HNG DN CHN ON, IU TR V

D PHNG BNH LAO

(Ban hnh km theo Quyt nh s: 4263 /Q-BYT ngy 13 thng 10 nm 2015

ca B trng B Y t)

0
 CHN ON BNH LAO

Lao l mt bnh truyn nhim do vi khun lao (Mycobacterium tuberculosis) gy nn.

Bnh lao c th gp tt c cc b phn ca c th, trong lao phi l th lao ph bin
nht (chim 80 85% tng s ca bnh) v l ngun ly chnh cho ngi xung quanh.
1. Ngi nghi lao phi
1.1. Ngi nghi lao phi khi c cc triu chng sau:
- Ho ko di trn 2 tun (ho khan, ho c m, ho ra mu) l triu chng nghi lao quan
trng nht.
Ngoi ra c th:
- Gy st, km n, mt mi.
- St nh v chiu.
- Ra m hi trm ban m.
- au ngc, i khi kh th.
1.2. Nhm nguy c cao cn ch :
- Ngi nhim HIV.
- Ngi tip xc trc tip vi ngun ly, c bit tr em.
- Ngi mc cc bnh mn tnh: lot d dy-t trng, i tho ng, suy thn mn,...
- Ngi nghin ma tu, ru, thuc l, thuc lo.
- Ngi s dng cc thuc c ch min dch ko di nh Corticoid, ho cht iu tr ung
th,
1.3. Cc trng hp c bt thng trn Xquang phi u cn xem xt pht hin lao phi.
2. Chn on lao phi
2.1. Lm sng
- Ton thn: St nh v chiu, ra m hi m, chn n, mt mi, gy st cn.
- C nng: Ho, khc m, ho ra mu, au ngc, kh th.
- Thc th: Nghe phi c th c ting bnh l (ran m, ran n,....).
2.2. Cn lm sng
- Nhum soi m trc tip tm AFB: Tt c nhng ngi c triu chng nghi lao phi c
xt nghim m pht hin lao phi. thun li cho ngi bnh c th chn on c
trong ngy n khm bnh, xt nghim 2 mu m ti ch cn c p dng thay cho xt
nghim 3 mu m nh trc y. Mu m ti ch cn c hng dn cn thn
ngi bnh ly ng cch (Ph lc 1), thi im ly mu 1 v mu 2 phi cch nhau t
nht l 2 gi.
1
- Xt nghim Xpert MTB/RIF (nu c th): cho kt qu sau khong 2 gi vi nhy v
c hiu cao.
- Nui cy tm vi khun lao: Nui cy trn mi trng c cho kt qu dng tnh sau 3-4
tun. Nui cy trong mi trng lng (MGIT - BACTEC) cho kt qu dng tnh sau 2
tun. Cc trng hp pht hin ti cc bnh vin tuyn tnh nn c khuyn khch xt
nghim nui cy khi c iu kin.
- Xquang phi thng quy: Hnh nh trn phim Xquang gi lao phi tin trin l thm
nhim, nt, hang, x hang, c th co ko 1/2 trn ca ph trng, c th 1 bn hoc 2
bn. ngi c HIV, hnh nh Xquang phi t thy hnh hang, hay gp tn thng t
chc k v c th vng thp ca phi. Xquang phi c gi tr sng lc cao vi nhy
trn 90% vi cc trng hp lao phi AFB(+). Cn tng cng s dng Xquang phi ti
cc tuyn cho cc trng hp c triu chng h hp. Tuy nhin cn lu c hiu
khng cao, nn khng khng nh chn on lao phi ch bng 1 phim Xquang phi.
2.3. Chn on xc nh
Chn on xc nh:
- Xc nh s c mt ca vi khun lao trong m, dch ph qun, dch d dy.
- Khi c cc triu chng lm sng, cn lm sng m khng xc nh c s c mt ca
vi khun lao, cn c kin ca thy thuc chuyn khoa lao quyt nh chn on.
Tiu chun chn on da theo xt nghim soi m trc tip tm AFB
- Lao phi AFB(+): C t nht 1 mu m hoc dch ph qun, dch d dy c kt qu soi
trc tip AFB(+) ti cc phng xt nghim c kim chun bi Chng trnh chng lao
Quc gia.
- Lao phi AFB(-): Khi c t nht 2 mu m AFB(-), ngi bnh cn c thc hin quy
trnh chn on lao phi AFB(-) (xem ph lc 2).
Ngi bnh c chn on lao phi AFB(-) cn tho mn 1 trong 2 iu kin sau:
C bng chng vi khun lao trong m, dch ph qun, dch d dy bng phng
php nui cy hoc cc k thut mi nh Xpert MTB/RIF.
c thy thuc chuyn khoa chn on v ch nh mt phc iu tr lao y
da trn (1) lm sng, (2) bt thng nghi lao trn Xquang phi v (3) thm 1 trong 2
tiu chun sau: HIV(+) hoc khng p ng vi iu tr khng sinh ph rng.
Lao k: L mt trong cc th lao phi.
Lm sng: Triu chng c nng thng rm r: st cao, kh th, tm ti. Triu chng thc
th ti phi ngho nn (c th ch nghe thy ting th th). nhng ngi bnh suy kit
triu chng lm sng c th khng rm r.
Chn on xc nh: Lm sng: cp tnh vi cc triu chng ho, st cao, kh th, c th tm
ti. Xquang phi c nhiu nt m, kch thc u, m u v phn b khp 2 phi (3
u). Xt nghim m thng m tnh. Ngoi ra xt nghim vi khun trong cc mu bnh
phm (dch ph qun, dch no ty, mu) c th dng tnh.

2
Ngoi tn thng ti phi, lao k thng c lao ngoi phi, trong cn ch n lao mng
no, nht l tr em v ngi nhim HIV.
2.4. Chn on phn bit vi mt s bnh: Gin ph qun, ung th phi, vim phi, p xe
phi, bnh phi tc nghn mn tnh, bnh phi k sinh trng. ngi c HIV cn phn bit
ch yu vi vim phi, nht l vim phi do Pneumocystis jiroveci hay cn gi l
Pneumocystis carinii (PCP).
3. Chn on lao ngoi phi
3.1. Chn on lao ngoi phi
Lao ngoi phi l th lao kh chn on - do vy tip cn chn on, ngi thy thuc
trong qu trnh thm khm ngi bnh phi hng ti v tm kim cc du hiu ca bnh
lao, phn bit vi cc bnh l ngoi lao khc v ch nh lm cc k thut, xt nghim t
chn on xc nh da trn:
- Cc triu chng, du hiu c quan ngoi phi nghi bnh.
- Ly bnh phm t cc v tr tn thng xt nghim:
Tm vi khun bng k thut nhum soi trc tip, nui cy, Xpert MTB/RIF (vi bnh
phm dch no ty, m, dch ph qun, dch d dy).
M bnh hc tm hnh nh tn thng lao.
- c cc thy thuc chuyn khoa chn on v ch nh phc iu tr.
- Lun tm kim xem c lao phi phi hp khng, nu c lao phi s l c s quan trng
cho chn on lao ngoi phi.
- Chn on lao ngoi phi n thun khng kt hp vi lao phi thng kh khn, cn
da vo triu chng nghi lao (st v chiu ko di, ra m hi ban m, st cn); triu
chng ti ch ni c quan b tn thng, nguy c mc lao.
- Mc chnh xc ca chn on ph thuc nhiu vo kh nng pht hin ca cc k
thut h tr nh: Xquang, siu m, sinh thit, xt nghim vi khun hc.
- Cn lun chn on phn bit vi cc bnh khc.
3.2. Chn on mt s lao ngoi phi thng gp
3.2.1. Lao hch
Lm sng: V tr thng gp nht l hch c, in hnh l dc c c n chm, nhng
cng c th cc v tr khc. Hch sng to, lc u hch chc, ring r, di ng, khng au
sau dnh vo nhau v t chc di da, km di ng, hch nhuyn ha, r m. C th khi
v li so xu.
Chn on xc nh: Sinh thit hch, chc ht hch xt nghim m bnh hc, t bo thy
cht hoi t b u, t bo bn lin, t bo lympho, nang lao; nhum soi trc tip tm thy
AFB; ngoi ra c th tm vi khun lao bng phng php nui cy bnh phm chc ht hch.
3.2.2. Trn dch mng phi (TDMP) do lao
Triu chng lm sng: au ngc, kh th tng dn, khm phi c hi chng 3 gim.
3
 Xquang ngc thy hnh m m thun nht, mt gc sn honh, ng cong
Damoiseau. Siu m mng phi c dch.
Chn on xc nh: Chc ht khoang mng phi thy dch mu vng chanh, rt him
khi dch mu hng, dch tit, u th thnh phn t bo lympho; c th tm thy bng chng
vi khun lao trong dch mng phi bng nhum soi trc tip v nui cy. Sinh thit mng
phi m hoc qua soi mng phi ly bnh phm chn on vi khun hc hoc m bnh t
bo.
3.2.3. Trn dch mng tim (TDMT) do lao
Triu chng lm sng: Cc triu chng ph thuc vo s lng dch v tc hnh thnh
dch mng tim. Triu chng thng gp bao gm: au ngc, kh th, tnh mch c ni, ph
chi di. Khm c tim nhp nhanh, huyt p kt, mch o ngc nu c hi chng p tim
cp. Nghe c ting c mng tim giai on sm hoc ting tim m khi trn dch nhiu.
Xquang ngc thy bng tim to, hnh git nc, hnh i b. in tim c in th thp
cc chuyn o, sng T m v ST chnh. Siu m c dch mng ngoi tim.
Chn on xc nh: Chc ht dch mng tim, dch thng mu vng chanh, dch tit, t
bo lympho chim u th. C th tm thy bng chng vi khun lao trong dch mng tim
bng nhum soi trc tip v nui cy.
3.2.4. Trn dch mng bng (TDMB) do lao
Triu chng lm sng: C cc du hiu trn dch mng bng (g c vng thp thay i
theo t th, sng v, du hiu g c bn c giai on mun, ). C th s thy cc u
cc, m cng trong bng. C th c du hiu tc hoc bn tc rut do cc hch dnh vo
rut.
Siu m bng c cc hnh nh gi lao mng bng: hch mc treo to, hch sau mng
bng, dch khu tr gia cc m dnh, ni soi bng thy cc ht lao.
Chn on xc nh: Chc ht dch mng bng mu vng chanh, i khi c, dch tit, t
bo lympho chim u th. C th tm thy bng chng vi khun lao trong dch mng bng
bng nhum soi trc tip, nui cy. Soi bng v sinh thit l k thut rt c gi tr cho
chn on trong hu ht cc trng hp. Trn tiu bn sinh thit thy hoi t b u, nang
lao.
3.2.5. Lao mng no-no
Triu chng lm sng: Bnh cnh vim mng no khi pht bng au u tng dn v ri
lon tri gic. Khm thng thy c du hiu c cng v du hiu Kernig (+). C th c du
hiu tn thng dy thn kinh s no v du hiu thn kinh khu tr (thng lit dy 3, 6, 7,
ri lon c trn). Cc tn thng tu sng c th gy ra lit 2 chi di (lit cng hoc lit
mm).
Chc dch no tu p lc tng, dch c th trong (giai on sm), nh vng (giai on
mun), c khi vn c. Xt nghim sinh ho dch no ty thng thy protein tng v ng
gim. T bo trong dch no tu tng va thng di 600 t bo/mm3 v t bo lympho
chim u th, giai on sm t l neutro tng nhng khng c bch cu thoi ha (m)

