แนวทางเวชปฏิบัติการรักษาโรคในเด็ก 2557

100 ·π«∑“߇«™ªØ∫‘ μ— °‘ “√√—°…“«—≥‚√§„π‡¥°Á æ.». 2557 ¿“«–«≥— ‚√§·μà°”‡π¥‘ (Congenital tuberculosis) °“√«π‘ ‘®©¬— ‡°≥±å°“√«‘π®‘ ©¬— ª√–°Õ∫¥«â ¬ 1. √Õ¬‚√§‡°¥‘ ¿“¬„πÕ“¬ÿ 1  —ª¥“Àå·√° 2. ¡’ primary complex „πμ∫— 3. ¡«’ ≥— ‚√§„π√–∫∫ ◊∫æ—π∏¢åÿ Õß·¡àÀ√◊Õ„π√° ·≈– 4.  “¡“√∂μ¥— °“√쥑 À≈ß— §≈Õ¥ ‚¥¬°“√∑” ∫◊ §πâ ª√–«μ—  ‘ ¡— º — «≥— ‚√§ Õ¬“à ߧ√∫∂«â π Õ“°“√· ¥ß∑“ߧ≈π‘ ‘° ‡¥Á°∑‡’Ë ªπì «—≥‚√§·μà°”‡π¥‘ ¡—°®–§≈Õ¥°Õà π°”Àπ¥ ·≈–¬—߉¡¡à ’Õ“°“√ · ¥ß„¥Ê ∑“ߧ≈‘π‘° ‡ªπì ‡«≈“À≈“¬«π— ∂÷ßÀ≈“¬ —ª¥“À剥â Õ“°“√∑’Ëæ∫∫àÕ¬ §Õ◊ ¿“«–À“¬„®≈”∫“° ÕàÕπ‡æ≈’¬ ¥¥Ÿ π¡™“â ¡—°¡’‰¢â Àߥÿ Àß‘¥ ∑âÕßÕ◊¥ ·≈– ‚μ™â“ ‡¡Õ◊Ë μ√«®√à“ß°“¬®–æ∫ μ—∫‚μ ¡“â ¡‚μ μÕà ¡π”È ‡À≈Õ◊ ß‚μ  à«π¿“«–‡¬Ë◊Õ À¡âÿ  ¡ÕßÕ°— ‡ ∫ ·≈–μ«— ‡À≈Õ◊ ß æ∫‰¥â‰¡à∫àÕ¬ °“√μ√«®∑“ßÀâÕߪؑ∫—μ°‘ “√ ¿“«–π·’È æ∑¬ å “¡“√∂«π‘ ®‘ ©¬— ‰¥â‰¡ßà “à ¬ ‡πÕË◊ ß®“°Õ“°“√‰¡®à ”‡æ“– ·≈– ¡“√¥“Õ“®®–¥Ÿª°μ‘ ‰¡à¡’Õ“°“√· ¥ß„¥Ê «‘∏’∑¥ Õ∫∑Ë’™à«¬„Àâ°“√«‘π‘®©—¬¥—ß μàÕ‰ªπÈ’ 1. °“√∑”∑¥ Õ∫∑‡ÿ ∫Õ√å§ÿ≈‘π ´Ëß÷ ¡—°®–„Àºâ ≈≈∫‡¡ÕË◊ ·√°‡°‘¥ °“√·ª≈ º≈®÷ß∑”‰¥â¬“° 2. ¿“æ∂“à ¬√ß—  ∑’ √«ßÕ° ≈°— …≥–∑æË’ ∫®–‰¡®à ”‡æ“– ·≈–·¬°®“°ªÕ¥ Õ°— ‡ ∫®“°‡™◊ÕÈ ÕπË◊ Ê ‰¥¬â “° Õ“®æ∫‡ªπì ≈—°…≥– scattered infiltrates, bron- chopneumonia, consolidation °Á‰¥â

·π«∑“߇«™ªØ‘∫μ— °‘ “√√°— …“«—≥‚√§„π‡¥°Á æ.». 2557 101 3. ¿“æ CT scan ¢Õß abdomen ‡ÀÁπ periportal hypodensity 4. °“√¬Õâ ¡ ∑’ π°√¥ AFB ·≈–‡æ“–‡™ÕÈ◊ «≥— ‚√§ ®“° ß‘Ë  ßà μ√«® ‰¥·â °àgastric aspirate À√Õ◊ endotracheal aspirate „πºªŸâ É«¬∑’Ë„ à endotrachealtube, spinal fluid, ear discharge ·≈–™È‘π‡πÈ◊Õ√° §«√∑”∑ÿ°√“¬ Õ“®æ®‘ “√≥“μ√«®®“° liver biopsy, lymph node biopsy, bonemarrow aspirate ·≈–°“√‡æ“–‡™È◊Õ«—≥‚√§®“°‡≈◊Õ¥ μ“¡§«“¡‡À¡“– ¡·≈–®”‡ªìπ„π·μ≈à –√“¬ 5. æ‘®“√≥“ àßμ√«® polymerase chain reaction (PCR) ®“° ‘ßË  àßμ√«®¢â“ßμâπ 6. °“√μ√«®™È‘π‡πÈ◊Õ∑“ß欓∏‘«‘∑¬“ æ‘®“√≥“ àßμ√«®®“° √°/‡¬◊ËÕ∫ÿ¡¥≈Ÿ° ·≈– liver biopsy, lymph node biopsy μ“¡§«“¡‡À¡“– ¡·≈–®”‡ªìπ„π·μà≈–√“¬°“√√°— …“ ºâŸªÉ«¬‡¥Á°∑’ˉ¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ«—≥‚√§·μà°”‡π‘¥ §«√®–‰¥â√—∫°“√√°— …“∑π— ∑∑’ Ë’‰¥√â ∫— °“√«π‘ ®‘ ©¬— ‚√§ ‰¡®à ”‡ªπì μÕâ ß√Õº≈∑“ßÀÕâ ߪØ∫‘ μ— °‘ “√¬π◊ ¬π—À“°‡¥°Á ¡Õ’ “°“√√πÿ ·√ߧ«√®–‰¥√â ∫— °“√¥·Ÿ ≈‡ªπì 懑 »… °“√√°— …“§«√ª√–°Õ∫¥â«¬¬“Õ¬à“ßπÕâ ¬ 2-3 μ«— ∑Ë’‰«μàÕ‡™ÈÕ◊ «—≥‚√§ ¬“∑’Ë„™â„π°“√√—°…“¡’¥—ßπ’È 1. 2HRZAm/10HR °√≥’∑’Ë¡’Õ“°“√Àπ—° ·≈–®”‡ªìπμâÕ߉¥â√—∫ “√πÈ”∑“ßÀ≈Õ¥‡≈Õ◊ ¥ 2. 2HRZE/4-10HR °√≥∑’ ¡’Ë Õ’ “°“√‰¡√à πÿ ·√ß ·≈– “¡“√∂√∫— ª√–∑“𬓉¥â

102 ·π«∑“߇«™ªØ∫‘ —μ°‘ “√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 ‡Õ° “√Õâ“ßÕß‘ 1. WHO Global Tubercuolosis report 2012 :- WHO/HTM/TB/2012.6 2. Newton SM, Brent A,Anderson S,Whittaker E, Kappmann B, Pediatric tuberculosis. Lancet Infect Dis 2008; 8: 498-510. 3. WHO. Guideline for national tuberculosis programme on the manage- ment of tuberculosis in children. Geneva. World Health Organization 2006. 4. Graham SM, Marais BJ, Gie RP. Clinical features and index of suspi- cious of tuberculosis in children. In: Schaaf HS, Zumla AI, eds. Tubercu- losis: A Comprehensive Clinical Reference. St. Louis: Elsevier Inc. 2009: 154-63. 5. æ√‘ ß— °√Ÿ ‡°¥‘ æ“π™‘ . °“√«‘π‘®©¬— «≥— ‚√§„π‡¥°Á (Pediatric Tuberculosis Diagnosis). „π: æ√‘ —ß°√Ÿ ‡°‘¥æ“π‘™, ‡æ≥≥‘π“∑å ‚Õ‡∫Õ√å¥Õ√‡å øÕ√,å °≈ÿ °—≠≠“ ‚™§‰æ∫Ÿ≈¬å°®‘ , ∫°. ·π«∑“ߪØ∫‘ —μ«‘ —≥‚√§√–¬–·Ωß„π‡¥Á° æ.». 2553. °√ÿ߇∑æœ: °Õß∑ÿπ‚≈° ¥â“π«—≥‚√§. 2553: 32-68. 6. Fischer GB, Andrade CF, Lima JB. Pleural tuberculosis in children. Paediatr Respir Rev. 2011; 12: 27-30. 7. McAdams HP, Erasmus J, Winter JA. Radiologic manifestations of pul- monary tuberculosis. Radiol Clin North Am. 1995; 33: 655-78. 8. Marais BJ, Gie RP, Schaaf HS, Starke JR, Hesseling AC, Donald PR, et al. A proposed radiological classification of childhood intra-thoracic tuberculosis. Pediatr Radiol. 2004; 34: 886-94.

·π«∑“߇«™ªØ∫‘ —μ°‘ “√√—°…“«≥— ‚√§„π‡¥Á° æ.». 2557 1039. Updated guidelines for using interferon gamma release assays to de- tect M. tuberculosis infection. MMWR 2010; 59: RR5 1-28.10. Chang K, Lu W. Wang J, et al. Rapid and effective diagnosis of tuber- culosis and rifampicin resistance with XpertMTB/RIF assay: a meta- analysis. J Infect 2012; 64: 580-8.11. World Health Organization. Rapid advice: treatment of tuberculosis in children 2010. http://whqlibdoc.who.int/publications/2010/9789241500 449_eng.pdf12. World Health Organization. Treatment of tuberculosis guidelines. 4th ed., 2010.13. Shah I. Multidrug-resistant tuberculosis in children. The Pediatric infec- tious disease journal 2012 Sep; 31: 970-2.14. American Academy of Pediatrics. Tuberculosis. In: Picekering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of the Com- mittee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2012: 736-59.15. Gilbert DN, Moellering RC, Eliopoulos GM, Chambers HF, Saag MS. The Stanford Guide to Antimicrobial Therapy 2012. 42nd Edition. 2012: 214-20.16. ∑«’ ‚™μ‘æ‘∑¬ ÿππ∑å. °“√¥·Ÿ ≈√°— …“«≥— ‚√§¥◊ÕÈ ¬“À≈“¬¢π“π (MDR-TB) „π‡¥Á°. „π: æ‘√—ß°√Ÿ ‡°‘¥æ“≥™‘ , «√’ –™—¬ «≤— π«√’ ‡¥™, ∑«’ ‚™μæ‘ ∑‘ ¬ πÿ π∑,å ∫√√≥“∏°‘ “√. Update on Pediatric Infectious Diseases 2013, °√ßÿ ‡∑æ¡À“π§√: ∫√‘…—∑ ∫¬’ Õπ¥å ‡ÕÁπ‡∑Õ√å‰æ√´å ®”°—¥, 2556: 106-15.

104 ·π«∑“߇«™ªØ∫‘ μ— °‘ “√√—°…“«≥— ‚√§„π‡¥°Á æ.». 2557 17. CDC. Guidelines for environmental infection control in health-care facili- ties. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep. 2003; 52(RR-10): 1-42. 18. CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep. 2005 Dec 30;54(RR-17): 1-141. 19. WHO. Epidemic-prone & pandemic - prone acute respiratory diseases: Infection prevention & control in health care facilities 2007. http:// www.who.int/csr/resources/publication 20. Atkinson J, Chartier Y, Lúcia Pessoa-Silva C, Jensen P, Li Y,Seto WH. Natural Ventilation for Infection Control in Health-Care Settings 2009. http://www.who.int/water_sanitation_health/publications/natural_ven tilation/en/index.html 21. WHO policy on TB infection control in health-care facilities, congregate settings and households. 2009. http://www.who.int/tb/publications/2009/ 9789241598323/en/index.html 22. Patel VP, Desai TR, Chavda BG, Katira RM. Extemporaneous Dosage form for oral liquids. Available at http://pharmacophorejournal.com/march- april2011-article1.pdf. Accessed: August 13, 2011. 23. «π‘¥“ ‡¥™“«“»π,å π«¿√≥å «‘¡≈ “√–«ß§,å æ√»√’ Õß‘ ‡®√≠‘  πÿ ∑√, Õ—≠™≈’ Õ“√¬ ™¬— ™“≠ ∫√√≥“∏‘°“√. Pediatric Dose ©∫—∫æ‘¡æ§å √ßÈ— ∑’Ë 3 °≈ÿà¡ß“π‡¿ —™°√√¡  ∂“∫—π ÿ¢¿“懥Á°·Ààß™“μ‘¡À“√“™‘π’. °√ßÿ ‡∑æœ :  ”π°— æ‘¡æå™—¬‡®√≠‘ , 2553.

