Tap Chl Tai Mui Hgng Viet Nam - Voiume (59-20). N°2- Aprii, 2014
©ANH GIA HIEU QUA DIEU TRI VA TINH AN TOAN CUA MONTELUKAST d BENH NHAN VIEM MUI DI UTMG
COHENPHEQUAN
Tran Hdi Yin\ Vu Minh Thitt^,
Pham Vdn Third, Phiing Chi Thiln', Nguyin Thi Kim Huan^, TOM TAT
Viem mdi di img (VMDlf) vd hen phi qudn (HPQ) la benh co ty le tucmg ddl cao.
Cysteinyl Leukotrlen, chia khoa ciia cdc trieu chung viem mill dl img (VMDlf) vd hen phi qudn (HPQ) khong bl chgn dung bdi Steroid vd khdng Histamin. Montelukast da phong toa dugc cdc thu the nay vd chimg to co hieu qud trong dieu trl cd VMDlf vd HPQ the nhe vd trung blnh. Phugng Phdp NC: Nghien cuu can thiep theo doi doc, tu doi chimg cho 50 benh nhdn lira tudi tu 18-60 tudi dugc chdn dodn xdc dlnh la VMDlf co HPQ. Ket qud:
Ket qud sau 12 thdng dieu trl, cdc trieu chung ldm sdng deu cdi thien ro ret: cd su tien trien ddng ke ddi v&i cdc trieu chung ve Hen phe qudn vdo ban ngdy 81,5% vd tien triin ddi v&i cdc trieu chirng ban dem 83,1%. Benh nhdn cd su tien trien ddng ke voi cdc triiu chiing VMDlf (vi du hdt hgi 82,5%; chdy mUi 92,5% ; nggt mUi 85%). Viec sir dung thudc Hen vd viem mUi cUng dugc gidm thieu (82,3%). Ket lugn: Lieu phdp Montelukast lOmg/ngdy Id mdt phuong phdp dieu trj hieu qud vd an todn ddi vol benh nhdn VMDlf co HPQ. Tdt cd cdc benh nhdn deu cd y dlnh tiep tuc sir dung lieu phdp Montelukast.
Montelukast dung ngp tdt, phdn img phu rdt nhe (01 benh nhdn) hgi hudn ndn vd sau do trg lgi blnh thu&ng sau 10 phut
Tir khda: viem mUl dl img, hen phi qudn, montelukast SUMMARY
Allergic Rhinitis (AR) and Asthma are highly prevalent diseases. Cysteinyl leukotrienes, key drivers of symptom in both asthma and early and late AR response, are not blocked by steroids or antihistamines. Montelukast has proven to be efficacious in the treatment of both AR and asthma.Patients and method: the auto controlled descriptive follow-up study on 50patients aged 18-60 years old with allergic asthma. Results: after 12 months oftreatment, the clinical symptoms were markedly Improved: there Is significant progress for the symptoms of asthma at 81.5 %, and 83.1 % on the development of symptoms at night. Patients with significant progress with AR symptoms (sneezing 82,5%, rhinorrhea 92,5%, blocked nose 85%). Asthma drugs and AR drugs are also used reducing (82,3%). Conclusion: Montelukast lOmg Is an effective and safe treatment for allergic asthma patients. All patients had the intention to continue using Montelukast. Montelukast is well tolerated, side effects are mild (appeared in 01 patients).
Keywords: allergic rhinitis, asthma, montelukast
'Benli vien Tai Mui Hgng TLT
^Bai hoc Y Ha Noi 'Bai ligc Y Hai Phong Nhan bai 10/3. Duyet in 20/4/2014
68
Tap chl Tai Mui Hpng Vifit Nam - Volume (59-20). N°2-April, 2014
1. DAT VAN DE
Nghien cuu lam sang dich tfi hgc vd smh ly benh cho thdy mfit mdi quan he chuc ndng va miln dich manh me giiia mui va phe qudn. Miii bi kich thich cd thfi gdy CO that phe quan boi mfit trung gian rhinobronchial phan xa vd viem cd ngudn goc tir cdc di nguyen dudng khi hit vdo mui va viem phe qudn kich boat. Phfi qudn d cac ddi tugng man cam dan dfin vifim mui thdng qua he tuan hoan. Mfii quan he dich tfi gida vifim mui vd hen cho thdy rd rang phdn ldn bfinh nhdn mac hen phfi quan di ling hay khdng dj iing dfiu mac chiing viem miii.
Trong nhifiu nam qua, mfii lifin he giiia hen phfi qudn vd vifim mui di iing vfin dugc cho Id cd mdt co sd dj iing chung. Tuy nhien, nhihig nghifin ciiu gdn day cho thdy viem mui di ung tang gap 3 lan khd nang phat trifin thdnh hen phe quan tren cdc dfii tugng di dng vd khfing di iing. Thuc tfi, hon 40% cda cdc ca vifim mui di iing bi hen phe qudn, trong khi dd ban 80% benh nhdn mac hen phfi quan di iing cd kem theo viem mui di ling. (} nhung bfinh nhdn hen phe quan nay, viem mfii di ung cd thfi la nguyen nhdn do benh khdng dugc kifim soat triet de vd nguy CO mdt kifim soat bfinh hen gia tang Cling vdi muc do nghifim trgng cua dj ung.
