哮喘和COPD的藥學(xué)監(jiān)護(hù)專家講座

哮喘和慢性阻塞性肺病

藥學(xué)監(jiān)護(hù)王卓衛(wèi)生部臨床藥師（師資）培訓(xùn)基地中國人民解放軍臨床藥學(xué)中心第二軍醫(yī)大學(xué)長海醫(yī)院藥學(xué)部哮喘和COPD的藥學(xué)監(jiān)護(hù)第1頁藥學(xué)監(jiān)護(hù)了解與回顧實(shí)施藥學(xué)監(jiān)護(hù)標(biāo)準(zhǔn)模式臨床藥師提供藥學(xué)監(jiān)護(hù)哮喘患者藥學(xué)監(jiān)護(hù)關(guān)鍵點(diǎn)COPD患者藥學(xué)監(jiān)護(hù)關(guān)鍵點(diǎn)哮喘和COPD的藥學(xué)監(jiān)護(hù)第2頁藥學(xué)監(jiān)護(hù)了解與回顧哮喘和COPD的藥學(xué)監(jiān)護(hù)第3頁pharmaceuticalcare藥學(xué)監(jiān)護(hù)起源于美國，國內(nèi)又稱藥學(xué)服務(wù)。其關(guān)鍵思想是經(jīng)過藥師與臨床醫(yī)護(hù)人員共同協(xié)作，為病人提供直接負(fù)責(zé)藥品治療，并主動監(jiān)測治療全過程，以改進(jìn)病人治療效果，最終提升病人生活質(zhì)量為目標(biāo)。哮喘和COPD的藥學(xué)監(jiān)護(hù)第4頁藥學(xué)服務(wù)目標(biāo)取得改進(jìn)病人生活質(zhì)量既定結(jié)果。包含：①治愈疾??；②消除或減輕癥狀；③阻止或延緩疾病進(jìn)程；④預(yù)防疾病或癥狀再次發(fā)生。哮喘和COPD的藥學(xué)監(jiān)護(hù)第5頁IntroductionPharmaceuticalCareThedirect,responsibleprovisionofmedication-relatedcareforthepurposeofachievingdefiniteoutcomesthatimproveapatient’squalityoflife(ASHPStatementonPharmaceuticalCare)Whatapharmacistdoestoimprovepatientcareandpatientsafety哮喘和COPD的藥學(xué)監(jiān)護(hù)第6頁P(yáng)harmaceuticalCareApatient-centeredpracticePractitionerassumesresponsibilityforapatient’sdrugrelatedneedsPractitionerisheldaccountableforthecareprovided哮喘和COPD的藥學(xué)監(jiān)護(hù)第7頁工作開展藥學(xué)監(jiān)護(hù)是藥師在臨床疾病治療中參加并主導(dǎo)一個工作過程，是多學(xué)科協(xié)作綜合地考慮整體診療計劃前提下，從藥學(xué)角度對治療計劃進(jìn)行合理設(shè)計、執(zhí)行、監(jiān)測和及時調(diào)整，實(shí)施過程需要患者和醫(yī)護(hù)人員緊密協(xié)作。哮喘和COPD的藥學(xué)監(jiān)護(hù)第8頁工作職責(zé)藥師對治療結(jié)果負(fù)責(zé)最少表現(xiàn)為以下三個方面：①發(fā)覺潛在或?qū)嶋H存在用藥問題；②處理實(shí)際發(fā)生用藥問題；③預(yù)防潛在用藥問題發(fā)生。哮喘和COPD的藥學(xué)監(jiān)護(hù)第9頁藥學(xué)監(jiān)護(hù)與藥品治療藥品治療是臨床治療主要方式之一藥品治療是多學(xué)科協(xié)作臨床服務(wù)藥學(xué)監(jiān)護(hù)是優(yōu)化藥品治療主要伎倆藥學(xué)監(jiān)護(hù)是臨床藥師工作關(guān)鍵哮喘和COPD的藥學(xué)監(jiān)護(hù)第10頁實(shí)施藥學(xué)監(jiān)護(hù)標(biāo)準(zhǔn)模式ASHPguidelinesonastandardizedmethodforpharmaceuticalcare.AmJHealth-SystPharm.1996;53:1713–6.哮喘和COPD的藥學(xué)監(jiān)護(hù)第11頁FunctionsofPharmaceuticalCare?

