哮喘和COPD的药学监护课件

哮喘和慢性阻塞性肺病

的药学监护王卓卫生部临床药师（师资）培训基地中国人民解放军临床药学中心第二军医大学长海医院药学部药学监护的理解与回顾实施药学监护的标准模式临床药师提供的药学监护哮喘患者药学监护要点COPD患者药学监护要点药学监护的理解与回顾pharmaceuticalcare药学监护来源于美国，国内又称药学服务。其核心思想是通过药师与临床医护人员共同协作，为病人提供直接负责的药物治疗，并积极监测治疗的全过程，以改善病人的治疗效果，最终提高病人的生活质量为目标。药学服务的目的获得改善病人生活质量的既定结果。包括：①治愈疾病；②消除或减轻症状；③阻止或延缓疾病进程；④防止疾病或症状的再次发生。IntroductionPharmaceuticalCareThedirect,responsibleprovisionofmedication-relatedcareforthepurposeofachievingdefiniteoutcomesthatimproveapatient’squalityoflife(ASHPStatementonPharmaceuticalCare)WhatapharmacistdoestoimprovepatientcareandpatientsafetyPharmaceuticalCareApatient-centeredpracticePractitionerassumesresponsibilityforapatient’sdrugrelatedneedsPractitionerisheldaccountableforthecareprovided工作开展药学监护是药师在临床疾病治疗中参与并主导的一种工作过程，是多学科协作综合地考虑整体诊疗计划的前提下，从药学角度对治疗计划进行合理的设计、执行、监测和及时调整，实施过程需要患者和医护人员紧密协作。工作职责药师对治疗结果负责至少表现为以下三个方面：①发现潜在的或实际存在的用药问题；②解决实际发生的用药问题；③防止潜在的用药问题发生。药学监护与药物治疗药物治疗是临床治疗的主要方式之一药物治疗是多学科协作的临床服务药学监护是优化药物治疗的主要手段药学监护是临床药师的工作核心实施药学监护的标准模式ASHPguidelinesonastandardizedmethodforpharmaceuticalcare.AmJHealth-SystPharm.1996;53:1713–6.FunctionsofPharmaceuticalCare•

Collectingandorganizingpatient-specificinformation,•Determiningthepresenceofmedication-therapyproblems,•Summarizingpatients’healthcareneeds,•Specifyingpharmacotherapeuticgoals,•Designingapharmacotherapeuticregimen,•Designingamonitoringplan,•Developingapharmacotherapeuticregimenandcorrespondingmonitoringplanincollaborationwiththepatientandotherhealthprofessionals,•Initiatingthepharmacotherapeuticregimen,•Monitoringtheeffectsofthepharmacotherapeuticregimen,and•Redesigningthepharmacotherapeuticregimenandmonitoringplan.CollectingandOrganizingPertinentPatient-SpecificInformationDeterminingthePresenceofMedication-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.SummarizingPatients’HealthCareNeeds.SpecifyingPharmacotherapeuticGoals.DesigningaPharmacotherapeuticRegimen.DesigningaMonitoringPlanforthePharmacotherapeuticRegimen.DevelopingaPharmacotherapeuticRegimenandCorrespondingMonitoringPlan.InitiatingthePharmacotherapeuticRegimen.MonitoringtheEffectsofthePharmacotherapeuticRegimen.RedesigningthePharmacotherapeuticRegimenandMonitoringPlan.DevelopingaPharmaceuticalCarePlanStep1.GatheringInformationThepharmacistshouldgatheranaccuratemedicationhistory,includingbothprescriptionandnonprescriptionmedicationsandthereasonsthemedicationswereprescribedortaken.Thepharmacistwilllikelyhavetoobtainsomeinformationfromthephysician,suchaslaboratorytestresultsandhospitalizations.Oncethisinformationiscompiled,thepreparationofaPCP(PharmaceuticalCarePlan)canbegin.Step2.IdentifyingProblemsFromthepatient'smedicationprofile,onlyoneproblemisevident:diagnosisofasthma.Ifapplicable,otherproblemshouldalsobelisted.Subjectivefindingsarethosethatthepatientdescribes(e.g.,'Ifeeltiredallthetime,“Ifeelbloated,”or"Iwokeupcoughing").Objectivefindingsarethosethatcanbeobservedormeasuredbythepharmacist(e.g.,patientappearstired,bloodpressureis180/105,pittingedemainankles).Inthepatientwithasthma,thepharmacistwouldhavethepatientuseapeakexpiratoryflowmeterandrecordtheresults.Step3.AssessingProblemsThepharmacistanalyzesandintegratestheinformationgatheredinsteps1and2anddrawsconclusionsinpreparationfordevelopingapatient-specificPCP.Forexample,intheasthmacase,thepharmacistmayfirstinvestigatetheetiologyofthefactorsthatexacerbatedtheasthma.Thepharmacistshouldattempttodetermineifdrugs(eg.,aspirin,nonsteroidalanti-inflammatoryagents,orbeta-blockers)causedorexacerbatedtheasthmainthepatient.Thus,theimportanceofanaccurateandcompletedrughistorybecomesevident.Next,thepharmacistassessestheseverityoftheasthma.ThiscouldbeaccomplishedbydeterminingthePEFR,examiningthepatient'sdailysymptomandpeakflowdiary,ordeterminingifthepatienthadbeenhospitalizedandplacedonsteroidsoramechanicalventilator.Step4.DevelopingthePlanThepharmacistestablishesgoalslinkedtoeachofthepatient'sproblemsandspecifiesacourseofactionaimedatmeetingeachgoal.Eachgoal(i.e.,desiredimprovement)shouldbestatedintermsofmeasurableoutcomesthatindicatetheextenttowhichtheparticularproblemhasbeenresolved.Often,thepatienthasseveralproblems,andtheplanmustbecomprehensiveenoughtohaveapositiveeffectontheoverallhealthofthepatient.Step5.EvaluatingtheAchievementofOutcomesOutcomesthatwillbeusedtoevaluatethesuccessofthePCPtreatmentplanmustbemeaningful,measurable,andmanageable.Outcomesarespecific,measurableindicatorsforthegoalsoftreatment.Thus,theyshouldbeidentifiedintheplanningprocess.Theoutcomeslistedforasthmawouldinclude,butnotbelimitedto,lowerfrequencyandseverityofacuteexacerbations,fewerphysicianofficevisits,eliminationofsideeffects,PEFRsthatneverfallbelow80%ofpreviouspersonal-bestpredictedrates,feweremergencydepartmentvisits,maintenanceofactivitiesthatenhancethepatient'squalityoflifeandmayhavebeenlimitedbythedisease.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.临床药师提供的药学监护哮喘的药学监护COPD的药学监护支气管哮喘诊断流程图病史典型反复发作喘息、气急、胸闷或咳嗽多与接触刺激性因素有关。症状可缓解有节律性波动规律不典型体检异常哮鸣音呼气相延长无异常发现肺功能通气功能PEF监测阻塞性障碍正常舒张试验激发试验排除其他肺部疾病阳性变异率

