氣喘與吸入劑

三軍總醫院松山分院
胸腔內科
健保氣喘慢性照護課程講師
彭士軒
01 什麼是氣喘？

02 如何治療氣喘？

03 怎麼選擇氣喘吸入劑？

04 本院目前有的吸入劑
什麼是氣喘？
 氣道氣流的變化
支氣管狹窄
氣道壁增厚
微觀病生理 氣道黏液分泌增加

氣喘診斷 呼吸道症狀
喘鳴
呼吸困難
巨觀臨床症狀
胸悶
咳嗽
症狀好發於早上及夜間
Your Text Here
肺功能障礙
You can simply impress your audience Insert Your Image
and add a unique zing and appeal to
your Presentations.
 正常的氣管 氣喘病人的氣管

Your Picture Here Your Picture Here

支氣管慢性發炎 (Chronic inflammatory) 的疾病。

因外在物質產刺激，產生過度反應 (hyperresponsiveness) 。
支氣管的阻塞可因為治療或自發性使支氣管恢復原本的管徑： Reversible( 可逆
性)。
如何治療氣喘？
氣喘藥物治療
呼吸道發炎
抗發炎藥物
01 口服類固醇

02 吸入型皮質類固醇
03 白三烯拮抗劑
04 乙二型交感神經興奮劑
05 副交感神經拮抗劑
06 茶鹼製劑 支氣管收縮
支氣管擴張劑
口服型類固醇 ? 吸入型類固醇 ? 是一樣的嗎 ?

作用於全身，具全身 僅作用於肺部，較少全
性副作用。 身性副作用。
GINA 2018
Step 1 treatment is for pa-
tients with symptoms
<twice/month and no risk
factors for exacerbations

Previously, no controller
was recommended for
Step 1, only SABA as
needed

GINA 2018, Box 3-5

 GINA 2019
Step 2 首選可給予 ICS( 每天使 Confirmation of diagnosis if necessary
用 asthma
Personalized ) 或 ICS/Formoterol
management: ( 需要時 Symptom control & modifiable
risk factors (including lung function)
Assess, Adjust, Review response
使用 ) Comorbidities
Inhaler technique & adherence
Patient goals

Step 1 首選即給予 ICS/ Symptoms

高劑量 ICS/LABA 改為 Step 5 才使
Formoterol ( 需要時使 Exacerbations
Side-effects 用
用) Lung function
Patient satis- Treatment of modifiable risk
faction factors & comorbidities STEP 5
Asthma medication options:
Non-pharmacological strategies
Adjust treatment up and down for in- Education & skills training
High dose
ICS-LABA
dividual patient needs Asthma medications STEP 4
Refer for
STEP 3 phenotypic
Medium dose
assessment
STEP 2 ICS-LABA ± add-on
PREFERRED STEP 1 Low dose therapy, e.g.-
CONTROLLER Daily low dose inhaled corticosteroid ICS-LABA tiotropium,
to prevent exacerbations As-needed (ICS), or as-needed low dose ICS-for- anti-IgE,
and control symptoms low dose anti-IL5/5R,
moterol * anti-IL4R
ICS-for-
Other Low dose* ICS
moterol Leukotriene receptor antagonist (LTRA), or Medium dose High dose Add low dose
controller options taken whenever low dose ICS taken whenever SABA taken † ICS, or low ICS, add-on OCS, but
SABA is taken dose tiotropium, or consider
† add-on LTRA # side-effects
ICS+LTRA #
PREFERRED As-needed low dose ICS-formoterol * As-needed low dose ICS-formoterol ‡
RELIEVER
Other
reliever option As-needed short-acting β2 -agonist (SABA)

從 Step1 起至 Step 5 急救藥物首選

皆為 ICS/Formoterol ( 需要時使 SABA
† Off-label; separate or combination 使用太頻繁將導致氣喘
* Off-label; data only with budesonide-formoterol (bud-form
ICS and SABA inhalers
Low-dose ICS-form is the reliever for patients prescribed
) ‡
bud-form or BDP-form maintenance and reliever therapy
1