Ngoai cac mfii lien he dich tfi hgc cdn cd cdc bdng chting cho thdy hen vd viem mui di ling cd co chfi benh sinh va mifin dich tuong t^r nhau. VMDLT dugc ddc trung bdi chiing viem man tinh nifim mac mfii, cd nhifiu difim tuong ddng voi chiing viem
dudng hd hdp duoi dugc ghi nhdn d nhung benh nhdn hen phfi quan bao gdm su gia tdng tfi bao mast va bach cdu di toan, sir kich boat T-lymphocyte va bifiu hien gia tang cytokine. Tu dd, cdc hudng ddn ung hp cho vific kfit hgp phuang phdp chdn doan va chiia tri VMDU" cd HPQ thuong dugc ggi la "bfinh khi qudn di iing" hoac hpi chiing viem miii di iing cd hen phfi quan (Asthma Rhinitis).
Difiu tri vifim raui di irng cd HPQ khdng chi lam gidm tac nghen viem miii va xoang, ma cdn cd the lam gidm mdn cam dudng hd hap dudi va trieu chung cua benh HPQ. Dieu tri viem mui di iing la mgt difim quan trgng trong kiem soat HPQ. Khi cd su tham gia ciia Leukotrienes cystein vao sinh ly bfinli hgc cua bfinh hen va VMDU cho thdy su ngan ham thu thfi Leukotrienes cystein cua Montelukast cd thfi mang lai lpi ich trong difiu tri cho bfinh nhdn VMDU" cd HPQ. Muc dinh nghien cuu cua chung tdi dfi ddnh gia tdc dung cai thien va kiem sodt trifiu chiing lam sang d benh nhan VMDU' cd HPQ cua Montelukast.
2. DOI TU'ONG VA PHU'ONG PHAP NGHIEN cifV
2.1. Do! tugng, thdi gian, dia diem nghien cihi
2.1.1. Ddi twang nghien ciru: Gdm 50 benh nhdn VMDU cd HPQ, dugc dieu tri Montelukast lieu lOmg/ngay trong thdi gian 1 nam
2.1.2. Thdi gian vd dja diem nghien cwu:
tu thdng 9/2011 dfin 8/2013 tai khoa mifin
Tap chl Tai MOi Hpng Viet Nam - Volume (59-20). N°2- Apnl, 2014
dich lam sang Benh vien Dai hoc Y Hai Phong.
2.2. TIEU C H U A N C H O N BENH NHAN
* Dugrc chin doan la VMDU' co HPQ, neu
CO :
Cac trieu chiing cua VMDU phai co tiSn sii tir 2 nam tro len va cac trieu chiing cua HPQ phai co tiSn su tvi 1 nam tra len
Ti^n sir di ilng va hen ph8 quan (ca nhan va gia dinh).
Co test lay da voi DN cho kit qua ducmg tinh.
Lam sdng:
• VMDU: Co cac trieu chiing cua
VMDU ban ngdy: nghet miai, chay nuac miii, ngiia miii, hat hoi. Cac trieu chiing nay xuit hien thanh con, nhieu can teong mot dot. Ban dem: Kho ngu, thiic giic MI dem, nghet mOi khi thiic day. Co thS xuit hien trieu chiing a mat (mat do).
HPQ: Co tridu chiing lam sang chinh cua HPQ: kho tho v6i cac dac diim;
Kho tha xuit hien thanh timg con, ngoai can nguai b$nh binh thuong, con kho tha thuang xay ra ve dem, kho tha ra la chu ySu. Kit hop viSi kham thuc thi a ph6i. Do chiic nang ho Hip : FEVl va FEVl % giam tten 20%
HEN PHE QUAN BAC 1,2,3 THEO PHAN LOAI CUA GINA Bang 2.1: Cac miic do cua HPQ theo GINA (2006).
Miic do Bad: Nhe,
cdch qudng Bdcll: Nhe,
dai ddng Bgc UI: Vua,
daiddng
Trifiu chiing hang ngay
< llan/tudn dot biing phat ngan
>1 lan/tudn nhung
<1 lan/ngay, cd thfi anh hudng den hoat dgng thfi luc
Hang ngay, anh hudng den hoat dpng thfi luc. Su dung thudc cat con hang ngay
Sd con dfim
< 2 Idn/thdng
>2 Idn/thang
>1 Idn/tudn
PEF, FEVl
>80 %
>80 %
60-80 %
Dao ddng PEF/ngay
<20 %
20-30 %
>30 %
* Cdc xet nghiem co bdn trong gidi han binh thudng, cac xet nghiem sinh hda vfi chiic nang gan va than binh thudng
* Tudi: tat ca cac benh nhan tir 15 tudi trd len.
