한국 성인 천식의 진료 지침 · 2014. 10. 24. · 2011년 개정판...

2011년 개정판

만성기도폐쇄성질환 임상연구센터

대한천식알레르기학회

한국 성인 천식의

진료 지침

2011

– 2007

( : A102065) –

i

3

.

.

40

.

,

. 2004

, ,

4 1,128 2004 0.52%, 2003 48.4%

. 250,000

, 2007

10 15.3 , , , , 6

.

. 1992 1994

1998

2003

.

. 2000 AIRIAP (Asthma

Insights and Reality in Asia Pacific) 4 52%, 1

26%

0.2% .

1990

,

.

(evidence-based medicine)

ii

-

.

.

.

.

2004 .

2004 3 10

, ,

SIGN

GINA, NIH expert panel , , , ,

PICO 34

. 2006

GINA 5

2006 GINA

“2007 ”

.

( www.allergy.or.kr, www.kaim.or.kr,

www.guideline.or.kr ), 100 , , 1

, ‘

, ’

16 253 , , , , ,

.

, ,

iii

(www.kaaf.org)

.

2011 4 ( 2

, ,

TNF-α ,

) 2007

, , PICO

,

3 GINA

. 2011

, , , ,

.

,

.

. 3

.

.

2011 3

iv

16

.

, , ,

,

, , , .

지침 개정본 개발위원회 (위원장 외 가나다 순)

실무위원회 (위원장 외 가나다 순)

v

감수위원 (가나다 순)

“ 2011 ” 2010 5 2011 3 10

. 2010 5

.

2007

SIGN

, 3

. 4

2 ,

, TNF-α

,

PICO

, .

3 GINA

2011 1

. 2011 2 8 , 2011 2 3 2

.

4

PICO .

vi

1) 2

?

2) 16

?

3) TNF-α ?

4) ?

Pubmed, Cochrane database, KoreaMed

,

,

.

2 .

(Level of Evidence) .

A:

(randomized controlled trial: RCT) (meta-analysis)

B: ,

,

C: ,

D:

GINA Global Strategy for Asthma

Management and Prevention(2009 ), NHLBI Expert Panel Report 3: Guidelines for the Diagnosis

and Management of Asthma(2007 ), British Guideline on the Management of Asthma(2009

)

.

3

vii

.

.

,

, .

www.allergy.or.kr, www.kaim.or.kr, www.guideline.or.kr

.

,

(www.kaaf.org)

.

2007

( : A102065)

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

. (community settings)

. (acute care settings)

.

.

.

.

Contents

2

, (airway hyperresponsiveness)

, .

.

, , ,

. ,

.

, ,

( 1-1).

,

( )

, (

IgE ,

), ,

( ) .

.

3

.

1-18% .

.

.

3

1983 5.7%, 1990 10.1%, 2000 13.0%,

12.8% 2000

. 1995 7.7%, 2.7%, 2000 9.1%,

5.3% . 2000 14.4%, 2005

13.0%, 2008 11.7% , 2000 9.4%, 2005

7.6%, 2008 7.9% . 2000

,

, , ,

.

(hygiene hypothesis) .

, 1998 8,823

12.8% 3.6% . , 12

134 (1.2%) 7.4%

, . 2,467

(2001 ),

40 2%, 40-54 3.8%, 55-64 7.7%, 65 12.7%

50

.

250,000 . 2004

10 1.7

7,500 3,000-4,000 .

. 5.5-14.5%

, , , , . 2000

,

14%, 7% .

( ,

) ( ,

) . 2004

4

2005 , , ,

4 1,148 . 2004 (GDP)

0.52%, 2003 48.4%, 2003 85.7%

.

(GINA 2009) .

•

.

• .

• .

• .

• .

• .

(

) ( 1-2).

: , ( , , ), , , , : , , , ( ) /

5

. ,

. , 1

.

. ,

. , ,

,

.

.

.

.

. IgE (

); ; , , ; Th1

Th2 ( )

. IgE

, 5

IgE .

.

.

- 2

. .

.

.

.

6

. 14

. ,

. . ,

.

. .

.

.

/

. , ,

,

.

