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Cough guideline 2016
1
2
™◊ËÕÀπ—ß ◊Õ ¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢°“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à
·Ààߪ√–‡∑»‰∑¬ æ.». 2559
ISBN: 978-616-91693-1-4
®—¥æ‘¡æå‚¥¬  ¡“§¡ ¿“Õߧå°√‚√§À◊¥·Ààߪ√–‡∑»‰∑¬
 ¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬ „πæ√–∫√¡√“™Ÿª∂—¡¿å
 ¡“§¡‚√§¿Ÿ¡‘·æâ ‚√§À◊¥ ·≈–«‘∑¬“¿Ÿ¡‘§ÿâ¡°—π·Ààߪ√–‡∑»‰∑¬
√“™«‘∑¬“≈—¬ ‚ μ »Õ π“ ‘°·æ∑¬å ·Ààߪ√–‡∑»‰∑¬
 ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬
æ‘¡æå§√—Èß∑’Ë 1 2559
®”π«πæ‘¡æå 2,000 ‡≈à¡
æ‘¡æå∑’Ë ∫√‘…—∑ ∫’¬Õπ¥å ‡ÕÁπ‡∑Õ√å‰æ√´å ®”°—¥
3¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
 “√∫—≠
§”π” _________________________ 4
√“¬π“¡§≥–°√√¡°“√ºŸâ∑√ߧÿ≥«ÿ≤‘ ______________ 5
§”™’È·®ß§ÿ≥¿“æÀ≈—°∞“π·≈–πÈ”Àπ—°§”·π–π” _________ 7
∫∑π” _________________________ 10
§”®”°—¥§«“¡ ______________________ 10
 “‡Àμÿ¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß _________________ 11
·π«∑“ß°“√ª√–‡¡‘πºŸâªÉ«¬ _________________ 12
欓∏‘ √’√«‘∑¬“¢ÕßÕ“°“√‰Õ ________________ 18
°“√ª√–‡¡‘𧫓¡√ÿπ·√ß·≈–º≈°√–∑∫¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß _____ 19
°“√√—°…“‡∫◊ÈÕßμâπ ____________________ 20
 “‡ÀμÿÕ“°“√‰Õ‡√◊ÈÕ√—ß„π¿“æ√—ß ’ªÕ¥ª°μ‘∑’Ëæ∫∫àÕ¬ ________ 21
¿“§ºπ«° 1 ·π«∑“ß°“√√—°…“ºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à___ 37
¿“§ºπ«° 2 «‘∏’°“√ àÕßμ√«®®¡Ÿ° ·≈–μ√«®§Õ æ√âÕ¡¿“æª√–°Õ∫ _ 38
¿“§ºπ«° 3 °“√∑¥ Õ∫ ¡√√∂¿“æªÕ¥‚¥¬ ‰ª‚√‡¡μ√’¬å·≈–
°“√∑¥ Õ∫§«“¡‰«À≈Õ¥≈¡ ___________ 41
¿“§ºπ«° 4 °≈‰°°“√‡°‘¥Õ“°“√‰Õ _____________ 43
¿“§ºπ«° 5 μ“√“ß· ¥ß§«“¡·μ°μà“ß√–À«à“ß‚√§
eosinophilic airway ™π‘¥μà“ßÊ _________ 44
‡Õ° “√Õâ“ßÕ‘ß _____________________ 45
Cough guideline 2016
Cough guideline 2016
6
9) √».πæ.æß»°√ μ—πμ‘≈’ªî°√
10) √».æ≠.Õ√æ√√≥ ‚æ™πÿ°Ÿ≈
11) æ.Õ.æ≠.‡æ™√“ ∫ÿ≠¬ß √√§å™—¬
12) √».æ≠.ª√‘¬π—π∑å ®“√ÿ®‘π¥“
13) º».πæ.Œ‘‚√™‘ ®—π∑“¿“°ÿ≈
14) º».πæ.»‘«»—°¥‘Ï ®ÿ∑Õß
15) º».πæ.Õ¿‘™“μ‘ §≥‘μ∑√—æ¬å
16) º».πæ.¡π–æ≈ °ÿ≈ª√“≥’μ
17) º».æ≠.ª√–¿“æ√ æ√ ÿ√‘¬–»—°¥‘Ï
18) º».¥√.πæ.°√‡°’¬√μ‘  π‘∑«ß»å
19) º».¥√.æ≠.«‘¿“√—μπå ¡πÿ≠“°√
20) º».æ≠.∑‘™“ ƒ°…åæ—≤π“æ‘æ—≤πå
21) Õ.πæ.‡©≈’¬« æŸ≈»‘√‘ªí≠≠“
22) Õ.æ≠.‡ªïò¬¡≈“¿ · ß “¬—≥Àå
23) Õ.¥√.∑‘æ“æ√ æ߅凡…“
24) Õ.πæ.∏’√–»—°¥‘Ï ·°â«Õ¡μ«ß»å
25) Õ.æ≠.°—≈¬“ ªí≠®æ√æ≈
26) Õ.æ≠.¡π« ’ ª“®’π∫Ÿ√«√√≥å
27) Õ.πæ.∏π“ Õ—ß ÿ«√—ß…’
28) Õ.πæ.æ≈æß»å ™¬“ß»ÿ
29) Õ.πæ. —πμ‘  ‘≈—¬√—μπå
30) Õ.æ≠.«√«√√≥ »‘√‘™π–
31) º».æ≠.¡≥±‘√“ ¡≥’√—μπ–æ√
32) º».πæ. ¡∫Ÿ√≥å ®—π∑√å °ÿ≈æ√
7¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
§”™’È·®ß§ÿ≥¿“æÀ≈—°∞“π·≈–πÈ”Àπ—°§”·π–π”
§ÿ≥¿“æÀ≈—°∞“π (Quality of evidence)
§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1
À¡“¬∂÷ßÀ≈—°∞“π∑’ˉ¥â®“°
1.1 °“√∑∫∑«π·∫∫¡’√–∫∫ (systematic review) ®“°°“√»÷°…“·∫∫
°≈ÿà¡ ÿà¡μ—«Õ¬à“ß §«∫§ÿ¡ (randomized controlled clinical trials)
À√◊Õ
1.2 °“√»÷°…“·∫∫°≈ÿà¡ ÿà¡μ—«Õ¬à“ß §«∫§ÿ¡∑’Ë¡’§ÿ≥¿“楒‡¬’ˬ¡Õ¬à“ßπâÕ¬
1 ©∫—∫
§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 2
À¡“¬∂÷ßÀ≈—°∞“π∑’ˉ¥â®“°
2.1 °“√∑∫∑«π·∫∫¡’√–∫∫¢Õß°“√»÷°…“§«∫§ÿ¡·μà‰¡à‰¥â ÿà¡μ—«Õ¬à“ß
(non-randomized controlled clinical trials) À√◊Õ
2.2 °“√»÷°…“§«∫§ÿ¡·μà‰¡à‰¥â ÿà¡μ—«Õ¬à“ß∑’Ë¡’§ÿ≥¿“楒‡¬’ˬ¡ À√◊Õ
2.3 À≈—°∞“π®“°√“¬ß“π°“√»÷°…“∑’Ë„™â√Ÿª·∫∫«‘®—¬Õ◊ËπÊ (cohort, case-
control) ∑’ˉ¥â√—∫°“√ÕÕ°·∫∫«‘®—¬‡ªìπÕ¬à“ߥ’ ´÷Ëß¡“®“° ∂“∫—πÀ√◊Õ
°≈ÿà¡«‘®—¬¡“°°«à“Àπ÷Ëß·Ààß/°≈ÿà¡
2.4 À≈—°∞“π®“°æÀÿ°“≈“πÿ°√¡ (multiple time series)
2.5 º≈°“√«‘®—¬æ∫ª√–‚¬™πåÀ√◊Õ‚∑…®“°°“√ªØ‘∫—μ‘∑’ˇ¥àπ™—¥¡“°
8
§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3
À¡“¬∂÷ßÀ≈—°∞“π∑’ˉ¥â®“°
3.1 °“√»÷°…“‡™‘ßæ√√≥π“ (descriptive studies) À√◊Õ
3.2 °“√»÷°…“§«∫§ÿ¡∑’Ë¡’§ÿ≥¿“ææÕ„™â
§ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 4
4.1 √“¬ß“π¢Õߧ≥–°√√¡°“√ºŸâ‡™’ˬ«™“≠ §«“¡‡ÀÁπæâÕßÀ√◊Õ©—π∑“¡μ‘
(consensus) ¢Õߧ≥–ºŸâ‡™’ˬ«™“≠∫πæ◊Èπ∞“πª√– ∫°“√≥å∑“ߧ≈‘π‘°
À√◊Õ
4.2 √“¬ß“πÕπÿ°√¡ºŸâªÉ«¬®“°°“√»÷°…“„πª√–™“°√μà“ß°≈ÿà¡·≈–§≥–
ºŸâ»÷°…“Õ¬à“ßπâÕ¬2©∫—∫√“¬ß“πÀ√◊Õ§«“¡‡ÀÁπ∑’ˉ¡à‰¥âºà“π°“√«‘‡§√“–Àå
Õ¬à“ß¡’√–∫∫
πÈ”Àπ—°§”·π–π” (Strength of recommendation)
πÈ”Àπ—°§”·π–π” ++
À¡“¬∂÷ߧ«“¡¡—Ëπ„®¢Õߧ”·π–π”„Àâ∑”Õ¬Ÿà„π√–¥—∫ Ÿß ‡æ√“–¡“μ√°“√
¥—ß°≈à“«¡’ª√–‚¬™πåÕ¬à“߬‘ËßμàÕºŸâªÉ«¬ ·≈–§ÿâ¡§à“ (cost effective) 秫√∑”é
πÈ”Àπ—°§”·π–π” +
À¡“¬∂÷ߧ«“¡¡—Ëπ„®¢Õߧ”·π–π”„Àâ∑”Õ¬Ÿà„π√–¥—∫ª“π°≈“ß ‡π◊ËÕß®“°
¡“μ√°“√¥—ß°≈à“«Õ“®¡’ª√–‚¬™πåμàÕºŸâªÉ«¬ ·≈–Õ“®§ÿâ¡§à“„π¿“«–®”‡æ“– çπà“∑”é
9¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
πÈ”Àπ—°§”·π–π” +/-
À¡“¬∂÷ߧ«“¡¡—Ëπ„®¬—߉¡à‡æ’¬ßæÕ„π°“√„À⧔·π–π” ‡π◊ËÕß®“°¡“μ√°“√
¥—ß°≈à“«¬—ß¡’À≈—°∞“π‰¡à‡æ’¬ßæÕ„π°“√ π—∫ πÿπÀ√◊Õ§—¥§â“π«à“Õ“®¡’À√◊ÕÕ“®‰¡à¡’
ª√–‚¬™πåμàÕºŸâªÉ«¬·≈–Õ“®‰¡à§ÿâ¡§à“ ·μà‰¡à°àÕ„À⇰‘¥Õ—πμ√“¬μàÕºŸâªÉ«¬‡æ‘Ë¡¢÷Èπ
¥—ßπ—Èπ°“√μ—¥ ‘π„®°√–∑”¢÷ÈπÕ¬Ÿà°—∫ªí®®—¬Õ◊ËπÊ çÕ“®∑”À√◊Õ‰¡à∑”é
πÈ”Àπ—°§”·π–π” -
À¡“¬∂÷ߧ«“¡¡—Ëπ„®Àâ“¡∑”Õ¬Ÿà„π√–¥—∫ª“π°≈“߇π◊ËÕß®“°¡“μ√°“√¥—ß°≈à“«
Õ“®‰¡à¡’ª√–‚¬™πåμàÕºŸâªÉ«¬·≈–‰¡à§ÿâ¡§à“ çÀ“°‰¡à®”‡ªìπ‰¡àπà“∑”é
πÈ”Àπ—°§”·π–π” - -
À¡“¬∂÷ߧ«“¡¡—Ëπ„®Àâ“¡∑”Õ¬Ÿà„π√–¥—∫ Ÿß ‡æ√“–¡“μ√°“√¥—ß°≈à“«Õ“®
‡°‘¥‚∑…À√◊Õ°àÕ„À⇰‘¥Õ—πμ√“¬μàÕºŸâªÉ«¬ 牡৫√∑”é
10
∫∑π”
Õ“°“√‰Õ‡√◊ÈÕ√—߇ªìπÕ“°“√∑’Ëæ∫∫àÕ¬„π‡«™ªØ‘∫—μ‘·≈–Õ“®°àÕ„À⇰‘¥ªí≠À“
μàÕºŸâªÉ«¬∑—Èß∑“ß°“¬ (physical) ∑“ß®‘μ„® (psychological) ·≈–∑“ß —ߧ¡ (so-
cial) ¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢°“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à©∫—∫π’ȇªìπ
¢âÕ·π–π” ”À√—∫·æ∑¬å‡«™ªØ‘∫—μ‘∑—Ë«‰ª„π°“√«‘π‘®©—¬·≈–°“√√—°…“‡∫◊ÈÕßμâπ°àÕπ
 àßæ∫ºŸâ‡™’ˬ«™“≠ Õπ÷Ëß ¢âÕ·π–π”μà“ßÊ „π·π«∑“ß©∫—∫π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√
ªØ‘∫—μ‘ ·≈–‰¡à¡’º≈∫—ߧ—∫∑“ß°ÆÀ¡“¬ ºŸâ„™â “¡“√∂ªØ‘∫—μ‘·μ°μà“߉ª®“°¢âÕ·π–π”
„π°√≥’∑’Ë¡’¢âÕ®”°—¥¢Õß ∂“π∫√‘°“√·≈–∑√—欓°√ À√◊Õ¡’‡Àμÿº≈Õ◊ËπÊ ‚¥¬„™â
«‘®“√≥≠“≥´÷Ë߇ªìπ∑’ˬա√—∫·≈–Õ¬Ÿà∫πæ◊Èπ∞“πÀ≈—°«‘™“°“√ ·≈–®√√¬“∫√√≥
1) §”®”°—¥§«“¡
Õ“°“√‰Õ‡©’¬∫æ≈—π À¡“¬∂÷ßÕ“°“√‰Õ∑’Ë¡’√–¬–‡«≈“πâÕ¬°«à“ 3  —ª¥“Àå
Õ“°“√‰Õ°÷Ë߇©’¬∫æ≈—π À¡“¬∂÷ßÕ“°“√‰Õ∑’Ë¡’√–¬–‡«≈“√–À«à“ß 3 ∂÷ß 8
 —ª¥“Àå
Õ“°“√‰Õ‡√◊ÈÕ√—ß À¡“¬∂÷ßÕ“°“√‰Õ∑’Ë¡’√–¬–‡«≈“‡°‘π 8  —ª¥“Àå
·μà„π‡«™ªØ‘∫—μ‘√–¬–‡«≈“ 8  —ª¥“ÀåÕ“®π“π‡°‘π‰ª ºŸâªÉ«¬Õ“®¡“æ∫
·æ∑¬å‡√Á«°«à“ 8  —ª¥“À剥â(1-5)
„π¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢°“√√—°…“ºŸâªÉ«¬
‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à©∫—∫π’È ®–°≈à“«∂÷ß “‡ÀμÿÕ“°“√‰Õ∑’Ë¡’√–¬–‡«≈“‡°‘π 3  —ª¥“Àå
¢÷Èπ‰ª „π∑“ߪؑ∫—μ‘À“°ºŸâªÉ«¬¡’Õ“°“√‰Õ∑’Ë¡’√–¬–‡«≈“μ—Èß·μà 3  —ª¥“Àå¢÷Èπ‰ª‚¥¬∑’Ë
‰¡à¡’°“√μ‘¥‡™◊ÈÕ∑“߇¥‘πÀ“¬„® à«π∫ππ”¡“°àÕπ ·π–π”«à“§«√ª√–‡¡‘πÀ“ “‡Àμÿ
¢ÕßÕ“°“√‰Õμ“¡¢âÕ·π–π”©∫—∫π’È
11¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
2)  “‡Àμÿ¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß
§«√·¬° “‡Àμÿ∑’Ë√ÿπ·√ßÕÕ°‰ª°àÕ𠇙àπ ¡–‡√Áߪե «—≥‚√§ªÕ¥ ªÕ¥Õ—°‡ ∫
‡√◊ÈÕ√—ß ‚¥¬Õ“»—¬ª√–«—μ‘ μ√«®√à“ß°“¬ ·≈–¿“æ√—ß ’∑√«ßÕ° (chest x-ray) ‚¥¬
‡πâπÀ“Õ“°“√‡μ◊Õπ (alarming symptoms) ‰¥â·°à ‰Õ‡ªìπ‡≈◊Õ¥ ‡ ’¬ß·À∫ ‰¢â
πÈ”Àπ—°≈¥ Õ“°“√‡Àπ◊ËÕ¬‚¥¬‡©æ“–¢≥–æ—°À√◊Õ‡«≈“°≈“ߧ◊π ª√–«—μ‘°“√‡ªìπ
ªÕ¥Õ—°‡ ∫∫àÕ¬Ê °≈◊π≈”∫“° °≈◊π‡®Á∫ ·≈– ”≈—°
„π‡∫◊ÈÕßμâπÀ“°¿“æ√—ß ’∑√«ßÕ°ª°μ‘ „πºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß  “‡Àμÿ∑’Ë
æ∫∫àÕ¬ ‰¥â·°à
1) °≈ÿà¡‚√§À◊¥
1.1 Asthma
1.2 Cough variant asthma
1.3 Non-asthmatic eosinophilic bronchitis
2) Upper Airway Cough Syndrome (UACS)
2.1 Rhinitis
2.2 Sinusitis
2.3 Posterior nasal drip
3) Gastro-esophageal reflux disease (GERD)/laryngopharyngeal
reflux (LPR)
4) ¬“ angiotensin converting enzyme inhibitor (ACE-I)
5) °“√ Ÿ∫∫ÿÀ√’Ë
6) ‚√§¢ÕßÀ≈Õ¥≈¡ ‰¥â·°à À≈Õ¥≈¡Õ—°‡ ∫‡√◊ÈÕ√—ß (chronic bronchitis)
12
„π°≈ÿࡺŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ°÷Ë߇©’¬∫æ≈—π °≈à“«§◊Õμ—Èß·μà 3  —ª¥“Àå¢÷Èπ‰ª ·μà
‰¡à‡°‘π 8  —ª¥“Àå  “‡Àμÿ∑’Ëæ∫∫àÕ¬Õ’°Õ¬à“ßÀπ÷Ë߉¥â·°à Õ“°“√‰ÕÀ≈—ß®“°°“√μ‘¥‡™◊ÈÕ
∑“߇¥‘πÀ“¬„® (post-infectious cough)
Õ—μ√“°“√‡°‘¥Õ“°“√‰Õ‡√◊ÈÕ√—ß®“° “‡Àμÿμà“ßÊ ¢â“ßμâπ·μ°μà“ß°—π√–À«à“ß
ª√–‡∑»∑“ßμ–«—πμ°·≈–ª√–‡∑»∑“ßμ–«—πÕÕ° ‚¥¬ “‡Àμÿ®“° GERD ¡’
√“¬ß“πæ∫∫àÕ¬„πª√–‡∑»∑“ßμ–«—πμ°(2, 3)
·μàæ∫πâÕ¬°«à“¡“°„πª√–‡∑»∑“ß
μ–«—πÕÕ°(1, 5, 6)
¢âÕ¡Ÿ≈¢Õߪ√–‡∑»‰∑¬„πªï æ.». 2540 æ∫«à“ “‡ÀμÿÕ“°“√‰Õ
‡√◊ÈÕ√—ß‚¥¬∑’Ë¿“æ√—ß ’∑√«ßÕ°ª°μ‘ ‰¥â·°à postnasal drip ·≈– post-infectious
cough æ∫ª√–¡“≥√âÕ¬≈– 45 asthma æ∫√âÕ¬≈– 26 postnasal drip √à«¡°—∫
asthma æ∫√âÕ¬≈– 13 ¬“ ACE-I æ∫√âÕ¬≈– 4 bronchiectasis æ∫√âÕ¬≈– 4
idiopathic æ∫√âÕ¬≈– 3 ·≈–æ∫ GERD ‡æ’¬ß√âÕ¬≈– 1.6(6)
„πª√–‡∑»·∂∫‡Õ‡™’¬ æ∫«à“¡’°≈ÿà¡Õ“°“√‰Õ‡√◊ÈÕ√—ß™π‘¥¡’‡ ¡À–∑’Ë„Àâ
§”®”°—¥§«“¡·μ°μà“ß®“°„πª√–‡∑»∑“ßμ–«—πμ° ‰¥â·°à sinobronchial syn-
drome(1)
3) ·π«∑“ß°“√ª√–‡¡‘πºŸâªÉ«¬
3.1 °“√´—°ª√–«—μ‘
3.1.1 ≈—°…≥–Õ“°“√‰Õ (characteristics) §«√´—°ª√–«—μ‘μà“ßÊ ¥—ß
μàÕ‰ªπ’È
1) √–¬–‡«≈“∑’Ë¡’Õ“°“√‰Õ·≈–°“√¥”‡π‘π¢Õß‚√§
2) Õ“°“√‰Õ‡ªìπ·∫∫¡’‡ ¡À– (productive) À√◊Õ‰¡à¡’‡ ¡À–
(nonproductive)
13¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
3) Õ“°“√‰Õ¡’‡ ¡À–‡√◊ÈÕ√—ß∑’ˇªìπ¡“π“πÀ√◊Õ‡ªìπÊ À“¬Ê ∫“ߧ√—Èß
¡’‡ ¡À–‡À≈◊Õ߇¢’¬«À√◊Õªπ‡≈◊Õ¥ æ∫‰¥â„πÀ≈Õ¥≈¡‚ªÉßæÕß
(bronchiectasis)
4) Õ“°“√‰Õ¡’°“√‡ª≈’ˬπ·ª≈ßμ“¡™à«ß‡«≈“√–À«à“ß«—π (diurnal
variation)
5) ªí®®—¬∑’Ë°√–μÿâπÕ“°“√‰Õ ‡™àπ Õÿ≥À¿Ÿ¡‘ °≈‘Ë𠇪√¬å À√◊Õ aero-
sol °“√ÕÕ°°”≈—ß°“¬ À√◊ÕÀ≈—ß√—∫ª√–∑“πÕ“À“√¡◊ÈÕ„À≠à
6) Õ“°“√‰Õ¡’§«“¡ —¡æ—π∏å°—∫∑à“∑“ß ‡™àπ ·¬à≈߇¡◊ËÕ°â¡μ—«À√◊Õ
πÕπ√“∫ Õ“°“√‰ÕÀ≈—ß°‘πÕ“À“√ ¡—°‡°‘¥„π™à«ß 10 π“∑’À≈—ß
°‘πÕ“À“√ À√◊ÕÕ“°“√‰Õ¡’§«“¡ —¡æ—π∏å°—∫°“√查 °“√À—«‡√“–
°“√√âÕ߇æ≈ß ¡—°æ∫„π gastroesophageal reflux ‡π◊ËÕß®“°
¡’°“√≈¥≈ߢÕß lower esophageal sphincter tone Õ“°“√
· ∫√âÕπ¬Õ¥Õ° (heartburn) ‡√Õ‡ª√’Ȭ« (regurgitation) æ∫
‰¥â·μà‰¡à∫àÕ¬„πºŸâªÉ«¬∑’Ë¡’Õ“°“√°√¥‰À≈¬âÕπ∑’Ë¡’Õ“°“√πÕ°
À≈Õ¥Õ“À“√ (extra-esophageal GERD)
7) Õ“°“√°√–·Õ¡ (throat clearing) æ∫„π postnasal drip
syndrome À√◊Õ‚æ√߉´π— Õ—°‡ ∫‡√◊ÈÕ√—ß
8) Õ“°“√‡μ◊Õπ (alarming symptoms) ¢Õß‚√§∑’ËÕ“®‡ªì𠓇Àμÿ
√ÿπ·√ߢÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß ‰¥â·°à ‰Õ‡ªìπ‡≈◊Õ¥ ‡ ’¬ß·À∫ ‰¢â
πÈ”Àπ—°≈¥ Õ“°“√‡Àπ◊ËÕ¬ ‚¥¬‡©æ“–¢≥–æ—°À√◊Õ‡«≈“°≈“ߧ◊π
‡®Á∫Àπâ“Õ°‡«≈“À“¬„®‡¢â“≈÷°Ê ·≈–ª√–«—μ‘°“√‡ªìπªÕ¥Õ—°‡ ∫
∫àÕ¬Ê
3.1.2 ¬“∑’Ë„™âª√–®” ‰¥â·°à angiotensin converting enzyme inhibitor
(ACE-I)
14
3.1.3 ª√–«—μ‘‚√§ª√–®”μ—« ‡™àπ ‚√§¿Ÿ¡‘·æâ (atopic diseases) ‰¥â·°à ¿Ÿ¡‘·æâ
®¡Ÿ° ¿Ÿ¡‘·æ⺑«Àπ—ß ·≈–ª√–«—μ‘‚√§ autoimmune diseases
3.1.4 Õ“™’æ ß“πÕ¥‘‡√°  —μ«å‡≈’Ȭß
Õ“™’æ∑’Ë¡’§«“¡‡ ’ˬ߉¥â·°à §π∑”¢π¡ªíß ™à“ß∑”º¡ ∑”Õÿμ “À°√√¡
‡°’ˬ«°—∫ºâ“ ‡°…μ√°√√¡ ·≈–‡≈’Ȭߠ—μ«å
3.1.5 ª√–«—μ‘°“√ Ÿ∫∫ÿÀ√’Ë
§«√´—°ª√–«—μ‘∑—Èß active ·≈– passive smoker À“°¡’ª√–«—μ‘°“√
 Ÿ∫∫ÿÀ√’Ë „Àâª√–‡¡‘πμàÕ¥—ßπ’È „πºŸâªÉ«¬∑’ˇªìπ active smoker ∂“¡ª√–«—μ‘®”π«π
·≈–√–¬–‡«≈“∑’Ë Ÿ∫ À“°¡’°“√‡ª≈’ˬπ·ª≈ߧ«“¡∂’Ë¢Õß°“√‰ÕÀ√◊Õ¡’Õ“°“√‰Õ‡ªìπ
‡≈◊Õ¥ §«√μ√«®§âπÀ“ “‡ÀμÿμàÕ °√≥’À¬ÿ¥ Ÿ∫∫ÿÀ√’Ë·≈â« ∫“ߧ√—ÈßÕ“°“√‰ÕÕ“®¬—ß
‰¡àÀ¬ÿ¥‡æ√“–¡’°“√‡ª≈’ˬπ·ª≈ߢÕß cough reflex ‰ª·≈â« ·μà¡—°®–‰Õ≈¥≈ß
3.1.6 Õ“°“√‰Õ‡√‘Ë¡μâπ®“°Õ“°“√‡ªìπÀ«—¥À√◊Õ°“√μ‘¥‡™◊ÈÕ∑“߇¥‘πÀ“¬„®
 à«π∫π (upper respiratory tract infection) π”¡“°àÕπÀ√◊Õ‰¡à ‚¥¬∂“¡Õ“°“√
‡√‘Ë¡¢Õß°“√‰Õ«à“¡’‡®Á∫§Õ À«—¥ πÈ”¡Ÿ°À√◊Õ‰¡à  à«π„À≠àÀ“°‡ªìπ®“°°“√μ‘¥‡™◊ÈÕ
∑“߇¥‘πÀ“¬„® à«π∫πÕ“°“√¡—°¥’¢÷Èπ‡√◊ËÕ¬Ê ¿“¬„π√–¬–‡«≈“‰¡à‡°‘π 8  —ª¥“Àå
‚¥¬‡©æ“–Õ“°“√‰ÕμÕπ°≈“ߧ◊π®–§àÕ¬Ê ≈¥≈ß°àÕπ ´÷ËߺŸâªÉ«¬ à«π¡“°∂⓬—߉¡à
À“¬ π‘∑ ·≈–∫“ß√“¬¡’Õ“°“√√ÿπ·√ß¡—°®–°—ß«≈·≈–¡“æ∫·æ∑¬å
3.1.7 ª√–«—μ‘ —¡º— °—∫‡¥Á°À√◊ÕºŸâªÉ«¬∑’ˇªìπ‰Õ°√π
§«“¡·μ°μà“ߢÕ߉հ√π°—∫°“√μ‘¥‡™◊ÈÕ∑“߇¥‘πÀ“¬„® à«π∫π®“°
‡™◊ÈÕ‰«√—  (viral infection) §◊Õ ‰Õ°√π®–¡’§«“¡√ÿπ·√ߢÕß°“√‰Õ¡“°¢÷Èπ ‰Õ¡“°
®πÕ“‡®’¬π ‚¥¬‰¡à¡’∑’∑à“«à“®–¥’¢÷Èπ ®π°«à“®– 2-3  —ª¥“Àå ·≈–¡—°‰Õ‰¥âπ“π∂÷ß
3 ‡¥◊Õπ „π§π∑’ˇªìπ√ÿπ·√ßÕ“®π“π∂÷ß 7 ‡¥◊Õπ
15¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
3.1.8 „πºŸâ∑’Ë¡’ªí≠À“°“√°≈◊π ¡’‚√§∑“ß√–∫∫ª√– “∑ ·≈–ºŸâ ŸßÕ“¬ÿ Õ“®¡’
ª√–«—μ‘‰Õ·≈– ”≈—°™à«ß√–À«à“ߥ◊Ë¡πÈ”·≈–°‘πÕ“À“√ 𔉪 Ÿà¿“«– ”≈—° (chronic
silent aspiration) 䴉
3.2 °“√μ√«®√à“ß°“¬
3.2.1 °“√μ√«® ÀŸ §Õ ®¡Ÿ° ‚¥¬„™â‰ø∑’Ë «à“߇撬ßæÕ àÕß∑’Ë™àÕß®¡Ÿ°
·≈–§Õ ‡æ◊ËÕÀ“«à“¡’°“√Õ—°‡ ∫¢Õß‚æ√ß®¡Ÿ° à«π inferior turbinate √‘¥ ’¥«ß®¡Ÿ°
(nasal polyp) ¡’‡ ¡À–À≈—ß§Õ (postnasal drip ∑’Ë posterior pharynx) ≈—°…≥–
cobble stone ∫√‘‡«≥ posterior pharynx À√◊ÕμàÕ¡∑Õπ´‘≈¡’¢π“¥„À≠àÀ√◊Õ‰¡à
3.2.2 °“√μ√«®√à“ß°“¬Õ◊ËπÊ ‰¥â·°à √‘¡Ω望°·μ°Õ—°‡ ∫ (cheilitis)
Õ“®¡’°“√·¥ßÕ—°‡ ∫√Õ∫√‘¡Ω望°‰¥â ¢Õ∫μ“≈à“ߧ≈È”¥” (allergic shiner) ‡°‘¥®“°
‡¬◊ËÕ®¡Ÿ°∑’Ë∫«¡∑”„Àâ¡’ chronic congestion ¢Õß lower eyelid venous plexus
À√◊Õº◊Ëπ·¥ß§—π∑’ËÀ—«μ“À√◊Õ‡ª≈◊Õ°μ“ Õ“°“√‡À≈à“π’È∫àß∫Õ°«à“ºŸâªÉ«¬¡’‡¬◊ËÕ®¡Ÿ°∫«¡
Õ—°‡ ∫‡√◊ÈÕ√—ß ´÷Ëß¡“°°«à“√âÕ¬≈– 80 ‡ªìπ‡¬◊ËÕ∫ÿ‚æ√ß®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ
3.2.3 °“√μ√«®ªÕ¥ ‡æ◊ËÕμ√«®À“‡ ’¬ßªÕ¥∑’˺‘¥ª°μ‘ ‰¥â·°à wheeze,
expiratory rhonchi ∫àß™’È∂÷ß¿“«–À≈Õ¥≈¡μ’∫ ·≈– coarse crepitation ∫àß™’È
∂÷ß°“√¡’‡ ¡À–„πÀ≈Õ¥≈¡ ¡—°æ∫„π bronchiectasis
3.3 °“√ ◊∫§âπÀ“ “‡Àμÿ (Investigations)
3.3.1 √–¥—∫ª∞¡¿Ÿ¡‘ (Primary care) ‰¥â·°à
3.3.1.1 ¿“æ√—ß ’∑√«ßÕ° (Chest X-ray) ·π–π”„Àâ∑”(1-5, 7)
‡æ◊ËÕ
§âπÀ“ “‡Àμÿ¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß ‡™àπ «—≥‚√§ªÕ¥ ¡–‡√Áߪե ∂â“æ∫§«“¡
º‘¥ª°μ‘„Àâ ◊∫§âπ‰ªμ“¡§«“¡º‘¥ª°μ‘π—Èπ (Level of evidence 1, Grade of
recommendation ++)
16
3.3.1.2 ¿“æ√—ß ’‰´π—  (plain x-ray of paranasal sinus) §«√∑”
„π°√≥’∑’Ë ß —¬¿“«–‰´π— Õ—°‡ ∫ ·≈–„πºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß∑’Ë¡’‡ ¡À–¡“°
·μàμ√«®‚æ√ß®¡Ÿ°·≈⫉¡àæ∫§«“¡º‘¥ª°μ‘(8, 9)
·π–π”„Àâ àß∂à“¬¿“æ√—ß ’¢Õ߉´π— 
