin thm
tn thng mi. Xt nghim AFB dng tnh lin tc hoc m tnh mt thi gian ri dng tnh
tr li hoc m tnh dng tnh xen k.
Chn on xc nh:

- Nui cy tm vi khun lao, khng sinh vi cc thuc chng lao hng 1 v hng 2.
- Phng php sinh hc phn t (lp trnh chui - sequencing): C th chn on nhanh bng
cch xc nh cc on gen khng thuc.
Phn loi bnh lao khng thuc:
- Khng thuc tin pht: L khng thuc ngi bnh cha tng iu tr thuc lao, nay mc
bnh lao khng thuc do ly nhim vi khun t ngi bnh b lao khng thuc.
- Khng thuc mc phi: L khng thuc ngi bnh iu tr lao, nhng do iu tr khng
ng gy ra cc chng lao khng thuc.
- Khng thuc ban u: L khng thuc ngi bnh khai bo cha dng thuc lao bao gi
(nhng khng xc nh c chc chn). Nh vy loi ny gm c khng thuc tin pht v mc
phi.
- Khng a thuc (MDR TB Multi drug Resistant TB): L khng thuc ngi bnh c vi khun
lao khng vi c 2 loi INH v Rifampicin.
- Siu khng thuc (XDR TB - Extensively drug Resistant TB): L nhng trng hp lao khng
a thuc c khng thm vi bt c thuc no trong nhm Quinolon v khng vi t nht mt loi
thuc chng lao hng 2 dng tim (Amikacin, Capreomycin hoc Kanamycin).
5. Phn loi bnh lao phi
a) Theo kt qu xt nghim soi trc tip
- Lao phi AFB(+)
- Lao phi AFB (-)
(Xem phn chn on)
b) Theo tin s iu tr lao
- Lao mi: Ngi bnh cha bao gi dng thuc hoc mi dng thuc chng lao di 1 thng.
- Lao ti pht: Ngi bnh c iu tr lao v c thy thuc xc nh l khi bnh, hay
hon thnh iu tr nay mc bnh tr li AFB (+).
- Lao iu tr tht bi: Ngi bnh mi iu tr ln u, cn AFB(+) trong m t thng iu tr
th 5 tr i, phi chuyn phc iu tr.
- Lao iu tr li sau b tr: Ngi bnh khng dng thuc trn 2 thng lin tc trong qu trnh
iu tr, sau quay tr li iu tr t u vi AFB (+) trong m.
- Chuyn n: Ngi bnh c chuyn t n v khc n tip tc iu tr.
- Lao mn tnh: Ngi bnh vn cn vi khun lao trong m sau khi dng cng thc ti tr c
gim st cht ch vic dng thuc.

- Khc:
+ Lao phi AFB(+) khc: L ngi bnh iu tr thuc lao trc y nhng khng xc nh
c phc v kt qu iu tr, nay chn on l lao phi AFB(+).
+ Lao phi AFB(-) v lao ngoi phi khc: L ngi bnh iu tr thuc lao trc y, nay
chn on lao phi AFB(-) hoc lao ngoi phi.
6. Chn on ng nhim Lao - HIV
a) Chn on nhim HIV ngi bnh lao
Tt c nhng ngi bnh lao cn c t vn v xt nghim HIV. Thc hin xt nghim HIV
theo hng dn ca B Y t.
b) Chn on lao ngi c HIV
Biu hin lm sng, cn lm sng ca bnh lao ngi c HIV thng khng in hnh v tin
trin nhanh dn ti t vong. Ti cc c s y t, c bit phng khm ngoi tr cho ngi nhim
HIV cn lun xc nh triu chng nghi lao (c t nht 1 trong 4 triu chng sau: Ho, st, st cn,
ra m hi m trn 2 tun) cho ngi bnh mi ln n khm v bt k l do no.
Quy trnh chn on lao phi ngi c HIV xem Ph lc 2 v Ph lc 3.
II. IU TR BNH LAO
1. Nguyn tc iu tr
a) Phi hp cc thuc chng lao: Mi loi thuc chng lao c tc dng khc nhau trn vi khun
lao (dit khun, km khun), do vy phi phi hp t nht 3 loi thuc chng lao trong giai on
tn cng v t nht 2 loi trong giai on duy tr.
b) Phi dng thuc ng liu: Cc thuc chng lao tc dng hp ng, mi thuc c mt nng
tc dng nht nh. Nu dng liu thp s khng hiu qu v d to ra cc chng vi khun khng
thuc, nu dng liu cao d gy tai bin.
c) Phi dng thuc u n: Cc thuc chng lao phi c ung cng mt ln vo thi gian
nht nh trong ngy v xa ba n t hp thu thuc ti a.
d) Phi dng thuc thi gian v theo 2 giai on tn cng v duy tr: Giai on tn cng ko
di 2, 3 thng nhm tiu dit nhanh s lng ln vi khun c trong cc vng tn thng ngn
chn cc t bin khng thuc. Giai on duy tr ko di 4 n 6 thng nhm tiu dit trit cc
vi khun lao trong vng tn thng trnh ti pht.
2. Nguyn tc qun l
a) Tt c cc bc s (cng v t) tham gia iu tr ngi bnh lao phi c tp hun theo
hng dn ca Chng trnh Chng lao Quc gia v bo co theo ng quy nh.
b) S dng phc chun thng nht trong ton quc.
c) iu tr sm ngay sau khi c chn on.