Collectingandorganizingpatient-specificinformation,?Determiningthepresenceofmedication-therapyproblems,?Summarizingpatients’healthcareneeds,?Specifyingpharmacotherapeuticgoals,?Designingapharmacotherapeuticregimen,?Designingamonitoringplan,?Developingapharmacotherapeuticregimenandcorrespondingmonitoringplanincollaborationwiththepatientandotherhealthprofessionals,?Initiatingthepharmacotherapeuticregimen,?Monitoringtheeffectsofthepharmacotherapeuticregimen,and?Redesigningthepharmacotherapeuticregimenandmonitoringplan.哮喘和COPD的藥學(xué)監(jiān)護(hù)第12頁CollectingandOrganizingPertinentPatient-SpecificInformation哮喘和COPD的藥學(xué)監(jiān)護(hù)第13頁哮喘和COPD的藥學(xué)監(jiān)護(hù)第14頁哮喘和COPD的藥學(xué)監(jiān)護(hù)第15頁DeterminingthePresenceofMedication-TherapyProblems?Medicationswithnomedicalindication,?Medicalconditionsforwhichthereisnomedicationprescribed,?Medicationsprescribedinappropriatelyforaparticularmedicalcondition,?Inappropriatemedicationdose,dosageform,schedule,routeofadministration,ormethodofadministration,?Therapeuticduplication,?Prescribingofmedicationstowhichthepatientisallergic,?Actualandpotentialadversedrugevents,?Actualandpotentialclinicallysignificantdrug–drug,drug–disease,drug–nutrient,anddrug–laboratorytestinteractions,?Interferencewithmedicaltherapybysocialorrecreationaldruguse,?Failuretoreceivethefullbenefitofprescribedmedicationtherapy,?Problemsarisingfromthefinancialimpactofmedicationtherapyonthepatient,?Lackofunderstandingofthemedicationtherapybythepatient,and?Failureofthepatienttoadheretothemedicationregimen.哮喘和COPD的藥學(xué)監(jiān)護(hù)第16頁SummarizingPatients’HealthCareNeeds.SpecifyingPharmacotherapeuticGoals.DesigningaPharmacotherapeuticRegimen.DesigningaMonitoringPlanforthePharmacotherapeuticRegimen.DevelopingaPharmacotherapeuticRegimenandCorrespondingMonitoringPlan.InitiatingthePharmacotherapeuticRegimen.MonitoringtheEffectsofthePharmacotherapeuticRegimen.RedesigningthePharmacotherapeuticRegimenandMonitoringPlan.哮喘和COPD的藥學(xué)監(jiān)護(hù)第17頁DevelopingaPharmaceuticalCarePlanStep1.GatheringInformationThepharmacistshouldgatheranaccuratemedicationhistory,includingbothprescriptionandnonprescriptionmedicationsandthereasonsthemedicationswereprescribedortaken.Thepharmacistwilllikelyhavetoobtainsomeinformationfromthephysician,suchaslaboratorytestresultsandhospitalizations.Oncethisinformationiscompiled,thepreparationofaPCP(PharmaceuticalCarePlan)canbegin.哮喘和COPD的藥學(xué)監(jiān)護(hù)第18頁Step2.IdentifyingProblemsFromthepatient'smedicationprofile,onlyoneproblemisevident:diagnosisofasthma.Ifapplicable,otherproblemshouldalsobelisted.Subjectivefindingsarethosethatthepatientdescribes(e.g.,'Ifeeltiredallthetime,“Ifeelbloated,”or"Iwokeupcoughing").Objectivefindingsarethosethatcanbeobservedormeasuredbythepharmacist(e.g.,patientappearstired,bloodpressureis180/105,pittingedemainankles).Inthepatientwithasthma,thepharmacistwouldhavethepatientuseapeakexpiratoryflowmeterandrecordtheresults.