‡æ◊Ëՙ૬«‘π‘®©—¬‚√§ (Level of evidence 4, Grade of recommendation +)
„π°√≥’∑’Ëæ∫ maxillary sinus ¢ÿàπ∑÷∫ À√◊Õæ∫¡’√–¥—∫¢Õ߇À≈« ∫àß™’È«à“¡’‚Õ°“ 
‡ªìπ‚√§‰´π— Õ—°‡ ∫®“°‡™◊ÈÕ·∫§∑’‡√’¬ Ÿß¡“°(10)
3.3.1.3 °“√μ√«® ¡√√∂¿“æªÕ¥
1) ·π–π”„Àâ∑” ‰ª‚√‡¡μ√’¬å (spirometry) „π√“¬∑’Ë ß —¬
‚√§À≈Õ¥≈¡(2)
‡æ◊ËÕ§âπÀ“¿“«–À≈Õ¥≈¡μ’∫ (airway obstruction)(3)
(Level of
evidence 2, Grade of recommendation ++) [√“¬≈–‡Õ’¬¥„π¿“§ºπ«°] „π
°√≥’∑’ËÕ¬Ÿà„π ∂“π∑’Ë∑’Ë∑”°“√μ√«®‰¡à‰¥â ·π–π”„Àâ¡’°“√ àßμàÕºŸâ‡™’ˬ«™“≠
2) °“√«—¥§à“ peak expiratory flow rate (PEFR) °àÕπ·≈–
¿“¬À≈—ß°“√„Àâ Ÿ¥¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï —Èπ‡æ’¬ß§√—È߇¥’¬« ‰¡à·π–π”
„Àâ∑”‡π◊ËÕß®“°‰¡à‡∑’ˬßμ√߇¡◊ËÕ‡∑’¬∫°—∫§à“ forced expiratory volume „π‡«≈“
1 «‘π“∑’ (FEV1) „π°“√«‘π‘®©—¬¿“«–À≈Õ¥≈¡μ’∫(11)
(Level of evidence 2, Grade
of recommendation +/-) ·μà°“√„™â serial PEFR „π°√≥’∑’Ë ß —¬‚√§À◊¥
¬—߉¡à¡’°“√»÷°…“‡æ’¬ßæÕ∑’Ë®–·π–π”„Àâ∑”„πºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß (Level of
evidence 4, Grade of recommendation +/-)
3.3.2 √–¥—∫∑ÿ쑬¿Ÿ¡‘ (Secondary care)·π–π”„Àâ∑”„π°√≥’∑’Ë¡’ºŸâ‡™’ˬ«™“≠
䴉ᡈ
3.3.2.1 Indirect laryngoscopy ‡æ◊ËÕ§âπÀ“À≈—°∞“π¢Õß laryngopha-
ryngeal reflux ·π–π”„Àâ∑”„π°√≥’∑’Ë¡’ºŸâ‡™’ˬ«™“≠∑“ßÀŸ §Õ ®¡Ÿ° (ENT)(3)
(Level
of evidence 1, Grade of recommendation ++)
17¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
3.3.2.2 Bronchoprovocative test ‡ªìπ°“√∑¥ Õ∫§«“¡‰«À≈Õ¥≈¡
(airway hyperresponsiveness, AHR) [√“¬≈–‡Õ’¬¥„π¿“§ºπ«°] ·π–π”„Àâ
∑”„π°√≥’∑’˺≈°“√μ√«® ‰ª‚√‡¡μ√’¬åª°μ‘·≈– ß —¬¿“«–À≈Õ¥≈¡‰«‡°‘π‡π◊ËÕß®“°
º≈ ‰ª‚√‡¡μ√’¬å∑’˪°μ‘¬—߉¡à “¡“√∂μ—¥ “‡ÀμÿÕ“°“√‰Õ∑’ˇ°‘¥®“° asthma ‰¥â(2, 12)
°“√∑¥ Õ∫§«“¡‰«À≈Õ¥≈¡∑”‰¥â‚¥¬«‘∏’ methacholine challenge test À“°
º≈°“√μ√«® methacholine challenge test ‡ªìπº≈≈∫  “¡“√∂μ—¥°“√«‘π‘®©—¬
‚√§À◊¥ÕÕ°‰ª‰¥â∂⓺ŸâªÉ«¬‰¡à‡§¬‰¥â√—∫¬“ Ÿ¥§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å¡“°àÕπ(13)
(Level of
evidence 2, Grade of recommendation +)
3.3.2.3 ‡Õ°´‡√¬å§Õ¡æ‘«‡μÕ√åªÕ¥ (High-resolution computed
tomography, HRCT) „π°√≥’∑’Ë ß —¬‚√§À≈Õ¥≈¡‚ªÉßæÕß (bronchiectasis) ‚√§
interstitial lung diseases À√◊ÕÀ≈Õ¥≈¡¢π“¥‡≈Á°Õ—°‡ ∫ (bronchiolitis) ∑’˺≈
°“√μ√«®¿“æ√—ß ’∑√«ßÕ°ª°μ‘(3)
(Level of evidence 3, Grade of recommen-
dation +)
3.3.2.4 ‡Õ°´‡√¬å§Õ¡æ‘«‡μÕ√å‰´π—  (Computerized tomography
of paranasal sinus) ‰¡à·π–π”„Àâ àßμ√«®‡Õ°´‡√¬å§Õ¡æ‘«‡μÕ√å‰´π—  „π°“√
μ√«®‡∫◊ÈÕßμâπ(9)
(Level of evidence 2, Grade of recommendation -) ·π–π”
„Àâ∑”‡©æ“–„π√“¬∑’Ë®–‰¥â∑”°“√ºà“μ—¥‰´π—  À√◊Õ¡’¿“«–·∑√°´âÕπ™π‘¥√⓬·√ß
‡™àπ¿“«–·∑√°´âÕπ∑“ßμ“·≈– ¡Õß ·≈–„πºŸâ∑’ˉ¡àμÕ∫ πÕßμàÕ°“√√—°…“¥â«¬
¬“(4)
(Level of evidence 3, Grade of recommendation ++)
3.3.2.5 °“√μ√«®‡æ◊ËÕ ◊∫§âπ¿“«–°√¥‰À≈¬âÕπ ¡’°“√μ√«®‰¥âÀ≈“¬
«‘∏’ ‰¥â·°à
1) 24-hour esophageal pH monitoring
2) Esophageal manometry/impedance testing
(Level of evidence 2, Grade of recommendation +/-)
18
3.3.2.6 °“√μ√«®π—∫®”π«πÕ‘‚Õ ‘‚πøî≈„π‡ ¡À– (sputum eosi-
nophil) ∑”‰¥â¬“°„π∑“ߪؑ∫—μ‘ ª√‘¡“≥Õ‘‚Õ ‘‚πøî≈„π‡ ¡À–¡’§«“¡ —¡æ—π∏å°—∫
√–¥—∫‰πμ√‘°ÕÕ°‰´¥å„π≈¡À“¬„®ÕÕ° (fractional exhaled nitric oxide, FeNO)
°“√«—¥√–¥—∫ FeNO ‡æ◊ËÕ„™â·¬° “‡ÀμÿÕ“°“√‰Õ®“° eosinophilic inflammation
√–¥—∫ FeNO ¡’§à“ Ÿß¢÷Èπ„πÕ“°“√‰Õ∑’ˇ°‘¥®“° asthma, cough variant asthma
·≈– non-asthmatic eosinophilic bronchitis(14)
·≈–„™â∑”𓬰“√μÕ∫ πÕß
μàÕ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥„πºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß(15)
·π–π”„Àâ∑”À“°∑”‰¥â„π
°√≥’∑’Ë≈Õß„Àâ°“√√—°…“¥â«¬¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥·≈⫬—߉¡à‰¥âº≈ ‡æ◊Ëՙ૬
„π°“√ª√—∫¬“μàÕ‰ª (Level of evidence 2, Grade of recommendation +)
3.3.2.7 √–¥—∫ specific IgE „π‡≈◊Õ¥ À√◊Õ skin prick test μàÕ
aeroallergen ¡’ª√–‚¬™πå„π°“√¬◊π¬—π°“√«‘π‘®©—¬¿“«–‚æ√ß®¡Ÿ°Õ—°‡ ∫®“°
¿Ÿ¡‘·æâ(4)
(Level of evidence 2, Grade of recommendation ++)
4) 欓∏‘ √’√«‘∑¬“¢ÕßÕ“°“√‰Õ
‡°‘¥®“°‡ âπª√– “∑‡«°— ∂Ÿ°°√–μÿâπºà“πμ—«√—∫ —≠≠“≥∑’ˇ≈’Ȭ߄πÕ«—¬«–
μà“ßÊ ´÷Ëß„π√–∫∫°“√À“¬„®ª√–°Õ∫¥â«¬
1. C-fibers (nociceptor cough) Õ¬Ÿà∫√‘‡«≥ mucosa ¢ÕßÀ≈Õ¥≈¡
∂Ÿ°°√–μÿâπ‚¥¬ “√§—¥À≈—Ëß®“°‡´≈≈åÕ—°‡ ∫ (inflammatory mediators) À√◊Õ “√
∑’Ë°àÕ„À⇰‘¥°“√√–§“¬‡§◊Õß (irritants)
2. Cough receptors (mechanoreceptor cough) Õ¬Ÿà„μâμàÕ epi-
thelium ¢Õß larynx, trachea ·≈– mainstem bronchus ∂Ÿ°°√–μÿâπ‚¥¬°“√
 —¡º—  (punctuate mechanical) ·≈–‰¡àμÕ∫ πÕßμàÕ “√‡§¡’¬°‡«âπ “√∑’ˇªìπ°√¥
19¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
Õ“°“√‰Õ¬—߇°‘¥®“°°“√°√–μÿâπ∑’ËÕ«—¬«–Õ◊Ëπ∑’ˇ≈’Ȭߥ⫬‡ âπª√– “∑‡«°— 
‰¥â·°à À≈Õ¥Õ“À“√ °√–‡æ“–Õ“À“√ À—«„® ·≈–ÀŸ™—ÈππÕ° ‡ªìπμâπ  —≠≠“≥®“°
μ—«√—∫®– àߺà“π‰ª¬—ß nucleus tractus solitarius (nTS) „π brainstem ∑”„Àâ
‡°‘¥ çreflex coughé ‚¥¬°“√ àß —≠≠“≥‰ª¬—ß°≈â“¡‡π◊ÈÕ∑’ˇ°’ˬ«¢âÕß°—∫°“√‰Õ
πÕ°®“°π’ÈÕ“°“√‰Õ¬—ß “¡“√∂§«∫§ÿ¡‰¥â‚¥¬ ¡Õß à«π cortex çurge to coughé
À√◊Õ çbehavioral coughé ‚¥¬¡’§«“¡√Ÿâ ÷°·≈–Õ“√¡≥凢ⓡ“‡°’ˬ«¢âÕß ‚¥¬
‡©æ“–°≈ÿà¡Õ“°“√‰Õ‡√◊ÈÕ√—ß ‡™àπ √Ÿâ ÷°§—π„π§ÕμâÕß°“√‰Õ‡Õ“‡ ¡À–ÕÕ°¡“ Õ“°“√
‰Õ‡√◊ÈÕ√—ß à«πÀπ÷Ë߇ªìπº≈®“°°“√∑’Ë cough reflex ¡’§«“¡‰«‡°‘πμàÕμ—«°√–μÿâπ
·¡âμ—«°√–μÿâππ—Èπ‰¡à√ÿπ·√ß ´÷ËßÕ“®‡ªìπº≈®“°°“√μ‘¥‡™◊ÈÕ‚¥¬‡©æ“–‡™◊ÈÕ‰«√—  °“√
Õ—°‡ ∫ (inflammation) ‡ªìπμâπ À≈—°°“√√—°…“Õ“°“√‰Õ§◊Õ √—°…“ “‡Àμÿ∑’Ë∑”„Àâ
‡°‘¥μ—«°√–μÿâπ ·≈–Õ“®„À⬓À√◊Õ “√∑’ˬ—∫¬—ÈßÕ“°“√‰Õ
5) °“√ª√–‡¡‘𧫓¡√ÿπ·√ß·≈–º≈°√–∑∫¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß
5.1) °“√ª√–‡¡‘π·∫∫ subjective ‰¥â·°à cough severity score, cough
diary ‚¥¬§«“¡√ÿπ·√ß¡“°¢÷Èπ„πºŸâ∑’Ë¡’Õ“°“√‰Õ°≈“ߧ◊π √∫°«π°“√πÕπÀ≈—∫ °“√
ª√–‡¡‘π¥â«¬«‘∏’π’È„™â¥Ÿ°“√‡ª≈’ˬπ·ª≈ß„π§π‡¥‘¡«à“‡ªìπÕ¬à“߉√ ·μà„™â‰¡à‰¥â‡¡◊ËÕ
‡ª√’¬∫‡∑’¬∫√–À«à“ß∫ÿ§§≈ „πμà“ߪ√–‡∑»„™â·∫∫ Õ∫∂“¡ Leicester ∑’ˉ¥â√—∫
°“√ validation „πºŸâ∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß‚¥¬ª√–‡¡‘πº≈°√–∑∫®“°Õ“°“√‰Õ„π
3 ¡‘μ‘ ‰¥â·°à ∑“ß°“¬ (physical) ∑“ß®‘μ„® (psychological) ·≈–∑“ß —ߧ¡
(social) ·≈–§ÿ≥¿“æ™’«‘μ °“√ª√–‡¡‘π¥â«¬«‘∏’π’È„™â‰¥â¥’∑—Èß„π§π‡¥’¬«°—π·≈–
√–À«à“ß∫ÿ§§≈ ·≈–¬—ß¡’°“√»÷°…“À“§à“ minimal clinical importance diffe-
rence¢Õß°“√‡ª≈’ˬπ·ª≈ß∑’Ë¡’π—¬ ”§—≠∑“ߧ≈‘π‘°(16)
„πª√–‡∑»‰∑¬‰¥â¡’°“√·ª≈
·∫∫ Õ∫∂“¡ Leicester ‡ªìπ©∫—∫¿“…“‰∑¬·≈–∑¥ Õ∫§«“¡‡∑’ˬßμ√ß·≈â«„π
ºŸâªÉ«¬ºŸâ„À≠à∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß(17)
20
5.2) °“√ª√–‡¡‘π·∫∫ objective ‚¥¬°“√„™â‡§√◊ËÕß¡◊Õπ—∫§«“¡∂’Ë¢Õß°“√
‰Õ ´÷Ë߬—߉¡à‡ªìπ∑’Ë·æ√àÀ≈“¬·≈–¡’√“§“·æß
6) °“√√—°…“‡∫◊ÈÕßμâπ
Õ“°“√‰Õ°÷Ë߇©’¬∫æ≈—πÀ√◊Õ‰Õ‡√◊ÈÕ√—ßÕ“®‡°‘¥®“° “‡ÀμÿÀπ÷ËßÀ√◊ÕÀ≈“¬ “‡Àμÿ
„π‡«≈“‡¥’¬«°—π  “‡Àμÿ∑’Ëæ∫‰¥â∫àÕ¬„π°√≥’∑’Ë¿“æ√—ß ’∑√«ßÕ°ª°μ‘ ‰¥â·°à ¬“ ACE
inhibitor, UACS, cough variant asthma ·≈– GERD ¿“¬À≈—ß®“°À¬ÿ¥¬“
ACE-I À“°¡’°“√„™â¬“π’È·≈–À¬ÿ¥°“√ Ÿ∫∫ÿÀ√’Ë·≈â«
°“√√—°…“‡∫◊ÈÕßμâπ„π°√≥’∑’Ë ß —¬ UACS §«√‡√‘Ë¡®“° ¬“μâ“πŒ’ μ“¡’π
(antihistamine) ·≈–/À√◊Õ¬“ decongestant (Level of evidence 3, Grade of
recommendation +) ∂â“μÕ∫ πÕߥ’Õ“°“√‰Õ¡—°¥’¢÷Èπ¿“¬„π 2  —ª¥“Àå
„π°√≥’∑’Ë¡’ª√–«—쑇¢â“‰¥â°—∫‚√§À◊¥ ·π–π”„Àâ‡æ‘Ë¡°“√√—°…“¥â«¬¬“¢¬“¬
À≈Õ¥≈¡ (beta-2 agonist bronchodilator) ·≈–/À√◊Õ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å
™π‘¥ Ÿ¥ (inhaled corticosteroid À√◊Õ ICS) (Level of evidence 1, Grade
of recommendation ++) ·≈–/À√◊Õ§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥√—∫ª√–∑“π‰¡à‡°‘π
2  —ª¥“Àå¢÷ÈπÕ¬Ÿà°—∫§«“¡√ÿπ·√ߢÕßÕ“°“√ °“√μ√«®‡æ‘Ë¡‡μ‘¡‚¥¬μ√«® metha-
choline ‡æ◊ËÕ·¬°‚√§À◊¥·≈–Õ“°“√‰Õ∑’ˇ°‘¥®“°°“√Õ—°‡ ∫™π‘¥Õ‘‚Õ ‘‚πøî≈ (non-
asthmatic eosinophilic bronchitis) À“°μ√«®‰¡à‰¥â °“√„À⬓§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å
™π‘¥ Ÿ¥ ·≈–/À√◊Õ  ‡μ’¬√Õ¬¥å™π‘¥√—∫ª√–∑“π 2  —ª¥“Àå  “¡“√∂√—°…“Õ“°“√‰Õ
∑’ˇ°‘¥®“°°“√Õ—°‡ ∫™π‘¥Õ‘‚Õ ‘‚πøî≈·≈–‚√§À◊¥‰¥â (steroid-responsive cough)
(Level of evidence 3, Grade of recommendation +) ∂â“μÕ∫ πÕߥ’
Õ“°“√‰Õ¡—°¥’¢÷Èπ¿“¬„π 2-4  —ª¥“Àå „π°√≥’∑’ˉ¡àμÕ∫ πÕßμàÕ°“√√—°…“¥â«¬¬“
§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å Õ“®μâÕßæ‘®“√≥“°“√μ√«®‡æ‘Ë¡‡μ‘¡‚¥¬μ√«® methacholine
1
21¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
·≈–°“√«—¥°“√Õ—°‡ ∫™π‘¥Õ‘‚Õ ‘‚πøî≈ ·μà ”À√—∫·æ∑¬å‡«™ªØ‘∫—μ‘ ∑—Ë«‰ª§«√
æ‘®“√≥“ àߪ√÷°…“·æ∑¬åºŸâ‡™’ˬ«™“≠
À“°ºŸâªÉ«¬¡’Õ“°“√‰Õ√à«¡°—∫Õ“°“√¢Õß¿“«–°√¥‰À≈¬âÕπ (GERD) ∑’Ë™—¥‡®π
À√◊Õ¡’Õ“°“√°√¥‰À≈¬âÕπ‰¡à™—¥‡®π ·μà‰¥âμ—¥ª√–‡¥Áπμà“ßÊ ¢â“ßμâπ·≈â« ‰¥â·°à
UACS ·≈–‚√§À◊¥  “¡“√∂æ‘®“√≥“„Àâ°“√√—°…“¥â«¬¬“≈¥°√¥‰¥â ·μàμâÕߥŸº≈°“√
μÕ∫ πÕßμàÕ°“√√—°…“∑’ËÕ¬à“ßπâÕ¬ 4  —ª¥“Àå À“°‰¥â¬“‰ª 8-12  —ª¥“Àå·≈⫬—ß
‰¡à¥’¢÷Èπ§«√À¬ÿ¥¬“ ·≈–æ‘®“√≥“ àߪ√÷°…“·æ∑¬åºŸâ‡™’ˬ«™“≠
7)  “‡ÀμÿÕ“°“√‰Õ‡√◊ÈÕ√—ß„π¿“æ√—ß ’ªÕ¥ª°μ‘∑’Ëæ∫∫àÕ¬
7.1 ACE inhibitor induced cough
æ∫Õÿ∫—μ‘°“√≥åª√–¡“≥√âÕ¬≈– 10 ∂÷ß 30  Ÿß¢÷Èπ„π‡æ»À≠‘ß«—¬°≈“ß
§π Õ“°“√‰Õ¡—°‡ªìπÀ≈—ß®“°‰¥â¬“‡ªìπ√–¬–‡«≈“À≈“¬«—π®π∂÷ßÀ≈“¬ —ª¥“Àå „π
∫“ß°√≥’ºŸâªÉ«¬‰¥â¬“¡“π“πÀ≈“¬‡¥◊Õπ§àÕ¬¡“‡°‘¥Õ“°“√‰Õ‰¥â‡¡◊ËÕ¡’μ—«°√–μÿâ𠇙àπ
°“√μ‘¥‡™◊ÈÕÀ«—¥ Õ“°“√‰Õ®“°¬“π’È¡—°‰¡àμÕ∫ πÕßμàÕ¬“¢¬“¬À≈Õ¥≈¡À√◊Õ¬“
°¥Õ“°“√‰Õ Õ“°“√‰ÕÀ“¬‰¥â‡ÕßÀ≈—ßÀ¬ÿ¥¬“¿“¬„π 1-4  —ª¥“Àå(18)
À“°ºŸâªÉ«¬‰Õ
‡√◊ÈÕ√—ߧ«√À¬ÿ¥¬“ (Level of evidence 3, Grade of recommendation +)
7.2 Cough variant asthma
≈—°…≥–∑’Ë ”§—≠∑“ߧ≈‘π‘°§◊ÕºŸâªÉ«¬¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß∑’ˇ¢â“‰¥â°—∫‚√§À◊¥
‡™àπ ‰Õ‡«≈“°≈“ߧ◊π ‰ÕÀ≈—ß®“°‰¥â√—∫°“√°√–μÿâπ À√◊Õ “√°àÕ¿Ÿ¡‘·æâ ‚¥¬∑’ˉ¡à¡’
‡ ’¬ßÀ«’¥ À√◊Õ‰¡à¡’Õ“°“√‡Àπ◊ËÕ¬ ‰Õ à«π„À≠à‰¡à¡’‡ ¡À–À√◊Õ¡’‡æ’¬ß‡≈Á°πâÕ¬ ‚¥¬
‰¡à¡’¿“«–μ‘¥‡™◊ÈÕ∑“߇¥‘πÀ“¬„®π”¡“°àÕπ(19)
‚√§π’ÈμÕ∫ πÕߥ’μàÕ°“√√—°…“¥â«¬¬“
¢¬“¬À≈Õ¥≈¡ À“°ºŸâªÉ«¬μÕ∫ πÕߥ’μàÕ¬“¢¬“¬À≈Õ¥≈¡ §«√∑”°“√∑¥ Õ∫
‡æ◊ËÕ¬◊π¬—π°“√«‘π‘®©—¬‚√§À◊¥μ“¡·π«∑“ß°“√ªØ‘∫—μ‘ ”À√—∫ºŸâªÉ«¬‚√§À◊¥(12)
22
°“√√—°…“‚√§À◊¥
1. „π°√≥’∑’Ë¡’Õ“°“√‰Õ‡ªìπ§√—Èߧ√“«(intermittent)Õ“®æ‘®“√≥“„À⬓ β2-
agonist ™π‘¥√—∫ª√–∑“πÀ√◊Õ™π‘¥ Ÿ¥∑’ËÕÕ°ƒ∑∏‘Ï —Èπ(1)
(Level of evidence 2,
Grade of recommendation ++) ‡æ◊ËÕ∫√√‡∑“Õ“°“√¢Õß‚√§À◊¥ (relievers)
®“°°“√À¥‡°√ÁߢÕß°≈â“¡‡π◊ÈÕ‡√’¬∫À≈Õ¥≈¡ °“√μÕ∫ πÕߥŸ®“°Õ“°“√‰Õ¥’¢÷Èπ
„π 2-4  —ª¥“Àå
2. À“°Õ“°“√‰Õ‡ªìπμ≈Õ¥μàÕ‡π◊ËÕß (persistent) À√◊Õ‰¡àμÕ∫ πÕßμàÕ¬“
„π¢âÕ 1 æ‘®“√≥“„À⬓∑’Ë„™â§«∫§ÿ¡‚√§À◊¥ (controllers) „™â‡æ◊ËÕ√—°…“°“√Õ—°‡ ∫
‡√◊ÈÕ√—ߢÕßÀ≈Õ¥≈¡ ¬“∑’Ë¡’ª√– ‘∑∏‘¿“楒∑’Ë ÿ¥ §◊Õ ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥
(inhaled corticosteroid À√◊Õ ICS)(12)
(Level of evidence 1, Grade of
recommendation ++) ‚¥¬¬—∫¬—Èß°“√ √â“ß “√∑’ˇ°’ˬ«¢âÕß°—∫°“√Õ—°‡ ∫®“°
‡¡Á¥‡≈◊Õ¥¢“«·≈–¬—ß¡’¬“°≈ÿà¡Õ◊ËπÊ∑’Ë “¡“√∂„™â‰¥â‡™à𠬓μâ“π≈‘«‚§‰μ√Õ’π (leuko-
triene receptor antagonist, LTRA)(20)
(Level of evidence 1, Grade of
recommendation ++) º≈°“√√—°…“¥â«¬¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥·≈–
¬“μâ“π≈‘«‚§‰μ√Õ’π„π¥â“πÕ“°“√‰ÕæÕÊ °—π·μà ICS ªÑÕß°—π°“√¥”‡π‘π‚√§‰ª Ÿà
classic asthma À√◊Õ wheezing ‰¥â¥’°«à“ LTRA(21)
À“°¬—ߧ«∫§ÿ¡‰¡à‰¥â  “¡“√∂
„™â¬“¢¬“¬À≈Õ¥≈¡∑’ËÕÕ°ƒ∑∏‘Ϭ“« (long-acting β2-agonist, LABA) ∑’˺ ¡°—∫
¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥ (ICS/LABA)(22)
‡æ◊ËÕ‡ √‘¡ƒ∑∏‘Ï°—π(23)
(Level of
evidence 1, Grade of recommendation ++)
À“°„Àâ°“√√—°…“¥â«¬¬“¢â“ßμâπ·≈–μ‘¥μ“¡·≈⫉¡à‰¥âº≈¿“¬„π‡«≈“ 4  —ª¥“Àå
§«√æ‘®“√≥“ àßμàÕ·æ∑¬åºŸâ‡™’ˬ«™“≠
7.3 Upper airway cough syndrome
°≈ÿà¡Õ“°“√π’Ȫ√–°Õ∫¥â«¬ rhinitis, sinusitis ·≈– postnasal drip ∑’Ë
23¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
∑”„Àâ¡’Õ“°“√‰Õ ¡’¡Ÿ°‰À≈≈ß§Õ °√–·Õ¡∫àÕ¬Ê ‰´π— Õ—°‡ ∫ À¡“¬∂÷ß‚æ√ß
Õ“°“»¢â“ß®¡Ÿ° (À√◊Õ‡√’¬°«à“‰´π— ) ‡°‘¥°“√Õ—°‡ ∫ ´÷Ëß “‡Àμÿ à«π„À≠à∑’Ë∑”„Àâ
‚æ√߉´π— Õ—°‡ ∫®–‡°‘¥μ“¡À≈—ß®“°‚æ√ß®¡Ÿ°Õ—°‡ ∫ (rhinitis) ¥—ßπ—Èπ®÷ß®–‡√’¬°
√«¡«à“ çrhinosinusitisé
7.3.1 ‰´π— Õ—°‡ ∫ (sinusitis)
°“√·∫àß™π‘¥¢Õ߉´π— Õ—°‡ ∫  “¡“√∂·∫à߉¥â‡ªìπ‰´π— Õ—°‡ ∫
‡©’¬∫æ≈—π (acute rhinosinusitis) ·≈–‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß (chronic rhinosinusitis,
CRS) ‚¥¬„™â√–¬–‡«≈“∑’ËπâÕ¬°«à“ 12  —ª¥“Àå À√◊Õ 12  —ª¥“Àå¢÷Èπ‰ª ‡ªìπμ—«·∫àß
‰´π— Õ—°‡ ∫∑’Ë∑”„À⇰‘¥Õ“°“√‰Õ‡√◊ÈÕ√—ß¡—°‡°‘¥®“°‰´π— Õ—°‡ ∫·∫∫‡√◊ÈÕ√—ß´÷Ëß “¡“√∂
·∫à߬àÕ¬‰¥âÕ’°‡ªìπ‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß∑’Ë¡’√‘¥ ’¥«ß®¡Ÿ° (CRS with nasal polyp)
À√◊Õ‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß∑’ˉ¡à¡’√‘¥ ’¥«ß®¡Ÿ° (CRS without nasal polyp)  ”À√—∫
‚√§∑“߉´π— ∑’Ë∑”„Àâ —¡æ—π∏å°—∫Õ“°“√‰Õ‡√◊ÈÕ√—ßπ—Èπ Õ“°“√‰Õ∑’ˇ°‘¥¢÷ÈπÕ“®‡ªìπ
®“°¡Ÿ°∑’ˉÀ≈≈ߧհ√–μÿâπ∑“߇¥‘πÀ“¬„® à«π≈à“ß ·≈–/À√◊Õ °“√Õ—°‡ ∫∑’ˇ°‘¥∑’Ë
∑“߇¥‘πÀ“¬„® à«π∫π‡°’Ë¬«¢âÕ߉ª Ÿà∑“߇¥‘πÀ“¬„® à«π≈à“ß (united airway
inflammation)
‡°≥±å°“√«‘π‘®©—¬‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß
1) Õ“°“√ ”§—≠ Õߪ√–°“√§◊Õ Õ“°“√§—¥®¡Ÿ° ·≈–πÈ”¡Ÿ°‰À≈ ´÷Ëß
Õ“®®–‡ªìπ πÈ”¡Ÿ°‰À≈ÕÕ°¡“∑“ß√Ÿ®¡Ÿ° (anterior rhinorrhea) À√◊Õ¡Ÿ°‰À≈≈ߧÕ
(postnasal drip) √à«¡°—∫√–¬–‡«≈“∑’ˇªìπ 12  —ª¥“Àå¢÷Èπ‰ª
2) °“√μ√«®√à“ß°“¬‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß ‚¥¬·æ∑¬å‡«™ªØ‘∫—μ‘∑—Ë«‰ª
 “¡“√∂„™â‰ø©“¬ À√◊Õ otoscope  àÕß√Ÿ®¡Ÿ°‡æ◊ËÕª√–‡¡‘π«à“ ¡’°“√Õ—°‡ ∫¢Õß
‡¬◊ËÕ∫ÿ‚æ√ß®¡Ÿ° √‘¥ ’¥«ß®¡Ÿ° ·≈–„™â‰¡â°¥≈‘Èπ‡æ◊ËÕμ√«®¥Ÿ«à“¡’¡Ÿ°‰À≈≈ߧÕÀ√◊Õ‰¡à
24
°“√μ√«®∑“ß√—ß ’‚¥¬°“√‡ÕÁ°´å‡√¬å‰´π—  (Plain-film of paranasal sinus)
¡’§«“¡·¡à𬔄π°“√«‘π‘®©—¬μË”(24)
∂â“æ∫§«“¡º‘¥ª°μ‘ °Á “¡“√∂„Àâ°“√«‘π‘®©—¬
À“°¬—ß ß —¬‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß®“°≈—°…≥–∑“ߧ≈‘π‘° ·μà‡ÕÁ°´å‡√¬åå‰´π— ª°μ‘°Á
¬—߉¡à “¡“√∂μ—¥°“√«‘π‘®©—¬ÕÕ°‰¥â
°“√√—°…“‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß
