170-176/362Epiglottitis F

∫∑§«“¡«‘ ™ “°“√
Ω“ªî¥°≈àÕ߇ ’¬ßÕ—°‡ ∫
‡©’¬∫æ≈—π
(Acute Epiglottitis)
ª“√¬– Õ“»π–‡ π æ.∫.
√Õß»“ µ√“®“√¬å
¿“§«‘™“ ‚ µ π“ ‘° ≈“√‘ß´å«‘∑¬“
§≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈
¡À“«‘∑¬“≈—¬¡À‘¥≈
Ω“ªî¥°≈àÕ߇ ’¬ßÕ—°‡ ∫‡©’¬∫æ≈—π (acute epiglottitis) ‡ªìπ‚√§∑’Ë
¡’§«“¡√ÿπ·√ß ·≈–Õ“®Õ—πµ√“¬∂÷ß™’«‘µ‰¥â ‡π◊ËÕß®“° “¡“√∂°àÕ„À⇰‘¥¿“«–
Õÿ¥°—Èπ¢Õß∑“߇¥‘πÀ“¬„® à«πµâπ (upper airway obstruction) Õ¬à“ß
‡©’¬∫æ≈—π‰¥â¿“¬„π√–¬–‡«≈“Õ—π —Èπ ‡æ’¬ß‰¡à°’Ë™—Ë«‚¡ß ·≈– “¡“√∂‡°‘¥¢÷Èπ‰¥â
„πºŸâ∑’Ë¡’ ÿ¢¿“æ·¢Áß·√ߥ’¡“µ≈Õ¥. ‚¥¬∑—Ë«‰ª·≈â« epiglottitis ¡—°‡°‘¥„π‡¥Á°
‡≈Á°Õ“¬ÿ 2-6 ªï Õ¬à“߉√°Áµ“¡ “¡“√∂æ∫‚√§π’ȉ¥â„π∑ÿ°Õ“¬ÿ ·¡â·µàÕ¥’µ
ª√–∏“π“∏‘∫¥’¢Õß À√—∞Õ‡¡√‘°“ George Washington °Á‡ ’¬™’«‘µ¥â«¬‚√§∑’Ë
¡’Õ“°“√·≈–Õ“°“√· ¥ß‡¢â“‰¥â°—∫ epiglottis ´÷Ëß„π¢≥–π—Èπ ªï æ.». 2342
√Ÿâ®—°°—π„π™◊ËÕ¢Õß Cynanche trachealis.1 ºŸâªÉ«¬®–¡’°“√Õ—°‡ ∫·≈–∫«¡¢Õß
epiglottis ·≈– supraglottic structures Õ◊ËπÊ ‰¥â·°à aryepiglottic folds
·≈– arytenoids ¥—ßπ—Èπ°“√«‘π‘®©—¬«à“ acute supraglottitis ®÷ßπà“®–‰¥â
§«“¡À¡“¬∑’Ë∂Ÿ°µâÕß·≈–§√Õ∫§≈ÿ¡°«à“.
“‡Àµÿ
Acute supraglottitis ‡°‘¥®“°°“√Õ—°‡ ∫µ‘¥‡™◊ÕÈ ‚¥¬‡™◊ÕÈ °àÕ‚√§∑’ Ë ”§—≠
·≈–æ∫∫àÕ¬∑’Ë ÿ¥‚¥¬‡©æ“–„π°≈ÿࡺŸâªÉ«¬‡¥Á°§◊Õ Hemophilus influenzae
type B (HIB). ‡™◊ÈÕ HIB π’È¡—°¡’§«“¡√ÿπ·√ß °àÕ„À⇰‘¥ªí≠À“°“√Õÿ¥°—Èπ∑“ß
‡¥‘πÀ“¬„®‰¥â∫àÕ¬ ·≈–¡’√–¬–‡«≈“°“√¥”‡π‘π‚√§∑’Ë —Èπ ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫
‡™◊ÈÕ™π‘¥Õ◊ËπÊ. πÕ°®“°π’È HIB ¬—ß “¡“√∂°√–®“¬‰ªµ“¡°√–· ‡≈◊Õ¥ °àÕ„Àâ
‡°‘¥‚√§Õ◊ËπÊ µ“¡¡“‰¥â ‡™àπ meningitis, pneumonia, arthritis ‡ªìπµâπ.
‡™◊ÕÈ °àÕ‚√§™π‘¥Õ◊πË Ê2-7 ∑’æË ∫«à“‡ªì𠓇Àµÿ¢Õß acute supraglottitis √Õß≈ß¡“
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‰¥â·°à group-A ·≈– non group-A beta-hemolytic Streptococcus, Streptococcus pneumoniae, alpha hemolytic Streptococcus, Staphylococcus aureus,
Pseudomonas species, Candida albicans, non-typable Hemophilus influenzae, Hemophilus parainfluenzae, Escherichia coli, Enterobacter cloacae,
Pasteurella multocida, Varicella zoster ‡ªìπµâπ. πÕ°®“°π’È Õ—πµ√“¬®“°‰Õ§«“¡
√âÕπ °Á “¡“√∂∑”„À⇰‘¥°“√∫«¡ ·≈–Õ—°‡ ∫¢Õß supraglottic structures ‰¥â‡™àπ°—π.