* Bfinh nhan tu nguyen tham gia 2.3. Tiiu chudn hgi trie
nhan:
Se loai khdi nghifin ciiu nay cac benh
Tap chi Tai Mui Hpng Vi#t Nam - Volume-(59-20). N°2- April. 2014
* Khdng cd day du cac trifiu chiing cua VMDU va HPQ
* HPQ bac 4 theo phan loai cua GU^A
* Dang bi benh ly nhifim khudn cdp d mui xoang : nhu vifim mui mu, viem xoang mu, "cdm ciim"...
* Dang bi bfinh ly nhifim khudn cap d duong bd hdp dudi: viem phe quan, vifim phdi...
* Bfinh nhdn mdc cdc bfinh toan than phdi hgp: benh tim mach, viem gan, vifim thdn, benh he thfing...
* Dang dieu tri trong viing 2 tuan trudc dd bang cac thudc khdng histamin, corticoid (tai chd vd toan than), thudc lam ben vung mang tfi bdo (cromoglycate...), thufic kich thich betai-adrenergic (Salbutamol...); hodc cac bai thufic dfing y chGa di iing ndi chung.
2,4. PHU'ONG PHAP NGHIEN ClTU 2.4.1. Thiet ki nghiin cwu
Nghiin cuu thd: nghiem ldm sdng, lien cuu tu ddi chung trudc vd sau diiu tri 2.4.2. Cac thu nghiem can lam sdng
Cdc phuong phdp chdn dodn khdng ddc hieu in vivo
* Do chuc nang hfi hap: dua vao cac thdng sd FVC, FEVl, FEV1% dfi xac dinh ngudi bfinh cd rdi loan thdng khi tac nghen
* Chup X.quang tim phdi
* Dinh lugng IgE toan phdn trong huyet thanh: IgE toan phdn trong huyet thanh dugc do bdng phuong phap mifin djch phdng xa hoac mifin dich enzym (ELIZA) vd dugc tinh ra don vi Ul/ml 2.4.2.1. Qui trinh diiu tr}
- B?nh nhdn dugc dieu tri VMDU cd HPQ vdi Montelukast I Omg mpt ldn mpt
ngay vao budi tdi trudc khi di ngu trong vdng 12 thdng.
2.4.2.2. Quy trinh theo ddi benh nhan vd ddnh gid hieu qud dieu tri
Sau 1,3, 6, 12 thang difiu tri benh nhdn se dupc tham khdm ldm sang dfi so sanh vd ddnh gid hifiu qua difiu tri
2.4.2.3. Quy trinh theo doi tac dung phu va tinh an toan cua Montelukast
Binh nhdn dugc iheo doi trong sudt qud trinh diiu tri ve cdc tdc dung phu cd thi gap khi diing Montelukast vd ldm cdc xet nghiim ve chiic ndng gan than khi cdn ihiet trong thdi gian diiu tri vd khi kit thuc giai dogn diiu tri di ddnh gid tinh an todn cua Montelukast
2.5. Xir ly so lieu
* Cac sd lieu tren dugc xu ly tren mdy tfnh vdi chuong trinh phan mfim SPSS 15.0
* Test Student khi so sanh 2 ty lfi vd so sdnh tmng binh
* Cdc thfing sd cd y nghTa thfing kfi khi p<0.05
3. KET QUA NGHIEN ClTU 3.1. Dac diem chung
3.1.1. Dgc diim vi tudi, gi&i, vd th&i gian mac binh
3.1.1.1. Tudi
Bang 3.1: Phan b6 theo tudi Lira tudi
1 6 - 2 9 30 - 39 40 - 49 5 0 - 55 Tong
S6 benh nhan
20 13 10 8 50
Ty le %
40 25 20 15 100
Tap chl Tai IMui Hong Vi#t Nam - Volume (59-20). N°2- April, 2014
Nhan xet: Tren 50 henh nhan chiing toi gap nhieu nhat a nhom 16-29 tuoi chiem 40%, tiip din la nhom 30-39 tuoi chiim 25%, 40-49 tudi chiim 20% va nhom it nhit 50-55 tu6i chiim 15%.
3.1.1.2. Giii:
Trong s6 50 benh nhan, chiing toi thiy CO 24 nii va 26 nam.
&
Bi^u dd 3.1: Ty le vdgidi Nhgn xet: Ty lfi nam vd nir trong nhdm nghien ciiu la tuong duang nhau 26/24 ngudi mac bfinh.
3.1.1.3. Thdi gian mac binh Bang 3 2: Phdn bo theo thdi gian Thai gian
(nam) 1 - 5
6 - 10 11 - 15
>16 T6ng s6
Sd benh nhan
11 19 7 13 50
Ty le % 22,5 37,5 15 25 100 Nhdn xet: Tat ca cac benh nhan deu co thai gian mac benh la tten 1 nam. S6 benh nhan mac benh tir 6-10 nam chiem ty le cao nhit (37,5%).