4
 Chn on xc nh: Da vo bnh cnh lm sng, c im dch no ty v xt nghim
sinh ha t bo dch no tu, c th tm thy bng chng vi khun lao trong dch mng no
bng nui cy (t l dng tnh cao hn khi nui cy trn mi trng lng) hoc cc phng
php mi nh Xpert MTB/RIF, nhum soi trc tip AFB (+) vi t l rt thp.
Chp MRI no c th thy hnh nh mng no dy v tn thng no gi lao, ngoi
ra chp MRI no gip chn on phn bit bnh l khc no (U no, Vim no, p xe no,
Sn no).
Chn on loi tr vi cc cn nguyn khc nh: vim mng no m, vim mng no
nc trong v cc bnh l thn kinh khc.
3.2.6. Lao xng khp
Triu chng lm sng: Hay gp ct sng vi c im: au lng, hn ch vn ng,
au ti ch tng ng vi t sng b tn thng (giai on sm); giai on mun gy bin
dng g ct sng hoc c du hiu chn p tu gy lit.
Ngoi ct sng lao cn hay gp cc khp ln vi biu hin: sng au khp ko di,
khng sng , khng i xng, c th d m b u.
Chp Xquang, CT, MRI ct sng, khp thy hp khe t, xp t sng hnh chm, c th
thy mnh xng cht v hnh p xe lnh cnh ct sng, hp khe khp.
Chn on xc nh: Da vo lm sng v cc c im tn thng trn Xquang, CT,
MRI ct sng, khp. Nu c p xe lnh, d m xt nghim m p xe tm AFB cho t l
dng tnh cao. Sinh thit t chc cho php chn on m bnh t bo.
3.2.7. Lao tit niu - sinh dc
Lm sng: Hay gp triu chng ri lon bi tit nc tiu (i but, i dt) ko di tng
t, iu tr khng sinh sau li b li, c th i mu khng c mu cc, i c, au
tht lng m .
Lao sinh dc nam: Sng au tinh hon, mo tinh hon, t gp vim cp tnh, trn dch
mng tinh hon.
Lao sinh dc n: Ra kh h, ri lon kinh nguyt, dn dn mt kinh, v sinh.
Chn on xc nh: Tm thy vi khun lao trong nc tiu, dch mng tinh hon, dch
d, kh h bng nui cy (t l dng tnh cao hn khi cy trn mi trng lng), nhum soi
trc tip AFB(+) vi t l rt thp. Chp UIV thy hnh nh gi lao (i thn ct ct, hang
lao, niu qun cht hp). Soi bng quang, soi t cung v sinh thit xt nghim m bnh, t
bo c nang lao, xt nghim vi khun lao. Chc ht dch mng tinh hon (c c im nh
lao cc mng khc trong c th), chc d u tinh hon xt nghim t bo c vim lao.
3.2.8. Cc th lao khc t gp hn: Lao da, lao lch, lao gan, v.v chn on hoc c phi
hp vi lao phi hoc bng sinh thit chn on m bnh t bo.
4. Chn on lao khng thuc (s chn on xem ph lc 3)
Cc i tng nguy c mc lao khng thuc:
- Ngi bnh lao tht bi iu tr phc II.
5
- Ngi nghi lao hoc ngi bnh lao mi c tip xc vi ngi bnh lao khng thuc.
- Ngi bnh lao tht bi iu tr phc I.
- Ngi bnh lao khng m ha m sau 2 hoc 3 thng iu tr phc I hoc II.
- Ngi nghi lao ti pht hoc ngi bnh lao ti pht (phc I hoc II).
- Ngi nghi lao iu tr li sau b tr hoc ngi bnh lao iu tr li sau b tr (phc I
hoc II).
- Ngi bnh lao mi pht hin c HIV (+).
- Cc trng hp khc: bao gm ngi nghi lao hoc ngi bnh lao c tin s dng thuc
lao trn 1 thng, ngi nghi lao hoc ngi bnh lao c tin s iu tr lao y t t
nhng khng r kt qu iu tr.
- Ngi bnh lao mi (HIV m tnh hoc khng r).
Lm sng:
- Ngi bnh khi ang iu tr lao nhng cc triu chng st, ho, khc m khng thuyn
gim hoc thuyn gim mt thi gian ri li xut hin tr li vi cc triu chng tng ln,
ngi bnh tip tc st cn.
- Tuy nhin bnh lao khng thuc c th c chn on ngi cha bao gi mc lao v
triu chng lm sng ca lao a khng c th khng khc bit so vi bnh lao thng
thng.
Cn lm sng:
- Xt nghim AFB, nui cy dng tnh lin tc hoc m tnh mt thi gian ri dng tnh
tr li hoc m tnh, dng tnh xen k ngi ang iu tr lao.
- Xt nghim khng sinh cho kt qu khng vi cc thuc chng lao hng 1, hng 2.
- Cc k thut sinh hc phn t c th chn on nhanh lao a khng thuc: Hain test,
Xpert MTB/RIF.
- Hnh nh tn thng trn phim Xquang phi khng thay i hoc xut hin thm tn
thng mi trong qu trnh iu tr ng phc c kim sot. Trng hp lao khng
thuc pht hin ngi cha bao gi mc lao, hnh nh tn thng trn phim Xquang c
th khng khc bit so vi bnh lao thng thng.
Chn on xc nh lao khng thuc:
Cn c vo kt qu khng sinh hoc cc xt nghim chn on nhanh c WHO chng
thc (Hain test, Xpert MTB/RIF), tiu chun chn on cho cc th bnh lao khng thuc
c xc nh nh sau:
- Khng n thuc: Ch khng vi duy nht mt thuc chng lao hng mt khc
Rifampicin.
- Khng nhiu thuc: Khng vi t hai thuc chng lao hng mt tr ln m khng cng
ng thi khng vi Isoniazid v Rifampicin.
- a khng thuc: Khng ng thi vi t nht hai thuc chng lao l Isoniazid v
Rifampicin.
6
- Tin siu khng: Lao a khng c khng thm vi hoc bt c thuc no thuc nhm
Fluoroquinolone hoc vi t nht mt trong ba thuc hng hai dng tim (Capreomycin,
Kanamycin, Amikacin) (ch khng ng thi c 2 loi thm).
- Siu khng thuc: Lao a khng c khng thm vi bt c thuc no thuc nhm
Fluoroquinolone v vi t nht mt trong ba thuc hng hai dng tim (Capreomycin,
Kanamycin, Amikacin).
- Lao khng Rifampicin: Khng vi Rifampicin, c hoc khng khng thm vi cc thuc
lao khc km theo (c th l khng n thuc, khng nhiu thuc, a khng thuc hoc
siu khng thuc). Tuy nhin Vit Nam hin nay, cc chng khng vi Rifampicin
th c ti trn 90% c km theo khng Isoniazid, v vy khi pht hin khng Rifampicin
ngi bnh c coi nh a khng thuc v thu nhn iu tr phc IV.
5. Chn on lao ng nhim HIV
5.1. Chn on nhim HIV ngi bnh lao
Tt c nhng ngi bnh lao cn c cung cp t vn v xt nghim HIV (PITC:
Provider Initiated HIV Testing and Counseling: cn b y t ch ng t vn, xut v cung
cp dch v xt nghim HIV cho ngi bnh lao). Thc hin quy trnh xt nghim HIV theo
hng dn ca B Y t:
5.1.1. T vn trc xt nghim chn on HIV
Hnh thc t vn ty tng i tng v iu kin c th c th p dng hnh thc t vn
sau y:
- T vn theo nhm, v d: cho cc nhm phm, can phm; nhm hc vin cc trung tm
cha bnh - dy ngh,
- T vn cho tng c nhn.
- Ngoi ra t ri, t bm tuyn truyn... c th c s dng trong qu trnh t vn.
Ni dung t vn bao gm:
- Tm hiu v tin s lm xt nghim chn on HIV ca ngi bnh,
- Gii thch l do v li ch ca vic xt nghim HIV chn on, iu tr v d phng
i vi ngi bnh, cc thng tin sau cn c cung cp cho ngi bnh:
Ngi mc lao cng c kh nng b nhim HIV,
Chn on HIV sm v iu tr thch hp lao v HIV s cho kt qu tt hn iu tr
lao n thun.
- Xc nhn tnh t nguyn v bo mt ca xt nghim chn on HIV,
- Khng nh vic t chi xt nghim HIV s khng nh hng n kh nng tip cn ca
ngi bnh i vi nhng dch v khm cha bnh khc,
- Gii thiu v dch v chuyn tip nu nh kt qu xt nghim l dng tnh,
- Gii p nhng thc mc - bn khon ca ngi bnh.
5.1.2. Xt nghim chn on nhim HIV
7
- Khi ngi bnh ng , h s k mt bn cam kt v bn cam kt ny c lu li trong
h s ngi bnh.
- Mu ca ngi bnh c thu thp v gi n c s y t c kh nng thc hin test sng
lc ti cc n v PITC thuc Chng trnh chng lao. Nu test sng lc c kt qu
dng tnh, mu mu s c tip tc gi n phng xt nghim c php khng nh
HIV (thng thng l Trung Tm Y t d phng tuyn tnh hoc trung tm HIV/AIDS
hoc nhng phng xt nghim c cp chng ch khc) thc hin. Thng thng kt
qu s c sau 7 10 ngy sau khi mu mu c gi xt nghim.
5.1.3. Tr kt qu - T vn sau khi c kt qu xt nghim
Ty theo kt qu cui cng, nhn vin y t ni t vn s chn mt trong cc tnh hung
sau tip tc t vn cho ngi mc lao:
Nu kt qu xt nghim chn on HIV m tnh:
- Thng bo cho ngi bnh kt qu xt nghim m tnh.
- T vn gip ngi bnh hiu ng v kt qu xt nghim v ngha ca giai on ca s
ng thi khuyn ngi bnh nn xt nghim li sau 6 n 12 tun mt trung tm t
vn xt nghim HIV t nguyn (nu c yu t nguy c).
- T vn cho ngi bnh v nguy c ly nhim HIV v bin php d phng, k c khuyn
bn tnh ca h cn c xt nghim chn on HIV.
- Gii thiu chuyn tip ngi bnh n cc dch v can thip d phng ly nhim HIV
nu h c yu cu.
Nu kt qu xt nghim chn on HIV dng tnh:
- Thng bo kt qu xt nghim HIV cho ngi bnh bit, gii thch cho ngi bnh v kt
qu xt nghim.
- H tr tinh thn, tm l cho ngi bnh.
- T vn cho ngi bnh v s cn thit ca chm sc - iu tr HIV, thng tin cc dch v
h tr sn c tip theo cho ngi bnh.
- T vn cc cng vic cn thit ngay: tip tc iu tr bnh lao, d phng cc bnh ly
truyn cho bn thn v ngi thn.
- Trao i vi ngi bnh cch tit l kt qu HIV dng tnh cho v, chng, ngi thn...
ng vin t vn nhng ngi ny xt nghim HIV t nguyn.
- Gii thiu, hi chn vi c s iu tr, to iu kin chuyn tip ngi bnh n cc dch
v chm sc HIV c ng k iu tr ARV sm nht c th v iu tr d phng
bng Cotrimoxazole.
- Sau gii thiu cn theo di h tr tip tc chn chn ngi bnh tip cn c dch
v.
Nu kt qu xt nghim chn on HIV l khng xc nh:
- Gii thch ngi bnh hiu ng v kt qu xt nghim.

8
- H tr tinh thn, tm l cho ngi bnh.
- T vn v cc bin php d phng ly nhim HIV.
- Hn xt nghim li sau 14 ngy.
5.2. Chn on lao ngi c HIV
Biu hin lm sng, cn lm sng ca bnh lao ngi c HIV thng khng in hnh
v tin trin nhanh dn ti t vong.
Ti cc c s y t, c bit cc phng khm ngoi tr cho ngi nhim HIV cn lun
sng lc lao cho ngi nhim HIV mi ln n khm do bt k l do no.
Chn on mc lao ngi nhim HIV do thy thuc quyt nh, da trn yu t nguy
c mc lao, cc biu hin lm sng v cn lm sng nh sau:
5.2.1. Cc yu t nguy c mc lao ngi nhim HIV
- Ngi bnh c tin s iu tr lao.
- Ngi bnh c tip xc vi ngun ly lao.
- Ngi bnh c tin s cha bnh trong cc c s cai nghin hoc tri giam.
- Tnh trng suy dinh dng.
- Tin s nghin ru, ma ty.
5.2.2. Cc du hiu lm sng
Sng lc bnh lao ngi HIV nhm loi tr kh nng mc lao cung cp iu tr d
phng bng INH theo quy nh ng thi pht hin nhng bt thng nghi lao hoc khng
loi tr c bnh lao chuyn khm chuyn khoa pht hin bnh lao.
Ngi nhim HIV nu khng c c 4 triu chng sau y c th loi tr c khng mc
lao tin trin v c th xem xt iu tr d phng lao bng INH:
- Ho.
- St nh v chiu.
- St cn.
- Ra m hi trm.
Nu c t nht 1 hoc nhiu triu chng trn th cn gi khm chuyn khoa pht hin
bnh lao. Cc du hiu ny thng din tin nhanh v t p ng vi cc iu tr thng
thng. Ngi nhim HIV nu c bt k du hiu h hp no cng cn c khm pht hin
lao phi.
V thc hnh lm sng, thy thuc cn pht hin ngi bnh c du hiu nguy him khi
n khm hoc nhp vin, bao gm: khng t i li c, nhp th >30 ln/pht, st cao >39
C, mch nhanh >120 ln/pht - c nhng c nhng quyt nh x tr ph hp. (Xem
s x tr ph lc 5)
5.2.3. Cn lm sng
Vi khun hc:
9
- Xt nghim m: Ty theo iu kin c s vt cht v t chc, c th thc hin nh sau:
Nhum soi m trc tip: c p dng tuyn huyn hoc cc im knh. Cn ch
hng dn ngi bnh ly m ng cch, c th 2 mu ti ch cch nhau t nht 2
gi. Thi gian cho kt qu trong ngy n khm.
Xpert MTB/RIF: l xt nghim ng dng cng ngh sinh hc phn t nhn din
c vi khun lao v tnh cht khng Rifampicin. Thi gian cho kt qu khong 2
gi. Ngi bnh nhim HIV nghi lao l i tng c u tin xt nghim Xpert
MTB/RIF.
Cy m: c thc hin khi nhum soi m trc tip c kt qu AFB m tnh. p
dng nhng ni c iu kin c s vt cht ph hp nh bnh vin tuyn tnh tr
ln. C s khng c kh nng nui cy, c th ly mu m chuyn n cc phng
xt nghim thc hin nui cy. Thi gian cho kt qu dng tnh sau 2 tun (nu cy
mi trng lng) v sau 3 4 tun (nu cy mi trng c).
- Bnh phm khc cng c kh nng tm thy vi khun lao: trong dch mng phi, dch
mng tim, dch mng bng, hch,
Chn on hnh nh:
- X quang:
Lao phi: giai on lm sng nhim HIV sm, khi sc khng cha nh hng
nhiu, hnh nh tn thng trn Xquang ngc khng khc bit so vi ngi HIV m
tnh. giai on mun, tn thng thng lan ta 2 ph trng vi nhng hnh nh
tn thng dng nt, t chc lin kt lan ta, t thy hnh nh hang, c th gp hnh
nh hch rn phi, hch cnh ph qun cn phn bit vi vim phi do
Pneumocystis Carinii (PCP).
Lao ngoi phi: hnh nh ty theo c quan b phn tn thng.
- Chp ct lp vi tnh (CT scan): thy hnh nh cc tn thng nh hang lao hoc cc tn
thng gi lao.
M bnh hc gii phu bnh: sinh thit hch, chc hch thc hin chn on m bnh
t bo hc c cc thnh phn c trng nh hoi t b u, t bo hnh dp, nang lao,
Chn on lao ngi nhim HIV:
- Da vo lm sng: sng lc 4 triu chng Ho, st, st cn, ra m hi m vi bt k thi
gian no.
- Cn lm sng: khi c bt thng nghi lao trn phim Xquang ngi bnh c triu chng
nghi lao k trn, c th chn on xc nh lao. Cc xt nghim khc: xt nghim m
nhum soi trc tip, nui cy nhanh, cn u tin ch nh xt nghim Xpert MTB/RIF
cho ngi c HIV.
Chn on loi tr lao tin trin ngi nhim HIV:

10
Khi sng lc lm sng ngi bnh khng c bt k triu chng no trong 4 triu chng ( ho,
st, st cn, ra m hi trm) th c th loi tr lao hot ng v cho ngi bnh dng INH
iu tr phng sm.
Quy trnh chn on lao phi ngi HIV(+) (xem ph lc 4 v 5)
6. Chn on bnh lao tr em
a s tr em mc bnh lao phi (chim 70 - 80%), trong ch yu l lao s nhim,
lao ngoi phi ch chim 20-30%.
Xt nghim tm AFB hoc vi khun lao trong cc bnh phm ly t tr em thng cho t
l dng tnh rt thp. Do vic chn on bnh lao tr em ch yu da vo ba yu t:
(i) tin s tip xc vi ngun ly trong vng 1 nm, (ii) cc du hiu lm sng nghi lao v
(iii) tn thng nghi lao trn phim Xquang. Tr c t nht 2 trong 3 yu t trn c th chn
on v cho iu tr lao phng mc lao tin trin khi tr ln.
6.1. Cc yu t nguy c khin tr d mc bnh lao
Khi tr em c mt trong cc yu t sau s lm tng kh nng mc lao khi c triu chng
lm sng nghi lao:
- C tin s tip xc gn gi vi ngun ly lao.
- Tr em di 5 tui.
- Tr em nhim HIV.
- Tr em suy dinh dng nng.
- Tr em m yu ko di sau khi mc si.
6.2. Cc phng php chn on
6.2.1. Khai thc tin s
- Tin s tip xc vi ngun ly: Tr c tin s sng cng nh vi ngi mc bnh lao
phi trong vng 1 nm tr li l mt trong 3 yu t quan trng chn on lao.
- Tin s cc triu chng lm sng nghi lao: st cn hoc khng tng cn, hoc hay ti
din cc triu chng vim nhim ng h hp (ho/kh kh, c th st nh...) v cc
triu chng khc ty theo c quan b lao.
6.2.2. Khm lm sng
- nh gi tnh trng dinh dng: cn tr v hi tui i chiu trn biu cn nng
xem tr c nh cn hoc suy dinh dng khng. Tr mc lao c st cn hoc khng tng
cn, suy dinh dng.
- Triu chng c nng nghi lao phi: Ho dai dng, kh kh, c th st nh,cc triu
chng ny khng ci thin khi iu tr bng khng sinh ph rng 5-7 ngy (khng iu tr
bng Rifampixin v cc khng sinh thuc nhm Fluoroquinolones) hoc hay ti din cc
triu chng h hp.
- Khm thc th c quan nghi b lao: phi, mng no, hch, xng khp...
- Nghe phi: c th thy ran m, ran n, i khi ch nghe thy ran rt ph qun, ran ngy.
11
6.2.3. Xt nghim vi khun
- Xt nghim tm AFB hoc vi khun lao bt k khi no, vi bt k bnh phm g c th
ly c, u tin xt nghim Xpert MTB/RIF, hoc nui cy nhanh (nu c iu kin).
- Kt qu xt nghim vi khun lao thng l m tnh. Bi vy, chn on bnh lao tr em
khng nht thit phi da vo bng chng vi khun.
6.2.4. Chp Xquang
- Cn chp Xquang c quan nghi ng b lao nh: Phi, xng khp, ct sng,...Cc tn
thng nghi lao trn Xquang tr em c tin s tip xc ngun ly hoc tr em c cc
triu chng lm sng nghi lao c gi tr chn on lao.
- Nhng hnh nh bt thng trn phim Xquang lng ngc thng quy (thng v nghing)
gi v lao phi tr em:
Hch bch huyt cnh kh ph qun hoc hch rn phi to, hoc in hnh ca phc
hp nguyn thy trn Xquang ngc.
Nt, thm nhim nhu m phi.
Cc ht k nhu m phi.
Hang lao (c th thy tr em ln).
Trn dch mng phi hoc mng tim c xu hng gp tr ln.
Vim rnh lin thy phi.
6.2.5. Mt s k thut can thip h tr chn on lao tr em
- Ht dch d dy tr nh.
- Ly m kch thch (kh dung nc mui u trng 5%).
- Chn on hnh nh: CT, MRI, siu m.
- Chc ht, sinh thit cc t chc nghi lao nh hch ngoi vi, p xe lnh, chc tu sng ly
dch xt nghim sinh ho, t bo, t chc hc v vi khun hc.
- Ni soi ph qun ht ra ph qun ly bnh phm xt nghim.
6.2.6. Xt nghim HIV
Tt c tr em chn on mc bnh lao cn c xt nghim HIV.
6.3. Chn on lao phi tr em
Ba yu t cn tm chn on lao phi tr em:
o Tin s tip xc vi ngun ly lao trong vng 1 nm tr li.
o Triu chng lm sng nghi lao (khng p ng vi iu tr thng thng).
o Hnh nh tn thng trn Xquang phi nghi lao.
Chn on lao phi khi tr c t nht 2 trong 3 yu t trn.
(Xem s hng dn quy trnh chn on bnh lao phi tr em ph lc s 6)
6.4. Chn on lao ngoi phi tr em
12
 Ba yu t cn tm chn on lao ngoi phi tr em:
o C tin s tip xc vi ngun ly trong vng 1 nm.
o Triu chng lm sng nghi lao (ty theo tng b phn b lao).
o Du hiu nghi lao trn phim chp Xquang ty theo b phn b lao (cn chp c
Xquang phi, nu thy c tn thng nghi lao trn phim chp phi rt c gi tr
h tr cho chn on lao ngoi phi).
Quyt nh chn on lao ngoi phi khi tr c t nht 2 trong 3 yu t trn
Cc triu chng lm sng thng gp, xt nghim v cc khuyn co i vi cc Lao ngoi
phi tr em theo nhm tui c tm tt bng di y:

V tr Lao Biu hin lm sng hay gp Xt nghim Khuyn co

ngoi phi
- Thng thy hch c - Chc ht kim - iu tr lao hch
nh khi c iu
Lao hch - Khng i xng, khng au, - Nu c hch ngoi vi to cng
kin nui cy
ngoi vi lc u hch chc, di ng, hch bn tim BCG, xem xt kh nng
v xt nghim t
pht trin chm. Sau hch vim hch do BCG. Nu xc nh
bo.
mm, dnh v c th r hch vim do tim BCG ch x tr
- Mantoux thng ti ch hch vim.
dng tnh mnh.
R ro ph nang gim v g c Chp Xquang - iu tr lao
Lao mng C th c au ngc Chc dch mng - Nu dch mng phi c m xem
phi phi * kh nng vim m mng phi v
chuyn ln tuyn trn.