”À√—∫ºŸªâ «É ¬ºŸ„â À≠à æ∫«à“ HIB ¬—ߧ߇ªìπ‡™◊ÕÈ °àÕ‚√§∑’ Ë ”§—≠ ·µàæ∫«à“¡’‡™◊ÕÈ °àÕ‚√§™π‘¥Õ◊πË Ê
„π —¥ à«π∑’ˇæ‘Ë¡¡“°¢÷Èπ.
Õÿ∫—µ‘°“√≥å
Õÿ∫—µ‘°“√≥å¢Õß‚√§π’Èæ∫‰¥â§àÕπ¢â“ßπâÕ¬ ‚¥¬‡©æ“–À≈—ß®“°∑’Ë¡’°“√‡√‘Ë¡„™â HIB
vaccine Õ¬à“ß·æ√àÀ≈“¬„π™à«ßªï æ.». 2528-2533 À≈“¬Ê ª√–‡∑»∑“ßµ–«—πµ°¡’
Õÿ∫—µ‘°“√≥å¢Õß‚√§π’È„πºŸâªÉ«¬‡¥Á°≈¥≈ßÕ¬à“ß™—¥‡®π2,3,8 „π∑“ßµ√ß°—π¢â“¡ ºŸâªÉ«¬ºŸâ„À≠à
¡’Õ∫ÿ µ— °‘ “√≥å¢Õß‚√§π’„È π —¥ à«π∑’¡Ë “°¢÷πÈ .2,9 ®“°°“√»÷°…“„π Rhode Island2 ª√–‡∑»
À√—∞Õ‡¡√‘°“„π™à«ßªï æ.». 2518-2535 ¡’ºŸâªÉ«¬‚√§ acute supraglottitis ∑—ÈßÀ¡¥
407 √“¬ æ∫«à“Õÿ∫—µ‘°“√≥å¢Õß‚√§π’È„π‡¥Á°≈¥≈ßÕ¬à“ß™—¥‡®π®“° 6.1 √“¬µàÕª√–™“°√
100,000 §π„π™à«ß 3 ªï·√°¢Õß°“√»÷°…“ ‡À≈◊Õ‡æ’¬ß 0.3 √“¬µàÕª√–™“°√ 100,000
§π„π™à«ß 3 ªï ÿ¥∑⓬¢Õß°“√»÷°…“ „π¢≥–∑’Ë°≈ÿࡺŸâ„À≠à æ∫«à“¡’Õÿ∫—µ‘°“√≥å¢Õß‚√§
π’ȇæ‘Ë¡¢÷Èπ®“° 0.78 √“¬ ‡ªìπ 2.9 √“¬µàÕª√–™“°√ 100,000 §π ‡¡◊ËÕ‡∑’¬∫™à«ß√–¬–
‡«≈“ 3 ªï·√°·≈– 3 ªï ÿ¥∑⓬¢Õß°“√»÷°…“ ·≈–¬—ßæ∫«à“ —¥ à«π¢ÕߺŸâªÉ«¬¡’°“√
‡ª≈’ˬπ·ª≈߉ª®“°®”π«πºŸâªÉ«¬ºŸâ„À≠à∑’ˇªìπ‚√§π’ȇ撬ß√âÕ¬≈– 31 „π™à«ß 3 ªï·√°
‡æ‘Ë¡¢÷Èπ‡ªìπ√âÕ¬≈– 97 „π™à«ß 3 ªï ÿ¥∑⓬ ®“°·π«‚πâ¡¥—ß°≈à“«∑”„Àâ acute supraglottitis ¡’∫∑∫“∑¡“°¢÷Èπ„π°≈ÿࡺŸâªÉ«¬ºŸâ„À≠à Õ¬à“߉√°Áµ“¡ ∂÷ß·¡â«à“Õÿ∫—µ‘°“√≥å¢Õß
‚√§π’È‚¥¬√«¡®–‰¡à¡“°. ·µà ‘Ëß ”§—≠§◊Õ §«√„Àâ°“√«‘π‘®©—¬‚√§π’ȉ¥âµ—Èß·µà‡π‘ËπÊ ·≈–
„Àâ°“√√—°…“∑’Ë∂Ÿ°µâÕß ‡æ◊ËÕªÑÕß°—π‰¡à„À⇰‘¥¿“«–·∑√°´âÕπµàÕ√–∫∫∑“߇¥‘πÀ“¬„®∑’Ë
√ÿπ·√ß∂÷ß·°à™’«‘µ.