·π«∑“߇«™ªØ‘∫—μ°‘ “√√°— …“«—≥‚√§„π‡¥°Á æ.». 2557 10524. «π‘¥“ ‡¥™“«“»π,å π«¿√≥å «¡‘ ≈ “√–«ß§,å æ√»√’ Ց߇®√‘≠ πÿ ∑√ ∫√√≥“∏‘°“√. Pediatric Extemporaneous Compounding ¬“‡μ√¬’ ¡æ‡‘ »…‡©æ“–√“¬ ”À√∫— ‡¥°Á °≈¡ÿà ß“π‡¿ ™— °√√¡  ∂“∫π—  ¢ÿ ¿“懥°Á ·Àßà ™“μ¡‘ À“√“™π‘ .’ °√ßÿ ‡∑æœ :  ”π°— æ¡‘ æå ™¬— ‡®√≠‘ , 2552.25. American Academy of Pediatrics. Tuberculosis. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of the Com- mittee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2012:736-59.26. Loto OM, Awowole I.Tuberculosis in pregnancy: a review.J Pregnancy. 2012;379271.27. Mirium A, Prakash MJ. Tuberculosis in preganacy and in neonate. In: Schaaf HS, Zumla AI, editors. Tuberculosis: A Comprehensive Clinical Reference. St. Louis: Elsevier Inc.; 2009. p.572-580.28. Skevaki CL, Kafetzis DA. Tuberculosis inneonates and infants: epi- demiology, pathogenesis, clinical menifestations, diagnosis, and management issues. Paediatr Drugs 2005; 7: 219-34.29. Whittaker E, Kampmann B. Perinatal tuberculosis: new challenges in the diagnosis and treatment of infants and newborn. Early Hum Dev 2008; 84: 795-9.30. Brewer TF. Preventing tuberculosis with Bacillus Calmette-Gurein vaccine: A meta-analysis of literature. Clin Infect Dis 2000; 31(suppl 3): S64-7.

106 ·π«∑“߇«™ªØ‘∫μ— °‘ “√√—°…“«≥— ‚√§„π‡¥Á° æ.». 2557 31. Sirinavin S, Chotpitayasunondh T, Suwanjutha S, et al. Protective efficacy of neonatal Bacillus Calmette-Guerin vaccination against tuberculosis. Pediatr Infect Dis J 1991; 10: 359-65. 32. Hesseling AC, Cotton MF, Fordham von Reyn C, Graham SM, Gie RP, Hussey GD. Consensus statement on the revised World Health Organi- zation recommendations for BCG vaccination in HIV-infected infants. Int J Tuberc Lung Dis 2008; 12: 1376-9. 33. Goraya JS, Virdi VJS. Treatment of BCG-lymphadenitis-a meta-analysis. Pediatr Infect Dis J 2001; 20: 632-4. 34. Bernatowska EA, Wolska-Kusnierz B, Pac M, et al. Disseminated bacil- lus Calmette-Guérin infection and immunodeficiency. Emerg Infect Dis 2007; 13: 799-801. 35. Fujiwara PI, Clevenbergh P, Dlodlo RA. Management of adults living with HIV/AIDS in low-income, high-burden settings, with special reference to persons with tuberculosis. Int J Tuberc Lung Dis 2005; 9: 946-58. 36. Kwara A, Ramachandran G, Swaminathan S. Dose adjustment of the non-nucleoside reverse transcriptase inhibitors during concurrent rifampi- cin-containing tuberculosis therapy: one size does not fit all. Expert Opin Drug Metab Toxicol 2010; 6: 55-68. 37. Manosuthi W, Ruxrungtham K, Likanonsakul S, Prasithsirikul W, Inthong Y, Phoorisri T, et al. Nevirapine levels after discontinuation of rifampicin therapy and 60-week efficacy of nevirapine-based antiretroviral therapy in HIV-infected patients with tuberculosis. Clin Infect Dis 2007; 44: 141-4.

·π«∑“߇«™ªØ‘∫—μ°‘ “√√°— …“«—≥‚√§„π‡¥°Á æ.». 2557 10738. Marais BJ, Rabie H, Cotton MF. TB and HIV in children - advances in prevention and management. Paediatr Respir Rev 2011; 12(1): 39-45.39. Mycobacterial infections. Guidelines for the prevention and treatment of opportunistic infections among HIV-exposed and HIV-infected children. MMWR 2009; 58: 19-25.40. Schenker S, Martin RR, Hoyumpa AM. Antecedent liver disease and drug toxicity. J Hepatol, 1999; 31: 1098-105.41. Dhiman RK, Saraswat VA, Rajekar H, Reddy C, Chawla YK. A guide to the management to tuberculosis in patients with chronic liver disease. JCEH, 2012; 2: 260-70.42. Guidelines for Treatment of Tuberculosis in patients with Renal disease. Queensland Tuberculosis Control Centre. http://www.health.qld.gov.au/ ph/documents/qtbcc/32537.pdf.43. Shing-Chi Lau, Patrick Pa-Shing Yeung, Niko Kei-Chiu Tse, et al. Drug prescription in renal diseases. Practical paediatric nephrology 2005; 40: 348-57.44. Kumar R, Gupta N, Sabharwal A. Congenital tuberculosis. Indian J Pediatr, 2005; 72: 631-3.

108 ·π«∑“߇«™ªØ‘∫μ— °‘ “√√°— …“«≥— ‚√§„π‡¥Á° æ.». 2557

·π«∑“߇«™ªØ‘∫—μ°‘ “√√—°…“«≥— ‚√§„π‡¥°Á æ.». 2557 109 ¿“§ºπ«° 1 °“√¢È÷π∑–‡∫¬’ πºâŸªÉ«¬·≈–§”𬑠“¡ μ“¡§”𬑠“¡¢ÕßÕߧ°å “√Õπ“¡¬— ‚≈°ªï æ.». 2552 ®”·π°ºªŸâ «É ¬ 4 ·∫∫¥ß— π’È 1. μ“¡Õ«—¬«–∑’‡Ë ªìπ«≥— ‚√§ 2. μ“¡º≈‡ ¡À– („π°√≥’«≥— ‚√§ªÕ¥) 3. μ“¡ª√–«μ— ‘°“√√—°…“„πÕ¥μ’ 4. μ“¡°“√쥑 ‡™È◊Õ‡Õ™‰Õ«’1. °“√¢Èπ÷ ∑–‡∫’¬π‚¥¬°“√®”·π°ºŸâªÉ«¬°àÕπ√°— …“ ®”·π°μ“¡ ¢âÕ 1. Õ«—¬«–∑’ˇªìπ«≥— ‚√§ ·≈– ¢Õâ 2. º≈‡ ¡À– (¥—ßμ“√“ß∑’Ë 1) «—≥‚√§ªÕ¥ (Pulmonary Tuberculosis: PTB) §◊Õ°“√∑’Ë¡’欓∏‘ ¿“æ¢Õß«—≥‚√§„π‡π◊ÈÕªÕ¥À√◊Õ ‡ªìπ«—≥‚√§πÕ°ªÕ¥∑Ë’¡√’ Õ¬‚√§„πªÕ¥√«à ¡¥«â ¬ ë «≥— ‚√§ªÕ¥¬Õâ ¡‡ ¡À–æ∫‡™Õ◊È (PTB SS+) À¡“¬∂ß÷ ºªâŸ «É ¬«≥— ‚√§ªÕ¥∑¡Ë’ º’ ≈¬Õâ ¡‡ ¡À–°Õà π‡√Ë‘¡√—°…“æ∫‡™ÈÕ◊ «≥— ‚√§Õ¬à“ßπâÕ¬ 1 §√È—ß

110 ·π«∑“߇«™ªØ‘∫—μ°‘ “√√°— …“«≥— ‚√§„π‡¥°Á æ.». 2557μ“√“ß∑’Ë 1 °“√®”·π°ºâŸªÉ«¬μ“¡Õ«¬— «–·≈–º≈‡ ¡À–√Õ¬‚√§ √Õ¬‚√§¢ÕßÕ«—¬«– º≈°“√μ√«®¬Õâ ¡  √ÿª°“√®”·π°ºâŸªÉ«¬ „πªÕ¥ πÕ°ªÕ¥ À“«≥— ‚√§¡’ ¡À’ √Õ◊ ‰¡¡à ’ ‡ ¡À–æ∫‡™ÕÈ◊ PTB, SS+¡’ ¡À’ √Õ◊ ‰¡¡à ’ ‡ ¡À–‰¡æà ∫‡™◊ÕÈ PTB, SS neg (·μ§à «√¡’º≈‡æ“–‡™◊ÈÕ ‡æ◊ÕË ¬◊π¬π— °“√«‘π‘®©—¬)¡’ ¡À’ √Õ◊ ‰¡¡à ’ ‰¡¡à º’ ≈‡ ¡À– PTB, SS not done‰¡¡à ’ ¡’ ‰¡«à “à æ∫‡™◊ÈÕÀ√◊Õ‰¡à EPTB (·μ৫√¡º’ ≈‡æ“–‡™ÕÈ◊ ¬π◊ ¬—π°“√«π‘ ‘®©—¬) ë «≥— ‚√§ªÕ¥¬Õâ ¡‡ ¡À–‰¡àæ∫‡™Õ◊È (PTB SS neg) À¡“¬∂ß÷ 1) ºŸâ∑¡Ë’ ≈’ —°…≥–∑“ߧ≈π‘ ‘°‡¢â“‰¥°â ∫— «≥— ‚√§√«à ¡°∫— - μ√«®¬Õâ ¡‡ ¡À–∑Ë¡’ §’ ≥ÿ ¿“æ 2 §√—ßÈ ‰¡àæ∫‡™È◊Õ«≥— ‚√§ (μâÕß ‡ªπì collected sputum Õ¬à“ßπâÕ¬ 1 §√Èß— ) ·≈– - ¿“æ∂“à ¬√—ß ∑’ √«ßÕ°‡¢“â ‰¥°â ∫— «—≥‚√§√–¬–≈°ÿ ≈“¡ ·≈– - ‰¡àμÕ∫ πÕßμàÕ¬“ªØ‘™’«π– (‰¡à§«√„™â¬“„π°≈ÿà¡ Fluoro- quinolone‡πÕ◊Ë ß®“°¡ƒ’ ∑∏μÏ‘ Õà ‡™Õ◊È «≥— ‚√§Õ“®¡º’ ≈∑”„Àºâ ªŸâ «É ¬ «≥— ‚√§¡Õ’ “°“√¥¢’ È÷π™—«Ë §√“«) À√Õ◊ ¡’°“√μ‘¥‡™È◊Õ‡Õ™‰Õ«√’ «à ¡ ¥â«¬ 2) ºâŸªÉ«¬«—≥‚√§ªÕ¥∑’Ë¡’º≈¬âÕ¡‡ ¡À–°àÕπ‡√Ë‘¡√—°…“‰¡àæ∫‡™È◊Õ«—≥‚√§À√Õ◊ ‰¡à‰¥¬â âÕ¡·μºà ≈‡æ“–‡™ÈÕ◊ æ∫‡™◊ÕÈ «—≥‚√§ (M. tuberculosis )