Tr em di 5 tui mc th lao lan trn v nng.

au u, kh chu, quy khc, - Chc d ty sng Nhp vin iu tr lao **
nn, hn m/gim hoc mt ly dch no tu *.
Lao mng
thc, co git, c cng, thp
no - Xquang phi
phng, lit,
Du hiu lm sng c th rm Xquang phi iu tr hoc chuyn ln tuyn trn
r: kh th, st cao, tm ti
Lao k
(khng tng xng vi du
hiu thc th phi), hn m,
suy kit
Tr em t 5 tui tr ln

Bng to dn, c trng, g Chc ht dch mng Chuyn ln tuyn trn **

c vng thp hoc c cc bng *
Lao mng
m cng trong bng
bng
au ct sng vng tn Chp Xquang ct Chuyn ln tuyn trn**
thng, au tng khi vn sng
Lao ct
ng. Ct sng b bin dng,
sng
c th chn b yu/b lit
13
 - Tim nhp nhanh Xquang lng ngc Chuyn ln tuyn trn**
Lao mng - Ting tim m Siu m tim, chc
ngoi tim dch mng tim *
- Mch kh bt
- Kh th
- Gp cui cc xng di, Chp Xquang/ ht Chuyn ln tuyn trn **
khp sng bin dng, hn ch dch khp *
Lao xng
vn ng.
khp
- Trn dch mt bn, thng
khp gi hoc khp hng.
* c im: dch lng mu vng chanh, protein cao, nhum soi trc tip c cc t bo bch
cu, ch yu l t bo lympho.
** Nu khng chuyn c bt u iu tr lao.
(Xem s hng dn quy trnh chn on bnh lao tr em ph lc s 7)
7. Phn loi bnh lao
7.1. Phn loi bnh lao theo v tr gii phu
- Lao phi: Bnh lao tn thng phi ph qun, bao gm c lao k. Trng hp tn
thng phi hp c phi v c quan ngoi phi c phn loi l lao phi.
- Lao ngoi phi: Bnh lao tn thng cc c quan ngoi phi nh: Mng phi, hch,
mng bng, sinh dc tit niu, da, xng, khp, mng no, mng tim,... Nu lao nhiu b
phn, th b phn c biu hin tn thng nng nht (lao mng no, xng, khp,...)
c ghi l chn on chnh.
7.2. Phn loi lao phi theo kt qu xt nghim nhum soi trc tip
- Lao phi AFB(+) v lao phi AFB (-).
- Xem thm tiu chun phn chn on.
7.3. Phn loi bnh lao theo kt qu xt nghim vi khun
- Ngi bnh lao c bng chng vi khun hc: l ngi bnh c kt qu xt nghim dng
tnh vi t nht mt trong cc xt nghim: nhum soi m trc tip; nui cy; hoc xt
nghim vi khun lao c TCYTTG chng thc (nh Xpert MTB/RIF).
- Ngi bnh lao khng c bng chng vi khun hc (chn on lm sng): l ngi bnh
c chn on v iu tr lao bi thy thuc lm sng m khng p ng c tiu
chun c bng chng vi khun hc. Bao gm cc trng hp c chn on lao da
trn hnh nh Xquang bt thng nghi lao; da trn triu chng lm sng, tin s; hoc
cc ca lao ngoi phi khng c xt nghim tm thy vi khun lao. Cc trng hp ngi
bnh lao khng c bng chng vi khun (chn on lm sng) sau tm thy vi khun
lao bng cc xt nghim cn c phn loi li l ngi bnh lao c bng chng vi
khun.
7.4. Phn loi ngi bnh lao theo tin s iu tr lao

14
- Mi: Ngi bnh cha bao gi dng thuc chng lao hoc mi dng thuc chng lao
di 1 thng.
- Ti pht: Ngi bnh c iu tr lao v c thy thuc xc nh l khi bnh, hay
hon thnh iu tr nay mc bnh tr li vi kt qu AFB(+).
- Tht bi iu tr: Ngi bnh c AFB(+) t thng iu tr th 5 tr i, phi chuyn phc
iu tr, ngi bnh AFB(-) sau 2 thng iu tr c AFB(+), ngi bnh lao ngoi
phi xut hin lao phi AFB(+) sau 2 thng iu tr, ngi bnh trong bt k thi im
iu tr no vi thuc chng lao hng 1 c kt qu xc nh chng vi khun lao khng a
thuc.
- iu tr li sau b tr: Ngi bnh khng dng thuc lin tc t 2 thng tr ln trong qu
trnh iu tr, sau quay tr li iu tr vi kt qu AFB(+).
- Khc:
Lao phi AFB(+) khc: L ngi bnh iu tr thuc lao trc y vi thi gian
ko di trn 1 thng nhng khng xc nh c phc v kt qu iu tr hoc
khng r tin s iu tr, nay chn on l lao phi AFB(+).
Lao phi AFB (-) v lao ngoi phi khc: L ngi bnh iu tr thuc lao trc
y vi thi gian ko di trn 1 thng nhng khng xc nh c phc v kt qu
iu tr hoc c iu tr theo phc vi nh gi l hon thnh iu tr, hoc
khng r tin s iu tr, nay c chn on lao phi AFB(-) hoc lao ngoi phi.
- Chuyn n: Ngi bnh c chuyn t n v iu tr khc n tip tc iu tr (lu
: nhng ngi bnh ny khng thng k trong bo co Tnh hnh thu nhn ngi bnh
lao v Bo co kt qu iu tr lao, nhng phi phn hi kt qu iu tr cui cng cho
n v chuyn i).
7.5. Phn loi ngi bnh theo tnh trng nhim HIV
- Ngi bnh lao/HIV(+): Ngi bnh lao c kt qu xt nghim HIV(+).
- Ngi bnh lao/HIV(-): Ngi bnh lao c kt qu xt nghim HIV(-), cc ngi bnh
lc u kt qu HIV(-) nhng sau xt nghim li c kt qu HIV dng tnh cn c
phn loi li.
- Ngi bnh lao khng r tnh trng HIV: Ngi bnh lao khng c kt qu xt nghim
HIV, nhng ngi bnh ny sau khi c kt qu xt nghim HIV cn c phn loi li.
7.6. Phn loi ngi bnh da trn tnh trng khng thuc
Da theo phn loi ca T chc Y t Th gii v cc phn loi ny khng loi tr ln
nhau:
- Khng n thuc: Ch khng vi duy nht mt thuc lao hng mt khc Rifampicin.
- Khng nhiu thuc: Khng vi t hai thuc lao hng mt tr ln m khng cng ng
thi khng vi Isoniazid v Rifampicin.
- a khng thuc: Khng ng thi vi t nht hai thuc chng lao l Isoniazid v
Rifampicin.
15
- Tin siu khng thuc: Lao a khng c khng thm vi bt c thuc no thuc nhm
Fluoroquinolone hoc vi t nht mt trong ba thuc hng hai dng tim (Capreomycin,
Kanamycin, Amikacin).
- Siu khng thuc: Lao a khng c khng thm vi bt c thuc no thuc nhm
Fluoroquinolone v vi t nht mt trong ba thuc hng hai dng tim (Capreomycin,
Kanamycin, Amikacin).
- Lao khng Rifampicin: Khng vi Rifampicin, c hoc khng khng thm vi cc thuc
lao khc km theo (c th l khng n thuc, khng nhiu thuc, a khng thuc hoc
siu khng thuc).
7.6.1. Phn loi ngi bnh lao a khng theo tin s iu tr
- Lao a khng mi: Ngi bnh lao a khng cha c tin s iu tr lao hoc mi iu
tr lao di 1 thng (cn c th gi l lao a khng nguyn pht).
- Ti pht: l ngi bnh c tin s iu tr lao trc y, c kt lun khi bnh hay
hon thnh iu tr, nay c chn on l lao a khng.
- Tht bi cng thc I: Ngi bnh lao a khng c tin s l ngi bnh lao tht bi iu
tr cng thc I trc y.
- Tht bi cng thc II: Ngi bnh lao a khng c tin s l ngi bnh lao tht bi iu
tr cng thc II trc y.
- iu tr li sau b tr: L ngi bnh c tin s iu tr lao trc y, c kt lun l
b tr, nay c chn on l lao a khng.
- Lao a khng khc: l ngi bnh lao a khng khng r kt qu iu tr trc y.
7.6.2. Phn loi ngi bnh lao a khng theo xt nghim trc iu tr
- S+, C+: Ngi bnh lao a khng c xt nghim trc iu tr nhum soi trc tip dng
tnh, nui cy dng tnh.
- S-, C+: Ngi bnh lao a khng c xt nghim trc iu tr nhum soi trc tip m
tnh, nui cy dng tnh.
- S+, C-: Ngi bnh lao a khng c xt nghim trc iu tr nhum soi trc tip dng
tnh, nui cy m tnh.
7.7. Phn loi ngi bnh lao theo tin s iu tr (theo phn loi mi ca TCYTTG)
Lu : Hin nay CTCLQG ang chnh sa biu mu theo phn loi mi ca WHO, v vy
phn loi sau y ch p dng khi c biu mu mi.
- Lao mi: ngi bnh cha bao gi dng thuc chng lao hoc mi dng thuc chng lao
di 1 thng.
- Ngi bnh iu tr li: l ngi bnh dng thuc chng lao t 1 thng tr ln. Ngi
bnh iu tr li bao gm:
Ti pht: ngi bnh c iu tr lao trc y v c xc nh l khi bnh,
hay hon thnh iu tr ln iu tr gn y nht, nay c chn on l mc lao tr
li.
16
 Tht bi: ngi bnh c iu tr lao trc y v c xc nh tht bi iu tr
ln iu tr gn y nht.
iu tr li sau b tr: ngi bnh iu tr lao trc y v c xc nh b tr
ln iu tr gn y nht.
iu tr li khc: cc trng hp tng iu tr lao trc y nhng khng xc nh
c kt qu iu tr.
- Ngi bnh khng r v tin s iu tr: l cc ngi bnh khng r tin s iu tr,
khng th xp vo mt trong cc loi trn.

17
 XT NGHIM AFB NHUM SOI TRC TIP
PHNG PHP NHUM ZIEHL NEELSEN

1. Mc ch
M t k thut nhum soi trc tip tm AFB (Acid Fast- Bacilli) theo phng php
nhum Ziehl-Neelsen (ZN) s dng knh hin vi quang hc.
2. Bnh phm
2.1. Loi bnh phm
- Bnh phm m t cht lng: c nhy m, th tch mu t nht 2 ml.

m nhy m m C mu Nc bt

- Cn bnh phm sau ly tm.

- Khun lc mc trn mi trng c.
- Canh khun t tp MGIT (+).
2.2. Yu cu v hnh chnh
- Mu phi ng trong cc/tp theo qui nh.
- Mu phi y thng tin trn thn dng c cha mu.
- Phiu xt nghim (XN) phi thng tin ngi bnh.
- Thng tin trn mu v phiu xt nghim phi ph hp.
3. Trang thit b - Vt liu
3.1. Thit b
- T an ton sinh hc cp I c kim chun hng nm.
- n gas hoc n cn c nh tiu bn.
- My lm kh tiu bn ( ni c s lng mu nhiu trong ngy).
- Bn nhum tiu bn.
- ng h pht.

18
- Knh hin vi quang hc 2 mt vi vt knh 100X, 10X.
- Ni hp hoc l t.
- Thng rc c np y.
3.2. Vt liu
- Lam knh c u m.
- Bt ch en HB.
- Que pht m dng 1 ln (tre, g).
- Vi nc.
- B ha cht nhum ZN.
- Que c u bng (gc) t la h nng tiu bn.
- Gi nhum tiu bn.
- Giy lau knh.
- Hp ng tiu bn.
- Gi tiu bn sau khi dn, gi tiu bn sau khi nhum.
- Giy lc thuc nhum.
- Dng c v ti nilon cha cht thi.
- Du soi knh.
4. Ha cht
4.1. Chun b ha cht nhum ZN
4.1.1. Dung dch nhum mu Ziehl s Carbol Fuchsin 0,3%
- Cng thc:
Phenol tinh th...50gam
Cn Ethylic 950 ..........100ml
Fuchsin basis3gam
Nc ct ..850ml
- Cch pha: Ho tan phenol trong 100ml cn, thm 3 g Fuchsin ha tan, lc hn dch
trn vo 850 ml nc ct, lc u.
4.1.2. Dung dch ty mu cn acid HCl 3%
- Cng thc:
Acid HCl m c30ml
Cn Ethylic 950..970ml
- Cch pha: Cho t t acid m c vo chai cha 970 cn. Khng lm ngc li v
gy n.
19
4.1.3. Dung dch nhum nn xanh Methylen 0,3%
- Cng thc:
Methylen blue ...3gam
Nc ct1000ml.
- Cch pha: Ha tan 3g Methylen blue trong 1000ml nc ct.
4.2. Bo qun v hn s dng
- Tuyn tnh pha ha cht nhum ZN, lc v kim tra cht lng t yu cu, cp cho
tuyn huyn theo chu k hng thng.
- Ha cht mu ca ZN phi c bo qun trong chai thy tinh mu.
- B ha cht nhum ZN v b chai bo qun thuc nhum phi dn nhn ghi tn ha cht,
nng , ngy pha v hn s dng.
- Bo qun ha cht ni thong mt, trnh nh nng mt tri.
- Khi thay ha cht mi, phi ra sch chai c trnh to cn fuchsin gy li sai dng.
5. Nguyn l
Mycobacteria (trong c vi khun lao) c lp vch sp dy nn kh bt mu vi thuc
nhum thng thng v c tnh khng cn - acid. Phng php nhum Ziehl do thuc
nhum c cha phenol v h nng khi nhum nn fuchsin ngm qua lp vch ca vi khun,
khi ty mu bng dung dch cn-acid 3%, AFB vn gi c mu Fuchsin trong khi cc
t bo v vi khun khc b ty mt mu , bc nhum nn to s tng phn gia AFB
mu trn mu nn xanh sng.
6. Cc bc thc hin
6.1. Chun b
- S dng lam knh mi, khng c vt xc hoc mc, lau cn 950 v lm kh.
- Cp nht thng tin ngi bnh vo s xt nghim trc khi thc hin k thut.
- S xt nghim thng nht t s xt nghim, phiu xt nghim, cc m v lam knh. S
xt nghim gm 2 phn: t s l s th t trong s xt nghim, mu s l s th t ca
mu (V d: 120/1, 120/2). i chiu v kim tra cc thng tin cn thn trnh nhm ln.
S xt nghim theo th t t u nm n cui nm.
- Dng bt ch en HB vit s xt nghim ln u m ca lam knh. Khng chm tay vo
phn lam knh cn li.
- Sp xp cc m v lam knh theo th t trnh nhm ln.
- Khi ng t ATSH trc khi s dng t nht 15 pht thanh lc kh.
- Sp xp dng c/vt liu cn thit vo t ATSH: my lm kh tiu bn (bt my 50-
600C), que dn tiu bn, b can cha cht st khun, gi ng tiu bn, khay c lt khn,
giy thm dung dch st khun, lam knh v cc m.
6.2. Dn tiu bn
20
6.2.1. Bnh phm m
- M np cc m nh nhng, t np nga trn khay.
- Quan st k mu m, dng u vt ca que pht m chn mnh m nhy m, nh
nhng ct mu m bng cch di cnh vt que tre vo thnh cc m.
- t mu m ln gia lam knh trng s vi cc m, dng mt vt que tre dn m trn
lam theo hnh bu dc kch thc 1x2cm, quay mi nhn que tre dn tip to mn cho
vt dn. Dn m u n, lin tc theo hnh xon c t trung tm ra ngoi hoc theo
kiu tc ri, dn n khi thy m hi se. Khng dn khi m kh.
- Hy que pht m vo b can c cht st khun.
- t tiu bn ln gi kh t nhin hoc lm kh trn my lm kh tiu bn.
- y li np cc m.