ºŸ™â “¬®–¡’‚Õ°“ ‡ªìπ‚√§π’‰È ¥â ߟ °«à“ºŸÀâ ≠‘ß2,7,9,10 ·≈– “¡“√∂æ∫‚√§π’‰È ¥â„π∑ÿ°™à«ß
‡«≈“¢Õßªï ‚¥¬¡’Õ—µ√“§«“¡™ÿ°¢Õß‚√§‰¡à·µ°µà“ß°—π¡“°π—°„π·µà≈–ƒ¥Ÿ°“≈.2,9,10
≈—°…≥–∑“ߧ≈‘π°‘
‡¡◊ËÕ‡°‘¥°“√Õ—°‡ ∫ Ω“ªî¥°≈àÕ߇ ’¬ß (epiglottis) ®–∫«¡¡“°¢÷Èπ‡√◊ËÕ¬Ê (¿“æ∑’Ë
1) ∫“ߧ√—ÈßÕ“®æ∫µÿà¡ÀπÕ߇≈Á°Ê ‡°‘¥¢÷Èπ‚¥¬‡©æ“–∫√‘‡«≥ lingual surface ∑”„Àâ
epiglottis ∂Ÿ°‡∫’¬¥ ·≈–¡â«πµ—«‰ª∑“ߥâ“πÀ≈—ß·≈–≈ß≈à“ß ∑“߇¥‘πÀ“¬„® à«π laryngeal inlet ®–∂Ÿ°ªî¥°—Èπ‰ª∑’≈–πâÕ¬ ‡ ¡À–·≈–πÈ”≈“¬∫√‘‡«≥π’È®–¡’ª√‘¡“≥¡“°¢÷Èπ
‡π◊ËÕß®“°Õ“°“√°≈◊π‡®Á∫·≈–°≈◊π≈”∫“°¢ÕߺŸâªÉ«¬ ´÷Ëß¡’ à«π´È”‡µ‘¡ ∑”„Àâ∑“߇¥‘π
À“¬„® à«π∫π∂Ÿ°Õÿ¥°—Èπ‰¥â¡“°¢÷Èπ.
°ÿ¡¿“æ—π∏å 2558 171
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ºŸâªÉ«¬®–¡’Õ“°“√‰¢â, À“¬„®≈”∫“°, ‡®Á∫§Õ ·≈–°≈◊π≈”∫“° Õ“®¡’Õ“°“√ª«¥ÀŸ
‡π◊ËÕß®“° referred pain ‰¥â.2 °“√µ√«®√à“ß°“¬æ∫«à“ ºŸâªÉ«¬¡—°À“¬„®‡√Á«, À“¬„®‡¢â“
ÕÕ°™à«ß —ÈπÊ ‡æ◊ËÕ≈¥°“√‡§≈◊ËÕπ‰À«¢Õß supraglottic area ºŸâªÉ«¬®–欓¬“¡®”°—¥
°‘®°√√¡¢Õßµ—«‡Õß ‚¥¬°“√π—Ëßπ‘ËßÊ ‚π⡵—«‰ª¥â“πÀπâ“ „™â¡◊Õ∑—Èß Õߢâ“ߧȔ¬—π‰«â ‡™‘¥
§Õ·≈–¬◊Ëπ§“߉ª¥â“πÀπâ“ ‡æ◊ËÕ∑”„Àâ∑“߇¥‘πÀ“¬„®‚≈àß¡“°∑’Ë ÿ¥ æ∫≈—°…≥–¢Õß°“√
Õÿ¥°—πÈ ∑“߇¥‘πÀ“¬„® à«πµâπ‰¥â„π√–¥—∫§«“¡√ÿπ·√ßµà“ßÊ µ—ßÈ ·µàπÕâ ¬‰ª®π∂÷ß¡“° ‰¥â·°à
tachypnea, dyspnea, retraction of chest wall, inspiratory stridor. ºŸâªÉ«¬¡’
πÈ”≈“¬‰À≈¬âÕ¬ÕÕ°∑“ß¡ÿ¡ª“° (drooling) °≈◊π‡®Á∫ (odynophagia) ·≈–°≈◊π≈”∫“°
(dysphagia) ‡ ’¬ß查®–‡ª≈’Ë¬π‰ª ¡’≈—°…≥–·∫∫ muffled voice. °“√µ√«®√à“ß°“¬
∫√‘‡«≥ oral cavity ·≈– oropharynx π—È𠧫√∑”¥â«¬§«“¡πÿà¡π«≈ ·≈–‰¡à·π–π”
„ÀâΩóπµ√«®¥â«¬§«“¡√ÿπ·√ß À√◊Õ„™â‰¡â°¥≈‘Èπ‚¥¬‡©æ“–„π°≈ÿࡺŸâªÉ«¬‡¥Á° ·≈–ºŸâªÉ«¬∑’Ë
¡’°“√Õÿ¥°—Èπ∑“߇¥‘πÀ“¬„® à«πµâπ ‡π◊ËÕß®“°Õ“®∑”„À⇰‘¥ laryngospasm ‰¥âßà“¬.