Consider adding HDM SLIT for sensitized patients with aller-

#

用) 發作變嚴重、致死率變高 gic rhinitis and FEV >70% predicted

建議不要再單獨使用 SABA
© Global Initiative for Asthma, www.ginasthma.org
當每年使用 ≥ 3 支的 SABA ，氣喘發作而需
住院或急診的風險增加 2 倍 2

Critical thresholds for risk1:

Children n = 41,753
Children: 3 SABA canisters in 12 months
Adults n = 59,684
Adults: 2 SABA canisters in 6 months
怎麼選擇氣喘吸入劑？
Insert the title of your subtitle Here
選擇哪一種吸入型藥物 ?
There are two main types of inhalers: MDI and DPI
MDIs DPIs†
Delivers medication in Delivers medication in dry powder
aerosol form through a pressur- form as the user inhales
ised canister

Ellipta Diskus
With spacer Without spacer

Aerolizer Turbuhaler

SMI HandiHaler Breezhaler

Delivers medica-
Respimat
tion as a soft mist

Nexthaler Flexhaler
• List of DPIs is not exhaustive.
†

• DPI, dry powder inhaler; MDI, metered dose inhaler; SMI, soft mist inhaler
Lung Deposition Of Inhaled Medication
Is Dependent On Particle Size1,2
Total lung
deposition: 56% 50% 46%

Deposition in small airways

Deposition in large and intermediate
airways
S: Slow aerosol inhalation
F: Fast aerosol inhalation
Size in MMAD
*p<0.001 1,5µm vs. 3 µm and 6µm
MMAD: mass median aerodynamic diameter

1. Usmani OS, et al. Am J Respir Crit Care Med

2005;172(12):1497-504; 2. van den Berge M, et al. Allergy
2013;68(1):16-26
UsmaniOS et al , AJRCCM 2005
UsmaniOS et al , AJRCCM 2005
Small Particles = Low Oropharyngeal Deposition

UsmaniOS et al , AJRCCM 2005

最適粒子大小
最適當的粒子大小範圍約在 1-5 微米，此範圍的粒子大小比超微粒粒子大小（ < 1.0
微米）更可增加肺沉積率，更能散佈在整個肺支氣管樹（ in vitro study ） 1-4

吸氣流速 : 31 升 / 分鐘
⾼達 80% 的這些粒⼦會隨呼
氣出來，也因此臨床上無效果

傳遞之藥物比例
1-5 微米的藥物較 <1 微米
的藥物更容易沉積在肺部
呼出比例

(%)
肺部沉積比例
口咽沉積比例

空氣動力學粒徑 ( 微
米)

• 吸必擴都保粉狀吸入器較耐舒樂吸入劑，可提供較⾼比例
2
(41.8% vs 26.5%) 的最佳⼤⼩粒⼦ （ 1~5 微米）
*Percentages shown are for the budesonide component of Symbicort® Turbuhaler®.
** Percentages shown are for the beclomethasone component of Foster® NEXThaler®.
1. Demoly P, et al. Respir Med 2014; 108: 1195-1203.
2. De Boer AH, et al. Eur J Pharm Biopharm 2015; 96: 14351.
3. Hozawa S, Terada M, Hozawa M. Pulm Pharmacol Ther 2011; 24: 571-576.
4. Hozawa S, Terada M, Hozawa M. Pulm Pharmacol Ther 2014; 27: 190-196.

Data based on in vitro studies, therefore the relevance to clinical efficacy is unclear.
 Budesonide/Formoterol used as
Maintenance And Reliver Therapy (MART)

• BUO/FORM MART provides asthma

control as good or better than com-
parators in mild-moderate and mod-
erate-severe asthma

• BUO/FORM MART prolongs the time

to first asthma exacerbation versus all
comparators tested

• BUO/FORM MART reduces the rate

of asthma exacerbation compared
with either treatment options, with a
lower overall corticosteroid exposure
Maintenance And Reliever Treatment
3-5 分鐘迅速緩解病人症狀

Change in FEV1(ml)

BDP/F
100/6µg, two puffs b.i.d.