3.2. Thay doi ISm sang tru'd'c va sau 12 thang dieu tri
3.2.1. Thay Si trieu chiimg viem mui di Ong tru&c va sau 12 thdng tiiu tri 3.2.1.1. Hdt hai:
90-^^- 80Cr- i(y-r
5U'.>
4 0 % 30%
\[V}-
M' •
^1
1 • ft- • 1 1
*
27.T';.
._:: - | I.
N,ln^ Tninj; binh Khong bi
Bi^u dd 3.2: Kgt qua v l trieu chung hat hci Nhgn xet: Tdt ca cdc bfinh nhdn tnrdc dieu tri dfiu bi hat hoi, trong do hau hfit la hat hoi d miic do nang, lifin tuc thdnh trdng nhieu cai (87,5%). Sau difiu tri, so lugng b?nh nhdn hat hoi giam cdn 72.5%, giam nhifiu d nhdm hat hoi nang (cdn 17.5%), giam hem so vdi trudc difiu tri cd y nghTa thdng ke vdi p<0,001. Cd 14 trudng hgp khong cdn thdy hat hoi sau khi dieu tri 12 thdng (27.5%).
3.2.1.2 Chdy mUi
1
Bieu dd 3.3: K6t qua v l trieu chung chay mui
Nhgn xet: Tat ca cac bfinh nhdn trudc difiu tri dfiu cd bieu hien chay mui, trong dd
Tap chi Tai MQi Hgng Viet Nam - Volume (59-20). N°2- April, 2014
muc dp nang (chay miii nhifiu, lien tuc) chiem tdi mpt niia (50%). Sau difiu tri sd b?nh nhan chdy mui nang la 7,5% gidm hon so vdi trudc difiu tri Id 42,5%
(p<0,001). Cd 30% bfinh nhan khdng cdn chdy miii sau dieu tri.
3 2.1.3- Nggt miii
67,55
t I •!
• SauitiOu 1 B i l u dd 3.4: K i t q u a v l trieu chirngngat mui
Nh^n xet:
Sau difiu tri s6 bfinh nhdn cd bieu hifin ngat mui giam xufing cdn 55%, thdp hon so vdi trudc dieu tri. Tuy nhifin sd b$nh nhdn gidm ngat miii chu yeu nam d nhdm ngat miic do trung binh. Van cdn 7 trong sd 11 benh nhdn ngat ndng khdng hfi gidm tri?u chiing ngat mui sau difiu tri. Cd 45 % b^nh nhan sau dieu tri khdng cdn ngat miii.
3.2.2. Thay dSi cdc triiu chu-ng hen phi qudn trwdc vd sau 12 thdng dieu tri
Bang 3.3. Thay ddi cSc tneu chung hen p h i qudn trudc v ^ sau 12 thdng dieu tri
K^t qua Tri$u ciii>ng
Kh6 thd Ho Ti>cng(fc
Tdng
Trifdc dieu tri n 30 41 31 50
%
60 82,5 62,5 100
Sau 12 h^ng dieu tri
n 9 13 14 50
%
17,5 25 27,5 100
P
<0,01
Nhdn xet:
Qua bdng trfin cho thdy sir thay ddi cac trifiu chiing co nang sau difiu tri bang Montelukast:
- Trifiu chiing khd thd: Trudc dieu tri 60% bfinh nhdn khd thd, sau 12 thang dieu tri cdn 17,5% bfinh nhdn khd thd.
- Trifiu chiing ho ve dem, day la bieu hifin thudng gap cua hen phfi qudn ciing gidm ro ret sau khi difiu tri bang Montelukast. Trudc difiu tri cd 82,5% benh nhdn ho ve dem, sau 12 thang cdn 25%
bfinh nhdn ho ve dem.
- Trifiu chung tuc nguc: Trudc difiu tri cd 62,5% bfinh nhdn tuc nguc, sau 12 thdng difiu tri cdn 27,5% benh nhan tuc nguc. Su thay dfii cac trieu chung co nang trudc, 12 thang dieu tri cd y nghia thdng kfi vdi p< 0,01.
Bang 3 4 Thay ddi trifiu chdng thuc t h l d phdi sau d i l u trj Montelukast
K i t qua
Trieu chu'ng
Ran rit Ran ng^y
Ran rit + ran ngSy Khong co ran Tdng
Tru'd'c d i l u trj n 14 5 27
4 60
%
27,5 10 55 7,5 100
Sau didu tri 12 thang n 4 3 6 37 50
%
7,5 5 12,5
75 100
P
<0,05
Nhdn xet:
Qua bdng tren cho thdy cd sir thay ddi theo chifiu hudng gidm ddn theo thoi gian
Tap chi Tai Mui Hgng Viet Nam - Volume (59-20). N 2- April. 2014
dieu tri cac trifiu chiing thuc the d phdi.
Trudc dieu tri 55% bfinh nhdn cd ran rit, ran ngay, sau 12 thang dieu tri cdn 12,5%.
Ty le bfinh nhdn cd ran rit d phoi trudc dieu tri Id 27,5%, sau 12 thang difiu tri cdn 7,5%. Ty lfi bfinh nhdn khdng ran tang dan theo thdi gian difiu tri. Su khdc bifit nay cd y nghia thdng kfi vdi p < 0,05.