1.1 °“√√—°…“‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß„π°√≥’∑’Ë¡’°“√°”‡√‘∫‡©’¬∫æ≈—π(25)
æ‘®“√≥“
„À⬓μâ“π®ÿ≈™’懪ìπ‡«≈“ 3-4  —ª¥“Àå
1.1.1 ¬“μâ“π®ÿ≈™’æ∑’˧«√‡≈◊Õ°„™âÕ—π¥—∫·√° (first-line antibiotics)
‰¥â·°à amoxicillin „π°√≥’∑’Ë·æâ penicillin „Àâ‡≈◊Õ° macrolides ‰¥â·°à clari-
thromycin À√◊Õ azithromycin
1.1.2 ¬“μâ“π®ÿ≈™’æ∑’˧«√‡≈◊Õ°„™âÕ—π¥—∫ Õß (second-line antibio-
tics)
1) ¬“μâ“π®ÿ≈™’æ™π‘¥ Beta-lactam/ beta-lactamase inhibi-
tor 䴉ᡈ amoxicillin/clavulanate
2) Second À√◊Õ third generation cephalosporin ‰¥â·°à
cefuroxime, cefpodoxime proxetil À√◊Õ cefdinir
3) Respiratory fluoroquinolones ‰¥â·°à levofloxacin À√◊Õ
moxifloxacin
1.2 °“√√—°…“¥â«¬¬“Õ◊ËπÊ(26)
1.2.1 °“√√—°…“¿“«–°“√Õ—°‡ ∫ ‰¥â·°à ¬“ ‡μ’¬√Õ¬¥å™π‘¥æàπ®¡Ÿ°
(nasal steroid) ‡ªìπÕ—π¥—∫·√° ‡ªìπ‡«≈“ 12  —ª¥“Àå (Level of evidence 1,
Grade of recommendation ++)
25¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
1.2.2 °“√‡æ‘Ë¡°“√√–∫“¬¡Ÿ°ÀπÕß∑’˧â“ß„π‰´π— „Àâ√–∫“¬‰¥â¥’¢÷Èπ
(promoting drainage from paranasal sinuses) ‚¥¬≈â“ß®¡Ÿ°¥â«¬πÈ”‡°≈◊Õ (Level
of evidence 1, Grade of recommendation ++)
1.2.3 ¬“ decongestant ™π‘¥æàπÀ√◊Õ°‘π ·π–π”„Àℙ⠔À√—∫
ºŸâ∑’Ë¡’Õ“°“√§—¥®¡Ÿ° ·μଗ߉¡à¡’À≈—°∞“π«à“∑”„Àâ‚√§‰´π— Õ—°‡ ∫À“¬‰¥â‡√Á«·≈–
¡“°°«à“ºŸâªÉ«¬∑’ˉ¡à‰¥â√—∫¬“ ∂â“„™â™π‘¥æàπ·π–π”„™â‰¡à‡°‘π 5 «—π  à«π™π‘¥°‘π
·π–π”„™â‰¡à‡°‘π 10 -14 «—π (Level of evidence 3, Grade of recommenda-
tion +)
1.2.4 ¬“μâ“πŒ‘ μ“¡’π ·π–π”„Àâ„™â„π√“¬∑’Ë¡’ª√–«—μ‘/Õ“°“√¢Õß
‚√§¿Ÿ¡‘·æâ‡∑à“π—Èπ „π°√≥’∑’Ë®–„™â¬“„π°≈ÿà¡π’È ‰¡à·π–π”„Àâ„™â™π‘¥ first genera-
tion ‡™àπ chlorpheniramine ‡æ√“–∑”„Àâ¡Ÿ°‡À𒬫 ·≈–‡°‘¥Õ“°“√ßà«ß´÷¡
 “¡“√∂„Àâ°“√√—°…“‡∫◊ÈÕßμâπ (Empirical treatment) ¥—ß°≈à“«¢â“ß
μâπ°àÕπ°“√μ√«®‡æ◊ËÕ§âπÀ“ “‡Àμÿ™π‘¥Õ◊ËπÊ „π°√≥’∑’˺ŸâªÉ«¬‰¥â√—∫°“√¥Ÿ·≈√—°…“
‡∫◊ÈÕßμâπ·≈â« 4  —ª¥“Àå ºŸâªÉ«¬¬—߉¡à¡’°“√μÕ∫ πÕßÕ¬à“ß¡’π—¬ ”§—≠§«√ àß„Àâ
·æ∑¬å‡©æ“–∑“߇æ◊ËÕμ√«®„π‚æ√ß®¡Ÿ°‚¥¬≈–‡Õ’¬¥‚¥¬°“√„™â°≈âÕ߇∑‡≈ ‚§ª
(nasal telescopy) ‚¥¬‡©æ“–Õ¬à“߬‘Ëß∑’Ë∫√‘‡«≥™àÕß∑“ß√–∫“¬¡Ÿ°À√◊ÕÀπÕß®“°
‚æ√߉´π— ¡“∑’Ë‚æ√ß®¡Ÿ° (middle meatus)
7.3.2 ‚æ√ß®¡Ÿ°Õ—°‡ ∫ (Rhinitis)
‚æ√ß®¡Ÿ°Õ—°‡ ∫ (rhinitis) ‡°‘¥®“°°“√Õ—°‡ ∫¢Õ߇¬◊ËÕ∫ÿ‚æ√ß®¡Ÿ°
´÷Ë߇°‘¥‰¥â®“°À≈“¬ “‡Àμÿ À“°‡°‘¥®“°¿Ÿ¡‘·æâ ‡√’¬°«à“ allergic rhinitis (AR) À“°
‰¡à‰¥â‡°‘¥®“°¿Ÿ¡‘·æâ ‡√’¬°«à“ non-allergic rhinitis (NAR) ´÷Ëß¡’‰¥âÀ≈“¬æ¬“∏‘
°”‡π‘¥ ‡™àπ vasomotor rhinitis, drug-induced, hormonal-induced, environ-
26
ment/irritant-induced, gustatory reflex À√◊Õ°“√Õ—°‡ ∫™π‘¥Õ’‚Õ ‘‚πøî≈‚¥¬
‰¡à‰¥â‡°‘¥®“°¿Ÿ¡‘·æâ (non-allergic rhinitis with eosinophilia syndrome, NARES)
°“√«‘π‘®©—¬‚æ√ß®¡Ÿ°Õ—°‡ ∫
ª√–°Õ∫¥â«¬Õ“°“√¡“°°«à“ 1 „π 3 Õ“°“√¥—ßμàÕ‰ªπ’È 1) §—πÀ√◊Õ®“¡
(sneezing) 2) πÈ”¡Ÿ°‰À≈ (rhinorrhea) À√◊Õ 3) §—¥®¡Ÿ° (congestion) Õ¬à“߉√
°Áμ“¡ 1 „π 3 ¢ÕߺŸâªÉ«¬Õ“®¡’Õ“°“√∑’ˉ¡à®”‡æ“– (unrecognized form) ‡™àπ
Õ“°“√°√–·Õ¡ (throat clearing), ª“°·ÀâßÀ√◊Õ§Õ·ÀâßÀ≈—ßμ◊ËππÕπ ´÷ËßÕ“®‡°‘¥
®“°§—¥®¡Ÿ°‡√◊ÈÕ√—ß®πÕ⓪“°À“¬„® (mouth breathing), ª«¥¡÷π»’√…–®“°§—¥®¡Ÿ°
(headache), ÀŸÕ◊ÈÕ®“°°“√∫«¡¢Õ߇¬◊ËÕ∫ÿ‚æ√ß®¡Ÿ°®π∑”„Àâ Eustachian tube
dysfunction, ·≈–Õ“°“√§—π∫√‘‡«≥‡¬◊ËÕ‡¡◊Õ°„°≈⇧’¬ß ‡™àπ §—π‡æ¥“𪓰 §—πÀŸ
§—πμ“ ·≈–§—π„π§Õ ‡ªìπμâπ Õ¬à“߉√°Áμ“¡Õ“°“√‰Õπ—Èπ “¡“√∂æ∫„π‚√§‚æ√ß®¡Ÿ°
Õ—°‡ ∫‰¥â‚¥¬‰¡à‰¥â™à«¬·¬°·¬–«à“‡°‘¥®“° AR À√◊Õ NAR(27)
‚¥¬Õ“°“√‰ÕÕ“®‡°‘¥
®“°°“√‡æ‘Ë¡ capsaicin cough sensitivity ®“°°“√Õ—°‡ ∫¢Õß∑“߇¥‘πÀ“¬„®
®“°°“√ —¡º—  “√°àÕ¿Ÿ¡‘·æâ(28)
Õ“°“√∑’Ë∑”„Àâ ß —¬‚æ√ß®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ
¡“°¢÷Èπ ‰¥â·°à §—π ®“¡ ·≈–Õ“°“√∑“ßμ“ „π¢≥–∑’ËÕ“°“√πÈ”¡Ÿ°‰À≈·≈–§—¥®¡Ÿ°
æ∫‰¥â„π‚æ√ß®¡Ÿ°Õ—°‡ ∫‡°◊Õ∫∑ÿ° “‡Àμÿ °“√μ√«®√à“ß°“¬Õ“®æ∫§«“¡º‘¥ª°μ‘
„π‚æ√ß®¡Ÿ°À√◊Õ‰¡à°Á‰¥â
°“√√—°…“‚æ√ß®¡Ÿ°Õ—°‡ ∫
1. °“√√—°…“‚æ√ß®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ
‡πâπ°“√≈¥°“√Õ—°‡ ∫¢Õ߇¬◊ËÕ∫ÿ®¡Ÿ°∑’ˇ°‘¥®“°°“√ —¡º—  “√°àÕ¿Ÿ¡‘·æâ
¥â«¬¬“ ‡μ’¬√Õ¬¥å™π‘¥æàπ®¡Ÿ° (Level of evidence 1, Grade of recommen-
dation ++) ¬“Õ◊ËπÊ ∑’ËÕ“®æ‘®“√≥“„™â√—°…“Õ“°“√§—π ®“¡ À√◊Õ√—°…“‡ªìπ¬“À≈—°
27¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
À“°¡’Õ“°“√‰¡à√ÿπ·√ß ‰¥â·°à ¬“μâ“πŒ’ μ“¡’π·∫∫√—∫ª√–∑“π™π‘¥‰¡àßà«ß (Level
of evidence 1, Grade of recommendation ++) ·≈–°“√√—°…“μ“¡Õ“°“√ ‡™àπ
°“√≈â“ß®¡Ÿ°¥â«¬πÈ”‡°≈◊Õ (Level of evidence 3, Grade of recommendation
+) °“√‡æ‘Ë¡¬“μâ“π≈‘«‚§‰μ√Õ’π (Leukotriene receptor antagonist, LTRA) ‡¡◊ËÕ
√—°…“¥â«¬¬“μâ“πŒ’ μ“¡’πÀ√◊Õ¬“ ‡μ’¬√Õ¬¥å™π‘¥æàπ®¡Ÿ°·≈⫉¡à‰¥âº≈ ‰¡à¡’ª√–‚¬™πå
„π°“√√—°…“‚æ√ß®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ (Level of evidence 2, Grade of
recommendation -) ¬°‡«âπ„π°√≥’∑’Ë¡’‚√§À◊¥√à«¡¥â«¬ (Level of evidence 2,
Grade of recommendation ++)(29)
Õ¬à“߉√°Áμ“¡‚√§‚æ√ß®¡Ÿ°Õ—°‡ ∫®“° “‡Àμÿ
Õ◊ËπÊÕ“®‰¡àμÕ∫ πÕßμàÕ°“√√—°…“¥—ß°≈à“«¢â“ßμâπÀ“° ß —¬¿“«–π’È·μà‰¡àμÕ∫ πÕß
μàÕ°“√√—°…“¿“¬„π 4  —ª¥“Àå §«√æ‘®“√≥“ àßμàÕºŸâ‡™’ˬ«™“≠ (¥Ÿ®“°·π«∑“ß°“√
μ√«®√—°…“‚√§®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâ„π§π‰∑¬ ©∫—∫ª√—∫ª√ÿß æ.». 2554)
2. °“√√—°…“¿“«–¡Ÿ°‰À≈≈ß§Õ (postnasal drip) ∑’ˉ¡à¡’¿“«–
‰´π— Õ—°‡ ∫
„™â¬“μâ“πŒ’ μ“¡’π√ÿàπ∑’Ë 1 ‰¥â·°à dexbrompheniramine ·≈–/À√◊Õ
pseudoephedrine „π¿“«–‰Õ‡√◊ÈÕ√—ß·π–π”„Àâ√—°…“π“π 3  —ª¥“Àå·≈⫪√–‡¡‘π
º≈ (Level of evidence 4, grade of recommendation +)  à«π¬“ ipratropium
™π‘¥æàπ®¡Ÿ°Õ“®‰¥âª√–‚¬™πå„π°“√≈¥Õ“°“√πÈ”¡Ÿ°‰À≈®“°‚æ√ß®¡Ÿ°Õ—°‡ ∫ (Level
of evidence 4, Grade of recommendation +/-) ·μà¢âÕ¡Ÿ≈°“√≈¥Õ“°“√‰Õ¬—ß
‰¡à™—¥‡®π(30-32)
7.4 Nonasthmatic eosinophilic bronchitis
‚√§π’ȇ°‘¥®“°°“√Õ—°‡ ∫™π‘¥Õ‘‚Õ ‘‚πøî≈∫√‘‡«≥∑“߇¥‘πÀ“¬„® à«π≈à“ß
ºŸâªÉ«¬¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß·∫∫¡’‡ ¡À–À√◊Õ‰¡à¡’‡ ¡À–°Á‰¥â √âÕ¬≈– 60 ¡’ rhinitis √à«¡
¥â«¬‚¥¬¡—°‡ªìπ allergic rhinitis √âÕ¬≈– 10 ¢ÕߺŸâªÉ«¬¡’ peripheral eosino-
28
philia ·≈–√âÕ¬≈– 20 ¡’ specific IgE antibodies „Àâº≈∫«°(33)
°“√μ√«®
 ¡√√∂¿“æªÕ¥¡—°‰¡àæ∫°“√μÕ∫ πÕßμàÕ°“√∑¥ Õ∫¥â«¬¬“¢¬“¬À≈Õ¥≈¡ ¡’
‡æ’¬ß√âÕ¬≈– 12 ∑’ËÕ“®μÕ∫ πÕßμàÕ°“√∑¥ Õ∫¥â«¬¬“¢¬“¬À≈Õ¥≈¡ °“√μ√«®
methacholine º≈ª°μ‘ °“√μ√«® serial peak flow æ∫ diurnal variation ‰¥â
æÕÊ °—∫ cough variant asthma °“√Õ—°‡ ∫„πÀ≈Õ¥≈¡ “¡“√∂μ√«®æ∫‡´≈≈å
Õ—°‡ ∫™π‘¥Õ‘‚Õ ‘‚πøî≈‰¥â®“°‡ ¡À– πÈ”≈â“ߪե ·≈–™‘Èπ‡π◊ÈÕ‰¥â‡™àπ‡¥’¬«°—∫‚√§À◊¥
Õ¬à“߉√°Áμ“¡ √–¥—∫ fractional exhaled nitric oxide (FeNO) „πºŸâªÉ«¬ eosino-
philic bronchitis ‰¡à Ÿß‡À¡◊Õπ„πºŸâªÉ«¬ asthma À√◊Õ cough variant asthma(14)
°“√√—°…“ Nonasthmatic eosinophilic bronchitis
¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥„π¢π“¥ Ÿß (budesonide 800 mcg
μàÕ«—π À√◊Õ‡∑’¬∫‡∑à“) (Level of evidence 4, Grade of recommendation ++)
º≈°“√μÕ∫ πÕߥ’„π 2-4  —ª¥“Àå(34)
‚√§π’ȉ¡àμÕ∫ πÕßμàÕ¬“¢¬“¬À≈Õ¥≈¡ √–¬–
‡«≈“„π°“√√—°…“¬—߉¡à·πàπÕπ·π–π”„ÀâÀ≈’°‡≈’ˬߠ“√°àÕ¿Ÿ¡‘·æâ·≈– “√√–§“¬‡§◊Õß
À“°¡’ª√–«—μ‘ —¡º— ™—¥‡®π À“°‰¡àμÕ∫ πÕßμàÕ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥„π
¢π“¥ Ÿß Õ“®æ‘®“√≥“¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥°‘π(2)
(Level of evidence 4,
Grade of recommendation +)
7.5 Õ“°“√‰Õ®“°¿“«–°√¥‰À≈¬âÕπ (Cough related reflux disease)
‚√§À√◊Õ¿“«–°√¥‰À≈¬âÕ𠇪ìπ¿“«–∑’Ë¡’°“√¬âÕπ°≈—∫¢Õß¡«≈ “√„π
°√–‡æ“–Õ“À“√ (gastric content) ¢÷Èπ¡“ ŸàÀ≈Õ¥Õ“À“√ ª√–°Õ∫¥â«¬∑—Èß°√¥∑’Ë
‡°‘¥®“°πÈ”¬àÕ¬®“°°√–‡æ“–Õ“À“√ À√◊ÕÕ“®‡ªìπ¥à“ß∑’ˇ°‘¥®“°πÈ”¬àÕ¬∑’ËÀ≈—Ëß®“°
≈”‰ â‡≈Á°À√◊Õ·°ä (35)
Õ“°“√¢Õß¿“«–°√¥‰À≈¬âÕπ¡’À≈“°À≈“¬ ‚¥¬Õ“°“√∫“ßÕ¬à“ß°Á‰¡à¡’
29¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
§«“¡‡©æ“–‡®“–®ßμàÕ‚√§ °“√´—°ª√–«—쑇ªìπ ‘Ëß ”§—≠ πÕ°®“°®”‡ªìπ„π°“√
«‘π‘®©—¬·≈â« ¬—ߙ૬„π°“√‡≈◊Õ°„Àâ°“√√—°…“‰¥âÕ¬à“߇À¡“– ¡¬‘Ëߢ÷Èπ¥â«¬
‚¥¬∑—Ë«‰ªÕ“°“√¢ÕߺŸâªÉ«¬∑’Ë¡’‚√§¥—ß°≈à“« Õ“®¡’Õ“°“√∑“ߧ≈‘π‘°∑’Ë
·∫à߉¥â‡ªìπ°≈ÿà¡„À≠àÊ ª√–°Õ∫¥â«¬
1) Õ“°“√¢ÕßÀ≈Õ¥Õ“À“√ (esophageal symptoms) ¡’Õ“°“√‡¥àπ
2 Õ“°“√ ‰¥â·°à Õ“°“√· ∫√âÕπ¬Õ¥Õ° (heartburn) ·≈–Õ“°“√‡√Õ‡ª√’Ȭ« (re-
gurgitation) Õ’°Õ“°“√∑’Ëæ∫‰¥â‰¡à∫àÕ¬π—°§◊ÕÕ“°“√‡®Á∫Àπâ“Õ° (chest pain) „π
°≈ÿà¡Õ“°“√¢ÕßÀ≈Õ¥Õ“À“√π’ȇÕ߬—ß¡’°“√·∫à߬àÕ¬ÕÕ°‡ªìπ¿“«–·∑√°´âÕπ∑’ˇ°‘¥
®“°°√¥‰À≈¬âÕπ‚¥¬‡ªìπ≈—°…≥–∑’Ëæ∫‰¥â®“°°“√ àÕß°≈âÕßμ√«®∑“߇¥‘πÕ“À“√‡ªìπ
4 ≈—°…≥– §◊Õ ·º≈Õ—°‡ ∫¢ÕßÀ≈Õ¥Õ“À“√ (erosive esophagitis) À≈Õ¥Õ“À“√
μ’∫®“°·º≈Õ—°‡ ∫¢ÕßÀ≈Õ¥Õ“À“√ (esophageal stricture) Baretteûs esopha-
gus ·≈–¡–‡√ÁßÀ≈Õ¥Õ“À“√ (esophageal cancer) ™π‘¥ adenocarcinoma
2) Õ“°“√πÕ°À≈Õ¥Õ“À“√ (extraesophageal symptoms) ª√–°Õ∫
¥â«¬ Õ“°“√μà“ßÊ ∑’ˉ¡à —¡æ—π∏å°—∫À≈Õ¥Õ“À“√‚¥¬μ√ß ‰¥â·°à Õ“°“√‰Õ ·≈–°≈àÕß
‡ ’¬ßÕ—°‡ ∫®“°¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ¢÷ÈπÀ≈Õ¥§Õ (laryngopharyngeal reflux
À√◊Õ LPR) ÀÕ∫À◊¥ ·≈–øíπºÿ πÕ°®“°π’Ȭ—ß¡’Õ“°“√∑’˧“¥«à“Õ“®‡ªìπº≈®“°¿“«–
°√¥‰À≈¬âÕπ ∑’Ë∂Ÿ°®—¥Õ¬Ÿà„π°≈ÿà¡π’È ‰¥â·°à ‰´π— Õ—°‡ ∫ §ÕÀÕ¬Õ—°‡ ∫ ÀŸ™—Èπ°≈“ß
Õ—°‡ ∫‡√◊ÈÕ√—ß ·≈–ªÕ¥‡ªìπæ—ߺ◊¥(35, 36)
®–‡ÀÁπ‰¥â«à“ Õ“°“√‰Õ‡√◊ÈÕ√—ß ‰´π— Õ—°‡ ∫ À√◊Õ¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ
¢÷ÈπÀ≈Õ¥§Õ (laryngopharyngeal reflux À√◊Õ LPR) ∑’ˇ°‘¥®“°¿“«–°√¥‰À≈¬âÕπ
≈â«π‡ªìπÕ“°“√πÕ°À≈Õ¥Õ“À“√∑—Èß ‘Èπ ´÷Ëߧ«“¡·μ°μà“ß√–À«à“ßÕ“°“√πÕ°À≈Õ¥
Õ“À“√·≈–Õ“°“√¢ÕßÀ≈Õ¥Õ“À“√ §◊Õ æ¬“∏‘ √’√«‘∑¬“°“√‡°‘¥‚√§ √«¡∂÷ß°“√
μÕ∫ πÕßμàÕ°“√√—°…“
30
Õ“°“√‰Õ®“°¿“«–πÈ”¬àÕ¬‰À≈¬âÕππ’È “¡“√∂°√–μÿâπ„À⇰‘¥¿“«–‰Õ‡√◊ÈÕ√—߉¥â
‚¥¬ºà“π°≈‰°Õ—π„¥Õ—πÀπ÷Ëß À√◊ÕÀ≈“¬°≈‰° ¥—ßπ’È
1) Esophagopharyngeal reflux (microaspiration theory)(37)
°“√
°√–μÿâπÀ≈Õ¥§Õ‚¥¬μ√ß®“°¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ
2) Laryngeal chemoreflex (reflex pathway ª√–°Õ∫¥â«¬ afferent limb
§◊Õ stimulated superior laryngeal nerve ·≈– efferent limb ‚¥¬ recurrent
laryngeal nerve)
3) Vagally mediated reflex (¡’ sensory stimulation ¢Õß distal eso-
phagus ‚¥¬‰¡à¡’ laryngeal stimulation ´÷Ëß∑”„À⇰‘¥ laryngospasm À√◊ÕÕ“°“√
‰Õ ºà“π∑“ß afferent limb of vagus nerve)
4) ¿“«–πÈ”¬àÕ¬°√–μÿâπ√–∫∫ª√– “∑Õ—μ‚π¡—μ‘°“√‡°‘¥°“√‰Õ„Àâ‡æ‘Ë¡¢÷Èπ
(Increased cough reflex)
5) ¿“«–°“√‰Õ °àÕ„À⇰‘¥¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ®“°°“√‰Õπ—Èπ‡ªìπ«ß®√(38-41)
°“√«‘π‘®©—¬‰Õ‡√◊ÈÕ√—ß®“°¿“«–°√¥‰À≈¬âÕπ
°“√«‘π‘®©—¬∑”‰¥â‰¡àßà“¬π—° ‚¥¬æ∫«à“ √âÕ¬≈– 43-75 ¢ÕߺŸâªÉ«¬°≈ÿà¡π’È ‰¡à¡’
Õ“°“√∑“ßÀ≈Õ¥Õ“À“√√à«¡¥â«¬(42, 43)
·μà°Á¡’¢âÕ¡Ÿ≈«à“ ¿“«–°√¥‰À≈¬âÕπÕ“®‡ªìπ
‡Àμÿ¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—߉¥â∂÷ß√âÕ¬≈– 10 ‚¥¬∑—Ë«‰ª§«√π÷°∂÷ß¿“«–°√¥‰À≈¬âÕπ„π
ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß∑’Ë¡’≈—°…≥–¥—ßμàÕ‰ªπ’È ‰Õ‰¡à¡’‡ ¡À– ºŸâªÉ«¬∑’Ë¡’Õ“°“√°”‡√‘∫À≈—ß
√—∫ª√–∑“πÕ“À“√¡◊ÈÕ„À≠àÀ√◊Õ ¡’Õ“°“√∫àÕ¬„π∑à“πÕπ(44)
°“√«‘π‘®©—¬¿“«–πÈ”¬àÕ¬
‰À≈¬âÕπ∑’Ë∑”„À⇰‘¥Õ“°“√‰Õπ—È𠧫√«‘π‘®©—¬μ“¡¢—ÈπμÕπ∑’Ë∂Ÿ°μâÕß ‡æ√“–„π∫“ߧ√—Èß
Õ“°“√πÈ”¬àÕ¬‰À≈¬âÕ𠇙àπ · ∫√âÕπ∑√«ßÕ° À√◊Õ‡√Õ‡ª√’Ȭ« ‰¡à¡’Õ“°“√‡¥àπ™—¥
„πºŸâªÉ«¬‡À≈à“π’È ·≈–Õ“®∑”„À⇰‘¥°“√«‘π‘®©—¬º‘¥æ≈“¥‰¥â ¥—ßπ—Èπ°“√«‘π‘®©—¬Õ“°“√
31¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
‰Õ‡√◊ÈÕ√—ß®“°¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ ®÷ߧ«√§”π÷ß·≈–μ—¥ª√–‡¥Áπ∑’ËÕ“®‡ªì𠓇Àμÿ
Õ◊ËπÊ μ“¡¢—ÈπμÕπ°àÕπ„Àâ°“√«‘π‘®©—¬ ¥—ßπ’È (45)
(Level of evidence 4, Grade of
recommendation ++)
1. ºŸâªÉ«¬ —¡º— ¡≈¿“«–∑“ßÕ“°“» À√◊Õ “√√–§“¬‡§◊Õß À√◊Õ‡ªìπºŸâ Ÿ∫
∫ÿÀ√’ËÕ¬ŸàÀ√◊Õ‰¡à
2. ºŸâªÉ«¬‰¥â√—∫¬“ ACE-I Õ¬ŸàÀ√◊Õ‰¡à
3. ¿“æ∂à“¬√—ß ’ªÕ¥§«√ª°μ‘ À√◊Õ‡ªìπ√Õ¬‚√§‡°à“∑’ˉ¡à°àÕ„À⇰‘¥Õ“°“√
4. ‰¡à¡’¿“«–ÀÕ∫À◊¥„πªí®®ÿ∫—π ‚¥¬Õ“°“√‰Õπ—Èπ‰¡à¥’¢÷ÈπÀ≈—ß√—°…“ÀÕ∫À◊¥
À√◊Õ°“√«‘π‘®©—¬¿“«–ÀÕ∫À◊¥¥â«¬°“√°√–μÿâπ¥â«¬ methacholine ‰¥âº≈≈∫
5. ‰¡à¡’¿“«–Õ“°“√‰Õ®“°‚√§¥â“π®¡Ÿ°À√◊Õ‰´π— 
6. ‰¡à¡’Õ“°“√‰Õ®“°¿“«– nonasthmatic eosinophilic bronchitis ‚¥¬
«‘π‘®©—¬®“°°“√μ√«® eosinophil „π‡ ¡À–‡ªìπ≈∫·≈–Õ“°“√‰Õπ—Èπ‰¡à¥’¢÷Èπ®“°
°“√„™â inhaled À√◊Õ systemic corticosteroids
 à«π„À≠à·≈â«°“√«‘π‘®©—¬‰Õ‡√◊ÈÕ√—ß®“°¿“«–°√¥‰À≈¬âÕπ ‰¡à‰¥â àß ◊∫§âπ
‡æ‘Ë¡‡μ‘¡‡æ◊ËÕ¬◊π¬—π°“√«‘π‘®©—¬‚√§‚¥¬∑—π∑’ ‡π◊ËÕß®“°°“√μ√«®æ‘‡»…∑—ÈßÀ≈“¬¡’
¢—ÈπμÕπ∑’˧àÕπ¢â“߬ÿà߬“° ·≈–Õ“®°àÕ„À⇰‘¥§«“¡‰¡à ÿ¢ ∫“¬·°àºŸâ‡¢â“√—∫°“√μ√«®
∫â“ß πÕ°®“°π’Ȭ—ß¡’¢âÕ®”°—¥À≈“¬ª√–°“√„π°“√·ª≈º≈ ¥—ßπ—ÈπÀ“°¡’Õ“°“√
∑’ˇ¢â“‰¥â°—∫‰Õ‡√◊ÈÕ√—ß®“°¿“«–°√¥‰À≈¬âÕπ ·≈–‰¥âμ—¥ª√–‡¥Áπ¢âÕ 1-6 ¢â“ßμâπ·≈â«
„π∑“ߪؑ∫—μ‘®÷ß„Àâ°“√√—°…“‰ª‡≈¬·≈â«¥Ÿ°“√μÕ∫ πÕßμàÕ°“√√—°…“(44)
°√≥’ºŸâªÉ«¬‰¡àμÕ∫ πÕßμàÕ proton pump inhibitor °“√ ◊∫§âπ‡æ‘Ë¡‡μ‘¡
¬—ßÕ“®‰¥âª√–‚¬™πå„π∫“ß°√≥’ Õ¬à“߉√°Á¥’·æ∑¬åºŸâ àߧ«√√Ÿâª√–‚¬™πå·≈–¢âÕ®”°—¥
¢Õß°“√μ√«®·μà≈–«‘∏’ ¥—ßμàÕ‰ªπ’È
32
1. °“√ àÕß°≈âÕßμ√«®∑“߇¥‘πÕ“À“√ à«πμâπ (Esophagogastroduo-
denoscopy) Õ“®‰¥âª√–‚¬™πå °√≥’∑’Ëμ√«®æ∫«à“¡’°“√Õ—°‡ ∫ (erosive esopha-
gitis) ∫√‘‡«≥ÀŸ√Ÿ¥À≈Õ¥Õ“À“√ à«π≈à“ß À√◊Õæ∫≈—°…≥–¢Õß Barrettûs esopha-
gus °Á “¡“√∂¬◊π¬—π«à“¡’°“√‰À≈¬âÕπ¢Õß “√®“°°√–‡æ“–Õ“À“√®√‘ß ·μà‡π◊ËÕß®“°
¡’§«“¡‰«„π°“√μ√«®μË” ¡’°“√»÷°…“¢π“¥‡≈Á°æ∫«à“ „πºŸâ∑’Ë¡’Õ“°“√¢Õß°√¥‰À≈
¬âÕπ„πÀ≈Õ¥Õ“À“√ æ∫≈—°…≥–¥—ß°≈à“«‰¥â∂÷ß√âÕ¬≈– 55 ·μà„πºŸâ∑’Ë¡’Õ“°“√‰Õ
‡√◊ÈÕ√—ß‚¥¬∑’ˉ¡à¡’Õ“°“√¢ÕßÀ≈Õ¥Õ“À“√ ®–æ∫≈—°…≥–¥—ß°≈à“«‰¥â‡æ’¬ß√âÕ¬≈– 16
‡∑à“π—Èπ(46)
2. °“√«—¥§à“§«“¡‡ªìπ°√¥-¥à“ß„πÀ≈Õ¥Õ“À“√ 24 ™—Ë«‚¡ß °“√μ√«®π’È
∂◊Õ«à“‡ªìπ°“√μ√«®¡“μ√∞“π (gold standard) „π°“√«‘π‘®©—¬°√¥‰À≈¬âÕπ ‚¥¬
°“√»÷°…“¢π“¥‡≈Á°À≈“¬°“√»÷°…“∫àß™’È«à“°“√μ√«®«‘∏’π’È ™à«¬¬◊π¬—π°“√«‘π‘®©—¬«à“
ºŸâªÉ«¬¡’°√¥‰À≈¬âÕπ‰¥âμ—Èß·μà√âÕ¬≈–60-100(47)
 à«π§«“¡®”‡æ“–μË”§◊Շ撬ß√âÕ¬≈–
66(48)
∑—Èßπ’È°“√μ√«®æ∫«à“¡’°“√‰À≈¬âÕπ ‰¡à‰¥â¬◊π¬—π«à“°“√‰À≈¬âÕπ‡ªìπμâπ‡Àμÿ
¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß ·μàμâÕߥŸ§«“¡ —¡æ—π∏å√–À«à“ß°“√‡°‘¥°√¥‰À≈¬âÕπ°—∫Õ“°“√
‰Õ (symptom association) ´÷Ëߺ≈°“√»÷°…“μà“ßÊ ¬—ß¡’§«“¡À≈“°À≈“¬¡“°
3. Multichannel intraluminal impedance pH monitoring ‡æ◊ËÕ