ºŸâªÉ«¬„π·µà≈–√“¬ Õ“®¡’√–¥—∫§«“¡√ÿπ·√ß Õ“°“√ ·≈–Õ“°“√· ¥ß∑’Ë·µ°µà“ß
°—πÕÕ°‰ª ¢âÕ ”§—≠§◊Õ„π°≈ÿࡺŸâªÉ«¬‡¥Á°∑’ˇªìπ acute supraglottitis ¡—°¡’Õ“°“√
√ÿπ·√ß°«à“ ·≈–¡—°¡’°“√Õÿ¥°—Èπ¢Õß∑“߇¥‘πÀ“¬„® à«πµâπ‰¥âßà“¬°«à“ ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫
°—∫ºŸâ„À≠à. ºŸâªÉ«¬‡¥Á°∑’ˇªìπ‚√§π’È®÷ß¡’‚Õ°“ ‡°‘¥ sudden laryngospasm ·≈– respiratory arrest ‰¥âµ≈Õ¥‡«≈“. ‘Ëß∑’Ë¡’§«“¡ —¡æ—π∏å°—∫§«“¡√ÿπ·√ߢÕß°“√Õÿ¥°—Èπ∑“߇¥‘π
À“¬„® à«πµâπ§◊Õ respiratory difficulty, stridor, drooling ·≈– Hemophilus influenzae bacteremia „π¢≥–∑’˺ŸâªÉ«¬∑’Ë¡’Õ“°“√‡®Á∫§Õ ·≈–°≈◊π≈”∫“°‡ªìπÀ≈—° ¡—°¡’
°“√¥”‡π‘π¢Õß‚√§∑’ˉ¡à√ÿπ·√ß ·≈–¡’‚Õ°“ ‡°‘¥°“√Õÿ¥°—Èπ∑“߇¥‘πÀ“¬„® à«πµâπ‰¥â
πâÕ¬°«à“.2
°“√ ◊∫§âπ‡æ‘Ë¡‡µ‘¡
°“√ àß lateral neck radiograph ‡æ◊ËÕ¥Ÿ‡ß“¢Õß supraglottic structures ¡’
à«π™à«¬„π°“√«‘π‘®©—¬‚√§π’È ·µà¬—߇ªìπ∑’Ë∂°‡∂’¬ß∂÷ߧ«“¡®”‡ªìπ·≈–§«“¡ª≈Õ¥¿—¬„π
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°“√ àßµ√«® ‡π◊ËÕß®“°ºŸâªÉ«¬¡’·π«‚πâ¡∑’Ë®–‡°‘¥°“√Õÿ¥°—Èπ¢Õß∑“߇¥‘πÀ“¬„® à«πµâπ
‰¥âµ≈Õ¥‡«≈“ ‚¥¬‡©æ“–‡¡◊ËÕ‰¥â√—∫°“√°√–µÿâπ‰¡à«à“®–‡ªìπ°“√µ√«®, °“√‡®“–‡≈◊Õ¥,
°“√√âÕ߉Àâ¢ÕߺŸâªÉ«¬ √«¡∑—Èß°“√®—¥∑à“ºŸâªÉ«¬„π¢≥–∂à“¬¿“æ‡Õ°´‡√¬å. πÕ°®“°π’È „π
ÀâÕß∂à“¬¿“æ‡Õ°´‡√¬å ¡—°‰¡à¡’§«“¡æ√âÕ¡„π°“√¥Ÿ·≈ºŸâªÉ«¬ ‡¡◊ËÕ‡°‘¥¿“«–©ÿ°‡©‘π¢÷Èπ
°“√µ—¥ ‘π„® àßµ√«® lateral neck radiograph ®÷ߧ«√æ‘®“√≥“‡ªìπ√“¬Ê ‰ª ‚¥¬
·π–π”„Àâ àßµ√«® „π°√≥’∑’Ë°“√«‘π‘®©—¬‚√§¬—߉¡à™—¥‡®π·≈–ºŸâªÉ«¬¬—߉¡à¡’ªí≠À“∑“ß
‡¥‘πÀ“¬„®Õÿ¥°—Èπ ·æ∑¬å§«√‡ΩÑ“¥Ÿ·≈ºŸâªÉ«¬Õ¬à“ß„°≈♑¥ ¢≥–ºŸâªÉ«¬∂Ÿ° à߉ªµ√«®
·≈–·æ∑¬å§«√‡ªìπºŸâ®—¥∑à“ºŸâªÉ«¬‡Õߥ⫬§«“¡πÿà¡π«≈ „π¢≥–∑’Ë àߺŸâªÉ«¬‰ªµ√«®
·æ∑¬å§«√¡’‡§√◊ËÕß¡◊Õ·≈–Õÿª°√≥凵√’¬¡æ√âÕ¡„π°“√¥Ÿ·≈∑“߇¥‘πÀ“¬„® ‡¡◊ËÕ‡°‘¥°“√
Õÿ¥°—Èπ∑“߇¥‘πÀ“¬„®¢÷Èπ.
°“√µ√«® lateral neck radiograph „πºŸâªÉ«¬ acute supraglottitis ®–æ∫‡ß“
¢Õ߇π◊ÈÕ‡¬◊ËÕ∫√‘‡«≥ epiglottis ·≈– aryepiglottic fold ∑’Ë∫«¡Àπ“¢÷Èπ (thumb sign)
∫√‘‡«≥ vallecula ´÷Ë߇§¬¡’‡ß“¢Õß≈¡Õ¬Ÿà°Á®–À“¬‰ª (vallecula sign)11 (¿“æ∑’Ë 2)
·≈–¡’ distention ¢Õß hypopharynx Õ¬à“߉√°Áµ“¡ ºŸâªÉ«¬∫“ß√“¬Õ“®¡’º≈∂à“¬¿“æ
‡Õ°´‡√¬åª°µ‘‰¥â.