d) iu tr phi c theo di v kim sot trc tip: Kim sot vic tun th iu tr ca ngi
bnh, theo di kt qu xt nghim m, theo di din bin lm sng, x tr kp thi cc bin
chng ca bnh v tc dng ph ca thuc.
) Thy thuc cn t vn y cho ngi bnh trc, trong v sau khi iu tr ngi bnh
thc hin tt liu trnh theo quy nh.
e) Chng trnh Chng lao Quc gia m bo cung cp thuc chng lao min ph, y v u
n.
3. Ch nh v phc iu tr
a) Cc thuc chng lao thit yu (Hng 1)
Chng trnh Chng lao Vit Nam quy nh 5 thuc chng lao thit yu l: Isoniazid (H),
Rifampicin (R), Pyrazinamid (Z), Streptomycin (S) v Ethambutol (E). Thuc cn phi bo qun
trong nhit mt, trnh m. Chng trnh Chng lao chu trch nhim cung cp y , lin tc
thuc chng lao c cht lng.
b) Ch nh v phc iu tr
Phc I: 2S (E)HRZ/6HE hoc 2S(E)RHZ/4RH (Ch p dng khi thc hin kim sot trc tip
c giai on duy tr).
- Hng dn:
+ Giai on tn cng ko di 2 thng, gm 4 loi thuc dng hng ngy, E c th thay th cho S.
+ Giai on duy tr ko di 6 thng gm 2 loi thuc l H v E dng hng ngy hoc 4 thng gm
2 loi thuc R v H dng hng ngy.
- Ch nh: Cho cc trng hp ngi bnh lao mi (cha iu tr lao bao gi hoc tng iu
tr lao nhng di 1 thng).
Phc II: 2SHRZE/1HRZE/5H3 R3 E3
- Hng dn: Giai on tn cng ko di 3 thng, 2 thng u tin vi c 5 loi thuc chng lao
thit yu (SHRZE) dng hng ngy, 1 thng tip theo vi 4 loi thuc (HRZE) dng hng ngy.
Giai on duy tr ko di 5 thng vi 3 loi thuc H, R v E dng 3 ln mt tun.
- Ch nh: Cho cc trng hp ngi bnh lao ti pht, tht bi phc I, iu tr li sau b tr,
mt s th lao nng v phn loi khc (phn phn loi theo tin s iu tr).
Phc III: 2HRZE/4HR hoc 2HRZ/4HR
- Hng dn: Giai on tn cng ko di 2 thng, gm 4 loi thuc (HRZE) hoc 3 loi thuc
(HRZ) dng hng ngy, iu tr cho tt c cc th lao tr em. Giai on duy tr ko di 4 thng
gm 2 loi thuc l H v R dng hng ngy.
- Ch nh: Cho tt c cc th lao tr em. Trong trng hp lao tr em th nng c th cn nhc
dng phi hp vi S.

c) Liu lng thuc: Thc hin theo Ph lc 4.