«‘π‘®©—¬¿“«–°√¥ÕàÕπÀ√◊Õ¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ∑’ˉ¡à„™à°√¥ À√◊Õ°√¥·°ä ‰À≈¬âÕπ
¢÷ÈπÀ≈Õ¥§Õ
°“√√—°…“Õ“°“√‰Õ®“°¿“«–°√¥‰À≈¬âÕπ
·π«∑“ß°“√√—°…“‚¥¬∑—Ë«‰ª ·π–π”„Àℙ⬓≈¥°“√À≈—Ëß°√¥ ∑—Èßπ’È proton
pump inhibitor ¡’ª√– ‘∑∏‘¿“æ„π°“√≈¥°“√À≈—Ëß°√¥‰¥â¥’°«à“ histamine receptor
2 antagonist ‚¥¬·π–π”„Àℙ⬓ proton pump inhibitor „π¢π“¥ Ÿß ·≈–
33¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
√–¬–‡«≈“π“π°«à“„π°≈ÿà¡ typical À√◊Õ esophageal GERD ‰¥â·°à omeprazole
¢π“¥ 20 mg 1 ‡¡Á¥ °àÕπÕ“À“√ ‡™â“·≈–‡¬Áπ À√◊Õ proton pump inhibitor
μ—«Õ◊Ëπ∑’Ë¡’¢π“¥‡∑’¬∫‡∑à“°—𠇪ìπ‡«≈“Õ¬à“ßπâÕ¬ 4-8  —ª¥“Àå (Level of evidence
2, Grade of recommendation ++) ·≈â«¥Ÿº≈°“√μÕ∫ πÕßμàÕ°“√√—°…“∑’ËÕ¬à“ß
πâÕ¬ 4  —ª¥“Àå À“°‰¥â¬“‰ª 8-12  —ª¥“Àå·≈⫬—߉¡à¥’¢÷Èπ§«√À¬ÿ¥¬“·≈– àßμàÕ
ºŸâ‡™’ˬ«™“≠
‚¥¬ºŸâ‡™’ˬ«™“≠ à«π„À≠à·π–π”„Àℙ⬓≈¥°“√À≈—Ëß°√¥‡ªìπ°“√√—°…“‡∫◊ÈÕß
μâπ ‡π◊ËÕß®“°¡’º≈®“°°“√»÷°…“∑¥≈Õß·∫∫‡ªî¥ (open-label trial)(49)
∫àß™’È«à“
ºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß∑’Ë ß —¬«à“‡ªìπº≈®“°°√¥‰À≈¬âÕπ μÕ∫ πÕßμàÕ°“√
√—°…“¥â«¬¬“≈¥°“√À≈—Ëß°√¥™π‘¥ proton pump inhibitors ∑—Èß¢π“¥¡“μ√∞“π
(«—π≈–§√—Èß) ·≈–¢π“¥ Ÿß («—π≈– 2 §√—Èß)(46)
Õ¬à“߉√°Á¥’°“√»÷°…“·∫∫°“√«‘‡§√“–Àå
Õ¿‘¡“π ®“° 9 °“√»÷°…“ ‡ª√’¬∫‡∑’¬∫¬“≈¥°“√À≈—Ëß°√¥°—∫¬“À≈Õ° æ∫«à“‰¡à¡’
§«“¡·μ°μà“ß°—π (odds ratio, OR 0.46; 95% CI 0.19-1.15)(41)
´÷Ëß°Á Õ¥§≈âÕß
°—∫°“√»÷°…“·∫∫ ÿࡇª√’¬∫‡∑’¬∫Õ’° 2 °“√»÷°…“(50, 51)
∑—Èßπ’È ¡’°“√«‘‡§√“–Àå«à“ º≈
°“√»÷°…“∑’Ë·μ°μà“ß°—π¢â“ßμâπ πà“®–‡ªìπº≈®“°«‘∏’°“√«‘π‘®©—¬∑’ËÀ≈“°À≈“¬ ∑”„Àâ
‰¥âºŸâªÉ«¬„π°“√»÷°…“∑’Ë¡’§«“¡À≈“°À≈“¬¡“°(48)
Õ¬à“߉√°Á¥’ °“√„À⬓ proton pump
inhibitor °Á¬—ß·π–π”„Àℙ⇪ìπ¡“μ√∞“π‡∫◊ÈÕßμâπ ·μà„Àâμ‘¥μ“¡¥Ÿ°“√μÕ∫ πÕß
¿“¬„π 4-8  —ª¥“Àå ´÷Ë߇ªìπμ—«∫àß™’È∑’Ë¥’«à“ºŸâªÉ«¬πà“®–‰¥âª√–‚¬™π宓° proton pump
inhibitor(46)
À“°‰¡à¡’°“√μÕ∫ πÕ߇≈¬ §«√À¬ÿ¥¬“·≈â«∑”°“√ ◊∫§âπ‡æ‘Ë¡‡μ‘¡ ‡æ◊ËÕ
·¬°‚√§·≈–„Àâ°“√«‘π‘®©—¬
7.6 Post-infectious cough
Õ“°“√‰Õ¿“¬À≈—ß°“√μ‘¥‡™◊ÈÕ∑“߇¥‘πÀ“¬„® à«π∫π (upper respira-
tory tract infection, URI) æ∫‰¥â∫àÕ¬„π‡«™ªØ‘∫—μ‘ ¡—°¡’ª√–«—μ‘°“√μ‘¥‡™◊ÈÕ∑“ß
34
‡¥‘πÀ“¬„® à«π∫ππ”¡“°àÕπ à«π„À≠à‰¡à‡°‘π 2  —ª¥“À宓°‡™◊ÈÕ‰«√—  Mycoplasma,
Chlamydia À√◊Õ Moraxella catarrhalis Õ“°“√Õ◊ËπÊ À“¬‰ª ‡À≈◊Õ·μàÕ“°“√‰Õ
Õ“°“√‰Õπ“π¢÷Èπ‰¥â„πºŸâªÉ«¬∑’Ë¡’‚√§À≈Õ¥≈¡Õ¬Ÿà¥â«¬ Õ¬à“߉√°Áμ“¡√–¬–‡«≈“‰Õ
®“°¿“«–π’ȉ¡à§«√‡°‘π 8  —ª¥“Àå À“°‡°‘π 8  —ª¥“Àå §«√ ◊∫§â𠓇ÀμÿÕ◊Ëπ(2)
Õÿ∫—μ‘°“√≥å„πºŸâ„À≠àª√–¡“≥√âÕ¬≈– 10 ∂÷ß 25 ·≈–®–æ∫ Ÿß¢÷Èπ‡ªìπ√âÕ¬≈– 25
∂÷ß 50 ®“°°“√μ‘¥‡™◊ÈÕ Mycoplasma À√◊Õ Bordetella pertussis 欓∏‘°”‡π‘¥
¬—߉¡à™—¥‡®π °≈‰°∑’Ë∑”„À⇰‘¥ cough hypersensitivity ‚¥¬ºà“π∑“ß airway
inflammation ·≈–°“√°√–μÿâπ airway sensory nerves ·≈– cholinergic motor
pathway ∑”„À⇰‘¥ bronchoconstriction ·≈– airway hyperresponsiveness
μ“¡¡“(52)
‚¥¬ cough hypersensitivity π’ȇªìπ‡æ’¬ß™—Ë«§√“«  “¡“√∂À“¬‰¥â‡Õß
À“°‰¡à‰¥â‡°‘¥®“° Bordetella pertussis
Õ“°“√‰Õ®“° Pertussis
‡√‘Ë¡¥â«¬Õ“°“√π”§≈⓬‰¢âÀ«—¥ 2  —ª¥“Àå°àÕπ μ“¡¥â«¬Õ“°“√‰Õ‡ªìπ™ÿ¥Ê
Õ“‡®’¬πÀ≈—ß‰Õ √à«¡°—∫ inspiratory whoop (æ∫‰¥â‰¡à∫àÕ¬„πºŸâ„À≠à) °“√¬◊π¬—π
°“√«‘π‘®©—¬Õ“»—¬ polymerase chain reaction ®“° “√§—¥À≈—Ëß∫√‘‡«≥ naso-
pharynx (sensitivity 80-100%) (Level of evidence 3, Grade of recom-
mendation +/-) ‰¥âº≈¥’°«à“ culture (sensitivity 25-50%) (Level of evidence
3, Grade of recommendation +) À√◊Õ serology (pertussis IgG, IgA titer)
‚¥¬‡®“– 2 §√—Èß §√—Èß·√° 2  —ª¥“ÀåÀ≈—ß®“°¡’Õ“°“√‰Õ·≈–§√—ÈßμàÕ‰ª 3-4  —ª¥“Àå
(sensitivity 60%)(53)
(Level of evidence 3, Grade of recommendation
+/-)
35¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
°“√√—°…“ Post-infectious cough
„π°√≥’∑’ˉ¡à‰¥â‡°‘¥®“° pertussis
Õ“°“√‰Õ¿“¬À≈—ß°“√μ‘¥‡™◊ÈÕ∑“߇¥‘πÀ“¬„® à«π∫π¡—°®–À“¬‰¥â‡Õß ‰¡à‡°‘π
8  —ª¥“Àå °“√√—°…“∑’Ë¡’√“¬ß“π ‰¥â·°à §Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥(54, 55)
(Level of
evidence 4, Grade of recommendation +), √“¬∑’Ë¡’Õ“°“√‰Õ¡“°Ê Õ“®®–„™â
inhaled ipratropium(56)
(Level of evidence 2, Grade of recommendation
+) À√◊Õ¬“ ‡μ’¬√Õ¬¥å™π‘¥°‘π (prednisolone 30-40 mg μàÕ«—π) √–¬– —ÈπÊ 1-2
 —ª¥“Àå (3)
(Level of evidence 3, Grade of recommendation +/-) À“°‰¡à‰¥â
º≈ Õ“®æ‘®“√≥“°“√„™â¬“°¥Õ“°“√‰Õ (Level of evidence 4, Grade of
recommendation +) °“√√—°…“∑’Ë¡’√“¬ß“π«à“‰¡à‰¥âº≈‰¥â·°à montelukast(57)
(Level of evidence 1, Grade of recommendation -)
„π°√≥’∑’˺ŸâªÉ«¬‡ªìπ¿Ÿ¡‘·æ⮡Ÿ°Õ¬Ÿà‡¥‘¡ °“√μ‘¥‡™◊ÈÕ∑“߇¥‘πÀ“¬„® à«π∫π
®–∑”„ÀâÕ“°“√¿Ÿ¡‘·æ⮡Ÿ°°”‡√‘∫ ∫«¡·≈–º≈‘μ¡Ÿ°¡“°·≈–‡À𒬫∑”„À⇰‘¥°“√‰Õ
‡æ√“–¡’ postnasal drip ‰¥â „Àâ√—°…“·∫∫¿Ÿ¡‘·æ⮡Ÿ°¥â«¬°“√æàπ≈â“ß®¡Ÿ°¥â«¬
πÈ”‡°≈◊Õ·≈–¬“ ‡μ’¬√Õ¬¥å™π‘¥æàπ®¡Ÿ°
°“√√—°…“Õ“°“√‰Õ®“° pertussis
„π√–¬–·√° „™â¬“ªØ‘™’«π– macrolide ‰¥â·°à erythromycin À√◊Õ tri-
methoprim/sulfamethoxazole ‡ªìπ‡«≈“ 2  —ª¥“Àå(52, 53)
·≈–·π–π”„Àâ isola-
tion ‡ªìπ‡«≈“ 5 «—πÀ≈—ß®“°‡√‘Ë¡°“√√—°…“ (Level of evidence 1, Grade of
recommendation ++) ‰¡à·π–π”„À⬓§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å ¬“¢¬“¬À≈Õ¥≈¡∑’Ë
ÕÕ°ƒ∑∏‘Ϭ“« ·≈–¬“ pertussis immunoglobulin (Level of evidence 1, Grade
of recommendation -)
36
Sinobronchial syndrome
„πª√–‡∑»·∂∫‡Õ‡™’¬ æ∫«à“¡’°≈ÿà¡Õ“°“√‰Õ‡√◊ÈÕ√—ß™π‘¥¡’‡ ¡À–∑’Ë¡’¿“æ
√—ß ’∑√«ßÕ°·≈–‰´π— º‘¥ª°μ‘ ·≈–„Àâ™◊ËÕ‚√§«à“ sinobronchial syndrome ¿“«–
π’ȉ¡àæ∫À√◊Õæ∫‰¥âπâÕ¬¡“°„π™“«μ–«—πμ°·≈–‰¡à¡’·π«∑“ß°“√√—°…“∑’Ë√–∫ÿ‰«â„π
chronic cough guidelines ®“°∑“ßμ–«—πμ°·μàÕ“®æ∫‰¥â„π‡Õ‡™’¬(1)
ºŸâªÉ«¬
¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß·∫∫¡’‡ ¡À–≈—°…≥– mucoid À√◊Õ mucopurulent Õ“°“√
∑“ߧ≈‘π‘°∑’Ë∑”„Àâπ÷°∂÷ߧ◊Õ°“√∑’Ë¡’Õ“°“√√à«¡°—π¢Õ߉´π— Õ—°‡ ∫‡√◊ÈÕ√—ß (chronic
sinusitis) √à«¡°—∫Õ“°“√Õ—°‡ ∫∑“߇¥‘πÀ“¬„® à«π≈à“ß (chronic lower airway
inflammation) ‰¥â·°à diffuse bronchiectasis À√◊Õ diffuse panbronchiolitis
(DBP) À√◊Õ chronic bronchitis
Õ“°“√∑’Ë∫àß∂÷߉´π— Õ—°‡ ∫‰¥â·°à postnasal drip, nasal discharge ·≈–
throat clearing Õ“°“√¡—°®–·¬à≈߇¡◊ËÕ¡’ upper respiratory tract infection
°“√μ√«®√à“ß°“¬æ∫ post nasal drip ·≈– cobble stone appearance ∫√‘‡«≥
oropharynx °“√‡æ“–‡™◊ÈÕ‡ ¡À–¡—°¢÷Èπ pneumococcus ·≈– H. influenzae
º≈°“√μ√«®√–¥—∫ serum IgA ·≈– cold agglutinins  Ÿß¢÷Èπ °“√μ√«®∑“ß√—ß ’
æ∫¿“æ√—ß ’‰´π—  À√◊Õ‡ÕÁ°´‡√¬å§Õ¡æ‘«‡μÕ√å (computed tomography) º‘¥ª°μ‘
∑’ˇ¢â“‰¥â°—∫‰´π— Õ—°‡ ∫
°“√√—°…“ Sinobronchial syndrome
°√≥’Õ“°“√‰¡à√ÿπ·√ß expectorant ∑”„ÀâÕ“°“√¥’¢÷Èπ‰¥â ∂â“Õ“°“√√ÿπ·√ß
·π–π”„Àâ 14-membered ring macrolides ‰¥â·°à erythromycin 300-600 mg
μàÕ«—π clarithromycin 250-500 mg μàÕ«—π À√◊Õ roxithromycin 150-300 mg
μàÕ«—𠇪ìπ‡«≈“ 2-12  —ª¥“Àå (Level of evidence 3, Grade of recommenda-
tion +)
37¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
¿“§ºπ«° 1
·π«∑“ß°“√√—°…“ºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à
μ√«®¿“æ√—ß ’ªÕ¥ (CXR) ‡æ◊ËÕ§âπÀ“ “‡Àμÿ®“°ªÕ¥ ‡™àπ «—≥‚√§ ¡–‡√Áß ´÷ËßÕ“®
æ∫ “‡ÀμÿÕ“°“√‰Õ®“°À≈“¬‡Àμÿ√à«¡°—π À“° CXR ª°μ‘ „Àâ°“√√—°…“‡∫◊ÈÕßμâπ
μ“¡¢—ÈπμÕπ À“°Õ“°“√‡¢â“‰¥â°—∫
- Upper Airway Cough Syndrome (UACS)
„Àâ°“√√—°…“‡∫◊ÈÕßμâπ·≈– ◊∫§âπÀ“ “‡Àμÿ∑’Ë®”‡æ“–
- Asthma
„Àâ°“√√—°…“‡∫◊ÈÕßμâπ ·≈–æ‘®“√≥“∑” Spirometry, bronchodilator reversibility
- Non-asthmatic eosinophil bronchitis (NAEB)
„Àâ°“√√—°…“‡∫◊ÈÕßμâπ
- Gastroesophageal Reflux Disease (GERD)
„Àâ°“√√—°…“‡∫◊ÈÕßμâπ
°“√μ√«®«‘π‘®©—¬‡æ‘Ë¡‡μ‘¡
- Spirometry or peak expiratory flow variability
(if not be evaluated)
- Bronchial provocation test
- Plain sinus imaging (if not be evaluated) + CT sinus
- 24h esophageal pH monitoring
À√◊Õ 24 h-pH / impedance test
- Endoscope (Nasal, larynx or Bronchoscope)
- Swallowing Evaluation
-  “‡ÀμÿÕ◊ËπÊ
ª√–‡¥Áπæ‘®“√≥“∑’Ë ”§—≠
- √—°…“μ“¡ “‡Àμÿ∑’Ë ß —¬Õ¬à“߇μÁ¡∑’Ë
- μ‘¥μ“¡§«“¡ ¡Ë”‡ ¡Õ¢Õß°“√√—°…“
- ‡π◊ËÕß®“° “‡Àμÿ°“√‰Õ‡√◊ÈÕ√—ßÕ“®¡’‰¥âÀ≈“¬ “‡Àμÿ„π
ºŸâªÉ«¬√“¬Àπ÷ËßÊ §«√„Àâ°“√μ√«®·≈–√—°…“‡æ‘Ë¡‡μ‘¡®“°
°“√√—°…“‡¥‘¡∑’ËμÕ∫ πÕ߇撬ß∫“ß à«π
38
¿“§ºπ«° 2
«‘∏’°“√ àÕßμ√«®®¡Ÿ°
1) μ√«®¥â«¬‰ø©“¬∑’Ë· ß «à“ß Ÿß „π¢≥–∑’Ë„À⺟âªÉ«¬·Àßπ§Õ·≈–¥—π
ª≈“¬®¡Ÿ°¢÷Èπ‡æ◊ËÕ∑”„Àâ‡ÀÁπ√Ÿ®¡Ÿ°‰¥âßà“¬ ¢âÕ¥’§◊Õ –¥«°·≈–ßà“¬ ·μà¢âÕ®”°—¥ §◊Õ
®–μ√«®‰¡à‰¥âÀ“°¡’¢π®¡Ÿ°¡“° ·≈–‰¡à “¡“√∂‡ÀÁπ√“¬≈–‡Õ’¬¥«à“¡’¡Ÿ°¢â“ß„π
Õ¬à“߉√
2) °“√ àÕß®¡Ÿ°¥â«¬ Otoscope ∏√√¡¥“ ®–‡ÀÁπ‰¥â¥’¢÷Èπ°«à“«‘∏’·√°
3) °“√ àÕß®¡Ÿ°¥â«¬°≈âÕß digital otoscope ®–¡’°”≈—ߢ¬“¬ Ÿß ‡ÀÁπ‰¥â
™—¥‡®π
39¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
«‘∏’°“√μ√«®§Õ
‡æ◊ËÕμ√«®À“Õ“°“√· ¥ß¢Õß postnasal drip syndrome ‡™àπ ¿“«– glan-
dular pharyngitis, tonsil enlargement ‚¥¬„™â‰ø©“¬∑’Ë «à“ß Ÿß „π¢≥–„Àâ
ºŸâ≈ÕßÕ⓪“°°«â“ß·≈–À“¬„®‡¢â“∑“ߧÕ≈÷°Ê ‚¥¬‰¡àμâÕß„™â‰¡â°¥≈‘Èπ‰¥â À“°¡Õß
‰¡à‡ÀÁπ®÷ߧàÕ¬„™â‰¡â°¥≈‘Èπ μ√«® àÕß™â“Ê √Ÿª· ¥ß¿“«– glandular pharyngitis
(≈Ÿ°»√™’È)
√Ÿª´â“¬·≈–¢«“∫π · ¥ß∂÷ß¿“«–®¡Ÿ°∫«¡ (complete nasal obstruction) √Ÿª´â“¬·≈–
¢«“≈à“ß · ¥ß∂÷ß¿“«–∑’Ë¡’¡Ÿ°‡À𒬫¡“° ∑”„À⇰‘¥Õ“°“√ postnasal drip, °√–·Õ¡‰Õ
40
°“√μ√«®æ∫§«“¡º‘¥ª°μ‘∑’Ë∫àß™’È«à“¡’¿“«–‡¬◊ËÕ®¡Ÿ°∫«¡Õ—°‡ ∫‡√◊ÈÕ√—ß(chronic
rhinitis)
√Ÿª· ¥ß¿“«–√‘¡Ω望°·μ°Õ—°‡ ∫ (cheilitis) ‡°‘¥®“°®¡Ÿ°μ—π∑”„ÀâμâÕß
À“¬„®∑“ߪ“°∫àÕ¬Ê
√Ÿª´â“¬· ¥ß¢Õ∫μ“≈à“ߧ≈È”¥” (allergic shiner)
√Ÿª¢«“· ¥ßº◊Ëπ·¥ß§—π∑’ËÀ—«μ“À√◊Õ‡ª≈◊Õ°μ“ (periorbital dermatitis)
À¡“¬‡Àμÿ:√Ÿª¿“æ∑—ÈßÀ¡¥‰¥â√—∫Õπÿ≠“μ„À⇺¬·æ√ஓ°ºŸâªÉ«¬·≈–
». πæ. ‡°’¬√μ‘ √—°…å√ÿàß∏√√¡
41¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
¿“§ºπ«° 3
°“√∑¥ Õ∫ ¡√√∂¿“æªÕ¥‚¥¬ ‰ª‚√‡¡μ√’¬å·≈–°“√∑¥ Õ∫§«“¡‰«À≈Õ¥≈¡
°“√∑¥ Õ∫ ¡√√∂¿“æªÕ¥‚¥¬ ‰ª‚√‡¡μ√’¬å
™à«¬∫àß™’È«à“¡’°“√μ’∫¢ÕßÀ≈Õ¥≈¡ (airway obstruction) ·π–π”„Àâ∑”„π
ºŸâªÉ«¬∑’Ë¡’ª√–«—μ‘·≈–°“√μ√«®√à“ß°“¬∑’Ë ß —¬‚√§À◊¥ ‡æ◊ËÕ«—μ∂ÿª√– ß§å 1) ¬◊π¬—π
«à“¡’¿“«–À≈Õ¥≈¡μ’∫ ·≈–ª√–‡¡‘𧫓¡√ÿπ·√ß ·≈– 2) ª√–‡¡‘π«à“¡’°“√μÕ∫
 πÕßμàÕ¬“ Ÿ¥¢¬“¬À≈Õ¥≈¡ (reversibility) °àÕπ°“√√—°…“ ·≈–/À√◊Õ ¡’°“√
μÕ∫ πÕßμàÕ°“√„™â¬“√—°…“‚√§À◊¥À√◊Õ‰¡à (variable airflow limitation) ‚¥¬°“√
¬◊π¬—π«à“¡’¿“«–À≈Õ¥≈¡μ’∫ æ‘®“√≥“®“°§à“ FEV1/FVC ¡’§à“πâÕ¬°«à“ 0.75-0.8
„πºŸâ„À≠à∑’Ë¡’Õ“¬ÿπâÕ¬°«à“ 60 ªï ·≈–°“√μÕ∫ πÕßμàÕ¬“ Ÿ¥¢¬“¬À≈Õ¥≈¡ æ‘®“√≥“
®“°§à“ ¡√√∂¿“æªÕ¥ FEV1 ‡æ‘Ë¡¢÷Èπ¡“°°«à“ 200 ml ·≈–¡“°°«à“√âÕ¬≈– 12
À≈—ß Ÿ¥¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘χ√Á« 20 π“∑’ ·≈–/À√◊Õ À≈—ß°“√‰¥â¬“
controller √—°…“‚√§À◊¥‡ªìπ‡«≈“Õ¬à“ßπâÕ¬ 4  —ª¥“Àå
¿“«–À≈Õ¥≈¡μ’∫∑’Ë¡’§«“¡º—πº«π (variable airflow obstruction) ¥—ß
°≈à“« “¡“√∂μ√«®‰¥â‚¥¬«‘∏’Õ◊ËπÊ ‰¥â·°à °“√«—¥ peak expiratory flow rate (PEFR)
°“√«—¥ peak expiratory flow rate (PEFR) ‚¥¬°“√μÕ∫ πÕßμàÕ¬“ Ÿ¥
¢¬“¬À≈Õ¥≈¡ æ‘®“√≥“®“°§à“ PEFR ∑’ˇæ‘Ë¡¢÷Èπ¡“°°«à“ 60 L/min À√◊Õ‡æ‘Ë¡¢÷Èπ
¡“°°«à“√âÕ¬≈– 20 À≈—ß Ÿ¥¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘χ√Á« ·μà°“√∑¥ Õ∫
¥â«¬°“√«—¥ PEFR ¡’§«“¡‡∑’ˬßμ√ßπâÕ¬°«à“ ‰ª‚√‡¡μ√’¬å °“√„™â PEFR ‡æ◊ËÕ
μ√«®À“¿“«–À≈Õ¥≈¡μ’∫∑’Ë¡’§«“¡º—πº«π ‚¥¬°“√«—¥ PEFR „π™à«ß 1-2  —ª¥“Àå
42
 “¡“√∂„™â„π°“√«‘π‘®©—¬·≈–ª√–‡¡‘π‚√§À◊¥‰¥â¥’°«à“ §π∑’ˇªìπ‚√§À◊¥®–¡’§«“¡
º—πº«π¡“°°«à“§πª°μ‘ (¡“°°«à“√âÕ¬≈– 10) ‚¥¬°“√«—¥ PEFR «—π≈– 2 §√—Èß
„π¢≥–¬—߉¡à‰¥â‡√‘Ë¡°“√√—°…“ À√◊Õ PEFR ‡æ‘Ë¡¢÷Èπ¡“°°«à“√âÕ¬≈– 20 ¿“¬À≈—ß
°“√√—°…“¥â«¬¬“§«∫§ÿ¡‚√§À◊¥‡ªìπ‡«≈“ 4  —ª¥“Àå
°“√§”π«≥§à“§«“¡º—πº«π¢Õß PEFR (peal flow variability,
PFV)
PFV (%) = (§à“ PEFR ¢Õß«—π∑’Ë Ÿß ÿ¥ - §à“ PEFR ¢Õß«—π∑’ËμË” ÿ¥) À“√
¥â«¬§à“‡©≈’ˬ¢Õß PEFR (§à“ PEFR  Ÿß ÿ¥¢Õß«—π + §à“ PEFR μË” ÿ¥¢Õß«—π/2)
·≈⫧Ÿ≥¥â«¬ 100%
°“√∑¥ Õ∫§«“¡‰«¢ÕßÀ≈Õ¥≈¡ (Bronchoprovocative test)
 “¡“√∂∑”‰¥â¥â«¬°“√„Àâ Ÿ¥ “√°√–μÿâπ “√ histamine À√◊Õ∑’Ëπ‘¬¡„πªí®®ÿ∫—π
‰¥â·°à methacholine ∑’˧«“¡‡¢â¡¢âπ‡√‘Ë¡®“°πâÕ¬‰ª¡“° ·≈–«—¥§à“ ¡√√∂¿“æªÕ¥
‚¥¬°“√μ√«® ‰ª‚√‡¡μ√’¬å¿“¬À≈—ß°“√ Ÿ¥¬“·μà≈–§«“¡‡¢â¡¢âπ«à“¡’°“√≈¥≈ߢÕß
§à“ ¡√√∂¿“æªÕ¥ FEV1 ¡“°°«à“√âÕ¬≈– 20 ®“°§à“°àÕπ Ÿ¥¬“ methacholine
À“°§«“¡§«“¡‡¢â¡¢âπ¢Õß methacholine ∑’Ë„™â„π°“√°√–μÿâπ„À⇰‘¥°“√≈¥≈ß
¢Õß FEV1 ¡“°°«à“√âÕ¬≈– 20 ®“°§à“°àÕπ Ÿ¥¬“ (PC20) μË”°«à“ 8 mg/dl ∂◊Õ«à“
¡’¿“«–À≈Õ¥≈¡‰« ∂â“ PC20 μË”°«à“ 1 mg/dl ∂◊Õ«à“¿“«–À≈Õ¥≈¡‰«√ÿπ·√ß
(severe AHR)  à«π§à“ PC20 ∑’Ë¡“°°«à“ 16 mg/dl ∂◊Õ«à“º≈°“√∑¥ Õ∫‡ªìπ≈∫
°“√∑¥ Õ∫ methacholine challenge test „π°“√«‘π‘®©—¬‚√§À◊¥ ¡’§à“
positive predictive value √âÕ¬≈– 60-88
43¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
¿“§ºπ«° 4
°≈‰°°“√‡°‘¥Õ“°“√‰Õ
44
¿“§ºπ«° 5
μ“√“ß· ¥ß§«“¡·μ°μà“ß√–À«à“ß‚√§ eosinophilic airway ™π‘¥μà“ßÊ(1)
Classic asthma CVA NAEB AC
Õ“°“√ ‰Õ ‡Àπ◊ËÕ¬ «’È¥ ‰ÕÕ¬à“߇¥’¬« ‰Õ√à«¡°—∫Õ“°“√ ‰ÕÕ¬à“߇¥’¬«
∑“ß upper airway
Atopy 60-80% 40-80% 20-70% 40-50%
Variable airflow limitation + + - -
AHR + + - -
Cough hypersensitivity - - ‡æ‘Ë¡ ‡æ‘Ë¡
°“√μÕ∫ πÕßμàÕ + + ‰¡à∑√“∫ -
¬“¢¬“¬À≈Õ¥≈¡
°“√μÕ∫ πÕßμàÕ + + + +
 ‡μ’¬√Õ¬¥å
°“√μÕ∫ πÕßμàÕ + + ‰¡à∑√“∫ +
¬“μâ“πŒ‘ μ“¡’π
°“√≈¥≈ߢÕß ¡√√∂¿“æªÕ¥ + + + -
°“√¥”‡π‘π‚√§‡ªìπ‚√§À◊¥ 30% 10% πâÕ¬¡“°
Sputum eosinophil >3% ∫àÕ¬ ∫àÕ¬ μâÕß¡’„π°“√«‘π‘®©—¬ ∫àÕ¬
FeNO ‡æ‘Ë¡ ‡æ‘Ë¡ ‡æ‘Ë¡ ‰¡à‡æ‘Ë¡
Submucosal eos ‡æ‘Ë¡ ‡æ‘Ë¡ ‡æ‘Ë¡ ‡æ‘Ë¡
Mast cell in ASM ‡æ‘Ë¡ ‰¡à‡æ‘Ë¡ ‰¡à‡æ‘Ë¡ ‰¡à∑√“∫
Subepithelial thickening + + + ‰¡à∑√“∫
Vascular proliferation + + + ‰¡à∑√“∫
CVA=cough variant asthma, NAEB=non-asthmatic eosinophilic bronchitis, AC=allergic cough,
AHR= airway hyperresponsiveness, eos= eosinophil, FeNO= fractional exhaled nitric oxide,
ASM= airway smooth muscle
45¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559
‡Õ° “√Õâ“ßÕ‘ß
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Cough guideline 2016
Cough guideline 2016