S dng que tre c u vt theo hnh nh

6.2.2. Cn bnh phm sau li tm
- Nh 1 2 git cn ln gia lam knh, dn tiu bn theo kch thc 1 x 2 cm.
- Cc bc tip theo ging nh tiu bn m.
6.2.3. Canh khun MGIT (+)
- Quan st tup MGIT (+) nu c cn vn y tup, dng pipet nha v trng ht nh
lp cn vn nh 1 git vo lam knh to nn albumin, dn nh nhng.
- Nu canh khun c u ht 1 2 git lm tiu bn.
- Cc bc tip theo ging nh tiu bn m.
6.2.4. Khun lc t nui cy c
- Ly khun lc t tup cy nghin nh vo 1 git nc ct trn lam knh to huyn dch
hi c, dn tiu bn.
- Cc bc tip theo ging nh tiu bn m.
6.3. C nh tiu bn:
H nng tiu bn qua ngn la n cn 3 ln mi ln khong 3 giy (mt tiu bn nga
ln trn).
21
6.4. Nhum tiu bn: 3 bc
6.4.1 Nhum mu
- Xp tiu bn theo th t trn gi nhum, mi tiu bn cch nhau t nht 1 cm.
- Ph dung dch Fuchsin 0,3% kn ton b b mt lam knh.
- H nng tiu bn t pha di n khi Fuchsin bc hi.
- t nht 5 pht.
- Nu Fuchsin trn ra ngoi, b sung thm Fuchsin v h nng li.
- Ra tiu bn nh nhng cho tri ht thuc nhum.
- Nghing tiu bn cho ro nc.
6.4.2. Ty mu
- Ph y dung dch acid - cn ln tiu bn, 3 pht.
- Ra nc. Nghing tiu bn cho ro nc.
- Sau khi ra, cc tiu bn khng cn mu hng.
- Nu tiu bn vn cn mu hng, ty li ln 2, thi gian t 1 3 pht cho n khi ht mu
hng, ra li nc.
6.4.3. Nhum nn
- Ph y dung dch xanh Methylene 0,3% ln tiu bn.
- 30 giy - 1 pht.
- Ra nc, nghing tiu bn cho ro nc.
Ch : cho vi nc chy nh nhng t u tiu bn. KHNG xi vi nc thng vo vt
dn.
6.5. Lm kh tiu bn
Xp tiu bn ln gi kh t nhin, hoc bng my lm kh tiu bn.
Ch : KHNG lm kh tiu bn bng cch h tiu bn qua ngn la hay dng khn hoc
giy thm kh.
6.6. Soi knh hin vi
6.6.1. Ly vi trng
- Bt ngun in.
- Lau th knh, vt knh v t quang bng giy lau chuyn dng.
- Xoay vt knh x10 vo trc quang hc.
- t tiu bn ln mm knh, s dng vt knh x10 ly vi trng.
- Nh mt git du soi vo u tri ca vt dn, git du ri t do khng chm u ng
nh git vo vt dn trnh nhim cho.

22
- Xoay vt knh x100 vo trc quang hc. Du soi to thnh 1 lp mng gia vt knh
x100 v tiu bn.
- Khng vt knh chm tiu bn.
- iu chnh c vi cp nh nhng nhn hnh nh r nt.
Ch : Khng soi tiu bn t v khng r vi trng v c th hng vt knh
Ch dng c vi cp vi vt knh x100.
6.6.2. Cch soi tiu bn v nhn nh kt qu
- Cch soi: cn phi h thng v chun ha, soi dng gia t tri sang phi (tng ng
vi 100 vi trng). iu chnh c vi cp cho hnh nh r nt nht, quan st k t ngoi vi
vo trung tm vi trng pht hin AFB. c xong vi trng th nht, chuyn sang
c cc vi trng k tip cho n ht dng. Khi cn c >100 vi trng, chuyn dng k
tip t phi qua tri (theo hnh v).

Soi tiu bn mt cch h thng

- Nhn nh kt qu:
Hnh nh AFB t bnh phm: AFB c hnh que mnh, hi cong, bt mu , ng
ring bit hay xp thnh tng cm, d nhn bit trn nn xanh. m s lng AFB v
ghi kt qu theo qui nh nh bng 1.
23
 Bng 1: Quy nh ghi kt qu xt nghim AFB nhum ZN

S lng AFB Kt qu Phn loi

0 AFB / 100 vi trng m tnh
1 - 9 AFB / 100 vi trng Dng tnh Ghi s lng AFB c th
10 - 99 AFB / 100 vi trng Dng tnh 1+
1 -10 AFB /1 vi trng Dng tnh 2+
(soi t nht 50 vi trng)
>10 AFB / 1 vi trng Dng tnh 3+
(soi t nht 20 vi trng)

Hnh nh AFB t khun lc trn nui cy c: AFB mu xp thnh m dy c

hoc thnh tng bi ln.
Hnh nh AFB t tup MGIT(+): AFB mu kt thnh cun thng (cord forming)
hoc thnh m hoc ri rc ring bit.
6.6.3. Lu tr tiu bn
- Khng ghi kt qu soi trn tiu bn.

24
- Cc tiu bn sau khi soi xong, lm sch du soi bng cch xp tiu bn vo hp bo qun
c lt giy mm thm du soi chy xung. Hm sau, lau phn du soi cn ng li
cnh tiu bn.
- Xp cc tiu bn vo hp ng tiu bn theo th t trong s xt nghim phc v cho
cng tc kim nh tiu bn.
- Hp tiu bn lu ni thong, kh ro v trnh nh nng trc tip.
7. Ghi chp v bo co kt qu
- Kim tra s XN trn tiu bn trng vi s ghi trn phiu XN.
- Ghi kt qu soi knh vo phn xt nghim ca phiu XN v s xt nghim.
- Ghi ngy thng lm XN v k tn vo phiu v s xt nghim.
- Kt qu dng tnh phi ghi bng mc trong s xt nghim.
- Thc hin bo co thng, bo co qu v bo co nm theo qui nh ca CTCLQG.
8. Kim tra cht lng
8.1. Kim tra cht lng thuc nhum
- Kim tra cht lng thuc nhum ngay sau khi pha l mi:
Chun b sn l tiu bn t mu m bit trc kt qu m tnh v dng tnh mc
1 +.
Mi l thuc nhum mi pha nhum 3 tiu bn dng v 3 tiu bn m ng qui
trnh k thut.
Kt qu thuc nhum t cht lng: tiu bn dng thy AFB bt mu trn nn
xanh sng, khng thy cn thuc nhum, tiu bn m khng thy AFB.
Kt qu thuc nhum khng t cht lng: tiu bn dng khng thy AFB hoc
AFB nht mu, nn xanh ti, thy cn thuc nhum, tiu bn m thy AFB.
Kim tra cht lng nhum tiu bn hng ngy: nhum chng dng v m cng m
nhum tiu bn thng thng. c kt qu chng dng v chng m trc khi c
tiu bn ca ngoi bnh.
Khi kt qu kim tra khng t, phi xem xt li ton b qu trnh t thuc nhum,
tiu bn chng n k thut nhum soi, nhum thm l tiu bn chng mi nu kt
qu vn khng t phi hy b thuc nhum.
- Ch s dng v cp pht thuc nhum kim tra m bo cht lng.
- Phi c s pha, kim tra, qun l v cp pht thuc nhum.
- Hn s dng thuc nhum 1 thng theo qui nh ca CTCLQG.
- Chai l ng thuc nhum phi c dn nhn v hn s dng, c bo qun ni
thong mt, kh ro v trnh nh nng mt tri.
8.2. Kim tra cht lng tiu bn theo 6 tiu chun
25
8.2.1. Cht lng bnh phm
- S c mt ca bch cu a nhn, i thc bo.
- Cht lng bnh phm t yu cu khi soi:
C trn 25 bch cu a nhn/1VT phng i 100x (vt knh 10x, th knh 10x)
hay 3-4 bch cu a nhn/1VT vi vt knh du.
Hoc c i thc bo.
- Bnh phm t cht lng kt qu xt nghim mi chnh xc.
8.2.2. Kch thc tiu bn
Kch thc 1x2cm, c hnh ovan nm gia lam knh
657 / 1

1cm

2cm
8.2.3. mn cmc
- Bnh phm c dn u m
t mn cn thit.
- Tiu bn t v mn:
B mt tiu bn lin tc, u n, khng b rng, bong tri.
Soi knh: Cc vi trng lin tc khng c nhiu vi trng rng, sng u n.
8.2.4. dy
- Tiu bn t tiu chun c dy khong 0,04 mm, khi tiu bn kh, cha nhum c th
kim tra bng cch mt t giy c ch in xung di tiu bn cch 4-5 cm nu nhn
thy ch m c th c c l t, khng c c ch l dy, nhn ch qu r l
mng.

Qu mng t dy Qu dy
26
- Nu qu dy tiu bn c nhiu lp, khng soi thu, vi trng xanh ti; Nu qu mng cc
vi trng tha tht, nn xanh nht.
8.2.5. Nhum v ty mu
- Tiu bn nhum v ty mu t: AFB bt mu phn bit r rng vi nn mu xanh
- Tiu bn nhum v ty mu khng t:
AFB nht mu c th do ty qu hoc nhum cha (thi gian, sc nng...).
Nn cng mu do ty mu cha kh phn bit r AFB (nhng tiu bn nhn
bng mt thng cn mu l ty cha t).
Nn xanh m, AFB ti do nhum nn qu lu.
8.2.6. sch
- Tiu bn t sch: Soi khng thy cc cn bn, cn Fuchsin, tinh th..
- Tiu bn khng t sch: Soi thy cc cn bn, cn Fuchsin, tinh thdo thuc
nhum c cn hoc do h qu nng trong khi nhum Fuchsin.
8.3. Kim nh tiu bn
- Thc hin kim nh tiu bn theo phng php kim nh theo l (LQAS)
- PXN tuyn tnh thc hin kim nh tiu bn hng thng cho tuyn huyn.
- PXN tuyn trung ng kim nh cho tuyn tnh hng qu hoc kim tra ngu nhin trong
cc t KTGS qu.
8.4. c sai kt qu - Hu qu - Cch phng nga
8.4.1.Hu qu li sai dng
- Ngi bnh b iu tr mt cch khng cn thit.
- nh gi sai kt qu, tng t l ngi bnh lao.
- Lng ph thuc.
- Ngi bnh khng tin tng vo xt nghim.
8.4.2. Phng nga li sai dng
- Cht lng knh hin vi tt.
- S dng tiu bn mi, khng c vt xc.
- S dng que pht m ring cho tng bnh phm.
- Ha cht nhum Ziehl t cht lng.
- Khng dung dch Fuchsin kh trong khi nhum.
- Khng c thc n hoc cht x trong mu m.
- Lau vt knh du sau mi ln soi tiu bn dng.
- i chiu s xt nghim chnh xc, thng tin ngi bnh ph hp.
27
- Ghi chp v bo co kt qu chnh xc.
8.4.3. Hu qu ca li sai m
- Ngi bnh lao khng c iu tr c th t vong.
- Ngi bnh tip tc truyn bnh cho nhng ngi xung quanh.
- nh gi kt qu iu tr sai lch.
- Ngi bnh khng tin tng vo xt nghim.
8.4.4. Phng nga li sai m
- Cht lng knh hin vi tt.
- m bo m t cht lng (t nht 2 ml, c nhy m).
- Ha cht nhum Ziehl t cht lng.
- Thc hin ng qui trnh k thut: Chn mnh m c, m lm tiu bn, dn tiu bn
t dy, c nh tiu bn tt, nhum fuchsin nng v thi gian.
- Phi c 100 vi trng.
- i chiu s xt nghim chnh xc, thng tin ngi bnh ph hp.
- Ghi chp v bo co kt qu chnh xc.
8.5. Cc vn pht sinh khi soi knh v cch gii quyt

Vn Nguyn nhn Gii php

sng ca vi - T quang qu thp - Nng t quang ln
trng khng t - T quang b ng - M chn sng ra
Bng ti trong vi - Th knh b bn - Lau sch th knh
trng chuyn ng - B mt ca th knh b - Thay th knh mi
khi xoay th knh xc
Hnh nh khng r - Mt tiu bn b lt - Lt tiu bn ln
khi soi vt knh du ngc - Di chuyn vt knh x 100
- C bt kh trong du nhanh t bn ny sang bn kia
- Ch s dng du soi cht
- Cht lng du soi km lng tt.

- Vt knh b bn - Lau sch vt knh

Hnh nh khng r - C du vt knh - Lau sch vt knh

khi soi vt knh - C lp bi trn b mt
phng i nh ca vt knh - Thay vt knh mi
- Vt knh c th b v

28
8.6. Bo qun knh hin vi
- t KHV ni vng chc, kh ro, khng c bi, trnh nh nng trc tip. m cao
c th lm mc b phn quang hc (vt knh, th knh, t quang..) v b phn c hc b
han r.
- Trnh va chm mnh lm hng knh hin vi, khng vt knh chm vo tiu bn
- Ch s dng c vi cp khi soi vt knh du
- Lau b phn quang hc bng giy lau chuyn dng, lau sch du soi trn b mt vt knh
du ngay sau khi s dng
- V sinh knh sau mi ngy s dng.
- Khi khng s dng knh trng thi ngh: tt ngun in, xoay vt knh ra khi trc
quang hc, h t quang, ph knh trnh bi.
- Nu c iu kin bo qun KHV trong t bo qun knh chuyn dng.
- Nu pht hin knh b hng tuyt i khng c t tho ra sa cha phi bo ngi c
trch nhim gii quyt.
9. Thc hnh an ton PXN
- Sp xp b tr phng xt nghim nhum soi trc tip hp l.
- S dng t ATSH theo qui nh, m bo lung kh lu thng trong t khng b nh
hng bi cc vt liu che lp. Kt thc cng vic, lau t bng cn 700.
- Cc thao tc k thut phi nh nhng trnh to ht m: m np l m, ly mnh m,
dn tiu bn., c nh khi tiu bn cha kh hon ton.
- Kh nhim vt liu ly nhim theo qui nh.

29
 XT NGHIM AFB NHUM SOI TRC TIP
PHNG PHP NHUM HUNH QUANG N LED

1. Mc ch
M t k thut nhum soi trc tip tm AFB (Acid- Fast- Bacilli) theo phng php nhum
hunh quang s dng knh hunh quang n LED.
2. Bnh phm
m v cn bnh phm sau li tm (khng nhum hunh quang chng vi khun).
3. Trang thit b v vt liu
Ging phng php nhum Ziehl Neelsen. Thay th KHV quang hc bng KHV hunh
quang n LED.
- Cu to KHV n LED: 30 phn
1. Dim th knh (c th tho ra nu ngi s dng cm thy khng thun tin).
2. Th knh.
3. ng gn th knh.
4. ng cha h thng lng knh.
5. Cn chuyn i quang h (quang h truyn qua/quang h phn x).
6. Nt bt/tt v iu chnh cng chiu sng cho quang h phn x.
7. Tay xch.
8. B chuyn ngun in.
9. Cm n bo cng chiu sng cho quang h truyn qua.
10. Nt bt/tt v iu chnh cng chiu sng cho quang h truyn qua.
11. Nt iu chnh vi cp (bn phi).
12. Nt iu chnh v cp (bn phi).
13.Nt iu chnh di chuyn mm knh (chiu tri - phi).
14. Nt iu chnh di chuyn mm knh (chiu trc - sau).
15. Cht c nh t quang.
16. Ngun chiu sng.
17. G phin lc nh sng vng.
18. Mn trp (c nh).
19. Cp vt chnh t quang chnh tm.

30
 20. T quang.
21. Vt knh.
22. Mm knh.
23. Cn kp lam knh.
24. Vng xoay gn vt knh.
25. n bo ngun chiu sng quang h phn x (mu xanh dng: bt; cng
chiu sng t l thun vi chiu sng ca n bo).
26. Cn iu chnh mn chp ca t quang.
27. Nt iu chnh theo chiu thng ng.
28. Nt iu chnh v cp (bn tri).
29. Nt iu chnh vi cp (bn tri).
30.Vng iu chnh mt khi di chuyn nt v cp.
- Cc bc s dng knh hin vi hunh quang n LED: 8 bc
Bc 1. Ni ngun in hoc dng pin. ng chn sng.
Bc 2: La chn nh sng hunh quang (gt nt ngc chiu kim ng h
phafluorescence) ( cng tc s 5).
Bc 3: Chnh nt on/of iu chnh nh sng hunh quang (s 6).
Bc 4: Quan st tiu bn bng vt knh 10 X, s dng v cp.
Bc 5: iu chnh khong cch gia 2 ng th knh c 1 hnh nh trng nhau.
Bc 6: Chnh vi cp c hnh nh r nt.
Bc 7: Chuyn vt knh 20 X quan st tm AFB.
Bc 8: Quan st k vi trng, sau chuyn vi trng khc theo chiu di tiu bn
bng nt di chuyn (s 13, 14).