, , , , .

.

.

.

,

.

(endotoxin)

.

.

(respiratory syncytial virus, RSV) (parainfluenza virus)

7

. RSV

40% .

, , RSV

. .

“ ” “

” .

, “ ” , ,

. ,

.

.

, ,

.

. 300

(isocyanate) ,

, IgE

( 1-3).

,

IgE IgG

.

.

(allergenicity) ,

isocyanate , .

, 10 1

. Isocyanate 5%,

2.1-13% . 50%

, IgE IgG

. . , , , ,

.

.

(citrus red mite) , IgE

.

8

, . (two spotted spider mite)

, ,

.

.

,

.

, 24

‘ (reactive airway dysfunction syndrome)’ , ‘ (irritant

induced asthma)’ .

.

.

.

(Isocyanate) Toluene diisocyanate (TDI)

Methylene diisocyanate (MDI) (reactive dyes)

terephthaloyl chloride (Anhydride)

Methyltetra hydrophthalic anhydride (wood dust)

,

, , , ,

(epoxy resin )

,

( ),

9

Amoxacillin Aminocephsporanic acid (7-ACA) Aminocephalosporanic thiazine (ACT) Cefteram pivoxil Biodiastase Pronase

( , , , )

(latex)(seafood)(flux)

(Amines)(Formaldehyde)(Acrylate)

(Persulfate) (Chlorine) (sodium hypochlorite)

, ,

,

, ,

.

.

,

. 1

4 .

,

. .

10

.

.

,

.

.

, .

, ,

.

, ,

n-6 (n-6 polyunsaturated fatty acid) , n-3

.

. ,

.

,

. .

.

,

. , ,

.

. ,

, T (TCR invariant NKT cell), Th2 T ,

11

( 1-4). ,

( 1-5).

, (leukotrienes), D2 . IgE

( ) . .

. , .

T . IL-4, IL-5, IL-9, IL-13 B IgE . Th2

Th2 (regulatory) T . Th1 Th2 T

(invariant natural killer T cell) .

. T (naïve) T Th2

.

IgE .

.

.

. , , .

.

.

, .

. (neurotrophin)

, .

12

100 ( 1-6).

. (eotaxin) TARC (thymus and

activation regulated chemokines) MDC (macrophage-derived chemokines) Th2 .

(proinflammatory) .

.

, . IL-1β TNF-α , GM-CSF

. IL-5 Th2 , IL-4 Th2 , IL-13 IgE

.

.

, (inducible NO synthase) .

.

Th2 .

,

(airway remodeling) ( 1-7). ,

. .

. , . , .

(hypertrophy) (hyperplasia) . ,

.

13

VEGF (vascular endothelial growth factor) .

.

( 1-8).

. .

. .

, .

.

,

. .

, .

( 1-9).

.

, (plateau) .

.

, .

14

, , ( : )

. (rhinovirus),

(respiratory syncytial virus) ,

.

, , ,

.

.

. .

. , ,

.

. ,

.

, ,

, .

, .

20

.

,

.

.

.

21

, , ,

. , ,

.

, , ,

.

, , ,

. 2-1 .

1. ?2. ?3. ?4. ?5. ?6. ?

,

.

.

(cough variant asthma)

, .

.

. , , ,

, .

. 5-10

30-45

22

.

.

. 2

2 6

.

.

.

, , .

, ,

. ,

, .

(the work of breathing) .

. ,

, , , .

.

. ,

, .

,

.

. 5 ,

1 (FEV1) (PEF)

.

,

. (200-400 mg

23

(salbutamol = albuterol)) FEV1 ( PEF) ,

. .

.

1 (FEV1) (FVC)

. FEV1 1L .

, , . FEV1/

FVC . 75-80% ,

90% . . 10-20 FEV1

12% 200mL .

, .

.

,

.

(trapping) FEV1

.

.

. .

1-2

.

(Min%Max) ,

.

PEF = PEF − PEF

× 100 1/2( PEF + PEF)

24

.

, 20% 20%

.

,

.

,

.

FEV1 15%

(methacholine, histamine ) FEV1 20%

(PC20: provocative concentration of 20% fall in FEV1)

. .

