1. Ðại cương về bệnh suyễn:
Bệnh suyễn là một bệnh về hô hấp rất thường xảy ra và là một trong những bệnh hàng đầu tại nhà thương cũng như tại phòng mạch. Tại Hoa Kỳ cứ 20 người dân thì một người bị bệnh suyễn. Người Việt chúng ta không có thống kê chính thức nhưng tỷ lệ người mắc bệnh suyễn chắc cũng không ít hơn thế.
Thế nào là bệnh suyễn?
Uỷ ban nghiên cứu về suyễn của cơ quan US National Institutes of Health đưa ra định nghĩa như sau: bệnh suyễn là bệnh viêm đường hô hấp gây ra khó thở khò khè, nghẹt thở, ép ngực và ho, thường về đêm hay về sáng sớm, xảy ra từng cơn, tự nhiên có thể trở lại bình thường hay do chữa trị. Bệnh suyễn xảy ra ở mọi lứa tuổi và phái tính, nhưng phái nam thường bị nhiều hơn nếu bị suyễn trước tuổi vị thành niên, sau đó thì phái nữ dẫn đầu. Hiện nay thì suyễn là một bệnh tuy nguy hiểm nhưng chữa được và thường đáp ứng nhanh chóng với cách trị liệu, và tuy tỉ lệ tử vong thấp chỉ vào khoảng 1% số bệnh nhân nhập viện (khoảng 5000 người cho mỗi năm) nhưng suyễn kinh niên có thể gây một số biến chứng như suy tim rất nguy hiểm.
Trong phạm vi bài này, chúng tôi chỉ đưa ra một số vấn đề thông thường nhất và thực tế nhất mà người bị suyễn cần biết để có thể tự giúp mình chữa bệnh hữu hiệu hơn.
2. Tại sao lại có bệnh suyễn:
Căn bản của bệnh suyễn là do phế quản bị co thắt lại phối hợp với các chất đờm nhớt trong phế quản tiết ra nhiều quá làm nghẹt thở. Những nghiên cứu mới đây cho thấy những hiện tượng này xảy ra khi phế quản bị viêm do phản ứng của cơ thể chống lại tác nhân gây ra bệnh xảy ra tại phế quản. Có hai nguyên nhân chính đóng vai trò quan trọng để gây ra bệnh suyễn là bệnh dị ứng và bệnh không do dị ứng.
Nguyên nhân dị ứng (Allergy) chiếm đa số trường hợp, thường mang yếu tố di truyền, do những chất gây dị ứng có thể là bọ nhà (ở trong chăn, gối, thảm), dán, lông thú vật, nhất là mèo hay chó, thức ăn như đậu phộng, hay đồ biển, và phấn hoa. Cơn suyễn có thể đến ngay khi tiếp xúc hay chậm trễ sau vài giờ mới sinh bệnh. Những nguyên nhân gây dị ứng này cũng giống như ở trong bệnh viêm mũi dị ứng, cho nên người bị dị ứng có thể chỉ bị viêm mũi, viêm mắt hay suyễn, hay bị đủ thứ, vừa ngứa mắt, nghẹt mũi, vừa bị suyễn.
Nguyên nhân khác dị ứng: xảy ra ít hơn, như nhiễm trùng đường hô hấp trên, viêm mũi, viêm xoang mũi, sặc đồ ăn, hở cuống bao tử, thay đổi thời tiết, bị căng thẳng, đồ đạc trong nhà hay một số hoá chất như lưu huỳnh, chất chlorine. Có ba nguyên nhân quan trọng khác là:
- aspirin và các chất chống đau tương tự như Motrin, Advil, v.v..
- vận động thể dục thể thao: đây là nguyên nhân gây suyễn làm một số người hiểu lầm là bị suyễn thì không tập thể dục thể thao được, cơn suyễn có thể đến trong vòng 3 phút sau khi hết vận động, rồi có thể trở lại bình thường trong vòng 1 đến hai giờ hay có thể kéo dài hơn.
- Khói thuốc lá hoặc do mình hút hoặc hút thụ động (mình ngửi khói thuốc người khác hút, second hand smoking). Một số chất không hợp ở sở làm cũng có thể gây bệnh suyễn, có khi từ nhiều tuần lễ hay nhiều năm tiếp xúc mới phát bệnh suyễn.