31
Hnh nh KHV hunh quang n LED

32
4. Ha cht nhum hunh quang
4.1 Ha cht t pha
4.1.1. Dung dch Auramine 0,1%
- Cng thc:
Auramin O: 1 gam
Phenol: 30 gam
Cn 95% 100 ml
Nc ct 870 ml
- Cch pha
Ha tan 30 gam phenol vo 100 ml cn 950
Thm 1 gam Auramin O vo dung dch trn,
Trn u. C th s dng my trn,
Cho nc ct va 1000 ml,
Lc qua giy lc v cha vo chai mu,
Dn nhn ghi r tn ha cht, nng , v ngy pha,
Vn cht nt chai gi trong t, trnh nh sng mt tri.
Hn s dng 1 thng.
4.1.2. Dung dch cn ty acid HCl 0,5%
- Cng thc:
Cn 700 995 ml
HCl 5 ml
- Cch pha:
Cho 995 ml cn 700 vo bnh 2 lt,
Rt t t acid HCl vo bnh, trn u,
Dn nhn ghi tn ha cht, nng v ngy pha,
Vn cht nt chai gi trong t, trnh nh sng mt tri,
Hn s dng 1 thng.
4.1.3. Dung dch Methylene blue 0,3%
- Cng thc:
Methylene blue: 3 gam
Nc ct: 1000 ml
33
 - Cch pha:
Ha tan xanh methylen trong nc ct.
Dn nhn ghi tn ha cht, nng v ngy pha.
Vn cht nt chai gi trong t, trnh nh sng mt tri.
Hn s dng 1 thng.
4.2. Ha cht hunh quang nhanh (b kt):
- QBC. FAST AuraminO: chai 250 ml mu nu.
- QBC. FAST Decolerizer/Quencher: chai 250 ml mu xanh.
B ha cht trong hn s dng.
5. Nguyn l
Mycobacteria c lp vch sp dy, khi nhum Auramine thm vo vi khun do c phenol
trong dung dch nhum, khi ty mu bng dung dch acid-cn AFB vn gi c mu vng
ca auramine do c tnh khng acid, nhum nn bng xanh methylene to mu nn ti,
thun nht cho nh sng pht quang. Khi soi bng nh sng hunh quang AFB pht quang
mu vng sng tng phn r rng trn nn ti.
Knh hin vi hunh quang c u im l soi nhanh hn KHV quang hc (nh sng trng) vi
nhum Ziehl Neelsen v c bit c gi tr nhng phng xt nghim c khi lng cng
vic ln. K thut ny cng c nhy cao hn nhng mu bnh phm t vi khun v s vi
trng c quan st nhiu hn.
6. Cc bc thc hin
6.1. Chun b tiu bn
Cc bc lm tiu bn, c nh tiu bn ging nh phng php nhum ZN.
6.2. Cc bc nhum hunh quang( ha cht t pha)
6.2.1: Nhum mu Auramine
- Xp tiu bn theo th t trn gi nhum, mi tiu bn cch nhau t nht 1 cm.
- Ph dung dch Auramine 0,1 % kn ton b b mt tiu bn.
- t nht 15 pht.
- Ra tiu bn nh nhng cho tri ht thuc nhum.
- Nghing tiu bn cho ro nc.
6.2.2 Ty mu
- Ph y dung dch acid - cn 0,5% ln tiu bn, 2 pht.
- Ra nc. Nghing tiu bn cho ro nc.
- Sau khi ra, cc tiu bn khng cn mu vng.

34
- Nu tiu bn vn cn mu vng, ty li ln 2, thi gian t 1 2 pht cho n khi ht mu
vng, ra li nc.
6.2.3. Nhum nn
- Ph y dung dch xanh Methylene 0,3% ln tiu bn.
- 1 - 2 pht.
- Ra nc, nghing tiu bn cho ro nc.
6.2.4. Lm kh tiu bn
- tiu bn kh t nhin nhit PXN hock lm kh my lm kh tiu bn.
- Xp tiu bn vo hp trnh nh sang.
6.3. Cc bc nhum hunh quang nhanh (b kit QBC)
6.3.1. Nhum mu Auramine
- Xp tiu bn theo th t trn gi nhum, mi tiu bn cch nhau t nht 1 cm.
- Ph dung dch FAST AuraminO kn vt dn.
- 1-2 pht.
- Ra tiu bn nh nhng cho tri ht thuc nhum.
- Nghing tiu bn cho ro nc.
6.3.2. Ty mu v nhum nn
- Ph dung dch FAST Decolerizer/Quencher kn vt dn.
- 1 pht.
- Ra nc. Nghing tiu bn cho ro nc.
- tiu bn kh t nhin nhit PXN hoc lm kh my lm kh tiu bn
- Xp tiu bn vo hp trnh nh sng.
Hnh nh m t cc bc nhum hunh quang bng ha cht t pha (ph lc 16)
7. c tiu bn, ghi chp v bo co kt qu
7.1. Ly vi trng
- Bt ngun in.
- La chn nh sng hunh quang (gt nt ngc chiu kim ng h pha fluorescence).
- Chnh nt on/of iu chnh nh sng hunh quang.
- Xoay vt knh x10 vo trc quang hc.
- t tiu bn ln mm knh, s dng vt knh x10 ly vi trng.
- iu chnh khong cch gia 2 ng th knh c 1 hnh nh trng nhau.
- Xoay vt knh x 20 vo trc quang hc.

35
- Chnh vi cp c hnh nh r nt.
7.2. Cch soi tiu bn v nhn nh kt qu
- Cch soi: cn phi h thng v chun ha, soi dng gia t tri sang phi (tng ng
vi 30 vi trng). iu chnh c vi cp cho hnh nh r nt nht, quan st k t ngoi vi
vo trung tm vi trng pht hin AFB. c xong vi trng th nht, chuyn sang
c cc vi trng k tip cho n ht dng.
Khi cn c > 1 dng, chuyn dng k tip t phi qua tri.
- Hnh th AFB trn tiu bn nhum hunh quang: AFB dng trc khun mnh, mu vng
pht quang trn nn ti, AFB ng ring r hoc thnh tng m. Ch : Mt s thnh
phn khc c th bt mu vng pht quang hoc khng nhng hnh th khng in hnh.
Lu : khi cn xc nh r hnh nh AFB, chuyn vt knh 40, sau li chuyn v vt
knh 20 tip tc nhn nh kt qu.
- Phn loi kt qu nh bng 2.

Hnh nh AFB trn tiu bn nhum hunh quang

36
 Bng 2: Quy nh ghi kt qu xt nghim AFB nhum hunh quang

S lng AFB
Kt qu Kt qu
quan st bng vt knh 20 X
0 AFB/ 1 dng m tnh m tnh
129 AFB/ 1 dng Dng tnh Ghi s lng AFB c th
30299 AFB/ 1 dng Dng tnh 1+
10100 AFB/ 1 VT
Dng tnh 2+
(soi t nht 10 VT)
>100 AFB/ 1 VT
Dng tnh 3+
(soi t nht 4 VT)
Ghi ch: 1 dng tng ng 30 vi trng, VT: vi trng

Bng 3: So snh ghi kt qu xt nghim AFB 2 phng php nhum

Nhum ZN Nhum hunh quang Nhum hunh quang

Kt qu (phng i 1000 ln) (phng i 200 ln) (phng i 400 ln)
1 dng = 2cm = 100VT 1 dng = 2cm = 20VT 1 dng = 2cm = 40VT
m tnh 0 AFB / 100 VT 0 AFB/ 20 VT 0 AFB / t nht 40 VT
Ghi s lng
1 - 9 AFB / 100 VT 129 AFB/ 20 VT 1-19 AFB / 40 VT
AFB c th
20-199 AFB/ 40 VT
1+ 10 - 99 AFB / 100 VT 30299 AFB/ 20 VT
(Soi t nht 40 VT)
1 -10 AFB /1 VT 10100 AFB/ 1 VT 5-50 AFB/ 1 VT
2+
(soi t nht 50 VT) (soi t nht 10 VT) (Soi t nht 20 VT)
>10 AFB / 1 VT >100 AFB/ 1 VT >50 AFB/ 1 VT
3+
(soi t nht 20 VT) (soi t nht 4 VT) (Soi t nht 8 VT)

7.3. Ghi chp v bo co kt qu

- Kim tra s XN trn tiu bn trng vi s ghi trn phiu XN.
- Ghi kt qu soi knh vo phiu XN v s xt nghim.
- Ghi ngy thng lm XN v k tn vo phiu v s xt nghim.

37
- Kt qu dng tnh phi ghi bng mc trong s xt nghim.
- Kt qu xt nghim c tr ngay sau khi c kt qu.
7.4. Lu tr tiu bn
- Khng ghi kt qu soi trn tiu bn.
- Xp cc tiu bn vo hp ng tiu bn theo th t trong s xt nghim phc v cho
cng tc kim nh tiu bn.
- Hp tiu bn lu ni thong, kh ro v trnh nh nng trc tip.
8. Kim tra cht lng
8.1. Kim tra cht lng thuc nhum
- Kim tra cht lng thuc nhum ngay sau khi pha l mi:
Chun b sn l tiu bn t mu m bit trc kt qu m tnh v dng tnh mc
1 +.
Mi l thuc nhum mi pha nhum 3 tiu bn dng v 3 tiu bn m ng qui
trnh k thut.
Kt qu thuc nhum t cht lng: tiu bn dng thy AFB bt mu vng pht
quang trn nn ti, khng thy cn thuc nhum, tiu bn m khng thy AFB.
Kt qu thuc nhum khng t cht lng: tiu bn dng khng thy AFB hoc
AFB bt mu vng nht khng pht quang hoc pht quang yu, nn khng ti, c
nhiu thnh phn khc pht quang, thy cn thuc nhum, tiu bn m thy AFB.
- Kim tra cht lng thuc nhum hng tun: nhum chng dng v m cng m,
nhum tiu bn thng thng. c kt qu chng dng v chng m trc khi c tiu
bn ca ngi bnh.
- Khi kt qu kim tra khng t, phi xem xt li ton b qu trnh t thuc nhum, tiu
bn kim tra n k thut nhum soi, nhum thm l tiu bn chng mi nu kt qu vn
khng t phi hy b thuc nhum.
- Ch s dng v cp pht thuc nhum kim tra m bo cht lng.
- Phi c s pha, kim tra, qun l v cp pht thuc nhum.
- Hn s dng thuc nhum 1 thng.
- Chai l ng thuc nhum phi c dn nhn v hn s dng, c bo qun ni
thong mt, kh ro v trnh nh nng mt tri.
8.2. Kim tra cht lng tiu bn
8.2.1. Tiu chun nh gi (3 tiu chun)
8.2.1.1. Kch thc tiu bn
Xem mc 9.2.2. Kch thc tiu bn (Bi Xt nghim AFB nhum soi trc tip bng
phng php nhum Ziehl Neelsen).

38
8.2.1.2 mn
Xem mc 9.2.3. mn (Bi Xt nghim AFB nhum soi trc tip bng phng php
nhum Ziehl Neelsen).
8.2.1.3 dy
Xem mc 9.2.4. dy (Bi Xt nghim AFB nhum soi trc tip bng phng php
nhum Ziehl Neelsen).
8.2.2. Phng php nh gi
- Thc hin kim nh tiu bn theo phng php kim nh theo l (LQAS).
- nh gi cht lng tiu bn nhum theo 3 tiu chun: kch c, dy v mn.
8.3. Nguyn nhn sai kt qu dng
8.3.1. Nguyn nhn sai dng
- Cht lng thuc nhum khng t (nc ct pha Auramine nhim AFB).
- K thut nhum cha ng: cc tiu bn qu st, xi nc mnh AFB t tiu bn
dng trn sang tiu bn khc, ty mu cha ..).
- Nhn nh sai AFB do XNV thiu kinh nghim nhm ln vi cc cht pht quang khc
(thc n, cn Auramine..).
- Cht lng knh km hoc iu chnh cha ng.
8.3.2. Nguyn nhn sai m
- Cht lng bnh phm khng t (khng chn c mnh m dn tiu bn).
- Cht lng thuc nhum khng t (nng Auramine <0,1%, nng acid cn qu
0,5%).
- K thut nhum cha ng: Ty mu qu, thi gian nhum Auramine khng , nhum
nn qu lu.
- C nh tiu bn qu nng.
- c tiu bn cha mt dng.
- Thi gian t khi nhum v c qu lu (tiu bn khng gi trong hp ti).
8.4. Bo qun knh hin vi
- t KHV ni vng chc, kh ro, khng c bi, trnh nh nng trc tip. m cao
c th lm mc b phn quang hc (vt knh, th knh, t quang..) v b phn c hc b
han r.
- Trnh va chm mnh lm hng knh hin vi.
- Ch s dng c vi cp khi cn chnh r nt hnh nh.
- Lau b phn quang hc bng giy lau chuyn dng.
- V sinh knh sau mi ngy s dng.

39
- Khi khng s dng knh trng thi ngh: tt ngun in, xoay vt knh ra khi v
tr quan st, nng mm knh ht c v ph knh trnh bi.
- Nu c iu kin bo qun KHV trong t bo qun knh chuyn dng.
- Nu pht hin knh b hng tuyt i khng c t tho ra sa cha phi bo ngi c
trch nhim gii quyt.
9. Thc hnh an ton PXN (ging phng php nhum ZN)
Xem mc 9. Thc hnh an ton ca bi xt nghim AFB nhum soi trc tip phng php
nhum ZIEHL NEELSEN.

40
 XQUANG TRONG CHN ON LAO PHI

1. Vai tr ca Xquang trong chn on lao phi

- Xquang phi c nhy cao, v vy cn c s dng rng ri sng lc lao phi. Tt
c ngi bnh c triu chng h hp (ho, khc m, kh th) vi bt k thi gian no
u nn c chp Xquang ngc sng lc lao phi, c bit ngi c nguy c cao nh
i ng, ngi gi, suy dinh dng, nhim HIV, ...
- Tuy nhin, c hiu trn phim chp Xquang khng cao, v vy khng nn chn on
xc nh lao phi ch da phim Xquang n thun.
- S thay i c im tn thng theo thi gian v p ng iu tr s mang li ngha
tt hn cho chn on, v vy cn chp Xquang nhiu thi im hoc i chiu vi
phim chp trc y.
- Cc hnh nh tn thng trn phim Xquang ca lao phi khng ch gp ring trong lao
m cn gp trong nhiu bnh l khc (Tnh c hiu khng cao).
- Mi hnh thi v c im tn thng khng phi lc no cng gp y trn mt
ngi bnh. Nn cng nhiu yu t gi cng c gi tr hng ti Lao phi.
2. Cc k thut Xquang trong chn on
- pht hin v chn on lao phi c nhiu k thut X quang, nhng ph bin nht l
chp phi thng thng quy ( t th sau - trc), chp phi nghing thng quy v chp
nh phi t th n ngc ( t th Lordotic).
- Vi nhng trng hp kh chn on bng cc k thut Xquang thng quy, ngi ta
tin hnh chp ct lp vi tnh (CT). Mt s k thut Xquang khc cng c s dng
chn on phn bit: dng hnh ph qun (soi ph qu o), chp ng mch phi, chiu
phi trn truyn hnh tng sng,
- Trong hot ng iu tra lao phi trong cng ng: ngi ta s dng cc xe Xquang
hunh quang lu ng: MMR (Mass Miniature Radiography-Photofluography) hoc xe
Xquang k thut s (Digital MobileX-ray Car).
3. Quy trnh k thut chp Xquang ngc thng quy
- Quy trnh chp phi thng (xem ph lc 11).
- Quy trnh chp phi nghing (xem ph lc 12).
- Quy trnh chp phi t th nh phi n (t th Lordotique) (xem ph lc 13).
4. M t v phn tch hnh nh Xquang ca lao phi trn phim phi thng quy
4.1. Hnh nh tn thng
4.1.1. Nt: l mt bng m c kch thc nh, ng knh nt k 2mm (lao k), 2mm <
ng knh nt nh 5mm, 5mm < ng knh nt to < 10mm. m ca nt rt thay
i: c th tng phn rt t so vi m phi xung quanh hoc gn bng m ca mch

