Y HOC VIET NAM THANG 12 - SO 2/2010
THAY DOI LAM SANG 0 BENH NHAN VIEM M O I Dj UnNG DO Dj NGOYEN LONG VO DIEU TRI M l i N DICH DAC HIEU DUtTNG DOAl LlTOI
I ^ ^ ^ : -k
Vu Minh Thuc*, Pham Van Thiic*', Huynh Quang Thuan'
T O M T A T :
Viem mui dj iing la mpt b§nh ly do rdi loan dap ling mi§n djch qua co ch§' tdng hgp IgE. Dieu trj mi§n dich dac hieu bang dj nguyen, dac bi$t la dudng nho difdi ludi la phuong phap dac hieu va co hi6u qua the hi6n SLf giam man cam cija co th^ ddi vdi dj nguyen g§y benh.
Sau dieu trj 100 benh nhSn vi^m mui dj iing bdi dj nguydn I6ng vu (44 nam, 56 nQ), cac trieu chiing co nang deu giam : trifu chiing hat hoi la giam nhieu nhat. Cac trieu chiing chay mui, ngat mui giam it han.
Trieu chiing thuc the : tinh trang niem mac (mau sac va su phu ne, xuat tiet djch) co tdt len, tinh trang qua phat cudn dudi cho l<et qua thap hon
Co 3 trudng hgp I<h6ng thay ddi ngat mOi sau di^u tri.
Tat ca cac trieu chirng da giam dang ke sau khi dieu trj dudng nho dudi ludi 9 thang (p< 0,001).
Khdng co su lien quan giiia su giam trieu chiing vdi tudi (r = 0,071; p = 0,484.) hoac vdi gidi tfnh ma co y nghla thdng kg.
TCf khoa: vi&m mui dj iing, mi§n dich dac hieu dudng dudi ludi, Idng vu
S U M M A R Y
Clincalchanges of patients with allergic rhinitis caused by feather allergen and treated by
sublingual immunotherapy
Allergic rhinitis is a disease due to disorders of IgE mediated allergic response. Allergen specific immunotherapy, especially sublingual immunotherapy, is a specific and effective treatment decreasing patients'sensitive levels with the allergen. "^•'••
After the treatment, in 100 patients with allergic rhinitis because allergens feathers (44 male, 56 female) all symptoms were reduced: sneezing symptom was decreased the most. Rhinorrhea and nasal congestion was reduced less.
The entity symptoms: state of mucous membrane (colors, oedema and secretion) was better; state of Inferior turbinate hypertrophy was reduced.
3 cases didn't change nasal congestion after the treatment.
All symptoms were significantly reduced after treatment orally under the tongue after year 9 months (p <0.001).No association between a decrease in symptoms with age or sex that is statistically significant (age: r = 0071, p = 0484, gender: r = -0158, p = 0117).
Key words: Allergic rhinitis, immunotherapy, feather ,r-. i ?^ •;, •>;;i'^ : - ]•. u 0; .
I. OAT V A N OE
Viem miii di ting la benh rit pho bien trong chuy6n khoa Tai MQi Hgng va chuyen khoa Di iing a cac nutdc tren the gidi [10].
Chien lirgc dieu tri Vi6m mui di iing phu thugc vao 4 nguyen ly co ban la tranh tiep xiic vdfi di nguy6n, dieu tri thuoc, di6u tri mi6n dich dac hieu va tuyen truyen giao due cho benh nhto. t ... .
Tat ca cac thudc diiu tri di utig hien co chi hirdfng tdi cai thien cac trieu chiing cua di ling ma khong tac dgng den nhiing nguyen nhan gay ra hoac anh huong den xu hudmg phat trien tu nhien ngay cang xau di ciia benh. !
* Benh vien Tai Mui Hgng TW, ** Dgi Hgc Y Hdi Phdng,'" Benh vien 103.