,

. , , ,

.

.

.

(NO) (CO)

. (FeNo)

( B),

.

. IgE

. ,

.

25

.

.

,

. IgE

. IgE

.

. IgE .

, , ,

. .

. :

-

-

-

- ,

- ( : )

- ( : )

,

. ,

. ,

.

.

26

. , , “

” .

.

( )

. ,

. /

.

.

.

.

. ,

. .

. ,

. (

)

.

. 2 4 PEF

2 PEF .

, .

(COPD)

.

. ,

“ ” “ ”

27

. ,

.

.

.

.

( ) .

. ‘ ’ ,

. ( , , )

,

.

,

,

.

.

.

, ‘ ’

.

.

, ,

.

28

.

.

,

.

.

2-2 ‘ ’, ‘ ’, ‘ ’

( D).

(Asthma Control Test, ACT)

.

.

. (Asthma Control Test, ACT),

(Asthma Control Questionnaire, ACQ), (Asthma Therapy Assessment

Questionnaire, ATAQ) . .

.

.

-2 / 3 /

/

-2 / 3 /

(PEF FEV1) ‡< 80%

: , , , FEV1, , .

‘ ’

29

, ,

.

.

.

.

.

,

,

.

, ,

, , ,

.

.

, .

, .

.

. ,

, ,

4

.

.

“ ” “

” .

34

.

(controller) (reliever) .

35

2

2

IgE (Omalizumab)

2

2

, , ( , , ) .

.

(metered-dose inhalers, MDIs), (breath-actuated MDIs), (dry powder

inhalers, DPIs), (soft mist inhalers), .

, , , ,

. ,

.

.

. .

. .

36

.

,

.

. , ,

.

, ,

- ,

. 3-1

. , , ,

- .

.

400μg/ ,

. ,

.

.

.

.

Beclomethasone dipropionateBudesonideCiclesonideFlunisolideFluticasone propionateMometasone furoateTriamcinolone acetonide

200-500200-40080-160

500-1,000100-250200-400

400-1,000

500-1,000400-8,000160-320

1,000-2,000250-500400-800

1,000-2,000

1,000-2,000800-1,600320-1,280

>2,000500-1,000800-1,200

>2,000

37

.

, , .

(spacer) .

( )

. (ciclesonide) (prodrug)

.

.

,

, , , , (

) ( ) ,

. (ciclesonide), (budesonide),

(fluticasone)

. 400μg/

.

, ,

, , .

- , BDP 1,000μg/ ( )

12% ,

. ,

, (posterior-subcapsular cataract)

.

. ,

, .

(montelukast),

(pranlukast), (zafirlukast) (zileuton)

38

.

. .

.

,

.

,

.

2 ,

.

. (zileuton)

.

- (Churg-Strauss syndrome)

. -

.

2 (formoterol) (salmeterol)

.

,

2 .

, 2

. , ,

, .

2

( , ).

2

.

. ,

39

.

,

. 2

,

.

2 , ,

. 2 2

.

(the US Food and Drug

Administration, FDA) (Health Canada) 2

, .

2

( B).

2 ,

,

.

2

.

.

1 2 .

. ,

.

.

2 .

(≥10mg/kg/ ) ,

, ,

. , , ,

40

. , .

, ,

, .

, , , , ,

(cimetidine, quinolone , macrolide ) .

.

.

.

.

.

2 (salbutamol), (terbutaline),

(bambuterol, ) . 2

.

2 2 .

( ), , . 2

. 2

.

41

2 ( ) (tulobuterol) .

(FDA) .

2 .

IgE (omalizumab) IgE .

.

IgE ,

. IgE

.

11-50 IgE

.

, (2 ) .

.

, .

( ) , (mineralocorticoid)

, ( )

, .

, , , - - , , , ,

, .

.

- (Churg-Strauss Syndrome)

. , ,

42

, , , ,

.

.

.

7.5mg/ 6 5mg/ 3 ( 2mg / ) T score < -2.5, Z score <-1 .

2 .

.

, , , 10 : ( A). 10 : ( A).

