胸腔內科

1. Drugs for obstructive lung disease
2. Drugs for infectious disease
3. Drugs for chemotherapy
4. Drugs for symptomatic relief

Drugs for obstructive lung disease
 COPD and asthma ( including stable condition and acute exacrbation
 Inhaled medication: prefer medicine oral medication
IV and IM medication

GINA (Global Initiative for Asthma)
Guidelines 2002
Intermittent
Mild persistent
Moderate persistent
Severe persistent
Shortacting ß
2 p.r.n
Inhaled Corticosteroid
Sustained-release theophylline
Leukotriene Modifier
Longacting ß
2 agonist
Oral steroid

GOLD guideline (2003)
0: at risk I: mild II: moderate III: severe IV: very severe
Aviodance of risk factors; influenza vaccination
Add short acting bronchodilator when needed
Add regular one or more long acting bronchodilator; Add rehabilitation
Add inhaled steroid
Add long term O2

Inhalation Therapy
液態或固態的粒子懸浮在氣體中便稱
為氣霧(aerosol).經由氣霧粒子攜帶藥
物,水或食鹽水進入呼吸道達到治療的效
果稱為吸入治療.
1.
藥物吸入治療
2.
非藥性( blind )吸入治療(含水或
食鹽水粒子)

Indication and goal of inhaled therapy
1.
呼吸道給藥
2.
稀釋肺部分分泌物與誘發取痰
(hydration of pulmonary secretions and sputum induction)
3. 吸入氣體的濕化
(humidification of inspired gases)

Devices of inhaled therapy
1.
噴嘴式噴霧器 jet nebeulizer
2.
超音波噴霧器 ultrasonic nebeulizer
3.
定量吸入器 metered dose inhaler (MDI)
4.
乾粉吸入器 dry power inhaler (DPI), including rotadisk, turbuhaler, accuhaler & easyhaler

Jet nebeulizer

Spacer as adjuvant therapy

 Rotadisk
 Easyhaler
 Accuhaler
 Turbuhaler

Easyhaler

Accuhaler ( 胖胖魚 )

Turbuhaler ( 都保 )

Reliever
Short acting b
2 -agonists
(cold color)
Controller
Inhaled corticosteroids
(warm color)

各種器具之優缺點比較
優點
Nebulizer 吸入率8-12%且不需病人配合
可用於人工氣道與呼吸器患者
可作高劑量與持續性治療
不含氟氯化碳不污染環境
MDI 可用於人工氣道與呼吸器患者
方便便宜不易污染
缺點
不經濟藥品易浪費
耗時長易污染
需高流量氣體作動力來源
DPI 吸入率12-16%且不需病人配合
不含氟氯化碳不污染環境
攜帶方便便宜不易污染
吸入率9-12%且須病人高度配合
人工氣道與呼吸器患者吸入率只有4-6%
氟氯化碳會破壞環保
需較高之吸氣流速
無法使用於人工氣道與呼吸器患者
易受濕氣影響

1. b
2 -

Short acting b
2 agonist
1. Ventolin ( Salbutamol ), nebeulizer , 1 amp
(5mg/2.5 ml), q30 min – q6h prn; MDI 2 puff prn
2. Bricanyl ( Terbutaline hydrochloride ),
Turbuhaler , 200mg/100 dose, 1-2 puff qid prn

Long acting b
2 agonist
Serevent
( Salmeterol xinafoate ),
Accuhaler , 50mg/60
1-2 puff bid
Oxis ( formoterol ),
9 ug / dose.
Turbuhaler 1 puff bid

Anticholinergic Agent
Atrovent
( Ipratropium bromide )
1. MDI , 200 puffs/10 ml,
2-3 puff qid
2. Nebeulizer solution,
0.5mg/2ml/vial,
1 vial qid

Combined β 2 agonist and anticholinergic drug ( Combivent )
 Combivent
(Ipratropium + albuterol)
2puff Qid

 Pulmicort ( Budesonide )
Turbuhaler : 200ug/200dose/bot,
2-4 puff bid
Nebeulizer : 1000ug/2ml/vial,
0.5 -1 vial bid
 Flixotide
( Fluticasone propionate )
Accuhaler
,
250mg/puff/60dose,
1 puff bid
MD I, 50mg/puff/200dose

(Long acting β 2 agonist + steroid)
 Symbicort
( Budesonide + formoterol )
Turbuhaler, 200 puff,
1~2 puff bid
 Seretide
(Fluticasone propionate + Salmeterol )
Accuhaler; 1 puff bid

1. b
2 agonist inolin ( 1# tid-qid); meptin ( 1# bid), bambec 1# qn
2. Xanthine derivates
Phyllocontin 1# bid-tid ( 不可磨碎 ) , theophylline 2# qn or 1# q12h ( 可磨粉，適合
NG feeding 者 )
3. Steroid: prednisolone 0.5-1mg/kg qd
4. Leukotrine modifier:
Accolate 1# bid singulair 1# qd

1. Epiphephrine
IM: 0.5 ml sc
IV: 0.5-1 ml slowly IVD
2. Ipradol ( Hexoprenaline Sulfate )
1 amp(5ug/2ml) IM or IV slowly
3. Aminophylline
(must add in saline)
Loading dose: 250 mg x 30 min
 250 x 8 hours
 6-15 mg/kg qd (serum level 10-20ug/dL)