Muc dich cua dieu tri miin dich dac hieu la lam cho benh nhan tro nen dung nap ddi v6i di nguyen ma hg mSn cam bang each cho tiep xiic deu dan vdi chinh nhiing di nguyen do. Miin dich lieu phap bang duomg tiem lam giam dang ka cac trieu chiing va so' lugng thuoc sir dung nhung viec iing dung phuong phap nay doi khi bi han che do co mgt so' tac dung phu CO the xay ra. Bofi vay mien dich lieu phap bang ducfng dudi ludi hien dang thu hut cac nha lam sang.
II. oo'l T J p N G NGHIEN CLfU
- 100 benh nhan tai benh vien Tai Mui Hgng Trung uong, liia tuoi tir 17 - 39 dugc chan doan mdc benh Viem mui di iing do mat bui nha Long vii qua khai thac benh sir, kham lam sang, test lay da, xet nghiem dich miii.
xet nghiem phan iing phan hiiy mastocyte.
Tat ca cac benh nhan deu co test liy da duong tinh v6i di nguyen Long vii.
III. P H U O N G P H A P N G H I E N CCfU
Phuang phap thir nghiem lam sang tien ciiu.
Thdi gian nghien curu tir thang 06/2009 de'n 06/2010.
So' lieu nghien ciiu dugc xir ly toan thdng ke theo chucfng tnnh STA-WIN.
- Dieu tri mi^n dich lieu phap duong nho dudi luoi:
Nghien ciiu tie'n ciiu va thii nghiem lam sang tu do'i chiing
Phdc do vd thdi gian dieu tri
Lieu lugng can dugc diiu chinh titn co sd tinh phan iing ciia mdi benh nhan.
Di nguyen LOng vu cua Benh vien Tai Mui Hong Trung uong Thi bat dau (24 ngay)
Ngay 1- 4: 1 de'n 10 gipt / IR/ml
Ngay 5-8:1 den 10 giot 10 IR/ml
Ngay 9-15: 1 den 20 gipt 100 IR/ml
Ngay 16-24 : 5 ddn 20 giot 300 IR/ml
Thi duy tri (300 IR/ml)
20 gipt /ngay trong vong 4 tuan, sau d6 20 gipt 3 lan/ tuan trong vong 24 thang
IV. KET Q U A NGHIEN CCfU • ^ 4.1. Dac diem chung
Nhom benh nhan nghien ciiu bao gom 44 nam vl 1 56 nii Tudi trung binh 30.04 ±1.10, trong do tudi 17-39.
86 ngudi sdng d thanh phd, 14 ngudi sdng d ndng thdn.
Tien su gia dinh cd benh di iing xuat hien d 37 benh nhan.
4.2. Tien trien cua cac trieu churng co nang 4.2.1. Hat hai:
Bang 3.2. Tie'n trien trieu chiing hat hdi
Nang Trung binh Khong
Trudc didu tri 55 (55 %) 38 (38%1
ism
Sau dieu tri 7 (7%)
p<0,001
51 (51%) 42 (42%)
Y HOC VIET NAM THANG 12 - SO 2/2010
- 93 benh nhan trudc dieu tri deu bi hat hoi, trong dd hau het la hat hoi d miic do nang, lien tuc thanh trang nhieu cai (55%)
Sau dieu tri, so' lugng benh nhan hat hoi giam cdn 58%, trong dd giam nhieu d nhdm hat hcfi nang (cdn 7%), giam hon so vdi trudc dieu tri cd y nghia thd'ng ke vdi p<0,001.
Cd 42 trudng hgp khdng cdn thay hat hoi sau khi dieu tri 9 thang (42%) 4.2.2. Chdy mdi
Bang 3.3. Tie'n trien trieu chiing chay nudc mQi
Trudc dieu tri Sau dieu tri
Nang 60 (60 %)
17(17%) p<0,001
Trung binh 30 (30%) 46 (46%)
Khong 10(10%) 37 (37%)
90% benh nhan trudc dieu tri deu cd bidu hien chay miii, trong dd miic do nang
(chay miii nhieu, lien tuc) chie'm 60%. '"' '• ' Sau dieu tri so' benh nhan chay mQi nang la 17% giam hon so vdi trudc dieu tri la
602%(p<0,001)
Cd 37% benh nhan khdng cdn chay mui sau dieu tri - • "•'•-'• ''-•'•'.