3.3.3. Kit qud thay doi thdng khi phdi sau khi ^eu tri bang Montelukast
Bang 3.5. So sanh chT sd thong khi phdi tru'dc va sau dilu tri bSng Montelukast KM qua
Chl tieu FVC FEVl Chi so Gaensier
XiSD( % s6 ly thuyit) Tru'd'c dilu
tti 73,36+9.57 68,06+12,39 57,62+11,57
Sau 12 thang dilu trj 94,07+8,59 83,66+8,38 82,37+9,19
P
<0,05
Nhdn xet:
Qua bang cho thay co su gia tang din cac chi tieu theo thai gian diiu tri:
* Chi s6 FVC:
Truoc dieu tri, FVC trung binh la 73,36%, sau diiu tti 3 thang la 76,46%, sau 12 thang diiu tri la 94,07%.
* Chi s6 FEVl:
- Truoc dieu tri, FEVl trung binh la 68,06%, sau diiu tri 3 thang la 72,20%, sau diiu tri 12 thang la 83,66% .
* Chi so Gaensier:
- Truoc dieu tri, chi so Gaensier trung binh la 67,52%, sau diiu tri 3 thang la
71,57%, sau diiu tti 12 thiing la 82,37%.
Sit thay ddi cac chl tieu trudc va sau, 12 thang diiu tri co y nghla thSng ke voi p<0,05.
3.3.4. Bdnh gid tinh an todn c&a Montelukast
Bang 3.6. Tac dung ichong mong mu6n cija Sunguiair
Kit qua Trieu chd'ng
Bau ddu Bufin ndn Dau bung R6i loan tieu hoa
Tdng cong n 1 1 0
%
2,0 2,0 0,00 0,00 Nhdn xet:
Hen phfi qudn, VMDU" Id bfinh man tinh, phdi ufing thudc dai ngay, thdm chi ca ddi, do vdy lua chgn cac thuoc cd hifiu qua dieu tri, it tdc dung phu la uu tien hang ddu cua cdc nhd ldm sang. Trong qua trinh difiu tri chiing tfii chi gap mgt sd tac dung khdng mong mudn trfin 1 bfinh nhan nhu: dau dau (2,0%o), budn ndri (2,0%). Tuy nhifin benh nhan ndy cdm thay binh thudng trd lai sau
10 phut.
4.BAN LUAN 4.L Dale diem chung 4.1.1. Vi tudi
Trong nghifin ciiu cua chiing tdi, benh nhdn d liia tudi tir 16 dfin 29 la cao nhdt chifim 40%; tu 30 dfin 39 tudi la 25%; tir 40 dfin 49 tudi Id 20%; tu 50 dfin 55 tudi la 15% Id thdp nhdt. Thai gian mdc benh tir 1 dfin > 16 nam, difiu do cho thdy lua tuoi mdc bfinh VMDU" kem theo HPQ Id rit 74
Tap chi Tai Mui Hgng Viet Nam - Volume (59-20). N*'2- April, 2014
som. VMDU* cd chieu hudng bit ddu tii luc cdn tre va qua nhieu nam sau cang trd nfin xau hon rdi gidm di vao Iiic tudi gia.
Nghien cuu ciia chiing tdi phu hgp vdi kfit ludn cua cac tac gia trong va ngodi nudc khac. Yfiu td nguy co bao gom gen vd mdi trudng sdng. Khi ca thfi da dugc di tmyfin kha nang tao ra khang the IgE vdi mdt chdt gay di iing (vi du di nguyfin bui nha) thi ngay khi co thfi tiep xiic vdi mdt sd lupng di nguyfin vua dii, lap tdc ca thfi tao ra cac khang the IgE dac hifiu vdi di nguyen do. CJ Ilia tufii thanh thifiu nifin, ddy Id luc co thfi cd he thfing mifin dich hodn chinh dfi sinh ddp ung khang the m£tnh nhat va VMDU"
thfi hifin ro rdng nhdt. Liia tudi nhd hoac cao tudi, dap iing mien dich hoac chua hodn thifin hoac dd bi gidm sdt nfin t^' lfi mac benh it hon. Tudi cang cao, ty lfi vifim mui man tinh khfing do di iing chifim vi tri n6i trfii do rfii loan thdn kinh tu chu tai mui vd ton thuong niem mac miii do cac yeu to mdi truong khdc nhu hod chat dfic h^i, d nhifim khdng khi, khdi thudc, su tdn cfing ciia vi khudn, vi rut...
4.1.2. Vigi&i
Trong nghien ciiu cua chung toi cho thay ti lfi nam/nQ la 21/19. Bifiu nay phu hgp vdi cac tdc ngoai nudc cho rang NMDU, HPQ khdng cd lifin quan vfi gidi.
Tiic Id ty le mac bfinh d nam vd nd la ngang bdng nhau.