4. iu tr lao cho nhng trng hp c bit
a) Cc trng hp lao nng: Lao mng no, lao k, lao mng tim, mng bng, mng phi 2 bn,
ct sng, lao rut v lao sinh dc-tit niu cn hi chn vi chuyn khoa lao quyt nh iu tr
ngay bng phc II. Thi gian dng thuc c th ko di, ty thuc vo tin trin v mc
bnh.
b) iu tr lao ph n c thai hoc cho con b: S dng phc iu tr 2RHZE/4RH, khng
dng Streptomycin v thuc ny c th gy ic cho tr.
c) ang dng thuc trnh thai: Rifampicin tng tc vi thuc trnh thai, lm gim tc dng ca
thuc trnh thai. V vy nn khuyn ph n khi ang s dng Rifampicin hy chn phng php
trnh thai khc.
d) Ngi bnh c ri lon chc nng gan
- Nu ngi bnh c tn thng gan nng t trc:
+ Phi c iu tr ni tr ti bnh vin v theo di chc nng gan trc v trong qu trnh iu
tr.
+ Phc iu tr s do bc s chuyn khoa quyt nh tu kh nng dung np ca ngi bnh.
+ Sau khi ngi bnh dung np tt, men gan khng tng v c p ng tt v lm sng, c th
chuyn iu tr ngoi tr v theo di st.
- Nhng trng hp tn thng gan do thuc chng lao:
+ Ngng s dng thuc lao, iu tr h tr chc nng gan cho n khi men gan v bnh thng,
ht vng da. Cn theo di lm sng v men gan.
+ Nu khng p ng hoc c biu hin vim gan do thuc, chuyn n c s chuyn khoa
iu tr.
- Trng hp ngi bnh lao nng c tn thng gan c th t vong nu khng iu tr thuc
lao th dng 02 loi thuc t c vi gan l S, E hoc kt hp vi Ofloxacin. Khi ht cc biu hin
ca tn thng gan th tr li iu tr bng cc thuc dng.
) Ngi bnh c suy thn
Phc 2RHZ/4RH tt nht iu tr lao cho ngi bnh suy thn. Thuc H, R, Z c th dng liu
bnh thng ngi bnh suy thn.
e) Ngi bnh lao nhim HIV/AIDS
Cc thuc chng lao c tc dng tt vi bnh lao ngi bnh lao/HIV. iu tr lao cho ngi
bnh HIV/AIDS ni chung khng khc bit so vi ngi bnh khng nhim HIV/AIDS. Khi iu tr
cn lu mt s im sau:

- Tin hnh iu tr lao sm ngi HIV c chn on lao.

- Phi hp iu tr thuc chng lao vi iu tr d phng nhim trng c hi khc bng
Cotrimoxazol v ARV (theo hng dn hin hnh).
- Thn trng khi iu tr phi hp ARV v c hin tng tng tc thuc gia Rifampicin vi cc
thuc c ch men sao chp ngc Non-nucleocide v cc thuc c ch men Protease.
g) Bnh lao khng thuc chng lao (Theo Hng dn qun l iu tr lao khng thuc ca
Chng trnh Chng lao Quc gia).
5. Qun l iu tr
- Thc hin theo ng chin lc DOTS (Directly Observed Treatment, Short Course): Trc
tip gim st vic dng tng liu thuc ca ngi bnh, m bo ngi bnh dng ng loi
thuc, ng liu, u n v thi gian.
- Sau khi c chn on xc nh, ngi bnh cn c ng k iu tr ngay, cng sm cng tt.
Mi ngi bnh c mt s ng k, th ngi bnh v phiu iu tr.
- Thy thuc ch nh iu tr, ngi theo di cn hng dn, t vn cho ngi bnh v ngi
nh kin thc v bnh lao.
- Ngi gim st trc tip c th l cn b y t, ngi tnh nguyn vin cng ng, ngi nh
ngi bnh c t vn y v gim st trc tip trong iu tr lao.
- Nhng ngi bnh ang iu tr trong giai on tn cng nu b tr 2 ngy lin hoc giai on
duy tr b tr 1 tun th cn b y t cn tm ngi bnh v gii thch cho h quay li iu tr.
- Khi chuyn ngi bnh i ni khc iu tr phi km theo phiu chuyn v cc h s ngi
bnh theo quy nh. Ni nhn ngi bnh phi c phiu phn hi cho c s chuyn sau khi nhn
v ng k iu tr tip v phiu phn hi kt qu iu tr khi kt thc iu tr.
6. Theo di iu tr
Ngoi vic theo di nh gi p ng lm sng v tc dng ph ca thuc (nu c), ngi bnh
iu tr lao cn phi c xt nghim m theo di:
- i vi th lao phi AFB(+): Cn phi xt nghim m 3 ln
+ Phc I:
2SRHZ/6HE: Xt nghim m vo cui thng th 2, 5, 7 (hoc 8).
2RHZE/4HR: Xt nghim m vo cui thng th 2, 4 v 6.
+ Phc II: Xt nghim m vo cui thng th 3, 5 ,7 (hoc 8).
+ Phc III: Xt nghim m vo cui thng th 2 v 5.
- i vi th lao phi AFB(-): Xt nghim m hai ln cui thng th 2 v 5.