4 . 2 . 3 . N g g t m d i
Bang 3.4. Tie'n trien trieu chiing ngat mui
Trudc dieu tri Sau dieu tri
Nang 11(11%)
3 (3%)
Trung binh 46 (46%) 21 (21%)
Khong 43 (43%) 75 (75%)
- Trudc dieu tri, 57/100 benh nhan cd bieu hien ngat mQi, chie'm ty le 57%, trong do phan Idn la benh nhan ngat mui timg luc, timg ben, khdng lien tuc (46%). Cd 11 benh nhan ngat mQi lien tuc trong ngay, chiem ty i e i i % .
- Sau dieu tri sd benh nhan cd bidu hien ngat mQi giam xudng cdn 24%, thap hon so vdfi trudc dieu tri. Tuy nhien sd benh nhan giam ngat mui chii yeu nam d nhdm ngat
mirc do trung binh. VSn cdn 3 trong sd 11 benh nhan ngat nang khdng he giam trieu chiing ngat mui sau dieu tri. Sau khi tham kham ddi chie'u tinh hdc mui thi tha'y cac benh nhan nay deu cd cudn dudi qua phat d miic do nang, khdng cdn kha nang co hoi.
- Sau didu tri, 75% benh nhan khdng cd ngat mQi nua, day deu la cac trudng hgp trudc dieu tri cd bieu hien ngat mui trung binh (timg luc, timg ben khdng lien tuc).
:^o,- c c r i n (Ki>'
4.3. Cac trieu chiifng thuc the 4.3.1. Tinh trgng niem mgc
Bang 3.5. Tie'n trien tinh trang niem mac mQi
(ui'!> nr»iO
Trudc dieu tri Sau dieu tn
Nang 18(18%)
5 (5%)
Trung binh 71 (71%) 49 (49%)
Binh thudng 11 (11%) 46 (46%) p<0,001
Tat ca cac benh nhan trudc dieu tri cd tinh trang niem mac phii ne, nhgt mau, trong dd 18 benh nhan la nhgt nhieu, 71 benh nhan nhgt nhe.
Sau didu tri sd benh nhan cdn tinh trang niem mac mui nhgt mau, phu nd giam con 54 benh nhan (54%), su khac biet cd y nghia thd'ng ke (p<0,05)
Cd 31 trudng hgp tinh trang niem mac ve binh thudng sau dieu tri.
4.3.2. Tinh trgng qud phdt cudn mdi dudi
Bang 3.6. Tien tridn tinh trang qua phat cudn mui dudi
Trudc dieu tri Sau dieu tri
Nang 10(10%)
3 (3%)
Trung binh 34 (34%) 25 (25%)
Binh thi/dng 56 (56%) 72 (72%)
Trudc dieu tri, cudn mQi dudi qua phat tha'y trong 44 trudng hgp (44%). Trong dd 10 trudng hgp (10%) la cd cudn dudi qua phat miic do nang, khdng hoac co hoi ra't it khi dat thudc.
Sau didu tri, tinh trang cudn dudi khdng qua phat 72 benh nhan (72%) cd tang hon so vdi trudc didu tri (56%)
Tuy nhien trong 3 trudng hgp cudn dudi qua phat nang thi khdng cd trudng hgp nao thay ddi tinh trang nay trong qua trinh didu tri, trung vdi 3 trudng hgp ngat mQi miic do nang cQng khdng thay ddi sau khi didu tri.
Tat ca cac trieu chiing da giam dang ke sau khi dieu tri dudng nhd dudi ludi 9 thang (p< 0,001).
Khdng cd sir lien quan giQa su giam trieu chimg vdi tudi ( r = 0,071; p = 0,484.) hoac vdi gidi tinh ( r = -0.158, p = 0.117) ma cd y nghla thd'ng ke.