Những nguyên nhân trên, dù do dị ứng hay không do dị ứng, tác động đến bệnh nhân khác biệt nhau. Có người chỉ tiếp xúc với một yếu tố là lên cơn suyễn, nhiều người khác phải tiếp xúc với nhiều yếu tố cùng một lúc mới gây bệnh, nhưng dù do yếu tố nào đi nữa thì cũng đều có triệu chứng như nhau và phần lớn trường hợp người ta không tìm ra nguyên nhân chắc chắn nào đã làm lên cơn suyễn. Khi cần, người ta phải dùng phương pháp miễn dịch rất công phu để truy tầm yếu tố gây bệnh nhưng đôi khi cũng không tìm ra.
Như trên đã đề cập đến, yếu tố di truyền cũng đóng vai trò quan trọng, gây ra bệnh suyễn. Có những gia đình có nhiều người bị bệnh suyễn, có thể bố mẹ hay anh em đều bị suyễn. Nhưng không phải ai trong gia đình có người suyễn là phải bị suyễn, mà còn cần nhiều yếu tố khác tác động vào, và mỗi người trong gia đình có thể có nguyên nhân gây suyễn khác nhau, như có người bị suyễn do lông chó mèo, có người do phấn hoa…
3. Triệu chứng:
Thường khi đến khám bệnh, bệnh nhân nên cho bác sĩ biết chi tiết về bệnh của mình, làm việc chẩn đoán bệnh và hướng trị liệu rõ ràng hơn. Bệnh nhân nên cho bác sĩ biết những chi tiết sau đây: thời gian bị bệnh xảy ra thường xuyên không, độ nặng nhẹ của mỗi cơn suyễn, có lệ thuộc vào mùa nào không, những yếu tố nào thường gây bệnh suyễn, từ ở nhà đến ở sở làm, những chất gây dị ứng như phấn hoa.. hay có liên hệ đến thể dục thể thao không, những thuốc nào thường dùng khi lên cơn suyễn, và có theo đúng cách dùng thuốc không, có tự ý bỏ thuốc không.
Triệu chứng thông thường nhất là thở khò khè (wheezing) nghe như tiếng sáo thổi trong phổi, thở khó, tức ngực và ho. Mức độ nặng nhẹ và xảy ra thường xuyên hay không tuỳ trường hợp. Ðôi khi bệnh nhân chỉ thấy những cơn ho khan, hay ho có đờm. Nhiều trường hợp triệu chứng xảy ra tự nhiên. Trường hợp khác có những yếu tố kích thích triệu chứng mới xảy ra. Suyễn hay trở nặng về đêm và nặng nhất lúc sáng sớm.
Chẩn đoán bệnh suyễn thường dựa vào khám nghiệm lâm sàng. Khi lên cơn cấp tính, bệnh nhân tỏ vẻ lo sợ, mệt mỏi. Lúc đầu thở vào sâu, và thở ra kéo dài, khó khăn, càng về sau càng thở nông cạn hơn và có thể không nghe được tiếng khò khè nữa, báo hiệu giai đoạn hô hấp bị suy yếu, phổi và lồng ngực bị mệt. Ðôi khi không nghe tiếng thở ở một bên phổi có thể là triệu chứng của tràn khí màng phổi (pneumothorax). Một biến chứng quan trọng của suyễn nặng làm rách phổi. Khám bệnh lúc suyễn ở giai đoạn kinh niên thấy khác hơn: có thể thấy hơi thở bình thường chỉ khi thở ra hết sức mới nghe tiếng khò khè.
Ðể giúp độc giả có ý niệm về độ nặng nhẹ của bệnh suyễn, chúng tôi nêu ra bảng phân loại bệnh suyễn theo mức độ nặng nhẹ
- Ðộ suyễn nặng nhẹ
- Triệu chứng
- Triệu chứng về đêm
- Suyễn nhẹ
- Ðộ hai lần mỗi tuần, ít hơn một lần một ngày, ít lên sốt cấp tính
- Ðộ hai lần mỗi tháng
- Suyễn vừa
- Xảy ra hàng ngày, lên cơn cấp tính trên 2 lần mỗi tuần.
