แนวทางการวินิจฉัยและรักษา โรคหืดในประเทศไทย สำหรับผู้ใหญ่ พ.ศ. 2560 PDF

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·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.».
2560 ‰¥â¡’°“√ª√—∫ª√ÿß®“°©∫—∫ªï æ.». 2559 ‡æ◊ËÕ‡ªìπ·π«∑“ß ”À√—∫°“√√—°…“
‚√§À◊¥μ“¡À≈—°∞“π‡™‘ßª√–®—°…å ·≈–§«“¡‡ÀÁπ¢ÕßºŸâ‡™’Ë¬«™“≠μà“ßÊ ‚¥¬¡’°“√
ª√—∫‡ª≈’Ë¬π√“¬≈–‡Õ’¬¥®“°©∫—∫‡¥‘¡„πªï æ.». 2555 ´÷Ëß¡’§«“¡ Õ¥§≈âÕß·≈–
§«“¡·μ°μà“ß®“°·π«∑“ß¢Õß Global Initiative for Asthma (GINA) ¥—ß
√“¬≈–‡Õ’¬¥μàÕ‰ªπ’È§◊Õ °“√«‘π‘®©—¬‚√§À◊¥Õ“»—¬ª√–«—μ‘·≈–À≈—°∞“π°“√μ√«®æ∫
variable expiratory airflow limitation ‚¥¬‡πâπ∑’Ë°“√ àßμ√«® ‰ª‚√‡¡μ√’¬å‡æ◊ËÕ
¬◊π¬—π°“√«‘π‘®©—¬„π§√—Èß·√° À√◊Õ°“√«—¥§à“ ¡√√∂¿“æªÕ¥ PEF ∑’Ë¡’°“√º—πº«π
®“°°“√«—¥ 2 §√—Èß„π·μà≈–«—π„π™à«ß 1-2 —ª¥“Àå ‚¥¬°”Àπ¥∑’Ë√–¥—∫√âÕ¬≈– 10
‡ªìπ°“√¬◊π¬—π°“√«‘π‘®©—¬‚√§À◊¥´÷Ëß Õ¥§≈âÕß°—∫ GINA ”À√—∫·π«∑“ß„π©∫—∫
ªï æ.». 2560 ‰¥âμ—¥°“√®”·π°§«“¡√ÿπ·√ß¢Õß‚√§À◊¥ÕÕ°´÷Ëß·μ°μà“ß®“°©∫—∫„π
ªï æ.». 2555 ·≈–¢Õß GINA ·μà‡πâπ∑’Ë°“√ª√–‡¡‘π°“√§«∫§ÿ¡Õ“°“√¢Õß‚√§À◊¥
‚¥¬°”Àπ¥„Àâ‡À≈◊Õ‡æ’¬ß 2 √–¥—∫§◊Õ Õ“°“√¢Õß‚√§À◊¥∑’Ë§ÿ¡‰¥â·≈–§ÿ¡‰¡à ‰¥â ·≈–
„π·π«∑“ß©∫—∫ªï æ.». 2560 ‰¥â‡æ‘Ë¡ªí®®—¬‡ ’Ë¬ß„πÕπ“§μ¢Õß‚√§‡¢â“‰ªÕ—π‰¥â·°à
ªí®®—¬‡ ’Ë¬ßμàÕÀ◊¥°”‡√‘∫‡©’¬∫æ≈—π ªí®®—¬‡ ’Ë¬ßμàÕÀ≈Õ¥≈¡μ’∫∂“«√ ·≈–ªí®®—¬μàÕ
º≈¢â“ß‡§’¬ß°“√√—°…“ ´÷Ëßμà“ß®“°·π«∑“ß„πªï æ.». 2555 ·μà Õ¥§≈âÕß°—∫ GINA
„π à«π¢Õß¬“√—°…“‚√§À◊¥ ¡’°“√„™â¬“ Ÿ¥æàπ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å‡ªìπ§√—Èß§√“«
„πºŸâªÉ«¬‚√§À◊¥∑’Ë¡’ªí®®—¬‡ ’Ë¬ß∑’Ëμà“ß®“°©∫—∫ªï æ.». 2555 ·≈–‰¥â√–∫ÿ°“√„™â¬“
∫√√‡∑“Õ“°“√πÕ°®“°¬“°√–μÿâπμ—«√—∫∫’μâ“™π‘¥∑’ËÕÕ°ƒ∑∏‘Ï‡√Á«§◊Õ salbutamol
¬—ß “¡“√∂„™â¬“ Ÿ¥æàπ§Õ√åμ‘‚§ ‡μÕ√Õ¬¥åº ¡¬“°√–μÿâπμ—«√—∫∫’μâ“ formoterol
À“°„™â¬“¥—ß°≈à“«‡ªìπ¬“º ¡‡æ◊ËÕ§«∫§ÿ¡‚√§´÷Ëß Õ¥§≈âÕß°—∫ GINA ”À√—∫°“√
√—°…“„π√–¥—∫ 4 ‰¥â¡’°“√‡æ‘Ë¡¬“¢¬“¬À≈Õ¥≈¡∑’ËÕÕ°ƒ∑∏‘Ïμâ“πμ—«√—∫‚§≈‘‡πÕ√å®‘°∑’Ë
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 5

ÕÕ°ƒ∑∏‘Ï¬“«§◊Õ tiotropium ‡¢â“‰ª ·≈– ”À√—∫°“√√—°…“„π √–¥—∫ 5 ¡’°“√
√–∫ÿ∂ß÷ ‡«≈“∑’‡Ë À¡“– ¡¢Õß°“√„™â¬“ omalizumab ∑’‡Ë æ‘¡Ë ®“°„™â‡æ’¬ß 6 ‡¥◊Õπ‡ªìπ
1 ªïμ“¡¢âÕ¡Ÿ≈„π°“√»÷°…“ OXYGEN „πª√–‡∑»‰∑¬ ·≈–°“√√—°…“¥â«¬ bron-
chial thermoplasty ∑’Ë‡√‘Ë¡¡’°“√„™â „πª√–‡∑»‰∑¬·≈â« ·π«∑“ß©∫—∫ªï æ.». 2560
‰¥â‡æ‘Ë¡¬“∑’ËÕ“®¡’ „™â „πÕπ“§μ§◊Õ anti-IL-5 À√◊Õ mepolizumab πÕ°®“°π’È¬—ß
‰¥â‡æ‘Ë¡√“¬≈–‡Õ’¬¥«‘∏’°“√‡≈◊Õ°Õÿª°√≥å Ÿ¥¬“∑’Ë‡À¡“– ¡ ”À√—∫ºŸâªÉ«¬‚√§À◊¥ ´÷Ëß
Õ¥§≈âÕß°—∫ GINA ·≈–‰¥â‡æ‘Ë¡À—«¢âÕ‡√◊ËÕß guideline implementation ∑’Ë¡’°“√
®—¥μ—Èß Easy Asthma Clinic „πª√–‡∑»‰∑¬ ´÷Ëßμà“ß®“° GINA ªí®®ÿ∫—π°≈ÿà¡
Õ“°“√√à«¡√–À«à“ß‚√§À◊¥·≈–‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß (Asthma-COPD overlap
syndrome À√◊Õ ACOS) ‰¥â√—∫§«“¡ π„®¡“°¢÷Èπ ·≈–‰¥â∫√√®ÿ‰«â „π©∫—∫ªï æ.».
2560 ´÷Ëß Õ¥§≈âÕß°—∫ GINA ·≈– GOLD ·μàμà“ß®“°©∫—∫ªï æ.». 2555 ´÷Ëß¬—ß
μâÕß°“√¢âÕ¡Ÿ≈°“√»÷°…“‡æ‘Ë¡‡μ‘¡„πª√–‡∑»‰∑¬ ·≈– ”À√—∫°“√√—°…“∑’Ë ‰¡à „™â¬“
‰¥â·°â ‰¢‡√◊ËÕß §”·π–π”¢Õß¡“μ√°“√≈¥ª√‘¡“≥‰√ΩÿÉπμàÕ‚√§À◊¥ ®“°‰¡à·π–π”
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ÿ ¿“æ¥’‡¬’¬Ë ¡ (well-designed,
non-randomized controlled clinical trial) À√◊Õ
2.3 À≈—°∞“π®“°√“¬ß“π°“√»÷°…“μ“¡·ºπμ‘¥μ“¡‡Àμÿ‰ªÀ“º≈ (cohort)
À√◊Õ°“√»÷°…“«‘‡§√“–Àå§«∫§ÿ¡°√≥’¬Õâ πÀ≈—ß (case-control analytic
studies) ∑’Ë ‰¥â√—∫°“√ÕÕ°·∫∫«‘®—¬‡ªìπÕ¬à“ß¥’ ´÷Ëß¡“®“° ∂“∫—πÀ√◊Õ
°≈ÿà¡«‘®—¬¡“°°«à“Àπ÷Ëß·Ààß/°≈ÿà¡ À√◊Õ
2.4 À≈—°∞“π®“°æÀÿ°“≈“πÿ°√¡ (multiple-time series) ´÷Ëß¡’À√◊Õ‰¡à¡’
¡“μ√°“√¥”‡π‘π°“√ À√◊ÕÀ≈—°∞“π∑’Ë ‰¥â®“°°“√«‘®—¬∑“ß§≈‘π‘°√Ÿª·∫∫
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 7

Õ◊Ëπ À√◊Õ∑¥≈Õß·∫∫‰¡à¡’°“√§«∫§ÿ¡ ´÷Ëß¡’º≈ª√–®—°…å∂÷ßª√–‚¬™πå
À√◊Õ‚∑…®“°°“√ªØ‘∫—μ‘¡“μ√°“√∑’Ë‡¥àπ™—¥¡“° ‡™àπ º≈¢Õß°“√π”¬“
‡æÁππ‘´‘≈‘π¡“„™â „π√“« æ.». 2480 ®–‰¥â√—∫°“√®—¥Õ¬Ÿà „πÀ≈—°∞“π
ª√–‡¿∑π’È
§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3
À¡“¬∂÷ß À≈—°∞“π∑’Ë ‰¥â®“°
3.1 °“√»÷°…“æ√√≥π“ (descriptive studies) À√◊Õ
3.2 °“√»÷°…“§«∫§ÿ¡∑’¡Ë §’ ≥
ÿ ¿“ææÕ„™â (fair-designed, controlled clinical
trial)
§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 4
À¡“¬∂÷ß À≈—°∞“π∑’Ë ‰¥â®“°
4.1 √“¬ß“π¢Õß§≥–°√√¡°“√ºŸâ‡™’Ë¬«™“≠ª√–°Õ∫°—∫§«“¡‡ÀÁπæâÕßÀ√◊Õ
©—π∑“¡μ‘ (consensus) ¢Õß§≥–ºŸ‡â ™’¬Ë «™“≠∫πæ◊πÈ ∞“πª√– ∫°“√≥å
∑“ß§≈‘π‘° À√◊Õ
4.2 √“¬ß“πÕπÿ°√¡ºŸâªÉ«¬®“°°“√»÷°…“„πª√–™“°√μà“ß°≈ÿà¡·≈–§≥–
ºŸâ»÷°…“μà“ß§≥–Õ¬à“ßπâÕ¬ 2 ©∫—∫√“¬ß“π À√◊Õ§«“¡‡ÀÁπ∑’Ë ‰¡à ‰¥âºà“π
°“√«‘‡§√“–Àå·∫∫¡’√–∫∫ ‡™àπ ‡°√Á¥√“¬ß“πºŸâªÉ«¬‡©æ“–√“¬ (anec-
dotal report) §«“¡‡ÀÁπ¢ÕßºŸâ‡™’Ë¬«™“≠‡©æ“–√“¬®–‰¡à ‰¥â√—∫°“√
æ‘®“√≥“«à“‡ªìπÀ≈—°∞“π∑’Ë¡’§ÿ≥¿“æ„π°“√®—¥∑”·π«∑“ß‡«™ªØ‘∫—μ‘π’È
8
πÈ”Àπ—°§”·π–π” (Strength of Recommendation)
πÈ”Àπ—°§”·π–π” ++
À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õß§”·π–π”„Àâ∑”Õ¬Ÿà „π√–¥—∫ Ÿß ‡æ√“–¡“μ√°“√
¥—ß°≈à“«¡’ª√–‚¬™πåÕ¬à“ß¬‘ËßμàÕºŸâªÉ«¬ ·≈–§ÿâ¡§à“ (cost effective) ç§«√∑”é
πÈ”Àπ—°§”·π–π” +
À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õß§”·π–π”„Àâ∑”Õ¬Ÿà „π√–¥—∫ª“π°≈“ß ‡π◊ËÕß®“°
¡“μ√°“√¥—ß°≈à“«Õ“®¡’ª√–‚¬™πåμÕà ºŸªâ «É ¬ ·≈–Õ“®§ÿ¡â §à“„π¿“«–®”‡æ“– çπà“∑”é
πÈ”Àπ—°§”·π–π” +/-
À¡“¬∂÷ß §«“¡¡—Ëπ„®¬—ß‰¡à‡æ’¬ßæÕ„π°“√„Àâ§”·π–π” ‡π◊ËÕß®“°¡“μ√°“√
¥—ß°≈à“«¬—ß¡’À≈—°∞“π‰¡à‡æ’¬ßæÕ„π°“√ π—∫ πÿπÀ√◊Õ§—¥§â“π«à“Õ“®¡’À√◊ÕÕ“®
‰¡à¡’ª√–‚¬™πμàÕºŸâªÉ«¬·≈–Õ“®‰¡à§ÿâ¡§à“ ·μà ‰¡à°àÕ„Àâ‡°‘¥Õ—πμ√“¬μàÕºŸâªÉ«¬‡æ‘Ë¡¢÷Èπ
¥—ßπ—Èπ°“√μ—¥ ‘π„®°√–∑”¢÷ÈπÕ¬Ÿà°—∫ªí®®—¬Õ◊Ëπ Ê çÕ“®∑”À√◊Õ‰¡à∑”é
πÈ”Àπ—°§”·π–π” -
À¡“¬∂÷ß §«“¡¡—πË „®¢Õß§”·π–π”Àâ“¡∑” Õ¬Ÿà„π√–¥—∫ª“π°≈“ß ‡π◊ÕË ß®“°
¡“μ√°“√¥—ß°≈à“«‰¡à¡’ª√–‚¬™πåμàÕºŸâªÉ«¬·≈–‰¡à§ÿâ¡§à“ À“°‰¡à®”‡ªìπ ç‰¡àπà“∑”é
πÈ”Àπ—°§”·π–π” - -
À¡“¬∂÷ß §«“¡¡—Ëπ„®¢Õß§”·π–π”Àâ“¡∑”Õ¬Ÿà„π√–¥—∫ Ÿß ‡æ√“–¡“μ√°“√
¥—ß°≈à“«Õ“®‡°‘¥‚∑…À√◊Õ°àÕ„Àâ‡°‘¥Õ—πμ√“¬μàÕºŸâªÉ«¬ ç‰¡à§«√∑”é
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 9

·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„π
ª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2559
π‘¬“¡¢Õß‚√§À◊¥
‚√§À◊¥‡ªìπ‚√§∑’¡Ë §’ «“¡À≈“°À≈“¬¢ÕßÕ“°“√ (heterogeneous disease)
¡’≈°— …≥–°“√Õ—°‡ ∫‡√◊ÕÈ √—ß¢ÕßÀ≈Õ¥≈¡ ºŸªâ «É ¬¡’ª√–«—μÕ‘ “°“√∑“ß‡¥‘πÀ“¬„® ‰¥â·°à
À“¬„®‡ ’¬ßÀ«’¥ ÀÕ∫‡Àπ◊ËÕ¬ ·πàπÀπâ“Õ°·≈–Õ“°“√‰Õ ‚¥¬Õ“°“√ºŸâªÉ«¬¡’°“√
‡ª≈’Ë¬π·ª≈ß‰¥âÀ≈“¬√Ÿª·∫∫ „π¥â“π‡«≈“°“√¥”‡π‘π‚√§·≈–√–¥—∫§«“¡√ÿπ·√ß
√à«¡°—∫°“√μ√«®æ∫°“√·ª√ª√«π¢Õß°“√Õÿ¥°—πÈ À≈Õ¥≈¡„π™à«ß¢“ÕÕ° (variable
expiratory airflow limitation) ·≈–Õ“°“√Õ“®°”‡√‘∫ À√◊Õ°≈—∫‡ªìπ´È” Ê ‰¥â1
≈—°…≥–∑—Ë«‰ª¢Õß‚√§À◊¥
‚√§À◊¥æ∫‰¥âª√–¡“≥√âÕ¬≈– 7 ¢Õßª√–™“°√„πª√–‡∑»‰∑¬2 ºŸâªÉ«¬¡—°¡’
Õ“°“√·ª√ª√«π (variable symptoms) ‡™àπ À“¬„®‡ ’¬ßÀ«’¥ ‡Àπ◊ËÕ¬ßà“¬ ·πàπ
Àπâ“Õ°À√◊Õ‰Õ √à«¡°—∫ variable expiratory airflow limitation ‚¥¬∑’ËÕ“°“√
·≈–°“√Õÿ¥°—ÈπÀ≈Õ¥≈¡ (airflow limitation) “¡“√∂∂Ÿ°°√–μÿâπ‚¥¬°“√ÕÕ°
°”≈—ß°“¬ °“√ —¡º— “√°àÕ¿Ÿ¡‘·æâÀ√◊Õ “√∑’Ë∑”„Àâ‡°‘¥°“√√–§“¬‡§◊Õß °“√‡ª≈’Ë¬π
·ª≈ß ¿“æÕ“°“» ·≈–°“√μ‘¥‡™◊ÕÈ ∑“ß‡¥‘πÀ“¬„® ‡ªìπμâπ ‚√§À◊¥¡’≈°— …≥–À≈Õ¥≈¡
‰«‡°‘π (airway hyperresponsiveness) μàÕ “√°àÕ¿Ÿ¡‘·æâ À√◊Õ “√∑’Ë∑”„Àâ‡°‘¥
°“√√–§“¬‡§◊Õß ∑”„Àâ‡°‘¥°“√Õ—°‡ ∫‡√◊ÕÈ √—ß¢ÕßÀ≈Õ¥≈¡Õ¬à“ßμàÕ‡π◊ÕË ß·¡âºªŸâ «É ¬‰¡à¡’
Õ“°“√ À√◊ÕÕ“®¡’º≈μ√«® ¡√√∂¿“æªÕ¥∑’Ëª°μ‘‰¥â ·≈– “¡“√∂°≈—∫¡“§«∫§ÿ¡
Õ“°“√„Àâª°μ‘‰¥â¥â«¬°“√√—°…“∑’Ë‡À¡“– ¡ Õ“°“√¢Õß‚√§À◊¥·≈–°“√Õÿ¥°—Èπ¢Õß
À≈Õ¥≈¡Õ“®À“¬‡Õß‰¥âÀ√◊ÕÀ“¬¿“¬À≈—ß„Àâ¬“√—°…“ ·≈–‰¡à¡’Õ“°“√Õ’°‡ªìπ‡«≈“
10
π“πÀ≈“¬ —ª¥“ÀåÀ√◊Õ‡ªìπ‡¥◊Õπ ºŸâªÉ«¬∫“ß√“¬¡’Õ“°“√À◊¥°”‡√‘∫‡©’¬∫æ≈—π (exa-
cerbation) √ÿπ·√ß Õ“®∑”„Àâ‡ ’¬™’«‘μ‰¥â ·≈–¡’º≈°√–∑∫μàÕºŸâªÉ«¬·≈– —ß§¡
°“√«‘π‘®©—¬‚√§À◊¥
°“√«‘π‘®©—¬‚√§À◊¥ ª√–°Õ∫¥â«¬
1. Õ“°“√∑’Ë‡¢â“‰¥â°—∫‚√§À◊¥
2. ¡’À≈—°∞“π°“√μ√«®æ∫ variable expiratory airflow limitation
∑—Èßπ’ÈÕ“°“√∑“ß√–∫∫À“¬„® ‡™àπ ‰¥â¬‘π‡ ’¬ßÀ«’¥ (wheezing) ‰¡à®”‡æ“–
°—∫·§à „π‚√§À◊¥‡∑à“π—Èπ ®÷ß§«√ àßμ√«® ‰ª‚√‡¡μ√’¬å (spirometry) ‡æ◊ËÕ¬◊π¬—π
°“√«‘π‘®©—¬‚√§À◊¥μ—Èß·μà§√—Èß·√°∑’ËºŸâªÉ«¬¡“æ∫·æ∑¬å ‡π◊ËÕß®“°°“√ àßμ√«®¿“¬
À≈—ßºŸâªÉ«¬‰¥â√—∫°“√√—°…“¥â«¬¬“§«∫§ÿ¡Õ“°“√ (controller) ‰ª·≈â«®–‡°‘¥§«“¡
¬ÿàß¬“°„π°“√·ª≈º≈‰¥â¡“°°«à“ „π°√≥’∑’Ë ‰¡à “¡“√∂∑”°“√μ√«® ‰ª‚√‡¡μ√’¬å ‰¥â
°“√μ√«® peak expiratory flow (PEF) variability ®–™à«¬‡æ‘Ë¡§«“¡·¡àπ¬”
„π°“√«‘π‘®©—¬‰¥â¡“°¢÷Èπ1 (πÈ”Àπ—°§”·π–π” +, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 4)
°“√´—°ª√–«—μ‘ ≈—°…≥–Õ“°“√∑“ß√–∫∫À“¬„®∑’Ë‡¢â“‰¥â°—∫‚√§À◊¥
∂â“ºŸâªÉ«¬¡’Õ“°“√¥—ßμàÕ‰ªπ’È¡’ ‚Õ°“ ‡ªìπ‚√§À◊¥ ‰¥â·°à
1. ¡’Õ“°“√¡“°°«à“Àπ÷ßË Õ¬à“ß ‰¥â·°à À“¬„®‡ ’¬ßÀ«’¥ ‡Àπ◊ÕË ¬ ‰Õ À√◊Õ·πàπ
Àπâ“Õ°
2. Õ“°“√·¬à≈ß™à«ß°≈“ß§◊πÀ√◊Õ√ÿàß‡™â“
3. Õ“°“√·≈–§«“¡√ÿπ·√ß·ª√ª√«πμ≈Õ¥√–¬–‡«≈“
4. Õ“°“√ÀÕ∫À◊¥°√–μÿπâ ‚¥¬°“√μ‘¥‡™◊ÕÈ ‰¢âÀ«—¥ °“√ÕÕ°°”≈—ß°“¬ °“√ —¡º—
“√°àÕ¿Ÿ¡‘·æâ °“√‡ª≈’Ë¬π·ª≈ß ¿“æÕ“°“» À—«‡√“– À√◊Õ‚¥π “√∑’Ë
∑”„Àâ‡°‘¥°“√√–§“¬‡§◊Õß∑“ß‡¥‘πÀ“¬„® ‡™àπ §«—π√∂¬πμå §«—π∑ÿ°™π‘¥
À√◊Õ°≈‘Ëπ·√ß Ê
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 11