·π«∑“߇«™ªØ∫‘ —μ°‘ “√√°— …“«—≥‚√§„π‡¥°Á æ.». 2557 111 ë «≥— ‚√§ªÕ¥‰¡¡à º’ ≈μ√«®¬Õâ ¡‡ ¡À– (PTB SS not done) À¡“¬∂ß÷ ºªâŸ «É ¬«≥— ‚√§ªÕ¥∑’ˉ¥√â ∫— °“√√°— …“«≥— ‚√§‚¥¬‰¡à‰¥μâ √«®‡ ¡À–°Õà π°“√√°— …“ ë «—≥‚√§πÕ°ªÕ¥ (Extrapulmonary Tuberculosis: EPTB) §◊Õ°“√∑’Ë¡’欓∏‘ ¿“æ«—≥‚√§∑’ËÕ«—¬«–ÕË◊πÊ∑Ë’¡‘„™à‡π◊ÈÕªÕ¥ ‡™àπ ∑Ë’‡¬◊ÕÈ À¡âÿ ªÕ¥ μàÕ¡π”È ‡À≈◊Õß ™àÕß∑âÕß √–∫∫∑“߇¥π‘ ªí  “«– º«‘ Àπß— °√–¥Ÿ°/¢âÕ ·≈–‡¬◊ÕÈ Àâ¡ÿ  ¡Õß ‡ªìπμâπ - ∂“â æ∫‡æ¬’ ߧ«“¡º¥‘ ª°μ∑‘ Ë’μÕà ¡πÈ”‡À≈Õ◊ ß„π∑√«ßÕ° (Medias-tinal and/or hilar lymph nodes) À√◊ÕπÈ”„π™àÕ߇¬◊ËÕÀ¡ÿâ ªÕ¥ (Pleural effu-sion) ‚¥¬‰¡àæ∫√Õ¬‚√§„π‡πÕÈ◊ ªÕ¥®”·π°‡ªπì «—≥‚√§πÕ°ªÕ¥ - „π°√≥¡’ «’ ≥— ‚√§‡°¥‘ ¢πÈ÷ „πÀ≈“¬Õ«¬— «–æ√Õâ ¡Ê °π— μÕâ ߧ”πß÷ ∂ß÷Õ«¬— «–∑‡’Ë °¥‘ §«“¡√πÿ ·√ߢÕß‚√§·≈–„™√â –¬–‡«≈“„π°“√√°— …“∑π’Ë “π∑ ’Ë ¥ÿ ‡ªπì ”§≠— „π°“√≈ß°“√«‘π‘®©—¬‚√§2. °“√¢πÈ÷ ∑–‡∫¬’ π‚¥¬°“√®”·π°μ“¡ª√–«μ— °‘ “√√°— …“§√ß—È ∑ºË’ “à π¡“ À≈—ß®“°∑Ë’«‘π‘®©—¬ºâŸªÉ«¬«à“‡ªìπ«—≥‚√§·≈â« ®”‡ªìπμâÕß´—°ª√–«—μ‘«à“ºŸâªÉ«¬‡§¬√—°…“«—≥‚√§¡“°àÕπÀ√◊Õ‰¡à À“°‡§¬‰¥â√—∫°“√√—°…“ º≈°“√√—°…“§√È—ß°àÕπ‡ªìπÕ¬à“߉√ ‡æ√“–ª√–«—μ‘°“√√—°…“®–¡’º≈μàÕ°“√‡≈◊Õ°√–∫∫¬“Õߧ°å “√Õπ“¡—¬‚≈°·∫ßà ª√–‡¿∑¢Õß°“√¢πÈ÷ ∑–‡∫¬’ πºŸªâ «É ¬·∫∫π’È ÕÕ°‡ªìπ 6ª√–‡¿∑ ¥ß— πÈ’ „À¡à (New) ë ºŸªâ «É ¬∑Ë’‰¡à‡§¬√°— …“«≥— ‚√§¡“°Õà π ë ºâŸªÉ«¬∑Ë’‡§¬‰¥â√—∫¬“μâ“π«—≥‚√§¡“πâÕ¬°«à“ 1 ‡¥◊Õπ ·≈–‰¡à‡§¬¢πÈ÷ ∑–‡∫¬’ π„π·ºπß“π«—≥‚√§·Àßà ™“μ¡‘ “°Õà π

112 ·π«∑“߇«™ªØ‘∫μ— °‘ “√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 √°— …“´È”À≈—ß®“°¢“¥¬“ (Treatment after default) ª®í ®∫ÿ —π Õߧ°å “√Õπ“¡—¬‚≈°„™â§”«à“ Treatment after interruption ë ºªŸâ «É ¬∑°’Ë ≈∫— ¡“√°— …“Õ°’ À≈ß— ®“°¢“¥°“√√°— …“‰ª 2 ‡¥Õ◊ π쥑 μÕà °π— À√◊Õ¡“°°«à“ ‚¥¬¡’º≈μ√«®æ∫‡™ÕÈ◊ ¥«â ¬«‘∏’ Direct smear À√◊Õ Culture °≈—∫‡ªìπ´”È (Relapse) ª®í ®∫ÿ —π‡√¬’ °«“à recurrent ‡πÕË◊ ß®“°·¬°‰¡à ‰¥«â “à ‡°‘¥®“°‡™È◊Õμ—«‡¥‘¡ (True relapse) À√◊Õμ‘¥‡™ÈÕ◊ „À¡à (Re-infection) ë ºªŸâ «É ¬∑‡Ë’ §¬√°— …“«≥— ‚√§·≈–‰¥√â ∫— °“√«π‘ ®‘ ©¬— «“à À“¬·≈«â À√Õ◊ √∫— °“√ √—°…“§√∫·≈â« ·μà°≈—∫¡“‡ªìπ«—≥‚√§Õ’°‚¥¬§√È—ßπÈ’¡’º≈μ√«®æ∫‡™◊ÈÕ«—≥‚√§ ¥â«¬«‘∏’ Direct smear À√Õ◊ Culture √°— …“´È”À≈ß— ®“°≈¡â ‡À≈« (Treatment change after failure) ë ºŸªâ É«¬∑Ë’√°— …“¥«â ¬  μŸ √¬“ ”À√—∫ºâŸªÉ«¬„À¡à (New patient regi- men) ·μºà ≈‡ ¡À–‡¡ÕË◊ ‡¥◊Õπ∑’Ë 5 ¬ß— ∫«° À√◊ÕÀ≈—ß®“°π—πÈ ¬ß— §ß‡ªπì ∫«° (Re- mained positive) À√◊Õ°≈∫— ¡“‡ªπì ∫«°Õ°’ (Became positive) ë ºŸâªÉ«¬«—≥‚√§‡ ¡À–‰¡àæ∫‡™È◊Õ‡¡Ë◊Õ‡√‘Ë¡√—°…“ ·μàº≈‡ ¡À–‡¡Ë◊Õ È‘π  ¥ÿ ‡¥Õ◊ π∑Ë’ 2 °≈∫— ‡ªìπæ∫‡™È◊Õ √—∫‚Õπ (Transfer in) ë ºŸâªÉ«¬´÷Ëß√—∫‚Õπ®“° ∂“π欓∫“≈ÕË◊π ‚¥¬¢÷Èπ∑–‡∫’¬π·≈–‰¥â√—∫ °“√√°— …“·≈«â √–¬–Àπ÷ßË Õ◊ËπÊ (Other) ºâŸªÉ«¬«—≥‚√§∑Ë’‰¡à “¡“√∂®—¥°≈ÿࡇ¢â“„π°≈àÿ¡¥—ß°≈à“« ¢â“ßμâπ μ—«Õ¬à“߇™àπ

·π«∑“߇«™ªØ‘∫μ— °‘ “√√°— …“«—≥‚√§„π‡¥°Á æ.». 2557 113 ë ºªŸâ «É ¬∑Ë’‰¥√â ∫— ¬“√°— …“«≥— ‚√§®“°§≈π‘ °‘ À√Õ◊ Àπ«à ¬ß“π‡Õ°™π¡“·≈«â¡“°°«“à 1 ‡¥Õ◊ π ‚¥¬∑¬Ë’ ß— ‰¡‡à §¬¢π÷È ∑–‡∫¬’ π„π·ºπß“π«≥— ‚√§·Àßà ™“μ¡‘ “°Õà π ë ºŸâª«É ¬∑Ë’‰¡à√Ÿ«â “à ‡§¬‰¥â√∫— °“√√—°…“¡“°Õà πÀ√◊Õ‰¡à ë ºâªŸ «É ¬∑’‡Ë §¬√∫— °“√√—°…“¡“°Õà π ·μà‰¡∑à √“∫º≈°“√√—°…“ ë ºâŸªÉ«¬∑°Ë’ ≈∫— ¡“√—∫°“√√°— …“À≈—ߢ“¥¬“ ·μºà ≈‡ ¡À–‡ªìπ‰¡æà ∫‡™◊ÕÈ ë ºªŸâ «É ¬∑°’Ë ≈∫— ‡ªπì ´È”∑ºË’ ≈°“√μ√«®∑“ß·∫§∑‡’ √¬’ ‡ªπì ‰¡æà ∫‡™ÕÈ◊ (Bac-teriologically negative relapse) À√◊Õ‡ªìπ«—≥‚√§πÕ°ªÕ¥ RelapseExtrapulmonary TB)

114 ·π«∑“߇«™ªØ∫‘ μ— °‘ “√√—°…“«≥— ‚√§„π‡¥°Á æ.». 2557μ“√“ß∑Ë’ 2 °“√¢÷Èπ∑–‡∫’¬πºâªŸ «É ¬®”·π°μ“¡º≈°“√√—°…“§√—ßÈ ∑Ë’º“à π¡“º≈°“√√—°…“ º≈μ√«®¬Õâ ¡ AFB °“√¢÷Èπ∑–‡∫’¬π§√Èß— ∑’˺à“π¡“ °“√ªÉ«¬§√—ßÈ πÈ’‰¡‡à §¬¡ª’ √–«—μ°‘ “√√—°…“À√Õ◊ ∫«° À√Õ◊ ≈∫ ºªŸâ É«¬√“¬„À¡à (New)‡§¬√°— …“¡“ < 1 ‡¥Õ◊ π ∫«°¢“¥¬“ > 2 ‡¥◊Õπ쥑 μÕà °π— ºŸâªÉ«¬√°— …“´È”(Default) (Treatment After Default: TAD À√◊Õ Treatment After Interruption)Treatment success ∫«° ºŸâª«É ¬°≈—∫‡ªπì ´”È (Relapse)Treatment failed ∫«° ºªŸâ «É ¬√°— …“´”È À≈ß— °“√√—°…“ ≈¡â ‡À≈« (Treatment Change After Failure: TAF)ºŸâªÉ«¬«—≥‚√§∑Ë’¢Èπ÷ ∑–‡∫’¬π ∫«° À√Õ◊ ≈∫ √—∫‚Õπ (Transfer in)«—≥‚√§·≈â«·≈–∂Ÿ° àßμ—« ∫«° À√◊Õ ≈∫ Õ◊πË Ê (Other)¡“®“°∑’ÕË ◊π˺⪟ «É ¬«≥— ‚√§∑Ë’‰¡à “¡“√∂®—¥°≈ÿࡇ¢â“°—∫ºâŸªÉ«¬¥—ß°≈à“«¢“â ßμπâ ‡™πà ‰¡à∑√“∫ª√–«μ— ‘°“√√°— …“

·π«∑“߇«™ªØ∫‘ —μ°‘ “√√°— …“«—≥‚√§„π‡¥Á° æ.». 2557 1153. °“√¢È÷π∑–‡∫’¬πμ“¡º≈°“√√—°…“ √“¬≈–‡Õ’¬¥¥ß— μ“√“ß∑Ë’ 3μ“√“ß∑Ë’ 3 §”®”°¥— §«“¡º≈°“√√°— …“º≈°“√√°— …“ §”®”°—¥§«“¡√—°…“À“¬¢“¥ (Cure) ºŸâªÉ«¬«≥— ‚√§ªÕ¥¬âÕ¡‡ ¡À–æ∫‡™ÕÈ◊ ∑√’Ë °— …“®π§√∫ √«à ¡°∫— ¡’º≈¬Õâ ¡‡ ¡À–‡¥◊Õπ ÿ¥∑⓬·≈–º≈¬âÕ¡‡ ¡À–√—°…“§√∫ °Õà πÀπâ“πÈ—π„π√–À«“à ß°“√√°— …“‰¡æà ∫‡™È◊ÕÕ’°Õ¬à“ßπÕâ ¬(Treatment completed) 1 §√È—ß ë „πºŸªâ «É ¬«—≥‚√§ªÕ¥¬âÕ¡‡ ¡À–æ∫‡™◊ÕÈ ∑Ë’‰¥√â ∫—√°— …“ ”‡√®Á(Treatment success) °“√√°— …“®π§√∫·≈–·æ∑¬åμ¥—  π‘ „®„ÀÀâ ¬ÿ¥°“√√—°…“≈¡â ‡À≈« √—°…“‰¥â (·μà‰¡¡à º’ ≈‡ ¡À–À≈—ß°“√√—°…“§√∫(Treatment failure) ‡°≥±å√°— …“À“¬¢“¥¢“â ßμπâ ) ë „πºªŸâ É«¬«≥— ‚√§ªÕ¥¬Õâ ¡‡ ¡À–‰¡àæ∫‡™◊ÈÕÀ√◊Õ쓬 (Died) «—≥‚√§πÕ°ªÕ¥∑Ë’‰¥â√—∫°“√√°— …“®π§√∫·≈–·æ∑¬å¢“¥°“√√—°…“ (Default) μ¥—  π‘ „®„ÀâÀ¬¥ÿ °“√√°— …“‰¥â‚ÕπÕÕ° (Transfer out) º≈√«¡¢Õß√°— …“À“¬·≈–√—°…“§√∫ ë ºâªŸ É«¬«≥— ‚√§ªÕ¥‰¡à«“à √“¬„À¡àÀ√◊Õ√—°…“´”È ∑˺’ ≈ ‡ ¡À– (‰¡à«“à ¬Õâ ¡À√◊Շ擖‡™◊ÈÕ) ¬ß— æ∫‡™È◊Õ‡¡◊ÕË ‡¥Õ◊ π∑’Ë 5 ¢Õß√—°…“ À√◊Õ ë ºªâŸ É«¬«—≥‚√§„¥Ê ∑¡’Ë º’ ≈ DST ¬π◊ ¬π— «à“‡ªπì MDR-TB ¢≥–√°— …“Õ¬Ÿà‰¡«à à“π“π·§à‰Àπ ·≈– ‰¡«à à“¢≥–ππ—È º≈¬âÕ¡‡ ¡À–À√◊Õ Ë‘ß ßà μ√«®„¥Ê æ∫‡™◊ÈÕÀ√◊Õ‰¡à°Áμ“¡ 쓬‰¡à«“à ®“° “‡Àμÿ„¥Ê „π√–À«“à ß°“√√°— …“«≥— ‚√§ ¢“¥/À¬ÿ¥°“√√—°…“μ‘¥μàÕ°π— 2 ‡¥◊Õπ¢÷πÈ ‰ª‰¡«à à“ ®“° “‡Àμ„ÿ ¥Ê ºŸªâ «É ¬«≥— ‚√§∑’Ë∂Ÿ°¢÷Èπ∑–‡∫’¬π·≈«â ·μμà Õâ ß‚Õπ‰ª√—°…“ ∑’ÕË ◊πË ·≈–‰¡à “¡“√∂쥑 μ“¡º≈°“√√°— …“°≈—∫¡“‰¥â