Cough guideline 2016
Cough guideline 2016
Cough guideline 2016

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  • 3. 2 ™◊ËÕÀπ—ß ◊Õ ¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢°“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à ·Ààߪ√–‡∑»‰∑¬ æ.». 2559 ISBN: 978-616-91693-1-4 ®—¥æ‘¡æå‚¥¬  ¡“§¡ ¿“Õߧå°√‚√§À◊¥·Ààߪ√–‡∑»‰∑¬  ¡“§¡Õÿ√‡«™™å·Ààߪ√–‡∑»‰∑¬ „πæ√–∫√¡√“™Ÿª∂—¡¿å  ¡“§¡‚√§¿Ÿ¡‘·æâ ‚√§À◊¥ ·≈–«‘∑¬“¿Ÿ¡‘§ÿâ¡°—π·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬ ‚ μ »Õ π“ ‘°·æ∑¬å ·Ààߪ√–‡∑»‰∑¬  ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬ æ‘¡æå§√—Èß∑’Ë 1 2559 ®”π«πæ‘¡æå 2,000 ‡≈à¡ æ‘¡æå∑’Ë ∫√‘…—∑ ∫’¬Õπ¥å ‡ÕÁπ‡∑Õ√å‰æ√´å ®”°—¥
  • 4. 3¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559  “√∫—≠ §”π” _________________________ 4 √“¬π“¡§≥–°√√¡°“√ºŸâ∑√ߧÿ≥«ÿ≤‘ ______________ 5 §”™’È·®ß§ÿ≥¿“æÀ≈—°∞“π·≈–πÈ”Àπ—°§”·π–π” _________ 7 ∫∑π” _________________________ 10 §”®”°—¥§«“¡ ______________________ 10  “‡Àμÿ¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß _________________ 11 ·π«∑“ß°“√ª√–‡¡‘πºŸâªÉ«¬ _________________ 12 欓∏‘ √’√«‘∑¬“¢ÕßÕ“°“√‰Õ ________________ 18 °“√ª√–‡¡‘𧫓¡√ÿπ·√ß·≈–º≈°√–∑∫¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß _____ 19 °“√√—°…“‡∫◊ÈÕßμâπ ____________________ 20  “‡ÀμÿÕ“°“√‰Õ‡√◊ÈÕ√—ß„π¿“æ√—ß ’ªÕ¥ª°μ‘∑’Ëæ∫∫àÕ¬ ________ 21 ¿“§ºπ«° 1 ·π«∑“ß°“√√—°…“ºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à___ 37 ¿“§ºπ«° 2 «‘∏’°“√ àÕßμ√«®®¡Ÿ° ·≈–μ√«®§Õ æ√âÕ¡¿“æª√–°Õ∫ _ 38 ¿“§ºπ«° 3 °“√∑¥ Õ∫ ¡√√∂¿“æªÕ¥‚¥¬ ‰ª‚√‡¡μ√’¬å·≈– °“√∑¥ Õ∫§«“¡‰«À≈Õ¥≈¡ ___________ 41 ¿“§ºπ«° 4 °≈‰°°“√‡°‘¥Õ“°“√‰Õ _____________ 43 ¿“§ºπ«° 5 μ“√“ß· ¥ß§«“¡·μ°μà“ß√–À«à“ß‚√§ eosinophilic airway ™π‘¥μà“ßÊ _________ 44 ‡Õ° “√Õâ“ßÕ‘ß _____________________ 45
  • 7. 6 9) √».πæ.æß»°√ μ—πμ‘≈’ªî°√ 10) √».æ≠.Õ√æ√√≥ ‚æ™πÿ°Ÿ≈ 11) æ.Õ.æ≠.‡æ™√“ ∫ÿ≠¬ß √√§å™—¬ 12) √».æ≠.ª√‘¬π—π∑å ®“√ÿ®‘𥓠13) º».πæ.Œ‘‚√™‘ ®—π∑“¿“°ÿ≈ 14) º».πæ.»‘«»—°¥‘Ï ®ÿ∑Õß 15) º».πæ.Õ¿‘™“μ‘ §≥‘μ∑√—æ¬å 16) º».πæ.¡π–æ≈ °ÿ≈ª√“≥’μ 17) º».æ≠.ª√–¿“æ√ æ√ ÿ√‘¬–»—°¥‘Ï 18) º».¥√.πæ.°√‡°’¬√μ‘  π‘∑«ß»å 19) º».¥√.æ≠.«‘¿“√—μπå ¡πÿ≠“°√ 20) º».æ≠.∑‘™“ ƒ°…åæ—≤π“æ‘æ—≤πå 21) Õ.πæ.‡©≈’¬« æŸ≈»‘√‘ªí≠≠“ 22) Õ.æ≠.‡ªïò¬¡≈“¿ · ß “¬—≥Àå 23) Õ.¥√.∑‘æ“æ√ æ߅凡…“ 24) Õ.πæ.∏’√–»—°¥‘Ï ·°â«Õ¡μ«ß»å 25) Õ.æ≠.°—≈¬“ ªí≠®æ√æ≈ 26) Õ.æ≠.¡π« ’ ª“®’π∫Ÿ√«√√≥å 27) Õ.πæ.∏π“ Õ—ß ÿ«√—ß…’ 28) Õ.πæ.æ≈æß»å ™¬“ß»ÿ 29) Õ.πæ. —πμ‘  ‘≈—¬√—μπå 30) Õ.æ≠.«√«√√≥ »‘√‘™π– 31) º».æ≠.¡≥±‘√“ ¡≥’√—μπ–æ√ 32) º».πæ. ¡∫Ÿ√≥å ®—π∑√å °ÿ≈æ√
  • 8. 7¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 §”™’È·®ß§ÿ≥¿“æÀ≈—°∞“π·≈–πÈ”Àπ—°§”·π–π” §ÿ≥¿“æÀ≈—°∞“π (Quality of evidence) §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 1 À¡“¬∂÷ßÀ≈—°∞“π∑’ˉ¥â®“° 1.1 °“√∑∫∑«π·∫∫¡’√–∫∫ (systematic review) ®“°°“√»÷°…“·∫∫ °≈ÿà¡ ÿà¡μ—«Õ¬à“ß §«∫§ÿ¡ (randomized controlled clinical trials) À√◊Õ 1.2 °“√»÷°…“·∫∫°≈ÿà¡ ÿà¡μ—«Õ¬à“ß §«∫§ÿ¡∑’Ë¡’§ÿ≥¿“楒‡¬’ˬ¡Õ¬à“ßπâÕ¬ 1 ©∫—∫ §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 2 À¡“¬∂÷ßÀ≈—°∞“π∑’ˉ¥â®“° 2.1 °“√∑∫∑«π·∫∫¡’√–∫∫¢Õß°“√»÷°…“§«∫§ÿ¡·μà‰¡à‰¥â ÿà¡μ—«Õ¬à“ß (non-randomized controlled clinical trials) À√◊Õ 2.2 °“√»÷°…“§«∫§ÿ¡·μà‰¡à‰¥â ÿà¡μ—«Õ¬à“ß∑’Ë¡’§ÿ≥¿“楒‡¬’ˬ¡ À√◊Õ 2.3 À≈—°∞“π®“°√“¬ß“π°“√»÷°…“∑’Ë„™â√Ÿª·∫∫«‘®—¬Õ◊ËπÊ (cohort, case- control) ∑’ˉ¥â√—∫°“√ÕÕ°·∫∫«‘®—¬‡ªìπÕ¬à“ߥ’ ´÷Ëß¡“®“° ∂“∫—πÀ√◊Õ °≈ÿà¡«‘®—¬¡“°°«à“Àπ÷Ëß·Ààß/°≈ÿà¡ 2.4 À≈—°∞“π®“°æÀÿ°“≈“πÿ°√¡ (multiple time series) 2.5 º≈°“√«‘®—¬æ∫ª√–‚¬™πåÀ√◊Õ‚∑…®“°°“√ªØ‘∫—μ‘∑’ˇ¥àπ™—¥¡“°
  • 9. 8 §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 3 À¡“¬∂÷ßÀ≈—°∞“π∑’ˉ¥â®“° 3.1 °“√»÷°…“‡™‘ßæ√√≥π“ (descriptive studies) À√◊Õ 3.2 °“√»÷°…“§«∫§ÿ¡∑’Ë¡’§ÿ≥¿“ææÕ„™â §ÿ≥¿“æÀ≈—°∞“π√–¥—∫ 4 4.1 √“¬ß“π¢Õߧ≥–°√√¡°“√ºŸâ‡™’ˬ«™“≠ §«“¡‡ÀÁπæâÕßÀ√◊Õ©—π∑“¡μ‘ (consensus) ¢Õߧ≥–ºŸâ‡™’ˬ«™“≠∫πæ◊Èπ∞“πª√– ∫°“√≥å∑“ߧ≈‘π‘° À√◊Õ 4.2 √“¬ß“πÕπÿ°√¡ºŸâªÉ«¬®“°°“√»÷°…“„πª√–™“°√μà“ß°≈ÿà¡·≈–§≥– ºŸâ»÷°…“Õ¬à“ßπâÕ¬2©∫—∫√“¬ß“πÀ√◊Õ§«“¡‡ÀÁπ∑’ˉ¡à‰¥âºà“π°“√«‘‡§√“–Àå Õ¬à“ß¡’√–∫∫ πÈ”Àπ—°§”·π–π” (Strength of recommendation) πÈ”Àπ—°§”·π–π” ++ À¡“¬∂÷ߧ«“¡¡—Ëπ„®¢Õߧ”·π–π”„Àâ∑”Õ¬Ÿà„π√–¥—∫ Ÿß ‡æ√“–¡“μ√°“√ ¥—ß°≈à“«¡’ª√–‚¬™πåÕ¬à“߬‘ËßμàÕºŸâªÉ«¬ ·≈–§ÿâ¡§à“ (cost effective) 秫√∑”é πÈ”Àπ—°§”·π–π” + À¡“¬∂÷ߧ«“¡¡—Ëπ„®¢Õߧ”·π–π”„Àâ∑”Õ¬Ÿà„π√–¥—∫ª“π°≈“ß ‡π◊ËÕß®“° ¡“μ√°“√¥—ß°≈à“«Õ“®¡’ª√–‚¬™πåμàÕºŸâªÉ«¬ ·≈–Õ“®§ÿâ¡§à“„π¿“«–®”‡æ“– çπà“∑”é
  • 10. 9¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 πÈ”Àπ—°§”·π–π” +/- À¡“¬∂÷ߧ«“¡¡—Ëπ„®¬—߉¡à‡æ’¬ßæÕ„π°“√„À⧔·π–π” ‡π◊ËÕß®“°¡“μ√°“√ ¥—ß°≈à“«¬—ß¡’À≈—°∞“π‰¡à‡æ’¬ßæÕ„π°“√ π—∫ πÿπÀ√◊Õ§—¥§â“π«à“Õ“®¡’À√◊ÕÕ“®‰¡à¡’ ª√–‚¬™πåμàÕºŸâªÉ«¬·≈–Õ“®‰¡à§ÿâ¡§à“ ·μà‰¡à°àÕ„À⇰‘¥Õ—πμ√“¬μàÕºŸâªÉ«¬‡æ‘Ë¡¢÷Èπ ¥—ßπ—Èπ°“√μ—¥ ‘π„®°√–∑”¢÷ÈπÕ¬Ÿà°—∫ªí®®—¬Õ◊ËπÊ çÕ“®∑”À√◊Õ‰¡à∑”é πÈ”Àπ—°§”·π–π” - À¡“¬∂÷ߧ«“¡¡—Ëπ„®Àâ“¡∑”Õ¬Ÿà„π√–¥—∫ª“π°≈“߇π◊ËÕß®“°¡“μ√°“√¥—ß°≈à“« Õ“®‰¡à¡’ª√–‚¬™πåμàÕºŸâªÉ«¬·≈–‰¡à§ÿâ¡§à“ çÀ“°‰¡à®”‡ªìπ‰¡àπà“∑”é πÈ”Àπ—°§”·π–π” - - À¡“¬∂÷ߧ«“¡¡—Ëπ„®Àâ“¡∑”Õ¬Ÿà„π√–¥—∫ Ÿß ‡æ√“–¡“μ√°“√¥—ß°≈à“«Õ“® ‡°‘¥‚∑…À√◊Õ°àÕ„À⇰‘¥Õ—πμ√“¬μàÕºŸâªÉ«¬ 牡৫√∑”é
  • 11. 10 ∫∑π” Õ“°“√‰Õ‡√◊ÈÕ√—߇ªìπÕ“°“√∑’Ëæ∫∫àÕ¬„π‡«™ªØ‘∫—μ‘·≈–Õ“®°àÕ„À⇰‘¥ªí≠À“ μàÕºŸâªÉ«¬∑—Èß∑“ß°“¬ (physical) ∑“ß®‘μ„® (psychological) ·≈–∑“ß —ߧ¡ (so- cial) ¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢°“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à©∫—∫π’ȇªìπ ¢âÕ·π–π” ”À√—∫·æ∑¬å‡«™ªØ‘∫—μ‘∑—Ë«‰ª„π°“√«‘π‘®©—¬·≈–°“√√—°…“‡∫◊ÈÕßμâπ°àÕπ  àßæ∫ºŸâ‡™’ˬ«™“≠ Õπ÷Ëß ¢âÕ·π–π”μà“ßÊ „π·π«∑“ß©∫—∫π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ ªØ‘∫—μ‘ ·≈–‰¡à¡’º≈∫—ߧ—∫∑“ß°ÆÀ¡“¬ ºŸâ„™â “¡“√∂ªØ‘∫—μ‘·μ°μà“߉ª®“°¢âÕ·π–π” „π°√≥’∑’Ë¡’¢âÕ®”°—¥¢Õß ∂“π∫√‘°“√·≈–∑√—欓°√ À√◊Õ¡’‡Àμÿº≈Õ◊ËπÊ ‚¥¬„™â «‘®“√≥≠“≥´÷Ë߇ªìπ∑’ˬա√—∫·≈–Õ¬Ÿà∫πæ◊Èπ∞“πÀ≈—°«‘™“°“√ ·≈–®√√¬“∫√√≥ 1) §”®”°—¥§«“¡ Õ“°“√‰Õ‡©’¬∫æ≈—π À¡“¬∂÷ßÕ“°“√‰Õ∑’Ë¡’√–¬–‡«≈“πâÕ¬°«à“ 3  —ª¥“Àå Õ“°“√‰Õ°÷Ë߇©’¬∫æ≈—π À¡“¬∂÷ßÕ“°“√‰Õ∑’Ë¡’√–¬–‡«≈“√–À«à“ß 3 ∂÷ß 8  —ª¥“Àå Õ“°“√‰Õ‡√◊ÈÕ√—ß À¡“¬∂÷ßÕ“°“√‰Õ∑’Ë¡’√–¬–‡«≈“‡°‘π 8  —ª¥“Àå ·μà„π‡«™ªØ‘∫—μ‘√–¬–‡«≈“ 8  —ª¥“ÀåÕ“®π“π‡°‘π‰ª ºŸâªÉ«¬Õ“®¡“æ∫ ·æ∑¬å‡√Á«°«à“ 8  —ª¥“À剥â(1-5) „π¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢°“√√—°…“ºŸâªÉ«¬ ‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à©∫—∫π’È ®–°≈à“«∂÷ß “‡ÀμÿÕ“°“√‰Õ∑’Ë¡’√–¬–‡«≈“‡°‘π 3  —ª¥“Àå ¢÷Èπ‰ª „π∑“ߪؑ∫—μ‘À“°ºŸâªÉ«¬¡’Õ“°“√‰Õ∑’Ë¡’√–¬–‡«≈“μ—Èß·μà 3  —ª¥“Àå¢÷Èπ‰ª‚¥¬∑’Ë ‰¡à¡’°“√μ‘¥‡™◊ÈÕ∑“߇¥‘πÀ“¬„® à«π∫ππ”¡“°àÕπ ·π–π”«à“§«√ª√–‡¡‘πÀ“ “‡Àμÿ ¢ÕßÕ“°“√‰Õμ“¡¢âÕ·π–π”©∫—∫π’È
  • 12. 11¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 2)  “‡Àμÿ¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß §«√·¬° “‡Àμÿ∑’Ë√ÿπ·√ßÕÕ°‰ª°àÕ𠇙àπ ¡–‡√Áߪե «—≥‚√§ªÕ¥ ªÕ¥Õ—°‡ ∫ ‡√◊ÈÕ√—ß ‚¥¬Õ“»—¬ª√–«—μ‘ μ√«®√à“ß°“¬ ·≈–¿“æ√—ß ’∑√«ßÕ° (chest x-ray) ‚¥¬ ‡πâπÀ“Õ“°“√‡μ◊Õπ (alarming symptoms) ‰¥â·°à ‰Õ‡ªìπ‡≈◊Õ¥ ‡ ’¬ß·À∫ ‰¢â πÈ”Àπ—°≈¥ Õ“°“√‡Àπ◊ËÕ¬‚¥¬‡©æ“–¢≥–æ—°À√◊Õ‡«≈“°≈“ߧ◊π ª√–«—μ‘°“√‡ªìπ ªÕ¥Õ—°‡ ∫∫àÕ¬Ê °≈◊π≈”∫“° °≈◊π‡®Á∫ ·≈– ”≈—° „π‡∫◊ÈÕßμâπÀ“°¿“æ√—ß ’∑√«ßÕ°ª°μ‘ „πºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß  “‡Àμÿ∑’Ë æ∫∫àÕ¬ ‰¥â·°à 1) °≈ÿà¡‚√§À◊¥ 1.1 Asthma 1.2 Cough variant asthma 1.3 Non-asthmatic eosinophilic bronchitis 2) Upper Airway Cough Syndrome (UACS) 2.1 Rhinitis 2.2 Sinusitis 2.3 Posterior nasal drip 3) Gastro-esophageal reflux disease (GERD)/laryngopharyngeal reflux (LPR) 4) ¬“ angiotensin converting enzyme inhibitor (ACE-I) 5) °“√ Ÿ∫∫ÿÀ√’Ë 6) ‚√§¢ÕßÀ≈Õ¥≈¡ ‰¥â·°à À≈Õ¥≈¡Õ—°‡ ∫‡√◊ÈÕ√—ß (chronic bronchitis)
  • 13. 12 „π°≈ÿࡺŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ°÷Ë߇©’¬∫æ≈—π °≈à“«§◊Õμ—Èß·μà 3  —ª¥“Àå¢÷Èπ‰ª ·μà ‰¡à‡°‘π 8  —ª¥“Àå  “‡Àμÿ∑’Ëæ∫∫àÕ¬Õ’°Õ¬à“ßÀπ÷Ë߉¥â·°à Õ“°“√‰ÕÀ≈—ß®“°°“√μ‘¥‡™◊ÈÕ ∑“߇¥‘πÀ“¬„® (post-infectious cough) Õ—μ√“°“√‡°‘¥Õ“°“√‰Õ‡√◊ÈÕ√—ß®“° “‡Àμÿμà“ßÊ ¢â“ßμâπ·μ°μà“ß°—π√–À«à“ß ª√–‡∑»∑“ßμ–«—πμ°·≈–ª√–‡∑»∑“ßμ–«—πÕÕ° ‚¥¬ “‡Àμÿ®“° GERD ¡’ √“¬ß“πæ∫∫àÕ¬„πª√–‡∑»∑“ßμ–«—πμ°(2, 3) ·μàæ∫πâÕ¬°«à“¡“°„πª√–‡∑»∑“ß μ–«—πÕÕ°(1, 5, 6) ¢âÕ¡Ÿ≈¢Õߪ√–‡∑»‰∑¬„πªï æ.». 2540 æ∫«à“ “‡ÀμÿÕ“°“√‰Õ ‡√◊ÈÕ√—ß‚¥¬∑’Ë¿“æ√—ß ’∑√«ßÕ°ª°μ‘ ‰¥â·°à postnasal drip ·≈– post-infectious cough æ∫ª√–¡“≥√âÕ¬≈– 45 asthma æ∫√âÕ¬≈– 26 postnasal drip √à«¡°—∫ asthma æ∫√âÕ¬≈– 13 ¬“ ACE-I æ∫√âÕ¬≈– 4 bronchiectasis æ∫√âÕ¬≈– 4 idiopathic æ∫√âÕ¬≈– 3 ·≈–æ∫ GERD ‡æ’¬ß√âÕ¬≈– 1.6(6) „πª√–‡∑»·∂∫‡Õ‡™’¬ æ∫«à“¡’°≈ÿà¡Õ“°“√‰Õ‡√◊ÈÕ√—ß™π‘¥¡’‡ ¡À–∑’Ë„Àâ §”®”°—¥§«“¡·μ°μà“ß®“°„πª√–‡∑»∑“ßμ–«—πμ° ‰¥â·°à sinobronchial syn- drome(1) 3) ·π«∑“ß°“√ª√–‡¡‘πºŸâªÉ«¬ 3.1 °“√´—°ª√–«—μ‘ 3.1.1 ≈—°…≥–Õ“°“√‰Õ (characteristics) §«√´—°ª√–«—μ‘μà“ßÊ ¥—ß μàÕ‰ªπ’È 1) √–¬–‡«≈“∑’Ë¡’Õ“°“√‰Õ·≈–°“√¥”‡π‘π¢Õß‚√§ 2) Õ“°“√‰Õ‡ªìπ·∫∫¡’‡ ¡À– (productive) À√◊Õ‰¡à¡’‡ ¡À– (nonproductive)
  • 14. 13¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 3) Õ“°“√‰Õ¡’‡ ¡À–‡√◊ÈÕ√—ß∑’ˇªìπ¡“π“πÀ√◊Õ‡ªìπÊ À“¬Ê ∫“ߧ√—Èß ¡’‡ ¡À–‡À≈◊Õ߇¢’¬«À√◊Õªπ‡≈◊Õ¥ æ∫‰¥â„πÀ≈Õ¥≈¡‚ªÉßæÕß (bronchiectasis) 4) Õ“°“√‰Õ¡’°“√‡ª≈’ˬπ·ª≈ßμ“¡™à«ß‡«≈“√–À«à“ß«—π (diurnal variation) 5) ªí®®—¬∑’Ë°√–μÿâπÕ“°“√‰Õ ‡™àπ Õÿ≥À¿Ÿ¡‘ °≈‘Ë𠇪√¬å À√◊Õ aero- sol °“√ÕÕ°°”≈—ß°“¬ À√◊ÕÀ≈—ß√—∫ª√–∑“πÕ“À“√¡◊ÈÕ„À≠à 6) Õ“°“√‰Õ¡’§«“¡ —¡æ—π∏å°—∫∑à“∑“ß ‡™àπ ·¬à≈߇¡◊ËÕ°â¡μ—«À√◊Õ πÕπ√“∫ Õ“°“√‰ÕÀ≈—ß°‘πÕ“À“√ ¡—°‡°‘¥„π™à«ß 10 π“∑’À≈—ß °‘πÕ“À“√ À√◊ÕÕ“°“√‰Õ¡’§«“¡ —¡æ—π∏å°—∫°“√查 °“√À—«‡√“– °“√√âÕ߇æ≈ß ¡—°æ∫„π gastroesophageal reflux ‡π◊ËÕß®“° ¡’°“√≈¥≈ߢÕß lower esophageal sphincter tone Õ“°“√ · ∫√âÕπ¬Õ¥Õ° (heartburn) ‡√Õ‡ª√’Ȭ« (regurgitation) æ∫ ‰¥â·μà‰¡à∫àÕ¬„πºŸâªÉ«¬∑’Ë¡’Õ“°“√°√¥‰À≈¬âÕπ∑’Ë¡’Õ“°“√πÕ° À≈Õ¥Õ“À“√ (extra-esophageal GERD) 7) Õ“°“√°√–·Õ¡ (throat clearing) æ∫„π postnasal drip syndrome À√◊Õ‚æ√߉´π— Õ—°‡ ∫‡√◊ÈÕ√—ß 8) Õ“°“√‡μ◊Õπ (alarming symptoms) ¢Õß‚√§∑’ËÕ“®‡ªì𠓇Àμÿ √ÿπ·√ߢÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß ‰¥â·°à ‰Õ‡ªìπ‡≈◊Õ¥ ‡ ’¬ß·À∫ ‰¢â πÈ”Àπ—°≈¥ Õ“°“√‡Àπ◊ËÕ¬ ‚¥¬‡©æ“–¢≥–æ—°À√◊Õ‡«≈“°≈“ߧ◊𠇮Á∫Àπâ“Õ°‡«≈“À“¬„®‡¢â“≈÷°Ê ·≈–ª√–«—μ‘°“√‡ªìπªÕ¥Õ—°‡ ∫ ∫àÕ¬Ê 3.1.2 ¬“∑’Ë„™âª√–®” ‰¥â·°à angiotensin converting enzyme inhibitor (ACE-I)
  • 15. 14 3.1.3 ª√–«—μ‘‚√§ª√–®”μ—« ‡™àπ ‚√§¿Ÿ¡‘·æâ (atopic diseases) ‰¥â·°à ¿Ÿ¡‘·æâ ®¡Ÿ° ¿Ÿ¡‘·æ⺑«Àπ—ß ·≈–ª√–«—μ‘‚√§ autoimmune diseases 3.1.4 Õ“™’æ ß“πÕ¥‘‡√°  —μ«å‡≈’È¬ß Õ“™’æ∑’Ë¡’§«“¡‡ ’ˬ߉¥â·°à §π∑”¢π¡ªíß ™à“ß∑”º¡ ∑”Õÿμ “À°√√¡ ‡°’ˬ«°—∫ºâ“ ‡°…μ√°√√¡ ·≈–‡≈’Ȭߠ—μ«å 3.1.5 ª√–«—μ‘°“√ Ÿ∫∫ÿÀ√’Ë §«√´—°ª√–«—μ‘∑—Èß active ·≈– passive smoker À“°¡’ª√–«—μ‘°“√  Ÿ∫∫ÿÀ√’Ë „Àâª√–‡¡‘πμàÕ¥—ßπ’È „πºŸâªÉ«¬∑’ˇªìπ active smoker ∂“¡ª√–«—μ‘®”π«π ·≈–√–¬–‡«≈“∑’Ë Ÿ∫ À“°¡’°“√‡ª≈’ˬπ·ª≈ߧ«“¡∂’Ë¢Õß°“√‰ÕÀ√◊Õ¡’Õ“°“√‰Õ‡ªìπ ‡≈◊Õ¥ §«√μ√«®§âπÀ“ “‡ÀμÿμàÕ °√≥’À¬ÿ¥ Ÿ∫∫ÿÀ√’Ë·≈â« ∫“ߧ√—ÈßÕ“°“√‰ÕÕ“®¬—ß ‰¡àÀ¬ÿ¥‡æ√“–¡’°“√‡ª≈’ˬπ·ª≈ߢÕß cough reflex ‰ª·≈â« ·μà¡—°®–‰Õ≈¥≈ß 3.1.6 Õ“°“√‰Õ‡√‘Ë¡μâπ®“°Õ“°“√‡ªìπÀ«—¥À√◊Õ°“√μ‘¥‡™◊ÈÕ∑“߇¥‘πÀ“¬„®  à«π∫π (upper respiratory tract infection) π”¡“°àÕπÀ√◊Õ‰¡à ‚¥¬∂“¡Õ“°“√ ‡√‘Ë¡¢Õß°“√‰Õ«à“¡’‡®Á∫§Õ À«—¥ πÈ”¡Ÿ°À√◊Õ‰¡à  à«π„À≠àÀ“°‡ªìπ®“°°“√μ‘¥‡™◊ÈÕ ∑“߇¥‘πÀ“¬„® à«π∫πÕ“°“√¡—°¥’¢÷Èπ‡√◊ËÕ¬Ê ¿“¬„π√–¬–‡«≈“‰¡à‡°‘π 8  —ª¥“Àå ‚¥¬‡©æ“–Õ“°“√‰ÕμÕπ°≈“ߧ◊π®–§àÕ¬Ê ≈¥≈ß°àÕπ ´÷ËߺŸâªÉ«¬ à«π¡“°∂⓬—߉¡à À“¬ π‘∑ ·≈–∫“ß√“¬¡’Õ“°“√√ÿπ·√ß¡—°®–°—ß«≈·≈–¡“æ∫·æ∑¬å 3.1.7 ª√–«—μ‘ —¡º— °—∫‡¥Á°À√◊ÕºŸâªÉ«¬∑’ˇªìπ‰Õ°√𠧫“¡·μ°μà“ߢÕ߉հ√π°—∫°“√μ‘¥‡™◊ÈÕ∑“߇¥‘πÀ“¬„® à«π∫π®“° ‡™◊ÈÕ‰«√—  (viral infection) §◊Õ ‰Õ°√π®–¡’§«“¡√ÿπ·√ߢÕß°“√‰Õ¡“°¢÷Èπ ‰Õ¡“° ®πÕ“‡®’¬π ‚¥¬‰¡à¡’∑’∑à“«à“®–¥’¢÷Èπ ®π°«à“®– 2-3  —ª¥“Àå ·≈–¡—°‰Õ‰¥âπ“π∂÷ß 3 ‡¥◊Õπ „π§π∑’ˇªìπ√ÿπ·√ßÕ“®π“π∂÷ß 7 ‡¥◊Õπ
  • 16. 15¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 3.1.8 „πºŸâ∑’Ë¡’ªí≠À“°“√°≈◊π ¡’‚√§∑“ß√–∫∫ª√– “∑ ·≈–ºŸâ ŸßÕ“¬ÿ Õ“®¡’ ª√–«—μ‘‰Õ·≈– ”≈—°™à«ß√–À«à“ߥ◊Ë¡πÈ”·≈–°‘πÕ“À“√ 𔉪 Ÿà¿“«– ”≈—° (chronic silent aspiration) ‰¥â 3.2 °“√μ√«®√à“ß°“¬ 3.2.1 °“√μ√«® ÀŸ §Õ ®¡Ÿ° ‚¥¬„™â‰ø∑’Ë «à“߇撬ßæÕ àÕß∑’Ë™àÕß®¡Ÿ° ·≈–§Õ ‡æ◊ËÕÀ“«à“¡’°“√Õ—°‡ ∫¢Õß‚æ√ß®¡Ÿ° à«π inferior turbinate √‘¥ ’¥«ß®¡Ÿ° (nasal polyp) ¡’‡ ¡À–À≈—ß§Õ (postnasal drip ∑’Ë posterior pharynx) ≈—°…≥– cobble stone ∫√‘‡«≥ posterior pharynx À√◊ÕμàÕ¡∑Õπ´‘≈¡’¢π“¥„À≠àÀ√◊Õ‰¡à 3.2.2 °“√μ√«®√à“ß°“¬Õ◊ËπÊ ‰¥â·°à √‘¡Ω望°·μ°Õ—°‡ ∫ (cheilitis) Õ“®¡’°“√·¥ßÕ—°‡ ∫√Õ∫√‘¡Ω望°‰¥â ¢Õ∫μ“≈à“ߧ≈È”¥” (allergic shiner) ‡°‘¥®“° ‡¬◊ËÕ®¡Ÿ°∑’Ë∫«¡∑”„Àâ¡’ chronic congestion ¢Õß lower eyelid venous plexus À√◊Õº◊Ëπ·¥ß§—π∑’ËÀ—«μ“À√◊Õ‡ª≈◊Õ°μ“ Õ“°“√‡À≈à“π’È∫àß∫Õ°«à“ºŸâªÉ«¬¡’‡¬◊ËÕ®¡Ÿ°∫«¡ Õ—°‡ ∫‡√◊ÈÕ√—ß ´÷Ëß¡“°°«à“√âÕ¬≈– 80 ‡ªìπ‡¬◊ËÕ∫ÿ‚æ√ß®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ 3.2.3 °“√μ√«®ªÕ¥ ‡æ◊ËÕμ√«®À“‡ ’¬ßªÕ¥∑’˺‘¥ª°μ‘ ‰¥â·°à wheeze, expiratory rhonchi ∫àß™’È∂÷ß¿“«–À≈Õ¥≈¡μ’∫ ·≈– coarse crepitation ∫àß™’È ∂÷ß°“√¡’‡ ¡À–„πÀ≈Õ¥≈¡ ¡—°æ∫„π bronchiectasis 3.3 °“√ ◊∫§âπÀ“ “‡Àμÿ (Investigations) 3.3.1 √–¥—∫ª∞¡¿Ÿ¡‘ (Primary care) ‰¥â·°à 3.3.1.1 ¿“æ√—ß ’∑√«ßÕ° (Chest X-ray) ·π–π”„Àâ∑”(1-5, 7) ‡æ◊ËÕ §âπÀ“ “‡Àμÿ¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß ‡™àπ «—≥‚√§ªÕ¥ ¡–‡√Áߪե ∂â“æ∫§«“¡ º‘¥ª°μ‘„Àâ ◊∫§âπ‰ªμ“¡§«“¡º‘¥ª°μ‘π—Èπ (Level of evidence 1, Grade of recommendation ++)