41
mu, c khi m cao gn bng m xng hoc kim loi. Tp hp ca cc nt gi l
m thm nhim.
4.1.2. Thm nhim: l m m ng u c c im:
- C hnh ph qun hi.
- Khng y hoc co ko cc t chc ln cn.
- C th m theo nh khu: thy / phn thy hoc m ri rc.
4.1.3. Hang: l hnh sng gii hn bi mt b m trn khp kn lin tc, ng knh
0,5cm. sng ca hang cao hn ca nhu m phi, kch thc ca hang a dng: trung bnh
t 2 - 4cm, 4cm hang ln < 6cm, hang khng l 6cm, tuy nhin c th rt ln chim 1/2
ph trng, 1 thu phi.. hoc rt nh v tp trung li to hnh r t ong hoc rut bnh
m.
Thnh hang: c dy 2mm phn bit vi nhng bng gin ph nang. Trong lng hang
thng l hnh sng ca kh, i khi c mc dch hoc c bng m chim ch trong lng
hang (u nm) cn gi l hnh lim kh.
4.1.4. Di x m: l cc ng m c ng knh rng t 0,5 - 1 mm, thng to ging
hnh li hoc hnh vn .
4.1.5. Nt vi ho: m gn tng ng kim loi v cht cn quang, hoc m hn
xng, l nhng nt c m cao, ranh gii r, thng gp nhng trng hp lao n
nh hoc lao c
4.1.6. Bng m (u lao): Hnh trn hoc hnh ovan m ng u, b r, c th n c
hoc phi hp vi cc dng tn thng khc ca lao phi. Cn phn bit v kch thc, ranh
gii ca bng m, c nt vi ho khng? (nu c th ng tm hay lch tm).
4.1.7. Bng m gi nh l hch (thng gp trong lao s nhim): cc nhm hch thng
gp: nhm cnh kh qun, nhm kh ph qun, nhm rn phi, nhm di ch phn chia ph
qun gc phi v ph qun gc tri (Subcarina).
4.1.8. Hnh nh trn dch mng phi
- M ng u khng theo nh khu thu, phn thu: Gc gia ranh gii trn ca hnh m
vi thnh ngc l gc t.
- C xu hng y cc c quan b phn ln cn sang bn i din, lm rng cc khoang
lin sn: nu l trn dch mng phi t do.
- C xu hng co ko cc c quan b phn ln cn v bn tn thng, ko hp cc khoang
lin sn: nu l dy dnh mng phi hoc vi ha mng phi.
4.1.9. Hnh nh trn kh mng phi
- C hnh di sng dc theo mng phi bn b trn kh, rt r vng nh.
- Thy hnh mng phi tng di dng mt di vin,bao ly nhu m phi b co li.
- Khng thy hnh mch phi ngoi gii hn ca mng phi tng.
Xem ph lc 14: Hnh nh ca cc hnh thi tn thng lao
42
4.2. V tr tn thng
Tn thng lao thng gp vng cao ca phi.
- Thu trn v phn thu nh thu di ca hai phi: cc phn thu 1, 2, 3, 6. Mc
nng c th lan ra ht mt phi hoc c hai bn phi.
- Nu 2 bn , c th thy i xng hai bn hoc i xng ngang hoc i xng cho.
Tng hp hnh nh Xquang lao phi
a. Thng thy vng cao ca phi: vng nh - h n, cnh rn phi (tng ng vi
cc phn thy 1, 2, 3 v 6).
b. Tn thng hai bn c th l i xng ngang hoc i xng cho.
c. Tn thng an xen gia nhng hnh thi n nh (x vi) vi nhng hnh thi tin
trin (thm nhim, nt, hang ).
d. p ng chm vi thuc chng lao sau 1 thng iu tr (khi tn thng thay i rt
nhanh trong thi gian di 1/2 thng phi ht sc thn trng khi chn on lao phi).
4.3. S thay i hnh nh tn thng
Chp phim vo nhng thi im khc nhau nh gi s thay i ca tn thng
theo thi gian v p ng iu tr s mang li gi tr cao hn l chp phim ti 1 thi
im. i vi tn thng do lao thay i chm v khng p ng vi iu tr khng
sinh thng thng.
5. c im tn thng lao phi ngi nhim HIV
- Giai on lm sng sm ca nhim HIV (t bo CD4 200): Hnh nh tn thng ca
Lao phi / HIV(+) ni chung khng c s khc bit so vi hnh nh Lao phi /HIV( -)
- Giai on AIDS (t bo CD4 < 200): hnh nh tn thng lao khng cn in hnh na,
c mt s c im nh:
t thy tn thng hang.
Tn thng vng cao khng cn l ph bin, thay th vo tn thng c tnh lan
to (diffuse), thng c vng thp ca phi.
Hnh nh tin trin nhanh hn, lan ta, tn thng khong k nhiu hn, v vy t thy
tn thng an xen c thanh phn vi tui khc nhau phn nh qu trnh tin
trin chm nh thm nhim, nt, hang, x, vi ha.

43
 IU TR BNH LAO

1. Nguyn tc iu tr
1.1. Phi hp cc thuc chng lao
- Mi loi thuc chng lao c tc dng khc nhau trn vi khun lao (dit khun, km
khun, mi trng vi khun), do vy phi phi hp cc thuc chng lao.
Phi hp t nht 3 loi thuc chng lao trong giai on tn cng v t nht 2 loi trong
giai on duy tr.
- Vi bnh lao a khng: phi hp t nht 4 loi thuc chng lao hng 2 c hiu lc trong
giai on tn cng v duy tr.
1.2. Phi dng thuc ng liu
Cc thuc chng lao tc dng hp ng, mi thuc c mt nng tc dng nht nh.
Nu dng liu thp s khng hiu qu v d to ra cc chng vi khun khng thuc, nu
dng liu cao d gy tai bin. i vi lao tr em cn c iu chnh liu thuc hng
thng theo cn nng.
1.3. Phi dng thuc u n
- Cc thuc chng lao phi c ung cng mt ln vo thi gian nht nh trong ngy v
xa ba n t hp thu thuc ti a.
- Vi bnh lao a khng: dng thuc 6 ngy/tun, a s thuc dng 1 ln vo bui sng,
mt s thuc nh: Cs, Pto, Eto, PAS ty theo kh nng dung np ca ngi bnh - c th
chia liu 2 ln trong ngy (sng chiu) gim tc dng ph hoc c th gim liu
trong 2 tun u nu thuc kh dung np, nu ngi bnh c phn ng ph vi thuc
tim - c th tim 3 ln/tun sau khi m ha m.
1.4. Phi dng thuc thi gian v theo 2 giai on tn cng v duy tr
- Giai on tn cng ko di 2, 3 thng nhm tiu dit nhanh s lng ln vi khun c
trong cc vng tn thng ngn chn cc vi khun lao t bin khng thuc. Giai
on duy tr ko di 4 n 6 thng nhm tiu dit trit cc vi khun lao trong vng tn
thng trnh ti pht.
- Vi bnh lao a khng: Phc iu tr chun cn c thi gian tn cng 8 thng, tng
thi gian iu tr: 20 thng. Cc phc ngn hn cn ang trong th nghim.
2. Nguyn tc qun l
2.1. Tt c cc bc s (cng v t) tham gia iu tr ngi bnh lao phi c tp hun
theo hng dn ca Chng trnh Chng lao Quc gia v bo co theo ng quy nh.
2.2. S dng phc chun thng nht trong ton quc.
2.3. iu tr sm ngay sau khi c chn on.
2.4. iu tr phi c theo di v kim sot trc tip:

44
- Kim sot vic tun th iu tr ca ngi bnh, theo di kt qu xt nghim m, theo
di din bin lm sng, x tr kp thi cc bin chng ca bnh v tc dng ph ca
thuc. Vi bnh lao tr em phi theo di cn nng hng thng khi ti khm iu chnh
liu lng thuc.
- Vi bnh lao a khng:
Phi kim sot cht ch vic dng thuc hng ngy trong c liu trnh iu tr.
Phi hp cht ch gia cc trung tm im iu tr - tnh ln cn trong qun l iu
tr ngi bnh lao a khng.
Ngi bnh lao a khng nn iu tr ni tr (khong 2 tun) ti cc trung tm/im
iu tr lao a khng theo di kh nng dung np v x tr cc phn ng bt li ca
thuc (c th iu tr ngoi tr ngay t u cho ngi bnh ti cc a phng nu c
iu kin: gn trung tm iu tr lao a khng, nhn lc m bo cho vic theo di
v gim st ngi bnh mt cch cht ch).
Giai on iu tr ngoi tr iu tr c kim sot trc tip (DOT) c th thc hin ti
cc tuyn: qun huyn, x phng, ti khm hng thng ti cc trung tm/im iu
tr lao a khng theo di din bin lm sng, x tr kp thi bin chng ca bnh
v tc dng ph ca thuc, theo di cc xt nghim, Xquang v mt s thm khm
cn thit khc.
2.5. Thy thuc cn t vn y cho ngi bnh trc, trong v sau khi iu tr ngi
bnh thc hin tt liu trnh theo quy nh.
2.6. Chng trnh Chng lao Quc gia cung cp thuc chng lao m bo cht lng, min
ph, y v u n.
2.7. i vi ngi bnh lao a khng, cn thc hin chm sc gim nh v h tr tm l x
hi trong v sau qu trnh iu tr.
3. Ch nh v phc iu tr
3.1. Cc thuc chng lao:
Chng trnh Chng lao chu trch nhim cung cp y , lin tc thuc chng lao c
cht lng.
- Thuc chng lao thit yu (hng 1)
Cc thuc chng lao thit yu (hng 1) l: Isoniazid (H), Rifampicin (R), Pyrazinamid
(Z), Streptomycin (S), Ethambutol (E). Ngoi ra,
Hin nay TCYTTG khuyn co b sung 2 loi thuc chng lao hng 1 l Rifabutin
(Rfb) v Rifapentine (Rpt). Cc thuc chng lao thit yu hng 1 cn phi bo qun
trong nhit mt, trnh m.
- Thuc chng lao hng 2:
Cc thuc chng lao hng 2 ch yu c th phn ra thnh cc nhm nh sau:

45
 Thuc chng lao hng 2 loi tim: Kanamycin (Km); Amikacin (Am); Capreomycin
(Cm);
Thuc chng lao hng 2 thuc nhm Fluoroquinolones nh: Levofloxacin (Lfx);
Moxifloxacin (Mfx); Gatifloxacin (Gfx); Ciprofloxacin (Cfx); Ofloxacin (Ofx);
Thuc chng lao hng 2 ung: Ethionamide (Eto); Prothionamide (Pto); Cycloserine
(Cs); Terizidone (Trd); Para-aminosalicylic acid (PAS); Para-aminosalicylate sodium
(PAS-Na);
Cc thuc hng 2 thuc nhm 5 bao gm: Bedaquiline (Bdq); Delamanid (Dlm);
Linezolid (Lzd); Clofazimine (Cfz); Amoxicilline / Clavulanate (Amx / Clv);
Meropenem (Mpm); Thioacetazone (T); Clarithromycin (Clr).
Bng: Phn loi cc thuc chng lao theo nhm
Nhm Thuc Vit tt
Nhm I. Thuc chng lao hng 1 Streptomycin S
Rifampicin R
Isoniazid H
Ethambutol E
Pyrazinamide Z
Rifabutin Rfb
Rifapentine Rpt
Nhm II. Thuc chng lao hng 2 Kanamycin Km
tim Amikacin Am
Capreomycin Cm
Nhm III. Fluoroquinolones Levofloxacin Lfx
Moxifloxacin Mfx
Gatifloxacin Gfx
Nhm IV. Thuc lao hng 2 ung Ethionamide Eto
Prothionamide Pto
Cycloserine Cs
Terizidone Trd
Para-aminosalicylic acid PAS
Para-aminosalicylate sodium PAS-Na
Nhm V. Thuc chng lao hng 2 Bedaquiline Bdq
cha r hiu qu (bao gm c thuc Delamanid Dlm
mi)
46
 Linezolid Lzd
Clofazimine Cfx
Amoxicilline / Clavulanate Amx / Clv
Meropenem Mpm
Thioacetazone T
Clarithromycin Clr

3.2. Ch nh v phc iu tr lao:

Phc IA: 2RHZE(S)/4RHE
- Hng dn:
Giai on tn cng ko di 2 thng, gm 4 loi thuc dng hng ngy.
Giai on duy tr ko di 4 thng, gm 3 loi thuc l R, H v E dng hng ngy.
- Ch nh: cho cc trng hp bnh lao mi ngi ln (cha iu tr lao bao gi hoc
tng iu tr lao nhng di 1 thng). iu tr lao mng tim c th s dng corticosteroid
liu 2mg/kg cn nng v gim dn trong thng u tin.
Phc IB: 2RHZE/4RH
- Hng dn:
Giai on tn cng ko di 2 thng, gm 4 loi thuc dng hng ngy.
Giai on duy tr ko di 4 thng, gm 2 loi thuc l R v H dng hng ngy.
- Ch nh: cho cc trng hp bnh lao mi tr em (cha iu tr lao bao gi hoc
tng iu tr lao nhng di 1 thng). iu tr lao mng tim c th s dng corticosteroid
liu 2mg/kg cn nng v gim dn trong thng u tin.
Phc II: 2SRHZE/1RHZE/5RHE hoc 2SRHZE/1RHZE/5R3H3E3
- Hng dn:
Giai on tn cng ko di 3 thng, 2 thng u tin vi c 5 loi thuc chng lao
thit yu S, H, R, Z, E dng hng ngy, 1 thng tip theo vi 4 loi thuc (HRZE)
dng hng ngy.
Giai on duy tr ko di 5 thng vi 3 loi thuc H, R v E dng hng ngy.
(hoc dng cch qung 3 ln/tun).
- Ch nh:
Cho cc trng hp bnh lao ti pht, tht bi, iu tr li sau b tr, tin s iu tr
khc, khng r tin s iu tr m khng c iu kin lm xt nghim chn on lao
a khng nhanh.

47
 Cho cc trng hp bnh lao ti pht, tht bi, iu tr li sau b tr, tin s iu tr
khc, khng r tin s iu tr c lm xt nghim chn on lao a khng nhanh,
nhng kt qu khng khng a thuc.
Phc III A: 2RHZE/10RHE
- Hng dn:
Giai on tn cng ko di 2 thng, gm 4 loi thuc H, R, Z, E dng hng ngy.
Giai on duy tr ko di 10 thng, gm 3 loi thuc l R, H, E dng hng ngy.
- Ch nh: Lao mng no v lao xng khp ngi ln. iu tr lao mng no c th s
dng corticosteroid liu 2mg/kg cn nng v gim dn trong thng u tin v dng
Streptomycin trong giai on tn cng.
Phc III B: 2RHZE/10RH
- Hng dn:
Giai on tn cng ko di 2 thng, gm 4 loi thuc H, R, Z, E dng hng ngy.
Giai on duy tr ko di 10 thng, gm 2 loi thuc l R, H dng hng ngy.
- Ch nh: Lao mng no v lao xng khp tr em. iu tr lao mng no c th s
dng corticosteroid liu 2mg/kg cn nng v gim dn trong thng u tin v dng
Streptomycin trong giai on tn cng.
Phc IV: Theo hng dn Qun l lao khng thuc
Z E Km(Cm) Lfx Pto Cs (PAS) / Z E Lfx Pto Cs (PAS)
- Hng dn:
Giai on tn cng: 8 thng, gm 6 loi thuc Z E Km (Cm) Lfx Pto Cs (PAS) -
Cm, PAS c s dng thay th cho trng hp khng dung np Km,Cs, dng hng
ngy.
Giai on duy tr dng 5 loi thuc hng ngy.
Tng thi gian iu tr l 20 thng.
- Ch nh: Lao a khng thuc.
Phc c nhn cho ngi bnh lao siu khng thuc
- Hng dn: Theo nguyn tc
S dng Pyrazinamide v cc thuc thuc nhm I cn hiu lc.
S dng mt thuc tim cn nhy cm v c th s dng trong thi gian di (12 thng
hoc trong sut liu trnh). Nu c khng vi tt c cc thuc tim th khuyn co s
dng loi thuc m ngi bnh cha tng s dng hoc khng s dng thuc tim.
Nu ngi bnh c nguy c d ng vi thuc tim c hiu lc, cn nhc vic s dng
theo ng kh dung.
S dng Fluoroquinolone th h sau nh Moxifloxacin hoc Gatifloxacin.
48
 S dng tt c cc thuc nhm IV cha c s dng rng ri trong phc iu tr
trc y c th c hiu lc.
B sung hai hoc nhiu thuc nhm V (xem xt vic b sung Bedaquiline).
Xem xt vic b sung cc thuc c th s dng di dng cu tr khn cp
(compassionate use) nu c TCYTTG ph duyt.
Cn nhc vic s dng Isoniazid liu cao nu kt qu KS khng khng hoc khng
t vi gen kat G.
iu tr lao tim n
- Hng dn:
- Ngi ln: Isoniazid (INH) liu dng 300 mg/ngy, ung mt ln hng ngy trong 9
thng, phi hp Vitamin B6 liu lng 25mg hng ngy.
- Tr em: Isoniazid (INH) liu dng 10 mg/kg/ngy, ung mt ln vo mt gi nht
nh (thng ung trc ba n 1 gi), ung hng ngy trong 6 thng (tng s 180
liu INH).
- Ch nh:
+ Tt c nhng ngi nhim HIV (ngi ln) c sng lc hin khng mc bnh
lao.
+ Tr em di 5 tui v tr 0-14 tui c HIV sng cng nh vi ngi bnh lao phi,
nhng tr ny c xc nh khng mc lao.
3.3. Liu lng thuc chng lao: (xem ph lc 8)
4. iu tr lao cho nhng trng hp c bit
4.1. iu tr lao ph n c thai hoc cho con b
- Cc loi thuc Isoniazid, Rifampicin, Ethambutol v Pyrazinamid, c hp thu d dng
qua ng tiu ha v c kh nng i qua nhau thai. Nn dng vitamin B6 liu 25mg
hng ngy nu c dng INH.
- Kh nng tng nguy c nhim c gan trong khi mang thai v trong 2-3 thng u ca
thi k hu sn.
- Streptomycin c kh nng c cho tai thai nhi, Ethionamide v PAS (gy d tt bm sinh)
khng s dng trong thai k.
- Vic iu tr bnh lao khng thuc, c bit l lao a khng, trong khi mang thai v qun
l chm sc tr s sinh cn phi xem xt cn thn, qun l c hng dn ca thy thuc
chuyn khoa lao l bt buc.
4.2. ang dng thuc trnh thai
Rifampicin tng tc vi thuc trnh thai, lm gim tc dng ca thuc trnh thai. V vy
nu ph n ang ung thuc trnh thai iu tr lao bng phc c c Rifampicin c th
chn mt trong hai gii php: hoc dng thuc trnh thai c cha liu lng Estrogen cao
hn hoc dng bin php trnh thai khc.
49
4.3. Trng hp ngi bnh lao c bnh l gan
4.3.1. Nu ngi bnh c tn thng gan nng t trc
- Phi c iu tr ni tr ti bnh vin v theo di chc nng gan trc v trong qu
trnh iu tr.
- Phc iu tr s do bc s chuyn khoa quyt nh tu kh nng dung np thuc ca
ngi bnh.
- Sau khi ngi bnh dung np thuc tt, men gan khng tng v c p ng tt v lm
sng, c th chuyn iu tr ngoi tr v theo di st.
Ngi bnh lao c bnh gan mn tnh
+ Nu chc nng gan l bnh thng: c th tip tc iu tr v khng cn thit xt
nghim tr khi ngi bnh c triu chng ca nhim c gan.
+ Nu men gan cao t hn 2 ln gii hn trn ca bnh thng v khng km triu
chng nhim c gan, ngi bnh c th c bt u iu tr nhng phi theo di
nh gi triu chng ca nhim c gan v cc ch s men gan hng thng.
+ Nu men gan cao > 2 ln gii hn trn ca mc bnh thng, ngng iu tr lao v
phi tip tc qun l ti bnh vin.
+ Ngi bnh c bnh gan mn tnh khng nn dng Pyrazinamid, Isoniazid v
Rifampicin c th kt hp mt hoc hai loi thuc khng c vi gan nh
Streptomycin v Ethambutol. Hoc kt hp vi mt thuc nhm Fluoroquinilone.
Ngi bnh lao c vim gan cp tnh
Ngi bnh c bnh lao v ng thi bnh vim gan cp tnh (v d nh vim gan
siu vi cp tnh) khng lin quan n lao hoc iu tr lao. nh gi lm sng l cn
thit trong vic a ra quyt nh iu tr. Trong mt s trng hp c th tr hon
vic iu tr lao cho n khi bnh vim gan cp tnh iu tr n nh.
Trong trng hp cn thit phi iu tr bnh lao trong vim gan cp tnh, s kt hp
ca Streptomycin v Ethambutol trong 3 thng u tin l la chn an ton nht. Nu
vim gan n nh, sau ngi bnh c th dng Isoniazid v Rifampicin tip tc
giai on 6 thng. Nu vim gan khng n nh, Streptomycin v Ethambutol nn
tip tc cho tng cng 12 thng. Do , la chn iu tr l 3SE/6RH hoc 12SE.
Hoc c th cn nhc kt hp vi mt thuc nhm Fluoroquinilone (Lfx hoc Mfx).
4.3.2. Trng hp ngi bnh c xc nh c tn thng gan do thuc lao
- Ngng s dng nhng thuc lao gy c cho gan, xem xt s dng thuc
Fluroquinolones nu vic iu tr lao cn thit, iu tr h tr chc nng gan cho n khi
men gan v bnh thng, ht vng da. Cn theo di lm sng v men gan.
- Nu khng p ng hoc c biu hin vim gan do thuc, chuyn n c s chuyn khoa
iu tr. (xem phn pht hin, nh gi v x tr tc dng khng mong mun ca
thuc chng lao).