ª√–«—μ‘·≈–ª√–«—μ‘§√Õ∫§√—« §«√´—°ª√–«—μ‘ºŸâªÉ«¬∑’Ë¡’ ‚Õ°“ ‡ªìπ‚√§À◊¥
‰¥â·°à ª√–«—μ‘Õ“°“√√–∫∫∑“ß‡¥‘πÀ“¬„®™à«ß«—¬‡¥Á° ª√–«—μ‘‡¬◊ËÕ∫ÿ®¡Ÿ°Õ—°‡ ∫®“°
¿“«–¿Ÿ¡‘·æâ (allergic rhinitis) À√◊Õ¿Ÿ¡‘·æâº‘«Àπ—ß (eczema À√◊Õ atopic der-
matitis) ª√–«—μ‘‚√§À◊¥À√◊Õ¿Ÿ¡‘·æâ „π§√Õ∫§√—« ·μàÕ¬à“ß‰√°Áμ“¡ª√–«—μ‘‡À≈à“π’È
‰¡à®”‡æ“–‡®“–®ß ”À√—∫‚√§À◊¥ ·≈–‰¡àæ∫„πºŸâªÉ«¬∑ÿ°√“¬ ºŸâªÉ«¬∑’Ë¡’‡¬◊ËÕ∫ÿ®¡Ÿ°
Õ—°‡ ∫®“°¿“«–¿Ÿ¡‘·æâ §«√´—°ª√–«—μ‘∑“ß√–∫∫À“¬„®Õ¬à“ß≈–‡Õ’¬¥ ‡¡◊ÕË ß —¬«à“
¡’Õ“°“√‚√§À◊¥√à«¡¥â«¬
°“√μ√«®√à“ß°“¬
°“√μ√«®√à“ß°“¬„πºŸâªÉ«¬‚√§À◊¥ à«π„À≠à¡—°®–ª°μ‘ °“√μ√«®æ∫ ‘Ëßº‘¥
ª°μ‘∑’Ëæ∫∫àÕ¬‰¥â·°à ‡ ’¬ßÀ«’¥ (wheezing) ™à«ßÀ“¬„®ÕÕ° À√◊ÕÀ“¬„®ÕÕ°·√ß Ê
ºŸªâ «É ¬¡’Õ“°“√‚√§À◊¥°”‡√‘∫‡©’¬∫æ≈—πÕ¬à“ß√ÿπ·√ßÕ“®μ√«®‰¡àæ∫‡ ’¬ßÀ«’¥‡≈¬°Á ‰¥â
Õ“®μ√«®æ∫Õ“°“√· ¥ßÕ◊Ëπ Ê ¢Õß√–∫∫À“¬„®≈â¡‡À≈«‡©’¬∫æ≈—π ‡ ’¬ßÀ«’¥
“¡“√∂μ√«®æ∫‰¥â „πºŸâªÉ«¬∑’Ë¡’¿“«–À√◊Õ‚√§Õ◊Ëπ Ê ‰¥â ‡™àπ ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß
(Chronic obstructive pulmonary disease, COPD) °“√Õÿ¥°—πÈ ¢Õß∑“ß‡¥‘πÀ“¬„®
à«π∫π (upper airway obstruction) À√◊Õ¡’ ‘Ëß·ª≈°ª≈Õ¡Õÿ¥°—Èπ√–∫∫∑“ß‡¥‘π
À“¬„® °“√μ‘¥‡™◊ÈÕ∑“ß‡¥‘πÀ“¬„® tracheobrochomalacia ‰¡à§«√μ√«®æ∫
crackles À√◊Õ‡ ’¬ßÀ«’¥™à«ßÀ“¬„®‡¢â“ §«√μ√«®¥Ÿ®¡Ÿ°‡æ◊ËÕ¥Ÿ≈—°…≥–∫«¡·≈– ’
´’¥¢Õß inferior turbinate ·≈–μ√«®À“¥Ÿ«à“¡’√‘¥ ’¥«ß®¡Ÿ° (nasal polyp) √à«¡
¥â«¬À√◊Õ‰¡à
°“√μ√«® ¡√√∂¿“æªÕ¥„π°“√ª√–‡¡‘π‚√§À◊¥
1. °“√∑¥ Õ∫ ¡√√∂¿“æªÕ¥‚¥¬ ‰ª‚√‡¡μ√’¬å
™à«¬∫àß™’È°“√μ’∫¢ÕßÀ≈Õ¥≈¡ (airflow limitation) ‚¥¬·π–π”„Àâ∑”„π
ºŸâªÉ«¬∑’Ë¡’ª√–«—μ‘·≈–°“√μ√«®√à“ß°“¬∑’Ë ß —¬‚√§À◊¥ ‡æ◊ËÕ«—μ∂ÿª√– ß§å¥—ßμàÕ‰ªπ’È
12
1.1 ‡æ◊ÕË ¬◊π¬—π«à“¡’¿“«–À≈Õ¥≈¡μ’∫·≈–ª√–‡¡‘π§«“¡√ÿπ·√ß ‚¥¬æ‘®“√≥“
®“°§à“ FEV1/FVC ∑’Ë¡’§à“πâÕ¬°«à“ 0.75-0.80
1.2 ‡æ◊ËÕª√–‡¡‘π«à“¡’°“√μÕ∫ πÕßμàÕ¬“¢¬“¬À≈Õ¥≈¡æàπ Ÿ¥™π‘¥ÕÕ°
ƒ∑∏‘Ï‡√Á« (bronchodilator reversibility) °àÕπ°“√√—°…“ ·≈–/À√◊Õ
¡’°“√μÕ∫ πÕßμàÕ°“√„™â¬“√—°…“‚√§À◊¥À√◊Õ‰¡à (variable airflow
limitation) ·≈–°“√μÕ∫ πÕßμàÕ¬“¢¬“¬À≈Õ¥≈¡®–æ‘®“√≥“®“°
§à“ ¡√√∂¿“æªÕ¥ FEV1 ∑’Ë‡æ‘Ë¡¢÷Èπ¡“°°«à“ 200 ¡≈. ·≈–¡“°°«à“
√âÕ¬≈– 12 À≈—ß Ÿ¥¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï‡√Á« 15 π“∑’ ·≈–/
À√◊Õ À≈—ß°“√‰¥â¬“§«∫§ÿ¡‚√§À◊¥ (controller) √—°…“‚√§À◊¥‡ªìπ‡«≈“
Õ¬à“ßπâÕ¬ 4 —ª¥“Àå3
2. °“√«—¥ peak expiratory flow (PEF) ‚¥¬°“√μÕ∫ πÕßμàÕ¬“¢¬“¬
À≈Õ¥≈¡æàπ Ÿ¥™π‘¥ÕÕ°ƒ∑∏‘Ï‡√Á«
2.1 æ‘®“√≥“®“°§à“ PEF ∑’Ë‡æ‘Ë¡¢÷Èπ¡“°°«à“ 60 ≈‘μ√/π“∑’ À√◊Õ‡æ‘Ë¡¢÷Èπ
¡“°°«à“√âÕ¬≈– 20 À≈—ß‰¥â¬“¢¬“¬À≈Õ¥≈¡æàπ Ÿ¥™π‘¥ÕÕ°ƒ∑∏‘Ïƒ∑∏‘Ï
‡√Á« ·μà°“√∑¥ Õ∫¥â«¬°“√«—¥§à“ PEF ¡’§«“¡‡∑’Ë¬ßμ√ßπâÕ¬°«à“
‰ª‚√‡¡μ√’¬å (§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 4, πÈ”Àπ—°§”·π–π” +)
2.2 °“√„™â PEF ‡æ◊ËÕμ√«®À“¿“«–À≈Õ¥≈¡μ’∫∑’Ë¡’§«“¡º—πº«π ‚¥¬°“√
«—¥ PEF „π™à«ß 1-2 —ª¥“Àå “¡“√∂„™â«‘π‘®©—¬·≈–ª√–‡¡‘π‚√§À◊¥
‰¥â¥’°«à“ ºŸâªÉ«¬‚√§À◊¥®–¡’§«“¡º—πº«π¢Õß§à“ PEF ¡“°°«à“§πª°μ‘
‚¥¬«—¥ PEF «—π≈– 2 §√—Èß „π¢≥–¬—ß‰¡à ‰¥â‡√‘Ë¡°“√√—°…“ ª√–™“°√
ª°μ‘ “¡“√∂¡’§à“ PEF º—πº«π‰¥â√–À«à“ß√âÕ¬≈– 5 ∂÷ß 9 ·≈–ºŸâªÉ«¬
‚√§À◊¥®–¡’§à“ PEF º—πº«π¡“°°«à“√âÕ¬≈– 10 ´÷Ëß°“√®–«‘π‘®©—¬‚√§
À◊¥‰¥âμÕâ ßÕ“»—¬°“√´—°ª√–«—μ·‘ ≈–μ√«®√à“ß°“¬∑’‡Ë ¢â“‰¥â°∫— ‚√§À◊¥√à«¡
°—∫§à“ PEF variability (πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫
1) («‘∏’°“√§”π«≥§à“ PEF variability Õà“π„π¿“§ºπ«°∑’Ë 1)
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 13

2.3 °“√«—¥§à“ PEF ∑’Ë‡æ‘Ë¡¢÷Èπ¡“°°«à“√âÕ¬≈– 20 ¿“¬À≈—ß°“√√—°…“¥â«¬
¬“§«∫§ÿ¡‚√§À◊¥‡ªìπ‡«≈“ 4 —ª¥“Àå (πÈ”Àπ—°§”·π–π” +, §ÿ≥¿“æ
À≈—°∞“π√–¥—∫ 1)
3. °“√∑¥ Õ∫§«“¡‰«À≈Õ¥≈¡ (Airway hyperresponsiveness, AHR)
·π–π”„Àâ∑”„πºŸªâ «É ¬∑’¡Ë ª’ √–«—μ·‘ ≈–°“√μ√«®√à“ß°“¬∑’ Ë ß —¬‚√§À◊¥·μà°“√
μ√«®‚¥¬ ‰ª‚√‡¡μ√’¬å ‰¡àæ∫§«“¡º‘¥ª°μ‘ “¡“√∂∑”‰¥â¥â«¬°“√„Àâ Ÿ¥ “√°√–μÿâπ
‰¥â·°à methacholine ‚¥¬‡°≥±å°“√«‘π‘®©—¬‚√§À◊¥§«√¡’§à“ PC20 πâÕ¬°«à“ 8
¡°./¥≈.4 (πÈ”Àπ—°§”·π–π” +, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 4)
À“°ºŸªâ «É ¬¡’ª√–«—μ∑‘ ‡’Ë ¢â“‰¥â°∫— ‚√§À◊¥·≈–¡’Õ“°“√√ÿπ·√ß¥—ßμàÕ‰ªπ’È Õ“®æ‘®“√≥“

„Àâ°“√√—°…“‰ª°àÕπ‰¥â (πÈ”Àπ—°§”·π–π” +, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 4)
1) ª√–«—μ‘¢ÕßÕ“°“√∑“ß‡¥‘πÀ“¬„®∑’Ë·ª√ª√«π ·≈–À“¬„®‡ ’¬ßÀ«’¥
2) Õ“°“√ÀÕ∫‡Àπ◊ËÕ¬ ·πàπÀπâ“Õ°·≈–‰Õ ¡—°¡’Õ“°“√¡“°°«à“Àπ÷ËßÕ“°“√
Õ“°“√·≈–§«“¡√ÿπ·√ß·ª√‡ª≈’Ë¬πμ“¡‡«≈“
3) Õ“°“√‡ªìπ¡“°™à«ß°≈“ß§◊πÀ√◊Õ√ÿàß‡™â“
4) Õ“°“√°”‡√‘∫‚¥¬°“√ÕÕ°°”≈—ß°“¬ À—«‡√“– °“√ —¡º— “√°àÕ¿Ÿ¡‘·æâ
Õ“°“»‡¬Áπ À√◊Õ¿“¬À≈—ß°“√μ‘¥‡™◊ÈÕ∑“ß‡¥‘πÀ“¬„®
°“√«‘π‘®©—¬ ·≈–°“√«‘π‘®©—¬·¬°‚√§
°“√«‘π®‘ ©—¬‚√§À◊¥·≈–«‘π®‘ ©—¬·¬°‚√§π—πÈ πÕ°®“°μâÕßÕ“»—¬¢âÕ¡Ÿ≈ π—∫ πÿπ
·≈â« §«√„Àâ§«“¡ ”§—≠‡°’Ë¬«°—∫¢âÕ¡Ÿ≈§—¥§â“π¥â«¬‡æ√“–Õ“®∑”„Àâπ÷°∂÷ß‚√§Õ◊Ëπ∑’Ë
Õ“®¡’∫“ß≈—°…≥–√à«¡°—π ‡™àπ °“√¡’¿“«–À≈Õ¥≈¡μ’∫®“° “‡ÀμÿÕ◊Ëπ (μ“√“ß∑’Ë 1)
(πÈ”Àπ—°§”·π–π” +, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 4)
14
μ“√“ß∑’Ë 1 °“√«‘π‘®©—¬·¬°‚√§À◊¥
¢âÕ¡Ÿ≈§—¥§â“π‚√§À◊¥ °≈‰°°“√‡°‘¥ μ—«Õ¬à“ß‚√§
ª√–«—μ‘
Dyspnea on exertion COPD (stable)
‰Õ‡ªìπ‡≈◊Õ¥ Hemoptysis Bronchiectasis
Lung cancer
TB
Localized wheezing Structural airway Bronchiectasis
obstruction Lung cancer
Bronchostenosis ‡™àπ endobronchial TB
μ√«®√à“ß°“¬
Persistence of central Upper airway Tracheal stenosis
wheezing/stridor obstruction Tracheal tumor
Bilateral vocal cord paralysis
Lung cancer with tracheal invasion
Esophageal cancer invaded trachea
TB larynx, TB involved trachea
Wheezing aggravated Posterior wall of Tracheobronchomalacia
by forced expiration airway collapse
or cough
Sudden onset of wheezing Vocal cord dysfunction
that spontaneously resolved
abruptly Hoarseness of
voice, lump in throat
Wheezing with clubbing Bronchiectasis
of finger Lung cancer
Lung abscess
Cervical lymphadenopathy Lung cancer
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 15

μ“√“ß∑’Ë 1 °“√«‘π‘®©—¬·¬°‚√§À◊¥ (μàÕ)
¢âÕ¡Ÿ≈§—¥§â“π‚√§À◊¥ °≈‰°°“√‡°‘¥ μ—«Õ¬à“ß‚√§
°“√μ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√
Abnormal chest film that
explain wheezing, cough,
dyspnea
Spirometry showed COPD
irreversible airway Bronchiectasis
obstruction Chronic asthma with remodelling
Hypoxemia without Pulmonary Heart failure (cardiac wheezing)
hypercarbia congestion Pneumonia
Atelectasis
Pulmonary embolism
°“√ª√–‡¡‘π§«“¡√ÿπ·√ß¢Õß‚√§À◊¥ (Assessment of asthma

control)
°“√ª√–‡¡‘π‚√§À◊¥π—Èπ‡πâπ‰ª∑’Ë°“√ª√–‡¡‘π°“√§«∫§ÿ¡Õ“°“√¢Õß‚√§·≈–
°“√ª√–‡¡‘π§«“¡‡ ’Ë¬ß À√◊Õªí®®—¬‡ ’Ë¬ß„πÕπ“§μ‡æ◊ËÕ„Àâ°“√√—°…“∑’Ë‡À¡“– ¡·°à
ºŸâªÉ«¬ ‚¥¬°“√ª√–‡¡‘π°“√§«∫§ÿ¡Õ“°“√¢Õß‚√§À◊¥ (assessment of asthma
control) π—Èπ‡π◊ËÕß®“°Õ“°“√¢Õß‚√§À◊¥‰¡à¡’§«“¡ —¡æ—π∏å°—∫§à“ ¡√√∂¿“æªÕ¥
(FEV1) ®÷ß‰¥âμ¥— °“√∑¥ Õ∫ ‰ª‚√‡¡μ√’¬Õå Õ°‰ª®“°°“√ª√–‡¡‘π°“√§«∫§ÿ¡Õ“°“√
À√◊Õ√–¥—∫°“√§«∫§ÿ¡‚√§À◊¥ ‚¥¬°“√ª√–‡¡‘πÕ“°“√¢Õß‚√§π—Èπ¡’À≈“¬«‘∏’ ‰¥â·°à
°“√ª√–‡¡‘π√–¥—∫°“√§«∫§ÿ¡‚√§À◊¥‡ªìπ°≈ÿà¡À√◊Õ√–¥—∫°“√§«∫§ÿ¡ (categorical
symptoms control) À√◊Õ°“√„™â§à“§–·ππ∑’Ë¡“®“°·∫∫∑¥ Õ∫ (composite
score À√◊Õ numerical symptom control) ‡™àπ asthma control test (ACT)5
À√◊Õ asthma control questionnaire (ACQ)6 ¥—ß„π¿“§ºπ«°∑’Ë 2
16
°“√ª√–‡¡‘π√–¥—∫Õ“°“√‚√§À◊¥ (symptom assessment) ‡ªìπ°≈ÿà¡
∑”‰¥â ‚¥¬®”·π°ºŸâªÉ«¬‡ªìπ 2 °≈ÿà¡ §◊Õ ºŸâªÉ«¬∑’Ë§ÿ¡Õ“°“√¢Õß‚√§‰¥â·≈–
ºŸâªÉ«¬∑’Ë ‰¡à “¡“√∂§ÿ¡Õ“°“√¢Õß‚√§ ‚¥¬Õ“»—¬§”∂“¡ßà“¬ Ê °—∫Õ“°“√‚√§À◊¥„π
√Õ∫ 4 —ª¥“Àå∑’Ëºà“π¡“ (¥—ß√Ÿª∑’Ë 1) (πÈ”Àπ—°§”·π–π” +, À≈—°∞“π√–¥—∫ 4)
√–¥—∫°“√§«∫§ÿ¡‚√§À◊¥ Õ“°“√§ÿ¡‰¥â Õ“°“√§ÿ¡‰¡à‰¥â

(„π√Õ∫ 4 —ª¥“Àå∑’Ëºà“π¡“)
¡’Õ“°“√‚√§À◊¥‡°‘¥¢÷Èπ°≈“ß«—π „™à ‰¡à ‰™à
¡“°°«à“ 2 §√—ÈßμàÕ —ª¥“Àå
μ◊Ëπ°≈“ß¥÷°‡π◊ËÕß®“°À◊¥ „™à ‰¡à ‰™à
„™â¬“∫√√‡∑“Õ“°“√À◊¥°”‡√‘∫ „™à ‰¡à ‰™à ‰¡à¡’ ¡’¢âÕ„¥¢âÕÀπ÷Ëß
¡“°°«à“ 2 §√—ÈßμàÕ —ª¥“Àå
¡’¢âÕ®”°—¥„π°“√ÕÕ°·√ß ∑”°‘®°√√¡ „™à ‰¡à ‰™à
‡π◊ËÕß®“°‚√§À◊¥
√Ÿª∑’Ë 1 ·ºπº—ß°“√®”·π°√–¥—∫°“√§«∫§ÿ¡‚√§À◊¥
°“√ª√–‡¡‘πªí®®—¬‡ ’Ë¬ß„πÕπ“§μ (Risk factors assessment)

πÕ°‡Àπ◊Õ®“°°“√ª√–‡¡‘πÕ“°“√·≈â« §«√¡’°“√ª√–‡¡‘πªí®®—¬‡ ’Ë¬ß„π
Õπ“§μ¥â«¬‡æ◊ËÕæ‘®“√≥“„Àâ°“√√—°…“ (asthma controller medication) ªí®®—¬
‡ ’Ë¬ß„πÕπ“§μ‰¥â·°à ªí®®—¬‡ ’Ë¬ß„π°“√‡°‘¥À◊¥°”‡√‘∫‡©’¬∫æ≈—π (risk factors for
exacerbation) ªí®®—¬‡ ’Ë¬ßμàÕ°“√‡°‘¥À≈Õ¥≈¡μ’∫∂“«√ (risk factors for deve-
loping fixed airflow obstruction) ·≈–ªí®®—¬‡ ’Ë¬ßμàÕ°“√‡°‘¥º≈¢â“ß‡§’¬ß®“°
°“√√—°…“ (risk factors of medication side effect)1 (¥—ß· ¥ß„π√Ÿª∑’Ë 2)
À“°¡’ªí®®—¬‡ ’Ë¬ß‡æ’¬ß¢âÕ„¥¢âÕÀπ÷Ëß ·¡â«à“®–§ÿ¡Õ“°“√À◊¥‰¥â°Á∂◊Õ«à“¡’§«“¡‡ ’Ë¬ß
μàÕÕ“°“√¢Õß‚√§À◊¥∑’Ë·¬à≈ß„πÕπ“§μ
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 17

ªí®®—¬∑’Ë¡’º≈μàÕÕπ“§μ (Poor asthma outcome) ª√–°Õ∫¥â«¬
ªí®®—¬‡ ’¬Ë ßμàÕÀ◊¥°”‡√‘∫‡©’¬∫æ≈—π ªí®®—¬‡ ’Ë¬ßμàÕÀ≈Õ¥≈¡μ’∫∂“«√ ªí®®—¬μàÕº≈¢â“ß‡§’¬ß°“√√—°…“
(Risk factors of exacerbation) (Risk factors for developing (Risk factors of medica-
fixed airway obstruction) tion side effects)
ë ‰¡à “¡“√∂§ÿ¡Õ“°“√À◊¥‰¥â ë ‰¡à„™â¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å ë ∑“ß√–∫∫: ‰¥â¬“§Õ√åμ‘‚§
ë „™â¬“¢¬“¬À≈Õ¥≈¡ÕÕ°ƒ∑∏‘Ï‡√Á« ™π‘¥æàπ Ÿ¥ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥¢π“¥ Ÿß
∫√√‡∑“Õ“°“√ > 200 §√—ßÈ /‡¥◊Õπ ë °“√ Ÿ∫∫ÿÀ√’Ë·≈– —¡º— ¡≈æ‘… À√◊Õ‰¥â¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å
ë ‰¥â¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ „π·≈–πÕ°§√—«‡√◊Õπ ™π‘¥√—∫ª√–∑“π∫àÕ¬ Ê À√◊Õ
æàπ Ÿ¥‰¡àæÕ ë ¡’§à“ ¡√√∂¿“æªÕ¥∑’ËμË” ‰¥â¬“∑’Ë¡’º≈‡ªìπ CYP 450
ë §à“ ¡√√∂¿“æªÕ¥ FEV1 μË” ë ¡’ eosinophils „π‡≈◊Õ¥À√◊Õ inhibitor
(πâÕ¬°«à“√âÕ¬≈– 60 ¢Õß „π‡ ¡À– Ÿßº‘¥ª°μ‘ ë ‡©æ“–∑’:Ë „™â¬“§Õ√åμ‘‚§
§à“ª°μ‘) ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥¢π“¥ Ÿß
ë —¡º— “√°àÕ¿Ÿ¡‘·æâ·≈–∫ÿÀ√’Ë À√◊Õ Ÿ¥¬“‰¡à∂Ÿ°‡∑§π‘§
ë ‚√§À√◊Õ¿“«–∑“ß®‘μ‡«™
ë ‚√§√à«¡ ‡™àπ ‡¬◊ËÕ∫ÿ®¡Ÿ°Õ—°‡ ∫
®“°¿Ÿ¡·‘ æâÀ√◊Õ¿“«–Õâ«π
ë μ√«®æ∫«à“¡’ eosinophils
„π‡ ¡À–
ë μ—Èß§√√¿å
ë ‡§¬πÕπ„π‚√ßæ¬“∫“≈¥â«¬
Õ“°“√À◊¥°”‡√‘∫‡©’¬∫æ≈—πÀ√◊Õ
‰¥â√—∫°“√„ à∑àÕ™à«¬À“¬„®
ë À◊¥°”‡√‘∫‡©’¬∫æ≈—π > 1 §√—Èß
„πªïºà“π¡“‹
√Ÿª∑’Ë 2 ªí®®—¬∑’Ë¡’º≈μàÕÕπ“§μ¢Õß‚√§À◊¥ (Poor asthma outcome) ª√–°Õ∫¥â«¬
ªí®®—¬‡ ’Ë¬ßμàÕÀ◊¥°”‡√‘∫‡©’¬∫æ≈—π ªí®®—¬‡ ’Ë¬ßμàÕÀ≈Õ¥≈¡μ’∫∂“«√ ·≈–ªí®®—¬
μàÕº≈¢â“ß‡§’¬ß°“√√—°…“
18
°“√√—°…“‚√§À◊¥
ªí®®ÿ∫—π‡™◊ËÕ«à“°“√Õ—°‡ ∫‡ªìπ “‡Àμÿ¢Õß‚√§À◊¥ ¥—ßπ—Èπ°“√„™â¬“‡æ◊ËÕ≈¥°“√
Õ—°‡ ∫®÷ß‡ªìπ¬“À≈—°„π°“√√—°…“‚√§À◊¥ ‡π◊ÕË ß®“°¬“§Õ√åμ‚‘ § ‡μÕ√Õ¬¥å™π‘¥æàπ Ÿ¥
(inhaled corticosteroids, ICS) ¡’ª√– ‘∑∏‘¿“æ Ÿß„π°“√≈¥°“√Õ—°‡ ∫·≈–¡’º≈
¢â“ß‡§’¬ßμË” ”À√—∫¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï‡√Á«®–„™â‡æ◊ËÕ∫√√‡∑“Õ“°“√À◊¥
°”‡√‘∫‡∑à“π—πÈ ‚¥¬‡ªÑ“À¡“¬¢Õß°“√√—°…“§◊Õ °“√§«∫§ÿ¡‚√§À◊¥„Àâ ‰¥â (controlled
asthma) ·≈â«ª√—∫°“√√—°…“‡æ◊ÕË ∑’®Ë –„™â¬“„ÀâπÕâ ¬∑’ Ë ¥ÿ ∑’§Ë «∫§ÿ¡‚√§À◊¥‰¥â πÕ°®“°
π’È¬—ß¡’°“√√—°…“¥â«¬°“√‰¡à „™â¬“ ‡™àπ °“√øóôπøŸ ¡√√∂¿“æªÕ¥ °“√À¬ÿ¥ Ÿ∫∫ÿÀ√’Ë
°“√À≈’°‡≈’Ë¬ß “√°àÕ¿Ÿ¡‘·æâÀ√◊Õ “√∑’Ë°àÕ„Àâ‡°‘¥°“√–§“¬‡§◊Õß (¥—ß¿“§ºπ«°∑’Ë 3)
‡ªÑ“À¡“¬¢Õß°“√√—°…“
‡ªÑ“À¡“¬°“√√—°…“§◊Õ °“√§«∫§ÿ¡‚√§À◊¥ (asthma control) ´÷ËßÀ¡“¬∂÷ß
°“√§«∫§ÿ¡Õ“°“√„πªí®®ÿ∫—π (current control) ‰¥â·°à °“√‰¡à¡’Õ“°“√ÀÕ∫∑—Èß
°≈“ß«—π·≈–°≈“ß§◊π ‰¡àμâÕß„™â¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï‡√Á« ‰¡à¡’ ‚√§À◊¥
°”‡√‘∫‡©’¬∫æ≈—π “¡“√∂∑”°‘®°√√¡μà“ß Ê √«¡∑—Èß “¡“√∂ÕÕ°°”≈—ß°“¬‰¥âμ“¡
ª°μ‘ ¡’ ¡√√∂¿“æªÕ¥ª°μ‘ ·≈–°“√ªÑÕß°—π§«“¡‡ ’Ë¬ß∑’Ë®–‡°‘¥¢÷Èπ„πÕπ“§μ
(future risks prevention) ‰¥â·°à °“√°”‡√‘∫¢Õß‚√§À◊¥ °“√‡ ’¬™’«‘μ®“°‚√§À◊¥
°“√≈¥≈ß¢Õß ¡√√∂¿“æªÕ¥®π‡°‘¥°“√Õÿ¥°—Èπ∂“«√ (airway remodeling) ·≈–
Õ“°“√¢â“ß‡§’¬ß®“°°“√√—°…“1
ºŸâªÉ«¬‚√§À◊¥∑ÿ°§π§«√‰¥â√—∫¬“§«∫§ÿ¡‚√§∑’ËμâÕß„™âÕ¬à“ß ¡Ë”‡ ¡Õ·≈–¬“
∫√√‡∑“Õ“°“√‡¡◊ÕË ¡’Õ“°“√ ‚¥¬¡ÿßà ‡ªÑ“∑’®Ë –§«∫§ÿ¡Õ“°“√„πªí®®ÿ∫π— ·≈–°“√ªÑÕß°—π
§«“¡‡ ’Ë¬ß∑’Ë®–‡°‘¥¢÷Èπ„πÕπ“§μ®“°°“√√—°…“‚√§À◊¥‰¡à¥’ (future risks preven-
tion) ‚¥¬„™â¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥‡ªìπ¬“À≈—°„π°“√§«∫§ÿ¡‚√§·≈–
„Àâ‡√‘Ë¡„™â∑’Ë¢π“¥μË”°àÕπ „π°√≥’∑’Ë ‰¡à “¡“√∂„™â¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥
°ÁÕ“®„™â¬“μâ“π≈‘«‚§‰μ√Õ’π‡ªìπ¬“∑“ß‡≈◊Õ°∑¥·∑π‰¥â ∂â“„™â¬“§Õ√åμ‚‘ § ‡μ’¬√Õ¬¥å
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 19