- Trên một lần mỗi tuần
- Suyễn nặng
- Xảy ra thường trực mỗi ngày, giới hạn hoạt động người bệnh, lên cơn cấp tính thường xuyên
- Xảy ra thường xuyên
Phỏng theo "Guidelines for the Diagnosis and Management of Athsma" của National Athsma Education and Prevention Program, 1997 (có sửa đổi và đơn giản hoá).
Bệnh suyễn của người lớn tuổi:
Ngoài những trường hợp suyễn xảy ra từ trước không khỏi, người lớn tuổi cũng có thể bắt đầu bị bệnh suyễn. Triệu chứng suyễn của người lớn tuổi, trên 65 tuổi, cũng không khác những triệu chứng vừa nói ở trên. Tuy nhiên, người lớn tuổi có một số tính chất riêng biệt mà chúng ta cần biết, có những trường hợp người ta không thở khò khè mà chỉ thấy ho nhiều, tức ngực và khó thở. Chẩn đoán bệnh suyễn ở người già đôi khi khó khăn và phức tạp, vì họ thường có những bệnh phổi khác như viêm phế quản kinh niên (chronic bronchitis) hay bệnh khí thủng (emphysema) là hai hình thức của bệnh nghẹt phổi kinh niên (COPD: chronic obstructive pulmonary disease), phần lớn do thuốc lá, bệnh suy tim gây suyễn tim (cardiac asthma). Những triệu chứng suyễn có thể tăng và kéo dài vì nhiều người lớn tuổi bị suy yếu không ho mạnh để tống xuất đờm ra được và đờm đóng thành từng cục trong phế quản, nhiều khi phải hút ra bằng máy hút. Cho nên không phải cứ thấy ho là cho nhiều thuốc ho, nhất là thuốc ho có chất codeine, là tốt vì nó làm cho người ta càng khó thở hơn do đờm không tống ra được. Rất nhiều bệnh nhân và người nhà không hiểu điều này cứ đòi bác sĩ "tôi" (hay bố tôi, mẹ tôi) ho quá, bác sĩ cho thuốc ho nào mạnh hơn chứ thuốc ho đã cho yếu quá. "Thuốc ho càng mạnh càng hại cho bệnh nhân."
Bệnh suyễn ở trẻ con còn nhiều hơn người lớn. 1/3 trường hợp là suyễn của trẻ con dưới 18 tuổi. Bệnh suyễn có thể bắt đầu rất sớm từ khi một hai tuổi và có thể tự nhiên biến mất trong gần 50% trường hợp khi trẻ đến tuổi dạy thì (đến lúc này thì các thày thuốc bắc, thuốc nam tha hồ khoe tài chữa hết bệnh suyễn). Triệu chứng bệnh suyễn ở trẻ con cũng không khác ở người lớn, tuy nhiên nhiều trẻ con quá nhỏ không nói được cho bố mẹ biết khi chúng bắt đầu lên cơn để phản ứng kịp thời hoặc cho thuốc men, hoặc đi bác sĩ, hoặc gọi cấp cứu 911. Những dấu hiệu quan sát được là sự lo lắng, ho nhiều mà không sổ mũi, mặt mày lợt lạt, vả mồ hôi, thở nhanh, bứt rứt không đứng ngồi yên được, tự nhiên kêu mệt. Nếu trẻ con thở khò khè càng lúc càng nhiều mặc dù cho thuốc men đầy đủ như bác sĩ chỉ định, ngực và cổ co rút lại mỗi khi thở và nhất là môi và móng tay tím tái (dấu hiệu cho thấy thiếu dưỡng khí) là phải đưa đi cấp cứu tại bệnh viện hoặc gọi 911 ngay. Nếu trẻ con nào thường hay lên cơn suyễn và đang đi học, bố mẹ phải trực tiếp thông báo cho thầy cô giáo, nhất là thầy dậy về thể dục thể thao, ban y tế của trường biết về tình trạng của con mình để họ có thể xử sự khi các cháu lên cơn suyễn, và nhất là phải cho những người liên hệ điện thoại và các cách liên lạc hữu hiệu nhất để nhà trường và bệnh viện có thể liên lạc với mình bất cứ lúc nào. Nhiều người Việt chúng ta rất coi thường chuyện này.