116 ·π«∑“߇«™ªØ∫‘ μ— °‘ “√√—°…“«≥— ‚√§„π‡¥°Á æ.». 2557 ¿“§ºπ«° 2Àπ૬∫√°‘ “√μ√«® ∑¥ Õ∫ «‘∏’  ßË‘  àßμ√«® √“§“ (∫“∑) 1,500°≈à¡ÿ ªØ∫‘ —μ‘°“√Õâ“ßÕß‘ ™π— Diagnose: MTB LPA Sputum, 1,500 Ÿμ√«≥— ‚√§·Ààß™“μ‘ DST: RMP+INH RT-PCR Isolated 1,500 ”π—°«—≥‚√§ LPA Culture 600°√¡§«∫§ÿ¡‚√§ (Gene Xpert) 1,500 Diagnose: MTB sputum 1,500 ∂“∫—π∫”√“»π√“¥Ÿ√ DST: RMP Diagnose: MTB Sputum, DST: RMP+INH Isolated Culture ∂“∫π— «®‘ ¬— «‘∑¬“»“ μ√å Diagnose: MTB PCR Sputum, “∏“√≥ ¢ÿ RT-PCR Body Fluid,°√¡«‘∑¬“»“ μ√å Diagnose: MTB Body Tissue°“√·æ∑¬å DST: RMP+INH Sputum Isolated ∂“∫—π‚√§∑√«ßÕ° Diagnose: MTB LPA Culture°√¡°“√·æ∑¬å DST: RMP+INH Sputum, Isolated Culture

·π«∑“߇«™ªØ‘∫μ— °‘ “√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 117 ÀÕâ ߪØ∫‘ —μ‘°“√∑’‡Ë æ“–‡™ÕÈ◊ «—≥‚√§·≈– μ√«® Rapid Molecular Testing ßà μ√«® √“§“ (∫“∑) ™à«ß‡«≈“ÕÕ°º≈ ºâŸμ¥‘ μàÕ ‚∑√»æ— ∑å («π— ∑”°“√)putum,olated 1,500 2-7 𓬠¡»°— ¥Ï‘ ‡À√’¬≠∑Õß 02-212-2279ulture μàÕ 207utum 1,500 1-2putum, 1,500 2-7 π“ßÕ≠— ™π“ ∂“«√«π— 02-5903567-69olated Fax 02-5903574ultureputum, 600 3-5ody Fluid, ¥√.‡∫≠®«√√≥ ‡æ™√ ÿ¢»√‘ ‘ 02-580-1593ody Tissueputum 1,500 2-7olatedulture 1,500 2-7 π“ß®√‘ °“πμå ªÿ≠≠‚ æ√√≥ 02-580-3423putum, μÕà 1267olatedulture

118 ·π«∑“߇«™ªØ∫‘ μ— °‘ “√√°— …“«—≥‚√§„π‡¥Á° æ.». 2557Àπ૬∫√‘°“√μ√«® ∑¥ Õ∫ «∏‘ ’  ‘ßË  ßà μ√«® √“§“(∫“∑) 850∑πÿ «®‘ ¬— «≥— ‚√§¥ÕÈ◊ ¬“ Diagnose: MTB MAS-PCR, Sputum,»√‘ √‘ “™¡Ÿ≈π∏‘ ‘„π DST: RMP+INH RT-PCR, or Culture 1,500æ√–Õªÿ ∂—¡¿ å ¡‡¥®Á LPA 1,500æ√–‡®“â æË’π“߇∏Õœ DST: RMP+INH RT-PCR Sputum, 1,500 Diagnose: MTB RT-PCR Body Fluid, 2,000‚√ß欓∫“≈»‘√√‘ “™ DST: RMP+INH Body Tissue, ”π°— ß“πªÕÑ ß°π— (Gene Xpert) RT-PCR Isolated Culture 2,000§«∫§ÿ¡‚√§∑Ë’ 4 √“™∫√ÿ ’ Diagnose: MTB Sputum‚√ß欓∫“≈¡–°“√°— …å DST: RMP RT-PCR Isolated Culture‚√ß欓∫“≈√“¡“∏‘∫¥’ Diagnose: MTB RT-PCR sputum DST: RMP+INH Sputum, Body Fluid, Body Tissue, Isolated Culture, Paraflim block Sputum, Body Fluid, Body Tissue, Isolated Culture, Paraflim block

·π«∑“߇«™ªØ‘∫—μ°‘ “√√°— …“«—≥‚√§„π‡¥Á° æ.». 2557 119 àßμ√«® √“§“(∫“∑) ™«à ߇«≈“ÕÕ°º≈ ºŸμâ ‘¥μàÕ ‚∑√»æ— ∑å («—π∑”°“√)putum, Culture 850 2-7 ¥√. ՗ߧ≥“ ©“¬ª√–‡ √∞‘ / 02-419-8256-7 ¥√.‡∑Õ¥»—°¥‘Ï æ√“À¡≥–ππ— ∑πåputum,ody Fluid, 1,500 2-7 ¥√. »¿ÿ √ øßÑÿ ≈—¥¥“ 02-419-7062ody Tissue, 1,500 2-7 𓬉°√ƒ°…å  ÿ∏√√¡ 02-419-7063olated Cultureputum 032-310-761-3olatedulture 1,500 1-2 𓬫𑠗¬ À√‡Ÿ ®√≠‘ 034-542 031 μÕà 121utum 2,000 3-5putum, º». ¥√.æ∑‘ —°…å  —πμ‘π√‘ π— ¥√å 02-201-1399ody Fluid,ody Tissue, 2,000 2-7olated Culture,raflim blockputum,ody Fluid,ody Tissue,olated Culture,raflim block

120 ·π«∑“߇«™ªØ∫‘ μ— °‘ “√√—°…“«≥— ‚√§„π‡¥°Á æ.». 2557Àπ«à ¬∫√°‘ “√μ√«® ∑¥ Õ∫ «∏‘ ’  ßË‘  ßà μ√«® √“§“(∫“∑) 1,500 ”π°— ß“πªÕÑ ß°π— Diagnose: MTB LPA Sputum, 1,500§«∫§¡ÿ ‚√§∑’Ë 7 DST: RMP+INH RT-PCR Isolated Culture 1,500Õÿ∫≈√“™∏“π’ (Gene Xpert) RT-PCR sputum 1,500 Diagnose: MTB RT-PCR Sputum, 1,500 ”π°— ß“πªÕÑ ß°π— DST: RMP Isolated Culture§«∫§ÿ¡‚√§∑Ë’ 10 Diagnose: MTB RT-PCR sputum 1,500‡™¬’ ß„À¡à DST: RMP+INH ”π°— ß“πªÕÑ ß°π— sputum§«∫§¡ÿ ‚√§∑’Ë 12  ß¢≈“ (Gene Xpert)(TB ¬–≈“) Diagnose: MTB DST: RMP (Gene Xpert) Diagnose: MTB DST: RMP‚√ß欓∫“≈«™‘√–¿Ÿ‡°μÁ (Gene Xpert) RT-PCR sputum Diagnose: MTB DST: RMP

·π«∑“߇«™ªØ‘∫—μ°‘ “√√°— …“«—≥‚√§„π‡¥°Á æ.». 2557 121 àßμ√«® √“§“(∫“∑) ™«à ߇«≈“ÕÕ°º≈ ºâμŸ ‘¥μàÕ ‚∑√»æ— ∑åputum, («—π∑”°“√) 045-255-836olated Culture 053-140-772utum 1,500 2-7putum,olated Culture 1,500 1-2 π“ß “««≈— ¬“  ∑‘ ∏‘utum 1,500 2-7utum 1,500 1-2 𓬫√»°— ¥Ï‘  ∑ÿ “™¬—utum 1,500 1-2 𓬠“‚√𠇮“–‡≈– 073-212-332 μàÕ 116 Fax 073-211-727 1,500 1-2 π“ß«™— √‘π∑√å ≠“μ‘√—°…å 076-361-234 μÕà 1580

122 ·π«∑“߇«™ªØ‘∫μ— °‘ “√√—°…“«—≥‚√§„π‡¥°Á æ.». 2557√“¬™Ë◊ÕÀπ૬ߓπ/‚√ß欓∫“≈∑Ë ’ “¡“√∂∑”°“√‡æ“–‡≈È’¬ß‡™È◊Õ«≥— ‚√§ (Culture)≈”¥∫— ∑’Ë Àπ૬ߓπ/‚√ß欓∫“≈ 1 °≈ÿࡪØ∫‘ μ— ‘°“√Õ“â ßÕß‘ ™—π μŸ √«—≥‚√§·Àßà ™“μ‘ (NTRL) 2  ”π—°«≥— ‚√§ °√¡§«∫§¡ÿ ‚√§ ‚√ß欓∫“≈ª√– “π¡‘μ√ 3 ( ¡“§¡ª√“∫«≥— ‚√§·Àßà ª√–‡∑»‰∑¬) 4 °≈à¡ÿ ß“π®ÿ≈™’««∑‘ ¬“  ∂“∫π— ∫”√“»π√“¥√Ÿ 5 °≈¡àÿ ß“π®ÿ≈™’««‘∑¬“  ∂“∫—π‚√§∑√«ßÕ° ¿“§«™‘ “®≈ÿ ™«’ «‘∑¬“ 6 §≥–·æ∑¬»“ μ√å®ÿÓ≈ß°√≥å¡À“«∑‘ ¬“≈¬— 7 ‚√ß欓∫“≈»√‘ √‘ “™ 8 ∑ÿπ«‘®¬— «≥— ‚√§¥ÈÕ◊ ¬“ »‘√‘√“™¡Ÿ≈π∏‘ ‘ Àπ૬®≈ÿ ™’««‘∑¬“ ¿“§«‘™“欓∏‘«‘∑¬“§≥–·æ∑¬»“ μ√å 9 ‚√ß欓∫“≈√“¡“∏∫‘ ¥’  ∂“∫—π欓∏«‘ ∑‘ ¬“ »πŸ ¬Õå ”π«¬°“√·æ∑¬å 10 ‚√ß欓∫“≈æ√–¡ß°Æÿ ‡°≈â“ 11 Àπ«à ¬®ÿ≈™«’ «∑‘ ¬“ ‚√ß欓∫“≈√“™«∂‘ ’ 12  ”π°— ß“π™π—  Ÿμ√ “∏“√≥ ÿ¢  ”π—°Õπ“¡—¬°∑¡. 13  ”π—°ß“πªÑÕß°—π§«∫§ÿ¡‚√§∑Ë’ 1 °√ÿ߇∑æœ 14 ‚√ß欓∫“≈ ¡‡¥®Á æ√–ªπîò ‡°≈“â ‚√ß欓∫“≈‡®√≠‘ °√ßÿ ª√–™“√—°…å