™π‘¥æàπ Ÿ¥¢π“¥μË”·≈â«¬—ß§«∫§ÿ¡‚√§‰¡à ‰¥âÕ“®æ‘®“√≥“ª√—∫‡ªìπ¢π“¥ Ÿß À√◊Õ
„™â¬“§«∫§ÿ¡‚√§μ—«Õ◊Ëπ√à«¡¥â«¬ ‡™àπ ¬“¢¬“¬À≈Õ¥≈¡™π‘¥ Ÿ¥æàπ∑’ËÕÕ°ƒ∑∏‘Ï¬“«
(long-acting β2-agonist, LABA) ¬“μâ“π≈‘«‚§‰μ√Õ’π ·≈– theophylline ¡“
√à«¡°—∫¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥¢π“¥μË” ‚¥¬·π–π”„Àâ „™â LABA √à«¡
°—∫¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥„πÀ≈Õ¥‡¥’¬«°—π°àÕπ (ICS/LABA) ´÷Ëß„Àâ
ª√– ‘∑∏‘¿“æ¥’∑’Ë ÿ¥ à«π«‘∏’Õ◊Ëπ„Àâ „™â‡ªìπ∑“ß‡≈◊Õ° ·≈–„π°√≥’∑’Ë „™â ICS/LABA
∑’Ë¡’ formoterol ‡ªìπ LABA ™π‘¥ÕÕ°ƒ∑∏‘Ï‡√Á«°Á “¡“√∂„™â‡ªìπ∑—Èß¬“§«∫§ÿ¡·≈–
¬“∫√√‡∑“Õ“°“√‰¥â „πÀ≈Õ¥‡¥’¬«‰¥â (Maintenance and Reliever Therapy)7
(πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1) (¥—ßμ“√“ß∑’Ë 2)
¬“„π°“√√—°…“‚√§À◊¥ ·≈–·π«∑“ß„π°“√√—°…“‡æ◊ÕË §«∫§ÿ¡Õ“°“√ ·≈–

≈¥§«“¡‡ ’¬Ë ß„πÕπ“§μ (Medications and strategies for symptom
control and risk reduction)
¬“∑’Ë„™â„π°“√√—°…“‚√§À◊¥ (Asthma medications)
°“√√—°…“‚√§À◊¥‡πâπ°“√ª√—∫¬“‡ªìπ√–¥—∫ (stepwise approach) ‡æ◊ËÕ„Àâ
∂÷ß‡ªÑ“À¡“¬°“√§«∫§ÿ¡‚√§À◊¥‰¥â (asthma control) ‚¥¬¬“∑’Ë„™â „π°“√√—°…“‚√§
À◊¥π—Èπ “¡“√∂®”·π°‰¥â‡ªìπ 3 °≈ÿà¡1 §◊Õ
1) ¬“∑’Ë„™â„π°“√§«∫§ÿ¡‚√§ (Asthma controller medications) „™â
√—°…“°“√Õ—°‡ ∫¢ÕßÀ≈Õ¥≈¡ ≈¥°“√°”‡√‘∫‡©’¬∫æ≈—π ·≈–≈¥°“√‡°‘¥À≈Õ¥≈¡
μ’∫∂“«√ (fixed airflow obstruction)
2) ¬“∑’Ë„™â„π°“√∫√√‡∑“Õ“°“√ (Symptoms rescuer À√◊Õ reliever
medications) „™â‡ªìπ§√—ßÈ §√“« (as-needed) „π°√≥’¡Õ’ “°“√°”‡√‘∫ ·≈– “¡“√∂
„™âªÕÑ ß°—π¿“«–À≈Õ¥≈¡μ’∫®“°°“√ÕÕ°°”≈—ß°“¬ (exercise-induced broncho-
spasm, EIB)
20
3) ¬“∑’Ë„™â‡ √‘¡„π°“√√—°…“ (Add-on therapies) „π°√≥’∑’Ë‡ªìπ‚√§À◊¥
√–¥—∫√ÿπ·√ß (severe asthma) “¡“√∂„™â‡ √‘¡‰¥â À“°‰¡à “¡“√∂§«∫§ÿ¡Õ“°“√
‚√§À◊¥‰¥â¥â«¬¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥º ¡°—∫¬“ Ÿ¥¢¬“¬À≈Õ¥≈¡∑’Ë
ÕÕ°ƒ∑∏‘Ï¬“« (ICS/LABA)
μ“√“ß∑’Ë 2 °“√ª√—∫‡æ‘Ë¡À√◊Õ≈¥√–¥—∫°“√√—°…“ μ“¡√–¥—∫°“√§«∫§ÿ¡‚√§À◊¥ ·≈–¬“∑’Ë

„™â „π°“√√—°…“ ∑—Èß∑’Ë‡ªìπ¬“§«∫§ÿ¡‚√§À◊¥·≈–¬“∑’Ë „™â∫√√‡∑“Õ“°“√À◊¥
°”‡√‘∫‡©’¬∫æ≈—π
Decrease Treatment steps Increase
Step 1 Step 2 Step 3 Step 4 Step 5

Asthma education, environmental control, influenza vaccine
and pulmonary rehabilitation
As-needed RABA
Select one Select one Add one or more Add one or both
Low-dose Low-dose ICS Medium- or high- OCS
ICS plus LABA dose ICS/LABA (lowest dose)
Low dose
ICS ”À√—∫ Medium- or LTRA
ºŸâªÉ«¬∑’Ë¡’ high-dose ICS
High risk LTRA Low-dose ICS Sustained-release Anti-IgE
exacerbation plus LTRA theophylline Anti-IL-5†
Low dose ICS
plus sustained- Tiotropium bromide
release theophylline
RABA = rapid-acting β2-agonist, ICS = inhaled corticosteroid, ICS/LABA = inhaled cortico-
steroid plus long-acting β2-agonist, LTRA = leukotriene receptor antagonist, OCS = oral
corticosteroid)
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 21
¬“∑’Ë „™â „π‚√§À◊¥·∫àß‡ªìπ¬“∑’Ë·π–π” (preferred options) ·≈–¬“∑“ß
‡≈◊Õ°Õ◊Ëπ Ê (alternatives À√◊Õ others) ”À√—∫ ¬“§«∫§ÿ¡Õ“°“√„π·μà≈–√–¥—∫
¡’¬“∑’Ë‡≈◊Õ°„™â‡ªìπÕ—π¥—∫·√°·≈–μ—«‡≈◊Õ°Õ◊Ëπ Ê ‚¥¬æ‘®“√≥“®“°§ÿ≥ ¡∫—μ‘∑“ß
‡¿ —™«‘∑¬“¢Õß¬“ ª√– ‘∑∏‘¿“æ §«“¡ª≈Õ¥¿—¬ §«“¡æ÷ßæÕ„®¢ÕßºŸªâ «É ¬·≈–√“§“
Õ¬à“ß‰√°Áμ“¡°àÕπ°“√ª√—∫√–¥—∫¢Õß¬“§«∫§ÿ¡‚√§À◊¥ μâÕßæ‘®“√≥“ªí®®—¬∑’Ë àßº≈
„Àâ ‰¡à “¡“√∂§«∫§ÿ¡‚√§À◊¥‰¥â ‡™àπ Õ“°“√¥—ß°≈à“«‰¡à ‰¥â‡°‘¥®“°‚√§À◊¥ ºŸâªÉ«¬
„™â¬“‰¡à∂Ÿ°«‘∏’ ºŸâªÉ«¬‰¡à „™â¬“§«∫§ÿ¡‚√§Õ¬à“ß ¡Ë”‡ ¡Õ ·≈–ºŸâªÉ«¬‰¡à “¡“√∂
À≈’°‡≈’Ë¬ßªí®®—¬°√–μÿâπ∑’Ë∑”„Àâ ‚√§À◊¥§«∫§ÿ¡‰¡à ‰¥â
1. ¬“§«∫§ÿ¡‚√§À◊¥√–¥—∫ 1
æ‘®“√≥“„™â¬“¢¬“¬À≈Õ¥≈¡™π‘¥æàπ Ÿ¥ÕÕ°ƒ∑∏‘Ï‡√Á«‡æ◊ËÕ∫√√‡∑“Õ“°“√
‡ªìπ§√—Èß§√“« (as-needed inhaled RABA) ”À√—∫¬“∫√√‡∑“Õ“°“√À◊¥°≈ÿà¡
Õ◊Ëπ Ê ‡™àπ ¬“ Ÿ¥æàπÕÕ°ƒ∑∏‘Ïμâ“πμ—«√—∫‚§≈‘‡πÕ√å®‘° (ipratropium bromide)
¬“ RABA ™π‘¥√—∫ª√–∑“π À√◊Õ¬“ theophylline ∑’ËÕÕ°ƒ∑∏‘Ï —Èπ™π‘¥√—∫ª√–∑“π
Õ“®‡≈◊Õ°„™â ‰¥â·μàÕÕ°ƒ∑∏‘Ï™â“°«à“ à«π¬“√—∫ª√–∑“ππ—Èπ¡’º≈¢â“ß‡§’¬ß¡“°°«à“
¬“ Ÿ¥ (πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1)8,9 À“°ºŸâªÉ«¬¡’Õ“°“√À◊¥
πâÕ¬°«à“ 2 §√—ÈßμàÕ‡¥◊Õπ À√◊Õ‰¡à¡’Õ“°“√À◊¥°≈“ß¥÷° ·≈–‰¡à¡’ªí®®—¬ªí®®—¬‡ ’Ë¬ß
(risk factors) ·π–π”«à“‰¡àμâÕß„™â¬“§«∫§ÿ¡‚√§À◊¥ (controller medications)10,11
·μàÕ“®æ‘®“√≥“„™â¬“§Õ√åμ‚‘ § ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥¢π“¥μË” (low-dose ICS) „π
°√≥’∑’Ë¡’ªí®®—¬‡ ’Ë¬ß¥—ß°≈à“« (πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1)
2. ¬“§«∫§ÿ¡‚√§À◊¥√–¥—∫ 2
æ‘®“√≥“„™â¬“§Õ√åμ‚‘ § ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥„π¢π“¥μË”‡ªìπÕ—π¥—∫·√° √à«¡
°—∫°“√„™â¬“¢¬“¬À≈Õ¥≈¡™π‘¥æàπ Ÿ¥ÕÕ°ƒ∑∏‘‡Ï √Á«‡æ◊ÕË ∫√√‡∑“Õ“°“√‡ªìπ§√—ßÈ §√“«
(πÈ”Àπ—°§”·π–π” +++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1)10,12 „π°√≥’∑’Ë ‰¡à “¡“√∂∑π
22
º≈¢â“ß‡§’¬ß¢Õß¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥ À√◊Õ¡’Õ“°“√‰¡àæ÷ßª√– ß§å®“°
°“√„™â¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å À√◊Õ°√≥’ºŸâªÉ«¬‚√§À◊¥∑’Ë¡’Õ“°“√¢Õß®¡Ÿ°Õ—°‡ ∫
√à«¡¥â«¬ Õ“®æ‘®“√≥“„™â¬“μâ“π≈‘«‚§‰μ√Õ’π™π‘¥√—∫ª√–∑“π∑¥·∑π‰¥â (πÈ”Àπ—°
§”·π–π” +++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1)13,14 ·≈–Õ“®æ‘®“√≥“„™â¬“§Õ√åμ‘‚§
‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥‡ªìπ§√—Èß§√“«„πºŸâªÉ«¬∑’Ë¡’Õ“°“√‰¡à¡“°‰¥â ‡π◊ËÕß®“°Õ“°“√
‚√§À◊¥‡ªìπμ“¡ƒ¥Ÿ°“≈ ‚¥¬æ‘®“√≥“„Àâ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥∑—π∑’∑’Ë
‡√‘Ë¡¡’Õ“°“√ ·≈–„Àâ‡ªìπ‡«≈“ —Èπ Ê ª√–¡“≥ 4 —ª¥“Àå (πÈ”Àπ—°§”·π–π” ++,
§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3) ”À√—∫¬“ theophylline ∑’ÕË Õ°ƒ∑∏‘¬Ï “«™π‘¥√—∫ª√–∑“π
Õ¬à“ß‡¥’¬«π—Èπ‰¡à·π–π”„Àâ „™â‡æ√“–¡’ª√– ‘∑∏‘¿“æμË”„π‚√§À◊¥·≈–º≈¢â“ß‡§’¬ß
Ÿß15,16
3. ¬“§«∫§ÿ¡‚√§À◊¥√–¥—∫ 3
æ‘®“√≥“„™â¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥¢π“¥μË”√à«¡°—∫¬“ Ÿ¥¢¬“¬
À≈Õ¥≈¡™π‘¥∑’ËÕÕ°ƒ∑∏‘Ï¬“« (ICS/LABA) √à«¡°—∫¬“¢¬“¬À≈Õ¥≈¡™π‘¥ Ÿ¥æàπ
ÕÕ°ƒ∑∏‘Ï‡√Á«‡æ◊ËÕ∫√√‡∑“Õ“°“√‡ªìπ§√—Èß§√“«9,17,18 ”À√—∫°“√„™â¬“æàπ Ÿ¥º ¡
√–À«à“ß§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å°—∫ formoterol (ICS/formoterol) Õ—π‰¥â·°à bude-
sonide/formoterol À√◊Õ beclomethasone/formoterol ¢π“¥μË” ∫√‘À“√¬“
∑—Èß„™â§«∫§ÿ¡·≈–∫√√‡∑“Õ“°“√‡ªìπ§√—Èß§√“« (maintenance and reliever
therapy)7,19-23 „Àâº≈„π°“√≈¥°“√°”‡√‘∫‡©’¬∫æ≈—π¥’°«à“ ICS/LABA „π¢π“¥§ß∑’Ë
∑’Ë „™â ‡ ªì π ª√–®”√à « ¡°— ∫ ¬“¢¬“¬À≈Õ¥≈¡™π‘ ¥ æà π Ÿ ¥ ÕÕ°ƒ∑∏‘Ï ‡ √Á « ‡æ◊Ë Õ ∫√√‡∑“
Õ“°“√24 ”À√—∫¬“Õ◊πË Ê ∑’Ë„™â ‰¥â§Õ◊ ¬“§Õ√åμ‚‘ § ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥¢π“¥ª“π°≈“ß
À√◊Õ Ÿß11,25,26 À√◊Õ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥√à«¡°—∫¬“μâ“π≈‘«‚§‰μ√Õ’π27
À√◊Õ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥√à«¡°—∫¬“ theophylline ™π‘¥√—∫ª√–∑“π∑’Ë
ÕÕ°ƒ∑∏‘Ï¬“«28 ·μàª√– ‘∑∏‘¿“æ‰¡à¥’‡∑à“°—∫¬“æàπ Ÿ¥§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥åº ¡°—∫
¬“ Ÿ¥¢¬“¬À≈Õ¥≈¡∑’ËÕÕ°ƒ∑∏‘Ï¬“« (ICS/LABA)29,30 (πÈ”Àπ—°§”·π–π” +++,
§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1)
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 23

4. ¬“§«∫§ÿ¡‚√§À◊¥√–¥—∫ 4
æ‘®“√≥“„™â¬“§«∫§ÿ¡‚√§À◊¥ 2 ™π‘¥¢÷Èπ‰ª√à«¡°—∫¬“¢¬“¬À≈Õ¥≈¡™π‘¥
æàπ Ÿ¥ÕÕ°ƒ∑∏‘Ï‡√Á«‡æ◊ËÕ∫√√‡∑“Õ“°“√ ‚¥¬‡≈◊Õ°„™â¬“ Ÿμ√º ¡√–À«à“ß§Õ√åμ‘‚§
‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥¢π“¥ª“π°≈“ßº ¡°—∫¬“ Ÿ¥¢¬“¬À≈Õ¥≈¡∑’ËÕÕ°ƒ∑∏‘Ï¬“«
(medium dose ICS/LABA)17,24 ”À√—∫ºŸâªÉ«¬‚√§À◊¥∑’Ë ‰¥â√—∫°“√√—°…“¥â«¬¬“„π
√–¥—∫ 4 §«√ àß√—°…“μàÕ°—∫ºŸâ‡™’Ë¬«™“≠
ºŸâªÉ«¬∑’Ë¡’Õ“°“√‚√§À◊¥°”‡√‘∫‡©’¬∫æ≈—π∫àÕ¬ Ê §◊Õ¡“°°«à“ 1 §√—Èß¢÷Èπ‰ª
„π√Õ∫ªï∑º’Ë “à π¡“ °“√„™â¬“º ¡√–À«à“ß§Õ√åμ‚‘ § ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥¢π“¥°≈“ß
√à«¡°—∫ formoterol ∫√‘À“√¬“‚¥¬„™â∑ß—È ·∫∫§«∫§ÿ¡·≈–∫√√‡∑“Õ“°“√‡ªìπ§√—ßÈ §√“«
‰¥âº≈¥’ „π°“√≈¥°“√°”‡√‘∫‡©’¬∫æ≈—π24 (πÈ”Àπ—°§”·π–π” +++, §ÿ≥¿“æÀ≈—°∞“π
√–¥—∫ 1) ”À√—∫ºŸâªÉ«¬∑’Ë „™â¬“§«∫§ÿ¡‚√§À◊¥‡ªìπ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥
¢π“¥μË”º ¡°—∫¬“¢¬“¬À≈Õ¥≈¡∑’ËÕÕ°ƒ∑∏‘Ï¬“« √à«¡°—∫¬“¢¬“¬À≈Õ¥≈¡™π‘¥
æàπ Ÿ¥ÕÕ°ƒ∑∏‘Ï‡√Á«‡æ◊ËÕ∫√√‡∑“Õ“°“√‡ªìπ§√—Èß§√“« Õ“®‡æ‘Ë¡¢π“¥¢Õß¬“§Õ√åμ‘‚§
‡μ’¬√Õ¬¥å‡ªìπ¢π“¥∑’Ë Ÿß¢÷Èπº ¡°—∫¬“¢¬“¬À≈Õ¥≈¡∑’ËÕÕ°ƒ∑∏‘Ï¬“«17 (πÈ”Àπ—°
§”·π–π” +++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 2)
”À√—∫¬“∑“ß‡≈◊Õ°Õ◊Ëπ Ê „π°“√√—°…“‰¥â·°à °“√‡æ‘Ë¡¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å
™π‘¥æàπ Ÿ¥‡ªìπ¢π“¥ Ÿß‡ªìπ‡«≈“ 3-6 ‡¥◊Õπ25 „π°√≥’∑’Ë ‰¡à “¡“√∂§ÿ¡‚√§‰¥â¥â«¬
°“√„™â¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥¢π“¥ª“π°≈“ßº ¡°—∫¬“¢¬“¬À≈Õ¥≈¡
∑’ËÕÕ°ƒ∑∏‘Ï¬“« √à«¡°—∫¬“Õ◊Ëπ Ê ‡™àπ ¬“μâ“πμ—«√—∫≈‘«‚§‰μ√Õ’π„π√Ÿª√—∫ª√–∑“π
À√◊Õ¬“ theophylline ∑’ËÕÕ°ƒ∑∏‘Ï¬“«√Ÿª√—∫ª√–∑“π31 (πÈ”Àπ—°§”·π–π” ++,
§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 2) À√◊Õ‡æ‘Ë¡¬“μâ“πμ—«√—∫‚§≈‘π‡πÕ√å®‘°™π‘¥æàπ Ÿ¥‰¥â·°à
tiotropium bromide ¢π“¥ 5 ·≈– 10 ¡§°. „π°√≥’∑’ËºŸâªÉ«¬∑’Ë ‰¥â√—∫ ICS/LABA
¢π“¥ ŸßÕ¬Ÿà‡¥‘¡·≈â«π—Èπæ∫«à“ ¡’ª√– ‘∑∏‘¿“æ„π°“√‡æ‘Ë¡§à“ ¡√√∂¿“æªÕ¥‰¥â
·≈–™à«¬≈¥Õ“°“√À◊¥°”‡√‘∫‡©’¬∫æ≈—π32,33
24
¬“∑’Ë‡ªìπ¬“§«∫§ÿ¡‚√§À◊¥‡™àπ ¬“μâ“π≈‘«‚§‰μ√Õ’π™π‘¥√—∫ª√–∑“π À√◊Õ¬“
theophylline ∑’ËÕÕ°ƒ∑∏‘Ï¬“«‚¥¬Õ“®„™â√à«¡°—∫¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥
º ¡°—∫¬“¢¬“¬À≈Õ¥≈¡∑’ËÕÕ°ƒ∑∏‘Ï¬“«¢π“¥μË”À√◊Õª“π°≈“ß28,34 (πÈ”Àπ—°§”
·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 2)
5. ¬“§«∫§ÿ¡‚√§À◊¥√–¥—∫ 5 (§«√¥Ÿ·≈„π ∂“πæ¬“∫“≈∑’Ë¡’§«“¡‡™’Ë¬«™“≠)
æ∫«à“ºŸâªÉ«¬∑’Ë ‰¡à “¡“√∂§«∫§ÿ¡‚√§À◊¥‰¥â¥â«¬¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥
æàπ Ÿ¥¢π“¥ Ÿßº ¡°—∫¬“¢¬“¬À≈Õ¥≈¡∑’ËÕÕ°ƒ∑∏‘Ï¬“« (high dose ICS/LABA)
Õ“®æ‘®“√≥“„™â¬“‰¥â·°à ¬“μâ“πÕ‘¡¡Ÿ‚π‚°≈∫Ÿ≈π‘ Õ’·∫∫©’¥ (anti-IgE treatment À√◊Õ
omalizumab)38-42 (πÈ”Àπ—°§”·π–π” +++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1) ¬“§Õ√åμ‘‚§
‡μ’¬√Õ¬¥å™π‘¥√—∫ª√–∑“π¢π“¥μË” (Add-on low dose oral corticosteroid)43,44
(πÈ”Àπ—°§”·π–π” +, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3) À√◊Õ∑”°“√ àÕß°≈âÕßÀ≈Õ¥≈¡
·≈– bronchial thermoplasty45,46 (πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫
2)
¬“μâ“πÕ‘¡¡Ÿ‚π‚°≈∫Ÿ≈π‘ Õ’·∫∫©’¥ (monoclonal anti-IgE À√◊Õ omalizumab)
æ‘®“√≥“„™â „π°√≥’∑’Ë§«∫§ÿ¡‚√§‰¡à ‰¥â·≈–‡ªìπ allergic asthma ‚¥¬°“√∑¥ Õ∫
¿Ÿ¡‘·æâ∑“ßº‘«Àπ—ß„Àâº≈∫«°μàÕ “√°àÕ¿Ÿ¡‘·æâ „πÕ“°“» (aeroallergen) À√◊Õ°“√
μ√«®«—¥√–¥—∫¢Õß specific IgE „π‡≈◊Õ¥∑’Ë®”‡æ“–μàÕ “√°àÕ¿Ÿ¡‘·æâ „πÕ“°“» æ∫
«à“ omalizumab ™à«¬≈¥°“√‡°‘¥À◊¥°”‡√‘∫‰¥â35,36 °“√√—°…“¥â«¬¬“ omalizumab
π—Èπ§«√æ‘®“√≥“„πºŸâªÉ«¬¥—ßμàÕ‰ªπ’È (¥—ß¿“§ºπ«°∑’Ë 4) §◊Õ ¡’Õ“°“√‚√§À◊¥√ÿπ·√ß
·¡â«à“®–‰¥â√—∫°“√√—°…“¥â«¬¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥ ¢π“¥ Ÿßº ¡°—∫¬“
¢¬“¬À≈Õ¥≈¡∑’ÕË Õ°ƒ∑∏‘¬Ï “« ·μà¬ß— §ß¡’Õ“°“√¢Õß‚√§À◊¥∑’§Ë «∫§ÿ¡‰¡à‰¥â·≈–¡’°“√
°”‡√‘∫‡©’¬∫æ≈—π √à«¡°—∫¡’º≈°“√∑¥ Õ∫∑“ßº‘«Àπ—ßμàÕ “√°àÕ¿Ÿ¡‘·æâ „πÕ“°“»
‡ªìπ∫«° ¡’√–¥—∫¢Õß total IgE „π‡≈◊Õ¥√–À«à“ß 30-1,500 IU/¡≈.37 μâÕß¡’°“√
ª√–‡¡‘πº≈¿“¬À≈—ß„Àâ°“√√—°…“‰ª·≈â« 16 —ª¥“Àå ·≈–À“°‰¥âº≈¥’ §«√„Àâ¬“
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 25