  • 17. 16 3.3.1.2 ¿“æ√—ß ’‰´π—  (plain x-ray of paranasal sinus) §«√∑” „π°√≥’∑’Ë ß —¬¿“«–‰´π— Õ—°‡ ∫ ·≈–„πºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß∑’Ë¡’‡ ¡À–¡“° ·μàμ√«®‚æ√ß®¡Ÿ°·≈⫉¡àæ∫§«“¡º‘¥ª°μ‘(8, 9) ·π–π”„Àâ àß∂à“¬¿“æ√—ß ’¢Õ߉´π—  ‡æ◊Ëՙ૬«‘π‘®©—¬‚√§ (Level of evidence 4, Grade of recommendation +) „π°√≥’∑’Ëæ∫ maxillary sinus ¢ÿàπ∑÷∫ À√◊Õæ∫¡’√–¥—∫¢Õ߇À≈« ∫àß™’È«à“¡’‚Õ°“  ‡ªìπ‚√§‰´π— Õ—°‡ ∫®“°‡™◊ÈÕ·∫§∑’‡√’¬ Ÿß¡“°(10) 3.3.1.3 °“√μ√«® ¡√√∂¿“æªÕ¥ 1) ·π–π”„Àâ∑” ‰ª‚√‡¡μ√’¬å (spirometry) „π√“¬∑’Ë ß —¬ ‚√§À≈Õ¥≈¡(2) ‡æ◊ËÕ§âπÀ“¿“«–À≈Õ¥≈¡μ’∫ (airway obstruction)(3) (Level of evidence 2, Grade of recommendation ++) [√“¬≈–‡Õ’¬¥„π¿“§ºπ«°] „π °√≥’∑’ËÕ¬Ÿà„π ∂“π∑’Ë∑’Ë∑”°“√μ√«®‰¡à‰¥â ·π–π”„Àâ¡’°“√ àßμàÕºŸâ‡™’ˬ«™“≠ 2) °“√«—¥§à“ peak expiratory flow rate (PEFR) °àÕπ·≈– ¿“¬À≈—ß°“√„Àâ Ÿ¥¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘Ï —Èπ‡æ’¬ß§√—È߇¥’¬« ‰¡à·π–π” „Àâ∑”‡π◊ËÕß®“°‰¡à‡∑’ˬßμ√߇¡◊ËÕ‡∑’¬∫°—∫§à“ forced expiratory volume „π‡«≈“ 1 «‘π“∑’ (FEV1) „π°“√«‘π‘®©—¬¿“«–À≈Õ¥≈¡μ’∫(11) (Level of evidence 2, Grade of recommendation +/-) ·μà°“√„™â serial PEFR „π°√≥’∑’Ë ß —¬‚√§À◊¥ ¬—߉¡à¡’°“√»÷°…“‡æ’¬ßæÕ∑’Ë®–·π–π”„Àâ∑”„πºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß (Level of evidence 4, Grade of recommendation +/-) 3.3.2 √–¥—∫∑ÿ쑬¿Ÿ¡‘ (Secondary care)·π–π”„Àâ∑”„π°√≥’∑’Ë¡’ºŸâ‡™’ˬ«™“≠ ‰¥â·°à 3.3.2.1 Indirect laryngoscopy ‡æ◊ËÕ§âπÀ“À≈—°∞“π¢Õß laryngopha- ryngeal reflux ·π–π”„Àâ∑”„π°√≥’∑’Ë¡’ºŸâ‡™’ˬ«™“≠∑“ßÀŸ §Õ ®¡Ÿ° (ENT)(3) (Level of evidence 1, Grade of recommendation ++)
  • 18. 17¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 3.3.2.2 Bronchoprovocative test ‡ªìπ°“√∑¥ Õ∫§«“¡‰«À≈Õ¥≈¡ (airway hyperresponsiveness, AHR) [√“¬≈–‡Õ’¬¥„π¿“§ºπ«°] ·π–π”„Àâ ∑”„π°√≥’∑’˺≈°“√μ√«® ‰ª‚√‡¡μ√’¬åª°μ‘·≈– ß —¬¿“«–À≈Õ¥≈¡‰«‡°‘π‡π◊ËÕß®“° º≈ ‰ª‚√‡¡μ√’¬å∑’˪°μ‘¬—߉¡à “¡“√∂μ—¥ “‡ÀμÿÕ“°“√‰Õ∑’ˇ°‘¥®“° asthma ‰¥â(2, 12) °“√∑¥ Õ∫§«“¡‰«À≈Õ¥≈¡∑”‰¥â‚¥¬«‘∏’ methacholine challenge test À“° º≈°“√μ√«® methacholine challenge test ‡ªìπº≈≈∫  “¡“√∂μ—¥°“√«‘π‘®©—¬ ‚√§À◊¥ÕÕ°‰ª‰¥â∂⓺ŸâªÉ«¬‰¡à‡§¬‰¥â√—∫¬“ Ÿ¥§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å¡“°àÕπ(13) (Level of evidence 2, Grade of recommendation +) 3.3.2.3 ‡Õ°´‡√¬å§Õ¡æ‘«‡μÕ√åªÕ¥ (High-resolution computed tomography, HRCT) „π°√≥’∑’Ë ß —¬‚√§À≈Õ¥≈¡‚ªÉßæÕß (bronchiectasis) ‚√§ interstitial lung diseases À√◊ÕÀ≈Õ¥≈¡¢π“¥‡≈Á°Õ—°‡ ∫ (bronchiolitis) ∑’˺≈ °“√μ√«®¿“æ√—ß ’∑√«ßÕ°ª°μ‘(3) (Level of evidence 3, Grade of recommen- dation +) 3.3.2.4 ‡Õ°´‡√¬å§Õ¡æ‘«‡μÕ√å‰´π—  (Computerized tomography of paranasal sinus) ‰¡à·π–π”„Àâ àßμ√«®‡Õ°´‡√¬å§Õ¡æ‘«‡μÕ√å‰´π—  „π°“√ μ√«®‡∫◊ÈÕßμâπ(9) (Level of evidence 2, Grade of recommendation -) ·π–π” „Àâ∑”‡©æ“–„π√“¬∑’Ë®–‰¥â∑”°“√ºà“μ—¥‰´π—  À√◊Õ¡’¿“«–·∑√°´âÕπ™π‘¥√⓬·√ß ‡™àπ¿“«–·∑√°´âÕπ∑“ßμ“·≈– ¡Õß ·≈–„πºŸâ∑’ˉ¡àμÕ∫ πÕßμàÕ°“√√—°…“¥â«¬ ¬“(4) (Level of evidence 3, Grade of recommendation ++) 3.3.2.5 °“√μ√«®‡æ◊ËÕ ◊∫§âπ¿“«–°√¥‰À≈¬âÕπ ¡’°“√μ√«®‰¥âÀ≈“¬ «‘∏’ ‰¥â·°à 1) 24-hour esophageal pH monitoring 2) Esophageal manometry/impedance testing (Level of evidence 2, Grade of recommendation +/-)
  • 19. 18 3.3.2.6 °“√μ√«®π—∫®”π«πÕ‘‚Õ ‘‚πøî≈„π‡ ¡À– (sputum eosi- nophil) ∑”‰¥â¬“°„π∑“ߪؑ∫—μ‘ ª√‘¡“≥Õ‘‚Õ ‘‚πøî≈„π‡ ¡À–¡’§«“¡ —¡æ—π∏å°—∫ √–¥—∫‰πμ√‘°ÕÕ°‰´¥å„π≈¡À“¬„®ÕÕ° (fractional exhaled nitric oxide, FeNO) °“√«—¥√–¥—∫ FeNO ‡æ◊ËÕ„™â·¬° “‡ÀμÿÕ“°“√‰Õ®“° eosinophilic inflammation √–¥—∫ FeNO ¡’§à“ Ÿß¢÷Èπ„πÕ“°“√‰Õ∑’ˇ°‘¥®“° asthma, cough variant asthma ·≈– non-asthmatic eosinophilic bronchitis(14) ·≈–„™â∑”𓬰“√μÕ∫ πÕß μàÕ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥„πºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß(15) ·π–π”„Àâ∑”À“°∑”‰¥â„π °√≥’∑’Ë≈Õß„Àâ°“√√—°…“¥â«¬¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥·≈⫬—߉¡à‰¥âº≈ ‡æ◊Ëՙ૬ „π°“√ª√—∫¬“μàÕ‰ª (Level of evidence 2, Grade of recommendation +) 3.3.2.7 √–¥—∫ specific IgE „π‡≈◊Õ¥ À√◊Õ skin prick test μàÕ aeroallergen ¡’ª√–‚¬™πå„π°“√¬◊π¬—π°“√«‘π‘®©—¬¿“«–‚æ√ß®¡Ÿ°Õ—°‡ ∫®“° ¿Ÿ¡‘·æâ(4) (Level of evidence 2, Grade of recommendation ++) 4) 欓∏‘ √’√«‘∑¬“¢ÕßÕ“°“√‰Õ ‡°‘¥®“°‡ âπª√– “∑‡«°— ∂Ÿ°°√–μÿâπºà“πμ—«√—∫ —≠≠“≥∑’ˇ≈’Ȭ߄πÕ«—¬«– μà“ßÊ ´÷Ëß„π√–∫∫°“√À“¬„®ª√–°Õ∫¥â«¬ 1. C-fibers (nociceptor cough) Õ¬Ÿà∫√‘‡«≥ mucosa ¢ÕßÀ≈Õ¥≈¡ ∂Ÿ°°√–μÿâπ‚¥¬ “√§—¥À≈—Ëß®“°‡´≈≈åÕ—°‡ ∫ (inflammatory mediators) À√◊Õ “√ ∑’Ë°àÕ„À⇰‘¥°“√√–§“¬‡§◊Õß (irritants) 2. Cough receptors (mechanoreceptor cough) Õ¬Ÿà„μâμàÕ epi- thelium ¢Õß larynx, trachea ·≈– mainstem bronchus ∂Ÿ°°√–μÿâπ‚¥¬°“√  —¡º—  (punctuate mechanical) ·≈–‰¡àμÕ∫ πÕßμàÕ “√‡§¡’¬°‡«âπ “√∑’ˇªìπ°√¥
  • 20. 19¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 Õ“°“√‰Õ¬—߇°‘¥®“°°“√°√–μÿâπ∑’ËÕ«—¬«–Õ◊Ëπ∑’ˇ≈’Ȭߥ⫬‡ âπª√– “∑‡«°—  ‰¥â·°à À≈Õ¥Õ“À“√ °√–‡æ“–Õ“À“√ À—«„® ·≈–ÀŸ™—ÈππÕ° ‡ªìπμâπ  —≠≠“≥®“° μ—«√—∫®– àߺà“π‰ª¬—ß nucleus tractus solitarius (nTS) „π brainstem ∑”„Àâ ‡°‘¥ çreflex coughé ‚¥¬°“√ àß —≠≠“≥‰ª¬—ß°≈â“¡‡π◊ÈÕ∑’ˇ°’ˬ«¢âÕß°—∫°“√‰Õ πÕ°®“°π’ÈÕ“°“√‰Õ¬—ß “¡“√∂§«∫§ÿ¡‰¥â‚¥¬ ¡Õß à«π cortex çurge to coughé À√◊Õ çbehavioral coughé ‚¥¬¡’§«“¡√Ÿâ ÷°·≈–Õ“√¡≥凢ⓡ“‡°’ˬ«¢âÕß ‚¥¬ ‡©æ“–°≈ÿà¡Õ“°“√‰Õ‡√◊ÈÕ√—ß ‡™àπ √Ÿâ ÷°§—π„π§ÕμâÕß°“√‰Õ‡Õ“‡ ¡À–ÕÕ°¡“ Õ“°“√ ‰Õ‡√◊ÈÕ√—ß à«πÀπ÷Ë߇ªìπº≈®“°°“√∑’Ë cough reflex ¡’§«“¡‰«‡°‘πμàÕμ—«°√–μÿâπ ·¡âμ—«°√–μÿâππ—Èπ‰¡à√ÿπ·√ß ´÷ËßÕ“®‡ªìπº≈®“°°“√μ‘¥‡™◊ÈÕ‚¥¬‡©æ“–‡™◊ÈÕ‰«√—  °“√ Õ—°‡ ∫ (inflammation) ‡ªìπμâπ À≈—°°“√√—°…“Õ“°“√‰Õ§◊Õ √—°…“ “‡Àμÿ∑’Ë∑”„Àâ ‡°‘¥μ—«°√–μÿâπ ·≈–Õ“®„À⬓À√◊Õ “√∑’ˬ—∫¬—ÈßÕ“°“√‰Õ 5) °“√ª√–‡¡‘𧫓¡√ÿπ·√ß·≈–º≈°√–∑∫¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß 5.1) °“√ª√–‡¡‘π·∫∫ subjective ‰¥â·°à cough severity score, cough diary ‚¥¬§«“¡√ÿπ·√ß¡“°¢÷Èπ„πºŸâ∑’Ë¡’Õ“°“√‰Õ°≈“ߧ◊π √∫°«π°“√πÕπÀ≈—∫ °“√ ª√–‡¡‘π¥â«¬«‘∏’π’È„™â¥Ÿ°“√‡ª≈’ˬπ·ª≈ß„π§π‡¥‘¡«à“‡ªìπÕ¬à“߉√ ·μà„™â‰¡à‰¥â‡¡◊ËÕ ‡ª√’¬∫‡∑’¬∫√–À«à“ß∫ÿ§§≈ „πμà“ߪ√–‡∑»„™â·∫∫ Õ∫∂“¡ Leicester ∑’ˉ¥â√—∫ °“√ validation „πºŸâ∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß‚¥¬ª√–‡¡‘πº≈°√–∑∫®“°Õ“°“√‰Õ„π 3 ¡‘μ‘ ‰¥â·°à ∑“ß°“¬ (physical) ∑“ß®‘μ„® (psychological) ·≈–∑“ß —ߧ¡ (social) ·≈–§ÿ≥¿“æ™’«‘μ °“√ª√–‡¡‘π¥â«¬«‘∏’π’È„™â‰¥â¥’∑—Èß„π§π‡¥’¬«°—π·≈– √–À«à“ß∫ÿ§§≈ ·≈–¬—ß¡’°“√»÷°…“À“§à“ minimal clinical importance diffe- rence¢Õß°“√‡ª≈’ˬπ·ª≈ß∑’Ë¡’π—¬ ”§—≠∑“ߧ≈‘π‘°(16) „πª√–‡∑»‰∑¬‰¥â¡’°“√·ª≈ ·∫∫ Õ∫∂“¡ Leicester ‡ªìπ©∫—∫¿“…“‰∑¬·≈–∑¥ Õ∫§«“¡‡∑’ˬßμ√ß·≈â«„π ºŸâªÉ«¬ºŸâ„À≠à∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß(17)
  • 21. 20 5.2) °“√ª√–‡¡‘π·∫∫ objective ‚¥¬°“√„™â‡§√◊ËÕß¡◊Õπ—∫§«“¡∂’Ë¢Õß°“√ ‰Õ ´÷Ë߬—߉¡à‡ªìπ∑’Ë·æ√àÀ≈“¬·≈–¡’√“§“·æß 6) °“√√—°…“‡∫◊ÈÕßμâπ Õ“°“√‰Õ°÷Ë߇©’¬∫æ≈—πÀ√◊Õ‰Õ‡√◊ÈÕ√—ßÕ“®‡°‘¥®“° “‡ÀμÿÀπ÷ËßÀ√◊ÕÀ≈“¬ “‡Àμÿ „π‡«≈“‡¥’¬«°—π  “‡Àμÿ∑’Ëæ∫‰¥â∫àÕ¬„π°√≥’∑’Ë¿“æ√—ß ’∑√«ßÕ°ª°μ‘ ‰¥â·°à ¬“ ACE inhibitor, UACS, cough variant asthma ·≈– GERD ¿“¬À≈—ß®“°À¬ÿ¥¬“ ACE-I À“°¡’°“√„™â¬“π’È·≈–À¬ÿ¥°“√ Ÿ∫∫ÿÀ√’Ë·≈â« °“√√—°…“‡∫◊ÈÕßμâπ„π°√≥’∑’Ë ß —¬ UACS §«√‡√‘Ë¡®“° ¬“μâ“πŒ’ μ“¡’π (antihistamine) ·≈–/À√◊Õ¬“ decongestant (Level of evidence 3, Grade of recommendation +) ∂â“μÕ∫ πÕߥ’Õ“°“√‰Õ¡—°¥’¢÷Èπ¿“¬„π 2  —ª¥“Àå „π°√≥’∑’Ë¡’ª√–«—쑇¢â“‰¥â°—∫‚√§À◊¥ ·π–π”„Àâ‡æ‘Ë¡°“√√—°…“¥â«¬¬“¢¬“¬ À≈Õ¥≈¡ (beta-2 agonist bronchodilator) ·≈–/À√◊Õ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å ™π‘¥ Ÿ¥ (inhaled corticosteroid À√◊Õ ICS) (Level of evidence 1, Grade of recommendation ++) ·≈–/À√◊Õ§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥√—∫ª√–∑“π‰¡à‡°‘π 2  —ª¥“Àå¢÷ÈπÕ¬Ÿà°—∫§«“¡√ÿπ·√ߢÕßÕ“°“√ °“√μ√«®‡æ‘Ë¡‡μ‘¡‚¥¬μ√«® metha- choline ‡æ◊ËÕ·¬°‚√§À◊¥·≈–Õ“°“√‰Õ∑’ˇ°‘¥®“°°“√Õ—°‡ ∫™π‘¥Õ‘‚Õ ‘‚πøî≈ (non- asthmatic eosinophilic bronchitis) À“°μ√«®‰¡à‰¥â °“√„À⬓§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å ™π‘¥ Ÿ¥ ·≈–/À√◊Õ  ‡μ’¬√Õ¬¥å™π‘¥√—∫ª√–∑“π 2  —ª¥“Àå  “¡“√∂√—°…“Õ“°“√‰Õ ∑’ˇ°‘¥®“°°“√Õ—°‡ ∫™π‘¥Õ‘‚Õ ‘‚πøî≈·≈–‚√§À◊¥‰¥â (steroid-responsive cough) (Level of evidence 3, Grade of recommendation +) ∂â“μÕ∫ πÕߥ’ Õ“°“√‰Õ¡—°¥’¢÷Èπ¿“¬„π 2-4  —ª¥“Àå „π°√≥’∑’ˉ¡àμÕ∫ πÕßμàÕ°“√√—°…“¥â«¬¬“ §Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å Õ“®μâÕßæ‘®“√≥“°“√μ√«®‡æ‘Ë¡‡μ‘¡‚¥¬μ√«® methacholine 1
  • 22. 21¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 ·≈–°“√«—¥°“√Õ—°‡ ∫™π‘¥Õ‘‚Õ ‘‚πøî≈ ·μà ”À√—∫·æ∑¬å‡«™ªØ‘∫—μ‘ ∑—Ë«‰ª§«√ æ‘®“√≥“ àߪ√÷°…“·æ∑¬åºŸâ‡™’ˬ«™“≠ À“°ºŸâªÉ«¬¡’Õ“°“√‰Õ√à«¡°—∫Õ“°“√¢Õß¿“«–°√¥‰À≈¬âÕπ (GERD) ∑’Ë™—¥‡®π À√◊Õ¡’Õ“°“√°√¥‰À≈¬âÕπ‰¡à™—¥‡®π ·μà‰¥âμ—¥ª√–‡¥Áπμà“ßÊ ¢â“ßμâπ·≈â« ‰¥â·°à UACS ·≈–‚√§À◊¥  “¡“√∂æ‘®“√≥“„Àâ°“√√—°…“¥â«¬¬“≈¥°√¥‰¥â ·μàμâÕߥŸº≈°“√ μÕ∫ πÕßμàÕ°“√√—°…“∑’ËÕ¬à“ßπâÕ¬ 4  —ª¥“Àå À“°‰¥â¬“‰ª 8-12  —ª¥“Àå·≈⫬—ß ‰¡à¥’¢÷Èπ§«√À¬ÿ¥¬“ ·≈–æ‘®“√≥“ àߪ√÷°…“·æ∑¬åºŸâ‡™’ˬ«™“≠ 7)  “‡ÀμÿÕ“°“√‰Õ‡√◊ÈÕ√—ß„π¿“æ√—ß ’ªÕ¥ª°μ‘∑’Ëæ∫∫àÕ¬ 7.1 ACE inhibitor induced cough æ∫Õÿ∫—μ‘°“√≥åª√–¡“≥√âÕ¬≈– 10 ∂÷ß 30  Ÿß¢÷Èπ„π‡æ»À≠‘ß«—¬°≈“ß §π Õ“°“√‰Õ¡—°‡ªìπÀ≈—ß®“°‰¥â¬“‡ªìπ√–¬–‡«≈“À≈“¬«—π®π∂÷ßÀ≈“¬ —ª¥“Àå „π ∫“ß°√≥’ºŸâªÉ«¬‰¥â¬“¡“π“πÀ≈“¬‡¥◊Õπ§àÕ¬¡“‡°‘¥Õ“°“√‰Õ‰¥â‡¡◊ËÕ¡’μ—«°√–μÿâ𠇙àπ °“√μ‘¥‡™◊ÈÕÀ«—¥ Õ“°“√‰Õ®“°¬“π’È¡—°‰¡àμÕ∫ πÕßμàÕ¬“¢¬“¬À≈Õ¥≈¡À√◊Õ¬“ °¥Õ“°“√‰Õ Õ“°“√‰ÕÀ“¬‰¥â‡ÕßÀ≈—ßÀ¬ÿ¥¬“¿“¬„π 1-4  —ª¥“Àå(18) À“°ºŸâªÉ«¬‰Õ ‡√◊ÈÕ√—ߧ«√À¬ÿ¥¬“ (Level of evidence 3, Grade of recommendation +) 7.2 Cough variant asthma ≈—°…≥–∑’Ë ”§—≠∑“ߧ≈‘π‘°§◊ÕºŸâªÉ«¬¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß∑’ˇ¢â“‰¥â°—∫‚√§À◊¥ ‡™àπ ‰Õ‡«≈“°≈“ߧ◊π ‰ÕÀ≈—ß®“°‰¥â√—∫°“√°√–μÿâπ À√◊Õ “√°àÕ¿Ÿ¡‘·æâ ‚¥¬∑’ˉ¡à¡’ ‡ ’¬ßÀ«’¥ À√◊Õ‰¡à¡’Õ“°“√‡Àπ◊ËÕ¬ ‰Õ à«π„À≠à‰¡à¡’‡ ¡À–À√◊Õ¡’‡æ’¬ß‡≈Á°πâÕ¬ ‚¥¬ ‰¡à¡’¿“«–μ‘¥‡™◊ÈÕ∑“߇¥‘πÀ“¬„®π”¡“°àÕπ(19) ‚√§π’ÈμÕ∫ πÕߥ’μàÕ°“√√—°…“¥â«¬¬“ ¢¬“¬À≈Õ¥≈¡ À“°ºŸâªÉ«¬μÕ∫ πÕߥ’μàÕ¬“¢¬“¬À≈Õ¥≈¡ §«√∑”°“√∑¥ Õ∫ ‡æ◊ËÕ¬◊π¬—π°“√«‘π‘®©—¬‚√§À◊¥μ“¡·π«∑“ß°“√ªØ‘∫—μ‘ ”À√—∫ºŸâªÉ«¬‚√§À◊¥(12)
  • 23. 22 °“√√—°…“‚√§À◊¥ 1. „π°√≥’∑’Ë¡’Õ“°“√‰Õ‡ªìπ§√—Èߧ√“«(intermittent)Õ“®æ‘®“√≥“„À⬓ β2- agonist ™π‘¥√—∫ª√–∑“πÀ√◊Õ™π‘¥ Ÿ¥∑’ËÕÕ°ƒ∑∏‘Ï —Èπ(1) (Level of evidence 2, Grade of recommendation ++) ‡æ◊ËÕ∫√√‡∑“Õ“°“√¢Õß‚√§À◊¥ (relievers) ®“°°“√À¥‡°√ÁߢÕß°≈â“¡‡π◊ÈÕ‡√’¬∫À≈Õ¥≈¡ °“√μÕ∫ πÕߥŸ®“°Õ“°“√‰Õ¥’¢÷Èπ „π 2-4  —ª¥“Àå 2. À“°Õ“°“√‰Õ‡ªìπμ≈Õ¥μàÕ‡π◊ËÕß (persistent) À√◊Õ‰¡àμÕ∫ πÕßμàÕ¬“ „π¢âÕ 1 æ‘®“√≥“„À⬓∑’Ë„™â§«∫§ÿ¡‚√§À◊¥ (controllers) „™â‡æ◊ËÕ√—°…“°“√Õ—°‡ ∫ ‡√◊ÈÕ√—ߢÕßÀ≈Õ¥≈¡ ¬“∑’Ë¡’ª√– ‘∑∏‘¿“楒∑’Ë ÿ¥ §◊Õ ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥ (inhaled corticosteroid À√◊Õ ICS)(12) (Level of evidence 1, Grade of recommendation ++) ‚¥¬¬—∫¬—Èß°“√ √â“ß “√∑’ˇ°’ˬ«¢âÕß°—∫°“√Õ—°‡ ∫®“° ‡¡Á¥‡≈◊Õ¥¢“«·≈–¬—ß¡’¬“°≈ÿà¡Õ◊ËπÊ∑’Ë “¡“√∂„™â‰¥â‡™à𠬓μâ“π≈‘«‚§‰μ√Õ’π (leuko- triene receptor antagonist, LTRA)(20) (Level of evidence 1, Grade of recommendation ++) º≈°“√√—°…“¥â«¬¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥·≈– ¬“μâ“π≈‘«‚§‰μ√Õ’π„π¥â“πÕ“°“√‰ÕæÕÊ °—π·μà ICS ªÑÕß°—π°“√¥”‡π‘π‚√§‰ª Ÿà classic asthma À√◊Õ wheezing ‰¥â¥’°«à“ LTRA(21) À“°¬—ߧ«∫§ÿ¡‰¡à‰¥â  “¡“√∂ „™â¬“¢¬“¬À≈Õ¥≈¡∑’ËÕÕ°ƒ∑∏‘Ϭ“« (long-acting β2-agonist, LABA) ∑’˺ ¡°—∫ ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥ (ICS/LABA)(22) ‡æ◊ËÕ‡ √‘¡ƒ∑∏‘Ï°—π(23) (Level of evidence 1, Grade of recommendation ++) À“°„Àâ°“√√—°…“¥â«¬¬“¢â“ßμâπ·≈–μ‘¥μ“¡·≈⫉¡à‰¥âº≈¿“¬„π‡«≈“ 4  —ª¥“Àå §«√æ‘®“√≥“ àßμàÕ·æ∑¬åºŸâ‡™’ˬ«™“≠ 7.3 Upper airway cough syndrome °≈ÿà¡Õ“°“√π’Ȫ√–°Õ∫¥â«¬ rhinitis, sinusitis ·≈– postnasal drip ∑’Ë
  • 24. 23¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 ∑”„Àâ¡’Õ“°“√‰Õ ¡’¡Ÿ°‰À≈≈ß§Õ °√–·Õ¡∫àÕ¬Ê ‰´π— Õ—°‡ ∫ À¡“¬∂÷ß‚æ√ß Õ“°“»¢â“ß®¡Ÿ° (À√◊Õ‡√’¬°«à“‰´π— ) ‡°‘¥°“√Õ—°‡ ∫ ´÷Ëß “‡Àμÿ à«π„À≠à∑’Ë∑”„Àâ ‚æ√߉´π— Õ—°‡ ∫®–‡°‘¥μ“¡À≈—ß®“°‚æ√ß®¡Ÿ°Õ—°‡ ∫ (rhinitis) ¥—ßπ—Èπ®÷ß®–‡√’¬° √«¡«à“ çrhinosinusitisé 7.3.1 ‰´π— Õ—°‡ ∫ (sinusitis) °“√·∫àß™π‘¥¢Õ߉´π— Õ—°‡ ∫  “¡“√∂·∫à߉¥â‡ªìπ‰´π— Õ—°‡ ∫ ‡©’¬∫æ≈—π (acute rhinosinusitis) ·≈–‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß (chronic rhinosinusitis, CRS) ‚¥¬„™â√–¬–‡«≈“∑’ËπâÕ¬°«à“ 12  —ª¥“Àå À√◊Õ 12  —ª¥“Àå¢÷Èπ‰ª ‡ªìπμ—«·∫àß ‰´π— Õ—°‡ ∫∑’Ë∑”„À⇰‘¥Õ“°“√‰Õ‡√◊ÈÕ√—ß¡—°‡°‘¥®“°‰´π— Õ—°‡ ∫·∫∫‡√◊ÈÕ√—ß´÷Ëß “¡“√∂ ·∫à߬àÕ¬‰¥âÕ’°‡ªìπ‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß∑’Ë¡’√‘¥ ’¥«ß®¡Ÿ° (CRS with nasal polyp) À√◊Õ‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß∑’ˉ¡à¡’√‘¥ ’¥«ß®¡Ÿ° (CRS without nasal polyp)  ”À√—∫ ‚√§∑“߉´π— ∑’Ë∑”„Àâ —¡æ—π∏å°—∫Õ“°“√‰Õ‡√◊ÈÕ√—ßπ—Èπ Õ“°“√‰Õ∑’ˇ°‘¥¢÷ÈπÕ“®‡ªìπ ®“°¡Ÿ°∑’ˉÀ≈≈ߧհ√–μÿâπ∑“߇¥‘πÀ“¬„® à«π≈à“ß ·≈–/À√◊Õ °“√Õ—°‡ ∫∑’ˇ°‘¥∑’Ë ∑“߇¥‘πÀ“¬„® à«π∫π‡°’Ë¬«¢âÕ߉ª Ÿà∑“߇¥‘πÀ“¬„® à«π≈à“ß (united airway inflammation) ‡°≥±å°“√«‘π‘®©—¬‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß 1) Õ“°“√ ”§—≠ Õߪ√–°“√§◊Õ Õ“°“√§—¥®¡Ÿ° ·≈–πÈ”¡Ÿ°‰À≈ ´÷Ëß Õ“®®–‡ªìπ πÈ”¡Ÿ°‰À≈ÕÕ°¡“∑“ß√Ÿ®¡Ÿ° (anterior rhinorrhea) À√◊Õ¡Ÿ°‰À≈≈ß§Õ (postnasal drip) √à«¡°—∫√–¬–‡«≈“∑’ˇªìπ 12  —ª¥“Àå¢÷Èπ‰ª 2) °“√μ√«®√à“ß°“¬‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß ‚¥¬·æ∑¬å‡«™ªØ‘∫—μ‘∑—Ë«‰ª  “¡“√∂„™â‰ø©“¬ À√◊Õ otoscope  àÕß√Ÿ®¡Ÿ°‡æ◊ËÕª√–‡¡‘π«à“ ¡’°“√Õ—°‡ ∫¢Õß ‡¬◊ËÕ∫ÿ‚æ√ß®¡Ÿ° √‘¥ ’¥«ß®¡Ÿ° ·≈–„™â‰¡â°¥≈‘Èπ‡æ◊ËÕμ√«®¥Ÿ«à“¡’¡Ÿ°‰À≈≈ߧÕÀ√◊Õ‰¡à