50
4.4. Ngi bnh lao c suy thn.
Phc 2RHZ/4RH c th p dng iu tr lao cho ngi bnh suy thn. Cc loi thuc
u tay (Rifampicin, Isoniazid, Pyrazinamid) v Ethionamide, Prothionamide hon ton
chuyn ha qua gan, c th c s dng mt cch an ton vi liu bnh thng nhng
ngi bnh c suy thn. Tuy nhin, c th thay i phc iu tr v liu lng khi c suy
thn nng.
Ethionamide/Prothionamide cng c la chn trong phc iu tr ngi bnh a
khng thuc c suy thn (hiu chnh liu khi c suy thn nng).
i vi ngi bnh suy thn nng, chy thn nhn to: Trong suy thn nng hiu
chnh liu thuc lao iu tr l cn thit c tnh theo thanh thi ca creatinin. Isoniazid
i khi gy ra bnh no nhng ngi bnh c suy thn v trong nhng ngy chy thn (b
sung iu tr Pyridoxine ngn chn bnh thn kinh ngoi vi).
Trng hp bnh lao nng nguy c cao, e da tnh mng: la chn li ch v nguy
c, c th la chn Streptomycin v Ethambutol iu chnh liu l cn thit trong suy thn,
liu iu tr c tnh theo thanh thi ca creatinin.
Trong trng hp cn thit phi iu tr lao a khng, vic dng thuc chng lao hng 2
cho ngi bnh suy thn phi ht sc ch liu lng v thi gian gia cc liu.
4.5. Ngi bnh lao mc i tho ng (T)
- iu tr cng ging nh i vi tt c cc ngi bnh khc, ngi bnh T c nguy c
tn thng thn kinh ngoi vi, thuc INH c nguy c cao vim thn kinh ngoi vi, do
nn dng thm Pyridoxine (10-25mg/ngy).
- Kt hp cht ch vi thy thuc chuyn khoa kim sot ng huyt, cc bin chng
ca T. m bo ti u kim sot ng huyt, khi ng huyt n nh theo di
lng ng trong mu hng thng, gio dc ngi bnh tun th iu tr, ch n
ung, hot ng th cht.
- Xem xt n tng tc thuc trong vic kt hp iu tr lao v iu tr T (Rifampicin
vi nhm Sulphonylurea), cn nhc s dng thuc h ng mu bng insulin, nhm
thuc t gy tng tc vi thuc lao: Biguanide (v d: Metformin, khng c tng tc
vi Rifampicin, tuy nhin, Metformin gy tc dng ph n h tiu ha khi kt hp vi
thuc lao v thn trng nhng trng hp suy gan, thn).
4.6. Ngi bnh lao nhim HIV/AIDS
Cc thuc chng lao c tc dng tt vi bnh lao ngi bnh lao/HIV. iu tr lao cho
ngi bnh HIV/AIDS ni chung khng khc bit so vi ngi bnh khng nhim
HIV/AIDS. Khi iu tr cn lu mt s im sau:
- Tin hnh iu tr lao sm ngi HIV c chn on lao.
- Phi hp iu tr thuc chng lao vi iu tr d phng nhim trng c hi khc bng
Cotrimoxazol v ARV cng sm cng tt, ngay sau khi ngi bnh dung np thuc
chng lao (sau 2 tun u tin).

51
- Thn trng khi iu tr phi hp ARV v c hin tng tng tc thuc gia
Rifampicin vi cc thuc c ch men sao chp ngc Non-nucleocide v cc thuc c
ch men Protease.
- Hi chng phc hi min dch c th xy ra mt s ngi bnh nhim HIV iu tr lao
c s dng thuc khng virus biu hin bng cc triu chng lm sng, cn lm sng
nng ln iu tr triu chng, trong trng hp nng c th s dng Corticosteroid vi
liu lng 1mg/kg trong 1-2 tun.
5. Qun l iu tr
5.1. Qun l iu tr ngi bnh lao
- Sau khi c chn on xc nh, ngi bnh cn c ng k qun l iu tr ngay
cng sm cng tt ti mt n v chng lao tuyn huyn v tng ng. Cn b T
chng lao s ng k ngi bnh vo s KT, lp th ngi bnh, lp phiu iu tr c
kim sot theo di (mi ngi bnh s c mt s ng k, th ngi bnh v phiu
iu tr c kim sot), ng thi cn b chng lao huyn t vn cho ngi bnh kin thc
c bn v iu tr lao.
- Sau khi ng k qun l iu tr ti T chng lao ngi bnh c chuyn v x iu
tr, ti trm y t (TYT) x:
ng k ngi bnh vo s Qun l iu tr bnh lao (dng cho tuyn x v n v
tng ng)
Cn b chng lao x (gim st vin 1: GSV1) thc hin iu tr cho ngi bnh: nhn
thuc hng thng t tuyn huyn v cp pht cho ngi bnh 7-10 ngy/ln, ghi chp
phiu iu tr c kim sot, mi ln cp pht thuc l mt ln gim st, khm, t vn
cho ngi bnh
La chn ngi gim st h tr (gim st vin 2: GSV2): c th l cng tc vin
tuyn x nh: nhn vin Y t thn bn, hi vin cc hi, tnh nguyn vin hoc l
ngi thn ngi bnh, vic la chn ngi gim st h tr (GSV2) lm sao cho ph
hp nht vi tng c th ngi bnh, c cam kt tham gia vi y thng tin ca 3
bn: CBYT - Ngi bnh - GSV2
Cn b chng lao tuyn x t vn cch gim st h tr iu tr, kin thc c bn v
bnh lao, hnh thc v tn sut trao i thng tin gim st cho GSV2, vic t vn ny
c th c thc hin thm trong cc chuyn vng gia thm ngi bnh, GSV2 c th
c thay i trong qu trnh iu tr nu thy khng ph hp
CBYT x thc hin vng gia thm ngi bnh theo xc sut, c trng tm, trng
im, u tin thm nhng ngi bnh tin lng kh nng tun th iu tr km
- Nhiu trng hp ngi bnh lao c chn on ti tuyn tnh - iu tr ti tnh mt
thi gian sau mi chuyn v huyn qun l iu tr, mt s ni ngi bnh c iu
tr ni tr mt thi gian ti huyn sau mi chuyn v x iu tr, mt s ni n v
chng lao huyn trc tip qun l iu tr mt s ngi bnh - Nhng trng hp ngi
bnh ny sau khi iu tr ti cc tuyn trn - chuyn v huyn, x qun l iu tr phi
thc hin ng theo quy trnh nu trn
52
- Nhng ngi bnh ang iu tr trong giai on tn cng nu b tr hai ngy lin hoc
giai on duy tr b tr mt tun th cn b y t cn tm ngi bnh v gii thch cho h
quay li iu tr.
- Khi chuyn ngi bnh i ni khc iu tr phi km theo phiu chuyn v cc h s
ngi bnh theo quy nh. Ni nhn ngi bnh phi c phn hi tip nhn cho c s
chuyn ngay sau khi nhn v ng k iu tr tip, c phn hi kt qu iu tr khi kt
thc iu tr cho ni chuyn.
5.2. Qun l iu tr ngi bnh lao a khng
5.2.1. H thng qun l iu tr lao a khng
Qun l lao a khng c c thc hin ti cc n v trong h thng iu tr lao a
khng theo tiu chun v nhim v c th nh sau:
Trung tm iu tr
Tiu chun:
- C nhn lc iu tr ngi bnh lao a khng : c bc s, iu dng, t vn vin
c o to v lao a khng.
- C khoa/phng iu tr dnh ring cho ngi bnh MDR-TB m bo phng chng ly
nhim lao.
- C kh nng nui cy vi khun lao m bo ATSH (c phng xt nghim chun quc
gia (NRL) xc nhn).
- C kh nng chn on vi khun lao khng thuc (c NRL xc nhn).
Nhim v:
- Tm sot ngi nghi ng lao a khng chn on.
- Chn on vi khun lao khng thuc.
- T vn v thu nhn iu tr cho ngi bnh lao a khng ti tnh.
- T vn v thu nhn iu tr thi gian u cho ngi bnh lao a khng ca tnh ln cn
c phn cng.
- Ti khm cho ngi bnh lao a khng ca tnh v tnh ln cn c phn cng.
- Thc hin xt nghim nui cy theo di cho ngi bnh lao a khng ca tnh v tnh ln
cn c phn cng.
im iu tr
Tiu chun:
- C nhn lc iu tr ngi bnh lao a khng: c bc s c o to v lao a
khng.
- C khoa/phng dnh ring iu tr cho ngi bnh MDR-TB m bo phng chng ly
nhim lao.
Nhim v:
53
- Tm sot ngi nghi ng lao a khng chn on.
- Chn on vi khun lao khng thuc hoc vn chuyn mu n im chn on.
- T vn v thu nhn iu tr cho ngi bnh lao a khng ti tnh sau khi nhn kt qu
chn on MDR-TB.
- Ti khm cho ngi bnh lao a khng ca tnh.
- Thu nhn iu tr thi gian u cho ngi bnh lao a khng ca tnh ln cn c phn
cng (nu c).
- Ti khm cho ngi bnh MDR-TB ca tnh ln cn c phn cng (nu c).
Tnh ln cn
Tiu chun:
C kh nng qun l v iu tr ngi bnh lao a khng trong giai on ngoi tr.
Nhim v:
- Tm sot ngi nghi ng lao a khng: ly v vn chuyn mu bnh phm n im
chn on.
- T vn v gi ngi bnh lao a khng n im iu tr/trung tm iu tr theo phn
vng.
- Tip nhn v iu tr tip giai on ngoi tr cho ngi bnh lao a khng ca tnh.
- Ti khm hoc nhc nh ngi bnh lao a khng i khm ng lch.
5.2.2. Qun l iu tr ngi bnh lao a khng:
- Sau khi c chn on xc nh, ngi bnh lao a khng s c ng k qun l iu
tr ni tr ngay cng sm cng tt ti mt trung tm/im iu tr lao a khng
(Nu ngi bnh c pht hin chn on qua xt nghim m chuyn mu cn b
T chng lao qun huyn s mi ngi bnh n t vn, cam kt iu tr - chuyn ngi
bnh ti trung tm/im iu tr. Vi ngi bnh thuc cc tnh ln cn cn b T
chng lao qun huyn s mi ngi bnh n t vn, cam kt iu tr - chuyn ngi
bnh ti Phng Ch o tuyn (CT) BVLBP tnh Phng CT BVLBP tnh ng k v
chuyn tip ngi bnh ti trung tm/im iu tr theo h thng).
- Sau khi iu tr ni tr ti trung tm/im iu tr lao a khng (khong 2 tun) ngi
bnh lao a khng c chuyn iu tr ngoi tr
(iu tr ni tr khong 2 tun theo di dung np, x tr cc phn ng bt li ca
thuc l hnh thc ph bin, tuy nhin, c th iu tr ngoi tr ngay t u cho ngi
bnh ti cc a phng nu c iu kin: gn trung tm iu tr lao a khng, nhn
lc m bo cho vic theo di v gim st ngi bnh mt cch cht ch).
- Nu ngi bnh lao a khng thuc tnh c trung tm/im iu tr: Cn b trung
tm/im iu tr thng bo cho Phng CT - Phng CT thng bo cho T chng lao
qun huyn tip nhn ngi bnh v iu tr ngoi tr v nhn thuc iu tr cho ngi
bnh.
54
- Nu ngi bnh lao a khng thuc tnh ln cn s c chuyn v tnh ln cn thuc h
thng qun l iu tr lao a khng iu tr tip: Cn b trung tm/im iu tr thng
bo cho Phng CT ca BVLBP tnh ln cn Phng CT thng bo cho T chng lao
qun huyn tip nhn ngi bnh v iu tr ngoi tr v nhn thuc iu tr cho ngi
bnh.
- Ti T chng lao qun huyn: ngi bnh c th c qun l iu tr ti T chng lao
hoc c chuyn v x phng qun l iu tr (nu x phng c iu kin). Ti
y, ngi bnh hng ngy n T chng lao/Trm y t dng thuc (6 ngy/tun, tr
Ch nht), cn b T chng lao/Trm y t thc hin iu tr cho ngi bnh, cp nht
phiu iu tr, nhc nh ngi bnh ti khm hng thng ti cc trung tm/im iu
tr/im ti khm.
- Gim st ngi bnh lao a khng: c thc hin bi gim st vin 1 (l cn b T
chng lao huyn/hoc cn b chng lao tuyn x) vi tn sut hng thng n vng gia
thm ngi bnh, ngoi ra cn c thc hin bi gim st vin 2 (l ngi thn ngi
bnh hoc nhn vin y t thn bn): n c, h tr, ng vin ngi bnh dng thuc
hng ngy.
- Trong qu trnh iu tr nu ngi bnh b thuc phi tm n ngi bnh t vn, thuyt
phc ngi bnh quay li iu tr, nu ngi bnh b thuc 3 ngy phi bo co ln
tuyn trn phi hp tm gii php gii quyt.
- Khi chuyn ngi bnh i ni khc iu tr phi km theo phiu chuyn v cc h s
ngi bnh theo quy nh. Ni nhn ngi bnh phi c phn hi tip nhn cho c s
chuyn ngay sau khi nhn ngi bnh v ng k iu tr tip, c phn hi kt qu iu
tr khi kt thc iu tr cho ni chuyn.
6. Theo di iu tr bnh lao
6.1. Theo di iu tr bnh lao
Trong qu trnh iu tr ngi bnh cn c theo di nh sau:
- Ngi bnh cn c theo di kim sot vic dng thuc.
- Theo di nh gi p ng lm sng, Xquang v tc dng ph ca thuc. i vi tr em
phi cn hng thng iu chnh liu thuc theo cn nng.
- Xt nghim m theo di: ngi bnh lao phi cn phi xt nghim m theo di 3 ln
Phc 6 thng: Xt nghim m vo cui thng th 2, 5 v 6.
Phc 8 thng: Xt nghim m vo cui thng th 3, 5,7 (hoc 8).
X tr kt qu xt nghim m theo di
- Vi P I (bao gm c P IA v P IB), m cn AFB(+) cui thng th 2, chuyn
iu tr duy tr, lm xt nghim nhum soi trc tip cui thng th 3. Nu cui thng
th 3 cn AFB(+), cn chuyn m lm Hain test, Xpert MTB/RIF (hoc nui cy v
KS).
- Vi P II, nu AFB (+) cui thng th 3 th chuyn m lm Hain test, Xpert MTB/RIF
(hoc nui cy v KS).
55
- C P I v II, nu AFB(+) cui giai on tn cng th vn chuyn iu tr duy tr m
khng ko di tn cng thm 1 thng nh trc y.
- Lu : bt k thi im iu tr no vi thuc chng lao hng 1, khi xc nh c
chng vi khun lao khng a thuc th ngi bnh cn c ch nh P IV.
6.2. Theo di iu tr bnh lao a khng thuc
Trong qu trnh iu tr ngi bnh lao a khng cn c theo di cht ch nh sau:
- Ngi bnh lao a khng cn c kim sot cht ch vic dng thuc hng ngy (DOT)
trong c liu trnh iu tr.
- Giai on iu tr ni tr: Thm khm lm sng hng ngy ti ging bnh; giai on
iu tr ngoi tr Ti khm hng thng ti trung tm/im iu tr/im ti khm: khm
lm sng, theo di p ng iu tr, theo di bin chng bnh v tc dng ph ca thuc,
kim tra cn nng hng thng, theo di v cc xt nghim, chp Xquang v mt s thm
khm khc.
Theo di xt nghim c th nh sau:
Xt nghim nhum soi m trc tip lm hng thng.
Nui cy: giai on tn cng nui cy hng thng, giai on cng c nui cy hng
qu.
Khng sinh : trc iu tr v lm khng sinh nu ngi bnh c kt qu nui
cy vn dng tnh sau 4 thng iu tr.
Cng thc mu: 2 thng/ln trong giai on tn cng, hng qu trong giai on cng
c.
Chc nng gan: hng thng trong giai on tn cng, hng qu trong giai on cng
c.
Creatinin, Kali: hng thng trong giai on tn cng v hng qu trong giai on cng
c.
Hooc mon tuyn gip (TSH): 6 thng/ln v khi c ch nh.
Xt nghim HIV: trc iu tr v khi cn thit.
Th thai: trc iu tr v bt c khi no c nghi ng.
- Chp Xquang phi: 4 thng/ln trong giai on tn cng, 6 thng/ln trong giai on
cng c.
- o thnh lc trc iu tr v khi c ch nh.
- Soi y mt: trc iu tr v khi c ch nh.