哮喘和COPD的藥學(xué)監(jiān)護(hù)第19頁Step3.AssessingProblemsThepharmacistanalyzesandintegratestheinformationgatheredinsteps1and2anddrawsconclusionsinpreparationfordevelopingapatient-specificPCP.Forexample,intheasthmacase,thepharmacistmayfirstinvestigatetheetiologyofthefactorsthatexacerbatedtheasthma.Thepharmacistshouldattempttodetermineifdrugs(eg.,aspirin,nonsteroidalanti-inflammatoryagents,orbeta-blockers)causedorexacerbatedtheasthmainthepatient.Thus,theimportanceofanaccurateandcompletedrughistorybecomesevident.Next,thepharmacistassessestheseverityoftheasthma.ThiscouldbeaccomplishedbydeterminingthePEFR,examiningthepatient'sdailysymptomandpeakflowdiary,ordeterminingifthepatienthadbeenhospitalizedandplacedonsteroidsoramechanicalventilator.哮喘和COPD的藥學(xué)監(jiān)護(hù)第20頁Step4.DevelopingthePlanThepharmacistestablishesgoalslinkedtoeachofthepatient'sproblemsandspecifiesacourseofactionaimedatmeetingeachgoal.Eachgoal(i.e.,desiredimprovement)shouldbestatedintermsofmeasurableoutcomesthatindicatetheextenttowhichtheparticularproblemhasbeenresolved.Often,thepatienthasseveralproblems,andtheplanmustbecomprehensiveenoughtohaveapositiveeffectontheoverallhealthofthepatient.哮喘和COPD的藥學(xué)監(jiān)護(hù)第21頁Step5.EvaluatingtheAchievementofOutcomesOutcomesthatwillbeusedtoevaluatethesuccessofthePCPtreatmentplanmustbemeaningful,measurable,andmanageable.Outcomesarespecific,measurableindicatorsforthegoalsoftreatment.Thus,theyshouldbeidentifiedintheplanningprocess.Theoutcomeslistedforasthmawouldinclude,butnotbelimitedto,lowerfrequencyandseverityofacuteexacerbations,fewerphysicianofficevisits,eliminationofsideeffects,PEFRsthatneverfallbelow80%ofpreviouspersonal-bestpredictedrates,feweremergencydepartmentvisits,maintenanceofactivitiesthatenhancethepatient'squalityoflifeandmayhavebeenlimitedbythedisease.哮喘和COPD的藥學(xué)監(jiān)護(hù)第22頁Documentationshouldincludethesecomponents.1.Patientdatasuchasname,medicalrecordnumber,location,dateofhospitaladmission(ifapplicable).age,sex,height,weight,knownmedicationorotherallergies,andmedicationhistory.2.Nameofpharmacist(s)responsiblefordevelopingandimplementingthePCP.3.Patientproblem(s)listedIndividuallyinorderofpotentialpharmacotherapeuticimpact(highesttolowestpriority).4.Dateonwhichapatientproblemisidentified.Manydiseasesremainchronicthroughoutthepatient'slife.Problemssuchasurinarytractinfectionorupperrespiratorytractinfectionusuallyresolvein10to14days.哮喘和COPD的藥學(xué)監(jiān)護(hù)第23頁哮喘和COPD的藥學(xué)監(jiān)護(hù)第24頁哮喘和COPD的藥學(xué)監(jiān)護(hù)第25頁臨床藥師提供藥學(xué)監(jiān)護(hù)哮喘藥學(xué)監(jiān)護(hù)COPD藥學(xué)監(jiān)護(hù)哮喘和COPD的藥學(xué)監(jiān)護(hù)第26頁支氣管哮喘診療流程圖病史經(jīng)典重復(fù)發(fā)作喘息、氣急、胸悶或咳嗽多與接觸刺激性原因相關(guān)。癥狀可緩解有節(jié)律性波動規(guī)律不經(jīng)典體檢異常哮鳴音呼氣相延長無異常發(fā)覺肺功效通氣功效PEF監(jiān)測阻塞性障礙正常舒張?jiān)囼?yàn)激發(fā)試驗(yàn)排除其它肺部疾病陽性變異率