μ“√“ß∑’Ë 4 ™π‘¥¢Õß¬“„π°“√§«∫§ÿ¡‚√§À◊¥·≈–¬“∫√√‡∑“Õ“°“√‚√§À◊¥
°≈ÿà¡¬“§«∫§ÿ¡‚√§À◊¥ μ—«Õ¬à“ß¬“∑’Ë¡’„™â„πª√–‡∑»‰∑¬
(Controller medications)
1. ¬“§Õ√åμ‚‘ § ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥ ¬“™π‘¥æàπ Ÿ¥ ‰¥â·°à beclomethasone,
(ICS) budesonide, fluticasone
¬“™π‘¥√—∫ª√–∑“π ‰¥â·°à prednisolone
¬“™π‘¥©’¥‡¢â“°≈â“¡‡π◊ÈÕÀ√◊ÕÀ≈Õ¥‡≈◊Õ¥¥”
‰¥â·°à hydrocortisone, dexamethasone,
methylprednisolone
2. ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å º ¡°—∫ ‰¥â·°à fluticasonse-salmeterol,
¬“¢¬“¬À≈Õ¥≈¡∑’ËÕÕ°ƒ∑∏‘Ï¬“« budeso-nide-formoterol,
™π‘¥æàπ Ÿ¥ beclomethasone-formoterol
3. ¬“μâ“π≈‘«‚§‰μ√Õ’π™π‘¥ montelukast
√—∫ª√–∑“π
4. ¬“ xanthine ∑’ËÕÕ°ƒ∑∏‘Ï¬“« ‰¥â·°à theophylline ∑’ËÕÕ°ƒ∑∏‘Ï¬“«™π‘¥
™π‘¥√—∫ª√–∑“π √—∫ª√–∑“π ·≈– doxophylline
5. Anti-IgE omalizumab
6. Long-acting anticholinergic tiotropium handihaler ·≈– tiotropium
soft mist inhaler
°≈ÿà¡¬“∫√√‡∑“Õ“°“√ μ—«Õ¬à“ß
(Reliever medications)
1. ¬“¢¬“¬À≈Õ¥≈¡ ¬“ Ÿ¥™π‘¥ÕÕ°ƒ∑∏‘Ï‡√Á« ‰¥â·°à salbutamol
·≈– procaterol
¬“™π‘¥√—∫ª√–∑“π salbutamol, terbutaline,
bambuterol ·≈– procaterol
2. ¬“°≈ÿà¡ xanthine ¬“ aminophylline ™π‘¥©’¥·≈–°‘π
3. ¬“°√–μÿâπμ—«√—∫∫’μâ“°—∫¬“μâ“π ‰¥â·°à salbutamol-ipratropium bromide
‚§≈‘‡πÕ®‘°∑’ËÕÕ°ƒ∑∏‘Ï —Èπ ·≈– fenoterol-ipratropium bromide
26
μàÕ‡π◊ËÕß‡ªìπ√–¬–‡«≈“Õ¬à“ßπâÕ¬ 1 ªï38-41 ‡π◊ËÕß®“°¬“ omalizumab ¡’√“§“ Ÿß
·≈–‰¡à ‰¥âπ”¡“„™â‡ªìπ¬“‡¥’Ë¬« Ê „π°“√√—°…“‚√§À◊¥®÷ß§«√„Àâ àßºŸâªÉ«¬¡“∑”°“√
√—°…“°—∫·æ∑¬åºŸâ‡™’Ë¬«™“≠35,42 (πÈ”Àπ—°§”·π–π” +++, §ÿ≥¿“æÀ≈—°∞“π 1)
¬“√—∫ª√–∑“π§Õ√åμ‚‘ § ‡μ’¬√Õ¬¥å¢π“¥μË” §◊Õ prednisolone ¢π“¥‰¡à‡°‘π
7.5 ¡°. μàÕ«—π À√◊Õ‡∑’¬∫‡∑à“ ·μàμâÕß√–«—ß‡√◊ËÕßº≈¢â“ß‡§’¬ß∑—Ë«√–∫∫√à“ß°“¬∑’Ë
‡°‘¥®“°¬“43, 44(πÈ”Àπ—°§”·π–π” +++, §ÿ≥¿“æÀ≈—°∞“π 3) ”À√—∫°“√∑”
bronchial thermoplasty π—Èπ¬—ß¡’¢âÕ¡Ÿ≈®”°—¥ ®÷ßæ‘®“√≥“„™â „πºŸâªÉ«¬∫“ß√“¬
·≈–§à“„™â®à“¬ Ÿß¡“°45,46 °“√„™â®”π«π‡¡Á¥‡≈◊Õ¥¢“« eosinophils „π‡ ¡À–„π
°“√ª√—∫¬“≈¥°“√Õ—°‡ ∫¢ÕßÀ≈Õ¥≈¡ (sputum eosinophil-guided treatment)
™à«¬≈¥°“√‡°‘¥À◊¥°”‡√‘∫‡©’¬∫æ≈—π‡∑’¬∫°—∫°“√„™âÕ“°“√ª√—∫¬“47,48 ·π–π”„Àâ∑”
„π ∂“πæ¬“∫“≈∑’Ë¡’§«“¡‡™’Ë¬«™“≠ (πÈ”Àπ—°§”·π–π” +, §ÿ≥¿“æÀ≈—°∞“π 1)
πÕ°®“°π’·È π–π”„ÀâÀ“ “‡ÀμÿÕπ◊Ë Ê ∑’∑Ë ”„Àâ§¡ÿ ‚√§À◊¥‰¡à ‰¥â ‡™àπ ‚√§√à«¡ (comor-
bidities) ∑∫∑«π°“√«‘π‘®©—¬«à“∂Ÿ°μâÕßÀ√◊Õ‰¡à ∑∫∑«π«‘∏’°“√„™â¬“¢ÕßºŸâªÉ«¬ ·≈–
æ‘®“√≥“∂÷ß‚√§Õ◊Ëπ Ê ‡™àπ tracheobronchomalacia ‡ªìπμâπ
°“√¥Ÿ·≈ºŸâªÉ«¬∑’Ë§«∫§ÿ¡‚√§À◊¥‰¥â·≈–°“√≈¥¬“√—°…“‚√§À◊¥
(Stepping down asthma treatment when achieved control)
”À√—∫„π°√≥’∑’ËºŸâªÉ«¬ “¡“√∂§«∫§ÿ¡Õ“°“√‚√§À◊¥‰¥â·≈â« §«√¡’°“√≈¥
√–¥—∫°“√√—°…“À√◊Õ¬“≈ß ‚¥¬°“√μÕ∫ πÕßμàÕ°“√√—°…“π—Èπ„π·μà≈–¡‘μ‘¢Õß°“√
· ¥ßÕÕ°¢Õß‚√§®–¡’°“√μÕ∫ πÕßμàÕ°“√√—°…“¥â«¬¬“‡√Á«™â“·μ°μà“ß°—π‰ª§◊Õ
Õ“°“√ÀÕ∫°≈“ß§◊π (nocturnal symptoms) ®–μÕ∫ πÕß‡√Á«∑’Ë ÿ¥ μ“¡¥â«¬°“√
‡æ‘¡Ë ¢Õß ¡√√∂¿“æªÕ¥ FEV1 ®–¥’¢π÷È „π —ª¥“Àå∑’Ë 2 „π¢≥–∑’§Ë «“¡‰«¢ÕßÀ≈Õ¥≈¡
(airway hyper-responsiveness) ·∑∫®–‰¡à‡ª≈’Ë¬π·ª≈ß‡≈¬·≈–„™â‡«≈“π“π
‡ªìπªï®ß÷ ®–ª°μ‘ À√◊ÕÕ“®‰¡à≈¥≈ß‡≈¬°Á ‰¥â49 ®÷ß·π–π”„Àâ≈¥√–¥—∫¢Õß°“√√—°…“≈ß
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 27

(step down therapy) „π°√≥’∑º’Ë ªŸâ «É ¬Õ“°“√§ß∑’§Ë «∫§ÿ¡‰¥âÕ¬à“ßπâÕ¬ 3-12 ‡¥◊Õπ
§à“ ¡√√∂¿“æªÕ¥§ß∑’Ë·≈–‰¡à¡’°“√°”‡√‘∫‡©’¬∫æ≈—π‡°‘¥¢÷ÈπÕ’° °“√≈¥°“√√—°…“
‡√Á«À√◊Õ™â“·§à ‰Àπ¢÷Èπ°—∫§«“¡√ÿπ·√ß¢ÕßºŸâªÉ«¬„π·μà≈–√“¬ Õ¬à“ß‰√°Áμ“¡ºŸâªÉ«¬∑’Ë
§«∫§ÿ¡‚√§À◊¥‰¥â·≈â« ·μà¡ª’ ®í ®—¬‡ ’¬Ë ßμàÕ°“√°”‡√‘∫‡©’¬∫æ≈—πμâÕß„Àâ°“√√—°…“π“π
°«à“π’È ‰¡à§«√√’∫≈¥√–¥—∫°“√√—°…“ πÕ°®“°π’È¬—ß‰¡à·π–π”„ÀâÀ¬ÿ¥¬“§Õ√åμ‘‚§
‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥„πºŸªâ «É ¬‚√§À◊¥∑’‡Ë ªìπºŸâ „À≠à (πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æ
À≈—°∞“π√–¥—∫ 1)50
°“√·π–π”À√◊Õ„Àâ§«“¡√Ÿâ·°àºŸâªÉ«¬
°≈‰°∑’Ë ”§—≠„π°“√§«∫§ÿ¡‚√§À◊¥§◊Õ °“√„Àâ§«“¡√Ÿâ·°àºŸâªÉ«¬·≈–°“√Ωñ°
∑—°…–°“√¥Ÿ·≈√—°…“‚√§À◊¥„π¥â“πμà“ß Ê ‡æ◊ËÕ„ÀâºŸâªÉ«¬ “¡“√∂¥Ÿ·≈μ—«‡Õß„π‡∫◊ÈÕß
μâπ‰¥âÕ¬à“ß‡À¡“– ¡ (πÈ”Àπ—°§”·π–π” +, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 4) ‚¥¬ ‘Ëß∑’Ë
§«√ ÕπºŸâªÉ«¬‰¥â·°à
1. §«“¡√Ÿâ‡°’Ë¬«°—∫‚√§À◊¥ “‡Àμÿ °“√¥”‡π‘π‚√§ ·≈–°“√√—°…“
2. °“√μ‘¥μ“¡°“√¥”‡π‘π‚√§¥â«¬μπ‡Õß ·≈–Ωñ° —ß‡°μÕ“°“√
3. °“√ªØ‘∫μ— μ‘ π‡¡◊ÕË ¡’Õ“°“√°”‡√‘∫¢Õß‚√§ (written action plan) “¡“√∂
Õà“π‰¥â®“°¿“§ºπ«° 5
4. §«“¡ ”§—≠¢Õß°“√¡“μ‘¥μ“¡°“√√—°…“ ·≈–°“√„™â¬“Õ¬à“ßμàÕ‡π◊ËÕß
¡Ë”‡ ¡Õ
5. ‡∑§π‘§°“√„™â¬“ Ÿ¥æàπ™π‘¥μà“ß Ê
§«“¡√Ÿâ‡∫◊ÈÕßμâπ‡°’Ë¬«°—∫‚√§À◊¥∑’Ë§«√„Àâ§”·π–π”°—∫ºŸâªÉ«¬
1. °“√„Àâ§«“¡√Ÿâ·°àºŸâªÉ«¬·≈–≠“μ‘ ´÷Ëß ‘Ëß∑’Ë®– Õπ‰¡à®”‡ªìπμâÕß‡À¡◊Õπ
°—π ”À√—∫ºŸâªÉ«¬∑ÿ°§π ‡π◊ËÕß®“°§«“¡√Ÿâ·≈–§«“¡‡¢â“„®æ◊Èπ∞“π¢Õß·μà≈–§π‰¡à
‡À¡◊Õπ°—π
28
2. ‰¡à®”‡ªìπμâÕß Õπ∑ÿ°Õ¬à“ß„π§√—Èß‡¥’¬« ·μà§«√¡’°“√®¥∫—π∑÷° À√◊Õ
checklist «à“¡’·ºπ°“√®– Õπ‡√◊ËÕß„¥∫â“ß ·≈–∑∫∑«π‡¡◊ËÕ‰¥â Õπ‰ª·≈â« ‚¥¬
‡©æ“–‡√◊ËÕß∑’Ë ”§—≠À√◊Õ¡—°¡’°“√º‘¥æ≈“¥∫àÕ¬ Ê ‡™àπ °“√„™â¬“æàπ∑’Ë∂Ÿ°μâÕß „πºŸâ
∑’Ë¬—ß§«∫§ÿ¡Õ“°“√‰¡à ‰¥â
3. ”À√—∫ºŸªâ «É ¬‡¥Á°·≈–ºŸ â ßŸ Õ“¬ÿ §«√„Àâ§”·π–π”„π°“√¥Ÿ·≈°—∫ºŸªâ °§√Õß
À√◊Õ≠“μ‘¥â«¬
4. √–À«à“ß°“√„Àâ§”·π–π”°—∫ºŸâªÉ«¬ Õ“®®–„™âÕÿª°√≥å‡ √‘¡À√◊Õ¡’§Ÿà¡◊Õ
„ÀâºŸâªÉ«¬ ·≈–¡’°“√∂“¡ºŸâªÉ«¬«à“¡’¢âÕ ß —¬À√◊Õ‰¡à ‡¢â“„®À√◊Õ‰¡à ‡æ◊ËÕ∑’Ë®–‰¥â
Õ∏‘∫“¬‡æ‘Ë¡‡μ‘¡
5. ºŸâ ∑’Ë „Àâ§”·π–π”°—∫ºŸâªÉ«¬Õ“®®–‡ªìπ·æ∑¬å æ¬“∫“≈ ‡¿ —™°√ À√◊Õ
∫ÿ§≈“°√∑“ß “∏“√≥ ÿ¢Õ◊πË Ê °Á ‰¥â ´÷ßË ∑ÿ°§π§«√„Àâ§”·π–π”‰ª„π·π«∑“ß‡¥’¬«°—π
°√–∫«π°“√„Àâ§”·π–π”ºŸâªÉ«¬§«√ª√–°Õ∫¥â«¬
1. °“√‡ √‘¡ √â“ß§«“¡‡¢â“„®°—∫≠“μ‘·≈–ºŸâªÉ«¬ «à“∑ÿ°§π¡’ à«π√à«¡„π∑’¡
°“√√—°…“
2. °“√ ”√«®À√◊Õ —ß‡°μ«à“ºŸâªÉ«¬μâÕß°“√§”·π–π”¥â“π„¥‡ªìπæ‘‡»…À√◊Õ
‰¡à À√◊Õ¡’æ◊Èπ∞“π§«“¡√Ÿâ §«“¡‡¢â“„®‡ªìπÕ¬à“ß‰√
3. æŸ¥§ÿ¬∂÷ß§«“¡§“¥À«—ß„π°“√√—°…“‚√§¢ÕßºŸâªÉ«¬ ‘Ëß∑’ËºŸâªÉ«¬«‘μ°°—ß«≈
À√◊Õªí≠À“∑’ËºŸâªÉ«¬ª√– ∫ À√◊Õ§“¥«à“®–‡°‘¥¢÷Èπ ‡æ◊ËÕ™à«¬À“·π«∑“ß°“√·°â ‰¢
4. μ—ßÈ ‡ªÑ“À¡“¬„π°“√¥Ÿ·≈√—°…“√à«¡°—π√–À«à“ß∑’¡ºŸ√â °— …“°—∫ºŸªâ «É ¬·≈–≠“μ‘
À—«¢âÕ∑’Ë®–„Àâ§”·π–π”‡°’Ë¬«°—∫‚√§À◊¥‰¥â·°à
1. °“√«‘π‘®©—¬‚√§À◊¥ °“√¥”‡π‘π‚√§ ·≈– ‘Ëß°√–μÿâπ
2. ·π«∑“ß°“√√—°…“ ‡™àπ ¬“∑’Ë „™â‡æ◊ËÕ∫√√‡∑“Õ“°“√·≈–¬“‡æ◊ËÕ§«∫§ÿ¡
Õ“°“√
3. ™π‘¥¢Õß¬“∑’Ë„™â º≈¢â“ß‡§’¬ß∑’ËÕ“®®–‡°‘¥¢÷Èπ‰¥â®“°¬“∑’ËºŸâªÉ«¬„™âÕ¬Ÿà
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 29

4. °“√°”‡√‘∫¢Õß‚√§À◊¥ °“√ªØ‘∫—μ‘μ—«‡∫◊ÈÕßμâπ‡¡◊ËÕ‡°‘¥°“√°”‡√‘∫ ·≈–
°“√ªÑÕß°—π
5. Õ“°“√∑’Ë§«√®–μâÕß —ß‡°μ ‡™àπ Õ“°“√∑’Ë∫àß«à“Õ“®®–‡√‘Ë¡¡’°“√°”‡√‘∫
¢Õß‚√§
6. Õ“°“√∑’ËμâÕß¡“æ∫·æ∑¬å°àÕππ—¥
7. ‚√§√à«¡∑’ËÕ“®®–æ∫√à«¡°—∫‚√§À◊¥ ·≈–°“√ªØ‘∫—μ‘μ—«
°“√ Õπ·ºπ°“√¥Ÿ·≈μπ‡Õß„πºŸâªÉ«¬‚√§À◊¥
1. §«√ ÕπºŸâªÉ«¬∑ÿ°§π„Àâ√Ÿâ®—° —ß‡°μÕ“°“√¢Õßμπ ·≈– Õπ°“√ªØ‘∫—μ‘
μ—«‡∫◊ÈÕßμâπ‡¡◊ËÕ¡’Õ“°“√‡ª≈’Ë¬π·ª≈ß
2. §«√æ‘®“√≥“∂÷ß§«“¡ “¡“√∂„π°“√¥Ÿ·≈μπ‡Õß¢ÕßºŸªâ «É ¬·≈–≠“μ‘¥«â ¬
·≈–‡≈◊Õ°§”·π–π”„Àâ‡À¡“– ¡
3. ‘Ëß∑’Ë§«√ ÕπÀ√◊Õ·π–π”ºŸâªÉ«¬ ‰¥â·°à
- °“√μ‘¥μ“¡Õ“°“√¥â«¬μπ‡Õß∑’Ë∫â“π Õ“°“√∑’Ë∫àß«à“‚√§°”‡√‘∫ À√◊Õ
μ‘¥μ“¡§à“ peak expiratory flow
- ·ºπ°“√¥Ÿ·≈√—°…“‡¡◊ÕË ‡°‘¥Õ“°“√ „Àâ¥„Ÿ π·ºπªØ‘∫μ— °‘ “√‡¡◊ÕË ¡’Õ“°“√
À◊¥°”‡√‘∫ (asthma action plan) (¥Ÿ¿“§ºπ«°∑’Ë 5)
4. §«√·®°§Ÿà¡◊Õ„π°“√¥Ÿ·≈μπ‡Õß„Àâ°—∫ºŸâªÉ«¬
5. ¡’°“√μ√«® Õ∫§«“¡‡¢â“„® ·≈–∑—°…–„π°“√¥Ÿ·≈μπ‡Õß¢ÕßºŸâªÉ«¬
Õ¬à“ßμàÕ‡π◊ËÕß
°“√ Õπ°“√„™âÕÿª°√≥åæàπ¬“
1. °“√‡≈◊Õ°„™âÕÿª°√≥å∑’Ë‡À¡“– ¡ ∑”„ÀâºŸâªÉ«¬‰¥â√—∫¬“¥’¢÷Èπ àßº≈„Àâ°“√
§«∫§ÿ¡‚√§¥’¢÷Èπ
2. §«√‡≈◊Õ°„™âÕÿª°√≥å„Àâ‡À¡“– ¡°—∫ºŸâªÉ«¬·μà≈–§π (æ‘®“√≥“∑—Èß§«“¡
ßà“¬„π°“√„™â ·√ß Ÿ¥ √“§“¬“ ·≈–ª√– ‘∑∏‘¿“æ¢Õß¬“)
30
3. ¢âÕ§«√æ‘®“√≥“„π°“√‡≈◊Õ°Õÿª°√≥åæàπ¬“
3.1 ·√ß Ÿ¥¬“ (peak inspiratory flow rate) ∑’Ë«—¥‰¥â ºŸâªÉ«¬∑’Ë¡’·√ß
Ÿ¥πâÕ¬°«à“ 30 ≈‘μ√μàÕπ“∑’ ‰¡à§«√„™â¬“„π°≈ÿà¡ dry powder inhaler (DPI)51
(πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 2)
3.2 ¬“ pressurized metered dose inhaler (pMDI) μâÕßÕ“»—¬
∑—°…–„π°“√°¥·≈– Ÿ¥¬“∑’ Ë ¡— æ—π∏å°π— ∂â“„π°√≥’∑º’Ë ªŸâ «É ¬‰¡à “¡“√∂∑”‰¥â æ‘®“√≥“
„Àâ pMDI √à«¡°—∫°“√„™â°√–∫Õ° (spacer) À√◊Õæ‘®“√≥“‡≈◊Õ°¬“ Ÿ¥™π‘¥Õ◊Ëπ
3.3 ¬“ DPI ¡’À≈“¬‡∑§π‘§·μ°μà“ß°—π‰ª„π·μà≈–Õÿª°√≥å ‡™àπ turbu-
haler ·≈– accuhaler §«√μ√«® Õ∫«à“ºŸªâ «É ¬ “¡“√∂„™â¬“‰¥âÕ¬à“ß∂Ÿ°μâÕßÀ√◊Õ‰¡à
3.4 ‰¡à§«√‡≈◊Õ°„™âÕÿª°√≥åæàπ¬“À≈“¬ Ê ™π‘¥„πºŸâªÉ«¬§π‡¥’¬«°—π
‡π◊ËÕß®“°®–∑”„ÀâºŸâªÉ«¬ —∫ π‰¥â
3.5 §«√¡’°“√μ√«® Õ∫‡∑§π‘§°“√„™âÕªÿ °√≥åæπà ¬“«à“∂Ÿ°μâÕß‡À¡“– ¡
À√◊Õ‰¡à ‡ªìπ√–¬– Ê
°“√μ‘¥μ“¡«à“ºŸâªÉ«¬„™â¬“ ¡Ë”‡ ¡ÕÀ√◊Õ‰¡à
1. °“√„™â¬“∑’Ë ‰¡à ¡Ë”‡ ¡Õ àßº≈∑”„Àâ°“√§«∫§ÿ¡‚√§‰¡à¥’ ‚¥¬ “‡Àμÿ∑’Ë
ºŸâªÉ«¬„™â¬“‰¡à ¡Ë”‡ ¡ÕÕ“®®–¡“®“°À≈“¬ªí®®—¬ ‡™àπ §«“¡‡¢â“„®º‘¥„πÀ≈—°°“√
„™â¬“√—°…“‚√§ ¡’º≈¢â“ß‡§’¬ß®“°¬“ §«“¡¬“°ßà“¬¢ÕßÕÿª°√≥å √“§“¬“ À√◊Õ
À≈ß≈◊¡ ‡ªìπμâπ
2. ‡¡◊ËÕºŸâªÉ«¬¡“μ‘¥μ“¡°“√√—°…“®÷ß§«√∂“¡∂÷ßª√‘¡“≥¬“∑’Ë„™â „π·μà≈–«—π
«à“‡ªìπ‰ªμ“¡·ºπ°“√√—°…“À√◊Õ‰¡à ‡¡◊ÕË æ∫«à“ºŸªâ «É ¬‰¡à‰¥â„™â¬“ À√◊Õ„™â¬“‰¡à‡À¡“– ¡
‰¡à§«√μàÕ«à“ºŸâªÉ«¬ ·μà§«√ Õ∫∂“¡∂÷ß‡Àμÿº≈ ‡æ◊ËÕ«“ß·ºπ°“√√—°…“
3. ¥Ÿª√‘¡“≥¬“∑’Ë‡À≈◊ÕÕ¬Ÿà ‡æ◊ËÕμ√«® Õ∫«à“ºŸâªÉ«¬‰¥â „™â¬“μ“¡·ºπ°“√®√‘ß
À√◊Õ‰¡à
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 31