4.1.3. Thdi gian mdc binh
Thfii gian mdc bfinh tnmg binh trong nghien ciiu ciia chung tdi Id 8,41 nam.
VMDU" cd hen la benh man tinh keo dai va dieu trj dai dang, cdc benh nhdn xudt hifin b ^ d tudi tirong dfii tre. Hdu hfit cac bfinh nhan ngufin ciiu deu da qua difiu t i trifiu chiing nhifiu ndm khong da ho?c dd rdt it nfin thoi gjan mac b ^ rat cao.
4.2. Thay doi cac trieu chirng Iam sang tnrdc va sau dieu tri
4.2.1. Thay doi trieu chwng cor nang VMDlf
Khdo sdt ky ludng tifin su bfinh Id can cii de phan biet ddy la mdt VMDU thuc su hay chi la dgt cdp cua vifim mui do lanh.
Theo P.Demoly va J.Bousquet(1997), trieu chung difin lunh cua VMDU" quanh nam Id tac ngat mui. Cac trieu chiing hat hoi thanh trang, chay mui va ngiia mui di kem theo nhung khdng ndi trfii nhu trong VMDU"
theo mua (do phan hoa). Ciing theo tieu chuan chan doan VMDU" cua hai tac gia trfin thi VMDU" quanh ndm nhdt thifit phai cd tii hai trifiu chiing trd Ifin (trong sfi cdc trieu chiing hat hoi, ngiia mui, chdy miii, ngat mui), bieu hifin hon mfit gid mdi ngay ngoai dgt nhifim vi nit. Nghifin cuu cua Vii Cao Thien(1999) trfin 57 BN VMDU thi 100% dfiu cd tam chiing hat hoi, chay mui, ngat miii.
Kfit qud nghifin cuu ciia chung tdi la 87.5% sd BN cd tii 3 trifiu chiing trd Ifin, 20% cd tu 2 trieu chiing. Day la budc ddnh gia dau tien trudc khi khdm bfinh. Kfit qud cua chung tdi phu hgp vdi tieu chudn chan doan cua P.Demoly va J.Bousquet.
Cdc truomg hgp giam ngdi dfiu cd bifiu hien ngat mui d muc do nang va sau difiu tri tinh trang ngat mui cung khfing thay ddi. Nhu vdy tinh trang ngat mui nang vd giam ngui cd le lien quan den su thoai hod nifim mac mui gay ra va rdt it dap ling vdi dieu tri.
4.2.2. Thay doi trieu chumg ca nang, th^c thi vd thong khi phdi & benh nhdn hen phi quan sau dieu tri:
Theo ddi sir thay ddi cac trieu chiing CO ndng benh nhdn HPQ khi difiu tri bdng
Tap chi Tai MQi Hgng Viet Nam - Volume (59-20). N°2- April, 2014
Montelukast, chiing toi thdy trudc dieu tri 60% bfinh nhdn cd khd thd, 62,5% ludn cam thdy tiic nguc, 82,5%o ho vfi dfim. Sau 12 thang difiu tri, cdn 17,5% bfinh nhan cdn khd thd, 25% bfinh nhan ho, 27,5%
bfinh nhdn tiic nguc (Bdng 3.3 ). Su thay ddi cac trifiu chiing ca nang trudc vd sau 12 thdng difiu tri cd y nghia thdng kfi vdi p<0,01.
Ddi vdi cac trifiu chung thuc thfi, trudc difiu tri 55% benh nhdn cd ran rit, ran ngdy. Sau sau 12 thang cdn 12,5%
bfinh nhdn cd ran rit, ran ngdy (Bdng 3.4).
Ty le bfinh nhan cd ran don dgc nhu ran rit hoac ran ngdy cung giam rd so vdi trudc difiu tri. Su thay doi cac trieu chiing thuc thfi trudc vd sau 12 thang difiu tri cd y nghia thdng ke vdi p < 0,01. Difiu nay chiing td sau khi difiu tri bang Montelukast cung vdi su tdt Ifin vfi trifiu chdng CO ndng thi trifiu chiing thuc thfi cung gidm ddn theo thdi gian difiu tri phu hgp vdi dien bifin lam sang cua bfinh nhdn.
Su thay dfii cd y nghia thdng ke cac trieu chiing co nang vd thuc thfi sau 12 thang so vdi trudc difiu tri, difiu nay khang dinh hieu qua ro ret cua Montelukast lam dn dinh con hen, lam giam tat cd cdc trifiu chiing cua hen. Nhan xet nay cung phu hgp vdi cac nghien ciiu trong va ngodi nudc. Kfit qua nghifin ciiu cua Truong Hodng Viet (2009), trudc difiu tri bang Montelukast, 61,64% bfinh nhdn khd thd, 65,75% bfinh nhan tiic nguc, 52,95% bfinh nhan ho vfi dfim. Sau 12 thang difiu tri cdn 30,14% bfinh nhan khd thd, 19,18% benh nhan tiic nguc, 24,66% bfinh nhan ho vfi dfim [7].