°“√‡®“–‡≈◊Õ¥ °“√ àß hemoculture °“√∑” pharyngeal À√◊Õ supraglottic
culture §«√∑”À≈—ß®“°∑’ Ë “¡“√∂§«∫§ÿ¡∑“߇¥‘πÀ“¬„®¢ÕߺŸªâ «É ¬‰¥âÕ¬à“ߪ≈Õ¥¿—¬·≈â«
º≈°“√µ√«®‡≈◊Õ¥®–æ∫≈—°…≥–¢Õß leukocytosis ‡π◊ËÕß®“°‡ªìπ bacterial infection
º≈¢Õß hemoculture ·≈– supraglottic culture ®–„Àâº≈∫«°ª√–¡“≥√âÕ¬≈– 11752,7,9 ¢÷Èπ°—∫«à“¡’°“√„À⬓µâ“π®ÿ≈™’æ°àÕπ°“√‡æ“–‡™◊ÈÕÀ√◊Õ‰¡à ‡™◊ÈÕ à«π„À≠à®–‡ªìπ HIB
À≈—ß®“°¡’°“√„™â HIB vaccine Õ¬à“ß·æ√àÀ≈“¬ æ∫«à“¡’√“¬ß“π¢Õ߇™◊ÈÕ™π‘¥π’È≈¥≈ß
‚¥¬¡’Õÿ∫—µ‘°“√≥å¢Õ߇™◊ÈÕ„π°≈ÿà¡ Streptococcus ‡æ‘Ë¡¡“°¢÷Èπ.2,3,6,8
°“√√—°…“
§«“¡√à«¡¡◊Õ°—π√–À«à“ß °ÿ¡“√·æ∑¬å, ‚ µ »Õ π“ ‘°·æ∑¬å ·≈–«‘ —≠≠’·æ∑¬å
‡ªìπ ‘Ëß ”§—≠„π°“√¥Ÿ·≈ºŸâªÉ«¬ acute supraglottitis ‡æ◊ËÕ„À≥Ⱃ√«‘π‘®©—¬‚√§∑’Ë
√«¥‡√Á« ·≈–ªÑÕß°—π‰¡à„À⇰‘¥¿“«–·∑√°´âÕπ∑’Ë√ÿπ·√ß∂÷ß™’«‘µ. „π°≈ÿࡺŸâªÉ«¬‡¥Á° §«√
À≈’°‡≈’ˬ߰“√√∫°«πºŸâªÉ«¬‚¥¬‰¡à®”‡ªì𠇙àπ °“√‡®“–‡≈◊Õ¥, °“√„ÀâπÈ”‡°≈◊Õ, °“√
æ—π∏π“°“√‡¥Á° ‡æ◊ËÕ°“√µ√«®§Õ·≈–‡Õ°´‡√¬å §«√Õπÿ≠“µ„ÀâæàÕ ·¡àÀ√◊ÕºŸâ¥Ÿ·≈Õ¬Ÿà
„°≈♑¥ºŸâªÉ«¬‡æ◊ËÕ≈¥§«“¡«‘µ°°—ß«≈¢Õ߇¥Á° ´÷ËßÕ“®∑”„Àâªí≠À“°“√Õÿ¥°—Èπ∑“߇¥‘π
À“¬„®·¬à≈߉¥â
1. °“√§«∫§ÿ¡∑“߇¥‘πÀ“¬„®„ÀâÕ¬Ÿ„à π¿“«–∑’ª
Ë ≈Õ¥¿—¬ (safe airway control) ‡ªìπ ‘ßË ”§—≠∑’ Ë ¥ÿ „π°“√¥Ÿ·≈ºŸªâ «É ¬‚√§π’.È „πÕ¥’µ°“√‡®“–À≈Õ¥≈¡§Õ (tracheostomy) ‡§¬‡ªìπ«‘∏’Àπ÷Ëß„π°“√§«∫§ÿ¡∑“߇¥‘πÀ“¬„®„πºŸâªÉ«¬°≈ÿà¡π’È ®π°√–∑—Ëß„π™à«ß
20 ªï∑º’Ë “à π¡“ ‡∑§π‘§„π°“√„ à∑Õà ™à«¬À“¬„® (endotracheal intubation) ¡’°“√æ—≤π“
·≈–¡’§«“¡ª≈Õ¥¿—¬ Ÿß¡“°¢÷Èπ. ªí®®ÿ∫—π°“√„ à endotracheal tube ∂◊Õ‰¥â«à“‡ªìπ
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«‘∏’¡“µ√∞“π„π°“√¥Ÿ·≈∑“߇¥‘πÀ“¬„®¢ÕߺŸâªÉ«¬‚√§π’È Õ¬à“߉√°Á¥’ °“√µ—¥ ‘π„®„ à
endotracheal tube °Á¬—߇ªìπ∑’Ë∂°‡∂’¬ß°—πæÕ ¡§«√ ·≈–·π–π”„Àâæ‘®“√≥“Õ¬à“ß
√Õ∫§Õ∫¥—ßπ’È
1.1 „π°√≥’ ∑’Ë ºŸâ ªÉ « ¬¡“æ∫·æ∑¬å ¥â « ¬ªí ≠ À“°“√Õÿ ¥ °—È π ¢Õß∑“߇¥‘ π À“¬„®
Õ¬à“ß√ÿπ·√ß ·≈–®”‡ªìπµâÕ߉¥â√—∫°“√§«∫§ÿ¡∑“߇¥‘πÀ“¬„®Õ¬à“߇√àߥà«π∑—π∑’ ‡æ◊ËÕ
√—°…“™’«‘µºŸâªÉ«¬‰«â ·π–π”„Àâ欓¬“¡„ à orotracheal tube ‡ªìπ≈”¥—∫·√°°àÕπ „π
°√≥’π’ÈÕ“®∑”‰¥â¥â«¬§«“¡¬“°≈”∫“° ‡π◊ËÕß®“°ºŸâªÉ«¬¡—°¡’ supraglottic structures ∑’Ë
∫«¡ ‡ ¡À–·≈–πÈ”≈“¬ª√‘¡“≥¡“°®–ªî¥°—Èπ∫√‘‡«≥ laryngeal inlet ∑”„À≡à
“¡“√∂‡ÀÁπ‚§√ß √â“ß∑’˪°µ‘‰¥â. ·æ∑¬åÕ“®®”‡ªìπµâÕß„ à orotracheal tube ·∫∫ ÿà¡
‰ª¬—ß∫√‘‡«≥∑’˧“¥«à“®–‡ªìπ™àÕß∑“߇¢â“¢Õß°≈àÕ߇ ’¬ß ‚¥¬ —߇°µ®“°øÕßÕ“°“» À“°
‰¡à “¡“√∂„ à orotracheal tube ‰¥â¿“¬„π√–¬–‡«≈“Õ—π —Èπ ·≈–ºŸâªÉ«¬¡’Õ“°“√·¬à≈ß
„Àâæ‘®“√≥“∑” emergency cricothyroidotomy ∑—π∑’.
