2026-01-27 10:00AM
重點整理
一. 非藥物治療包括下降, 給氧氣.二. 藥物治療包括:
1. Nifedipine: 可作為氧氣和下降的輔助治療. 或沒有氧氣也無法下降的輔助治療. 但實驗證據不夠多.
2. Tadalafil/sildenafil:
3. dexamethasone: 學理上有效但沒有臨床試驗證實, 目前建議用於合併AMS/HACE的 HAPE病患
4. beta agonist: 也許有效但沒有臨床試驗證實
三. 無效(且可能有危害)的藥物包括: 其他利尿劑, 硝化甘油, 嗎啡.
Pharmacologic interventions — 藥物治療
A summary of medications used to treat HAPE is provided (table 4). More thorough discussions of these treatments are found below.
Nifedipine 透過降低肺血管阻力及肺動脈壓(但也會降低全身血管阻力與血壓). 可稍微改善動脈氧分壓(PaO2), 最常使用的劑量是每12小時 30mg(這是根據臨床經驗而非實驗數據). 用於健康人不太會造成明顯低血壓
高海拔肺水腫患者若處於脫水狀態. 給予 nifedipine 可能會造成血壓過低. 因此臨床醫師根據病程進展. 應準備隨時給予等張靜脈輸液(例如生理食鹽水)
Nifedipine — In the field setting, oxygen and descent remain the most important treatments for HAPE. Nifedipine may be considered adjunctive therapy when oxygen is unavailable and descent is difficult or impossible, although little clinical evidence supports the practice. (See 'General approach to treatment' above.)
Nifedipine is a nonspecific calcium channel blocker that acts by reducing pulmonary vascular resistance and PA pressure, as well as systemic resistance and blood pressure. It also slightly improves PaO2.
Recommended dosages vary, but a common regimen is to give 30 mg of a slow release formulation every 12 hours. Nifedipine is well tolerated by most patients and is unlikely to cause significant hypotension in previously healthy persons. Clinicians should give or be prepared to give isotonic intravenous fluid (eg, normal saline) to any critically ill HAPE patient who may be intravascularly depleted and is receiving nifedipine.
One unblinded uncontrolled study of six patients with HAPE found that nifedipine treatment led to clinical improvement [40]. However, another observational study involving 133 patients with HAPE reported that nifedipine offered no advantage when used as an adjunct to oxygen and descent [30].
Nifedipine is a nonspecific calcium channel blocker that acts by reducing pulmonary vascular resistance and PA pressure, as well as systemic resistance and blood pressure. It also slightly improves PaO2.
Recommended dosages vary, but a common regimen is to give 30 mg of a slow release formulation every 12 hours. Nifedipine is well tolerated by most patients and is unlikely to cause significant hypotension in previously healthy persons. Clinicians should give or be prepared to give isotonic intravenous fluid (eg, normal saline) to any critically ill HAPE patient who may be intravascularly depleted and is receiving nifedipine.
有一個非隨機研究, 六個HAPE患者使用nifedipine之後臨床狀況有改善. 但另一個觀察性研究, 有133位病患. 在使用氧氣及降低海拔高度時. 使用 nifedipine 並未獲得更多好處.
One unblinded uncontrolled study of six patients with HAPE found that nifedipine treatment led to clinical improvement [40]. However, another observational study involving 133 patients with HAPE reported that nifedipine offered no advantage when used as an adjunct to oxygen and descent [30].
Tadalafil and sildenafil — 威而鋼/犀利士
PDE-5i 透過阻斷cGMP降解而增加一氧化氮對肺血管的擴張效果.
一氧化氮是很強的肺血管擴張劑, 可降低缺氧性肺血管收縮. 降低HAPE患者的肺動脈壓. 威而鋼與犀利士可預防 HAPE. 但尚未在實驗證實能治療 HAPE
Tadalafil and sildenafil are phosphodiesterase-5 (PDE-5) inhibitors that augment the pulmonary vasodilatory effects of nitric oxide by blocking the degradation of cyclic guanosine monophosphate (cGMP), the intracellular mediator of nitric oxide. Nitric oxide is a potent pulmonary vasodilator and reduces hypoxic pulmonary vasoconstriction (HPV) and pulmonary hypertension in HAPE [5]. Both tadalafil and sildenafil have been shown to be effective as prophylaxis for HAPE, but neither has been studied as treatment [41-43]. (See 'Prophylactic medications' below.)
依照藥物作用機轉. 威而鋼/犀利士應該可以作為HAPE輔助治療(在無法取得氧氣. 無法降低海拔高度時使用)
威而鋼/犀利士由於 nifedipine 之處在於比較不會降低全身血壓. 用於輔助治療HAPE的劑量未知. 但比照使用於預防HAPE劑量應該是可以的.
威而鋼 每次10mg, 每12小時一次
犀利士 每次50mg, 每8小時一次
Nevertheless, based upon their mechanism of action, both tadalafil and sildenafil may be effective adjunct treatments for established HAPE when neither oxygen nor descent is an available option. These drugs may have advantages over nifedipine because they lower PA pressure with less risk of lowering systemic blood pressure. The appropriate dose for treatment is unknown but might be similar to that used for prophylaxis (tadalafil 10 mg by mouth every 12 hours; sildenafil 50 mg by mouth every eight hours).
類固醇-地塞米松
類固醇也許可用於預防 HAPE. 但是否能治療 HAPE 則未被研究過.
當
Dexamethasone — Although glucocorticoids may have a role in prophylaxis, they have not been studied as treatment for HAPE. We reserve glucocorticoids for treatment of high altitude cerebral edema or severe acute mountain sickness, which may co-exist with HAPE. (See 'Prophylactic medications' below.)
Dexamethasone — Although glucocorticoids may have a role in prophylaxis, they have not been studied as treatment for HAPE. We reserve glucocorticoids for treatment of high altitude cerebral edema or severe acute mountain sickness, which may co-exist with HAPE. (See 'Prophylactic medications' below.)
乙型作用劑(氣管擴張劑) 或許能用於治療HAPE.但尚未有研究.
(註: 其他成因肺水腫, 例如心衰竭, 腎衰竭, 過度輸液等等. 使用氣管擴張劑無效).
Beta agonist —
(註: 其他成因肺水腫, 例如心衰竭, 腎衰竭, 過度輸液等等. 使用氣管擴張劑無效).
Beta agonist —
Salmeterol may be useful in the treatment of HAPE, but this remains unstudied. (See 'Prophylactic medications' below.)
對HAPE無效或禁忌的治療方式:
利尿劑 硝化甘油 , 嗎啡
Ineffective or contraindicated therapies — Diuretic therapy, nitrates, and morphine are no longer recommended in the treatment of HAPE and could be harmful.
Ineffective or contraindicated therapies — Diuretic therapy, nitrates, and morphine are no longer recommended in the treatment of HAPE and could be harmful.
沒有留言:
張貼留言