. tranilast, repirinast, tasanolast, pemirolast, ozagrel,

celatrodast, amlexanox, ibudilast .

.

.

43

.

. (methotrexate)

.

. (cyclosporin) (gold)

. (macrolide) (troleandromycin)

(methylprednisolone) ,

.

.

. Tumor necrosis factor (TNF)-alpha

.

( B).

.

, , .

, , ,

.

,

. 75

Cochrane review

, , ( A). ,

.

.

44

.

( B).

,

.

3-3 , IgE

.

, ,

.

, ,

( 3-4).

. ,

.

, .

30 ,

1. IgE 2. 3. : , 4. 5.

1. 2. : , , 3.

1. (5 ) 2. 3.

45

, , , , , ,

.

2 ,

.

(salbutamol), (terbutaline), (fenoterol) . 2

(formeterol)

.

.

. 2

. 2

, .

, ,

. 4-6

.

(prednisolone) 15-50mg/ 3-10 .

.

.

(ipratropium

bromide) (oxitropium bromide) .

2 .

46

( A). 2 ,

,

.

.

.

( 2

) .

2 . ,

, 2 .

.

.

2 .

, . 2

.

/

. ,

. , (homeopathy),

(herb medication), , (ayurvedic medicine), (ionizer),

(osteopathy and chiropractic manipulation), (speleotherapy)

.

,

, .

(buteyko) (randomized controlled trial)

47

. (comfrey)

.

pyrrolozodone .

52

.

. ,

,

( 4.1-1).

( A).

.

53

:

. :

.

,

. 3

. 4.1-2

.

.

.

, ,

54

. ,

.

, .

.

( : )

( B).

, ,

. , , ,

.

.

, .

, .

.

.

.

, , ,

, , ,

1/3 2/3 .

.

.

.

.

,

55

50%

. .

.

.

.

( )

.

.

.

50% (non-adherence)

. .

(“ ?”).

4-1.3 .

(1 4 )

,

56

.

. ,

,

(Asthma Friendly School) ,

.

. 2007

· .

. (www.allergy.or.kr)

(www.kaaf.org) .

58

.

.

. -

.

.

.

“ ”

Th1 T

.

“ ” .

.

.

59

.

. ( B).

.

.

“ ” , ,

, . ( , , ,

/ , ) .

.

.

.

, , , .

.

.

.

.

.

( 4.2-1).

,

( A).

( B).

60

( B) .

, , ,

.

( 4.2-1).

, , .( ) ( )

55-60 .

.

.

.

HEPA .

.

/ .

.

HEPA .

.

.

HEPA .

61

.

.

( C).

. 50%

.

.

. , ,

. .

.

.

.

( B), . , ,

, , , .

( D).

.

.

, , ,

.

, , /

62

.

, .

( B).

.

( B).

( C)

.

.

( D). , , ,

.

, ,

.

.

. (NSAID)

. , ( A) .

.

24

.

63

.

.

3

. 3

.

(BMI) .

, , ,

( B).

, , ,

( , , , ) .

.

.

, , .

.

.

.

.

.

67

,

.

.

.

.

68

. 4.3-1 , ,

.

. (Asthma Control Test),

(Asthma Control Questionnaire), (Asthma Therapy Assessment Questionnaire),

(Asthma Control Scoring System)

.

4 4 .

. ,

. ,

-2 / 3 /

/

-2 / 3 /

(PEF FEV1) ‡

80%

: , , , FEV1, , .

* . ‘ ’ . 5 .

69

3

.

.

4.3-2

.

.

. 1

5 . 5

.

4.3-2 2

3

.

. ,

( ) .

. 2 5 .

1 , ,

2

( 4.3-1). 1

.

( B).

1 2 (

70

2

(1 2

)

+ 2

+ 2 ( )

IgE

+

+

(rapid-onset) 2 , 2 , (long-acting) 2 , . 2

.

↓

↑

1

71

A). , 2 ,

( A).

. ,

.

2

.

2 ( A).

( B).

2 5

. 2

( A).

3-1

.

( A). ,

( C).

2

.

( B)

. (nedocromil sodium, sodium cromoglycate)

( A).