·π«∑“߇«™ªØ∫‘ —μ°‘ “√√—°…“«—≥‚√§„π‡¥°Á æ.». 2557 123≈”¥—∫∑Ë’ Àπ«à ¬ß“π/‚√ß欓∫“≈ 15  ”π°— ß“πªÕÑ ß°—π§«∫§¡ÿ ‚√§∑’Ë 2 ®ß— À«—¥ √–∫√ÿ ’ 16 ‚√ß欓∫“≈ √–∫ÿ√’ 17 ‚√ß欓∫“≈æ√–π“√“¬≥¡å À“√“™ ≈æ∫ÿ√’ 18 ‚√ß欓∫“≈∫â“πÀ¡Ë’ 19 ‚√ß欓∫“≈π§√𓬰 20 ‚√ß欓∫“≈»πŸ ¬°å “√·æ∑¬ å ¡‡¥Á®æ√–‡∑æœ ¡. »√’π§√‘π∑√«‘‚√≤ 21  ”π°— ß“πªÑÕß°—π§«∫§¡ÿ ‚√§∑’Ë 3 ®—ßÀ«—¥™≈∫√ÿ ’ 22 ‚√ß欓∫“≈™≈∫√ÿ ’ 23 ‚√ß欓∫“≈√–¬Õß 24 ‚√ß欓∫“≈æ√–ª°‡°≈“⠮ߗ À«—¥®π— ∑∫√ÿ ’ 25 ‚√ß欓∫“≈ ¡∑ÿ √ª√“°“√ 26 ‚√ß欓∫“≈ ¡‡¥®Á æ√–¬æÿ √“™ ®ß— À«—¥ √–·°«â 27 ‚√ß欓∫“≈μ√“¥ 28  ”π°— ß“πªÕÑ ß°π— §«∫§ÿ¡‚√§∑Ë’ 4 ®ß— À«¥— √“™∫ÿ√’ 29 ‚√ß欓∫“≈√“™∫ÿ√’ 30 ‚√ß欓∫“≈π§√ª∞¡ 31 ‚√ß欓∫“≈æÀ≈æ≈æ¬ÿÀ‡ π“ ®ß— À«—¥°“≠®π∫ÿ√’ 32 ‚√ß欓∫“≈ ¡∑ÿ √ “§√ 33 ‚√ß欓∫“≈‡®â“æ√–¬“¬¡√“™ ®—ßÀ«—¥ ÿæ√√≥∫ÿ√’ 34 ‚√ß欓∫“≈∫“â π‚ªßÉ ®ß— À«—¥√“™∫ÿ√’ 35 ‚√ß欓∫“≈‚æ∏“√“¡ ®—ßÀ«—¥√“™∫√ÿ ’

124 ·π«∑“߇«™ªØ∫‘ μ— °‘ “√√°— …“«—≥‚√§„π‡¥Á° æ.». 2557≈”¥∫— ∑Ë’ Àπ«à ¬ß“π/‚√ß欓∫“≈ 36 ‚√ß欓∫“≈¥”‡π‘π –¥«° ®ß— À«¥— √“™∫√ÿ ’ 37  ”π—°ß“πªÕÑ ß°—π§«∫§¡ÿ ‚√§∑’Ë 5 ®ß— À«¥— π§√√“™ ¡’ “ 38 ‚√ß欓∫“≈¡À“√“™π§√√“™ ¡’ “ 39 ‚√ß欓∫“≈ √ÿ ‘π∑√å 40 ‚√ß欓∫“≈™¬— ¿¡Ÿ ‘ 41 ‚√ß欓∫“≈∫√ÿ ’√—¡¬å 42  ”π—°ß“πªÕÑ ß°—π§«∫§ÿ¡‚√§∑’Ë 6 ®—ßÀ«—¥¢Õπ·°πà 43 ‚√ß欓∫“≈¢Õπ·°àπ 44 ‚√ß欓∫“≈Õ¥ÿ √∏“π’ 45 ‚√ß欓∫“≈»√π’ §√π‘ ∑√å ®—ßÀ«¥— ¢Õπ·°àπ 46  ”π°— ß“πªÑÕß°—π§«∫§ÿ¡‚√§∑Ë’ 7 ®ß— À«—¥Õÿ∫≈√“™∏“π’ 47 ‚√ß欓∫“≈Õ”π“®‡®√≠‘ 48 ‚√ß欓∫“≈¬‚ ∏√ 49  ”π—°ß“πªÑÕß°π— §«∫§ÿ¡‚√§∑Ë’ 8 ®ß— À«—¥π§√ «√√§å 50  ”π—°ß“πªÕÑ ß°—π§«∫§ÿ¡‚√§∑Ë’ 9 ®ß— À«¥— æ‘…≥‚ÿ ≈° 51 ‚√ß欓∫“≈·¡à Õ¥ ®—ßÀ«—¥μ“° 52  ”π—°ß“πªÑÕß°—π§«∫§ÿ¡‚√§∑Ë’ 10 ®ß— À«¥— ‡™¬’ ß„À¡à 53 ‚√ß欓∫“≈¡À“√“™π§√‡™’¬ß„À¡à 54 ‚√ß欓∫“≈π§√æß‘ §å 55 ‚√ß欓∫“≈≈”ª“ß 56 ‚√ß欓∫“≈‡™’¬ß√“¬ª√–™“π‡ÿ §√“–Àå 57 ‚√ß欓∫“≈æ–‡¬“

·π«∑“߇«™ªØ‘∫μ— °‘ “√√—°…“«≥— ‚√§„π‡¥°Á æ.». 2557 125≈”¥—∫∑’Ë Àπ૬ߓπ/‚√ß欓∫“≈ 58 ‚√ß欓∫“≈‡™¬’ ߧ” ®ß— À«—¥æ–‡¬“ 59 ‚√ß欓∫“≈·æ√à 60 ‚√ß欓∫“≈π“à π 61 ‚√ß欓∫“≈ ¡‡¥®Á æ√–¬ÿæ√“™ª«í ®ß— À«—¥π“à π 62 ‚√ß欓∫“≈»√ ’ ß— «“≈ ®ß— À«—¥·¡àŒÕà ß Õπ 63  ”π°— ß“πªÑÕß°—π§«∫§ÿ¡‚√§∑’Ë 11 ®—ßÀ«—¥π§√»√’∏√√¡√“™ 64 ‚√ß欓∫“≈ ÿ√“…Ø√å∏“π’ 65 ‚√ß欓∫“≈μ–°«Ë— ª“É ®—ßÀ«¥— æß— ß“ 66 ‚√ß欓∫“≈°√–∫’Ë 67 ‚√ß欓∫“≈«™√‘ –¿‡Ÿ °Áμ 68  ”π—°ß“πªÑÕß°—π§«∫§¡ÿ ‚√§∑Ë’ 12 ®—ßÀ«—¥ ß¢≈“ (»πŸ ¬«å ≥— ‚√§∑Ë’ 12 ®—ßÀ«¥— ¬–≈“) 69 ‚√ß欓∫“≈À“¥„À≠à ®ß— À«¥—  ß¢≈“ 70 ‚√ß欓∫“≈ ß¢≈“ 71 ‚√ß欓∫“≈ μ≈Ÿ 72 §≥–·æ∑¬»“ μ√å ¡À“«∑‘ ¬“≈¬—  ß¢≈“π§√‘π∑√å 73 ‚√ß欓∫“≈»πŸ ¬å‚√§º«‘ Àπ—ß ®ß— À«¥— μ√—ß 74 ÀÕâ ߪؑ∫μ— °‘ “√¢Õß IOMÀ¡“¬‡Àμÿ: ¢Õâ ¡Ÿ≈ ≥ ‡¥Õ◊ π°√°Æ“§¡ æ.». 2556

126 ·π«∑“߇«™ªØ‘∫μ— °‘ “√√°— …“«≥— ‚√§„π‡¥Á° æ.». 2557

·π«∑“߇«™ªØ∫‘ —μ°‘ “√√—°…“«≥— ‚√§„π‡¥Á° æ.». 2557 127 ¿“§ºπ«° 3 °“√‡μ√’¬¡¬“摇»…‡©æ“–√“¬ √ªŸ ·∫∫¬“π”È  ”À√∫— ‡¥°Áμ“√“ß∑’Ë 1  Ÿμ√°“√‡μ√’¬¡¬“„π√Ÿª·∫∫¬“πÈ” ”À√∫— ‡¥Á°™Ë◊Õ¬“ Isoniazid Rifampicin Ethambutol Pyrazinamide§«“¡·√ß 10 mg/ml 60 ml 50 mg/ml 60 ml 50 mg/ml 64 ml 40 mg/ml 50 ml®”π«π‡¡¥Á tab 100 mg powder 3 g tab 400 mg tab 500 mg 6 ‡¡¥Á 8 ‡¡¥Á 4 ‡¡¥Áπ”È °√– “¬ type 2 type 4 type 1 type 1¬“∑’Ë„™â§«“¡§ßμ«— 21 «—π 30 «π— 30 «—π 30 «—π°“√‡°∫Á √°— …“ ¢«¥ ™’ “·≈– ¢«¥ ™’ “·≈– ¢«¥ ™’ “·≈– ¢«¥ ™’ “·≈– ‡°Á∫„πμ⟇¬Áπ ‡°Á∫„πμŸâ‡¬Áπ ‡°Á∫„πμ⟇¬Áπ ‡°Á∫„πμ⟇¬Áπ

128 ·π«∑“߇«™ªØ∫‘ μ— °‘ “√√—°…“«—≥‚√§„π‡¥°Á æ.». 2557 ‡¿ —™°√‡μ√’¬¡‚¥¬°“√∫¥ºß¬“„Àâ≈–‡Õ’¬¥·≈⫺ ¡°—∫πÈ”°√– “¬¬“ (vehicle) ∑‡’Ë À¡“– ¡°∫— §≥ÿ  ¡∫μ— ∑‘ “߇§¡·’ ≈–°“¬¿“æ¢Õ߬“ πÈ”°√– “¬¬“ (μ“√“ß∑’Ë 2) ∑Ë’„™â‰¥â·°à π”È °≈Ëπ— πÈ”‡™◊ËÕ¡ (simple syrup) ·≈–πÈ”°√– “¬¬“ ∑’¡Ë  ’ “√·¢«πμ–°Õπ ‚¥¬ “√·¢«πμ–°Õπ∑Ë’π‘¬¡„™â‰¥â·°à methylcellulose À√Õ◊ carboxymethyl cellulose „π∑π’Ë ’È®–¢Õ¬°μ—«Õ¬à“ßμ”√—∫∑’ˉ¥â‡μ√’¬¡‡æËÕ◊ „™â„π°“√√°— …“ºªâŸ «É ¬‡¥Á°«≥— ‚√§  ”À√—∫¬“«≥— ‚√§·π«∑’Ë 1 ‰¥â·°à Isoniazid suspension 10 mg/ml ™◊ËÕ¬“ Isoniazid tab 100 mg 6 ‡¡Á¥ π”È °√– “¬¬“∑Ë’„™â Vehicle type 2 «‘∏’°“√‡μ√’¬¡ 1. π”‡¡Á¥¬“∫¥„π‚°√ßà „À‡â ªìπºß≈–‡Õ¬’ ¥ 2. º ¡πÈ”°√– “¬¬“∑’≈–πâÕ¬μ“¡ geometric proportion ·≈â«∫¥„À⇢ⓠ‡ªπì ‡πÈ◊Õ‡¥’¬«°—π 3. ‡∑„ à¿“™π–∫√√®∑ÿ ‡’Ë μ√¬’ ¡‰«â 4. ‡μ¡‘ π”È °√– “¬¬“≈â“߬“∑‡’Ë À≈◊Õ„π‚°√àß ·≈–‡μ¡‘ „Àâ§√∫ 60 ml 5. ‡¢¬à“·√ßÊ ‡æÕ◊Ë „À⇢Ⓡªπì ‡πÕÈ◊ ‡¥’¬«°—π °“√‡°Á∫√—°…“ ‡°∫Á „πμŸâ‡¬πÁ §«“¡§ßμ—« 21 «π— ¢âÕ·π–π” Õ“®‡μ√¬’ ¡·∫∫ß“à ¬Ê ‚¥¬π”‡¡¥Á ¬“¡“∫¥„À‡â ªπì ºß≈–‡Õ¬’ ¥ ·≈«â ‡μ‘¡π”È °∫— sorbitol °Á‰¥â