  • 25. 24 °“√μ√«®∑“ß√—ß ’‚¥¬°“√‡ÕÁ°´å‡√¬å‰´π—  (Plain-film of paranasal sinus) ¡’§«“¡·¡à𬔄π°“√«‘π‘®©—¬μË”(24) ∂â“æ∫§«“¡º‘¥ª°μ‘ °Á “¡“√∂„Àâ°“√«‘π‘®©—¬ À“°¬—ß ß —¬‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß®“°≈—°…≥–∑“ߧ≈‘π‘° ·μà‡ÕÁ°´å‡√¬åå‰´π— ª°μ‘°Á ¬—߉¡à “¡“√∂μ—¥°“√«‘π‘®©—¬ÕÕ°‰¥â °“√√—°…“‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß 1.1 °“√√—°…“‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß„π°√≥’∑’Ë¡’°“√°”‡√‘∫‡©’¬∫æ≈—π(25) æ‘®“√≥“ „À⬓μâ“π®ÿ≈™’懪ìπ‡«≈“ 3-4  —ª¥“Àå 1.1.1 ¬“μâ“π®ÿ≈™’æ∑’˧«√‡≈◊Õ°„™âÕ—π¥—∫·√° (first-line antibiotics) ‰¥â·°à amoxicillin „π°√≥’∑’Ë·æâ penicillin „Àâ‡≈◊Õ° macrolides ‰¥â·°à clari- thromycin À√◊Õ azithromycin 1.1.2 ¬“μâ“π®ÿ≈™’æ∑’˧«√‡≈◊Õ°„™âÕ—π¥—∫ Õß (second-line antibio- tics) 1) ¬“μâ“π®ÿ≈™’æ™π‘¥ Beta-lactam/ beta-lactamase inhibi- tor ‰¥â·°à amoxicillin/clavulanate 2) Second À√◊Õ third generation cephalosporin ‰¥â·°à cefuroxime, cefpodoxime proxetil À√◊Õ cefdinir 3) Respiratory fluoroquinolones ‰¥â·°à levofloxacin À√◊Õ moxifloxacin 1.2 °“√√—°…“¥â«¬¬“Õ◊ËπÊ(26) 1.2.1 °“√√—°…“¿“«–°“√Õ—°‡ ∫ ‰¥â·°à ¬“ ‡μ’¬√Õ¬¥å™π‘¥æàπ®¡Ÿ° (nasal steroid) ‡ªìπÕ—π¥—∫·√° ‡ªìπ‡«≈“ 12  —ª¥“Àå (Level of evidence 1, Grade of recommendation ++)
  • 26. 25¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 1.2.2 °“√‡æ‘Ë¡°“√√–∫“¬¡Ÿ°ÀπÕß∑’˧â“ß„π‰´π— „Àâ√–∫“¬‰¥â¥’¢÷Èπ (promoting drainage from paranasal sinuses) ‚¥¬≈â“ß®¡Ÿ°¥â«¬πÈ”‡°≈◊Õ (Level of evidence 1, Grade of recommendation ++) 1.2.3 ¬“ decongestant ™π‘¥æàπÀ√◊Õ°‘π ·π–π”„Àℙ⠔À√—∫ ºŸâ∑’Ë¡’Õ“°“√§—¥®¡Ÿ° ·μଗ߉¡à¡’À≈—°∞“π«à“∑”„Àâ‚√§‰´π— Õ—°‡ ∫À“¬‰¥â‡√Á«·≈– ¡“°°«à“ºŸâªÉ«¬∑’ˉ¡à‰¥â√—∫¬“ ∂â“„™â™π‘¥æàπ·π–π”„™â‰¡à‡°‘π 5 «—π  à«π™π‘¥°‘π ·π–π”„™â‰¡à‡°‘π 10 -14 «—π (Level of evidence 3, Grade of recommenda- tion +) 1.2.4 ¬“μâ“πŒ‘ μ“¡’π ·π–π”„Àâ„™â„π√“¬∑’Ë¡’ª√–«—μ‘/Õ“°“√¢Õß ‚√§¿Ÿ¡‘·æâ‡∑à“π—Èπ „π°√≥’∑’Ë®–„™â¬“„π°≈ÿà¡π’È ‰¡à·π–π”„Àâ„™â™π‘¥ first genera- tion ‡™àπ chlorpheniramine ‡æ√“–∑”„Àâ¡Ÿ°‡À𒬫 ·≈–‡°‘¥Õ“°“√ßà«ß´÷¡  “¡“√∂„Àâ°“√√—°…“‡∫◊ÈÕßμâπ (Empirical treatment) ¥—ß°≈à“«¢â“ß μâπ°àÕπ°“√μ√«®‡æ◊ËÕ§âπÀ“ “‡Àμÿ™π‘¥Õ◊ËπÊ „π°√≥’∑’˺ŸâªÉ«¬‰¥â√—∫°“√¥Ÿ·≈√—°…“ ‡∫◊ÈÕßμâπ·≈â« 4  —ª¥“Àå ºŸâªÉ«¬¬—߉¡à¡’°“√μÕ∫ πÕßÕ¬à“ß¡’π—¬ ”§—≠§«√ àß„Àâ ·æ∑¬å‡©æ“–∑“߇æ◊ËÕμ√«®„π‚æ√ß®¡Ÿ°‚¥¬≈–‡Õ’¬¥‚¥¬°“√„™â°≈âÕ߇∑‡≈ ‚§ª (nasal telescopy) ‚¥¬‡©æ“–Õ¬à“߬‘Ëß∑’Ë∫√‘‡«≥™àÕß∑“ß√–∫“¬¡Ÿ°À√◊ÕÀπÕß®“° ‚æ√߉´π— ¡“∑’Ë‚æ√ß®¡Ÿ° (middle meatus) 7.3.2 ‚æ√ß®¡Ÿ°Õ—°‡ ∫ (Rhinitis) ‚æ√ß®¡Ÿ°Õ—°‡ ∫ (rhinitis) ‡°‘¥®“°°“√Õ—°‡ ∫¢Õ߇¬◊ËÕ∫ÿ‚æ√ß®¡Ÿ° ´÷Ë߇°‘¥‰¥â®“°À≈“¬ “‡Àμÿ À“°‡°‘¥®“°¿Ÿ¡‘·æâ ‡√’¬°«à“ allergic rhinitis (AR) À“° ‰¡à‰¥â‡°‘¥®“°¿Ÿ¡‘·æâ ‡√’¬°«à“ non-allergic rhinitis (NAR) ´÷Ëß¡’‰¥âÀ≈“¬æ¬“∏‘ °”‡π‘¥ ‡™àπ vasomotor rhinitis, drug-induced, hormonal-induced, environ-
  • 27. 26 ment/irritant-induced, gustatory reflex À√◊Õ°“√Õ—°‡ ∫™π‘¥Õ’‚Õ ‘‚πøî≈‚¥¬ ‰¡à‰¥â‡°‘¥®“°¿Ÿ¡‘·æâ (non-allergic rhinitis with eosinophilia syndrome, NARES) °“√«‘π‘®©—¬‚æ√ß®¡Ÿ°Õ—°‡ ∫ ª√–°Õ∫¥â«¬Õ“°“√¡“°°«à“ 1 „π 3 Õ“°“√¥—ßμàÕ‰ªπ’È 1) §—πÀ√◊Õ®“¡ (sneezing) 2) πÈ”¡Ÿ°‰À≈ (rhinorrhea) À√◊Õ 3) §—¥®¡Ÿ° (congestion) Õ¬à“߉√ °Áμ“¡ 1 „π 3 ¢ÕߺŸâªÉ«¬Õ“®¡’Õ“°“√∑’ˉ¡à®”‡æ“– (unrecognized form) ‡™àπ Õ“°“√°√–·Õ¡ (throat clearing), ª“°·ÀâßÀ√◊Õ§Õ·ÀâßÀ≈—ßμ◊ËππÕπ ´÷ËßÕ“®‡°‘¥ ®“°§—¥®¡Ÿ°‡√◊ÈÕ√—ß®πÕ⓪“°À“¬„® (mouth breathing), ª«¥¡÷π»’√…–®“°§—¥®¡Ÿ° (headache), ÀŸÕ◊ÈÕ®“°°“√∫«¡¢Õ߇¬◊ËÕ∫ÿ‚æ√ß®¡Ÿ°®π∑”„Àâ Eustachian tube dysfunction, ·≈–Õ“°“√§—π∫√‘‡«≥‡¬◊ËÕ‡¡◊Õ°„°≈⇧’¬ß ‡™àπ §—π‡æ¥“𪓰 §—πÀŸ §—πμ“ ·≈–§—π„π§Õ ‡ªìπμâπ Õ¬à“߉√°Áμ“¡Õ“°“√‰Õπ—Èπ “¡“√∂æ∫„π‚√§‚æ√ß®¡Ÿ° Õ—°‡ ∫‰¥â‚¥¬‰¡à‰¥â™à«¬·¬°·¬–«à“‡°‘¥®“° AR À√◊Õ NAR(27) ‚¥¬Õ“°“√‰ÕÕ“®‡°‘¥ ®“°°“√‡æ‘Ë¡ capsaicin cough sensitivity ®“°°“√Õ—°‡ ∫¢Õß∑“߇¥‘πÀ“¬„® ®“°°“√ —¡º—  “√°àÕ¿Ÿ¡‘·æâ(28) Õ“°“√∑’Ë∑”„Àâ ß —¬‚æ√ß®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ ¡“°¢÷Èπ ‰¥â·°à §—π ®“¡ ·≈–Õ“°“√∑“ßμ“ „π¢≥–∑’ËÕ“°“√πÈ”¡Ÿ°‰À≈·≈–§—¥®¡Ÿ° æ∫‰¥â„π‚æ√ß®¡Ÿ°Õ—°‡ ∫‡°◊Õ∫∑ÿ° “‡Àμÿ °“√μ√«®√à“ß°“¬Õ“®æ∫§«“¡º‘¥ª°μ‘ „π‚æ√ß®¡Ÿ°À√◊Õ‰¡à°Á‰¥â °“√√—°…“‚æ√ß®¡Ÿ°Õ—°‡ ∫ 1. °“√√—°…“‚æ√ß®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ ‡πâπ°“√≈¥°“√Õ—°‡ ∫¢Õ߇¬◊ËÕ∫ÿ®¡Ÿ°∑’ˇ°‘¥®“°°“√ —¡º—  “√°àÕ¿Ÿ¡‘·æ⠥⫬¬“ ‡μ’¬√Õ¬¥å™π‘¥æàπ®¡Ÿ° (Level of evidence 1, Grade of recommen- dation ++) ¬“Õ◊ËπÊ ∑’ËÕ“®æ‘®“√≥“„™â√—°…“Õ“°“√§—π ®“¡ À√◊Õ√—°…“‡ªìπ¬“À≈—°
  • 28. 27¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 À“°¡’Õ“°“√‰¡à√ÿπ·√ß ‰¥â·°à ¬“μâ“πŒ’ μ“¡’π·∫∫√—∫ª√–∑“π™π‘¥‰¡àßà«ß (Level of evidence 1, Grade of recommendation ++) ·≈–°“√√—°…“μ“¡Õ“°“√ ‡™àπ °“√≈â“ß®¡Ÿ°¥â«¬πÈ”‡°≈◊Õ (Level of evidence 3, Grade of recommendation +) °“√‡æ‘Ë¡¬“μâ“π≈‘«‚§‰μ√Õ’π (Leukotriene receptor antagonist, LTRA) ‡¡◊ËÕ √—°…“¥â«¬¬“μâ“πŒ’ μ“¡’πÀ√◊Õ¬“ ‡μ’¬√Õ¬¥å™π‘¥æàπ®¡Ÿ°·≈⫉¡à‰¥âº≈ ‰¡à¡’ª√–‚¬™πå „π°“√√—°…“‚æ√ß®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ (Level of evidence 2, Grade of recommendation -) ¬°‡«âπ„π°√≥’∑’Ë¡’‚√§À◊¥√à«¡¥â«¬ (Level of evidence 2, Grade of recommendation ++)(29) Õ¬à“߉√°Áμ“¡‚√§‚æ√ß®¡Ÿ°Õ—°‡ ∫®“° “‡Àμÿ Õ◊ËπÊÕ“®‰¡àμÕ∫ πÕßμàÕ°“√√—°…“¥—ß°≈à“«¢â“ßμâπÀ“° ß —¬¿“«–π’È·μà‰¡àμÕ∫ πÕß μàÕ°“√√—°…“¿“¬„π 4  —ª¥“Àå §«√æ‘®“√≥“ àßμàÕºŸâ‡™’ˬ«™“≠ (¥Ÿ®“°·π«∑“ß°“√ μ√«®√—°…“‚√§®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâ„π§π‰∑¬ ©∫—∫ª√—∫ª√ÿß æ.». 2554) 2. °“√√—°…“¿“«–¡Ÿ°‰À≈≈ß§Õ (postnasal drip) ∑’ˉ¡à¡’¿“«– ‰´π— Õ—°‡ ∫ „™â¬“μâ“πŒ’ μ“¡’π√ÿàπ∑’Ë 1 ‰¥â·°à dexbrompheniramine ·≈–/À√◊Õ pseudoephedrine „π¿“«–‰Õ‡√◊ÈÕ√—ß·π–π”„Àâ√—°…“π“π 3  —ª¥“Àå·≈⫪√–‡¡‘π º≈ (Level of evidence 4, grade of recommendation +)  à«π¬“ ipratropium ™π‘¥æàπ®¡Ÿ°Õ“®‰¥âª√–‚¬™πå„π°“√≈¥Õ“°“√πÈ”¡Ÿ°‰À≈®“°‚æ√ß®¡Ÿ°Õ—°‡ ∫ (Level of evidence 4, Grade of recommendation +/-) ·μà¢âÕ¡Ÿ≈°“√≈¥Õ“°“√‰Õ¬—ß ‰¡à™—¥‡®π(30-32) 7.4 Nonasthmatic eosinophilic bronchitis ‚√§π’ȇ°‘¥®“°°“√Õ—°‡ ∫™π‘¥Õ‘‚Õ ‘‚πøî≈∫√‘‡«≥∑“߇¥‘πÀ“¬„® à«π≈à“ß ºŸâªÉ«¬¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß·∫∫¡’‡ ¡À–À√◊Õ‰¡à¡’‡ ¡À–°Á‰¥â √âÕ¬≈– 60 ¡’ rhinitis √à«¡ ¥â«¬‚¥¬¡—°‡ªìπ allergic rhinitis √âÕ¬≈– 10 ¢ÕߺŸâªÉ«¬¡’ peripheral eosino-
  • 29. 28 philia ·≈–√âÕ¬≈– 20 ¡’ specific IgE antibodies „Àâº≈∫«°(33) °“√μ√«®  ¡√√∂¿“æªÕ¥¡—°‰¡àæ∫°“√μÕ∫ πÕßμàÕ°“√∑¥ Õ∫¥â«¬¬“¢¬“¬À≈Õ¥≈¡ ¡’ ‡æ’¬ß√âÕ¬≈– 12 ∑’ËÕ“®μÕ∫ πÕßμàÕ°“√∑¥ Õ∫¥â«¬¬“¢¬“¬À≈Õ¥≈¡ °“√μ√«® methacholine º≈ª°μ‘ °“√μ√«® serial peak flow æ∫ diurnal variation ‰¥â æÕÊ °—∫ cough variant asthma °“√Õ—°‡ ∫„πÀ≈Õ¥≈¡ “¡“√∂μ√«®æ∫‡´≈≈å Õ—°‡ ∫™π‘¥Õ‘‚Õ ‘‚πøî≈‰¥â®“°‡ ¡À– πÈ”≈â“ߪե ·≈–™‘Èπ‡π◊ÈÕ‰¥â‡™àπ‡¥’¬«°—∫‚√§À◊¥ Õ¬à“߉√°Áμ“¡ √–¥—∫ fractional exhaled nitric oxide (FeNO) „πºŸâªÉ«¬ eosino- philic bronchitis ‰¡à Ÿß‡À¡◊Õπ„πºŸâªÉ«¬ asthma À√◊Õ cough variant asthma(14) °“√√—°…“ Nonasthmatic eosinophilic bronchitis ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥„π¢π“¥ Ÿß (budesonide 800 mcg μàÕ«—π À√◊Õ‡∑’¬∫‡∑à“) (Level of evidence 4, Grade of recommendation ++) º≈°“√μÕ∫ πÕߥ’„π 2-4  —ª¥“Àå(34) ‚√§π’ȉ¡àμÕ∫ πÕßμàÕ¬“¢¬“¬À≈Õ¥≈¡ √–¬– ‡«≈“„π°“√√—°…“¬—߉¡à·πàπÕπ·π–π”„ÀâÀ≈’°‡≈’ˬߠ“√°àÕ¿Ÿ¡‘·æâ·≈– “√√–§“¬‡§◊Õß À“°¡’ª√–«—μ‘ —¡º— ™—¥‡®π À“°‰¡àμÕ∫ πÕßμàÕ¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥„π ¢π“¥ Ÿß Õ“®æ‘®“√≥“¬“§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥°‘π(2) (Level of evidence 4, Grade of recommendation +) 7.5 Õ“°“√‰Õ®“°¿“«–°√¥‰À≈¬âÕπ (Cough related reflux disease) ‚√§À√◊Õ¿“«–°√¥‰À≈¬âÕ𠇪ìπ¿“«–∑’Ë¡’°“√¬âÕπ°≈—∫¢Õß¡«≈ “√„π °√–‡æ“–Õ“À“√ (gastric content) ¢÷Èπ¡“ ŸàÀ≈Õ¥Õ“À“√ ª√–°Õ∫¥â«¬∑—Èß°√¥∑’Ë ‡°‘¥®“°πÈ”¬àÕ¬®“°°√–‡æ“–Õ“À“√ À√◊ÕÕ“®‡ªìπ¥à“ß∑’ˇ°‘¥®“°πÈ”¬àÕ¬∑’ËÀ≈—Ëß®“° ≈”‰ â‡≈Á°À√◊Õ·°ä (35) Õ“°“√¢Õß¿“«–°√¥‰À≈¬âÕπ¡’À≈“°À≈“¬ ‚¥¬Õ“°“√∫“ßÕ¬à“ß°Á‰¡à¡’
  • 30. 29¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 §«“¡‡©æ“–‡®“–®ßμàÕ‚√§ °“√´—°ª√–«—쑇ªìπ ‘Ëß ”§—≠ πÕ°®“°®”‡ªìπ„π°“√ «‘π‘®©—¬·≈â« ¬—ߙ૬„π°“√‡≈◊Õ°„Àâ°“√√—°…“‰¥âÕ¬à“߇À¡“– ¡¬‘Ëߢ÷Èπ¥â«¬ ‚¥¬∑—Ë«‰ªÕ“°“√¢ÕߺŸâªÉ«¬∑’Ë¡’‚√§¥—ß°≈à“« Õ“®¡’Õ“°“√∑“ߧ≈‘π‘°∑’Ë ·∫à߉¥â‡ªìπ°≈ÿà¡„À≠àÊ ª√–°Õ∫¥â«¬ 1) Õ“°“√¢ÕßÀ≈Õ¥Õ“À“√ (esophageal symptoms) ¡’Õ“°“√‡¥àπ 2 Õ“°“√ ‰¥â·°à Õ“°“√· ∫√âÕπ¬Õ¥Õ° (heartburn) ·≈–Õ“°“√‡√Õ‡ª√’Ȭ« (re- gurgitation) Õ’°Õ“°“√∑’Ëæ∫‰¥â‰¡à∫àÕ¬π—°§◊ÕÕ“°“√‡®Á∫Àπâ“Õ° (chest pain) „π °≈ÿà¡Õ“°“√¢ÕßÀ≈Õ¥Õ“À“√π’ȇÕ߬—ß¡’°“√·∫à߬àÕ¬ÕÕ°‡ªìπ¿“«–·∑√°´âÕπ∑’ˇ°‘¥ ®“°°√¥‰À≈¬âÕπ‚¥¬‡ªìπ≈—°…≥–∑’Ëæ∫‰¥â®“°°“√ àÕß°≈âÕßμ√«®∑“߇¥‘πÕ“À“√‡ªìπ 4 ≈—°…≥– §◊Õ ·º≈Õ—°‡ ∫¢ÕßÀ≈Õ¥Õ“À“√ (erosive esophagitis) À≈Õ¥Õ“À“√ μ’∫®“°·º≈Õ—°‡ ∫¢ÕßÀ≈Õ¥Õ“À“√ (esophageal stricture) Baretteûs esopha- gus ·≈–¡–‡√ÁßÀ≈Õ¥Õ“À“√ (esophageal cancer) ™π‘¥ adenocarcinoma 2) Õ“°“√πÕ°À≈Õ¥Õ“À“√ (extraesophageal symptoms) ª√–°Õ∫ ¥â«¬ Õ“°“√μà“ßÊ ∑’ˉ¡à —¡æ—π∏å°—∫À≈Õ¥Õ“À“√‚¥¬μ√ß ‰¥â·°à Õ“°“√‰Õ ·≈–°≈àÕß ‡ ’¬ßÕ—°‡ ∫®“°¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ¢÷ÈπÀ≈Õ¥§Õ (laryngopharyngeal reflux À√◊Õ LPR) ÀÕ∫À◊¥ ·≈–øíπºÿ πÕ°®“°π’Ȭ—ß¡’Õ“°“√∑’˧“¥«à“Õ“®‡ªìπº≈®“°¿“«– °√¥‰À≈¬âÕπ ∑’Ë∂Ÿ°®—¥Õ¬Ÿà„π°≈ÿà¡π’È ‰¥â·°à ‰´π— Õ—°‡ ∫ §ÕÀÕ¬Õ—°‡ ∫ ÀŸ™—Èπ°≈“ß Õ—°‡ ∫‡√◊ÈÕ√—ß ·≈–ªÕ¥‡ªìπæ—ߺ◊¥(35, 36) ®–‡ÀÁπ‰¥â«à“ Õ“°“√‰Õ‡√◊ÈÕ√—ß ‰´π— Õ—°‡ ∫ À√◊Õ¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ ¢÷ÈπÀ≈Õ¥§Õ (laryngopharyngeal reflux À√◊Õ LPR) ∑’ˇ°‘¥®“°¿“«–°√¥‰À≈¬âÕπ ≈â«π‡ªìπÕ“°“√πÕ°À≈Õ¥Õ“À“√∑—Èß ‘Èπ ´÷Ëߧ«“¡·μ°μà“ß√–À«à“ßÕ“°“√πÕ°À≈Õ¥ Õ“À“√·≈–Õ“°“√¢ÕßÀ≈Õ¥Õ“À“√ §◊Õ æ¬“∏‘ √’√«‘∑¬“°“√‡°‘¥‚√§ √«¡∂÷ß°“√ μÕ∫ πÕßμàÕ°“√√—°…“
  • 31. 30 Õ“°“√‰Õ®“°¿“«–πÈ”¬àÕ¬‰À≈¬âÕππ’È “¡“√∂°√–μÿâπ„À⇰‘¥¿“«–‰Õ‡√◊ÈÕ√—߉¥â ‚¥¬ºà“π°≈‰°Õ—π„¥Õ—πÀπ÷Ëß À√◊ÕÀ≈“¬°≈‰° ¥—ßπ’È 1) Esophagopharyngeal reflux (microaspiration theory)(37) °“√ °√–μÿâπÀ≈Õ¥§Õ‚¥¬μ√ß®“°¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ 2) Laryngeal chemoreflex (reflex pathway ª√–°Õ∫¥â«¬ afferent limb §◊Õ stimulated superior laryngeal nerve ·≈– efferent limb ‚¥¬ recurrent laryngeal nerve) 3) Vagally mediated reflex (¡’ sensory stimulation ¢Õß distal eso- phagus ‚¥¬‰¡à¡’ laryngeal stimulation ´÷Ëß∑”„À⇰‘¥ laryngospasm À√◊ÕÕ“°“√ ‰Õ ºà“π∑“ß afferent limb of vagus nerve) 4) ¿“«–πÈ”¬àÕ¬°√–μÿâπ√–∫∫ª√– “∑Õ—μ‚π¡—μ‘°“√‡°‘¥°“√‰Õ„Àâ‡æ‘Ë¡¢÷Èπ (Increased cough reflex) 5) ¿“«–°“√‰Õ °àÕ„À⇰‘¥¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ®“°°“√‰Õπ—Èπ‡ªìπ«ß®√(38-41) °“√«‘π‘®©—¬‰Õ‡√◊ÈÕ√—ß®“°¿“«–°√¥‰À≈¬âÕπ °“√«‘π‘®©—¬∑”‰¥â‰¡àßà“¬π—° ‚¥¬æ∫«à“ √âÕ¬≈– 43-75 ¢ÕߺŸâªÉ«¬°≈ÿà¡π’È ‰¡à¡’ Õ“°“√∑“ßÀ≈Õ¥Õ“À“√√à«¡¥â«¬(42, 43) ·μà°Á¡’¢âÕ¡Ÿ≈«à“ ¿“«–°√¥‰À≈¬âÕπÕ“®‡ªìπ ‡Àμÿ¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—߉¥â∂÷ß√âÕ¬≈– 10 ‚¥¬∑—Ë«‰ª§«√π÷°∂÷ß¿“«–°√¥‰À≈¬âÕπ„π ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß∑’Ë¡’≈—°…≥–¥—ßμàÕ‰ªπ’È ‰Õ‰¡à¡’‡ ¡À– ºŸâªÉ«¬∑’Ë¡’Õ“°“√°”‡√‘∫À≈—ß √—∫ª√–∑“πÕ“À“√¡◊ÈÕ„À≠àÀ√◊Õ ¡’Õ“°“√∫àÕ¬„π∑à“πÕπ(44) °“√«‘π‘®©—¬¿“«–πÈ”¬àÕ¬ ‰À≈¬âÕπ∑’Ë∑”„À⇰‘¥Õ“°“√‰Õπ—È𠧫√«‘π‘®©—¬μ“¡¢—ÈπμÕπ∑’Ë∂Ÿ°μâÕß ‡æ√“–„π∫“ߧ√—Èß Õ“°“√πÈ”¬àÕ¬‰À≈¬âÕ𠇙àπ · ∫√âÕπ∑√«ßÕ° À√◊Õ‡√Õ‡ª√’Ȭ« ‰¡à¡’Õ“°“√‡¥àπ™—¥ „πºŸâªÉ«¬‡À≈à“π’È ·≈–Õ“®∑”„À⇰‘¥°“√«‘π‘®©—¬º‘¥æ≈“¥‰¥â ¥—ßπ—Èπ°“√«‘π‘®©—¬Õ“°“√
  • 32. 31¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 ‰Õ‡√◊ÈÕ√—ß®“°¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ ®÷ߧ«√§”π÷ß·≈–μ—¥ª√–‡¥Áπ∑’ËÕ“®‡ªì𠓇Àμÿ Õ◊ËπÊ μ“¡¢—ÈπμÕπ°àÕπ„Àâ°“√«‘π‘®©—¬ ¥—ßπ’È (45) (Level of evidence 4, Grade of recommendation ++) 1. ºŸâªÉ«¬ —¡º— ¡≈¿“«–∑“ßÕ“°“» À√◊Õ “√√–§“¬‡§◊Õß À√◊Õ‡ªìπºŸâ Ÿ∫ ∫ÿÀ√’ËÕ¬ŸàÀ√◊Õ‰¡à 2. ºŸâªÉ«¬‰¥â√—∫¬“ ACE-I Õ¬ŸàÀ√◊Õ‰¡à 3. ¿“æ∂à“¬√—ß ’ªÕ¥§«√ª°μ‘ À√◊Õ‡ªìπ√Õ¬‚√§‡°à“∑’ˉ¡à°àÕ„À⇰‘¥Õ“°“√ 4. ‰¡à¡’¿“«–ÀÕ∫À◊¥„πªí®®ÿ∫—π ‚¥¬Õ“°“√‰Õπ—Èπ‰¡à¥’¢÷ÈπÀ≈—ß√—°…“ÀÕ∫À◊¥ À√◊Õ°“√«‘π‘®©—¬¿“«–ÀÕ∫À◊¥¥â«¬°“√°√–μÿâπ¥â«¬ methacholine ‰¥âº≈≈∫ 5. ‰¡à¡’¿“«–Õ“°“√‰Õ®“°‚√§¥â“π®¡Ÿ°À√◊Õ‰´π—  6. ‰¡à¡’Õ“°“√‰Õ®“°¿“«– nonasthmatic eosinophilic bronchitis ‚¥¬ «‘π‘®©—¬®“°°“√μ√«® eosinophil „π‡ ¡À–‡ªìπ≈∫·≈–Õ“°“√‰Õπ—Èπ‰¡à¥’¢÷Èπ®“° °“√„™â inhaled À√◊Õ systemic corticosteroids  à«π„À≠à·≈â«°“√«‘π‘®©—¬‰Õ‡√◊ÈÕ√—ß®“°¿“«–°√¥‰À≈¬âÕπ ‰¡à‰¥â àß ◊∫§âπ ‡æ‘Ë¡‡μ‘¡‡æ◊ËÕ¬◊π¬—π°“√«‘π‘®©—¬‚√§‚¥¬∑—π∑’ ‡π◊ËÕß®“°°“√μ√«®æ‘‡»…∑—ÈßÀ≈“¬¡’ ¢—ÈπμÕπ∑’˧àÕπ¢â“߬ÿà߬“° ·≈–Õ“®°àÕ„À⇰‘¥§«“¡‰¡à ÿ¢ ∫“¬·°àºŸâ‡¢â“√—∫°“√μ√«® ∫â“ß πÕ°®“°π’Ȭ—ß¡’¢âÕ®”°—¥À≈“¬ª√–°“√„π°“√·ª≈º≈ ¥—ßπ—ÈπÀ“°¡’Õ“°“√ ∑’ˇ¢â“‰¥â°—∫‰Õ‡√◊ÈÕ√—ß®“°¿“«–°√¥‰À≈¬âÕπ ·≈–‰¥âμ—¥ª√–‡¥Áπ¢âÕ 1-6 ¢â“ßμâπ·≈â« „π∑“ߪؑ∫—μ‘®÷ß„Àâ°“√√—°…“‰ª‡≈¬·≈â«¥Ÿ°“√μÕ∫ πÕßμàÕ°“√√—°…“(44) °√≥’ºŸâªÉ«¬‰¡àμÕ∫ πÕßμàÕ proton pump inhibitor °“√ ◊∫§âπ‡æ‘Ë¡‡μ‘¡ ¬—ßÕ“®‰¥âª√–‚¬™πå„π∫“ß°√≥’ Õ¬à“߉√°Á¥’·æ∑¬åºŸâ àߧ«√√Ÿâª√–‚¬™πå·≈–¢âÕ®”°—¥ ¢Õß°“√μ√«®·μà≈–«‘∏’ ¥—ßμàÕ‰ªπ’È
  • 33. 32 1. °“√ àÕß°≈âÕßμ√«®∑“߇¥‘πÕ“À“√ à«πμâπ (Esophagogastroduo- denoscopy) Õ“®‰¥âª√–‚¬™πå °√≥’∑’Ëμ√«®æ∫«à“¡’°“√Õ—°‡ ∫ (erosive esopha- gitis) ∫√‘‡«≥ÀŸ√Ÿ¥À≈Õ¥Õ“À“√ à«π≈à“ß À√◊Õæ∫≈—°…≥–¢Õß Barrettûs esopha- gus °Á “¡“√∂¬◊π¬—π«à“¡’°“√‰À≈¬âÕπ¢Õß “√®“°°√–‡æ“–Õ“À“√®√‘ß ·μà‡π◊ËÕß®“° ¡’§«“¡‰«„π°“√μ√«®μË” ¡’°“√»÷°…“¢π“¥‡≈Á°æ∫«à“ „πºŸâ∑’Ë¡’Õ“°“√¢Õß°√¥‰À≈ ¬âÕπ„πÀ≈Õ¥Õ“À“√ æ∫≈—°…≥–¥—ß°≈à“«‰¥â∂÷ß√âÕ¬≈– 55 ·μà„πºŸâ∑’Ë¡’Õ“°“√‰Õ ‡√◊ÈÕ√—ß‚¥¬∑’ˉ¡à¡’Õ“°“√¢ÕßÀ≈Õ¥Õ“À“√ ®–æ∫≈—°…≥–¥—ß°≈à“«‰¥â‡æ’¬ß√âÕ¬≈– 16 ‡∑à“π—Èπ(46) 2. °“√«—¥§à“§«“¡‡ªìπ°√¥-¥à“ß„πÀ≈Õ¥Õ“À“√ 24 ™—Ë«‚¡ß °“√μ√«®π’È ∂◊Õ«à“‡ªìπ°“√μ√«®¡“μ√∞“π (gold standard) „π°“√«‘π‘®©—¬°√¥‰À≈¬âÕπ ‚¥¬ °“√»÷°…“¢π“¥‡≈Á°À≈“¬°“√»÷°…“∫àß™’È«à“°“√μ√«®«‘∏’π’È ™à«¬¬◊π¬—π°“√«‘π‘®©—¬«à“ ºŸâªÉ«¬¡’°√¥‰À≈¬âÕπ‰¥âμ—Èß·μà√âÕ¬≈–60-100(47)  à«π§«“¡®”‡æ“–μË”§◊Շ撬ß√âÕ¬≈– 66(48) ∑—Èßπ’È°“√μ√«®æ∫«à“¡’°“√‰À≈¬âÕπ ‰¡à‰¥â¬◊π¬—π«à“°“√‰À≈¬âÕπ‡ªìπμâπ‡Àμÿ ¢ÕßÕ“°“√‰Õ‡√◊ÈÕ√—ß ·μàμâÕߥŸ§«“¡ —¡æ—π∏å√–À«à“ß°“√‡°‘¥°√¥‰À≈¬âÕπ°—∫Õ“°“√ ‰Õ (symptom association) ´÷Ëߺ≈°“√»÷°…“μà“ßÊ ¬—ß¡’§«“¡À≈“°À≈“¬¡“° 3. Multichannel intraluminal impedance pH monitoring ‡æ◊ËÕ «‘π‘®©—¬¿“«–°√¥ÕàÕπÀ√◊Õ¿“«–πÈ”¬àÕ¬‰À≈¬âÕπ∑’ˉ¡à„™à°√¥ À√◊Õ°√¥·°ä ‰À≈¬âÕπ ¢÷ÈπÀ≈Õ¥§Õ °“√√—°…“Õ“°“√‰Õ®“°¿“«–°√¥‰À≈¬âÕπ ·π«∑“ß°“√√—°…“‚¥¬∑—Ë«‰ª ·π–π”„Àℙ⬓≈¥°“√À≈—Ëß°√¥ ∑—Èßπ’È proton pump inhibitor ¡’ª√– ‘∑∏‘¿“æ„π°“√≈¥°“√À≈—Ëß°√¥‰¥â¥’°«à“ histamine receptor 2 antagonist ‚¥¬·π–π”„Àℙ⬓ proton pump inhibitor „π¢π“¥ Ÿß ·≈–