4. ®”π«π§√—Èß¢Õß°“√„™â¬“¢¬“¬À≈Õ¥≈¡‡æ◊ËÕ∫√√‡∑“Õ“°“√ ∂â“¡’°“√„™â
¡“°¢÷ÈπÕ“®®–‡ªìπ —≠≠“≥∫Õ°«à“ºŸâªÉ«¬‡√‘Ë¡¡’Õ“°“√°”‡√‘∫ À√◊Õ‡°‘¥®“°ºŸâªÉ«¬„™â
¬“§«∫§ÿ¡Õ“°“√‰¡à‡À¡“– ¡
Guideline Implementation
ªí≠À“ ”§—≠∑’Ëæ∫∑—Ë«‚≈°§◊Õ °“√π”‡Õ“·π«∑“ß°“√√—°…“‰ª„™â‡æ√“–®“°
°“√»÷°…“„πÀ≈“¬ Ê ª√–‡∑»12 √«¡∑—Èßª√–‡∑»‰∑¬3 æ∫«à“ºŸâªÉ«¬‚√§À◊¥‰¡à ‰¥â√—∫
°“√√—°…“μ“¡∑’Ë·π«∑“ß°”Àπ¥‰«â ®÷ß‡ªìπ∑’Ë¡“¢Õß°“√®—¥μ—Èß§≈‘π‘°‚√§À◊¥·∫∫
ßà“¬ Ê (Easy Asthma Clinic)13 μ“¡‚√ßæ¬“∫“≈™ÿ¡™π„πªï æ.». 2547 ‚¥¬À—«„®
¢Õß Easy Asthma Clinic §◊Õ °“√∑”·π«∑“ß°“√√—°…“‚√§À◊¥„Àâßà“¬¢÷Èπ °“√
®—¥√–∫∫∑’Ë‡æ‘Ë¡∫∑∫“∑¢Õßæ¬“∫“≈·≈–‡¿ —™°√„π°“√√à«¡¥Ÿ·≈ºŸâªÉ«¬·≈–°“√
æ—≤π“√–∫∫°“√®—¥‡°Á∫¢âÕ¡Ÿ≈·∫∫ÕÕπ‰≈πå ßà“¬μàÕ°“√«‘‡§√“–Àå·≈–μ‘¥μ“¡º≈
°“√√—°…“ ∑”„Àâ ‚√ßæ¬“∫“≈™ÿ¡™π‡≈Á° Ê ∑—«Ë ª√–‡∑»‰∑¬ “¡“√∂„Àâ°“√√—°…“‚√§À◊¥
‰¥âμ“¡¡“μ√∞“π ¡’°“√√à«¡¡◊Õ°—π¢Õß∑’¡·æ∑¬å æ¬“∫“≈ ·≈–‡¿ —™°√√¡∑”„Àâ
°“√√—°…“¡’§ÿ≥¿“æ Ÿß ºŸâªÉ«¬‚√§À◊¥®–¡’§ÿ≥¿“æ™’«‘μ∑’Ë¥’¢÷Èπ ‰¡àμâÕß∑ÿ°¢å∑√¡“π
°—∫Õ“°“√ÀÕ∫ ·≈–‰¡àμâÕßÀÕ∫√ÿπ·√ß®πμâÕß‡¢â“√—∫°“√√—°…“∑’ËÀâÕß©ÿ°‡©‘πÀ√◊Õ
πÕπ√—∫°“√√—°…“∑’Ë ‚√ßæ¬“∫“≈ ·≈–∑’Ë ”§—≠§◊Õ ¡’∞“π¢âÕ¡Ÿ≈°“√√—°…“‚√§À◊¥„π
ª√–‡∑»‰∑¬¡“°°«à“ 250,000 √“¬ ´÷Ëß®–‡ªìπª√–‚¬™πåμàÕ√–∫∫ “∏“√≥ ÿ¢¢Õß
ª√–‡∑» (√“¬≈–‡Õ’¬¥ “¡“√∂¥Ÿ‰¥â∑’Ë http://eac2.easyasthma.com/)
¢—ÈπμÕπ°“√∑”ß“π¢Õß Easy Asthma Clinic

1. ºŸªâ «É ¬∑ÿ°§π®–μâÕßæ∫°—∫æ¬“∫“≈°àÕπ‡æ◊ÕË ≈ß∑–‡∫’¬π·≈–ª√–‡¡‘π°“√
§«∫§ÿ¡‚√§À◊¥¢ÕßºŸªâ «É ¬‚¥¬„™â·∫∫ Õ∫∂“¡Õ¬à“ßßà“¬ Ê (asthma control ques-
tionnaires) ‡ √Á®·≈â«°Á„ÀâºŸâªÉ«¬‡ªÉ“æ’§‚ø«å (Peak Expiratory Flow, PEF) ‡æ◊ËÕ
«—¥§«“¡‡√Á« Ÿß ÿ¥∑’ËºŸâªÉ«¬ “¡“√∂‡ªÉ“‰¥â
32
·∫∫ Õ∫∂“¡∑’Ë „™â‡æ◊ËÕ°“√ª√–‡¡‘π°“√§«∫§ÿ¡‚√§À◊¥¢ÕßºŸâªÉ«¬ (asthma
control questionnaires) ®–„™â§”∂“¡ßà“¬ Ê 4 ¢âÕ ‰¥â·°à
1.1 „π™à«ß 4 —ª¥“Àå∑’Ëºà“π¡“ §ÿ≥¡’Õ“°“√‰Õ À“¬„®‰¡àÕ‘Ë¡ À√◊ÕÀ“¬„®
¡’‡ ’¬ß¥—ßÀ«’¥ „π™à«ß°≈“ß«—π∫â“ßÀ√◊Õ‰¡à °’Ë§√—Èß
1.2 „π™à«ß 4 —ª¥“Àå∑’Ëºà“π¡“ §ÿ≥μâÕß≈ÿ°¢÷Èπ¡“‰ÕÀ“¬„®Ωó¥·≈–·πàπ
Àπâ“Õ° À“¬„®¡’‡ ’¬ßÀ«’¥„π™à«ß°≈“ß§◊π∫â“ßÀ√◊Õ‰¡à °’Ë§√—Èß
1.3 „π™à«ß 4 —ª¥“Àå∑’Ëºà“π¡“ §ÿ≥„™â¬“∫√√‡∑“Õ“°“√ÀÕ∫ (¬“¢¬“¬
À≈Õ¥≈¡) ∫â“ßÀ√◊Õ‰¡à °’Ë§√—Èß
1.4 „π™à«ß 2 ‡¥◊Õπ∑’Ëºà“π¡“ §ÿ≥‡§¬ÀÕ∫¡“°®πμâÕß‰ª√—∫°“√√—°…“∑’Ë
ÀâÕß©ÿ°‡©‘πÀ√◊ÕμâÕß‡¢â“√—∫°“√√—°…“„π‚√ßæ¬“∫“≈∫â“ßÀ√◊Õ‰¡à
2. ‡¡◊ËÕæ¬“∫“≈ª√–‡¡‘π‡ √Á®°Á àßºŸâªÉ«¬‡¢â“æ∫·æ∑¬å ´÷Ëß·æ∑¬å®–„Àâ°“√
√—°…“μ“¡·π«∑“ß°“√√—°…“∑’Ë¥—¥·ª≈ß„Àâßà“¬ Ê °≈à“«§◊Õ ‡√“®–‰¡àμâÕß®”·π°
ºŸâªÉ«¬μ“¡§«“¡√ÿπ·√ß´÷Ëß¬“°·°à°“√®¥®” ·μà®–ª√–‡¡‘π«à“ºŸâªÉ«¬§«∫§ÿ¡‚√§À◊¥
‰¥âÀ√◊Õ‰¡à (§”«à“§«∫§ÿ¡‚√§‰¥âÀ¡“¬§«“¡«à“ ºŸâªÉ«¬μâÕß‰¡à¡’Õ“°“√∑—Èß°≈“ß«—π
·≈–°≈“ß§◊π μâÕß‰¡à „™â¬“¢¬“¬À≈Õ¥≈¡ μâÕß‰¡à ‰¥â√—∫°“√√—°…“∑’ËÀâÕß©ÿ°‡©‘π
·≈– PEF ‡°‘π√âÕ¬≈– 80 ¢Õß§à“¡“μ√∞“π) ∂â“ºŸâªÉ«¬¬—ß§«∫§ÿ¡‚√§À◊¥‰¡à ‰¥â
·æ∑¬å°Á®–„Àâ¬“√—°…“‚¥¬„Àâ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥¢π“¥ª“π°≈“ß
(500-1,000 ¡§°.) ‰ª°àÕπ ∂â“§√—ÈßμàÕ‰ªºŸâªÉ«¬¬—ß‰¡à “¡“√∂§«∫§ÿ¡‚√§À◊¥‰¥â°Á„Àâ
‡æ‘Ë¡¬“ ‚¥¬¬“∑’Ë®–„Àâ‡æ‘Ë¡°Á¡‡’ æ’¬ß¬“ 3 μ—«§◊Õ LABA, theophylline ·≈–¬“μâ“π
μ—«√—∫≈‘«‚§‰μ√Õ’π ∂â“§«∫§ÿ¡‚√§‰¥â°Á§àÕ¬ Ê ª√—∫≈¥¬“≈ß
3. À≈—ß®“°·æ∑¬å ß—Ë °“√√—°…“‡ √Á®®÷ß àßºŸªâ «É ¬æ∫°—∫‡¿ —™°√‡æ◊ÕË „Àâ§«“¡√Ÿâ
‡°’Ë¬«°—∫‡√◊ËÕß‚√§À◊¥·≈–°“√√—°…“ Õπ‡√◊ËÕß°“√„™â¬“æàπ Ÿ¥ √«¡∑—Èßμ√«® Õ∫
§«“¡√à«¡¡◊Õ„π°“√„™â¬“¢ÕßºŸâªÉ«¬
4. ¢âÕ¡Ÿ≈ºŸªâ «É ¬®–∂Ÿ°∫—π∑÷°„π∞“π¢âÕ¡Ÿ≈√«¡ºà“π‡«Á∫‰´¥å http://eac2.easy
asthma.com/
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 33
·π«∑“ß°“√¥Ÿ·≈√—°…“
ºŸâªÉ«¬¿“«–À◊¥°”‡√‘∫‡©’¬∫æ≈—π„πÀâÕß©ÿ°‡©‘π
¿“«–‚√§À◊¥°”‡√‘∫‡©’¬∫æ≈—ππ’È “¡“√∂¬◊π¬—π°“√«‘π‘®©—¬‰¥â®“°°“√μ√«®
¡√√∂¿“æªÕ¥´÷Ëß¡’§«“¡‰«·≈–·¡àπ¬”¡“°°«à“°“√Õ‘ßÕ“°“√·≈–Õ“°“√· ¥ß
‚¥¬®–μ√«®æ∫ expiratory airflow ≈¥≈ß ‡™àπ ®“°°“√«—¥ peak expiratory
flow (PEF) À√◊Õ forced expiratory volume in 1 second (FEV1) ‡ªìπμâπ ¿“«–
À◊¥°”‡√‘∫‡©’¬∫æ≈—π∑’Ë∑”„ÀâºŸâªÉ«¬μâÕß¡“√—°…“„πÀâÕß©ÿ°‡©‘π®—¥«à“‡ªìπ¿“«–À◊¥
°”‡√‘∫∑’Ë√ÿπ·√ß ºŸâªÉ«¬∑ÿ°√“¬®÷ß®”‡ªìπμâÕß‰¥â√—∫°“√ª√–‡¡‘π§«“¡√ÿπ·√ß¢Õß‚√§
æ√âÕ¡°—∫‡√‘Ë¡μâπ°“√√—°…“∑—π∑’∑’Ë ‰¥â√—∫°“√«‘π‘®©—¬ ·≈–¡’°“√μ‘¥μ“¡ª√–‡¡‘πº≈
¢Õß°“√√—°…“Õ¬à“ß‡ªìπ√–∫∫ ‡æ◊ËÕ≈¥Õ—μ√“‚√§°”‡√‘∫´È” (relapse) °“√πÕπ
‚√ßæ¬“∫“≈ (admission) ·≈–°“√‡ ’¬™’«‘μ (mortality)
1. °“√ª√–‡¡‘π‚√§
ºŸâªÉ«¬∑ÿ°√“¬μâÕß‰¥â√—∫°“√´—°ª√–«—μ‘·≈–μ√«®√à“ß°“¬Õ¬à“ß≈–‡Õ’¬¥ À“
“‡Àμÿ∑’Ë∑”„Àâ ‚√§À◊¥°”‡√‘∫ ª√–‡¡‘π√–¥—∫§«“¡√ÿπ·√ß¢Õß°“√°”‡√‘∫ (¥—ß· ¥ß
„πμ“√“ß∑’Ë 5) (πÈ”Àπ—°§”·π–π” +, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 4) ·≈–ªí®®—¬‡ ’Ë¬ß
μàÕ°“√‡ ’¬™’«‘μ¢ÕßºŸâªÉ«¬‡æ√“–¡’º≈μàÕ°“√√—°…“ ºŸâªÉ«¬∑’Ë¡’Õ“°“√‚√§À◊¥°”‡√‘∫
‡©’¬∫æ≈—π√ÿπ·√ß®πμâÕß√’∫„Àâ°“√™à«¬™’«‘μ·≈–„ à∑àÕ™à«¬À“¬„® ‰¥â·°à Õ“°“√ ´÷¡
‡¢’¬« À“¬„®·∫∫ air hunger ·≈– —≠≠“≥™’æ‰¡à§ß∑’Ë
34
μ“√“ß∑’Ë 5 °“√ª√–‡¡‘π§«“¡√ÿπ·√ß¢Õß¿“«–À◊¥°”‡√‘∫‡©’¬∫æ≈—π‚¥¬°“√μ√«®√à“ß°“¬
·≈–°“√ ◊∫§âπ‡∫◊ÈÕßμâπ
°“√ª√–‡¡‘π √ÿπ·√ßπâÕ¬∂÷ßª“π°≈“ß √ÿπ·√ß¡“°
(mild to moderate) (severe)
§«“¡√Ÿâ ÷°μ—« ¥’ °√–«π°√–«“¬ —∫ π
À√◊ÕÀ¡¥ μ‘
§«“¡ “¡“√∂„π°“√æŸ¥ æŸ¥‰¥â‡μÁ¡ª√–‚¬§ æŸ¥‰¡à‡μÁ¡ª√–‚¬§
ÿ¥ª√–‚¬§
Õ—μ√“°“√‡μâπ¢Õß™’æ®√ 100-120 > 120
(§√—Èß/π“∑’)
Õ—μ√“°“√À“¬„® (§√—Èß/π“∑’) < 30 > 30
°“√„™â°≈â“¡‡π◊ÈÕÀ“¬„® ”√Õß ‰¡à„™â „™â
Oxygen saturation 90-95% < 90% À√◊Õ¡’¿“«–‡¢’¬«
(room air) (cyanosis)
§à“ PEF > 50% (predicted < 50% (predicted
or best) or best)
ª√–«—μ∑‘ ‡’Ë ªìπªí®®—¬‡ ’¬Ë ß¢Õß°“√°”‡√‘∫√ÿπ·√ß·≈–Õ“®‡ ’¬Ë ßμàÕ°“√‡ ’¬™’«μ‘

‰¥â·°à ¡’ª√–«—μ‘À◊¥°”‡√‘∫‡©’¬∫æ≈—π®πμâÕß„ à∑àÕ™à«¬À“¬„®·≈–‡§√◊ËÕß™à«¬À“¬„®
‡§¬¡“√—°…“∑’ËÀâÕß©ÿ°‡©‘π·≈–μâÕßπÕπ√—°…“μ—«„π‚√ßæ¬“∫“≈¿“¬„π√–¬–‡«≈“
1 ªï∑’Ëºà“π¡“ „™âÀ√◊Õ‡æ‘ËßÀ¬ÿ¥¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥√—∫ª√–∑“π „™â¬“¢¬“¬
À≈Õ¥≈¡™π‘¥æàπ Ÿ¥ÕÕ°ƒ∑∏‘Ï‡√Á«¡“°°«à“ 1 À≈Õ¥μàÕ‡¥◊Õπ ¡’Õ“°“√∑“ß®‘μ‡«™
À√◊Õ¡’ªí≠À“∑“ß®‘μ —ß§¡ √«¡∂÷ßºŸâªÉ«¬∑’ËμâÕß„™â¬“πÕπÀ≈—∫ ¡’ª√–«—μ‘°“√√—°…“
‰¡àμàÕ‡π◊ËÕßÀ√◊Õ‰¡à„Àâ§«“¡√à«¡¡◊Õ„π°“√√—°…“ ·≈–ºŸâªÉ«¬‚√§À◊¥∑’Ë¡’°“√·æâÕ“À“√
√à«¡¥â«¬
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 35

2. °“√„ÀâÕÕ°´‘‡®π
§«√„ÀâÕÕ°´‘‡®π‡¡◊ËÕ√–¥—∫§«“¡Õ‘Ë¡μ—«¢ÕßÕÕ°´‘‡®π∑’Ë«—¥®“°ª≈“¬π‘È«
(SpO2) ·√°√—∫πâÕ¬°«à“√âÕ¬≈– 93 ·≈–§«√μ‘¥μ“¡ SpO2 Õ¬à“ßμàÕ‡π◊ÕË ß‡æ◊ÕË √—°…“
√–¥—∫¢Õß SpO2 „Àâ¡“°°«à“√âÕ¬≈– 9352-54 (πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æ
À≈—°∞“π√–¥—∫ 2)
3. °“√„Àâ¬“ Ÿ¥æàπ¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï‡√Á« (Inhaled rapid-acting

β2-agonist, RABA)
À≈—°°“√„Àâ¬“ Ÿ¥ RABA „πºŸâªÉ«¬À◊¥°”‡√‘∫©—∫æ≈—π∑’ËÀâÕß©ÿ°‡©‘π§◊Õ ®–
μâÕß∑”°“√ª√–‡¡‘π°“√μÕ∫ πÕßÀ≈—ß Ÿ¥æàπ¬“ 15-20 π“∑’‡ ¡Õ ‡æ◊ËÕ‡ªìπ‡°≥±å
™’È·π–«à“®–μâÕßæàπ¬“´È”Õ¬à“ßμàÕ‡π◊ËÕß μâÕß√—∫‰«â „π‚√ßæ¬“∫“≈ À√◊Õ “¡“√∂
®”Àπà“¬°≈—∫∫â“π‰¥â À≈—°°“√„Àâ RABA ¡’¥—ßπ’È
3.1 ‡√‘Ë¡„Àâ RABA ‡™àπ salbutamol 2.5-5 ¡°. ‚¥¬«‘∏’ nebulization À√◊Õ
salbutamol 400-1,000 ¡§°. (4-10 puffs) ºà“π‡§√◊ËÕß pMDI ∑’ËμàÕ°—∫ spacer
®“°π—Èπª√–‡¡‘π°“√μÕ∫ πÕß∑’Ë 15-20 π“∑’À≈—ß°“√æàπ¬“ À“°¬—ß‰¡à¥’¢÷Èπ À√◊Õ
¥’¢÷Èπ·μà¬—ß‰¡à∂÷ß‡°≥±å°“√®”Àπà“¬°≈—∫∫â“π “¡“√∂„Àâ´È”∑ÿ° 20 π“∑’„π™—Ë«‚¡ß
·√°55 √«¡®”π«π 3 §√—Èß (πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1)
3.2 À“°ºŸâªÉ«¬μÕ∫ πÕßμàÕ RABA ‰¡à¥’æÕÀ≈—ß°“√„Àâ¬“ 3 §√—Èß À√◊Õ
ºŸªâ «É ¬ÀÕ∫√ÿπ·√ß¡“° (severe) μ—ßÈ ·μà·√° Õ“®æ‘®“√≥“„Àâ¬“¢¬“¬À≈Õ¥≈¡ RABA
º ¡°—∫¬“μâ“πμ—«√—∫‚§≈‘π‡πÕ√å®°‘ ™π‘¥ÕÕ°ƒ∑∏‘‡Ï √Á«·∑π ‡æ√“–¡’¢Õâ ¡Ÿ≈«à“Õ“®™à«¬
‡æ‘Ë¡ ¡√√∂¿“æªÕ¥‰¥â¥’°«à“°“√æàπ RABA ‡æ’¬ßÕ¬à“ß‡¥’¬« (πÈ”Àπ—°§”·π–π”
++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1)
4. °“√„Àâ systemic corticosteroids

æ‘®“√≥“„Àâ systemic corticosteroid „πºŸªâ «É ¬À◊¥°”‡√‘∫‡©’¬∫æ≈—π∑ÿ°√“¬
36
∑’Ëμ√«®æ∫Õ“°“√· ¥ß∑’Ë√ÿπ·√ß¡“° (μ“√“ß∑’Ë 5) À√◊Õ¡’ª√–«—μ‘∑’Ë‡ªìπªí®®—¬‡ ’Ë¬ß
μàÕ°“√°”‡√‘∫√ÿπ·√ß ‚¥¬‡√‘Ë¡„Àâ∑—π∑’æ√âÕ¡°—∫°“√„Àâ¬“¢¬“¬À≈Õ¥≈¡™π‘¥æàπ Ÿ¥
§√—Èß·√°·≈–„ÀâμàÕ‡π◊ËÕß®πºŸâªÉ«¬®”Àπà“¬°≈—∫∫â“π √Ÿª·∫∫¬“∑’Ë „™âÕ“®‡ªìπ™π‘¥
©’¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ‡™àπ dexamethasone 4-5 ¡°. À√◊Õ hydrocortisone 100
¡°. ∑ÿ° 6-8 ™—Ë«‚¡ß „πºŸâªÉ«¬∑’Ë°”‡√‘∫‰¡à√ÿπ·√ß¡“°Õ“®„Àâ prednisolone √—∫
ª√–∑“π«—π≈– 30-50 ¡°. (0.5-1 ¡°./°°./«—π) ºŸâªÉ«¬∑’Ë ‰¥â¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å
™π‘¥©’¥À√◊Õ√—∫ª√–∑“π∑’ÀË Õâ ß©ÿ°‡©‘π∑ÿ°√“¬®”‡ªìπμâÕß‰¥â prednisolone √—∫ª√–∑“π
μàÕ‡π◊ËÕß‡¡◊ËÕ®”Àπà“¬°≈—∫∫â“πÕ’° 5-7 «—π56-58 (πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æ
À≈—°∞“π√–¥—∫ 1) ‡«≈“¢Õß°“√‡√‘¡Ë „Àâ¬“§Õ√åμ‚‘ § ‡μ’¬√Õ¬¥å™π‘¥©’¥À√◊Õ√—∫ª√–∑“π
∑’ËÀâÕß©ÿ°‡©‘π·≈–μàÕ‡π◊ËÕß∑’Ë∫â“π ‡ªìπªí®®—¬ ”§—≠μàÕ°“√≈¥°“√πÕπ‚√ßæ¬“∫“≈
·≈–°“√°”‡√‘∫´È” (relapse)59,60
5. °“√ª√–‡¡‘πº≈°“√√—°…“·≈–‡°≥±å°“√®”Àπà“¬ÕÕ°®“°ÀâÕß©ÿ°‡©‘π
ºŸâªÉ«¬∑’Ë√—°…“„πÀâÕß©ÿ°‡©‘π∑ÿ°√“¬®”‡ªìπμâÕß‰¥â√—∫°“√ª√–‡¡‘π°“√√—∫√Ÿâ
—≠≠“≥™’æ ·≈–§«“¡Õ‘Ë¡μ—«¢ÕßÕÕ°´‘‡®π„π‡≈◊Õ¥ (SpO2) μ—Èß·μà·√°√—∫·≈–
Õ¬à“ßμàÕ‡π◊ËÕß À“°æ∫«à“ºŸâªÉ«¬´÷¡ —≠≠“≥™’æ‰¡à§ß∑’Ë ·≈–/À√◊Õ SpO2 ≈¥≈ß
§«√„Àâ°“√√—°…“Õ¬à“ß‡À¡“– ¡·≈–∑—π∑à«ß∑’ à«πºŸªâ «É ¬∑’¡Ë ‰‘ ¥âÕ¬Ÿà„π¿“«–¥—ß°≈à“«
§«√‰¥â¬“ RABA ™π‘¥ Ÿ¥æàπμàÕ°—∫°√–∫Õ° spacer À√◊Õ‡§√◊ËÕßæàπ≈–ÕÕßΩÕ¬
·≈–ª√–‡¡‘πº≈μÕ∫ πÕßμàÕ°“√√—°…“Õ¬à“ß‡ªìπ¢—ÈπμÕπ
°“√μ√«®∑’Ë‡ªìπªí®®—¬ ”§—≠·≈–¡’§«“¡·¡àπ¬” Ÿß ÿ¥„π°“√§“¥§–‡πº≈
μÕ∫ πÕßμàÕ°“√√—°…“§◊Õ °“√«—¥ peak expiratory flow (PEF)61-63 ∑’Ë· ¥ß§à“
„π√Ÿª¢Õß√âÕ¬≈–¢Õß§à“ª°μ‘ (% predicted) À√◊Õ§à“∑’Ë¥’∑’Ë ÿ¥¢ÕßºŸâªÉ«¬¢≥–∑’Ë
‰¡à¡’Õ“°“√°”‡√‘∫ % personal best) ‚¥¬§«√«—¥§à“ PEF μ—Èß·μà°àÕπæàπ RABA
§√—Èß·√° ·≈– 15-20 π“∑’À≈—ßæàπ¬“ ‡æ◊ËÕ‡ªìπ‡°≥±å™à«¬·π–«à“ºŸâªÉ«¬§«√®–‰¥â
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 37