4. Trị liệu:
Mục đích chữa trị bệnh suyễn là giảm triệu chứng bệnh suyễn và cắt những cơn bệnh tối đa để người bệnh có thể sinh sống bình thường. Sự trị liệu không giống nhau, mà thay đổi tuỳ từng bệnh nhân một. Chỉ có một điểm chung là cố gắng để loại bỏ những tác nhân gây bệnh tối đa nếu có thể được như là thay đổi môi trường làm việc hay sinh sống, bỏ hút thuốc lá hay không gần gũi chó mèo nếu bị dị ứng với những thứ ấy. Nhưng nếu dị ứng với phấn hoa thì khó mà loại bỏ những tác nhân gây bệnh. Nếu suyễn do vận động thể dục thể thao thì phải tìm cách đối phó với suyễn chứ không giảm bớt vận động vì suyễn không đồng nghĩa với tàn phế.
Thuốc chữa bệnh suyễn rất đa dạng. Chúng tôi không đi vào chi tiết từng loại thuốc chữa suyễn, mà chỉ giới thiệu tổng quát các loại thuốc chữa bệnh suyễn đồng thời nêu rõ một số điểm thực tế cần biết. Thuốc suyễn được chia làm hai loại, một loại có tác dụng nhanh dùng để chữa các cơn cấp tính của suyễn, và một loại có tác dụng chậm dùng để chữa dằn chứng và lâu dài mục đích ngăn chận hoặc làm nhẹ những cơn suyễn.
Trị liệu cơn suyễn cấp tính: dùng những thuốc có tác dụng nhanh để làm bệnh nhân qua cơn khó thở càng sớm càng tốt.
- Cho thở oxy liên tục để giữ nồng độ dưỡng khí của máu trên 90% hay cao hơn nếu bệnh nhân có bệnh tim mạch hay có thai. Một số trường hợp quá nặng phải cho bệnh nhân vào máy thở hô hấp nhân tạo và thời gian trong máy thở lâu hay mau tuỳ trường hợp.
- Thuốc dãn phế quản: thường là Albuterol (thuốc giao cảm) dùng qua ống phun hơi có định liều (metered dose inhaler) nếu bị bệnh nhẹ và vừa, hoặc qua máy phun mù (nebulizer) nếu bị bệnh nặng.
- Chất Coricosteroid: có mục đích giảm viêm để phế quản bớt co thắt và tiết chất nhờn. Nếu cơn suyễn nặng thì dùng Steroid chích tĩnh mạch như Methylprednisolone, dùng đến khi triệu chứng thuyên giảm rõ rệt thì mới giảm liều lượng. Nếu còn suyễn nhẹ hay vừa thì có thể dùng thuốc steroid uống như Prednisone, có thể dùng lâu dài hơn với liều thuốc thấp 5mg mỗi ngày.
- Trụ sinh: thường không cần thiết, chỉ nên dùng khi có bệnh nhiễm trùng kèm theo, như bệnh sưng phổi hay viêm xoang mũi..
Trị liệu suyễn kinh niên: ở giai đoạn suyễn kinh niên, bệnh nhân thường dùng những thuốc có tác dụng chậm để giảm những cơn suyễn. Tuỳ theo mức độ suyễn nặng nhẹ như bảng phân loại trên, người ta dùng một hay nhiều loại thuốc cùng một lúc.
- Thuốc xịt corticosteroids (qua ống bơm hơi) an toàn hơn thuốc uống hay chích, ít cho tác dụng phụ, có thể dùng lâu dài. Một điều nên nhớ là sau khi xịt thuốc vào họng, phải xúc miệng để tránh bệnh mọc nấm ở họng hay khan tiếng. Những loại thông thường trên thị trường là Azmacort, Flovent, Vanceril…
- Thuốc xịt Salmeterol (qua ống bơm hơi) là loại dãn phếâ quản có tác dụng lâu dài (cùng họ với Albuterol có tác dụng mau). Xịt hai lần mỗi ngày tránh được lên cơn suyễn cấp tính thường xuyên.