3 2

( A).

.

72

3-4

( A). 2 (formoterol)

(budesonide)

, 2 (short-acting β2-agonist)

.

.

.

( A).

.

3

( A). (pressurized metered-dose inhaler)

( , spacer)

.

( A).

3

( A).

( B).

4 2 3 .

. 3 (difficult-to-

treat) .

4

2 . ,

( A). ,

2

( )

, 3-6 ( B). .

73

2 ( A). 4 (

B). 3-1 .

( A), 2

( A). 2

( B).

4

( D) ( A). , 4

.

.

IgE ( B).

. ,

.

4.3-1

.

. 1-3

3 . 2

1 .

74

3-4 .

3-4 .

.

.

. 5

.

.

,

.

( 4 , 4 ).

.

.

.

3 50%

( B).

1

( A).

2

75

50% 2 ( B).

2 ( D).

1 . 2

( B).

2

,

( D).

1

( D).

. .

.

.

2

( A). 4

( A). 7-14

.

(rapid-onset, long-acting) 2

. 2 2

76

4

.

.

2

( 4 4 ).

. ,

.

( 4.3-1),

. 4 ,

.

.

6

.

.

.

. (vocal cord

dysfunction) .

.

.

.

77

.

.

.

. , , ,

.

. ,

.

.

.

.

.

. ,

3-6

( D). ,

,

IgE

.

80

( ) , .

PEF FEV1 .

. ,

.

.

PEF

.

1 2 ,

81

.

.

-

- 1

-

-

- 2

-

-

.

.

. 4.4-1

.

. 20% PEF

1

.

1 .

.

1 20 2 2-4

82

. 3-4 2-4

1-2 6-10 .

.

PEF .

(MDI) .

80% 3-4

.

>30/

,

<100 100-120 >120

<10mmHg

10-25mmHg

>25mmHg

>80% 60-80%<60% (<100L/min)

<2

<45mmHg

>60mmHg

<45mmHg

<60mmHg

>45mmHg

>95% 91-95% <90%

83

(prednisolone 0.5-1mg/kg /24 )

2 1

80% .

.

. 4.4-2 .

.

,

, , ,

. ,

, , , .

PEF FEV1 .

.

(pulse oximetry) .

, 95% .

92% ( C).

X .

X

.

30-50% . PaO2

60mmHg PaCO2 ( >45mmHg)

.

84

•

• • •

• •

• •

• • • •

•

•

•

• • •

• • • •

• • • • •

• • • • •

• • • • • •

•

• •

• •

• •

•

• • •

• • • •

85

90% ( 95% ) (nasal

cannulae) . 100% PaCO2

. (oximetry) .

2 ( A). 2

(formoterol)

.

.

. 2

.

.

.

2

( B), ( A), , β2

(aminophylline) .

2

.

. β2

, (respiratory drive) β

(D).

1 ,

86

(D).

.

. .

- 2

-

-

. ,

.

4

(methylprednisolone) 60-80mg 1 ,

(hydrocortisone) 300-400mg . 40mg

, 200mg ( B). 7

14 , 3-5 1mg/kg

( B). ( B).

2

( B).

( B).

( 2.4mg ) 40mg

( A).

(20 2g 1 )

. FEV1 25-30% 1 60%

( A). (salbutamol)

( A).

87

.

.

.

.

. .

( ) 25% 40%

.

40-60%

. 60% .

.

- 7 ( 2

) .

- 2 .

- (ipratropium) .

- .

-

.

- .

- .

- .

.

-

.

88

.

. ,

,

( A). .

.

90

, , , , , , , ,

, .

. 1/3 1/3

1/3 .

,

.

.

, ,

.

.

.

, , .

, , , 2

.

( B).

. , ,

.

.

.

, ,

. ,

, . , ,

. 1

80%

91

( C). 6

24 .

, 100mg 8

24 ( C).

,

.

, 30%

. ,

. , ,

, ,

. Allergic Rhinitis and its Impact on Asthma (ARIA)

,

.

,

, .

, ,

.

( A). , ,

. H1

,

( A). ,

. ,

IgE ( A).