√—∫¬“æàπμàÕ À√◊Õ®”Àπà“¬ÕÕ°®“°ÀâÕß©ÿ°‡©‘π „π°√≥’∑Õ’Ë “°“√ÀÕ∫¥’¢π÷È ·≈–§à“ PEF
¥’¢÷Èπ ®–æ‘®“≥“„Àâ°“√®”Àπà“¬°≈—∫∫â“π‰¥â (πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æÀ≈—°
∞“π√–¥—∫ 2) (√“¬≈–‡Õ’¬¥ ¥—ß· ¥ß„πμ—«Õ¬à“ß√Ÿª∑’Ë 3)
6. ¬“·≈–°“√√—°…“‡æ‘Ë¡‡μ‘¡
¬“μâ“π®ÿ≈™’æ æ‘®“√≥“„Àâ‡©æ“–ºŸâªÉ«¬∑’Ë¡’°“√μ‘¥‡™◊ÈÕ·∫§∑’‡√’¬À√◊Õ ß —¬
«à“¡’°“√μ‘¥‡™◊ÈÕ ‡™àπ ¡’‰¢â Ÿß ‡ ¡À– ’‡¢’¬« À√◊Õ¡’¿“«–ªÕ¥Õ—°‡ ∫ ‡ªìπμâπ À≈’°
‡≈’Ë¬ß°“√„Àâ¬“°¥°“√‰ÕÀ√◊Õ¬“∑’Ë¡’º≈∑”„Àâ‡ ¡À–·Àâß À≈’°‡≈’Ë¬ß°“√„™â¬“°≈àÕ¡
ª√– “∑À√◊Õ¬“πÕπÀ≈—∫ ‡æ√“–Õ“®¡’ƒ∑∏‘Ï°¥°“√À“¬„® °“√„™â¬“ magnesium
sulfate (™π‘¥©’¥À√◊ÕæàπΩÕ¬≈–ÕÕß)64,65 Õ“®æ‘®“√≥“„™â „πºŸªâ «É ¬∫“ß√“¬∑’¡Ë Õ’ “°“√
√ÿπ·√ß¡“°·≈–‰¡àμÕ∫ πÕßμàÕ°“√√—°…“Õ¬à“ß‡μÁ¡∑’Ë (πÈ”Àπ—°§”·π–π” +, §ÿ≥¿“æ
À≈—°∞“π√–¥—∫ 1) ‰¡à·π–π”„Àâ „™â aminophylline ™π‘¥©’¥·≈–°“√™à«¬À“¬„®
·∫∫ noninvasive ventilation (NIV) „πºŸâªÉ«¬À◊¥°”‡√‘∫‡©’¬∫æ≈—π∑’ËÀâÕß©ÿ°‡©‘π
‡π◊ËÕß®“°¬—ß‰¡àæ∫¢âÕ∫àß™’È∑’Ë™—¥‡®π·≈–‰¡à≈¥Õ—μ√“°“√„ à∑àÕ™à«¬À“¬„®66 (πÈ”Àπ—°
§”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1) ·æ∑¬åÕ“®æ‘®“√≥“°“√„™â NIV „π
‡©æ“–∫“ß√“¬‡™àπ central airway collapse ·≈–μâÕßμ‘¥μ“¡°“√μÕ∫ πÕß
Õ¬à“ß„°≈â™‘¥ ‡æ◊ËÕæ√âÕ¡∑’Ë®–‡ª≈’Ë¬π‡ªìπ invasive ventilation ∑—π∑’∑’ËºŸâªÉ«¬Õ“°“√
·¬à≈ß
38
√Ÿª∑’Ë 3 · ¥ßμ—«Õ¬à“ß·ºπ°“√¥Ÿ·≈ºŸâªÉ«¬À◊¥°”‡√‘∫‡©’¬∫æ≈—π∑’Ë¡“√—°…“∑’ËÀâÕß©ÿ°‡©‘π
§≥–·æ∑¬»“ μ√å‚√ßæ¬“∫“≈√“¡“∏‘∫¥’
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 39
°“√√—°…“‚√§À◊¥„π°√≥’æ‘‡»…
‚√§À◊¥„πºŸâÀ≠‘ßμ—Èß§√√¿å (Asthma in pregnancy)
Õ“°“√¢Õß‚√§À◊¥„πºŸªâ «à ¬‚√§À◊¥∑’μË ß—È §√√¿åÕ“®·¬à≈ß §ß∑’Ë À√◊Õ¥’¢π÷È °Á ‰¥â ‚¥¬
¡’ ‚Õ°“ ‡ªìπ‰ª‰¥âæÕ Ê °—π ¿“«–À◊¥°”‡√‘∫‡©’¬∫æ≈—π (exacerbation) æ∫‰¥â∫àÕ¬
„π‰μ√¡“ ∑’Ë 2 ¢Õß°“√μ—Èß§√√¿å67 “‡Àμÿ®“°°“√‡ª≈’Ë¬π·ª≈ß¢ÕßŒÕ√å‚¡π·≈–
°“√ª√—∫‡ª≈’¬Ë π¬“Õ—π‡π◊ÕË ß¡“®“°§«“¡°—ß«≈¢Õß·æ∑¬å„π°“√„™â¬“„πºŸÀâ ≠‘ßμ—ßÈ §√√¿å
√«¡∂÷ß°“√μ‘¥‡™◊ÈÕ‰«√— ‡™àπ ‰¢âÀ«—¥„À≠à ‚√§À◊¥∑’Ë§«∫§ÿ¡Õ“°“√‰¥â ‰¡à¥’·≈–°“√
‡°‘¥À◊¥°”‡√‘∫‡©’¬∫æ≈—π®–∑”„Àâ‡°‘¥º≈‡ ’¬μàÕ°“√μ—ßÈ §√√¿å ‚¥¬Õ“®∑”„Àâ‡°‘¥¿“«–
‡¥Á°§≈Õ¥°àÕπ°”Àπ¥ πÈ”Àπ—°·√°§≈Õ¥μË” ‡æ‘Ë¡Õ—μ√“‡ ’¬™’«‘μ√–À«à“ß§≈Õ¥ À√◊Õ
∑”„Àâ¡“√¥“‡°‘¥¿“«–§√√¿å‡ªìπæ‘… °“√§«∫§ÿ¡‚√§À◊¥‰¡à „Àâ¡’Õ“°“√°”‡√‘∫68
®÷ß¡’§«“¡ ”§—≠∑’Ë ÿ¥„π°“√≈¥¿“«–·∑√°´âÕπ∑’Ë®–‡°‘¥¢÷Èπ√–À«à“ß°“√μ—Èß§√√¿å
°“√√—°…“‚√§À◊¥„πºŸÀâ ≠‘ßμ—ßÈ §√√¿å ‰¡à¡À’ ≈—°∞“π¬◊π¬—π«à“¬“√—°…“‚√§À◊¥™π‘¥
μà“ß Ê ‰¥â·°à ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥ ¬“¢¬“¬À≈Õ¥≈¡™π‘¥æàπ Ÿ¥ÕÕ°
ƒ∑∏‘Ï‡√Á« (β2-agonist) ¬“μâ“π≈‘«‚§‰μ√Õ’π™π‘¥√—∫ª√–∑“π (montelukast) ·≈–
theophylline ∑”„Àâ‡¥Á°„π§√√¿å‡°‘¥§«“¡æ‘°“√¡“°¢÷Èπ ¥—ßπ—Èπ¬“√—°…“‚√§À◊¥∑ÿ°
™π‘¥ “¡“√∂„™â ‰¥â „πÀ≠‘ßμ—ßÈ §√√¿å‡À¡◊Õπ°—∫°“√√—°…“μ“¡¡“μ√∞“π∑—«Ë ‰ª º≈‡ ’¬
®“°°“√§«∫§ÿ¡‚√§À◊¥‰¥â ‰¡à¥®’ –¡’¡“°°«à“º≈‡ ’¬®“°°“√„™â¬“§Õ√åμ‚‘ § ‡μ’¬√Õ¬¥å
™π‘¥æàπ Ÿ¥ ‚¥¬¬“°≈ÿà¡π’È®–™à«¬≈¥°“√‡°‘¥¿“«–À◊¥°”‡√‘∫‡©’¬∫æ≈—π‰¥â¥’ „π¢≥–
μ—Èß§√√¿å °“√≈¥¬“≈ß√–À«à“ßμ—Èß§√√¿å®–‡æ‘Ë¡§«“¡‡ ’Ë¬ß„π°“√‡°‘¥¿“«–À◊¥°”‡√‘∫
‡©’¬∫æ≈—π¡“°¢÷Èπ À≠‘ßμ—Èß§√√¿å∑’Ë§«∫§ÿ¡‚√§À◊¥‰¥â¥’Õ¬Ÿà·≈â«®÷ß‰¡à§«√ª√—∫≈¥¬“„π
√–À«à“ß°“√μ—Èß§√√¿å §«√√Õ„Àâ§≈Õ¥°àÕπ®÷ß®–æ‘®“√≥“ª√—∫≈¥¬“μ“¡§”·π–π”
„π°“√≈¥¬“ °√≥’∑‡’Ë °‘¥¿“«–À◊¥°”‡√‘∫‡©’¬∫æ≈—π “¡“√∂„Àâ°“√√—°…“¥â«¬¬“μà“ß Ê
μ“¡¡“μ√∞“π°“√√—°…“ª°μ‘ ‚¥¬æ¬“¬“¡„Àâ√–¥—∫§«“¡‡¢â¡¢âπÕÕ°´‘‡®π„π‡≈◊Õ¥
¡“°°«à“√âÕ¬≈– 94 ¢÷Èπ‰ª °√≥’°“√§≈Õ¥∑’ËμâÕß„™â°“√√–ß—∫§«“¡√Ÿâ ÷° °“√„™â
regional anesthesia ¥’°«à“°“√„™â general anesthesia à«πÀ≈—ß§≈Õ¥ “¡“√∂
40
„™â¬“√—°…“‚√§À◊¥‰¥â∑°ÿ ™π‘¥·≈–·π–π”„Àâπ¡∫ÿμ√‰¥âμ“¡ª°μ‘69 (πÈ”Àπ—°§”·π–π”
+, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3)
Aspirin-exacerbated respiratory disease (AERD)

¿“«– AERD ¡—°®–‡√‘Ë¡æ∫„πºŸâ „À≠à∑’ËÕ“¬ÿ‡©≈’Ë¬ª√–¡“≥ 30 ªï¢÷Èπ‰ª70
‚¥¬‡√‘¡Ë ®“°Õ“°“√À«—¥μ‘¥‡™◊ÕÈ ‰«√— ·≈â«‡°‘¥Õ“°“√‡¬◊ÕË ∫ÿ®¡Ÿ°Õ—°‡ ∫ πÈ”¡Ÿ°‰À≈·≈–
§—¥®¡Ÿ°‡√◊ÈÕ√—ßμ“¡¡“∑’Ë√—°…“§àÕπ¢â“ß¬“°®π‡°‘¥‡ªìπ‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß ®¡Ÿ°‰¡à ‰¥â
°≈‘πË (anosmia) ·≈–√‘¥ ’¥«ß®¡Ÿ° (nasal polyposis) Õ“°“√¢Õß‚√§À◊¥·≈–¿“«–
hypersensitivity μàÕ aspirin (ASA) ¡—°æ∫μ“¡À≈—ßÕ“°“√‡¬◊ÕË ∫ÿ®¡Ÿ°Õ—°‡ ∫ª√–¡“≥
1-5 ªï71
°“√√—°…“∑”‰¥â ‚¥¬ ·π–π”„ÀâÀ≈’°‡≈’Ë¬ß¬“ aspirin À“°¡’§«“¡®”‡ªìπ„π
°“√„™â¬“„π°≈ÿà¡π’È ·π–π”„Àâ „™â¬“°≈ÿà¡ COX-2 inhibitor ∑¥·∑π ¬“À≈—°∑’Ë„™â
§«∫§ÿ¡Õ“°“√¢Õß‚√§À◊¥„πºŸªâ «É ¬ AERD ‰¥â·°à ¬“§Õ√åμ‚‘ μ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥
à«π¬“μâ“π≈‘«‚§‰μ√Õ’π ‡™àπ montelukast “¡“√∂„™â‡ªìπ¬“‡ √‘¡„π°“√§«∫§ÿ¡
Õ“°“√¢Õß‚√§À◊¥„πºŸâªÉ«¬ AERD ‰¥â‡™àπ°—π72,73 (πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æ
À≈—°∞“π√–¥—∫ 1) ¬°‡«âπºŸâªÉ«¬∑’Ë¡’Õ“°“√¢Õß‚√§À◊¥√ÿπ·√ßÕ“®æ‘®“√≥“„™â¬“
§Õ√åμ‚‘ § ‡μ’¬√Õ¬¥å™π‘¥√—∫ª√–∑“π‡æ◊ÕË §«∫§ÿ¡Õ“°“√ °“√√—°…“¥â«¬«‘∏’ desensi-
tization μàÕ¬“°≈ÿà¡ aspirin ®”‡ªìπμâÕß∑”„π‚√ßæ¬“∫“≈¿“¬„μâ°“√¥Ÿ·≈¢Õß
·æ∑¬å‡©æ“–∑“ß‡ ¡Õ74 (πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3) ”À√—∫
¢âÕÀâ“¡„π°“√∑” desensitization ‰¥â·°à °“√μ—Èß§√√¿å ºŸâªÉ«¬∑’ËÕ“°“√¢Õß‚√§À◊¥
¬—ß‰¡à§ß∑’Ë ºŸâªÉ«¬∑’Ë¡’·º≈„π°√–‡æ“–Õ“À“√ À√◊Õ¡’ªí≠À“„π°“√·¢Áßμ—«¢Õß‡≈◊Õ¥75
°“√¥Ÿ·≈ºŸâªÉ«¬‚√§À◊¥∑’ËμâÕß‡¢â“√—∫°“√ºà“μ—¥
(Asthma and surgery)
°àÕπ°“√ºà“μ—¥ºŸâªÉ«¬‚√§À◊¥∑ÿ°√“¬§«√‰¥â√—∫°“√ª√–‡¡‘π√–¥—∫°“√§«∫§ÿ¡
¢Õß‚√§À◊¥76 (πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3) ª√–«—μ‘§«“¡∂’Ë
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 41

¢Õß¿“«–À◊¥°”‡√‘∫‡©’¬∫æ≈—π √–¥—∫§«“¡√ÿπ·√ß¢ÕßÀ◊¥°”‡√‘∫‡©’¬∫æ≈—π„π·μà≈–
§√—Èß77 ®”π«π·≈–™π‘¥¢Õß¬“∑’Ë „™â§«∫§ÿ¡‚√§À◊¥„πªí®®ÿ∫—π °“√μ‘¥‡™◊ÈÕ„π√–∫∫
∑“ß‡¥‘πÀ“¬„®78 ·≈–§à“ ¡√√∂¿“æªÕ¥ ‚¥¬§à“ FEV1 §«√¡“°°«à“√âÕ¬≈– 80
¢Õß§à“∑’Ë¥’∑’Ë ÿ¥¢ÕßºŸâªÉ«¬ ´÷ËßÀ“°Õ¬Ÿà „π‡°≥±åª°μ‘ ¡—°®–‰¡à¡’ªí®®—¬‡ ’Ë¬ß„π°“√‡°‘¥
¿“«–·∑√°´âÕπ∑—Èß„π√–À«à“ß·≈–À≈—ßºà“μ—¥79 √«¡∂÷ß§«√æ‘®“√≥“∂÷ß«‘∏’°“√
¥¡¬“ ≈∫·≈–™π‘¥¢Õß°“√ºà“μ—¥¥â«¬ ‚¥¬æ∫«à“°“√¥¡¬“ ≈∫‚¥¬°“√„ à∑àÕ™à«¬
À“¬„® §«“¡°—ß«≈À√◊Õ§«“¡‡®Á∫ª«¥√–À«à“ß°“√„Àâ¬“™“‡©æ“–∑’Ë ·≈–°“√ºà“μ—¥
∑’‡Ë °’¬Ë «¢âÕß°—∫À≈Õ¥≈¡ ™àÕß∑√«ßÕ° À√◊Õ™àÕß∑âÕß à«π∫π ‡ªìπªí®®—¬‡ ’¬Ë ß∑’ Ë “¡“√∂
°√–μÿâπ„ÀâÀ≈Õ¥≈¡μ’∫‰¥â79
°àÕπ°“√ºà“μ—¥§«√·π–π”„ÀâºŸâªÉ«¬ß¥ Ÿ∫∫ÿÀ√’ËÕ¬à“ßπâÕ¬ 2 ‡¥◊Õπ76 (πÈ”Àπ—°
§”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3) ·≈–§à“ ¡√√∂¿“æªÕ¥§«√¡’§à“ª°μ‘
À“°§à“ ¡√√∂¿“æªÕ¥μË”°«à“ª°μ‘ æ‘®“√≥“„Àâ√—∫ª√–∑“π¬“ prednisolone
1 ¡°./°°./«—π Ÿß ÿ¥‰¡à‡°‘π 40 ¡°. π“π 5 «—π °àÕπ°“√ºà“μ—¥ ‡æ◊ËÕ≈¥¿“«–
À≈Õ¥≈¡μ’∫√–À«à“ß°“√ºà“μ—¥80 (πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3)
¬°‡«âπÀ“°¡’‡«≈“‡μ√’¬¡μ—«°àÕπºà“μ—¥πâÕ¬°«à“ 5 «—π „Àâæ‘®“√≥“„™â¬“©’¥§Õ√åμ‘‚§
‡μ’¬√Õ¬¥å·∑π79 √à«¡°—∫„Àâ¬“¢¬“¬À≈Õ¥≈¡™π‘¥æàπ Ÿ¥ÕÕ°ƒ∑∏‘Ï‡√Á«°àÕπ°“√
ºà“μ—¥79 (πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3) À“°‡°‘¥¿“«–À≈Õ¥≈¡
μ’∫¢÷Èπ√–À«à“ß°“√ºà“μ—¥ „Àâ „™â¬“¢¬“¬À≈Õ¥≈¡™π‘¥æàπ Ÿ¥ÕÕ°ƒ∑∏‘Ï‡√Á« ‡™àπ
salbutamol81 √à«¡°—∫°“√„Àâ¬“©’¥§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å¢π“¥ Ÿß ‡™àπ methylpred-
nisolone 125 ¡°. ‡¢â“∑“ßÀ≈Õ¥‡≈◊Õ¥79 À√◊Õ‡∑’¬∫‡∑à“ ·μàÀ“°Õ“°“√À≈Õ¥≈¡
μ’∫¬—ß‰¡à¥’¢÷Èπ„Àâæ‘®“√≥“„™â¬“¥—ßμàÕ‰ªπ’Èμ“¡≈”¥—∫ ‰¥â·°à epinephrine ¢π“¥
0.5-2 ¡§°./π“∑’ À¬¥‡¢â“∑“ßÀ≈Õ¥‡≈◊Õ¥À√◊Õ magnesium sulfate ‡¢â“∑“ß
À≈Õ¥‡≈◊Õ¥79 (πÈ”Àπ—° §”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3) πÕ°®“°π’È
ºŸâªÉ«¬∑’Ë‡§¬‰¥â√—∫§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥æàπ Ÿ¥¢π“¥ Ÿß‡ªìπ√–¬–‡«≈“π“π À√◊Õ
‰¥â√—∫¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å ™π‘¥√—∫ª√–∑“ππ“π¡“°°«à“ 2 —ª¥“Àå„π™à«ß√–¬–
42
‡«≈“ 6 ‡¥◊Õπ∑’Ëºà“π¡“ §«√‰¥â√—∫¬“©’¥ hydrocortisone ¢π“¥ 2 ¡°./°°./§√—Èß
À√◊Õ 100 ¡°. ∑ÿ° 8 ™—Ë«‚¡ß‡¢â“∑“ßÀ≈Õ¥‡≈◊Õ¥√–À«à“ßºà“μ—¥ ‡π◊ËÕß®“°¡’§«“¡
‡ ’¬Ë ßμàÕ°“√‡°‘¥ adrenal crisis82,83 (πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫
2)
°≈ÿà¡Õ“°“√√à«¡√–À«à“ß‚√§À◊¥·≈–‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß
(Asthma-COPD overlap syndrome or ACOS)
„π∑“ßªØ‘∫—μ‘æ∫«à“ºŸâªÉ«¬ à«πÀπ÷Ëß¡’≈—°…≥–°“√¥”‡π‘π‚√§∑—Èß ÕßÕ¬à“ß
√–À«à“ß‚√§À◊¥·≈–‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß√à«¡°—π∑’Ë‡√’¬°«à“ Asthma-COPD over-
lap syndrome À√◊Õ ACOS °“√»÷°…“„πμà“ßª√–‡∑»æ∫√âÕ¬≈– 15-5084 ¢Õß
ºŸâªÉ«¬‚√§À≈Õ¥≈¡∑—ÈßÀ¡¥∑’Ë¡“√—°…“„π·ºπ°ºŸâªÉ«¬πÕ° ¬—ß‰¡à¡’°“√»÷°…“∑’Ë‡ªìπ
√–∫∫°—∫ ACOS „πª√–‡∑»‰∑¬ °“√«‘π‘®©—¬ ACOS Õ“»—¬≈—°…≥–∑“ß§≈‘π‘°
¢ÕßºŸâªÉ«¬‡π◊ËÕß®“°¬—ß‰¡à¡’‡°≥±åÀ√◊Õ·π«∑“ß„π°“√«‘π‘®©—¬∑’Ë™—¥‡®π ≈—°…≥–∑“ß
§≈‘π‘°¢Õß ACOS π—Èπ¡—°æ∫„πºŸâªÉ«¬ 2 °≈ÿà¡§◊Õ °≈ÿà¡∑’Ë¡’ª√–«—μ‘‚√§À◊¥„π«—¬‡¥Á°
·≈–¡’ª√–«—μ‘ Ÿ∫∫ÿÀ√’Ë À√◊Õ¡’°“√μ’∫¢ÕßÀ≈Õ¥≈¡®“°°“√∑¥ Õ∫ ¡√√∂¿“æªÕ¥
∑’Ë ‰¡àμÕ∫ πÕßμàÕ¬“¢¬“¬À≈Õ¥≈¡™π‘¥æàπ Ÿ¥ÕÕ°ƒ∑∏‘Ï‡√Á« ·≈–ºŸâªÉ«¬ªÕ¥Õÿ¥°—Èπ
‡√◊ÈÕ√—ß∑’Ëæ∫«à“¡’°“√Õ—°‡ ∫¢ÕßÀ≈Õ¥≈¡·≈–°√–· ‡≈◊Õ¥®“°‡¡Á¥‡≈◊Õ¥¢“«™π‘¥
Õ’ ‚Õ´‘‚πøî≈ (airway or systemic eosinophilia) À√◊Õ¡’º≈°“√μ√«® ¡√√∂¿“æ
ªÕ¥∑’ËμÕ∫ πÕßμàÕ¬“¢¬“¬À≈Õ¥≈¡™π‘¥æàπ Ÿ¥ÕÕ°ƒ∑∏‘Ï‡√Á«Õ¬à“ß¡“°85
Õ¬à“ß‰√°Áμ“¡ ¬—ß‰¡à¡‡’ °≥±åÀ√◊Õ·π«∑“ß°“√«‘π®‘ ©—¬∑’‡Ë ªìπ¡“μ√∞“π„πªí®®ÿ∫π—
°“√√—°…“ ACOS π—Èπ¬—ß‰¡à¡’·π«∑“ß¡“μ√∞“π Õ“®æ‘®“√≥“„™â¬“§Õ√åμ‘‚§ ‡μ’¬-
√Õ¬¥å™π‘¥æàπ Ÿ¥º ¡°—∫¬“¢¬“¬À≈Õ¥≈¡æàπ Ÿ¥™π‘¥ÕÕ°ƒ∑∏‘Ï¬“« (ICS/LABA)
·≈–/À√◊Õ √à«¡°—∫¬“μâ“πμ—«√—∫‚§≈‘π‡πÕ√å®‘° (long-acting anticholinergic) ´÷Ëß
μâÕß¡’°“√»÷°…“«‘®—¬μàÕ‰ª ∑—Èß„π·ßà°“√¥”‡π‘π‚√§·≈–°“√√—°…“‚√§ ”À√—∫ºŸâªÉ«¬
°≈ÿà¡Õ“°“√∑’Ëæ∫√à«¡√–À«à“ß‚√§À◊¥·≈–‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß1,85
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 43

¿“§ºπ«°∑’Ë 1
°“√«—¥§à“ PEF variability
°“√«—¥§à“ PEF ·π–π”„Àâ«—¥°àÕπ°“√„™â¬“¢¬“¬À≈Õ¥≈¡™π‘¥æàπ Ÿ¥ÕÕ°
ƒ∑∏‘Ï‡√Á« (pre-bronchodilator PEF) ‚¥¬°“√«—¥ peak flow variability §◊Õ °“√
«—¥ à«πμà“ß¢Õß§à“ PEF Ÿß ÿ¥°—∫§à“μË” ÿ¥ À“√¥â«¬§à“‡©≈’Ë¬¢Õß§à“ Ÿß ÿ¥°—∫μË” ÿ¥
·μà≈–«—π„π 1 —ª¥“Àå ‡°≥±å∑’Ë™à«¬„π°“√«‘π‘®©—¬‚√§À◊¥ §◊Õ§à“ PEF variability
¡“°°«à“√âÕ¬≈– 1086,87 (¥—ß√Ÿª∑’Ë 4)
average [PEFRhighest › PEFRlowest]