1.2 „π°√≥’∑º’Ë ªŸâ «É ¬¡“æ∫·æ∑¬å¥«â ¬Õ“°“√∑’‰Ë ¡à√πÿ ·√ß ‡™àπ ¡’Õ“°“√°≈◊π≈”∫“°
À√◊Õ‡®Á∫§Õ‡æ’¬ß‡≈Á°πâÕ¬ ‚¥¬‰¡à¡’ªí≠À“¢Õß°“√Õÿ¥°—Èπ∑“߇¥‘πÀ“¬„® ·π–π”„Àâ
µ√«®¬◊π¬—π°“√«‘π‘®©—¬¥â«¬ indirect À√◊Õ direct laryngoscopy ‚¥¬Õ“®„™â mirror
À√◊Õ flexible endoscopy „π ∂“π∑’Ë∑’Ë¡’Õÿª°√≥å ·≈–‡§√◊ËÕß¡◊Õæ√âÕ¡„π°“√§«∫§ÿ¡
∑“߇¥‘πÀ“¬„® ‡™àπ∑’ËÀâÕßºà“µ—¥ À√◊Õ ICU ·≈–Õ“® àßµ√«® lateral neck radiograph
√à«¡¥â«¬ À≈—߉¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ acute supraglottitis ·≈â« À“°æ∫«à“√–¥—∫
§«“¡∫«¡¢Õß supraglottic structures ‰¡à¡“° “¡“√∂„™â«‘∏’‡ΩÑ“√–«—ß —߇°µÕ“°“√
√à«¡°—∫°“√„À⬓µâ“π®ÿ≈™’æ∑’‡Ë À¡“– ¡‰¥â.2,7,10 ºŸªâ «É ¬„π°≈ÿ¡à π’ È «à π„À≠à¡°— À“¬®“°‚√§‚¥¬
‰¡à¡’°“√Õÿ¥°—Èπ¢Õß∑“߇¥‘πÀ“¬„® À√◊Õ à«ππâÕ¬ ‡¡◊ËÕ‡°‘¥ªí≠À“¢÷Èπ ¡—°®–¡’°“√¥”‡π‘π
‚√§∑’ˇ√Á« ·≈–‡°‘¥°“√Õÿ¥°—Èπ∑“߇¥‘πÀ“¬„® ®π®”‡ªìπµâÕß„ à endotracheal tube
¿“¬„π 12 ™—Ë«‚¡ßÀ≈—ß√—∫‰«â —߇°µÕ“°“√.
1.3 „π°√≥’ºŸâªÉ«¬¡’Õ“°“√°È”°÷ËßÕ¬Ÿà√–À«à“ߢâÕ 1.1 ·≈– 1.2 °≈à“«§◊Õ¡’Õ“°“√
174 §≈‘π‘° ªï∑’Ë 31 ©∫—∫∑’Ë 2
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À“¬„®≈”∫“° µ√«®æ∫ stridor, drooling ºŸâªÉ«¬Õ¬Ÿà„π∑à“ upright position ·≈–
Õ“®¡’°“√¥”‡π‘π‚√§∑’ˇª≈’ˬπ·ª≈ßÕ¬à“ß√«¥‡√Á«¿“¬„π√–¬–‡«≈“ —ÈπÊ. ºŸâªÉ«¬°≈ÿà¡π’È¡’
·π«‚πâ¡∑’Ë®–‡°‘¥°“√Õÿ¥°—Èπ∑“߇¥‘πÀ“¬„®∑’Ë√ÿπ·√ߢ÷Èπ‰¥âµ≈Õ¥‡«≈“ ∂÷ß·¡â«à“·æ∑¬å®–
“¡“√∂„™â«‘∏’‡ΩÑ“√–«—ß —߇°µÕ“°“√‰¥â ·µà¡’Õ—µ√“‡ ’Ë¬ß Ÿß∑’Ë®–‡°‘¥ªí≠À“ ·≈–¬“°∑’Ë
®–§«∫§ÿ¡∑“߇¥‘πÀ“¬„®‰¥âÕ¬à“ߪ≈Õ¥¿—¬„π¿“¬À≈—ß ¥—ßπ—πÈ °“√§«∫§ÿ¡∑“߇¥‘πÀ“¬„®
¥â«¬°“√„ à endotracheal tube µ—Èß·µà·√° ®÷߇À¡“– ¡·≈–ª≈Õ¥¿—¬°«à“ ‚¥¬„π
™à«ß·√°§«√„Àâ oxygen ·°àºŸâªÉ«¬∑“ß mask À√◊Õ mask with bag ·≈–√’∫π”µ—«
ºŸâªÉ«¬‰ª¬—ßÀâÕßºà“µ—¥‚¥¬‡√Á« °“√ àߺŸâªÉ«¬‡æ◊ËÕ∂à“¬¿“æ‡Õ°´‡√¬å„π°√≥’π’ȉ¡à ¡§«√