- Singulair hay Accolate (thuốc viên) là thuốc mới (thuốc kháng Leukotriene), và Cromolyn (thuốc xịt) có tác dụng dãn phế quản lâu dài (có cơ chế hoạt động khác thuốc Salmeterol trên), uống mỗi ngày một viên (hai thuốc trên) hay qua ống bơm hơi mỗi ngày nhiều lần (thuốc dưới) làm phế quản bớt bị co thắt và giảm cơn suyễn.
- Theophylline là thuốc chống suyễn lâu đời, đã một thời là thuốc hàng đầu để chữa suyễn. Hiện nay thỉnh thoảng người ta mới dùng thuốc này dưới hình thức thuốc uống, chứ không còn dùng thuốc chích nữa vì Theophylline có nhiều tác dụng phụ nguy hiểm.
Những điều cần nhớ khi dùng thuốc:
- Nên để ý đến các tác dụng của thuốc khác nhau tuỳ loại. Khi dùng thuốc có tác dụng lâu dài, phải dùng thuốc hàng ngày, nhất là trường hợp suyễn kinh niên vừa và nặng, thuốc mới có công hiệu giảm cơn suyễn. Thuốc này không cắt đứt cơn suyễn cấp tiến ngay được, lúc ấy lại phải dùng thuốc dãn phế quản có tác dụng nhanh như albuterol. Thành thử ra trong khi dùng thuốc có tác dụng chậm, lúc nào cũng giữ sẵn Albuterol để dùng ngay khi lên cơn suyễn.
- Qua kinh nghiệm cho thấy có nhiều người dùng thuốc xịt lâu ngày mà vẫn không biết cách xịt thuốc cho đúng, nên phải tham khảo ý kiếân của bác sĩ của mình khi dùng thuốc xịt để có thể tận dụng hết tác dụng của thuốc. Chẳng hạn, có người xịt hai cái liền cho mỗi lần hít vào bằng miệng, chỉ có cái xịt đầu tiên là vào phế quản, còn cái xịt thứ hai là ra ngoài, như vậy họ chỉ hưởng được nửa lượng thuốc cần thiết.
- Dù dùng thuốc nào đi nữa, bệnh nhân theo 3 điều này: (1) thăm viếng bác sĩ thường xuyên để điều chỉnh thuốc men cho phù hợp với bệnh trạng vì triệu chứng và độ nặng nhẹ cũng như yếu tố gây bệnh có thể thay đổi theo thời gian; (2) dùng thuốc thường xuyên theo đúng chỉ định của bác sĩ dù trong lúc không lên cơn, như thế mới giảm cơn suyễn đến thường xuyên và tránh hậu quả của suyễn; (3) bệnh nhân phải tìm hiểu những yếu tố gây bệnh suyễn cho mình, và bản thân cũng như gia đình mình nên tìm hiểu cặn kẽ về suyễn, công dụng các loại thuốc men và cách đối phó khi bệnh nhân lên cơn suyễn để giúp cho bệnh nhân hữu hiệu hơn.
5. Ống đo phế dung (Peak Flow Meter)
Nên dùng ống đo phế dung (hình 1) hay dung tích phổi (lung volume) để xem hơi thở ra có đủ để đánh giá độ nặng nhẹ của suyễn và công hiệu của thuốc. Ðây là phần quan trọng trong việc chữa suyễn và có thể ngăn cản những cơn suyễn nặng. Bệnh nhân thổi bằng miệng vào ống đo phế dung (hình 2) để đo dung tích phổi thở ra hết sức (peak expiratory flow hay PEF) sau khi đã hít vào hết sức. Trong mùa suyễn, bệnh nhân đo lúc sáng sớm và chiều tối, và 20 phút sau khi dùng thuốc dãn phế quản. (Xin liên lạc với bác sĩ của mình để hỏi làm thế nào để có ống đo phế dung cá nhân và cách dùng như thế nào cho đúng).
Kết quả của đo PEF là để đánh giá độ nặng của suyễn, PEF càng thấp nếu cơn suyễn càng nặng, xác định công hiệu của thuốc xịt có tác dụng nhanh như Albuterol: PEF gia tăng sau khi dùng thuốc chứng tỏ thuốc công hiệu, và nhận biết cơn suyễn sắp đến để chữa trị kịp thời.