Drugs for infectious lung disease
1. Community acquired pneumonia( CAP) with and without parapneumonic effusion
2. Hospital acquired pneumonia (HAP)
3. Pulmonary TB
5. Empyema thoracis and lung abscess
6. COPD or asthma with 2nd infection
8. Bronchiectasis with 2nd infection

Community acquired pneumonia
 Pathogens: S. pneumoniae; H. influenza; atypical pathogen ( M. pneumoniae,
C. pneumoniae ). Mixed infection, MSSA, and some G(-) bacillus…
 Mixed typical and atypical pathogen.
 Risks factor or host factor of specific pathogens in pneumonia

Community acquired pneumonia
 S. pneumonae : Penicilline, Rocephine or
Vancomycin, fluroquinolone
 H. influenza, G(-) bacillus : Unasyn, Augmentin or 2nd and 3rd cephalosporin and fluroquinolone
 Atypical pathogens : Erythromicin, klaricid,
Zithromax, tetracycline and fluroquinolone
 Mixed infection : Penicillin, Cleocin, Unasyn
 MSSA : Cefalosporin, Oxacilline

Hospital acquired pneumonia
 Pathogens: G(-) bacillus, P. aeruginosa, MRSA,
VRE, A. baummanii, Legionella..
 MRSA : Vancomycin, Targocid
 P. aeruginosa : Pipril/Tazocin, Fortum, Cravit,
Ciprofloxacin, Tienam and maxipime
 G(-) bacillus : 3rd cephalosporin
 Legionella : Erythromycin, Klaricid, Zithromax
 A. baummanii : Tienam

Pulmonary TB and TB pleurisy
 First line : INH, RIF, EMB, PZA
 Secondary line : Fluroquinolone, Aminoglycoside,
PAS, Ethionamide, and Cycloserine
 Standard therapy: 6 months
Intensive therapy X 2months: HERZ
Maintain therapy X 4 months HER
 If PZA is not used, Keep HER for 9 months

Pulmonary TB and TB pleurisy
 Side effect:
INH: hepatitis, peripheral neuropathy
RIF: hepatitis, jaundice, rash
EMB: neuritis
PZA: hepatiits, hyperuricemia, gouty
 Steroid & Vitamin B6
 Combination therapy:
Rifater: INH 80 + RIF 100 + PZA 250
Rifinah: INH 150 + RIF 30

Thoracis Empyema and
Lung Abscess
1. Treat as pneumonia
2. Adequate drainage
Tube drainage
Decortication
Repeated lung aspiration (abscess)
3. At least 3-4 weeks IV antibiotics treatment and total duration around 6-8 weeks

Most caused agents
1. H. influenza, G (-) coccobacillus
Tx: Ampicilline/Unasyn, Amoxicilline
/augmentin; 2nd cephalosporin, Macrolidw
2. Moraxella catarrhalis, G (-) diplococcus
Tx: Macrolide, Baktar, Augmentin or
Fluroquinolone, 3 rd generation cephalosporin
3. Streptococcus pneumoniae G(+) diplococcus
Tx: Penicillin, Amoxicilin/ Augmentin,
Ampicilline/ Unasyn

Bronchiectasis with secondary Infection
1. Initial: G(+) coccus + GNB:
Tx as COPD with 2nd infection
2. Later: GNB, especially P.spp
Floroquinolone:
3rd generation cephalosporins
Beta-lactam PCN + aminoglycoside
Tineam + aminoglycoside

1. Small cell lung cancer
( SCLC )
2. Non-small cell lung cancer
( NSCLC )

First choice
Cisplatin 75 mg/m² x 1 day
VP 16 100 mg/ m² x 3 days every 28 days
Second line
Topotecan 1.5-2.5 mg/m2
Taxol 135 mg/m2 ( 自費 ) every 21 or 28 days

First line
1. Gemzar 1000 mg/m² + Cisplatin
100 mg/m² + x I
2. Taxol 135 mg/m² + Cisplatin
75 mg/m² x I
3. Navelbine 25 mg/m² + Cispaltin
75 mg/m² x I
Second line
1. Taxotere 75 mg/m² x I /C or /S Cisplatin

Drugs for symptomatic relief
 Insomnia
 Cough
 Pain
 Shortness of breath

 看病人
 Haldol
 Type I receptor : Zopiclone , Zolpidem
 Type II receptor : Ativan , Valuim

Antitussive & Expectorants
1. Solution
2. Tablet or capsule
3. Nebular

1. Brown mixture ( B.M
)
含 opium, 5-10 ml tid – qid
2. Guaifenesin ( Unitussin or G.P
) reduce the visicosity of sputum antihistamine effect (+)
5-10 ml q4h - q6h
3. Fusoco
限小兒科使用 , 成人需自費

1. Brown mixture ( B.M
), 1-2# tid - qid
2. Bensau ( Benzonatate ) 1-2# tid - qid
3. Codeine 1# q6h prn
4. Bisco ( Bisolvon ) 1# qid
5. Danzen 1-2 # tid - qid
6. Mucora 1# qid
7. Medicon 1# tid –qid
# 以上藥品不得同時開
立三項 ( 含 ) 以上

1. Bisolvon aerosol + mucolytic agent
 help to expectorate
2. Lidocaine for refractory cough, 2mg/5ml IH
3. Gentamycin
40 mg IH q8h, as immunomodulater

 Acetaminophen
 NSAID
 Tramadol (50mg) & Tramadol-SR (100mg)
 Morphine (10mg PO, IM, IV)
 Fentanyl (25μg, 50μg)