Õ¬à“߬‘Ëß πÕ°®“°®–‰¡à‡°‘¥ª√–‚¬™πå·≈â« Õ“®∑”„À⺟âªÉ«¬¡’Õ—µ√“‡ ’ˬß∑’Ë®–‡°‘¥°“√
Õÿ¥°—Èπ∑“߇¥‘πÀ“¬„®¡“°¢÷Èπ ‡¡◊ËÕ∂÷ßÀâÕßºà“µ—¥·≈â« «‘ —≠≠’·æ∑¬å®–„Àâ inhalation
induction ¥â«¬§«“¡πÿà¡π«≈ ‚¥¬À≈’°‡≈’ˬ߰“√„Àâ muscle relaxant ®“°π—Èπ‡¡◊ËÕ
ºŸâªÉ«¬À≈—∫≈÷°¢÷Èπ ®÷ß∑”°“√‡ªî¥À≈Õ¥‡≈◊Õ¥¥” ‡æ◊ËÕ„ÀâπÈ”‡°≈◊Õ·≈–¬“∑’Ë®”‡ªìπ °àÕπ„ à
endotracheal tube Õ¬à“ߪ≈Õ¥¿—¬. ‚ µ »Õ π“ ‘°·æ∑¬å¡’Àπâ“∑’˵âÕ߇µ√’¬¡‡§√◊ËÕß
¡◊Õµà“ßÊ „Àâæ√âÕ¡ ‡™àπ rigid bronchoscopy set ·≈– tracheostomy set ‡º◊ËÕ„π
°√≥’©°ÿ ‡©‘π´÷ßË «‘ ≠
— ≠’·æ∑¬å‰¡à “¡“√∂§«∫§ÿ¡∑“߇¥‘πÀ“¬„®‰¥â. ·æ∑¬å§«√æ‘®“√≥“∑”
tracheostomy ‡¡◊ËÕ‰¡à·πà„®«à“®–„ à endotracheal tube ‰¥âÕ¬à“ߪ≈Õ¥¿—¬ À√◊Õ„π
°√≥’∑’ˉ¡à “¡“√∂„ à endotracheal tube ‰¥â ·≈–®”‡ªìπµâÕߧ«∫§ÿ¡∑“߇¥‘πÀ“¬„®
™—Ë«§√“«¥â«¬ rigid bronchoscope.
2. °“√„À⬓µâ“π®ÿ≈™’æ∑’ˇÀ¡“– ¡ ‚¥¬„À⬓µ“¡Õÿ∫—µ‘°“√≥å¢Õ߇™◊ÈÕ°àÕ‚√§
¬“µâ“π®ÿ≈™’槫√§√Õ∫§≈ÿ¡‡™◊ÈÕ Hemophilus influenzae ·≈–°≈ÿà¡ Streptococcus
Ampicillin ·≈– choramphenicol ‡§¬„™â‰¥âº≈¥’ ·µà‡π◊ËÕß®“°Õÿ∫—µ‘°“√≥å¢Õß Hemophilus influenzae strains ∑’Ë √â“ß beta-lactamase ¡’¡“°¢÷Èπ ·≈– choramphenicol
¡’º≈·∑√°´âÕπµàÕ°“√∑”ß“π¢Õ߉¢°√–¥Ÿ° ªí®®ÿ∫—π®÷߉¡à·π–π”„À⬓µâ“π®ÿ≈™’æ∑—Èß
Õß™π‘¥π’È. ªí®®ÿ∫—π¡’¬“µâ“π®ÿ≈™’æ„π°≈ÿà¡∑’Ë∑πµàÕ beta-lactamase enzyme ·≈–
§√Õ∫§≈ÿ¡‡™◊ÈÕ°àÕ‚√§‰¥â¥’ ‰¥â·°à cefuroxime, ceftriaxone, cefotaxime, ampicillin/
salbactam12-13 ‚¥¬„π™à«ß·√°§«√„À⬓µâ“π®ÿ≈™’æ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”°àÕπ ®π°√–∑—Ëß
ºŸâªÉ«¬ “¡“√∂∂Õ¥∑àՙ૬À“¬„®ÕÕ°‰¥â ´÷Ëß à«π„À≠à„™â‡«≈“ª√–¡“≥ 48-72 ™—Ë«‚¡ß
®“°π—Èπ®÷߇ª≈’ˬπ‡ªì𬓵â“π®ÿ≈™’æ™π‘¥√—∫ª√–∑“π ·≈–„ÀâµàÕ®π§√∫ 7-10 «—π. °“√
„Àâ corticosteroids ¬—߇ªìπ∑’Ë∂°‡∂’¬ß°—πÕ¬Ÿà ·≈–‰¡à¡’À≈—°∞“πÀ√◊Õ°“√»÷°…“„¥∑’Ë
π—∫ πÿπª√–‚¬™πå¢Õß°“√„™â¬“ corticosteroids π’È.