Nghifin ciiu cua Ahmed S, Atia NN (2010), ciing nhdn thay rdng cdc bfinh
nhdn HPQ dugc dp dung du ichdng bang Montelukast cd su cai thien tdt cac trieu chiing ldm sang [9].
Thay ddi thong khi phoi sau difiu tri:
Trong nghien cuu cua chiing tdi, trudc difiu tri bdng Montelukast, cdc chi so thdng khi phdi FVC, FEVl, Gaensier dfiu gidm dudi miic binh thudng, tuong iing vdi cdc bac hen (Bang 3.5). Kfit qua nay phu hop vdi nhdn xet cua mpt sd tac gid khdc. Nguyin Huy Luc (2002), nghifin ciiru ddc diem ldm sang, thdng khi phfii bfinh nhan HPQ vd bfinh phfii tac nghfin man tinh qua tham dd chuc nang hd hdp thdy rang cac chi sd FVC, FEVl, Gaensier deu gidm hon so vdi ngudi binh thudng. Nghien ciiu cua Truang Hodng Viet (2009) tren 73 bfinh nhdn HPQ, cho thay cac chi sd thong khi phdi d bfinh nhan HPQ deu giam dudi miic binh thudng tuong iing vdi bac hen [7].
Sau 12 thdng dieu tri bang Montelukast, chiing toi nhan thay tat cd cac chi tieu thdng khi phoi deu tang. CM sd FVC trung binh trudc difiu tri la 73,36±9,57, sau 12 thang difiu tri la 94,07±8,59. Chi sd FEVl trung binh trudc difiu tri la 68,06±12,39, sau 12 thang difiu tri la 83,66±8,38. Chi sfl Gaensier trung binh trudc difiu tri Id 67,52±11,57, sau 12 thang difiu tri la 82,37±9,19. Sir thay ddi cac chi sd cd y nghia thong ke vdi p < 0,05. Kfit qua nghifin ciiu cua Truong Hoang Vi?t (2009), sau khi difiu tri HPQ bdng Montelukast 3 thdng, 6 thang, 12 thang nhdn thdy cdc chi tifiu thong khi phdi dfiu tdng [7]. Cdc nghifin cuu trong va ngdai nudc vfi hen phfi quan cho rdng rdi loan chuc nang thdng khi phfii trong hen la rfii
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Tap chl Tai Mui Hgng Vidt Nam - Volume (59-20). N°2- April, 2014
loan d^ng, thay ddi theo timg benh nhdn va timg thoi ki trfin cung bfinh nhan, cd the hfii phuc hoan toan hay gan hoan todn sau difiu t4 [7] [9]. Nghien cdu cua chiing toi phu hgp vfii nhdn xet nay.
Tuy nhien, chung toi nhdn thdy su hfii phuc cua cdc chi tifiu thdng khi phfii la khdng tuang duong nhau, cdc chi tieu FEVl, PEF, FVC hdi phuc sdm, Nguyfin Huy Luc (2002) cho rang, nguyfin nhan do tinh trang vifim dudng thd cdn tdn tai ldu dai trong HPQ. Do cd su bifin ddi cham cua thfing khi phfii so vdi difin bifin ldm sang nfin cdn phdi difiu trj chdng vifim ldu dai kfit hgp vdi difiu tri tac nghen dudng thd vd theo ddi thdng khi dfi ddnh gid dien bifin va can thifip difiu tri kip thdi dfi dat dugc hieu qua cao trong dieu tri HPQ. Nhu vdy, su tu vdn va hudng din benh nhan theo ddi trong qua trinh difiu tri Id nhifim vu rdt quan trpng cua ngudi thay thudc.
4.3. Tdc dung khong mong muon trong qua trinh di^u tri
Sau 12 thdng difiu tri chung toi thdy ty le tdc d\mg khdng mong mudn khi difiu tri Montelukast rdt it gap, hdu hfit benh nhdn dung nap thufic tfit. Chiing tdi chi gap mdt so tac d\mg khdng mong mufin tren 1 bfinh nhdn nhu: budn ndn (2,0%). Tuy nhifin b?nh nhdn nay cam thdy binh thudng trd lai sau 10 phiit. Kfit qud nghien ciiu cua chung tdi tuong tu kfit qua cua Truang Hoang Viet vd cac tac gia trfin the gidi.
Trong cdc nghien ciiu Montelukast ciia cdc tdc gia khac cung cho kfit qua tuang tu, thudc khdng dnh hudng Ifin tim mach, khong dnh hucoig len he tifiu hda va xuang khdp. Vi v$y, montelukast dung dugc trfin nhifiu b?nh nhdn cd benh ly kfim theo ma khong sg tdc dyng phu cua thudc [9,10].
KET LUAN
Qua nghien cuu 50 bfinh nhdn VMDU*
cd hen phfi qudn dugc dieu tri bang montelukast trong 12 thang, chiing tdi rut ra mdt sd ket ludn sau:
5.1. Sir thay do! lam sang
5.1.1. Cdc triiu chimg ccf nang VMDlf:
- Hdt hod: Trudc difiu tri 100% bfinh nhan hat hoi trong dd d mdc do ndng, lien tuc thdnh trdng nhifiu cdi la 87,5% vd muc do trung binh Id 12,5%. Sau difiu tri miic do nang gidm xudng tir 87,5% cdn 17,5% va cd 27,5% benh nhan khdng cdn trifiu chiing hdt hoi.