PEF variability =
[PEFRhighest + PEFRlowest]/2
§à“ Ÿß ÿ¥
§à“μË” ÿ¥
√Ÿª∑’Ë 4 «‘∏’°“√«—¥§à“ PEF variability
44
¿“§ºπ«°∑’Ë 2
·∫∫ª√–‡¡‘πº≈°“√§«∫§ÿ¡‚√§À◊¥ Asthma Control Question-

naire (ACQ) ·≈– Asthma Control test (ACT)
·∫∫∑¥ Õ∫∑’Ë¡’°“√π”¡“„™â ‰¥â·°à ·∫∫ Õ∫∂“¡‡√◊ËÕß°“√§«∫§ÿ¡‚√§
ÀÕ∫À◊¥ (Asthma Control Test, ACT) ª√–°Õ∫‰ª¥â«¬§”∂“¡ 5 ¢âÕ „π°“√
ª√–‡¡‘πÕ“°“√¢Õß‚√§À◊¥„π√Õ∫ 4 —ª¥“Àå∑’Ëºà“π¡“ §–·ππ‡μÁ¡ 25 §–·ππ §à“
§–·ππ∑’Ë Ÿß∫àß∫Õ°«à“§ÿ¡‚√§À◊¥‰¥â¥’ §à“§–·ππ∑’ËμË”°«à“ 20 ∫àß™’È«à“§ÿ¡‚√§‰¡à ‰¥â
Siriraj Asthma Control Questionnaire ´÷ß°“√·ª≈º≈ §◊Õ ∂â“§–·ππ√«¡¢âÕ 1
∂÷ß ¢âÕ 5 ‡©≈’Ë¬ < 1.5 ∂◊Õ«à“‚√§À◊¥§«∫§ÿ¡‰¥â ·≈– >/= ∂◊Õ«à“‚√§À◊¥§«∫§ÿ¡‰¡à ‰¥â
(„ àμ“√“ß¢Õß siriraj Àπâ“ 73 ¢Õß‡≈à¡‡¢’¬«) ·≈– Asthma Control Question-
naire (ACQ)
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 45

Siriraj Asthma Control Questionnaire88
§”∂“¡ μ—«‡≈◊Õ°
1. „π™à«ß 1 —ª¥“Àå∑’Ëºà“π¡“ ∑à“πμâÕßμ◊Ëπ 0 ‰¡à¡’‡≈¬
°≈“ß¥÷° ‡π◊ÕË ß®“°Õ“°“√‚√§À◊¥∫àÕ¬·§à 1 π“π Ê §√—Èß (‰¡à‡°‘π 2 «—π)
‰Àπ ? 2 ∫àÕ¬ (¡“°°«à“ 2 «—π)
3 ∑ÿ°«—π
2. „π™à«ß 1 —ª¥“Àå∑’Ëºà“π¡“Õ“°“√¢Õß 0 ‰¡à¡’‡≈¬
‚√§À◊¥¡’º≈®”°—¥°‘®°√√¡¢Õß∑à“π·§à 1 ‡≈Á°πâÕ¬
‰Àπ ? 2 ª“π°≈“ß
3 ¡“°
3. „π™à«ß 1 —ª¥“Àå∑’Ëºà“π¡“∑à“π¡’Õ“°“√ 0 ‰¡à¡’‡≈¬
‡Àπ◊ËÕ¬μÕπ°≈“ß«—π ¡“°πâÕ¬·§à ‰Àπ ? 1 ‡≈Á°πâÕ¬ (1-2 §√—Èß/ —ª¥“Àå)
2 ª“π°≈“ß (3-5 §√—Èß/ —ª¥“Àå)
3 ¡“° (> 6 §√—Èß/ —ª¥“Àå)
4. „π™à«ß 1 —ª¥“Àå∑’Ëºà“π¡“∑à“π¡’Õ“°“√ 0 ‰¡à¡’‡≈¬
À“¬„®¥—ßÀ«’¥ ‡ªìπ‡«≈“π“π‡∑à“„¥ ? 1 ¡’‡≈Á°πâÕ¬
2 ª“π°≈“ß
3 ‡ªìπ à«π„À≠à
5. „π™à«ß 1 —ª¥“Àå∑’Ëºà“π¡“ ∑à“πμâÕß 0 ‰¡à ‰¥â „™â‡≈¬
„™â¬“æàπ Ÿ¥¢¬“¬À≈Õ¥≈¡ ‡©≈’Ë¬°’Ë§√—Èß 1 1-2 §√—Èß
μàÕ«—π ? 2 3-8 §√—Èß
3 > 8 §√—Èß
°“√·ª≈º≈§◊Õ∂â“§–·ππ√«¡¢âÕ 1 ∂÷ß ¢âÕ 5 ‡©≈’Ë¬
> 1.5 ∂◊Õ«à“ ‚√§À◊¥§«∫§ÿ¡‰¡à ‰¥â
< 1.5 ∂◊Õ«à“ ‚√§À◊¥§«∫§ÿ¡‰¥â
46
·∫∫ª√–‡¡‘π°“√§«∫§ÿ¡‚√§À◊¥ (ACT Score)
§”∂“¡¡’∑ß—È À¡¥ 5 ¢âÕ °√ÿ≥“μÕ∫§”∂“¡·μà≈–¢âÕ‚¥¬«ß°≈¡μ—«‡≈¢§”μÕ∫
∑’Ëμ√ß°—∫§«“¡‡ªìπ®√‘ß∑’Ë ÿ¥‡æ’¬ß§”μÕ∫‡¥’¬«
§”∂“¡ 1 „π™à«ß 4 —ª¥“Àå∑’Ëºà“π¡“ ∫àÕ¬·§à ‰Àπ∑’Ë ‚√§À◊¥∑”„Àâ§ÿ≥‰¡à “¡“√∂

∑”ß“π∑’Ë‡§¬∑”‰¥â ‰¡à«à“®–‡ªìπß“π∑’Ë∑”ß“π ∑’Ë ‚√ß‡√’¬π À√◊Õ∑’Ë∫â“π
§–·ππ
§”∂“¡ 2 „π™à«ß 4 —ª¥“Àå∑’Ëºà“π¡“ ∫àÕ¬·§à ‰Àπ∑’Ë§ÿ≥√Ÿâ ÷°À“¬„®‰¡àÕ‘Ë¡

§–·ππ
§”∂“¡ 3 „π™à«ß 4 —ª¥“Àå∑º’Ë “à π¡“ ∫àÕ¬·§à‰Àπ∑’§Ë ≥

ÿ ¡’Õ“°“√¢Õß‚√§À◊¥ (À“¬„®
¡’‡ ’¬ß«’¥È Ê ‰Õ À“¬„®‰¡àÕ¡‘Ë ·πàπÀπâ“Õ°À√◊Õ‡®Á∫Àπâ“Õ°) ®π∑”„ÀâμÕâ ß
μ◊Ëπ¢÷Èπ°≈“ß¥÷° À√◊Õμ◊Ëπ‡™â“°«à“ª°μ‘
§–·ππ
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 47

§”∂“¡ 4 „π™à«ß 4 —ª¥“Àå∑’Ëºà“π¡“ §ÿ≥μâÕß„™â¬“¢¬“¬À≈Õ¥≈¡™π‘¥æàπ Ÿ¥
ÕÕ°ƒ∑∏‘Ï‡√Á« À√◊Õ¬“‡¡Á¥¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï‡√Á«∫àÕ¬·§à ‰Àπ
‡æ◊ËÕ™à«¬„Àâ§ÿ≥À“¬„®‰¥â¥’¢÷Èπ
§–·ππ
§”∂“¡ 5 „π™à«ß 4 —ª¥“Àå∑’Ëºà“π¡“ §ÿ≥§‘¥«à“§ÿ≥ “¡“√∂§«∫§ÿ¡‚√§À◊¥¢Õß

§ÿ≥‰¥â¥’¡“°πâÕ¬·§à ‰Àπ
§–·ππ
§–·ππ„π·μà≈–¢âÕ¡“∫«°°—π‡ªìπ§–·ππ√«¡ §–·ππ√«¡
48
¿“§ºπ«°∑’Ë 3
°“√√—°…“‚¥¬‰¡à„™â¬“ (Non-pharmacological Therapies)

ª√–°Õ∫¥â«¬ ¡“μ√°“√„π°“√‡≈’Ë¬ßªí®®—¬‡ ’Ë¬ß ‘Ëß°√–μÿâπμà“ß Ê ·≈–
¡≈¿“«–∑’ËÕ“®°àÕ„Àâ‡°‘¥°“√°”‡√‘∫¢Õß‚√§À◊¥À√◊Õ°√–∑∫μàÕ°“√§«∫§ÿ¡‚√§®÷ßπ—∫
«à“¡’§«“¡ ”§—≠‰¡àπâÕ¬‰ª°«à“°“√„™â¬“ ¡“μ√°“√‡À≈à“π’È· ¥ß„πμ“√“ß∑’Ë 6
μ“√“ß∑’Ë 6 Non-pharmacological therapies „π°“√√—°…“‚√§À◊¥

ªí®®—¬‡ ’Ë¬ßÀ√◊Õ°√–μÿâπ §”·π–π”
1. °“√ Ÿ∫∫ÿÀ√’Ë·≈–°“√ ºŸâªÉ«¬‚√§À◊¥∑ÿ°√“¬∑’Ë¬—ß§ß Ÿ∫∫ÿÀ√’ËμâÕß‰¥â√—∫°“√∫”∫—¥
‰¥â√—∫§«—π∫ÿÀ√’Ë¡◊Õ Õß ‡æ◊ËÕ‡≈‘° Ÿ∫∫ÿÀ√’Ë ‚¥¬‡√Á«∑’Ë ÿ¥
∑ÿ° Ê §√—Èß∑’ËºŸâªÉ«¬‡¢â“√—∫°“√μ√«®μ‘¥μ“¡Õ“°“√ §«√‰¥â
√—∫°“√∫”∫—¥„Àâ‡≈‘°∫ÿÀ√’Ë ‚¥¬„™â·π«∑“ß ´÷Ëßª√–°Õ∫¥â«¬
3 ¢—ÈπμÕπ88 ¥—ßπ’È (πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æ
À≈—°∞“π√–¥—∫ 4)
1) Õ∫∂“¡: ‚¥¬ Õ∫∂“¡ºŸâªÉ«¬ 3 §”∂“¡ ‰¥â·°à Ÿ∫
∫ÿÀ√’ËÀ√◊Õ‰¡à Ÿ∫«—π≈–°’Ë¡«π ·≈– Ÿ∫∫ÿÀ√’Ë¡«π·√°
À≈—ßμ◊ËππÕππ“π·§à ‰Àπ æ√âÕ¡∫—π∑÷°º≈
2) ∫”∫—¥: ‰¥â·°à °“√„Àâ§”·π–π”·∫∫ —Èπ Ê ‚¥¬·æ∑¬å
·≈–∫ÿ§≈“°√«‘™“™’æ ÿ¢¿“æÕ◊πË Ê ∑’ÕË ¬Ÿà„π§≈‘π°‘ π—πÈ Ê
à«π°“√„Àâ§”ª√÷°…“·∫∫√“¬μ—«„Àâ∑”‚¥¬∫ÿ§≈“°√„π
§≈‘π‘°π—Èπ Ê ∑’Ë¡’§«“¡‡™’Ë¬«™“≠ À√◊ÕºŸâ‡™’Ë¬«™“≠„π
§≈‘π‘°‡≈‘°∫ÿÀ√’Ë ‚¥¬‡©æ“–°“√∫”∫—¥·∫∫°≈ÿà¡
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 49

μ“√“ß∑’Ë 6 Non-pharmacological therapies „π°“√√—°…“‚√§À◊¥ (μàÕ)
ªí®®—¬‡ ’Ë¬ßÀ√◊Õ°√–μÿâπ §”·π–π”
1. °“√ Ÿ∫∫ÿÀ√’Ë·≈–°“√ 3) À¡—Ëπμ‘¥μ“¡: §«√μ‘¥μ“¡ºŸâªÉ«¬Õ¬à“ß„°≈â™‘¥ æ√âÕ¡„Àâ
‰¥â√—∫§«—π∫ÿÀ√’Ë¡◊Õ Õß °“√∫”∫—¥´È”Õ¬à“ßμàÕ‡π◊ËÕß·π–π”„ÀâºŸâªÉ«¬ß¥‡«âπ°“√
(μàÕ) —¡º— °—∫§«—π∫ÿÀ√’Ë¡◊Õ Õß ‚¥¬·π–π”„Àâ ¡“™‘°„π
§√Õ∫§√—«‡≈‘°∫ÿÀ√’Ë À√◊Õß¥ Ÿ∫∫ÿÀ√’Ë „ π∫â “ π·≈–„π
√∂¬πμå89
2. Exercise training ∑”‰¥âÀ≈“¬·∫∫ ‡™àπ «à“¬πÈ” «‘Ëß≈Ÿà ªíòπ®—°√¬“π À√◊Õ‰∑™‘
™’°Ë ß ¡’À≈—°∞“π«à“™à«¬„ÀâºªŸâ «É ¬ “¡“√∂§«∫§ÿ¡‚√§À◊¥‰¥â¥’
¢÷Èπ §«“¡ “¡“√∂„π°“√ÕÕ°°”≈—ß°“¬ Ÿß ÿ¥ ·≈–§«“¡
∑π∑“π„π°“√ÕÕ°°”≈—ß°“¬¥’¢÷Èπ ¡√√∂¿“æªÕ¥¥’¢÷Èπ
Õ“°“√ÀÕ∫‡Àπ◊ËÕ¬≈¥≈ß §ÿ≥¿“æ™’«‘μ¥’¢÷Èπ °“√æ÷Ëßæ“
∫√‘°“√ “∏“√≥ ÿ¢ ‡™àπ °“√√—°…“À◊¥°”‡√‘∫ °“√„™â¬“
ªØ‘™’«π– °“√„™â¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥√—∫ª√–∑“π
·≈–°“√¡“ÀâÕß©ÿ°‡©‘π≈¥≈ß90-94 ·π–π”„Àâ∑”‚¥¬‡©æ“–
ºŸâªÉ«¬‚√§À◊¥√ÿπ·√ß·≈–§«∫§ÿ¡¬“°§«√‰¥â√—∫ exercise
training ∑’Ë‡À¡“– ¡Õ¬à“ßπâÕ¬ 5-7 §√—ÈßμàÕ —ª¥“Àå §√—Èß
≈– 20-30 π“∑’ μàÕ‡π◊ËÕß 6-8 —ª¥“Àå¢÷Èπ‰ª (πÈ”Àπ—°
§”·π–π” +, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3)
3. °“√Ωñ°À“¬„® Õ“»—¬À≈—°°“√ ‰¥â·°à °“√≈¥Õ—μ√“°“√À“¬„® °“√≈¥
(Breathing exercise) ª√‘¡“μ√¢Õß°“√À“¬„®·μà≈–§√—Èß ‡æ‘Ë¡°“√„™â°≈â“¡‡π◊ÈÕ
Àπâ“∑âÕß·≈–°≈â“¡‡π◊ÈÕ¥â“π¢â“ß∑√«ßÕ° „™â®¡Ÿ°„π°“√
À“¬„® ºàÕπ§≈“¬ ®“°°“√»÷°…“æ∫«à“ “¡“√∂≈¥Õ“°“√
ÀÕ∫‡Àπ◊ËÕ¬ ™à«¬„Àâ§ÿ≥¿“æ™’«‘μ¥’¢÷Èπ Õ’°∑—Èß™à«¬„ÀâºàÕπ
§≈“¬®“°§«“¡‡§√’¬¥∑“ßÕ“√¡≥å ‰¥âÕ’°¥â«¬95,96 ·π–π”
„Àâ∑”‚¥¬‡©æ“–„π√“¬∑’Ë¬—ß§ß¡’Õ“°“√ÀÕ∫‡Àπ◊ËÕ¬À√◊Õ
¡’§ÿ≥¿“æ™’«‘μ∑’Ë ‰¡à¥’ §«√‰¥â√—∫°“√Ωñ°À“¬„® (πÈ”Àπ—°
§”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 4)
50
ªí®®—¬‡ ’Ë¬ßÀ√◊Õ°√–μÿâπ §”·π–π”
4. °“√§«∫§ÿ¡ ¿“æ ·π–π”„Àâª√—∫·≈–§«∫§ÿ¡ ¿“æ·«¥≈âÕ¡∑—Èß∑’Ë∫â“π·≈–
·«¥≈âÕ¡∑—Èß¿“¬„π ∑’Ë∑”ß“π ‡æ◊ËÕ≈¥ªí®®—¬°√–μÿâπ¢Õß‚√§À◊¥ ‡™àπ ®—¥√–∫∫
·≈–¿“¬πÕ° ·≈– ∂à“¬‡∑Õ“°“»∑’Ë¥’ ®—¥„Àâ¡’· ß·¥¥ àÕß‰¥âÕ¬à“ß∑—Ë«∂÷ß
ªí®®—¬‡ ’Ë¬ßμà“ßÊ À≈’°‡≈’Ë¬ß°“√„™âæ√¡À√◊Õπÿàπ À≈’°‡≈’Ë¬ß°“√„™â¬“¶à“·¡≈ß
À≈’°‡≈’Ë¬ß§«—π∏Ÿª ·≈–®”°—¥∫√‘‡«≥¢Õß —μ«å‡≈’È¬ß‰«â
¿“¬πÕ°∫â“π ‡ªìπμâπ (πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æ
À≈—°∞“π√–¥—∫ 4)
·π–π”„Àâ´—°ª√–«—μ‘°“√∑”ß“π·≈–Õ“™’æ„πºŸâªÉ«¬∑’Ë‡√‘Ë¡¡’
Õ“°“√„π«—¬ºŸâ „À≠à∑°ÿ √“¬ À“°æ∫μâπ‡Àμÿ∑™’Ë ¥— ‡®π ·π–π”
„ÀâºŸâªÉ«¬À≈’°‡≈’Ë¬ß°“√ —¡º— °—∫ ‘Ëß°√–μÿâπ∑’Ë‡ªìπμâπ‡Àμÿ97
(πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 4)
°“√≈¥ª√‘¡“≥‰√ΩÿÉπ ‡™àπ °“√„™â‡§√◊ËÕßøÕ°Õ“°“»·≈–
°“√„™â‡§√◊ËÕßπÕπªÑÕß°—π‰√ΩÿÉπ ¬—ß‰¡à¡’À≈—°∞“π¬◊π¬—π
∂÷ßª√– ‘∑∏‘º≈¢Õß¡“μ√°“√‡À≈à“π’98È (πÈ”Àπ—°§”·π–π”
+/-, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1)
À≈’°‡≈’¬Ë ß°“√„™â¬“°≈ÿ¡à NSAIDs ·≈– beta-blockers „π
ºŸªâ «É ¬‚√§À◊¥ ·μàÀ“°®”‡ªìπμâÕß„™â „Àâæ®‘ “√≥“‡ª√’¬∫‡∑’¬∫
¢âÕ¥’·≈–¢âÕ‡ ’¬‡ªìπ√“¬ Ê ‰ª æ√âÕ¡∑—Èßπ—¥μ√«®μ‘¥μ“¡
Õ“°“√Õ¬à“ß„°≈â™‘¥99,100 (πÈ”Àπ—°§”·π–π” +, §ÿ≥¿“æ
À≈—°∞“π√–¥—∫ 2)
5. °“√≈¥πÈ”Àπ—° À“° “¡“√∂≈¥πÈ”Àπ—°≈ß‰¥â‡°‘π√âÕ¬≈– 10 ®“°‡¥‘¡101
®–™à«¬„Àâ§«∫§ÿ¡‚√§À◊¥‰¥â¥’¢÷Èπ ·≈– ¡√√∂¿“æªÕ¥¥’
¢÷Èπ ·π–π”„ÀâºŸâªÉ«¬≈¥πÈ”Àπ—° ‚¥¬®—¥„Àâ¡’ ‚ª√·°√¡≈¥
πÈ”Àπ—°∑’Ë‡ªìπ√Ÿª∏√√¡‚¥¬ À “¢“«‘™“™’æ (πÈ”Àπ—°§”
·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 2)
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 51

ªí®®—¬‡ ’Ë¬ßÀ√◊Õ°√–μÿâπ §”·π–π”
6. °“√©’¥«—§´’π ·π–π”„Àâ©’¥«—§´’πªÑÕß°—π‚√§‰¢âÀ«—¥„À≠àªï≈– 1 §√—Èß „π
ºŸâ ªÉ « ¬‚√§À◊ ¥ ‡©æ“–°≈ÿà ¡ ‚√§À◊ ¥ √ÿ π ·√ßª“π°≈“ß·≈–
√ÿπ·√ß¡“°102 à«π pneumococcal vaccine π—Èπ¬—ß‰¡à¡’
À≈—°∞“π∑’™Ë ¥— ‡®π (πÈ”Àπ—°§”·π–π” +, §ÿ≥¿“æÀ≈—°∞“π
√–¥—∫ 4)
7. §«“¡‡§√’¬¥∑“ß °“√»÷°…“æ∫«à“Õÿ∫—μ‘°“√≥å¢Õß‚√§´÷¡‡»√â“„πºŸâªÉ«¬‚√§
Õ“√¡≥å·≈–®‘μ„® À◊¥ Ÿß°«à“„π§π∑—Ë«‰ª103 ´÷Ëß àßº≈μàÕ°“√§«∫§ÿ¡‚√§À◊¥
·π–π”„Àâ§—¥°√ÕßºŸâªÉ«¬∑’Ë¡’Õ“°“√´÷¡‡»√â“À√◊Õ¡’§«“¡
°—ß«≈¡“°μàÕ‚√§À◊¥∑’Ë‡ªìπÕ¬Ÿà ‡æ◊ËÕ„Àâ§”·π–π”·≈–¥Ÿ·≈
ÿ¢¿“æ∑“ß®‘μ„®Õ¬à“ß‡À¡“– ¡ (πÈ”Àπ—°§”·π–π” +,
§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 4)
52
¿“§ºπ«°∑’Ë 4
¢—ÈπμÕπ°“√æ‘®“√≥“ºŸâªÉ«¬‚√§À◊¥∑’Ë§«√√—°…“¥â«¬¬“ anti-IgE
(omalizumab)
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 53

¿“§ºπ«°∑’Ë 5
·ºπªØ‘∫—μ‘μ—«‡¡◊ËÕ¡’Õ“°“√À◊¥°”‡√‘∫ (Asthma action plan)
“¡“√∂»÷°…“‰¥â®“°·Õææ≈‘‡§™—Ëπ∫π¡◊Õ∂◊Õ‚¥¬æ‘¡æå§”«à“ asthma care
´÷Ëßæ—≤π“‚¥¬∑’¡·æ∑¬å·≈–«‘»«°√®“°¡À“«‘∑¬“≈—¬∏√√¡»“ μ√å ´÷ËßπÕ°®“°®–¡’
·ºπªØ‘∫—μ‘°“√‡¡◊ËÕ¡’Õ“°“√À◊¥°”‡√‘∫·≈â« ¬—ß¡’‡π◊ÈÕÀ“‡°’Ë¬«°—∫§«“¡√Ÿâ‡√◊ËÕß‚√§À◊¥
°“√À≈’°‡≈’¬Ë ß ‘ßË °√–μÿπâ °“√„™â¬“æàπ Ÿ¥ °“√ª√–‡¡‘π√–¥—∫°“√§«∫§ÿ¡‚√§ °“√‡μ◊Õπ
°“√æàπ¬“·≈–‡«≈“π—¥æ∫·æ∑¬å ´÷ËßºŸâ π„® “¡“√∂¥“«πå‚À≈¥·Õææ≈‘‡§™—Ëππ’È ‰¥â
çø√’é
μ—«Õ¬à“ß·ºπ°“√ªØ‘∫—μ‘μπ‡∫◊ÈÕßμâπ‡æ◊ËÕ§«∫§ÿ¡Õ“°“√¢Õß‚√§À◊¥
(Action Plan)
1. ’‡¢’¬« „ÀâºªŸâ «É ¬„™â¬“‡À¡◊Õπ‡¥‘¡μ“¡ª°μ‘
2. ’ ‡ À≈◊ Õ ß ·π–π”„ÀâºŸâªÉ«¬„™â¬“¢¬“¬
√Õ√Ÿª À≈Õ¥≈¡æàπ Ÿ¥™π‘¥ÕÕ°ƒ∑∏‘Ï‡√Á« (β2-agonist)
4 puffs μ‘¥μàÕ°—π 3 §√—Èß ∑ÿ° 15-20 π“∑’ μ‘¥μàÕ
°—π 3 §√—Èß À“°‰¡à¥’¢÷Èπ„Àâ√’∫‰ªæ∫·æ∑¬å∑—π∑’
∂â“¥’¢÷Èπ„Àâæàπ¬“∑ÿ° 4-6 ™—Ë«‚¡ßμàÕ‰ªÕ’° 2 «—π
3. ’·¥ß ·π–π”„Àâ ‰ª‚√ßæ¬“∫“≈∑—π∑’
·≈–æàπ β2-agonist ∑ÿ° 15 π“∑’®π°«à“®–∂÷ß
‚√ßæ¬“∫“≈
* √“¬≈–‡Õ’¬¥°“√∑”·ºπ°“√ªØ‘∫μ— μ‘ π‡∫◊ÕÈ ßμâπ‡æ◊ÕË §«∫§ÿ¡Õ“°“√¢Õß‚√§À◊¥ (Action Plan) ·æ∑¬åº¥Ÿâ ·Ÿ ≈