正常陰性陽性陰性COPD？哮喘和COPD的藥學(xué)監(jiān)護(hù)第27頁哮喘分級連續(xù)有癥狀體力活動有限天天有癥狀影響活動和睡眠每七天1次，但<天天1次頻繁≥每七天1次>每個月2次，但<每七天1次60%預(yù)計值變異率>30%60-80%預(yù)計值變異率>30%80%預(yù)計值變異率20-30%治療前哮喘病情嚴(yán)重程度分級癥狀夜間癥狀FEV1或峰流速重度連續(xù)（第4級）中度連續(xù)（第3級）輕度連續(xù)（第2級）間歇狀態(tài)（第1級）<每七天1次，發(fā)作間歇無癥狀GINA≤每個月2次80%預(yù)計值變異率<20%哮喘和COPD的藥學(xué)監(jiān)護(hù)第28頁哮喘分級用藥提議輕度連續(xù)重度連續(xù)中度連續(xù)舒利迭50/100bid-50/250bid舒利迭50/250bid間歇發(fā)作輔舒酮125必可酮?250或1噴qd輔舒酮125必可酮?250或1噴,bidICS+LABA萬托林按需使用輔舒酮?125必可酮?250＋或1-2噴,qd若控制不好，此提議僅供參考，詳細(xì)詳見GINA哮喘和COPD的藥學(xué)監(jiān)護(hù)第29頁一級二級三級四級降級治療間斷發(fā)作輕度持續(xù)中度持續(xù)嚴(yán)重持續(xù)

適級開始治療哮喘控制最少3個月降級治療

哮喘長久治療分級方案GlobalInitiativeforAsthma()哮喘和COPD的藥學(xué)監(jiān)護(hù)第30頁哮喘管理模式哮喘和COPD的藥學(xué)監(jiān)護(hù)第31頁哮喘管理計劃教育評價和監(jiān)護(hù)哮喘防止誘因急性發(fā)作治療計劃規(guī)律隨訪GlobalInitiativeforAsthma建立個人診治計劃哮喘和COPD的藥學(xué)監(jiān)護(hù)第32頁在病區(qū)開展藥學(xué)監(jiān)護(hù)普通程序步驟1了解病情Patient步驟2審核方案Review步驟3確定方案Decision步驟4方案注釋Annotation步驟5監(jiān)護(hù)關(guān)鍵點(diǎn)Carepoints步驟6用藥教育Education步驟7觀察反應(yīng)Monitor步驟8評定反饋Assessment哮喘和COPD的藥學(xué)監(jiān)護(hù)第33頁全方面了解患者當(dāng)前病情、治療目標(biāo)和用藥史確認(rèn)藥品選擇、給藥方法安全、適當(dāng)幫助患者優(yōu)化用藥方案制訂用藥方案執(zhí)行細(xì)節(jié)用藥過程中加強(qiáng)安全性和有效性觀察關(guān)鍵點(diǎn)及節(jié)點(diǎn)加強(qiáng)患者對醫(yī)囑了解和正確執(zhí)行，提升依從性和療效觀察藥品治療效果和各種不良反應(yīng)對現(xiàn)行治療方案進(jìn)行評定，并深入優(yōu)化步驟1了解病情步驟2審核方案步驟3確定方案步驟4方案注釋步驟5監(jiān)護(hù)關(guān)鍵點(diǎn)步驟6用藥教育步驟7觀察反應(yīng)步驟8評定反饋主要目標(biāo)哮喘和COPD的藥學(xué)監(jiān)護(hù)第34頁步驟1：了解病情病人普通情況：年紀(jì)、性別、身高、體重、職業(yè)等；特殊病理生理：老年、兒童、哺乳、妊娠；肝、腎功效、特殊用藥史、藥品不良反應(yīng)史；疾病情況：病變部位、范圍、病因、誘因；疾病分型、分期、分度；并發(fā)癥、并存疾病；治療目標(biāo)：理想目標(biāo)和可行目標(biāo)主要矛盾和次要矛盾：輕重緩急哮喘和COPD的藥學(xué)監(jiān)護(hù)第35頁疾病情況肺炎：感染部位、范圍、分型、嚴(yán)重程度、病原…支氣管哮喘：分期、分級…COPD：分期、肺功效分級、誘因、并發(fā)癥（感染、心衰、呼衰）…肺癌：細(xì)胞分型、分級、分期…哮喘和COPD的藥學(xué)監(jiān)護(hù)第36頁方式與特點(diǎn)經(jīng)過問診、體檢、觀察及閱讀病歷及各類檢驗(yàn)資料，了解與藥療相關(guān)基本情況藥師與患者直接接觸、與醫(yī)護(hù)人員合作哮喘和COPD的藥學(xué)監(jiān)護(hù)第37頁步驟2：審核方案藥品選擇是否適當(dāng)：品種、規(guī)格、劑量、適應(yīng)證、禁忌證；給藥方法是否正確：給藥路徑、給藥時間、給藥療程、配伍情況、聯(lián)用情況；是否還有優(yōu)化可能：有沒有遺漏、有沒有重復(fù)、有沒有更佳替換哮喘和COPD的藥學(xué)監(jiān)護(hù)第38頁方式與特點(diǎn)每當(dāng)新開處方或治療方案更改時審核處方，尤其要考慮患者病理、生理情況及合并用藥之間相互作用，考慮藥品不良反應(yīng)與治療利益相互關(guān)系藥師與醫(yī)生緊密協(xié)作哮喘和COPD的藥學(xué)監(jiān)護(hù)第39頁步驟3：確定方案確定藥品、聯(lián)適用藥、配伍品種；確定給藥劑量、給藥時間、療程；確定給藥路徑和方法哮喘和COPD的藥學(xué)監(jiān)護(hù)第40頁方式與特點(diǎn)了解患者詳細(xì)情況，并考慮所用藥品藥代/藥效學(xué)特點(diǎn)，優(yōu)化并確定給藥方案藥師充分發(fā)揮藥