X tr kt qu xt nghim m theo di:

- i vi Phc I: Nu sau 2 thng tn cng xt nghim m AFB vn dng tnh th iu tr
tn cng thm 1 thng bng HRZ sau chuyn iu tr duy tr. Nu t thng th 5 tr i xt
nghim m AFB m tnh th tip tc iu tr duy tr, nu dng tnh coi l tht bi phi chuyn
Phc II.
- i vi Phc II: Nu sau 3 thng tn cng xt nghim m vn dng tnh th iu tr tn
cng thm 1 thng bng RHZE sau chuyn iu tr duy tr. Nu xt nghim AFB(+) trong m
t thng th 5 tr i, chuyn ngi bnh n c s iu tr lao khng thuc.
- i vi phc III: Nh Phc I.
7. nh gi kt qu iu tr
a) Khi: Ngi bnh iu tr thi gian v c kt qu xt nghim m m tnh t nht 02 ln k
t thng iu tr th 5 tr i.
b) Hon thnh iu tr: Ngi bnh iu tr thi gian nhng khng xt nghim m hoc ch
c xt nghim m 01 ln t thng th 5, kt qu m tnh.
c) Tht bi: Ngi bnh xt nghim m cn AFB(+) hoc AFB(+) tr li t thng th 5 tr i.
d) B iu tr: Ngi bnh b thuc lao lin tc trn 02 thng trong qu trnh iu tr.
) Chuyn i: Ngi bnh c chuyn i ni khc iu tr v c phiu phn hi. Nu khng c
phiu phn hi coi nh ngi bnh b tr.
e) Cht: Ngi bnh cht v bt c cn nguyn g trong qu trnh iu tr lao.
g) Khng nh gi: Nhng ngi bnh ng k iu tr lao nhng v l do no khng tip
tc iu tr cho n khi kt thc phc iu tr (v d: thay i chn on khc).
Lu : i vi ngi bnh lao phi AFB(-) hoc lao ngoi phi ch nh gi l hon thnh iu tr
khi iu tr ht phc .
III. PHNG BNH LAO
Bnh lao l bnh ly truyn qua ng h hp do ht phi khng kh c cha vi khun lao c
sinh ra trong qu trnh ho, khc, ht hi hoc ni chuyn vi ngi b lao phi trong giai on
tin trin. Do vy pht hin sm v iu tr sm lm gim nhanh chng kh nng ly truyn bnh
lao (sau 2-4 tun).
Nguy c nhim lao ca ngi tip xc tu thuc vo thi gian tip xc, mc thn mt, m
cc ht nhim khun trong khng kh v yu t ch th.
Nguy c chuyn t nhim lao sang mc bnh lao khong 10% trong i nu mt ngi b nhim
vi khun lao t lc nh, tuy nhin, nhng ngi suy gim min dch nh ng nhim HIV th
nguy c chuyn t nhim lao sang bnh lao s tng ln rt cao, khong 10%/ nm.
Phng bnh lao l p dng cc bin php nhm: (1) Gim nguy c nhim vi khun lao, v (2)
Gim nguy c chuyn t nhim lao sang bnh lao.