·π«∑“߇«™ªØ∫‘ μ— °‘ “√√°— …“«—≥‚√§„π‡¥°Á æ.». 2557 129Rifampicin suspension50 mg/ml™Ë◊Õ¬“ Rifampicin ºß¬“ 1.5 °√—¡πÈ”°√– “¬¬“∑Ë’„™â Vehicle type 4«‘∏’°“√‡μ√’¬¡1. π”ºß¬“∫¥„π‚°√ßà „À‡â ªìπºß≈–‡Õ¬’ ¥2. º ¡ glycerin ‡≈Á°πâÕ¬‡æË◊Õ„Àºâ ߬“‡ªï¬°·≈«â §Õà ¬Ê ∫¥®π‡ªπì ¢Õ߇À≈« ¢πâ (paste)3. ‡μ‘¡π”È °√– “¬¬“∑’≈–πâÕ¬μ“¡ geometric proportion ·≈â«∫¥„À⇢ⓠ‡ªìπ‡πÕÈ◊ ‡¥’¬«°—π4. ‡∑„ à¿“™π–∫√√®∑ÿ ’‡Ë μ√¬’ ¡‰«â5. ‡μ‘¡πÈ”°√– “¬¬“≈“â ߬“∑ˇ’ À≈◊Õ„π‚°√ßà ·≈–‡μ‘¡„À§â √∫ 30 ml6. ‡¢¬à“·√ßÊ ‡æË◊Õ„À⇢Ⓡªπì ‡πÕÈ◊ ‡¥’¬«°π—°“√‡°Á∫√—°…“ ¢«¥ ’™“·≈–‡°Á∫„πμ‡âŸ ¬πÁ§«“¡§ßμ—« 30 «—πEthambutol suspension50 mg/ml™Õ◊Ë ¬“ Ethambutol tab 400 mg 8 ‡¡¥ÁπÈ”°√– “¬¬“∑’Ë„™â Vehicle type 1«‘∏’°“√‡μ√’¬¡1. π”‡¡Á¥≈ß„π‚°√àß‡μ‘¡πÈ”‡≈Á°πâÕ¬‡æ◊ËÕ≈–≈“¬øî≈å¡∑Ë’‡§≈◊Õ∫À√◊Õ∫¥„À⇪ìπ ºß≈–‡Õ¬’ ¥·≈«â „™μâ –·°√ß°√Õß·ºàπ‡§≈Õ◊ ∫¬“ÕÕ°

130 ·π«∑“߇«™ªØ∫‘ μ— °‘ “√√—°…“«—≥‚√§„π‡¥°Á æ.». 2557 2. º ¡πÈ”°√– “¬¬“∑’≈–πâÕ¬μ“¡ geometric proportion ·≈â«∫¥„À⇢ⓠ‡ªìπ‡π◊ÕÈ ‡¥¬’ «°π— 3. ‡∑„ ¿à “™π–∫√√®ÿ∑Ë’‡μ√’¬¡‰«â 4. ‡μ¡‘ π”È °√– “¬¬“≈â“߬“∑ˇ’ À≈◊Õ„π‚°√ßà ·≈–‡μ¡‘ „Àâ§√∫ 64 ml 5. ‡¢¬à“·√ßÊ ‡æË◊Õ„À⇢“â ‡ªπì ‡πÈÕ◊ ‡¥’¬«°π— °“√‡°Á∫√—°…“ ‡°Á∫„πμ⟇¬πÁ §«“¡§ßμ«— 30 «—π Pyrazinamide suspension 40 mg/ml ™ËÕ◊ ¬“ Pyrazinamide tab 500 mg 4 ‡¡Á¥ π”È °√– “¬¬“∑Ë’„™â Vehicle type 1 «‘∏’°“√‡μ√’¬¡ 1. π”‡¡¥Á ¬“∫¥„π‚°√ßà „À⇪πì ºß≈–‡Õ’¬¥ 2. º ¡π”È °√– “¬¬“∑’≈–πâÕ¬μ“¡ geometric proportion ·≈â«∫¥„À⇢ⓠ‡ªìπ‡π◊ÕÈ ‡¥’¬«°π— 3. ‡∑„ à¿“™π–∫√√®∑ÿ ’‡Ë μ√¬’ ¡‰«â 4. ‡μ‘¡πÈ”°√– “¬¬“≈â“߬“∑Ë’‡À≈◊Õ„π‚°√àß ·≈–‡μ‘¡„À§â √∫ 50 ml 5. ‡¢¬“à ·√ßÊ ‡æ◊ÕË „À⇢“â ‡ªìπ‡π◊ÕÈ ‡¥¬’ «°—π °“√‡°Á∫√—°…“ ‡°Á∫„πμŸâ‡¬πÁ §«“¡§ßμ«— 30 «—π

·π«∑“߇«™ªØ∫‘ μ— °‘ “√√°— …“«—≥‚√§„π‡¥°Á æ.». 2557 131μ“√“ß∑’Ë 2 · ¥ß à«πª√–°Õ∫¢ÕßπÈ”°√– “¬¬“™π‘¥μà“ßÊ «à πª√–°Õ∫  μŸ √μ”√—∫π”È °√– “¬¬“ Vehicle type 1 Vehicle type 2 Vehicle type 4CMC Mucilage 14% 14% - 20% -70% Sorbitol 20% 5% - pH 5-6 pH 5-6Glycerol (Glycerin) - 1% - 0.1 %pH pH 5-6 - - qs to 100% 100%Paraben concentration 1%Sodium benzoate -Purified water 5%Simple syrup qs to 100% ¬“‡μ√¬’ ¡æ‡‘ »…‡©æ“–√“¬√ªŸ ·∫∫¬“πÈ” ”À√∫— ¬“«≥— ‚√§À≈ß— ‡μ√¬’ ¡§«√„™â∑—π∑’À√◊Õ„™â¿“¬„π 30«—π ´Ë÷ߺ⟪ɫ¬μâÕß„™âμ‘¥μàÕ°—π‡ªìπ‡«≈“π“π·≈–·æ∑¬¡å °— ®–π¥— ‡°‘π 1 ‡¥◊Õπ®÷ß¡ª’ í≠À“∑’ºË Ÿªâ «É ¬μÕâ ß¡“√—∫¬“∑°ÿ ‡¥◊Õπ ‡¿ —™°√ “¡“√∂‡μ√’¬¡¬“‡ªπì ·∫∫ 2 ¢«¥º ¡°π—  ”À√∫— isoniazid ‚¥¬¢«¥∑ÀË’ πË÷߇ªìπ¢«¥ ’™“„ àºß¬“ ¢«¥∑Ë’ Õ߇ªìπ¢«¥„ ∫√√®ÿπÈ”°√– “¬¬“ ‡¡◊ËÕºŸâªÉ«¬μâÕß°“√„™â¬“„À‡â ∑π”È °√– “¬¬“≈ß„π¢«¥∑Ë’¡’ºß¬“ª√–¡“≥§√ß÷Ë ¢«¥ ‡¢¬“à „Àâ‡¢â“°π— ®π‡ªìπ‡π◊ÈÕ‡¥¬’ «°π— ·≈â«®ß÷ ‡∑π”È °√– “¬¬“∑‡Ë’ À≈◊Õ≈߉ª„ÀâÀ¡¥ ‡¢¬“à„À‡â ¢“â °π— Õ°’ §√ß—È ÀπßË÷ ‡¢¬’ π«π— À¡¥Õ“¬Àÿ √Õ◊ «π—  ¥ÿ ∑“â ¬∑®Ë’ –„™¬â “¢«¥∑º’Ë  ¡πÈ’‰¥â≈ß∫π©≈“°∑’Ë¢«¥ ‡™πà ¬“ Isoniazid ¡’Õ“¬ÿ‰¥â 21 «π— À≈ß— º ¡ º ¡¬“«π— π’È´Ëß÷ μ√ß°—∫«—π∑’Ë 5  ß‘ À“§¡ «π—  ¥ÿ ∑“â ¬∑’Ë„™â‰¥â§Õ◊ ∫«°‰ª 21 «—π §◊Õ«π— ∑Ë’ 26 ‘ßÀ“§¡ ‡ªìπμπâ „À‡â ¢¬’ π«π— ∑Ë’ 26  ß‘ À“§¡∫π¢«¥ ·μ à à«π„À≠à¡°— ®–„™âÀ¡¥¢«¥°àÕπ«π— À¡¥Õ“¬ÿ ¥—ß√ªŸ

132 ·π«∑“߇«™ªØ∫‘ —μ°‘ “√√°— …“«—≥‚√§„π‡¥Á° æ.». 2557 ¬“‡μ√¬’ ¡æ‡‘ »…‡©æ“–√“¬™π¥‘ ºß·Àßâ ·≈–πÈ”°√– “¬¬“ „Àºâ ¥Ÿâ ·Ÿ ≈º ¡ ∑∫Ë’ â“πμ“¡§”·π–π” À≈—ߺ ¡¡Õ’ “¬ÿ 21 «—𠧔·π–π”°“√„™¬â “‡μ√’¬¡‡©æ“–√“¬ ë ¬“‡μ√’¬¡æ‘‡»…‡©æ“–√“¬„π√Ÿª¬“π”È π’È μâÕ߇πâπ„ÀâºâŸªÉ«¬À√◊պ⟠¥·Ÿ ≈μÕâ ߇¢¬“à ¢«¥„À⬓°√–®“¬∑Ë«— °π— „À⥒°Õà π√‘π¬“∑ÿ°§√—ßÈ ë «‘∏’‡°Á∫√°— …“¬“∑∂Ë’ °Ÿ μÕâ ß §Õ◊ ¬“∑˺’  ¡·≈â«„À⇰∫Á „πμŸ‡â ¬πÁ ë °“√‡μ√¬’ ¡¬“懑 »…‡©æ“–√“¬ ”À√∫— ‡¥°Á Õ“®¡¢’ Õâ ®”°¥— „π‡√ÕË◊ ß°“√ «‘®—¬§«“¡§ßμ—«¢Õ߬“„πÕÿ≥À¿Ÿ¡‘·≈– ‘Ëß·«¥≈âÕ¡¢Õߪ√–‡∑»‰∑¬

·π«∑“߇«™ªØ∫‘ —μ°‘ “√√°— …“«—≥‚√§„π‡¥°Á æ.». 2557 133 ®”‡ªìπÕ¬à“߬‘Ëß∑Ë’®–μâÕ߇°Á∫„Àâ∂Ÿ°μâÕß ‡¿ —™°√μâÕß„™â‡«≈“„π°“√ ‡μ√¬’ ¡¬“·≈–¥“â π°“√®¥— À“« — ¥Õÿ ªÿ °√≥å °√≥∑’ ¡’Ë º’ ªŸâ «É ¬‡¥°Á ®”π«π πâÕ¬ë °“√‡μ√’¬¡¬“摇»…‡©æ“–√“¬π’ȇªìπ·π«∑“ß„π°“√∫√‘À“√®—¥°“√ ¥â“𬓄ÀâºâŸªÉ«¬‡¥Á°∑Ë’‡ªìπ«—≥‚√§„À≥â√—∫¢π“¥¬“‡À¡“– ¡ ·≈– ‡¥°Á √∫— ¬“‰¥âß“à ¬¢÷πÈ  –¥«°¢È÷π ”À√—∫ºâ¥Ÿ Ÿ·≈

134 ·π«∑“߇«™ªØ∫‘ —μ°‘ “√√°— …“«≥— ‚√§„π‡¥°Á æ.». 2557 ¿“§ºπ«° 4 ·π«∑“߇°¬Ë’ «°—∫ ‘∑∏ª‘ √–‚¬™πå  ‘∑∏‘ª√–‚¬™π∑’ˉ¥√â ∫— ¢ÕߺªâŸ «É ¬«≥— ‚√§ ºŸâ¡ ’ ‘∑∏¢‘ Õ√—∫∫√°‘ “√ 1.  —≠™“쑉∑¬ ¡’‡≈¢ª√–®”μ—«ª√–™“™π 13 À≈—° ·≈–¡’ ‘∑∏‘À≈—° ª√–°π—  ÿ¢¿“æ·Ààß™“μ‘ À√Õ◊  ‘∑∏‘«“à ß 2. ∫ÿ§§≈‰√â ∂“π–´÷Ë߉¥â√—∫ ‘∑∏‘À≈—°ª√–°—π ÿ¢¿“æ μ“¡¡μ‘§≥– √∞— ¡πμ√‡’ ¡Õ◊Ë 23 ¡§’ .2555  ‘∑∏‘ª√–‚¬™π∑å Ë’‰¥√â ∫— 1. ¬“μâ“π«≥— ‚√§ a.  μŸ √æπ◊È ∞“π (First Line Drugs) b.  Ÿμ√¥◊ÈÕ¬“ (MDR-TB Drugs) 2. °“√μ√«®∑“ßÀÕâ ߪØ∫‘ μ— ‘°“√ a. °“√μ√«®∑“ßÀÕâ ߪؑ∫μ— ‘°“√æÈ◊π∞“π (AFB, CXR)