  • 34. 33¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 √–¬–‡«≈“π“π°«à“„π°≈ÿà¡ typical À√◊Õ esophageal GERD ‰¥â·°à omeprazole ¢π“¥ 20 mg 1 ‡¡Á¥ °àÕπÕ“À“√ ‡™â“·≈–‡¬Áπ À√◊Õ proton pump inhibitor μ—«Õ◊Ëπ∑’Ë¡’¢π“¥‡∑’¬∫‡∑à“°—𠇪ìπ‡«≈“Õ¬à“ßπâÕ¬ 4-8  —ª¥“Àå (Level of evidence 2, Grade of recommendation ++) ·≈â«¥Ÿº≈°“√μÕ∫ πÕßμàÕ°“√√—°…“∑’ËÕ¬à“ß πâÕ¬ 4  —ª¥“Àå À“°‰¥â¬“‰ª 8-12  —ª¥“Àå·≈⫬—߉¡à¥’¢÷Èπ§«√À¬ÿ¥¬“·≈– àßμàÕ ºŸâ‡™’ˬ«™“≠ ‚¥¬ºŸâ‡™’ˬ«™“≠ à«π„À≠à·π–π”„Àℙ⬓≈¥°“√À≈—Ëß°√¥‡ªìπ°“√√—°…“‡∫◊ÈÕß μâπ ‡π◊ËÕß®“°¡’º≈®“°°“√»÷°…“∑¥≈Õß·∫∫‡ªî¥ (open-label trial)(49) ∫àß™’È«à“ ºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß∑’Ë ß —¬«à“‡ªìπº≈®“°°√¥‰À≈¬âÕπ μÕ∫ πÕßμàÕ°“√ √—°…“¥â«¬¬“≈¥°“√À≈—Ëß°√¥™π‘¥ proton pump inhibitors ∑—Èß¢π“¥¡“μ√∞“π («—π≈–§√—Èß) ·≈–¢π“¥ Ÿß («—π≈– 2 §√—Èß)(46) Õ¬à“߉√°Á¥’°“√»÷°…“·∫∫°“√«‘‡§√“–Àå Õ¿‘¡“π ®“° 9 °“√»÷°…“ ‡ª√’¬∫‡∑’¬∫¬“≈¥°“√À≈—Ëß°√¥°—∫¬“À≈Õ° æ∫«à“‰¡à¡’ §«“¡·μ°μà“ß°—π (odds ratio, OR 0.46; 95% CI 0.19-1.15)(41) ´÷Ëß°Á Õ¥§≈âÕß °—∫°“√»÷°…“·∫∫ ÿࡇª√’¬∫‡∑’¬∫Õ’° 2 °“√»÷°…“(50, 51) ∑—Èßπ’È ¡’°“√«‘‡§√“–Àå«à“ º≈ °“√»÷°…“∑’Ë·μ°μà“ß°—π¢â“ßμâπ πà“®–‡ªìπº≈®“°«‘∏’°“√«‘π‘®©—¬∑’ËÀ≈“°À≈“¬ ∑”„Àâ ‰¥âºŸâªÉ«¬„π°“√»÷°…“∑’Ë¡’§«“¡À≈“°À≈“¬¡“°(48) Õ¬à“߉√°Á¥’ °“√„À⬓ proton pump inhibitor °Á¬—ß·π–π”„Àℙ⇪ìπ¡“μ√∞“π‡∫◊ÈÕßμâπ ·μà„Àâμ‘¥μ“¡¥Ÿ°“√μÕ∫ πÕß ¿“¬„π 4-8  —ª¥“Àå ´÷Ë߇ªìπμ—«∫àß™’È∑’Ë¥’«à“ºŸâªÉ«¬πà“®–‰¥âª√–‚¬™π宓° proton pump inhibitor(46) À“°‰¡à¡’°“√μÕ∫ πÕ߇≈¬ §«√À¬ÿ¥¬“·≈â«∑”°“√ ◊∫§âπ‡æ‘Ë¡‡μ‘¡ ‡æ◊ËÕ ·¬°‚√§·≈–„Àâ°“√«‘π‘®©—¬ 7.6 Post-infectious cough Õ“°“√‰Õ¿“¬À≈—ß°“√μ‘¥‡™◊ÈÕ∑“߇¥‘πÀ“¬„® à«π∫π (upper respira- tory tract infection, URI) æ∫‰¥â∫àÕ¬„π‡«™ªØ‘∫—μ‘ ¡—°¡’ª√–«—μ‘°“√μ‘¥‡™◊ÈÕ∑“ß
  • 35. 34 ‡¥‘πÀ“¬„® à«π∫ππ”¡“°àÕπ à«π„À≠à‰¡à‡°‘π 2  —ª¥“À宓°‡™◊ÈÕ‰«√—  Mycoplasma, Chlamydia À√◊Õ Moraxella catarrhalis Õ“°“√Õ◊ËπÊ À“¬‰ª ‡À≈◊Õ·μàÕ“°“√‰Õ Õ“°“√‰Õπ“π¢÷Èπ‰¥â„πºŸâªÉ«¬∑’Ë¡’‚√§À≈Õ¥≈¡Õ¬Ÿà¥â«¬ Õ¬à“߉√°Áμ“¡√–¬–‡«≈“‰Õ ®“°¿“«–π’ȉ¡à§«√‡°‘π 8  —ª¥“Àå À“°‡°‘π 8  —ª¥“Àå §«√ ◊∫§â𠓇ÀμÿÕ◊Ëπ(2) Õÿ∫—μ‘°“√≥å„πºŸâ„À≠àª√–¡“≥√âÕ¬≈– 10 ∂÷ß 25 ·≈–®–æ∫ Ÿß¢÷Èπ‡ªìπ√âÕ¬≈– 25 ∂÷ß 50 ®“°°“√μ‘¥‡™◊ÈÕ Mycoplasma À√◊Õ Bordetella pertussis 欓∏‘°”‡π‘¥ ¬—߉¡à™—¥‡®π °≈‰°∑’Ë∑”„À⇰‘¥ cough hypersensitivity ‚¥¬ºà“π∑“ß airway inflammation ·≈–°“√°√–μÿâπ airway sensory nerves ·≈– cholinergic motor pathway ∑”„À⇰‘¥ bronchoconstriction ·≈– airway hyperresponsiveness μ“¡¡“(52) ‚¥¬ cough hypersensitivity π’ȇªìπ‡æ’¬ß™—Ë«§√“«  “¡“√∂À“¬‰¥â‡Õß À“°‰¡à‰¥â‡°‘¥®“° Bordetella pertussis Õ“°“√‰Õ®“° Pertussis ‡√‘Ë¡¥â«¬Õ“°“√π”§≈⓬‰¢âÀ«—¥ 2  —ª¥“Àå°àÕπ μ“¡¥â«¬Õ“°“√‰Õ‡ªìπ™ÿ¥Ê Õ“‡®’¬πÀ≈—ß‰Õ √à«¡°—∫ inspiratory whoop (æ∫‰¥â‰¡à∫àÕ¬„πºŸâ„À≠à) °“√¬◊π¬—π °“√«‘π‘®©—¬Õ“»—¬ polymerase chain reaction ®“° “√§—¥À≈—Ëß∫√‘‡«≥ naso- pharynx (sensitivity 80-100%) (Level of evidence 3, Grade of recom- mendation +/-) ‰¥âº≈¥’°«à“ culture (sensitivity 25-50%) (Level of evidence 3, Grade of recommendation +) À√◊Õ serology (pertussis IgG, IgA titer) ‚¥¬‡®“– 2 §√—Èß §√—Èß·√° 2  —ª¥“ÀåÀ≈—ß®“°¡’Õ“°“√‰Õ·≈–§√—ÈßμàÕ‰ª 3-4  —ª¥“Àå (sensitivity 60%)(53) (Level of evidence 3, Grade of recommendation +/-)
  • 36. 35¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 °“√√—°…“ Post-infectious cough „π°√≥’∑’ˉ¡à‰¥â‡°‘¥®“° pertussis Õ“°“√‰Õ¿“¬À≈—ß°“√μ‘¥‡™◊ÈÕ∑“߇¥‘πÀ“¬„® à«π∫π¡—°®–À“¬‰¥â‡Õß ‰¡à‡°‘π 8  —ª¥“Àå °“√√—°…“∑’Ë¡’√“¬ß“π ‰¥â·°à §Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å™π‘¥ Ÿ¥(54, 55) (Level of evidence 4, Grade of recommendation +), √“¬∑’Ë¡’Õ“°“√‰Õ¡“°Ê Õ“®®–„™â inhaled ipratropium(56) (Level of evidence 2, Grade of recommendation +) À√◊Õ¬“ ‡μ’¬√Õ¬¥å™π‘¥°‘π (prednisolone 30-40 mg μàÕ«—π) √–¬– —ÈπÊ 1-2  —ª¥“Àå (3) (Level of evidence 3, Grade of recommendation +/-) À“°‰¡à‰¥â º≈ Õ“®æ‘®“√≥“°“√„™â¬“°¥Õ“°“√‰Õ (Level of evidence 4, Grade of recommendation +) °“√√—°…“∑’Ë¡’√“¬ß“π«à“‰¡à‰¥âº≈‰¥â·°à montelukast(57) (Level of evidence 1, Grade of recommendation -) „π°√≥’∑’˺ŸâªÉ«¬‡ªìπ¿Ÿ¡‘·æ⮡Ÿ°Õ¬Ÿà‡¥‘¡ °“√μ‘¥‡™◊ÈÕ∑“߇¥‘πÀ“¬„® à«π∫π ®–∑”„ÀâÕ“°“√¿Ÿ¡‘·æ⮡Ÿ°°”‡√‘∫ ∫«¡·≈–º≈‘μ¡Ÿ°¡“°·≈–‡À𒬫∑”„À⇰‘¥°“√‰Õ ‡æ√“–¡’ postnasal drip ‰¥â „Àâ√—°…“·∫∫¿Ÿ¡‘·æ⮡Ÿ°¥â«¬°“√æàπ≈â“ß®¡Ÿ°¥â«¬ πÈ”‡°≈◊Õ·≈–¬“ ‡μ’¬√Õ¬¥å™π‘¥æàπ®¡Ÿ° °“√√—°…“Õ“°“√‰Õ®“° pertussis „π√–¬–·√° „™â¬“ªØ‘™’«π– macrolide ‰¥â·°à erythromycin À√◊Õ tri- methoprim/sulfamethoxazole ‡ªìπ‡«≈“ 2  —ª¥“Àå(52, 53) ·≈–·π–π”„Àâ isola- tion ‡ªìπ‡«≈“ 5 «—πÀ≈—ß®“°‡√‘Ë¡°“√√—°…“ (Level of evidence 1, Grade of recommendation ++) ‰¡à·π–π”„À⬓§Õ√åμ‘‚§ ‡μ’¬√Õ¬¥å ¬“¢¬“¬À≈Õ¥≈¡∑’Ë ÕÕ°ƒ∑∏‘Ϭ“« ·≈–¬“ pertussis immunoglobulin (Level of evidence 1, Grade of recommendation -)
  • 37. 36 Sinobronchial syndrome „πª√–‡∑»·∂∫‡Õ‡™’¬ æ∫«à“¡’°≈ÿà¡Õ“°“√‰Õ‡√◊ÈÕ√—ß™π‘¥¡’‡ ¡À–∑’Ë¡’¿“æ √—ß ’∑√«ßÕ°·≈–‰´π— º‘¥ª°μ‘ ·≈–„Àâ™◊ËÕ‚√§«à“ sinobronchial syndrome ¿“«– π’ȉ¡àæ∫À√◊Õæ∫‰¥âπâÕ¬¡“°„π™“«μ–«—πμ°·≈–‰¡à¡’·π«∑“ß°“√√—°…“∑’Ë√–∫ÿ‰«â„π chronic cough guidelines ®“°∑“ßμ–«—πμ°·μàÕ“®æ∫‰¥â„π‡Õ‡™’¬(1) ºŸâªÉ«¬ ¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß·∫∫¡’‡ ¡À–≈—°…≥– mucoid À√◊Õ mucopurulent Õ“°“√ ∑“ߧ≈‘π‘°∑’Ë∑”„Àâπ÷°∂÷ߧ◊Õ°“√∑’Ë¡’Õ“°“√√à«¡°—π¢Õ߉´π— Õ—°‡ ∫‡√◊ÈÕ√—ß (chronic sinusitis) √à«¡°—∫Õ“°“√Õ—°‡ ∫∑“߇¥‘πÀ“¬„® à«π≈à“ß (chronic lower airway inflammation) ‰¥â·°à diffuse bronchiectasis À√◊Õ diffuse panbronchiolitis (DBP) À√◊Õ chronic bronchitis Õ“°“√∑’Ë∫àß∂÷߉´π— Õ—°‡ ∫‰¥â·°à postnasal drip, nasal discharge ·≈– throat clearing Õ“°“√¡—°®–·¬à≈߇¡◊ËÕ¡’ upper respiratory tract infection °“√μ√«®√à“ß°“¬æ∫ post nasal drip ·≈– cobble stone appearance ∫√‘‡«≥ oropharynx °“√‡æ“–‡™◊ÈÕ‡ ¡À–¡—°¢÷Èπ pneumococcus ·≈– H. influenzae º≈°“√μ√«®√–¥—∫ serum IgA ·≈– cold agglutinins  Ÿß¢÷Èπ °“√μ√«®∑“ß√—ß ’ æ∫¿“æ√—ß ’‰´π—  À√◊Õ‡ÕÁ°´‡√¬å§Õ¡æ‘«‡μÕ√å (computed tomography) º‘¥ª°μ‘ ∑’ˇ¢â“‰¥â°—∫‰´π— Õ—°‡ ∫ °“√√—°…“ Sinobronchial syndrome °√≥’Õ“°“√‰¡à√ÿπ·√ß expectorant ∑”„ÀâÕ“°“√¥’¢÷Èπ‰¥â ∂â“Õ“°“√√ÿπ·√ß ·π–π”„Àâ 14-membered ring macrolides ‰¥â·°à erythromycin 300-600 mg μàÕ«—π clarithromycin 250-500 mg μàÕ«—π À√◊Õ roxithromycin 150-300 mg μàÕ«—𠇪ìπ‡«≈“ 2-12  —ª¥“Àå (Level of evidence 3, Grade of recommenda- tion +)
  • 38. 37¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 ¿“§ºπ«° 1 ·π«∑“ß°“√√—°…“ºŸâªÉ«¬∑’Ë¡’Õ“°“√‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à μ√«®¿“æ√—ß ’ªÕ¥ (CXR) ‡æ◊ËÕ§âπÀ“ “‡Àμÿ®“°ªÕ¥ ‡™àπ «—≥‚√§ ¡–‡√Áß ´÷ËßÕ“® æ∫ “‡ÀμÿÕ“°“√‰Õ®“°À≈“¬‡Àμÿ√à«¡°—π À“° CXR ª°μ‘ „Àâ°“√√—°…“‡∫◊ÈÕßμâπ μ“¡¢—ÈπμÕπ À“°Õ“°“√‡¢â“‰¥â°—∫ - Upper Airway Cough Syndrome (UACS) „Àâ°“√√—°…“‡∫◊ÈÕßμâπ·≈– ◊∫§âπÀ“ “‡Àμÿ∑’Ë®”‡æ“– - Asthma „Àâ°“√√—°…“‡∫◊ÈÕßμâπ ·≈–æ‘®“√≥“∑” Spirometry, bronchodilator reversibility - Non-asthmatic eosinophil bronchitis (NAEB) „Àâ°“√√—°…“‡∫◊ÈÕßμâπ - Gastroesophageal Reflux Disease (GERD) „Àâ°“√√—°…“‡∫◊ÈÕßμâπ °“√μ√«®«‘π‘®©—¬‡æ‘Ë¡‡μ‘¡ - Spirometry or peak expiratory flow variability (if not be evaluated) - Bronchial provocation test - Plain sinus imaging (if not be evaluated) + CT sinus - 24h esophageal pH monitoring À√◊Õ 24 h-pH / impedance test - Endoscope (Nasal, larynx or Bronchoscope) - Swallowing Evaluation -  “‡ÀμÿÕ◊ËπÊ ª√–‡¥Áπæ‘®“√≥“∑’Ë ”§—≠ - √—°…“μ“¡ “‡Àμÿ∑’Ë ß —¬Õ¬à“߇μÁ¡∑’Ë - μ‘¥μ“¡§«“¡ ¡Ë”‡ ¡Õ¢Õß°“√√—°…“ - ‡π◊ËÕß®“° “‡Àμÿ°“√‰Õ‡√◊ÈÕ√—ßÕ“®¡’‰¥âÀ≈“¬ “‡Àμÿ„π ºŸâªÉ«¬√“¬Àπ÷ËßÊ §«√„Àâ°“√μ√«®·≈–√—°…“‡æ‘Ë¡‡μ‘¡®“° °“√√—°…“‡¥‘¡∑’ËμÕ∫ πÕ߇撬ß∫“ß à«π
  • 39. 38 ¿“§ºπ«° 2 «‘∏’°“√ àÕßμ√«®®¡Ÿ° 1) μ√«®¥â«¬‰ø©“¬∑’Ë· ß «à“ß Ÿß „π¢≥–∑’Ë„À⺟âªÉ«¬·Àßπ§Õ·≈–¥—π ª≈“¬®¡Ÿ°¢÷Èπ‡æ◊ËÕ∑”„Àâ‡ÀÁπ√Ÿ®¡Ÿ°‰¥âßà“¬ ¢âÕ¥’§◊Õ –¥«°·≈–ßà“¬ ·μà¢âÕ®”°—¥ §◊Õ ®–μ√«®‰¡à‰¥âÀ“°¡’¢π®¡Ÿ°¡“° ·≈–‰¡à “¡“√∂‡ÀÁπ√“¬≈–‡Õ’¬¥«à“¡’¡Ÿ°¢â“ß„π Õ¬à“߉√ 2) °“√ àÕß®¡Ÿ°¥â«¬ Otoscope ∏√√¡¥“ ®–‡ÀÁπ‰¥â¥’¢÷Èπ°«à“«‘∏’·√° 3) °“√ àÕß®¡Ÿ°¥â«¬°≈âÕß digital otoscope ®–¡’°”≈—ߢ¬“¬ Ÿß ‡ÀÁπ‰¥â ™—¥‡®π
  • 40. 39¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 «‘∏’°“√μ√«®§Õ ‡æ◊ËÕμ√«®À“Õ“°“√· ¥ß¢Õß postnasal drip syndrome ‡™àπ ¿“«– glan- dular pharyngitis, tonsil enlargement ‚¥¬„™â‰ø©“¬∑’Ë «à“ß Ÿß „π¢≥–„Àâ ºŸâ≈ÕßÕ⓪“°°«â“ß·≈–À“¬„®‡¢â“∑“ߧÕ≈÷°Ê ‚¥¬‰¡àμâÕß„™â‰¡â°¥≈‘Èπ‰¥â À“°¡Õß ‰¡à‡ÀÁπ®÷ߧàÕ¬„™â‰¡â°¥≈‘Èπ μ√«® àÕß™â“Ê √Ÿª· ¥ß¿“«– glandular pharyngitis (≈Ÿ°»√™’È) √Ÿª´â“¬·≈–¢«“∫π · ¥ß∂÷ß¿“«–®¡Ÿ°∫«¡ (complete nasal obstruction) √Ÿª´â“¬·≈– ¢«“≈à“ß · ¥ß∂÷ß¿“«–∑’Ë¡’¡Ÿ°‡À𒬫¡“° ∑”„À⇰‘¥Õ“°“√ postnasal drip, °√–·Õ¡‰Õ
  • 41. 40 °“√μ√«®æ∫§«“¡º‘¥ª°μ‘∑’Ë∫àß™’È«à“¡’¿“«–‡¬◊ËÕ®¡Ÿ°∫«¡Õ—°‡ ∫‡√◊ÈÕ√—ß(chronic rhinitis) √Ÿª· ¥ß¿“«–√‘¡Ω望°·μ°Õ—°‡ ∫ (cheilitis) ‡°‘¥®“°®¡Ÿ°μ—π∑”„ÀâμâÕß À“¬„®∑“ߪ“°∫àÕ¬Ê √Ÿª´â“¬· ¥ß¢Õ∫μ“≈à“ߧ≈È”¥” (allergic shiner) √Ÿª¢«“· ¥ßº◊Ëπ·¥ß§—π∑’ËÀ—«μ“À√◊Õ‡ª≈◊Õ°μ“ (periorbital dermatitis) À¡“¬‡Àμÿ:√Ÿª¿“æ∑—ÈßÀ¡¥‰¥â√—∫Õπÿ≠“μ„À⇺¬·æ√ஓ°ºŸâªÉ«¬·≈– ». πæ. ‡°’¬√μ‘ √—°…å√ÿàß∏√√¡
  • 42. 41¢âÕ·π–π”°“√ªØ‘∫—μ‘ “∏“√≥ ÿ¢ °“√√—°…“ºŸâªÉ«¬‰Õ‡√◊ÈÕ√—ß„πºŸâ„À≠à·Ààߪ√–‡∑»‰∑¬ æ.». 2559 ¿“§ºπ«° 3 °“√∑¥ Õ∫ ¡√√∂¿“æªÕ¥‚¥¬ ‰ª‚√‡¡μ√’¬å·≈–°“√∑¥ Õ∫§«“¡‰«À≈Õ¥≈¡ °“√∑¥ Õ∫ ¡√√∂¿“æªÕ¥‚¥¬ ‰ª‚√‡¡μ√’¬å ™à«¬∫àß™’È«à“¡’°“√μ’∫¢ÕßÀ≈Õ¥≈¡ (airway obstruction) ·π–π”„Àâ∑”„π ºŸâªÉ«¬∑’Ë¡’ª√–«—μ‘·≈–°“√μ√«®√à“ß°“¬∑’Ë ß —¬‚√§À◊¥ ‡æ◊ËÕ«—μ∂ÿª√– ß§å 1) ¬◊π¬—π «à“¡’¿“«–À≈Õ¥≈¡μ’∫ ·≈–ª√–‡¡‘𧫓¡√ÿπ·√ß ·≈– 2) ª√–‡¡‘π«à“¡’°“√μÕ∫  πÕßμàÕ¬“ Ÿ¥¢¬“¬À≈Õ¥≈¡ (reversibility) °àÕπ°“√√—°…“ ·≈–/À√◊Õ ¡’°“√ μÕ∫ πÕßμàÕ°“√„™â¬“√—°…“‚√§À◊¥À√◊Õ‰¡à (variable airflow limitation) ‚¥¬°“√ ¬◊π¬—π«à“¡’¿“«–À≈Õ¥≈¡μ’∫ æ‘®“√≥“®“°§à“ FEV1/FVC ¡’§à“πâÕ¬°«à“ 0.75-0.8 „πºŸâ„À≠à∑’Ë¡’Õ“¬ÿπâÕ¬°«à“ 60 ªï ·≈–°“√μÕ∫ πÕßμàÕ¬“ Ÿ¥¢¬“¬À≈Õ¥≈¡ æ‘®“√≥“ ®“°§à“ ¡√√∂¿“æªÕ¥ FEV1 ‡æ‘Ë¡¢÷Èπ¡“°°«à“ 200 ml ·≈–¡“°°«à“√âÕ¬≈– 12 À≈—ß Ÿ¥¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘χ√Á« 20 π“∑’ ·≈–/À√◊Õ À≈—ß°“√‰¥â¬“ controller √—°…“‚√§À◊¥‡ªìπ‡«≈“Õ¬à“ßπâÕ¬ 4  —ª¥“Àå ¿“«–À≈Õ¥≈¡μ’∫∑’Ë¡’§«“¡º—πº«π (variable airflow obstruction) ¥—ß °≈à“« “¡“√∂μ√«®‰¥â‚¥¬«‘∏’Õ◊ËπÊ ‰¥â·°à °“√«—¥ peak expiratory flow rate (PEFR) °“√«—¥ peak expiratory flow rate (PEFR) ‚¥¬°“√μÕ∫ πÕßμàÕ¬“ Ÿ¥ ¢¬“¬À≈Õ¥≈¡ æ‘®“√≥“®“°§à“ PEFR ∑’ˇæ‘Ë¡¢÷Èπ¡“°°«à“ 60 L/min À√◊Õ‡æ‘Ë¡¢÷Èπ ¡“°°«à“√âÕ¬≈– 20 À≈—ß Ÿ¥¬“¢¬“¬À≈Õ¥≈¡™π‘¥ÕÕ°ƒ∑∏‘χ√Á« ·μà°“√∑¥ Õ∫ ¥â«¬°“√«—¥ PEFR ¡’§«“¡‡∑’ˬßμ√ßπâÕ¬°«à“ ‰ª‚√‡¡μ√’¬å °“√„™â PEFR ‡æ◊ËÕ μ√«®À“¿“«–À≈Õ¥≈¡μ’∫∑’Ë¡’§«“¡º—πº«π ‚¥¬°“√«—¥ PEFR „π™à«ß 1-2  —ª¥“Àå
  • 43. 42  “¡“√∂„™â„π°“√«‘π‘®©—¬·≈–ª√–‡¡‘π‚√§À◊¥‰¥â¥’°«à“ §π∑’ˇªìπ‚√§À◊¥®–¡’§«“¡ º—πº«π¡“°°«à“§πª°μ‘ (¡“°°«à“√âÕ¬≈– 10) ‚¥¬°“√«—¥ PEFR «—π≈– 2 §√—Èß „π¢≥–¬—߉¡à‰¥â‡√‘Ë¡°“√√—°…“ À√◊Õ PEFR ‡æ‘Ë¡¢÷Èπ¡“°°«à“√âÕ¬≈– 20 ¿“¬À≈—ß °“√√—°…“¥â«¬¬“§«∫§ÿ¡‚√§À◊¥‡ªìπ‡«≈“ 4  —ª¥“Àå °“√§”π«≥§à“§«“¡º—πº«π¢Õß PEFR (peal flow variability, PFV) PFV (%) = (§à“ PEFR ¢Õß«—π∑’Ë Ÿß ÿ¥ - §à“ PEFR ¢Õß«—π∑’ËμË” ÿ¥) À“√ ¥â«¬§à“‡©≈’ˬ¢Õß PEFR (§à“ PEFR  Ÿß ÿ¥¢Õß«—π + §à“ PEFR μË” ÿ¥¢Õß«—π/2) ·≈⫧Ÿ≥¥â«¬ 100% °“√∑¥ Õ∫§«“¡‰«¢ÕßÀ≈Õ¥≈¡ (Bronchoprovocative test)  “¡“√∂∑”‰¥â¥â«¬°“√„Àâ Ÿ¥ “√°√–μÿâπ “√ histamine À√◊Õ∑’Ëπ‘¬¡„πªí®®ÿ∫—π ‰¥â·°à methacholine ∑’˧«“¡‡¢â¡¢âπ‡√‘Ë¡®“°πâÕ¬‰ª¡“° ·≈–«—¥§à“ ¡√√∂¿“æªÕ¥ ‚¥¬°“√μ√«® ‰ª‚√‡¡μ√’¬å¿“¬À≈—ß°“√ Ÿ¥¬“·μà≈–§«“¡‡¢â¡¢âπ«à“¡’°“√≈¥≈ߢÕß §à“ ¡√√∂¿“æªÕ¥ FEV1 ¡“°°«à“√âÕ¬≈– 20 ®“°§à“°àÕπ Ÿ¥¬“ methacholine À“°§«“¡§«“¡‡¢â¡¢âπ¢Õß methacholine ∑’Ë„™â„π°“√°√–μÿâπ„À⇰‘¥°“√≈¥≈ß ¢Õß FEV1 ¡“°°«à“√âÕ¬≈– 20 ®“°§à“°àÕπ Ÿ¥¬“ (PC20) μË”°«à“ 8 mg/dl ∂◊Õ«à“ ¡’¿“«–À≈Õ¥≈¡‰« ∂â“ PC20 μË”°«à“ 1 mg/dl ∂◊Õ«à“¿“«–À≈Õ¥≈¡‰«√ÿπ·√ß (severe AHR)  à«π§à“ PC20 ∑’Ë¡“°°«à“ 16 mg/dl ∂◊Õ«à“º≈°“√∑¥ Õ∫‡ªìπ≈∫ °“√∑¥ Õ∫ methacholine challenge test „π°“√«‘π‘®©—¬‚√§À◊¥ ¡’§à“ positive predictive value √âÕ¬≈– 60-88
  • 45. 44 ¿“§ºπ«° 5 μ“√“ß· ¥ß§«“¡·μ°μà“ß√–À«à“ß‚√§ eosinophilic airway ™π‘¥μà“ßÊ(1) Classic asthma CVA NAEB AC Õ“°“√ ‰Õ ‡Àπ◊ËÕ¬ «’È¥ ‰ÕÕ¬à“߇¥’¬« ‰Õ√à«¡°—∫Õ“°“√ ‰ÕÕ¬à“߇¥’¬« ∑“ß upper airway Atopy 60-80% 40-80% 20-70% 40-50% Variable airflow limitation + + - - AHR + + - - Cough hypersensitivity - - ‡æ‘Ë¡ ‡æ‘Ë¡ °“√μÕ∫ πÕßμàÕ + + ‰¡à∑√“∫ - ¬“¢¬“¬À≈Õ¥≈¡ °“√μÕ∫ πÕßμàÕ + + + +  ‡μ’¬√Õ¬¥å °“√μÕ∫ πÕßμàÕ + + ‰¡à∑√“∫ + ¬“μâ“πŒ‘ μ“¡’π °“√≈¥≈ߢÕß ¡√√∂¿“æªÕ¥ + + + - °“√¥”‡π‘π‚√§‡ªìπ‚√§À◊¥ 30% 10% πâÕ¬¡“° Sputum eosinophil >3% ∫àÕ¬ ∫àÕ¬ μâÕß¡’„π°“√«‘π‘®©—¬ ∫àÕ¬ FeNO ‡æ‘Ë¡ ‡æ‘Ë¡ ‡æ‘Ë¡ ‰¡à‡æ‘Ë¡ Submucosal eos ‡æ‘Ë¡ ‡æ‘Ë¡ ‡æ‘Ë¡ ‡æ‘Ë¡ Mast cell in ASM ‡æ‘Ë¡ ‰¡à‡æ‘Ë¡ ‰¡à‡æ‘Ë¡ ‰¡à∑√“∫ Subepithelial thickening + + + ‰¡à∑√“∫ Vascular proliferation + + + ‰¡à∑√“∫ CVA=cough variant asthma, NAEB=non-asthmatic eosinophilic bronchitis, AC=allergic cough, AHR= airway hyperresponsiveness, eos= eosinophil, FeNO= fractional exhaled nitric oxide, ASM= airway smooth muscle
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