1. Gim nguy c nhim lao

a) Kim sot v sinh mi trng
- Gim m cc ht nhim khun trong khng kh bng thng gi tt:
+ Ca i v ca s ca bung khm, khu ch v bung bnh cn c m cho thng gi t
nhin hoc dng qut in ng chiu lm long cc ht nhim khun v y vi khun ra
ngoi, di nh nng mt tri vi khun lao s d b tiu dit.
+ B tr v tr lm vic hp l theo chiu thng gi: Khng khng kh i t ngi bnh n cn
b y t. (S bung khm bnh xem Ph lc 5).
- Thay i hnh vi ca ngi bnh (v sinh h hp) nhm lm gim cc ht nhim khun ra mi
trng:
+ Dng khu trang hoc t nht c khn che ming khi tip xc ni chuyn vi ngi khc (cn
b y t), khi ht hi, ho.
+ Khc m vo giy hoc ca cc, b ng ni quy nh, ra tay x phng thng xuyn.
+ Ly m xt nghim ng ni quy nh, tt nht l ngoi tri, mi trng thng thong. Nu
khng, cn ni c thng gi tt, t kh nng tip xc ca nhn vin y t v nhng ngi khc.
Khng nn t ni ly m nhng phng nh ng kn hoc nh v sinh.
b) S dng phng tin phng h c nhn
Nhn vin y t: Khu trang thng thng t c tc dng bo v nhim vi khun lao. Nhng ni c
nguy c ly nhim cao cn dng khu trang t chun nh loi N95 hoc tng ng tr ln.
c) Gim tip xc ngun ly
- Cch ly: Nn c ni chm sc iu tr ring cho ngi bnh lao phi AFB(+), c bit vi lao
phi khng a thuc.
- Trong cc c s c bit nh tri giam, trung tm cha bnh, gio dc v lao ng x hi
(Trung tm 05/06) c th c nhiu ngi HIV(+) kh nng ly nhim rt cao, cn cch ly tho
ng nhng ngi bnh iu tr mi trnh c cc v dch nghim trng.
- Nhn vin y t cn tun th quy trnh khm, chm sc ngi bnh: Tip xc gin tip qua vch
knh, khm, hi bnh, thc hin t vn ngi bnh quay lng li. Thn thin qua hnh ng
c ch li ni ch khng nht thit phi tip xc trc tip.
- bo v cho ngi nhim HIV n khm: Cn xc nh nhng ngi nghi lao (ho khc)
hung dn h dng khu trang, giy che ming, chuyn n khu ch ring hoc phng cch ly
(nu c) v u tin khm trc gim thi gian tip xc.
2. Gim nguy c chuyn t nhim lao sang bnh lao
a) Tim vc xin BCG (Bacille Calmette-Gurin) do Chng trnh Tim chng m rng thc hin
nhm gip cho c th hnh thnh min dch chng li bnh lao khi b nhim lao. c tc dng
cn:

- Tim ng k thut, ng liu lng.

- Vc xin phi c bo qun ng, m bo cht lng trong ton b dy chuyn n tng liu
s dng cho tr.
Din bin: Sau khong 3 n 4 tun ti ch tim s c mt nt sng nh, r dch trong vi tun
ri kn ming ng vy. Khi vy rng s li mt so nh, mu trng, c th hi lm.
Bin chng tim BCG:
- Nt lot to (ng knh 5 8 mm) lm m v ko di, c th dng dung dch Rimifon (INH) 1%,
bt Rimifon (INH) hoc Rifampicin ti ch.
- Vim hch: t l di 1%, thng xut hin trong 6 thng sau tim, sng hch nch hoc hch
thng n cng bn tim, hch mm, di ng, sng chm v v, c th r ko di trong vi
thng ri lnh t nhin. Khi hch nhuyn ho c th chch v ra sch, rc bt Rimifon (INH)
hoc Rifampicin ti ch. Khng cn dng thuc chng lao ng ton thn.
b) iu tr d phng lao bng INH
- i tng:
+ Tt c nhng ngi nhim HIV (ngi ln v tr em) c sng lc hin khng mc bnh
lao tin trin.
+ Tr em di 5 tui tip xc trc tip vi ngun ly l ngi bnh lao phi AFB(+).
- Phc : Rimifon (INH) liu dng 5 mg/kg/ngy (ti a 300 mg/ngy); ung mt ln hng ngy
trong 9 thng; phi hp vitamin B6 liu lng 25mg hng ngy.
- Theo di nh gi: Cp thuc hng thng v nh gi vic dng thuc t nht 1 thng/ln. Nu
ngi bnh b tr, s liu b tr t hn 50% tng liu th c th b sung cho . Nu s liu b
qu 50% tng liu th nn bt u iu tr t u sau b tr.
- Tc dng ph:
+ Nh: Vim thn kinh ngoi vi. X tr bng vitamin B6 liu lng 100mg/ngy.
+ Nng: Tn thng gan (vng da, chn n, men gan tng cao). X tr: Ngng INH v chuyn
n cc c s y t iu tr. Khng c ung ru, bia trong thi gian dng thuc.
3. Thc hin phng ly nhim trong c s y t
Cc c s y t phi thc hin y Quy ch kim sot nhim khun bnh vin v Hng dn
kim sot ly nhim lao ti cc c s y t.
- Lnh o cn quan tm, c k hoch, quy trnh v phn cng ngi ph trch d phng ly
nhim lao ti n v. Cn u t thch hp cc iu kin cn thit phc v k hoch v quy trnh
d phng ly nhim cho nhn vin y t v cho ngi bnh ti n v.