·π«∑“߇«™ªØ∫‘ —μ°‘ “√√—°…“«—≥‚√§„π‡¥°Á æ.». 2557 135 b. °“√μ√«®‡æ“–‡™È◊Õ«—≥‚√§ (Sputum Culture) c. °“√∑¥ Õ∫§«“¡‰«μàÕ¬“μ“â π«—≥‚√§ (Drug Sensitivity Test- ing : DST) d. °“√μ√«®‡™Õ◊È «≥— ‚√§¥È◊Õ¬“¥â«¬«‘∏’ Molecular assay 3. °“√μ‘¥μ“¡°“√√—°…“·≈–°”°∫— °“√°π‘ ¬“ 4. °“√§âπÀ“ºŸâ —¡º — «—≥‚√§ ·≈–ºâªŸ «É ¬«—≥‚√§‡°≥±°å “√ àßμ√«®∑“ßÀâÕߪؑ∫—μ°‘ “√‡™È◊Õ«—≥‚√§¥◊ÈÕ¬“ 1. °“√μ√«®‡™Õ◊È «≥— ‚√§¥ÕÈ◊ ¬“ ¥«â ¬«‘∏’Molecular assay μ√«®‰¥â‰¡à‡°‘π 1 §√—ßÈ μàÕ§Õ√ å °“√√—°…“ ‚¥¬¡’À≈°— ‡°≥±å¥ß— πÈ’ a. ‡ªπì ºªŸâ «É ¬«≥— ‚√§„π√–∫∫À≈°— ª√–°π—  ¢ÿ ¿“æ·Àßà ™“μ‘μ“¡‡ßÕË◊ π‰¢ ºâŸ¡ ’ ‘∑∏‘¢Õ√∫— ∫√°‘ “√„π¢âÕ 4 ·≈– b. ‡ªπì ºªâŸ «É ¬«≥— ‚√§„π°≈¡àÿ „¥°≈ÿà¡ÀπßË÷ μàÕ‰ªπ’È ë Re-treatment :‰¥â·°à°≈àÿ¡ºªâŸ «É ¬«≥— ‚√§∑°’Ë ≈∫— ‡ªπì ´È” (Re- lapse), À√Õ◊ ¢“¥¬“¡“°°«“à 2 ‡¥Õ◊ π·≈«â °≈∫— ¡“√°— …“ (Treat- ment After Default ) ë On-treatment :‰¥·â °à °≈¡ÿà ºªâŸ «É ¬«≥— ‚√§√“¬„À¡‡à  ¡À–∫«° ∑’¡Ë º’ ≈°“√μ√«®‡ ¡À–¬ß— §ß‡ªìπ∫«°À≈ß— °“√√°— …“ 3 ‡¥Õ◊ π ë Pre-treatment : ‡©æ“–°≈¡àÿ ºªŸâ «É ¬∑¡’Ë ª’ √–«μ—  ‘ ¡— º — °∫— ºªâŸ «É ¬ «—≥‚√§¥◊ÈÕ¬“√«à ¡∫“â π (Household MDR-TB contact) c.  “¡“√∂ ßà μ√«® Molecular assay ‰¥‡â ©æ“–°√≥’ ‡ ¡À–∫«° (Smear positive) ‡∑à“ππ—È

136 ·π«∑“߇«™ªØ‘∫—μ°‘ “√√°— …“«≥— ‚√§„π‡¥°Á æ.». 2557 À¡“¬‡Àμÿ À“°¡’§«“¡®”‡ªìπμ√«®¡“°°«à“ 1 §√È—ßμàÕ§Õ√å  °“√ √°— …“μâÕ߉¥√â ∫— Õπÿ¡—μ‘ ‡ªìπ°√≥’懑 »…®“° ª ™. À√◊պ⇟ ™¬Ë’ «™“≠∑Ë’  ª ™. ·μßà μÈ—ß 2. °“√‡æ“–‡™ÕÈ◊ ·≈–∑¥ Õ∫§«“¡‰«μÕà ¬“«≥— ‚√§ ¥«â ¬«∏‘ S’ olid or liq- uid mediaμ√«®‰¥â‰¡‡à °π‘ 1 §√È—ßμàÕ§Õ√ å °“√√°— …“ ‚¥¬¡À’ ≈—°‡°≥±å¥—ßπÈ’ a. ‡ªìπºªŸâ «É ¬«—≥‚√§∑Ë’ ßà μ√«®‡™◊ÈÕ«≥— ‚√§¥◊ÈÕ¬“ ¥«â ¬«‘∏’ Molecu- lar assay (ºªâŸ É«¬∑’ Ë ßà μ√«®μ“¡‡°≥±å¢âÕ 1 ∑°ÿ √“¬ ¡’ ‘∑∏‘‰¥â √—∫°“√μ√«®‡æ“–‡™Õ◊È ·≈–∑¥ Õ∫§«“¡‰«μàÕ¬“«—≥‚√§ ¥«â ¬«‘∏’ Solid or liquid §«∫§Ÿà°π— ‰ª) À√Õ◊ b. ‡ªπì ºâŸª«É ¬«—≥‚√§√“¬„À¡à ∑’Ë¡’‡™◊ÕÈ ‡Õ™‰Õ«√’ «à ¡¥«â ¬ À√◊Õ c. ‡ªìπºâŸª«É ¬«—≥‚√§√“¬„À¡à „π‡√Õ◊ π®”  “¡“√∂ ßà μ√«®‡æ“–‡™ÈÕ◊ ·≈–∑¥ Õ∫§«“¡‰«μÕà ¬“ ‰¥∑â ßÈ— °√≥’‡ ¡À– ∫«° À√◊Õ≈∫

·π«∑“߇«™ªØ∫‘ μ— °‘ “√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 137μ“√“ß∑Ë’ 1  √ÿª‡ß◊ËÕπ‰¢°“√ àßμ√«®∑“ßÀÕâ ߪØ∫‘ —μ°‘ “√«≥— ‚√§¥◊ÕÈ ¬“ Molecular assay Solid / Liquid Culture & DST ∑‘ ∏ª‘ √–‚¬™πå ‰¡à‡°‘π 1 §√Èß— μàÕ§Õ√å  ‰¡à‡°‘π 1 §√Èß— μàÕ§Õ√å  °“√√°— …“ °“√√°— …“ Re-treatment Re-treatment ‡ ¡À–∫«° ∑’ˇ ¡À–∫«° ·≈–≈∫°≈ÿࡺ⟪«É ¬∑’ˉ¥â√∫—  ∑‘ ∏‘Ï On-treatment On-treatment ‡ ¡À–∫«° ∑ˇ’  ¡À–∫«° (À≈—ß°“√√—°…“ 3‡¥Õ◊ π) (À≈ß— °“√√—°…“ 3 ‡¥◊Õπ) Pre-treatment Pre-treatment (new case) (new case) ‡©æ“– „π°≈¡àÿ Household Household MDR-TB MDR-TB contact, HIV contact ∑Ë’‡ ¡À–∫«° ·≈–ºªŸâ «É ¬«≥— ‚√§„π‡√Õ◊ π®” ∑°ÿ √“¬¢Õâ °”Àπ¥‡√Ë◊Õ߇ ¡À–  àßμ√«®‡©æ“–°√≥’  ßà ‰¥∑â Èß— ‡ ¡À–∫«°·≈– ‡ ¡À–∫«°‡∑“à πÈπ— ‡ ¡À–≈∫ (¬°‡«âπ°≈àÿ¡ On treatment ∑Ë’ à߉¥â‡©æ“– ‡ ¡À–∫«°)À¡“¬‡Àμÿ- ºŸâªÉ«¬«—≥‚√§ Re-treatment ·≈– On-treatment À¡“¬∂÷ߺ⟪ɫ¬∑’ˇ¢â“ μ“¡‡°≥±å„π¢âÕ 1b-  ª ™. „Àâ ‘∑∏‘ºŸâªÉ«¬«—≥‚√§∑ÿ°√“¬∑’Ë à߇ ¡À–μ√«®¥â«¬«‘∏’ Molecular assay ‰¥â√—∫°“√μ√«®¥«â ¬«∏‘ ’‡æ“–‡™È◊Õ·≈–∑¥ Õ∫§«“¡‰«μÕà ¬“§«∫§à°Ÿ —𠉪∑ÿ°§√—Èß

138 ·π«∑“߇«™ªØ∫‘ μ— °‘ “√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 -  ª ™. ‰¡à„À â ∑‘ ∏‘°“√ ßà μ√«®¥â«¬«∏‘ ’ Molecular assay „πºªâŸ «É ¬‡ ¡À– ≈∫∑ÿ°°√≥’ - Àπ૬∫√‘°“√ “¡“√∂ à߇ ¡À–‡æË◊Õμ√«®‡æ“–‡™È◊Õ·≈–∑¥ Õ∫§«“¡‰«μàÕ ¬“ À√◊Õ Molecular assay ‚¥¬‰¡à‡ ’¬§à“„™®â “à ¬„¥Ê ‰¥â‡©æ“–Àπ૬μ√«® ∑’Ë¢πÈ÷ ∑–‡∫’¬π°∫—  ª ™. „π·μà≈–°≈¡ÿà ‡∑“à ππÈ— ∑ß—È πÈ’  ª ™. ®– π∫—  πÿπ ß∫ª√–¡“≥§“à μ√«®„À·â °àÀπ૬μ√«®‚¥¬μ√ß - À“°¡§’ «“¡®”‡ªπì μ√«®¡“°°«“à 1 §√ß—È μÕà §Õ√ å °“√√°— …“ μÕâ ߉¥√â ∫— Õπ¡ÿ μ— ‘ ‡ªπì °√≥’摇»…®“°  ª ™. À√◊Õº‡Ÿâ ™Ë¬’ «™“≠∑’Ë  ª ™. ·μßà μß—È °“√∫√‘À“√ß∫ª√–¡“≥·≈–°“√™¥‡™¬∫√°‘ “√  ª ™.  π∫—  ππÿ ß∫ª√–¡“≥ ”À√∫— °“√∫√À‘ “√®¥— °“√‚§√ß°“√«≥— ‚√§ ·∫∫§√∫«ß®√ „π√–∫∫À≈°— ª√–°π—  ¢ÿ ¿“æ·Àßà ™“μ‘ ªßï ∫ª√–¡“≥ 2556 ‚¥¬ ·∫ßà ‡ªìπÀ¡«¥ ¥ß— π’È 1.  π—∫ πÿπ¬“μ“â π«—≥‚√§ ¬“μâ“π«—≥‚√§∑’Ë ª ™. π—∫ πÿπ·°àÀπ૬∫√‘°“√ ¡’°“√∫√‘À“√®—¥°“√ ·∫∫√«¡»Ÿπ¬å ‚¥¬Õߧ尓√‡¿ —™°√√¡‡ªìπºŸâ¥”‡π‘π°“√®—¥´È◊Õ ∫√‘À“√§≈—ß ‡«™¿—≥±å ·≈–®¥—  ßà ¬“„Àâ·°àÀπ«à ¬∫√°‘ “√ μ“¡®”π«π∑®Ë’ “à ¬„Àâ·°àºâŸªÉ«¬ ·≈– ∫—π∑÷°°“√„™â¬“„π√–∫∫ “√ π‡∑»ºŸâªÉ«¬«—≥‚√§ ‡™àπ SMART TB À√◊Õ ‚ª√·°√¡ÕË◊π ∑Ë’ “¡“√∂ àߢÕâ ¡Ÿ≈„Àâ  ª ™. ‰¥μâ “¡¡“μ√∞“π¢Õâ ¡Ÿ≈∑’Ë  ª ™. °”Àπ¥ √“¬°“√¬“«—≥‚√§ª√–°Õ∫¥«â ¬ 1) ¬“μ“â π«≥— ‚√§æ◊Èπ∞“π (First Line Drugs) ë Isoniazid (H) 100 mg ë Rifampicin (R) 300 mg