¿“«–·∑√°´âÕπ
¿“«–·∑√°´âÕπ∑’ËÕ“®‡°‘¥¢÷Èπ ‰¥â·°à °“√·æ√à°√–®“¬¢Õ߇™◊ÈÕ‰ªµ“¡°√–· ‡≈◊Õ¥
∑”„À⇰‘¥ pneumonia, meningitis, septic arthritis, otitis media ‡ªìπµâπ. °“√
Õÿ¥°—Èπ∑“߇¥‘πÀ“¬„®∑’Ë√ÿπ·√ß Õ“®∑”„À⺟âªÉ«¬¡’ respiratory arrest ‡°‘¥Õ—πµ√“¬µàÕ
√–∫∫ª√– “∑ à«π°≈“߉¥â ®“°¿“«– hypoxia ·≈–Õ“®‡°‘¥ acute pulmonary edema
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À≈—ß®“°§«∫§ÿ¡∑“߇¥‘πÀ“¬„®‰¥â ‡π◊ËÕß®“°ºŸâªÉ«¬‰¥â√—∫°“√·°â‰¢°“√Õÿ¥°—Èπ¢Õß∑“ß
‡¥‘πÀ“¬„®Õ¬à“ß√«¥‡√Á« (postobstructive pulmonary edema). πÕ°®“°π’Ȭ—ß¡’
√“¬ß“π°“√‡°‘¥ congestive heart failure, deep vein thrombosis, retropharyngeal abscess ¥â«¬.
Õ—µ√“µ“¬¡’√“¬ß“π‰«âµß—È ·µà√Õâ ¬≈– 1.2-2.92,9 à«π„À≠à‡°‘¥®“°ªí≠À“°“√Õÿ¥°—πÈ ¢Õß
∑“߇¥‘πÀ“¬„® ´÷Ëß “¡“√∂ªÑÕß°—π ·≈–≈¥Õ—µ√“µ“¬ ¥â«¬°“√§«∫§ÿ¡∑“߇¥‘πÀ“¬„®
Õ¬à“ߪ≈Õ¥¿—¬·≈–∂Ÿ°µâÕß ¥—ß°≈à“«¡“·≈â«¢â“ßµâπ.
‡Õ° “√Õâ“ßÕ‘ß
1. Morens DM. Death of a president. N Engl J Med 1999; 341(24):1845-9.
2. Mayo-Smith MF, Spinale JW, Donskey CJ, Yukawa M, Li RH, Schiffman FJ. Acute epiglottitis : an 18-year experience in Rhode Island. Chest 1995; 108(6):1640-7.
3. Midwinter KI, Hodgson D, Yardley M. Paediatric epiglottitis : the influence of the
Haemophilus influenzae b vaccine, a ten-year review in the Sheffield region. Clin
Otolaryngol 1999; 24(5):447-8.
4. Slack CL, Allen GC, Morrison JE, Garren KC, Roback MG. Post-varicella epiglottitis and
necrotizing fasciitis. Pediatrics 2000; 105(1):e13.
5. Wine N, Lim Y, Fierer J. Pasteurella multocida epiglottitis. Arch Otolaryngol Head Neck
Surg 1997; 123(7):759-61.
6. Wenger JK. Supraglottitis and group A streptococcus. Pediatr Infect Dis J
1997;16(10):1005-7.
7. Frantz TD, Rasgon BM, Quesenberry CP. Acute epiglottitis in adults: analysis of 129
cases. JAMA 1994; 272(17):1358-60.
8. Garpenholt OR, Hugosson S, Fredlund H, Bodin L, Olcen P. Epiglottitis in Sweden before
and after introduction of vaccination against Haemophilus influenzae type b. Pediatr
Infect Dis J 1999; 18(6):490-3.
9. Hebert PC, Ducic Y, Boisvert D, Lamothe A. Adult epiglottitis in a Canadian Setting.
Laryngoscope 1998; 108(1): 64-9.
10. Park KW, Darvish A, Lovenstein E. Airway management for adult patients with acute
epiglottitis : a 12-year experience at an academic medical center (1984-1995).
Anesthesiology 1998; 88(1):254-61.
11. Ducic Y, Hebert PC, MacLachlan L, Neufeld K, Lamothe A. Description an evaluation of
the vallecula sign : a new radiologic sign in the diagnosis of adult epiglottitis. Ann
Emerg Med 1997; 30(1):1-6.
12. Darrow DH, Zwack GC. Infectious and inflammatory illness of the larynx, trachea, and
bronchi. In : Souza CD, Stankiewicz J, Pellitteri PK. Textbook of Pediatric Otolaryngology
Head and Neck Surgery volume II. Singular publishing group, Inc; 1999. p.87-102.
13. Newton OD III, Robert CS. Infections of the airway. In : Cummings CW, Fredrickson JM,
Harker LA, et al. Pediatric Otolaryngology Head and Neck Surgery. Mosby-year book,
Inc; 1998. p. 388-400.
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