V. BAN LUAN
5.1. Dac diem chung ciia benh nhan tham gia dieu tri
5.1.1. Ve tudi
Theo cac tac gia trong va ngoai nudc thi VMDLT bat dau d do tudi tuong ddi tre (dudi 30), cdn viem mQi van mach bat dau d do tudi Idn hon. Theo tac gia P.B. Boggs thi
khoang 80% VMDU" la dudi 30 tudi. Nghien ciiu cua Doan Thi Thanh Ha cd ket qua tudi trung binh nhdm nghien ciiu la 28,87 ± 10,99. Nghien ciiu ciia Nguydn Nhat Linh cd tudi trung binh la 27,5 ± 9,8. Nghien ciiu cua Nguydn Van Hudngtren 590 benh nhan VMDir cho tha'y 288 benh nhan (khoang50%) trong do tudi dudi 35.
Trong nghien ciiu cua chiing tdi, liia tudi trung binh ciia benh nhan den dieu tri la 30,04 ±1,10.
5.1.2. Vegidi
Nghien ciiu nay cho tha'y ti le nam nii khac nhau khdng cd y nghla thd'ng ke. Dieu nay phu hgp vdi cac tac gia trong va ngoai nudc cho rang VMDLT khdng cd hen quan ve gidi
5.2. Danh gia hieu qua dieu tri ve mdt lam sang
Cd mdt sd nghien ciiu da dugc thuc hifin vd dieu tri midn dich dac hieu bang di nguyen trong vai thap ky qua. Didu tri midn dich bang each tiem dudi da la mdt phuang phap da dugc sii dung nhidu nam d nhidu nudc, nhung gay khd khan cho benh nhan sii dung nen da han che' iing dung cua nd trong thuc te.
Fanta va cdng su sau khi da phat hien ra didu tri midn dich dudng dudi ludi va kdt luan rang didu tri dudi ludi dSn de'n nhung thay ddi he thd'ng trong phan iing midn dich vdi di
Y HOC VIET NAM THANG 12 - SO 2/2010
nguyen dua vao. Dudng dudi ludi dudng nhu da tao ra mdt su tien bg vdi each dua di nguyen vao co the, vi vay nd la phucmg phap dugc ua thich hon trong nghien ciiu cua chiing tdi. Su chap nhan ciia cac benh nhan vdi midn dich dudng dudi ludi la rat td't, dac biet d cac benh nhan da sii dung didu tri midn dich dudng tiem dudi da trudc khi chuydn sang dudng nhd dudi ludi.
5.2.1. Ve cdc trieu chdng ca ndng Cd 3 trieu chiing co nang can ban nhat cua VMDLT la hat hoi, chay mQi va ngat mQi.
Nhin vao bangtQ 3.2 de'n 3.4, tha'y sau didu tri thi ta't ca cac trieu chiing co nang ddu giam hon so vdi trudc khi didu tri. Tuy nhien miic do giam cua tiing trieu chiing rat khac nhau:
trieu chirng hat hoi la giam nhidu nha't. Cac trieu chung chay mQi cQng giam nhidu. Cdn trieu chiing ngat mui la giam it nha't va khdng cd trudng hgp nao ngat mQi nang trd vd miic binh thudng. Didu nay chiing td ngat mQi ben canh nguyen nhan la phii nd xung huyet (loai nay khi tham kham thay cdn dap iing vdi thudc CO mach) thi cdn nguyen nhan hay gap ciia ngat mui tren benh nhan VMDLT la thoai hoa niem mac, qua phat cudn dudi dac biet do lam dung thudc co mach. Ta't ca cac trudng hgp cd qua phat cudn dudi nang gay ngat mui nang ddu khdng dap iing vdi GMCDH. Theo chiing tdi GMCDH ket hgp vdi phau thuat chinh hinh cudn tren nhQng benh nhan nay la cin thiet dd giai quyet van de ngat mui.
5.2.2. Ve trieu chdng thuc the
Chiing tdi nghien ciiu tren tham kham ndi soi dd danh gia 2 trieu chiing thuc thd co ban trong viem mQi di iing la tinh trang niem mac mui va tinh trang cudn mui, dac biet la cudn dudi. Ket qua cho tha'y tinh trang niem mac (mau sac va su phu ne, xua't tie't dich) cd td't len, tuy nhien khdng cd trudng hgp niem
mac phii nd xuat tiet nang nao trd vd miic binh thudng sau didu tri.