- K hoch v quy trnh cn c ph bin rng ri cho nhn vin t cc bc qun l ngi
bnh, ly bnh phm, tun th quy trnh v sinh v phi c cng khai di dng bng biu,
bin bo d thy, d thc hin v khuyn khch mi nhn vin tham gia kim tra gim st, gp .
- nh k, ngi ph trch d phng ly nhim bo co vi lnh o v thc hin k hoch v
tham mu v cc im cn thc hin ci thin cht lng cng tc d phng ly nhim trong
n v.

PH LC 1
S QUY TRNH CHN ON LAO PHI AFB(-) (WHO, 2006)
(Ban hnh km theo Quyt nh s 979 /Q-BYT ngy 24 thng 3 nm 2009 ca B trng B Y
t)

Lu : iu tr th bng khng sinh ph rng khi cc triu chng nghi lao (ho khc m ko di,
st tht thng) cn tn ti. Khng s dng nhm Quinolon v nhm thuc ny c tc dng vi
vi khun lao do vy khng phn bit c gia vim do lao hay vi khun khc. Nu quyt
nh iu tr lao cn iu tr ht cng thc v thi gian tun th nguyn tc c kim sot trc
tip.

PH LC 2
S QUY TRNH CHN ON LAO PHI NGI HIV(+) KHNG C DU HIU NNG
(da trn hng dn ca WHO 2006, WPRO 2008)
(Ban hnh km theo Quyt nh s 979 /Q-BYT ngy 24 thng3 nm 2009 ca B trng B Y
t)

Ch thch:
a. Ngi bnh n khng c du hiu nng (t i li c, khng kh th, khng st cao, mch
di 120/pht).
b. Lao phi AFB(+) khi c t nht mt ln dng tnh,
c. AFB m tnh khi c 2 mu m AFB(-).
d. CPT: iu tr d phng bng Cotrimoxazol.

e. nh gi HIV bao gm: phn loi lm sng, xt nghim m CD4 v xem xt iu tr HIV/AIDS
(bao gm c ART).
f. Ch mt s ni c iu kin nui cy. Phim chp X-quang sn c t ln khm u tin, nu
c phim chp cc ln trc y so snh cng tt. Ngi bnh c nh gi k v lm sng
v X-quang phi chn on xc nh hoc loi tr.
g. PCP: Vim phi do Pneumocystis carinii cn gi l Pneumocystis jiroveci
h. Khng sinh ph rng (tr nhm Quinolon)
i. nh gi li theo quy trnh nu triu chng ti xut hin.

PH LC 3
S QUY TRNH CHN ON LAO PHI NGI HIV (+) C DU HIU NNG
(da trn hng dn ca WHO 2006, WPRO 2008)
(Ban hnh km theo Quyt nh s 979 /Q-BYT ngy 24 thng 3 nm 2009 ca B trng B Y
t)

Ch thch:
a. Du hiu nguy him bao gm mt trong cc du hiu sau: nhp th >30/pht, st >39oC, mch
>120/pht v khng t i li c.
b. Khng sinh ph rng tr nhm Quinolon.
c. Cc xt nghim ny cn c thc hin sm tng tc chn on.
d. AFB dng tnh c xc nh khi c t nht mt ln dng tnh, AFB m tnh - khi c 2 hay
nhiu hn cc mu AFB m tnh.
e. Lng gi li lao bao gm xt nghim AFB v lng gi lm sng.