- Chay mUi: Trudc difiu tri 100% bfinh nhdn chay nudc mdi trong dd d miic do nang, la 50,0%. Sau difiu tri muc do nang giam xudng tir 50,0% cdn 7,5% vd cd 30%
bfinh nhdn khdng cdn trifiu chiing chdy nudc mdi.
- Nggt mui: Trudc dieu tri cd tdi 90%
benh nhdn bi ngat miii trong dd d miic do ndng, la 22,5% va muc dp trung blnh la 67,5%. Sau dieu tri muc do ndng giam xudng tu 22,5% cdn 15% vd ty lfi bfinh nhan khfing cdn trieu chiing ngat mui tang tu 10% len 45%.
5.1.2. Cdc trieu ca nang, chwng thwc thi, thdng khi phdi cua hen:
- Kho thd: Trudc difiu tri cd 60% benh nhan cd trieu chimg khd thd, con khd thd thudng xudt hien ve dem, sau difiu tri gidm cdn 17,5%.
- Ho: Trudc difiu tri cd toi 82,5% cd bifiu hifin ho, sau difiu tri gidm cdn 25%.
- Twc nguc: trudc difiu tri cd 62,5%
sau difiu tri cdn 27,5%.
- Thdng khi phdi:
+ Chi sd FVC trung blnh trudc difiu tri Id 73,36±9,57, sau 12 thdng difiu tri la
T?p chi Tai Mui Hgng Viet Nam - Volume (59-20) N°2- April, 2014
94,07±8,59.
+ Chl sd FEVl trung binh trudc difiu tri la 68,06±12,39, sau 12 thang difiu tri la 83,66±8,38.
+ Chi sfi Gaensier trung binh trudc difiu tri la 67,52±11,57, sau 12 thdng difiu trila82,37±9,19.
5.2. Tac dung khong mong muon cua Montelukast:
Sau 12 thdng difiu tri tac dung khdng mong mudn khi difiu tri Montelukast rat it gap, hdu het benh nhan dung nap thudc tot, chiing tdi chl gap mdt so tac dung khdng mong muon trfin 1 bfinh nhdn nhu: dau ddu (2,0%), bufin ndn (2,0%). Tuy nhifin bfinh nhan nay cam thdy binh thudng trd lai sau 10 phiit va cac chi so huyfit hgc, sinh hda, gan than dfiu binh thudng sau thdi gian 12 thang su dung thudc.
TAI LIEU THAM KHAO 1. Nguyen Nang An (2006), Hen phfi
qudn, Bdi giang Di iing- mifin dich ldm sang, NXB Y hpc Ha npi tr 27-40 2. Huynh Khac Cudng, Pham Kien
Hun (2001) , Lien quan giita binh viim mUi di ung vd hen phe qudn. Tap chi Y hpc thuc hanh 12/2001,trl9-21.
3. Phan Quang Doan (2008), Tim hifiu mdi lifin quan cua vifim miii di iing vdi sir phat sinh cua hen phfi quan. Dfi tai CO sd Bfinh vifin Bach mai, tr 15-18 4. Trinh M^nh Hiing (1999), Kit qud
chdn dodn vd dieu tri ddc hieu hen phi qudn - viem mHi di ung do bui nhd.
Luan an tifin si Y khoa, Trudng Dai hgc Y Ha nfii. Ha ngi.
5. Vu Minh Thyc, Pham Van Thuc vd cong SIT (2011), Hen Phi Qudn, Tap 1, NXB Yhgc. Ha ndi.
6. TruOTig Hoang Viet (2009): Nghiin ciru su thay doi ldm sdng, thong khi phdi trong dieu tri vd du phdng hen phi qudn bang Singulair. Ludn van bac
sy chuyfin khoa 2, HVQY.
7. Allergic Rhinitis And Asthma Intemational Recommendations For Patients And Health Professionals In 10 Languages Main Category: Allergy Also Included In: Respiratory / Asthma; Ear, Nose and Throat Article Date: 26 Oct 2007 - 2:00 PDT 8. Ahmed S, Atia NN. (2010).
Simultaneous determination of montelukast as sparing therapy with some inhaled corticosteroids in plasma of asthmatic patients. J Pharm Biomed Anal. 2013 Feb 23;74:pp.250-6.
9. Sy Duong-Quy, Yihua Bei, et at (2013). Activation of RhoA/Rho-Mnase pathway accounts for pulmonary endothelial dysfunction inpatients with chronic obstructive pulmonary disease.
RhoA/ROCK Activation in Pulmonary Arteries in COPD. Physiological Reports.l(5):p.l-10.
10. From Wikipedia. Montelukast, the free encyclopedia, last modified on 1 September2009 at 14:21.
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