Ben canh dd, tinh trang cudn dudi cdn cho ke't qua thap hon so vdi tinh trang niem mac, cac trudng hgp td't len ddu la nhung trudng hgp trudc didu tri chi qua phat nhe.
Khdng cd trudng hgp nao qua phat nang td't len sau didu tri. Dd'i chie'u cac trudng hgp qua phat nang tha'y tuong iing vdi ngat mQi miic do nang va cQng khdng thay ddi ngat mui sau didu tri.
Hieu qua ciia didu tri sau 9 thang, dugc xac dinh bang danh gia trieu chiing, td't hon mong dgi trong nghien cuxi ciia chung tdi.
Mdt hieu qua nha't dinh ciia su phuc hdi nay cd the do hieu ung tam ly dugc didu tri, khi didu tri midn dich lien tuc ca d nha va d co sd vd di ling ciia chung tdi da cd tac ddng tich cue dd'i vdi benh nhan.
Nhidu cdng trinh nghien ciiu trong va ngoai nudc trong nhiing nam gan day ciia Nguydn Nang An, VQ Minh Thuc, Phan Quang Doan, Pham Van Thiic vd GMCDH d cac benh di ung do DN pha'n hoa, Idng vu cho tha'y ty le ke't qua dat d miic kha td't den ra't td't dat tir 60-82%, dii thdi gian tie'n hanh cd thd d miic khac nhau.
Cho tdi nay, theo chung tdi tim hidu, vSn chua cd nghien ciiu diy du ndi rd: khi nao thi dimg dgt didu tri GMCDH la tdt nha't? Mdt sd tac gia cho rang tren thuc te lam sang, ne'u GMCDH da dat dugc hieu qua tdt nha't thi hay cii duy tn mdt thdi gian dai nhat khi didu kien cho phep, song cQng khdng phai keo dai qua nhidu nam.
VI. KET LUAN
Didu tri midn dich dac hieu bang di nguyen, dudng nhd dudi ludi trong 9 thang cho 100 benh nhan viem mui di iing bdi di nguyen long vQ (44 nam, 56 nu), cac trieu
chung CO nang deu giam: trieu chung hat hoi la giam nhidu nha't. Cac trieu chung chay mQi, ngat mQi giam it hon.
Trieu chiing thuc the: tinh trang niem mac (mau sic va su phii nd, xua't tiet dich) cd td't len, tinh trang qua phat cudn dudi cho ket qua tha'p hon
Cd 3 trudng hgp khdng thay ddi ngat mQi sau didu tri.
Tat ca cac trieu chiing da giam dang kd sau khi dieu tri dudng nhd dudi ludi 9 thang (p< 0,001). • '
Khdng cd su lien quan giua su giam trieu chung vdi tudi (r = 0,071; p = 0,484) hoac vdi gidi tinh (r = -0.158, p = 0.117) ma cd y nghla thd'ng ke.
Ket qua sau 9 thang didu tri ne'u tinh d miic do thanh cdng ciia lieu phap nay qua danh gia trieu chung la td't hon mong dgi.
Didu tri midn dich dac hieu dudng nhd dudi ludi la mdt phuong phap dieu tri an toan, dd sir dung, hieu qua cao, benh nhan dd chap nhan va cdng tac didu tri. '• - ' TAI UEU THAM KHAO
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7. Nguydn Nang An va Cong sir (1997): "Viem miii di ioig, tinh hinh, nguyen nhdn, dnh hudng ciia moi trudng vd nhiing bien phdp phdng chdng tai cong ddng". De tai thuoc chuang trinh 01.08. Ha Noi.
8. Vu Minh Thuc (2009), ): ""Dieu die. tieu chudn hod Di nguyen long vii de dng dung trong dieu tri cdc benh di itng: hen phe qudn, viem mid di dng, viem kei mgc, me day ", De tai ca'p thanh phd, Ha noi