§«√æ‘®“√≥“„Àâ§”·π–π”·°àºªŸâ «É ¬‡ªìπ°√≥’‰ª ¢÷πÈ Õ¬Ÿ°à ∫— §«“¡ “¡“√∂·≈–§«“¡‡¢â“„®¢Õß„π°“√¥Ÿ·≈ºŸªâ «É ¬
(πÈ”Àπ—°§”·π–π” ++, §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 4)
54
‡Õ° “√Õâ“ßÕ‘ß
1. GINA. Global strategy for asthma management and prevention 2014 [online]. Available
at: http://www.ginasthma.org/guidelines-gina-report-global-strategy-for-asthma.html.
Accessed June 2014.
2. Worldwide variations in the prevalence of asthma symptoms: the International Study
of Asthma and Allergies in Childhood (ISAAC). Eur Respir J 1998;12:315-35.
3. Hanania NA, Celli BR, Donohue JF, Martin UJ. Bronchodilator reversibility in COPD.
Chest 2011;140:1055-63.
4. Crapo RO, Casaburi R, Coates AL, Enright PL, Hankinson JL, Irvin CG, et al. Guide-
lines for methacholine and exercise challenge testing-1999. This official statement of
the American Thoracic Society was adopted by the ATS Board of Directors, July
1999. Am J Respir Crit Care Med 2000;161:309-29.
5. Nathan RA, Sorkness CA, Kosinski M, Schatz M, Li JT, Marcus P, et al. Development
of the asthma control test: a survey for assessing asthma control. J Allergy Clin
Immunol 2004;113:59-65.
6. Juniper EF, OûByrne PM, Guyatt GH, Ferrie PJ, King DR. Development and validation
of a questionnaire to measure asthma control. Eur Respir J 1999;14:902-7.
7. OûByrne PM, Bisgaard H, Godard PP, Pistolesi M, Palmqvist M, Zhu Y, et al.
Budesonide/formoterol combination therapy as both maintenance and reliever
medication in asthma. Am J Respir Crit Care Med 2005;171:129-36.
8. Rau JL. The inhalation of drugs: advantages and problems. Respir care 2005;50:
367-82.
9. Cazzola M, Page CP, Calzetta L, Matera MG. Pharmacology and therapeutics of
bronchodilators. Pharmacol Rev 2012;64:450-504.
10. Pauwels RA, Pedersen S, Busse WW, Tan WC, Chen YZ, Ohlsson SV, et al. Early
intervention with budesonide in mild persistent asthma: a randomised, double-blind
trial. Lancet 2003;361:1071-6.
11. Boulet LP, Cowie RL, Negro RD, Brett W, Gold M, Marques A, et al. Comparison of
once- with twice-daily dosing of fluticasone propionate in mild and moderate asthma.
Can Respir J 2000;7:239-47.
12. Busse WW, Pedersen S, Pauwels RA, Tan WC, Chen YZ, Lamm CJ, et al. The Inhaled
Steroid Treatment As Regular Therapy in Early Asthma (START) study 5-year follow-
up: effectiveness of early intervention with budesonide in mild persistent asthma.
J Allergy Clin Immunol 2008;121:1167-74.
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 55

13. Wilson AM, Dempsey OJ, Sims EJ, Lipworth BJ. A comparison of topical budesonide
and oral montelukast in seasonal allergic rhinitis and asthma. Clin Exp Allergy
2001;31:616-24.
14. Busse W, Raphael GD, Galant S, Kalberg C, Goode-Sellers S, Srebro S, et al. Low-
dose fluticasone propionate compared with montelukast for first-line treatment of
persistent asthma: a randomized clinical trial. J Allergy Clin Immunol 2001;107:461-8.
15. Dahl R, Larsen BB, Venge P. Effect of long-term treatment with inhaled budesonide
or theophylline on lung function, airway reactivity and asthma symptoms. Respir
Med 2002;96:432-8.
16. Yurdakul AS, Taci N, Eren A, Sipit T. Comparative efficacy of once-daily therapy with
inhaled corticosteroid, leukotriene antagonist or sustained-release theophylline in
patients with mild persistent asthma. Respir Med 2003;97:1313-9.
17. Bateman ED, Boushey HA, Bousquet J, Busse WW, Clark TJ, Pauwels RA, et al. Can
guideline-defined asthma control be achieved? The Gaining Optimal Asthma ControL
study. Am J Respir Crit Care Med 2004;170:836-44.
18. Bernstein DI, Hébert J, Cheema A, Murphy KR, Chérrez-Ojeda I, Matiz-Bueno CE, et
al. Efficacy and onset of action of mometasone furoate/formoterol and fluticasone
propionate/salmeterol combination treatment in subjects with persistent asthma.
Allergy Asthma Clin Immunol 2011;7:21.
19. Pauwels RA, Löfdahl CG, Postma DS, Tattersfield AE, OûByrne P, Barnes PJ, et al.
Effect of inhaled formoterol and budesonide on exacerbations of asthma. Formoterol
and Corticosteroids Establishing Therapy (FACET) International Study Group. N
Engl J Med 1997;337:1405-11.
20. Boonsawat W, Thinkhamrop B. Role of budesonide/formoterol maintenance and
reliever therapy: a pragmatic study. Asian Pac J Allergy Immunol 2014;32:160-5.
21. Kaplan A, Ryan D. The role of budesonide/formoterol for maintenance and relief in
the management of asthma. Pulm Pharmacol Ther 2010;23:88-96.
22. Papi A. Inhaled BDP/formoterol extra-fine combination. Evidence and future per-
spectives. Pneumologie 2009;63 Suppl 2:S102-6.
23. Papi A, Corradi M, Pigeon-Francisco C, Baronio R, Siergiejko Z, Petruzzelli S, et al.
Beclometasone-formoterol as maintenance and reliever treatment in patients with
asthma: a double-blind, randomised controlled trial. Lancet Respir Med 2013;1:23-31.
24. Patel M, Pilcher J, Pritchard A, Perrin K, Travers J, Shaw D, et al. Efficacy and safety
of maintenance and reliever combination budesonide-formoterol inhaler in patients
56
with asthma at risk of severe exacerbations: a randomised controlled trial. Lancet
Respir Med 2013;1(1):32-42.
25. Booth H, Richmond I, Ward C, Gardiner PV, Harkawat R, Walters EH. Effect of high
dose inhaled fluticasone propionate on airway inflammation in asthma. Am J Respir
Crit Care Med 1995;152:45-52.
26. Currie GP, Syme-Grant NJ, McFarlane LC, Carey FA, Lipworth BJ. Effects of low
dose fluticasone/salmeterol combination on surrogate inflammatory markers in
moderate persistent asthma. Allergy 2003;58:602-7.
27. Vaquerizo MJ, Casan P, Castillo J, Perpiña M, Sanchis J, Sobradillo V, et al. Effect of
montelukast added to inhaled budesonide on control of mild to moderate asthma.
Thorax 2003;58:204-10.
28. Evans DJ, Taylor DA, Zetterstrom O, Chung KF, OûConnor BJ, Barnes PJ. A compari-
son of low-dose inhaled budesonide plus theophylline and high-dose inhaled
budesonide for moderate asthma. N Engl J Med 1997;337:1412-8.
29. Bjermer L, Bisgaard H, Bousquet J, Fabbri LM, Greening AP, Haahtela T, et al.
Montelukast and fluticasone compared with salmeterol and fluticasone in protecting
against asthma exacerbation in adults: one year, double blind, randomised, com-
parative trial. BMJ 2003;327(7420):891.
30. Fish JE, Israel E, Murray JJ, Emmett A, Boone R, Yancey SW, et al. Salmeterol
powder provides significantly better benefit than montelukast in asthmatic patients
receiving concomitant inhaled corticosteroid therapy. Chest 2001;120:423-30.
31. Virchow JC, Mehta A, Ljungblad L, Mitfessel H. Add-on montelukast in inadequately
controlled asthma patients in a 6-month open-label study: the MONtelukast In
Chronic Asthma (MONICA) study. Respir Med 2010;104:644-51.
32. Kerstjens HA, Disse B, Schröder-Babo W, Bantje TA, Gahlemann M, Sigmund R,
et al. Tiotropium improves lung function in patients with severe uncontrolled asthma:
a randomized controlled trial. J Allergy Clin Immunol 2011;128:308-14.
33. Kerstjens HA, Engel M, Dahl R, Paggiaro P, Beck E, Vandewalker M, et al. Tiotropium
in Asthma Poorly Controlled with Standard Combination Therapy. N Engl J Med
2012;367(13):1198-207.
34. Price DB, Hernandez D, Magyar P, Fiterman J, Beeh KM, James IG, et al. Randomised
controlled trial of montelukast plus inhaled budesonide versus double dose inhaled
budesonide in adult patients with asthma. Thorax 2003;58(3):211-6.
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 57

35. Humbert M, Beasley R, Ayres J, Slavin R, Hébert J, Bousquet J, et al. Benefits of
omalizumab as add-on therapy in patients with severe persistent asthma who are
inadequately controlled despite best available therapy (GINA 2002 step 4 treat-
ment): INNOVATE. Allergy 2005;60:309-16.
36. Bousquet J, Cabrera P, Berkman N, Buhl R, Holgate S, Wenzel S, et al. The effect of
treatment with omalizumab, an anti-IgE antibody, on asthma exacerbations and
emergency medical visits in patients with severe persistent asthma. Allergy 2005;60:
302-8.
37. Bousquet J, Rabe K, Humbert M, Chung KF, Berger W, Fox H, et al. Predicting and
evaluating response to omalizumab in patients with severe allergic asthma. Respir
Med 2007;101:1483-92.
38. Molimard M, Mala L, Bourdeix I, Le Gros V. Observational study in severe asthmatic
patients after discontinuation of omalizumab for good asthma control. Respir Med
2014;108:571-6.
39. Ohta K, Miyamoto T, Amagasaki T, Yamamoto M. Efficacy and safety of omalizumab
in an Asian population with moderate-to-severe persistent asthma. Respirology
2009;14:1156-65.
40. Braunstahl GJ, Leo J, Thirlwell J, Peachey G, Maykut R. Uncontrolled persistent
allergic asthma in practice: eXpeRience registry baseline characteristics. Curr Med
Res Opin 2011;27:761-7.
41. Poachanukoon O, Kawamatawong T, Saengasapaviriya A, Sittipunt C, Chantaphakul
H, Maneechotesuwan K, et al. Long-Term Effectiveness Of Omalizumab Treatment In
Thai Severe Asthmatic Patients: A Real-Life Experience. J Allergy Clin Immunol
2014;133:AB2.
42. M. Beeh K. Which patients should be treated with anti-IgE? Eur Respir Rev 2007;16:
85-7.
43. Dworski R, Fitzgerald GA, Oates JA, Sheller JR. Effect of oral prednisone on airway
inflammatory mediators in atopic asthma. Am J Respir Crit Care Med 1994;149:
953-9.
44. Walsh LJ, Wong CA, Oborne J, Cooper S, Lewis SA, Pringle M, et al. Adverse effects
of oral corticosteroids in relation to dose in patients with lung disease. Thorax
2001;56:279-84.
58
45. Cox G, Thomson NC, Rubin AS, Niven RM, Corris PA, Siersted HC, et al. Asthma
control during the year after bronchial thermoplasty. N Engl J Med 2007;356:
1327-37.
46. Castro M, Rubin AS, Laviolette M, Fiterman J, De Andrade Lima M, Shah PL, et al.
Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma:
a multicenter, randomized, double-blind, sham-controlled clinical trial. Am J Respir
Crit Care Med 2010;181:116-24.
47. Pavord ID, Pizzichini MM, Pizzichini E, Hargreave FE. The use of induced sputum to
investigate airway inflammation. Thorax 1997;52:498-501.
48. Green RH, Brightling CE, McKenna S, Hargadon B, Parker D, Bradding P, et al.
Asthma exacerbations and sputum eosinophil counts: a randomised controlled trial.
Lancet 2002;360(9347):1715-21.
49. Woolcock AJ. What are the important questions in the treatment of asthma? Clin
Exp Allergy Rev 2001;1:62-4.
50. Rank MA, Hagan JB, Park MA, Podjasek JC, Samant SA, Volcheck GW, et al. The
risk of asthma exacerbation after stopping low-dose inhaled corticosteroids: a sys-
tematic review and meta-analysis of randomized controlled trials. J Allergy Clin
Immunol 2013;131:724-9.
51. van der Palen J. Peak inspiratory flow through diskus and turbuhaler, measured by
means of a peak inspiratory flow meter (In-Check DIAL). Respir Med 2003;97:285-9.
52. Chien JW, Ciufo R, Novak R, Skowronski M, Nelson J, Coreno A, et al. Uncontrolled
oxygen administration and respiratory failure in acute asthma. Chest 2000;117:
728-33.
53. Rodrigo GJ, Rodriquez Verde M, Peregalli V, Rodrigo C. Effects of short-term 28%
and 100% oxygen on PaCO2 and peak expiratory flow rate in acute asthma: a
randomized trial. Chest 2003;124:1312-7.
54. Perrin K, Wijesinghe M, Healy B, Wadsworth K, Bowditch R, Bibby S, et al. Randomised
controlled trial of high concentration versus titrated oxygen therapy in severe
exacerbations of asthma. Thorax 2011;66:937-41.
55. Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for
beta-agonist treatment of acute asthma. Cochrane Database Syst Rev 2013;9:
CD000052.
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 59

56. Hasegawa T, Ishihara K, Takakura S, Fujii H, Nishimura T, Okazaki M, et al. Duration
of systemic corticosteroids in the treatment of asthma exacerbation; a randomized
study. Intern Med 2000;39:794-7.
57. Jones AM, Munavvar M, Vail A, Aldridge RE, Hopkinson L, Rayner C, et al. Prospec-
tive, placebo-controlled trial of 5 vs 10 days of oral prednisolone in acute adult
asthma. Respir Med 2002;96:950-4.
58. Alangari AA. Corticosteroids in the treatment of acute asthma. Ann Thorac Med
2014;9:187-92.
59. Chapman KR, Verbeek PR, White JG, Rebuck AS. Effect of a short course of
prednisone in the prevention of early relapse after the emergency room treatment of
acute asthma. N Engl J Med 1991;324:788-94.
60. Fiel SB, Swartz MA, Glanz K, Francis ME. Efficacy of short-term corticosteroid
therapy in outpatient treatment of acute bronchial asthma. Am J Med 1983;75:
259-62.
61. Nowak RM, Pensler MI, Sarkar DD, Anderson JA, Kvale PA, Ortiz AE, et al. Compari-
son of peak expiratory flow and FEV1 admission criteria for acute bronchial asthma.
Ann Emerg Med 1982;11:64-9.
62. Weber EJ, Silverman RA, Callaham ML, Pollack CV, Woodruff PG, Clark S, et al. A
prospective multicenter study of factors associated with hospital admission among
adults with acute asthma. Am J Med 2002;113:371-8.
63. Kawamatawong T, Boonsarngsuk V, Kiatboonsri S, Promajun P. Acute Asthma Treat-
ment Guideline implementatin - Ramathibodi experience. Respirology 2007;12:P-1-
007[A144].
64. Kew KM, Kirtchuk L, Michell CI. Intravenous magnesium sulfate for treating adults
with acute asthma in the emergency department. Cochrane Database Syst Rev
2014;5:CD010909.
65. Goodacre S, Cohen J, Bradburn M, Stevens J, Gray A, Benger J, et al. The 3Mg trial:
a randomised controlled trial of intravenous or nebulised magnesium sulphate
versus placebo in adults with acute severe asthma. Health Technol Assess 2014;18:
1-168.
66. Lim WJ, Mohammed Akram R, Carson KV, Mysore S, Labiszewski NA, Wedzicha JA,
et al. Non-invasive positive pressure ventilation for treatment of respiratory failure
due to severe acute exacerbations of asthma. Cochrane Database Syst Rev
2012;12:CD004360.
60
67. Schatz M, Harden K, Forsythe A, Chilingar L, Hoffman C, Sperling W, et al. The
course of asthma during pregnancy, post partum, and with successive pregnancies:
a prospective analysis. J Allergy Clin Immunol 1988;81:509-17.
68. Namazy JA, Schatz M. The safety of asthma medications during pregnancy: an
update for clinicians. Ther Adv Respir Dis 2014;8:103-10.
69. Gluck JC, Gluck PA. Asthma controller therapy during pregnancy. Am J Obstet
Gynecol 2005;192:369-80.
70. Berges-Gimeno MP, Simon RA, Stevenson DD. The natural history and clinical
characteristics of aspirin-exacerbated respiratory disease. Ann Allergy Asthma Immunol
2002;89:474-8.
71. Szczeklik A, Stevenson DD. Aspirin-induced asthma: advances in pathogenesis,
diagnosis, and management. J Allergy Clin Immunol 2003;111:913-21.
72. Dahlén SE, Malmström K, Nizankowska E, Dahlén B, Kuna P, Kowalski M, et al.
Improvement of aspirin-intolerant asthma by montelukast, a leukotriene antagonist:
a randomized, double-blind, placebo-controlled trial. Am J Respir Crit Care Med
2002;165:9-14.
73. Drazen JM. Asthma therapy with agents preventing leukotriene synthesis or action.
Proc Assoc Am Physicians 1999;111:547-59.
74. Pleskow WW, Stevenson DD, Mathison DA, Simon RA, Schatz M, Zeiger RS. Aspirin
desensitization in aspirin-sensitive asthmatic patients: clinical manifestations and
characterization of the refractory period. J Allergy Clin Immunol 1982;69:11-9.
75. Lee RU, Stevenson DD. Aspirin-exacerbated respiratory disease: evaluation and
management. Allergy Asthma Immunol Res 2011;3:3-10.
76. Smetana GW, Conde MV. Preoperative pulmonary update. Clin Geriatr Med
2008;24:607-24, vii.
77. Tirumalasetty J, Grammer LC. Asthma, surgery, and general anesthesia: a review.
J Asthma 2006;43:251-4.
78. Warner DO, Warner MA, Barnes RD, Offord KP, Schroeder DR, Gray DT, et al.
Perioperative respiratory complications in patients with asthma. Anesthesiology
1996;85:460-7.
79. Woods BD, Sladen RN. Perioperative considerations for the patient with asthma and
bronchospasm. Br J Anaesth 2009;103 Suppl 1:i57-65.
80. Silvanus MT, Groeben H, Peters J. Corticosteroids and inhaled salbutamol in
patients with reversible airway obstruction markedly decrease the incidence of
bronchospasm after tracheal intubation. Anesthesiology 2004;100:1052-7.
·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 61

81. Vichitvejpaisal P, Svastdi-Xuto O, Udompunturux S. The use of nebulized salbutamol
in patients with bronchospasm during anaesthesia: a clinical trial. J Med Assoc Thai
1991;74:397-403.
82. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of
Asthma-Summary Report 2007. J Allergy Clin Immunol 2007;120:S94-138.
83. Wakim JH, Sledge KC. Anesthetic implications for patients receiving exogenous
corticosteroids. AANA J 2006;74:133-9.
84. Louie S, Zeki AA, Schivo M, et al. The asthma-chronic obstructive pulmonary
disease overlap syndrome: pharmacotherapeutic considerations. Expert review of
clinical pharmacology 2013;6:197-219.
85. Zeki AA, Schivo M, Chan A, Albertson TE, Louie S. The Asthma-COPD Overlap
Syndrome: A Common Clinical Problem in the Elderly. J Allergy (Cairo) 2011;2011:
861926.
86. Reddel H, Ware S, Marks G, Salome C, Jenkins C, Woolcock A. Lancet. 1999;
353(9150):364-9.
87. Dekker FW, Schrier AC, Sterk PJ, Dijkman JH. Validity of peak expiratory flow
measurement in assessing reversibility of airflow obstruction. Thorax. 1992;47(3):
162-6.
88. Saejong R, Dejsomritrutai W.J Med Assoc Thai. 2011;94 Suppl 1:S72-6.
89. ÿ∑—»πå √ÿàß‡√◊ÕßÀ‘√—≠≠“, ∫√√≥“∏‘°“√. ·π«∑“ß‡«™ªØ‘∫—μ‘ ”À√—∫°“√∫”∫—¥‚√§‡ æ¬“ Ÿ∫„π
ª√–‡∑»‰∑¬. °√ÿß‡∑æœ: ‘π∑«’°‘® æ√‘Èπμ‘Èß; 2555.
90. U.S. Department of Health and Human Services. A Report of the Surgeon General.
The Health Consequences of Involuntary Exposure to Tobacco Smoke. Secondhand
Smoke: What It Means to You. Atlanta: U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention, National Center for Chronic
Disease Prevention and Health Promotion, Office on Smoking and Health, 2006
[accessed 2015, August 1].
91. Mendes FA, Almeida FM, Cukier A, Stelmach R, Jacob-Filho W, Martins MA, et al.
Effects of aerobic training on airway inflammation in asthmatic patients. Med Sci
Sports Exerc 2011;43(2):197-203.
92. S. Kiatboonsri, P. Charitwatchara, T. Kawamatawong, S. Kiawwan, K. Vongvivat, K.
Khupulsup. Effects of Tai Chi Qigong training on exercise performance and airway
inflammation in moderate to severe persistent asthma. Chest 2008;134:s540-3.
62
93. Heikkinen SA, Quansah R, Jaakkola JJ, et al. Effects of regular exercise on adult
asthma. Eur J Epidemiol 2012;27(6):397-407.
94. Vieira RP, Claudino RC, Duarte AC, Santos AB, Perini A, Faria Neto HC, et al.
Aerobic exercise decreases chronic allergic lung inflammation and airway remodeling
in mice. Am J Respir Crit Care Med 2007;176:871-7.
95. Mendes FA, Gonçalves RC, Nunes MP, Saraiva-Romanholo BM, Cukier A, Stelmach
R, et al. Effects of aerobic training on psychosocial morbidity and symptoms in
patients with asthma: a randomized clinical trial. Chest 2010;138(2):331-7.
96. Thomas M, Bruton A. Breathing exercises for asthma. Breathe 2014;10(4):313-2.
97. Freitas DA, Holloway EA, Bruno SS, Chaves GS, Fregonezi GA, Mendonça KP.
Breathing exercises for adults with asthma. Cochrane Database Syst Rev.
2013;10:CD001277.
98. de Groene GJ, Pal TM, Beach J, Tarlo SM, Spreeuwers D, Frings-Dresen MH, et al.
Workplace interventions for treatment of occupational asthma. Cochrane Database
Syst Rev. 2011;(5):CD006308.
99. Gøtzsche PC, Johansen HK. House dust mite control measures for asthma. Cochrane
Database Syst Rev. 2008;(2):CD001187.
100. Mascia K, Haselkorn T, Deniz YM, Miller DP, Bleecker ER, Borish L; TENOR Study
Group. Aspirin sensitivity and severity of asthma: evidence for irreversible airway
obstruction in patients with severe or difficult-to-treat asthma. J Allergy Clin Immunol
2005;116:970-5.
101. Salpeter S, Ormiston T, Salpeter E. Cardioselective beta-blockers for reversible
airway disease. Cochrane Database Syst Rev. 2002;(4):CD002992.
102. Ma J, Strub P, Xiao L, Lavori PW, Camargo CA Jr, Wilson SR, et al. Behavioral
Weight Loss and Physical Activity Intervention in Obese Adults with Asthma.
A Randomized Trial. Ann Am Thorac Soc. 2015;12(1):1-11.
103. Cates CJ, Rowe BH. Vaccines for preventing influenza in people with asthma.
Cochrane Database Syst Rev. 2013;2:CD000364.
104. Vliagoftis H. Psychological Stress and Asthma: A New Enemy Within. Int Arch
Allergy Immunol 2014;164:109-11.
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·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 29

·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 31

¢—ÈπμÕπ°“√∑”ß“π¢Õß Easy Asthma Clinic

ª√–«—μ∑‘ ‡’Ë ªìπªí®®—¬‡ ’¬Ë ß¢Õß°“√°”‡√‘∫√ÿπ·√ß·≈–Õ“®‡ ’¬Ë ßμàÕ°“√‡ ’¬™’«μ‘

·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 35

3. °“√„Àâ¬“ Ÿ¥æàπ¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï‡√Á« (Inhaled rapid-acting

4. °“√„Àâ systemic corticosteroids

·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 37

Aspirin-exacerbated respiratory disease (AERD)

·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 41

·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 43

average [PEFRhighest › PEFRlowest]

√Ÿª∑’Ë 4 «‘∏’°“√«—¥§à“ PEF variability

·∫∫ª√–‡¡‘πº≈°“√§«∫§ÿ¡‚√§À◊¥ Asthma Control Question-

·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 45

§”∂“¡ 1 „π™à«ß 4 —ª¥“Àå∑’Ëºà“π¡“ ∫àÕ¬·§à ‰Àπ∑’Ë ‚√§À◊¥∑”„Àâ§ÿ≥‰¡à “¡“√∂

§”∂“¡ 2 „π™à«ß 4 —ª¥“Àå∑’Ëºà“π¡“ ∫àÕ¬·§à ‰Àπ∑’Ë§ÿ≥√Ÿâ ÷°À“¬„®‰¡àÕ‘Ë¡

§”∂“¡ 3 „π™à«ß 4 —ª¥“Àå∑º’Ë “à π¡“ ∫àÕ¬·§à‰Àπ∑’§Ë ≥

·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 47

§”∂“¡ 5 „π™à«ß 4 —ª¥“Àå∑’Ëºà“π¡“ §ÿ≥§‘¥«à“§ÿ≥ “¡“√∂§«∫§ÿ¡‚√§À◊¥¢Õß

°“√√—°…“‚¥¬‰¡à„™â¬“ (Non-pharmacological Therapies)

μ“√“ß∑’Ë 6 Non-pharmacological therapies „π°“√√—°…“‚√§À◊¥

·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 49

·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 51

·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 53

* √“¬≈–‡Õ’¬¥°“√∑”·ºπ°“√ªØ‘∫μ— μ‘ π‡∫◊ÕÈ ßμâπ‡æ◊ÕË §«∫§ÿ¡Õ“°“√¢Õß‚√§À◊¥ (Action Plan) ·æ∑¬åº¥Ÿâ ·Ÿ ≈

·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 55

·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 57

·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 59

·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 61

·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§À◊¥„πª√–‡∑»‰∑¬ ”À√—∫ºŸâ „À≠à æ.». 2560 63

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