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1、2019/11/9,1,馬偕醫院小兒科部 李宏昌,The role of bronchodilator in treating cough in children,2019/11/9,2,202A 依據病歷記載及病況，不足以支持實施本項 (門、急、住診療/手術/麻醉/處置/治療/檢 驗/檢查/藥品/特材) 324A 同時已投予同性質藥物，用藥種重複,2019/11/9,3,住院案例-1,5歲男童，診斷為464.4 Croup 病史：Fever with productive cough and hoarseness for 3 days. The cough sounds like barki
2、ng. Progressive hoarseness and rhinorrhea was also noted 理學檢查：nose: some discharge; throat: injected; tonsil: Gr.II/IV. No exudates. Chest: symmetric expansion; breath sounds: bilateral rhonchi Chest X-Ray: bilateral perihilar infiltration with peribronchial cuffing,2019/11/9,4,住院案例-1,核刪Pulmicort Ne
3、bulising suspension(IH) 核刪理由： 依所附文獻，IV form dexamethasone為首選，為何捨有效且便宜的療法 依據診斷/病況，無使用類固醇吸入劑治療之必要 申請理由：病童因Croup而入院，治療方法可用吸入性類固醇達到消腫、抗發炎的結果,Inhaled corticosteroids also have demonstrated efficacy, with most trials using budesonide. However, according to most authors, the relative ease, speed, and cost
4、of administration make systemic corticosteroids preferable to nebulized formulations,2019/11/9,5,Croup: Treatment Updated: Nov 21, 2008,A single dose of dexamethasone has been shown to be effective in reducing the overall severity of croup if administered within the first 4-24 hours after onset of i
5、llness. The long half-life of dexamethasone (54 h) often allows for a single injection. Dexamethasone (0.15 mg/kg) is as effective as 0.3 mg/kg or 0.6 mg/kg in relieving symptoms of mild-to-moderate croup. It has the same efficacy if administered intravenously, intramuscularly, or orally. A single o
6、ral dose of prednisolone (1 mg/kg) resulted in more return visits than a single oral dose of dexamethasone (0.15 mg/kg). Inhaled budesonide has also proven to be effective but is more expensive; in one study, oral dexamethasone resulted in better improvement than nebulized budesonide.,2019/11/9,6,Co
7、ugh is an important defense mechanism that plays a major role in maintaining the integrity of the airways and can be voluntary or involuntary. The pathophysiology of cough is incompletely understood. Cough is commonly triggered by mechanical or chemical stimulation of receptors in the pharynx, laryn
8、x, trachea and bronchi. Cough receptors also exist in the nose, paranasal sinuses, external auditory ear canals, tympanic membranes, parietal pleura, esophagus, stomach, pericardium and diaphragm.,. NLHEP (National Lung Health Education Program ),2019/11/9,7,Medicines commonly used in treating cough
9、: Acetaminophen or ibuprofen: Antibiotics: Antiviral medicine: Breathing treatments: Cough medicine: Expectorant: Coughing the phlegm out of the lungs can help your child breathe easier. Should drink plenty of liquids when taking this type of medicine. Suppressant : May need a cough suppressant at n
10、ight so he can rest. May not be used if caregivers think it may be dangerous to stop your childs cough. Bronchodilators: to help open the air passages in his lungs. Bronchodilators can be given during a breathing treatment or by using an inhaler. by mouth or through an IV. Steroids: Steroid medicine
11、 may help to open air passages in the lungs so that the child can breathe easier.,2019/11/9,8,夫街談巷說，必有可採；擊轅之歌，有應風雅，匹夫之思，未易輕棄也。” 文選曹植與楊德祖書,巷說百物語,街談,2019/11/9,9,公益法律扶助會想到要上法院，很多人就會腳軟。 感冒藥普拿疼伏冒加強錠感冒什麼藥也比不上我的醫生開的藥，不然你就要吃。 牙膏黑人超氟牙膏掛保證。人生有些東西就是剝離不了，黑人牙膏就是其中一味。 門號威寶電信你如果覺得有賺到可以笑出來沒關係。（企業形象篇、低費率篇）。 鞋類La new
12、DCS舒適動能氣墊鞋走快較不晃、走久較不累、走遠較不倦。 罐頭珍開味含是泡菜火鍋大家都我火鍋黨主席。（愛之味系列就有3款） 保健品引藻片有人說，它是藻中之王。 音響VEA家庭劇院數位時代，享受就要VEA 保健品鳥頭牌愛福好男人不要只剩一隻嘴。 全國電子足感心。 十八銅人好鐵貼吃老，吃東西掉滿地，肌肉痠痛都是你害的。,2019/11/9,10,Summary of important points: Asthma is a common condition but it is not always the diagnosis in a coughing child. A careful clin
13、ical history is the key to diagnosis in asthma. Cough as the sole symptom of asthma is unusual. A family history of asthma, and family or personal history of atopy, eczema or allergic rhinitis, makes a diagnosis of asthma more likely. Physical examination may be normal in a child with asthma between
14、 episodes. The age at which children can perform spirometry is variable. In younger children, a trial of bronchodilator therapy with formal assessment of response may be appropriate if asthma is suspected.,2019/11/9,11,Diagnosing asthma in young children is difficult because children often: cough an
15、d wheeze with colds and chest infections but this is not necessarily asthma. Young children have very small, narrow airways and on average have a 6 -8 colds per year, usually between September and March.,2019/11/9,12,It is important not to over-diagnose asthma in children who in fact have a chronic
16、non-specific cough. Such children require no treatment, get better with time, and have normal long-term lung function“. The diagnosis of cough variant asthma should only be made in older children after variable airflow obstruction and response to bronchodilator has been demonstrated physiologically. In younger children, rational diagnostic criteria are an abnormally increased cough, with no evidence of any non-asthma diagnosi