FP/SALM
125/25µg, two puffs b.i.d.

p values shown, calculated between treatments

Minutes post-dosing
Ref.Papi A et al. Allergy 2007
本院目前有的氣喘吸入劑
Insert the title of your subtitle Here
 SABA SAMA ICS LABA LAMA
短效乙二型刺激劑 短效抗膽鹼藥物 吸入型類固醇 長效乙二型刺激劑 長效抗膽鹼藥物

Berodual 備喘全

Besmate 倍舒美

Duasma 帝舒滿

Foster 肺舒坦

Seretide 使肺泰

Symbicort 吸必擴

Spiriva 適喘樂

Spiolto 適倍樂

Trimbow 喘寶
 吸必擴 ® 於 2020 年 3 月正式取得緩解療法的適應症
台灣第一且唯一核准使用於所有氣喘嚴重程度的抗發炎緩解吸入劑 #

ICS, inhaled corticosteroid; LABA, long-acting ß2-agonist; OCS, oral corticosteroid; SABA, short-acting ß2-agonist # Indication with Symbicort Turbuhaler 160/4.5 only. *ICS in SYGMA2 study was budesonide. †GINA guidelines 2019. ‡SABA used in this study was terbutaline. 1. SYMBICORT®TURBUHALER
260/4.5, inhalation powder. Summary of Product Characteristics [anticipated new licence]. 2. Seberova E and Anderson A. Respir Med 2000;94(6):607-611. 3. Ventolin Evohaler® 100. Summary of Product Characteristics UK. 4. O’Byrne PM, et al., N Engl J Med 2018;378:1865-1876. 5.
Bateman ED, et al., N Engl J Med 2018;378:1877-1887. *GINA do no recommend to use different LABA for maintenance and reliever.
吸必擴 ® 抗發炎緩解療法 ± 維持療法 支持 GINA 2019 文獻一覽
研究涵蓋所有氣喘嚴重程度的氣喘病人，與 SABA± 維持療法做直接比較

抗發炎緩解療法 抗發炎緩解與維持療法
(Anti-Inflammatory Reliever) (Anti-Inflammatory Reliever & Maintenance)

SYGMA 11 SYGMA 22 STEP5 STAY7 COMPASS9

Novel PRACTICAL4* STEAM6† SMILE8 AHEAD10

START3* †

輕度氣喘 (Step 1-2) 中度至重度氣喘 (Step 3-5)

維持療法 (Maintenance)

抗發炎緩解療法 (Anti-Inflammatory Reliever, As-needed low dose ICS/Formoterol)

BUD = budesonide; FLU = fluticasone; FORM = formoterol; ICS = inhaled corticosteroid(s); LABA = long-acting β2-agonist; SABA = short-acting β2-agonist; SAL = salmeterol; SYGMA = SYmbicort Given as needed in Mild Asthma.
1. O’Byrne PM, et al. N Engl J Med. 2018;378:1865-1876; 2. Bateman ED, et al. N Engl J Med. 2018;378:1877-1887; 3. Beasley R, et al. N Engl J Med. 2019;380:2020-2030; 4. Hardy J, et al. Lancet. 2019 (ahead of print); 5. Scicchitano R, et al. Curr Med Res Opin. 2004;20:1403-1418; 6. Rabe KF,
et al. Chest. 2006;129:246-256; 7. O’Byrne PM, et al. Am J Respir Crit Care Med. 2005;171:129-136; 8. Rabe KF, et al. Lancet. 2006;368:744-753; 9. Kuna P, et al. Int J Clin Pract. 2007;61:725-736; 10. Bousquet J, et al. Respir Med. 2007;101:2437-2446. 11. 全民健康保險氣喘醫療給付改善方案教
育訓練和新課程 . *Novel START & PRACTICAL study is not included in GINA 2019. † Included patients with mild to moderate asthma. 27
謝謝指教 !!
 如何正確使用吸必擴都保粉狀吸入劑 ?
(Symbicort Turbuhaler) 衛教影片連結

平常使用 https://youtu.be/hIfQYBZAdhk
第一次開封

完整吐氣後，將吸嘴 關上瓶蓋，瓶蓋轉
含於兩唇間，深深用 緊，並請漱口。
嘴巴吸一口氣，閉氣
10 秒後，即完成 1
次用藥。
通常是先往右再往左轉，不過先往
哪一邊轉都沒有關係，重點是需要
聽到喀一聲就表示上藥完成。
1. Turbuhaler SmPC. Available at: https://tinyurl.com/y2nhluog