·π«∑“߇«™ªØ∫‘ —μ°‘ “√√°— …“«—≥‚√§„π‡¥Á° æ.». 2557 139 ë Rifampicin (R) 450 mg ë Pyrazinamide (Z) 500 mg ë Streptomycin (S) ë Ethambutol (E) 400 mg ë Ethambutol (E) 500 mg 2) ¬“μ“â π«≥— ‚√§¥ÈÕ◊ ¬“ (MDR-TB Drugs) ë Ethionamide 250 mg ë Kanamycin 1 gm injection ë Ofloxacin 200 mg ë Para-Amino Salicylic acid (PAS) 1gm ë Cycloserine 250 mg 3) ¬“√«¡À≈“¬¢π“π Fixed Dosed Combination (FDC) ë 2 FDC : Rifampicin 300 mg + INH 150 mg ·≈– Rifam- picin 150 mg + INH 100 mg ë 4 FDC : Rifampicin 150 mg + INH 75 mg + pyrazina- mide 400 mg + Ethambutol 275 mg °“√‡∫°‘ ¬“μâ“π«≥— ‚√§¥◊ÈÕ¬“ (MDR-TB Drugs) Àπ«à ¬∫√°‘ “√∑Ë’¢÷Èπ∑–‡∫’¬π‡ªπì MDR-TB Treatment center ‡∑à“πÈ—π®ß÷ ®– “¡“√∂‡∫°‘ ¬“μ“â π«≥— ‚√§¥Õ◊È ¬“‰¥â  ”À√∫— Àπ«à ¬∫√°‘ “√∑«—Ë ‰ª®– “¡“√∂‡∫‘°¬“μâ“π«—≥‚√§¥È◊Õ¬“‰¥â‡©æ“–¬“ Ofloxacin  ”À√—∫°√≥’ºâŸªÉ«¬·æ⬓„π μŸ √æπ◊È ∞“π‡∑“à ππ—È

140 ·π«∑“߇«™ªØ∫‘ μ— °‘ “√√—°…“«≥— ‚√§„π‡¥°Á æ.». 2557 2. ™¥‡™¬°“√μ√«®∑“ßÀÕâ ߪØ∫‘ —μ‘°“√«—≥‚√§ 2.1 °“√μ√«®∑“ßÀÕâ ߪؑ∫μ— ‘°“√æÈπ◊ ∞“𠙥‡™¬‡ªìπ‡ß‘π‡æË‘¡®“°ß∫‡À¡“®à“¬√“¬À—« (Capitation) „ÀâÀπ૬ ∫√‘°“√μ“¡º≈ß“π∑’Ë∫—π∑÷°¢âÕ¡≈Ÿ  àß„Àâ  ª ™. „πÕμ— √“¥ß— πÈ’ ë μ√«® AFB 20 ∫“∑/ μ«— Õ¬à“ß o μ√«® CAT 1,2,3 ‡∫‘°‰¥â‰¡‡à °‘π 3 ™ÿ¥Ê ≈– 3 samples (Slide) μÕà §Õ√å °“√√—°…“ o CAT 4 ‡∫‘°‰¥â‰¡à‡°π‘ 6 ™ÿ¥Ê ≈– 3 samples (Slide) μàÕ §Õ√ å °“√√—°…“ ë μ√«®‡Õ°´å‡√¬åªÕ¥ 100 ∫“∑/ §√ßÈ— o CAT 1,2,3 ‡∫°‘ ‰¥â‰¡à‡°π‘ 2 §√È—ß μÕà §Õ√ å °“√√—°…“ o CAT 4 ‡∫‘°‰¥â‰¡à‡°π‘ 5 §√—ßÈ μÕà §Õ√ å °“√√°— …“ À¡“¬‡Àμÿ CAT1 = 2 HRZE/4HR CAT2 = 2 HRZES/1HRZE/5HRE CAT3 = 2 HRZ/4HR CAT4 =  μŸ √¬“ ”À√∫— ºªâŸ «É ¬«≥— ‚√§¥ÕÈ◊ ¬“À≈“π¢π“π (MDR TB) 2.2 °“√μ√«®‡æ“–‡™ÈÕ◊ (Culture & DST) ·≈–μ√«®‡™È◊Õ«—≥‚√§ ¥ÈÕ◊ ¬“ °“√™¥‡™¬‡ªπì ‡ßπ‘ „ÀÀâ π«à ¬μ√«®∑¢’Ë πÈ÷ ∑–‡∫¬’ π°∫—  ª ™. ‰¡‡à °π‘ 1 §√ß—È μÕà §Õ√å °“√√°— …“ ¥ß— π’È ë μ√«®‡æ“–‡™ÈÕ◊ «—≥‚√§ 200 ∫“∑/μ«— Õ¬“à ß ßà μ√«® (Solid or Liquid)

·π«∑“߇«™ªØ‘∫μ— °‘ “√√°— …“«≥— ‚√§„π‡¥°Á æ.». 2557 141 ë ∑¥ Õ∫§«“¡‰«μàÕ¬“ 200 ∫“∑/μ—«Õ¬à“ß àßμ√«® (Solid or Liquid) ë Molecular assay 850 ∫“∑/μ«— Õ¬“à ß ßà μ√«® À¡“¬‡Àμÿ  ª ™. Õπÿ¡—μ‘™¥‡™¬°“√μ√«®‡æ“–‡™◊ÈÕ·≈–μ√«®§«“¡‰«¢Õ߇™◊ÈÕ«≥— ‚√§ (Culture & DST) ¥«â ¬«∏‘ ’ Liquid media ¥«â ¬‡ßÕË◊ π‰¢·≈–Õμ— √“™¥‡™¬‡¥‘¡„πªïß∫ª√–¡“≥ 2555  ”À√—∫‡ ¡À–∑’Ë àßμ√«®·≈–√“¬ß“πº≈¿“¬„π31 ∏—𫓧¡ 2555 ‡∑à“ππÈ—3. °“√ π∫—  πÿπ°®‘ °√√¡°“√¥·Ÿ ≈√°— …“ ¡’«—μ∂ÿª√– ß§å‡æË◊Õ π—∫ πÿπ°‘®°√√¡„¥Ê ∑’Ë àߺ≈μàÕº≈≈—æ∏å°“√√—°…“ºªŸâ «É ¬«≥— ‚√§„À∫â √√≈μÿ “¡‡ª“Ñ À¡“¬ ‡™πà °®‘ °√√¡μ¥‘ μ“¡°“√√°— …“ºªâŸ «É ¬«≥— ‚√§°‘®°√√¡°”°—∫°“√°‘𬓰‘®°√√¡‡¬’ˬ¡∫â“𠇪ìπμâπ ∑—ÈßπÈ’°Õß∑ÿπ«—≥‚√§ à«π°≈“߉¥∂â “à ¬‚Õπß∫ª√–¡“≥·≈–¿“√°®‘ „Àâ  ª ™. ‡¢μ‡ªπì º®Ÿâ ¥—  √√ß∫ª√–¡“≥„Àâ·°à ”π—°ß“π “∏“√≥ ÿ¢®—ßÀ«—¥ À√◊Õ ”π—°Õπ“¡—¬°√ÿ߇∑æ¡À“π§√ À√◊ÕÀπ૬∫√°‘ “√„πæ◊πÈ ∑’√Ë —∫º¥‘ ™Õ∫ μ“¡À≈°— ‡°≥±å‡ßÕË◊ π‰¢∑˧’ ≥–∑”ß“π„π√–¥∫—‡¢μ‡ÀπÁ ™Õ∫ ·≈–„Àâ  ª ™. ‡¢μ‡ªπì º°Ÿâ ”°∫— 쥑 μ“¡º≈°“√¥”‡ππ‘ ß“π„π√–¥∫—®ß— À«—¥„À∫â √√≈μÿ “¡‡ªÑ“À¡“¬4.  π∫—  πÿπ°®‘ °√√¡°“√§âπÀ“º Ÿâ ¡— º — ·≈–ºªâŸ «É ¬«≥— ‚√§ ¡«’ μ— ∂ªÿ √– ß§‡å æÕË◊  π∫—  ππÿ °®‘ °√√¡„¥Ê ∑‡Ë’ °¬Ë’ «¢Õâ ß°∫— °“√§πâ À“ºªâŸ «É ¬«≥— ‚√§√“¬„À¡·à ≈–π”‡¢“â  √àŸ –∫∫°“√¥·Ÿ ≈√°— …“·μ‡à ππË‘ Ê ‰¥·â °à °®‘ °√√¡μÕà ‰ªπ’ȇ™àπ °‘®°√√¡μ√«®§—¥°√Õߺ⟠—¡º— √à«¡∫â“π°—∫ºâŸªÉ«¬«—≥‚√§ °‘®°√√¡§âπÀ“ºªŸâ É«¬«—≥‚√§„π°≈à¡ÿ ‡ ¬Ë’ ß ‡ªπì μπâ ∑ßÈ— π°È’ Õß∑πÿ «—≥‚√§ «à π°≈“߉¥∂â à“¬‚Õπ

142 ·π«∑“߇«™ªØ‘∫μ— °‘ “√√°— …“«≥— ‚√§„π‡¥°Á æ.». 2557 ß∫ª√–¡“≥·≈–¿“√°®‘ „Àâ  ª ™. ‡¢μ‡ªπì º®Ÿâ ¥—  √√ß∫ª√–¡“≥„À·â ° à ”π°— ß“π  “∏“√≥ ¢ÿ ®ß— À«—¥ À√Õ◊  ”π—°Õπ“¡—¬°√ßÿ ‡∑æ¡À“π§√ À√◊ÕÀπ૬∫√‘°“√ „π æπÈ◊ ∑√Ë’ ∫— º¥‘ ™Õ∫ μ“¡À≈°— ‡°≥±‡å ßÕ◊Ë π‰¢∑§’Ë ≥–∑”ß“π„π√–¥∫— ‡¢μ‡ÀπÁ ™Õ∫ ·≈– „Àâ  ª ™.‡¢μ‡ªπì º°Ÿâ ”°∫— 쥑 μ“¡º≈°“√¥”‡ππ‘ ß“π„π√–¥∫— ®ß— À«¥— „À∫â √√≈μÿ “¡ ‡ªÑ“À¡“¬ (Õâ“ßÕ‘ß®“° §àŸ¡◊Õ∫√‘À“√ °Õß∑ÿπÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘ ª√–®”ªï ß∫ª√–¡“≥ 2556 /°“√∫√‘À“√ß∫∫√‘°“√ºŸâμ‘¥‡™◊ÈÕ‡Õ™‰Õ«’·≈–ºâŸªÉ«¬‡Õ¥ å ·≈–°“√∫√‘°“√ß∫ºŸâªÉ«¬«—≥‚√§ 2, Àπ“â 74-82) πÈ”¬“∑¥ Õ∫∑‡ÿ ∫Õ√§å ≈ÿ π‘ ‚√ß欓∫“≈®¥— ´Õ◊È π”È ¬“‚¥¬μ√ß∑ Ë’ ¿“°“™“¥ ‡∫Õ√å‚∑√ 02 2520161-4 „π°√≥¡’ ª’ ≠í À“  “¡“√∂쥑 μÕà Ω“É ¬‡¿ ™— °√√¡  ”π°— «≥— ‚√§ ‡∫Õ√å‚∑√ 02 211-1841 μàÕ 122

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·π«∑“߇«™ªØ‘∫μ— °‘ “√√°— …“«≥— ‚√§„π‡¥Á° æ.». 2557 145¿“æª√–°Õ∫√ªŸ ∑Ë’ 1 μàÕ¡π”È ‡À≈◊Õߢȗ«ªÕ¥‚μ ·≈– hyperaeration ¢Õߪե¢«“®“°¿“æ ¥â“πÀπâ“

146 ·π«∑“߇«™ªØ‘∫—μ°‘ “√√—°…“«≥— ‚√§„π‡¥Á° æ.». 2557 √Ÿª∑’Ë 2 Gohnûs complex √ªŸ ∑Ë’ 3 Calcification

·π«∑“߇«™ªØ‘∫μ— °‘ “√√°— …“«≥— ‚√§„π‡¥Á° æ.». 2557 147√Ÿª∑’Ë 4 Miliary infiltration√ªŸ ∑Ë’ 5 ≈°— …≥– Fibronodular infiltration ·≈– cavity „πºŸâªÉ«¬‡¥Á°Õ“¬ÿ 14 ªï

148 ·π«∑“߇«™ªØ‘∫μ— °‘ “√√°— …“«≥— ‚√§„π‡¥°Á æ.». 2557 √ªŸ ∑’Ë 6 Segmental atelectasis √ªŸ ∑Ë’ 7 Effusion

·π«∑“߇«™ªØ‘∫μ— °‘ “√√—°…“«—≥‚√§„π‡¥°Á æ.». 2557 149√Ÿª∑’Ë 8 °√–¥Ÿ° π— À≈ß—  «à π body ¥“â πÀπ“â ¬∫ÿ μ—«≈ß ·≈–∑”„À‡â °¥‘ §«“¡æ‘°“√ º¥‘ √ªŸ√Ÿª∑’Ë 9 °“√¬∫ÿ μ—«º¥‘ √Ÿª¢Õß body ¢Õß T5-T9 ·≈– Cold abscess „πºâªŸ É«¬ TB spine