Bệnh nhân đo PEF lúc đó không có triệu chứng khi hô hấp tốt nhất, ghi kết quả của PEF này số liệu căn bản, sau đó lấy kết quả mỗi lần đo sáng, chiều, sau khi dùng thuốc v.v.. người ta so sánh với PEF căn bản (theo % PEF căn bản). Cơn suyễn nhẹ từ 80% đến 100% PEF căn bản, cơn suyễn vừa từ 50% đến 80% PEF căn bản, còn cơn suyễn nặng nếu PEF dưới 50% căn bản. Tuy đo PEF rất có lợi và không tốn kém, trên thực tế phần lớn trường hợp người ta theo dõi triệu chứng là đủ và chỉ dùng ống đo phế dung khi đổi thuốc men để xem thuốc mới có công hiệu hay không.
6. Biến chứng của bệnh suyễn:
Biến chứng quan trọng nhất của suyễn là sưng phổi (pneumonia), tràn khí màng phổi (pneumothorax), và suy hô hấp, nhiều khi rất nặng cần phải dùng máy thở.
Với sự tiến bộ của y học hiện đại và phương tiện cấp cứu nhanh chóng và hữu hiệu, tử vong vì bệnh suyễn giảm đi rất nhiều, chỉ còn vào khoảng 1% những trường hợp nặng phải nhập viện. Những dấu hiệu có thể làm bệnh nhân chết vì cơn suyễn như:
- Trong quá khứ bị cơn suyễn cấp tính nặng, đã vào máy thở, hay phải vào phòng săn sóc đặc biệt (ICU).
- Từ hai lần nhập viện trở lên, hay từ ba lần vào phòng cấp cứu trở lên trong năm vừa rồi, hay tháng vừa qua đã nhập viện hay vào phòng cấp cứu.
- Dùng trên hai lọ xịt Albuterol trong một tháng.
- Ðang uống thuốc Steroid thường xuyên.
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- Bệnh tâm thần hay nghiện ngập.
Biến chứng do dùng thuốc chống suyễn tương đối hiếm, dùng thuốc Albuterol nhiều quá có thể làm hồi hộp, run tay chân, bứt rứt, uống thuốc Steroid lâu dài có thể gây xốp xương, giảm tính miễn dịch, bị mắt cườm, đau cổ, giữ nước lên cân, bệnh tiểu đường hay bệnh tâm thần. Nhưng từ khi sản xuất có thuốc xịt Steroid, dù dùng thuốc lâu dài, tác dụng phụ của thuốc chỉ còn khoảng % so với thuốc steroid uống hay chích, nên thuốc xịt Steroid được xem là an toàn.
7. Kết luận:
Trong khuôn khổ của bài này, chúng tôi không thể đưa hết những vấn đề về suyễn, tuy nhiên chúng tôi đã cố gắng nêu ra những chi tiết cần thiết để độc giả có thể sử dụng trong đời sống thực tế nếu mình hay người nhà của mình bị suyễn. Chữa suyễn chỉ là chữa ngọn, để giúp bệnh nhân qua được cơn suyễn để không làm hại đến tính mạng của bệnh nhân cũng như về lâu về dài tránh cho bệnh nhân bị những biến chứng để nếu sau này nếu bệnh nhân có tự nhiên khỏi hẳn bệnh suyễn sẽ có một đời sống hoàn toàn bình thường. Ðối với bệnh suyễn, trị liệu miễn dịch học (immunotherapy) không có kết quả nhiều như chữa viêm mũi dị ứng, vừa tốn kém, vừa mất thời giờ, nên chỉ dành cho những trường hợp bệnh không đáp ứng với nhiều thuốc dùng cùng một lúc mà vẫn không có kết quả tốt, hoặc trường hợp bị suyễn do nghề nghiệp mà không thể đổi nghề được. Ðiều quan trọng nhất là làm thế nào để tránh những nguyên nhân gây bệnh, nhưng phần lớn là khó tránh được, chẳng hạn như tránh phấn hoa là chuyện gần như không làm được. Ðiều cuối cùng nhắc nhở lại là luôn luôn dùng thuốc thường xuyên và theo đúng lời chỉ dặn của bác sĩ.
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Mathieson, Stuart (6 September 2015).
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The limit above simply provides a risk for calculating the second derivative-but does not present a definition.
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