, , ,

. .

,

. , 10 ( B).

92

.

, , 40

. 36-96% , 29-

70% .

.

.

.

. ,

,

.

. .

.

, .

(respiratory syncytial virus) , (rhinovirus)

, (parainfluenza), (influenza),

(adenovirus) (coronavirus) .

, - IgE ,

, .

.

,

4 .

, .

. .

93

3 ,

. (hiatal hernia)

, 2

.

. 1 , ,

, , .

, H2-

proton-pump inhibitor .

, .

.

28%

, .

, 20-30 .

. .

, , , ,

. , ,

, .

70% LTC4 (LTC4 synthase)

,

. .

, cyclooxygenase

. ,

.

94

, ,

. FEV1 70%

. (lysine-aspirin)

.

. , COX-1

hydrocortisone hemisuccinate .

.

COX-2

( B). ,

( B).

,

.

600-1,200mg

.

NSAID acetaminophen .

98

.

.

, ,

.

,

‘ ’ .

.

.

.

( : )

.

,

.

, , , ,

. , ,

99

.

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,

. ,

.

. ,

.

.

, .

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.

. .

? ? ( ,

) ?

?

? ? ? ? / / ? ? ? ( : , , 10 , ) ? ( / /

/ ) ? ? ? ( : )

100

.

.

. ,

(http://www.nationalasthma.org.au) (http://www.nhlbi.nih.gov) .

.

.

.

( : Asthma Control Test, Asthma Control

Questionnaire, Asthma Therapy Assessment Questionnaire).

.

.

.

.

.

.

.

(EAM: Easy

asthma management) .

IT

.

IT ,

EAM . EAM PC (personal computer)

. EAM

.

(ACT) .

EAM (www.kaaf.org)

.

101

.

.

. ,

.

.

35-50%

. ,

, .

, ,

.

.

.

.

.

2 .

(

)

.

( :

, ), ,

, ( , )

.

.

.

102

.

, , , .

,

.

50% .

2 , 2 50% .

,

.

.

. (

)

(QALY: Quality adjusted life

years) .

. QALY .

.

.

QALY .

GINA

GINA

(http://www.ginasthma.org). GINA

GINA GINA working group .

GINA .

, ,

.

. , ,

103

GINA

GINA 1995

. (www.allergy.or.kr), (www.

kaim.or.kr), (www.kaaf.org), (www.guideline.

or.kr) .

1998 5 GINA

.

, , .

, ,

. , , ,

. ,

, ,

, , . GINA

.

. GINA GINA

GINA

.

GINA 2005 1

.

, , .

GINA WHO GARD (http://www.who.int/respiratory/gard/en/)

. 2007

104

GARD KOREA . GARD

.

. (http://www.

GlobalADF.org) GARD

(international Union Against Tuberculosis and Lung

Disease; IUATLD) .

108

(

.)

.

, ,

, .

.

, .

.

10 .

.

■ ( )

■

■ , ( )

■

■ ( , )

■

■

■

■

■

:

.

109

(FEV1 12%, 200mL

) .

.

-2 / 3 /

/

-2 / 3 /

(PEF FEV1) ‡ < 80%

: , , , FEV1, , .

* ‘ ’ . 5 .

110

■ 2 ,

2 , , .

■ 2

.

2-3 ‘ ’,

‘ ’, ‘ ’ 3

.

.

4 .

Beclomethasone dipropionateBudesonide CiclesonideFlunisolideFluticasone propionateMometasone furoateTriamcinolone acetonide

200-500200-40080-160

500-1,000100-250200-400

400-1,000

> 500-1,000> 400-800> 160-320

> 1,000-2,000> 250-500> 400-800

> 1,000-2,000

> 1,000-2,000> 800-1,600> 320-1,280

> 2,000> 500-1,000> 800-1,200

> 2,000

111

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•

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• •

• •

• •

•

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112

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ISBN 978-89-90698-63-6 (93510)

2011년 개정판

한국 성인 천식의

진료 지침Korean Asthma Mananement

Guideline for Adults

한국 성인 천식의 진료 지침 · 2014. 10. 24. · 2011년 개정판...

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