正常阴性阳性阴性COPD？哮喘的分级持续有症状体力活动有限每天有症状影响活动和睡眠每周1次，但<每天1次频繁≥每周1次>每个月2次，但<每周1次

60%预计值变异率>30%60-80%预计值变异率>30%

80%预计值变异率20-30%治疗前哮喘病情严重程度分级症状夜间症状FEV1或峰流速重度持续（第4级）中度持续（第3级）轻度持续（第2级）间歇状态（第1级）<每周1次，发作间歇无症状GINA2010≤每个月2次

80%预计值变异率<20%哮喘分级用药建议轻度持续重度持续中度持续舒利迭50/100bid-50/250bid舒利迭50/250bid间歇发作辅舒酮125必可酮®250或1喷qd辅舒酮125必可酮®250或1喷,bidICS+LABA万托林按需使用辅舒酮®125必可酮®250＋或1-2喷,qd若控制不好，此建议仅供参考，具体详见GINA2002一级二级三级四级降级治疗间断发作轻度持续中度持续严重持续

适级开始治疗哮喘控制至少3个月降级治疗

哮喘长期治疗分级方案GlobalInitiativeforAsthma(2009)哮喘的管理模式哮喘管理计划教育评价和监护哮喘避免诱因急性发作的治疗计划规律随访GlobalInitiativeforAsthma建立个人诊治计划在病区开展药学监护的一般程序步骤1了解病情Patient步骤2审核方案Review步骤3确定方案Decision步骤4方案注释Annotation步骤5监护要点Carepoints步骤6用药教育Education步骤7观察反应Monitor步骤8评估反馈Assessment全面了解患者目前病情、治疗目标和用药史确认药物选择、给药方法安全、适当帮助患者优化用药方案制定用药方案执行细节用药过程中加强安全性和有效性观察的要点及节点加强患者对医嘱的理解和正确执行，提高依从性和疗效观察药物治疗的效果和各种不良反应对现行治疗方案进行评估，并进一步优化步骤1了解病情步骤2审核方案步骤3确定方案步骤4方案注释步骤5监护要点步骤6用药教育步骤7观察反应步骤8评估反馈主要目的步骤1：了解病情病人一般情况：年龄、性别、身高、体重、职业等；特殊病理生理：老年、儿童、哺乳、妊娠；肝、肾功能、特殊用药史、药物不良反应史；疾病情况：病变部位、范围、病因、诱因；疾病分型、分期、分度；并发症、并存疾病；治疗目标：理想目标和可行目标主要矛盾和次要矛盾：轻重缓急疾病情况肺炎：感染部位、范围、分型、严重程度、病原…支气管哮喘：分期、分级…COPD：分期、肺功能分级、诱因、并发症（感染、心衰、呼衰）…肺癌：细胞分型、分级、分期…方式与特点通过问诊、体检、观察及阅读病历及各类检查资料，了解与药疗有关的基本情况药师与患者直接接触、与医护人员合作步骤2：审核方案药物选择是否适当：品种、规格、剂量、适应证、禁忌证；给药方法是否正确：给药途径、给药时间、给药疗程、配伍情况、联用情况；是否还有优化可能：有无遗漏、有无重复、有无更佳的替代方式与特点每当新开处方或治疗方案更改时审核处方，特别要考虑患者的病理、生理状况及合并用药之间的相互作用，考虑药物的不良反应与治疗利益的相互关