PH LC 4
LIU LNG THUC CHNG LAO
(Ban hnh km theo Quyt nh s 979 /Q-BYT ngy 24 thng 3 nm 2009 ca B trng B Y
t)
Bng 1. Liu lng cc thuc chng lao theo cn nng
Loi thuc

Isoniazid
Rifampicin
Pyrazinamid
Ethambutol

Hng ngy
Liu lng (khong cch liu)
tnh theo mg/kg cn nng
5 (4-6)
10 (8-12)
25 (20-30)
Tr em 20 (15-25)

Mi tun 3 ln
Liu lng
( khong cch liu)
tnh theo mg/kg cn nng
10 (8 -12)
10 (8 -12)
35 (30-40)
30 (25-35)

Ngi ln 15 (15-20)
Streptomycin

15 (12-18)

15 (12-18)

Bng 2. S lng vin, l thuc n l dng hng ngy cho ngi ln theo cn nng
30-39
Giai on tn cng hng ngy S lng vin hoc l
H 100 mg (vin)
2
R 150 mg (vin)
2
Z 400 mg (vin)
2
E 400 mg (vin)
2
S 1g (l)
0,5
Giai on duy tr hng ngy
H 100mg (vin)
2
R 150 mg (vin)
2

Cn nng ca ngi bnh (kg)

40-54
55-70

>70

3
3
3
2
0,75

3
4
4
3
1

3
5
5
4
1

3
3

3
4

3
5

E 400 mg(vin)
Giai on duy tr tun 3 ln
H 300 mg(vin)
R 150 mg(vin)
E 400mg(vin)

1
2
2

2
3
4

2
4
6

3
5
6

Bng 3. S vin hn hp liu c nh dng hng ngy cho ngi ln theo cn nng
Thuc hn hp liu c nh

Cn nng (kg)
30-39 kg

Giai on tn cng hng ngy

HRZE (vin)
(75mg+150mg+400mg+275mg)

40-54 kg
55-70 kg
S vin

>70 kg

Giai on duy tr hng ngy

HR (75mg+150mg), vin

HE (150mg + 400mg), vin

1,5

HRZ (vin) (75mg+150mg+400mg)

Giai on duy tr - tun 3 ln

HR (150mg + 100mg) (vin)

PH LC 5
X TR MT S TC DNG PH THUNG GP
(Ban hnh km theo Quyt nh s 979 /Q-BYT ngy 24 thng 3 nm 2009 ca B trng B Y
t)
Tc dng ph
Loi nh:
Bun nn, nn ma, au bng
au khp
Cm gic nng bng chn.
Nc tiu hoc da cam
Nga, pht ban ngoi da
Loi nng:
Sc phn v
U tai, chng mt, ic
Xut huyt da, thiu mu tan huyt,
suy thn cp
Gim th lc (tr cn nguyn khc)
Vng da, vim gan (tr cn nguyn
khc)
Sc v purpura(vim trt da)

Thuc

Cch x l

R
Z

Sau ba n bui ti
Aspirin hoc thuc khng vim khng Steroid

Pyridoxin 50 70 mg/ngy

R
Tip tc dng
S,H,R,Z Ngng thuc, gii mn cm v th dng li.
S
S
R
E
Z,H,R
R

Ngng S, thay bng E, khng dng li

Ngng S, thay bng E
Ngng R, Khng bao gi dng li
Ngng E
Ngng thuc ch ht vim gan, th dng li H,
R
Ngng Rifampicin

PH LC 6
S BUNG KHM BNH LAO
(Ban hnh km theo Quyt nh s 979 /Q-BYT ngy 24 thng 3 nm 2009 ca B trng B Y
t)

Yu cu:
(1) Din tch ti thiu 12m2
(2) m bo thng kh ti thiu 12 chu k trao i kh/gi.
(3) Thy thuc ngi cch ngi bnh ti thiu 1m.
Ghi ch:
BS/D: Bc s/iu dng
NB: Ngi bnh