56
 Thi gian biu theo di iu tr

Thng XQ Soi Cy KS SGOT Creatinin HIV TSH o o Thai CTM

SGPT nghn
trc Kali Th Thnh
tip lc
lc

0 X X X X X X X X X X X X
1 X X X X *Kim Nu *Khi * *Khi
tra li TSH c c ch
2 X X X X Theo X
nu bt ch nh
di
3 X X X X thy thn nh
st
cn g th
4 X X X + X X X
thit o
5 X X Nu X X T3,T Khi
cy 4 c ch
6 X X X X X
m nh
7 X X cn X X
(+)
8 X X X X X X X
9 X
10 X
11 X X X X X
12 X
13 X
14 X X X X X X X
15 X
16 X
17 X X X X X
18 X
19 X
20 X X X X X X X

7. nh gi kt qu iu tr
7.1. nh gi kt qu iu tr bnh lao
nh gi kt qu iu tr: (ang p dng hin ti)
i vi Lao phi AFB(+):
Khi: ngi bnh iu tr thi gian v c kt qu xt nghim m m tnh thng
cui cng v t nht 1 ln ngay trc .
Hon thnh iu tr: ngi bnh iu tr thuc, thi gian nhng khng c xt
nghim m hoc ch c xt nghim m 1 ln kt qu m tnh.

57
 Tht bi: ngi bnh xt nghim m cn AFB(+) hoc AFB(+) tr li t thng th
nm tr i hoc ngi bnh c kt qu xc nh chng vi khun khng a thuc bt
k thi im no.
Cht: ngi bnh cht v bt c cn nguyn g trong qu trnh iu tr lao.
B iu tr: ngi bnh b thuc lao lin tc t 2 thng trong qu trnh iu tr.
Chuyn i: ngi bnh c chuyn i ni khc iu tr v c phn hi tip nhn,
(nhng khng c phn hi kt qu iu tr). Nu khng c phn hi tip nhn coi nh
ngi bnh b tr. Cc trng hp c phn hi kt qu iu tr s c nh gi kt
qu iu tr theo kt qu phn hi.
Khng nh gi: nhng ngi bnh ng k iu tr lao nhng v l do no
khng tip tc iu tr cho n khi kt thc phc iu tr (v d: thay i chn on
khc).
i vi ngi bnh lao phi AFB(-) hoc lao ngoi phi:
- Kt qu iu tr s c nh gi nh trn nhng khng c kt qu khi
- Ngi bnh AFB(-) sau 2 thng iu tr c AFB(+), ngi bnh lao ngoi phi xut hin
lao phi AFB(+) sau 2 thng iu tr c nh gi l tht bi.
nh gi kt qu iu tr theo khuyn co mi ca WHO: nh gi sau y ch p dng
khi c biu mu mi
Khi: ngi bnh lao phi c bng chng vi khun hc ti thi im bt u iu tr,
c kt qu xt nghim m trc tip hoc nui cy m tnh thng cui ca qu trnh
iu tr v t nht 1 ln trc .
Hon thnh iu tr: ngi bnh lao hon thnh liu trnh iu tr, khng c bng
chng tht bi, nhng cng khng c xt nghim m trc tip hoc nui cy m tnh
vo thng cui ca qu trnh iu tr v t nht 1 ln trc , bt k khng lm xt
nghim hay khng c kt qu xt nghim.
Tht bi: ngi bnh lao c kt qu xt nghim m trc tip hoc nui cy dng
tnh t thng th 5 tr i ca qu trnh iu tr.
Cht: ngi bnh lao cht do bt c nguyn nhn g trc hoc trong qu trnh iu
tr lao.
Khng theo di c: ngi bnh lao ngng iu tr lin tc t 2 thng tr ln.
Khng nh gi: ngi bnh lao khng c nh gi kt qu iu tr. Bao gm cc
trng hp chuyn ti n v iu tr khc v khng c phn hi kt qu iu tr,
cng nh cc trng hp n v bo co khng bit kt qu iu tr ca ngi bnh.
iu tr thnh cng: tng s khi v hon thnh iu tr.
7.2. nh gi kt qu iu tr lao a khng
Khi: hon thnh liu trnh theo hng dn ca CTCLQG v khng c du hiu tht
bi, ng thi c 3 mu nui cy m tnh lin tip cch nhau t nht 30 ngy trong
58
 giai on duy tr.
Hon thnh iu tr: hon thnh liu trnh theo hng dn ca CTCLQG v khng
c du hiu tht bi, tuy nhin khng y bng chng v 3 mu nui cy m tnh
lin tip cch nhau t nht 30 ngy trong giai on duy tr.
Tht bi: Ngng iu tr hoc thay i vnh vin t nht 2 thuc chng lao trong cng
thc iu tr v cc l do:
o Khng m ha vo cui giai on tn cng (*) hoc,
o Dng tnh tr li trong giai on duy tr sau khi m ha (**) hoc,
o C bng chng khng thm vi Fluoroquinolone hoc thuc tim hng hai,
hoc,
o C phn ng bt li ca thuc (ADRs).
Cht: ngi bnh cht do bt c nguyn nhn no trong qu trnh iu tr lao khng
thuc.
Khng theo di c: ngi bnh ngng iu tr lin tc t 2 thng tr ln do bt c
l do g.
Khng nh gi: ngi bnh khng c nh gi kt qu iu tr (bao gm c cc
trng hp chuyn n n v iu tr khc v cc trng hp khng bit kt qu iu
tr)
iu tr thnh cng: Tng cng ca khi v hon thnh iu tr
(*) m ha nui cy: c t nht 2 mu nui cy m tnh lin tip (cch nhau t nht 30 ngy).
(**) Dng tnh tr li: c t nht 2 mu nui cy dng tnh lin tip (cch nhau t nht 30
ngy) sau khi m ha. Ch s dng kt lun l tht bi nu dng tnh tr li trong
giai on duy tr.

59
 PHT HIN, NH GI, X TR
TC DNG KHNG MONG MUN CA THUC CHNG LAO

1. Cc khi nim c bn
- Tc dng khng mong mun - Phn ng c hi ca thuc (ADR: Adverse Drug
Reaction): Phn ng c hi ca thuc l mt phn ng c hi, khng nh trc v
xut hin liu thng dng cho ngi phng bnh, chn on, cha bnh hoc lm
thay i mt chc nng sinh l (T chc Y t Th gii - WHO).
- Gnh nng do tc dng khng mun ca thuc: Bnh nhn b tr, thay th thuc iu
tr, b bt thuc iu tr hoc thay i phc dn ti ko di liu trnh iu tr, tng
chi ph iu tr hoc gp tht bi iu tr v tnh trng khng thuc gia tng v c th
li di chng nng n
- Tc dng khng mong mun ca thuc lao thng gp: Triu chng tng men gan,
cc biu hin trn da, ri lon tiu ha, au khp, vim dy thn kinh, ri lon tin
nh
- Cc yu t nguy c lm tng tn sut xut hin ADR ngi bnh lao:
Phc iu tr ko di (6 thng n 2 nm), s dng nhiu thuc ng thi (
tng tc thuc), m rng cc phc lao a khng thuc, t l bnh mc km (HIV,
vim gan nghin ru, i tho ng), tnh trng suy dinh dng, ngi bnh khng
tun th iu tr, thi quen t dng thuc ca ngi bnh, hiu bit v kinh nghim
hn ch ca Cn b Y t.
Mt s yu t khc lm tng ADR vi thuc lao: Ln tui tng nguy c tn thng
gan, thn, ung nhiu ru v nghin ru lm tng tn thng gan., tnh trng
dinh dng, suy dinh dng c bit thiu vitamin B1 lm tng tc dng ca thuc
lao vi thn kinh ngoi vi, nhim vi rt nh vim gan, HIV, CMV, EBV lm tng
nguy c gy ra cc phn ng d ng chm vi thuc nh: DRESS, SJS, TEN, tn
thng gan.
2. Phn loi mc tc dng khng mong mun ca thuc lao (WHO):
- Mc 1: Thong qua hoc kh chu nh (<48 gi), khng yu cu can thip y t/liu
php iu tr.
- Mc 2: Gii hn cc hot ng t mc nh n mc trung bnh, c th cn vi s h
tr, khng yu cu hoc yu cu mc ti thiu can thip y t/liu php iu tr.
- Mc 3: Gii hn cc hot ng mt cch ng k, thng yu cu mt vi s h tr,
yu cu can thip y t / liu php iu tr hoc c th nhp vin.
- Mc 4: Gii hn hot ng rt nghim trng, yu cu c s h tr ng k, yu cu
can thip y t / liu php iu tr ng k, yu cu phi nhp vin hoc iu tr cp cu.

60
 3. Mt s tc dng khng mong mun thng gp vi thuc chng lao v hng
x tr

Thuc
Tc dng ph (cn nguyn Hng x tr
chnh)
Loi nh (mc 1-2) Tip tc dng
Bun nn, nn, au bng R Dng thuc lao sau ba n bui ti
Nc tiu hoc da cam R Tip tc dng thuc lao
Cn nhc iu tr Aspirin hoc thuc khng vim khng
Z >> E > H
au khp, sng khp Steroid
(xem thm ph lc 9)
Nga, pht ban ngoi da H<R<Z<E<S C th kt hp iu tr khng histamin.
(mc nh: 1-2)

Loi nng(mc 3-4) Tm ngng thuc hoc ngng v khng s dng li

Sc phn v
tai, chng mt, ic
Suy thn cp R<Km=Am>S thi ca creatinin
H+R>H>> Z>R
Vng da, Vim gan
(loi tr cn nguyn khc)
thuc nghi ng
S Ngng S, x tr Shock phn v, thay bng E, khng
dng li S
S Ngng S, thay bng E
- Tm ngng S (xem ph lc 9)
- Xem xt dng li, hiu chnh thuc lao theo thanh
- Suy thn cp l mt chng ch nh xa ca Km, Am,
S v R
- Ngng thuc nghi ng
- iu tr h tr chc nng gan cho n khi men gan v
bnh thng, ht vng da, th dng li H, Z, R. Theo di
lm sng v men gan. (xem ph lc 9)
- Bnh lao nng c th t vong c tn thng gan: dng
02 loi thuc t c vi gan l S, E hoc kt hp vi mt
thuc nhm Fluoroquinilone (Lfx hoc Mfx). Khi ht
cc biu hin ca tn thng gan th cn nhc tip tc
iu tr bng cc thuc dng.
- Nu khng p ng hoc c biu hin vim gan, theo
di cht ch, tham kho kin ca bc s chuyn khoa
61
 tiu ha khi cn thit.

Xut huyt, thiu mu tan (xem ph lc 9)

huyt, Purpura (vim trt R - Ngng R
da)
- Xut huyt gim tiu cu v thiu mu tan mu l mt
chng ch nh xa ca Rifampicin.
Gim th lc (tr cn E>>H - Ngng thuc nghi ng, cn kim tra th lc.
nguyn khc) - Triu chng ban u s ht nu dng iu tr thuc
nghi ng
- Gim th lc vnh vin c th l hu qu ca vic tip
tc iu tr khi c ADR
ADR trn da mc va - Dng tt c cc thuc n khi ht phn ng (xem ph
v nng (phn ng qu H<R<Z<E<S lc 9)
mn) - Nhn dng thuc gy ADR bng test kch thch
- ADR vn xy ra trong sut qu trnh thay i liu v
thuc gy ADR khng th tip tc dng, th iu tr gii
mn cm. C th kt hp thuc chng d ng: Corticoid,
khng Histamine
4. X tr mt s tc dng khng mong mun do thuc lao
4.1. Ngi bnh lao c tn thng gan do thuc lao
Theo di thng quy cc ch s men gan c bn:
- ngi bnh < 35 tui nu c cc ch s men gan bnh thng v khng c tin s bnh
gan: khng yu cu bt buc theo di cc ch s men gan nh k mi 4 - 6 tun, tr khi
ngi bnh c triu chng biu hin.
- ngi bnh > 35 tui, ngi bnh ung ru hng ngy, c ch s men gan khng bnh
thng hoc c tin s bnh gan: cn theo di cc ch s men gan nh k mi 4-6 tun.
4.1.1. Nguyn nhn
INH+Rifampicin > INH mt mnh >> Pyrazinamid mt mnh > Rifampicin mt mnh >
Ethionamide.
4.1.2. Biu hin lm sng
62
- Triu chng: Chn n, mt mi, bun nn, nn, au bng, au h sn phi, vng da,
vng mt.
- Du hiu: gan to, tng men gan.
4.1.3. X tr
- Ngng s dng thuc lao, iu tr h tr chc nng gan cho n khi men gan v bnh
thng, ht vng da. Cn theo di triu chng nng lin quan n suy gan.
- Nu chc nng gan khng ci thin hoc tin trin nng hn, cn chuyn n c s
chuyn khoa iu tr.
- Chn on phn bit vi vim gan viruts A, B, C., vim gan t min v bnh l ng
mt, cc yu t tim tng lm tng nguy c c tnh trn gan, v d: lm dng ru, tin
s s dng cc thuc c c tnh vi gan.
Cn nhc hng x tr da trn triu chng nhim c gan v tng men gan vi cc
mc sau
a) Men gan tng nh hn 5 ln gii hn trn bnh thng khng km triu chng lm
sng ( loi tr cn nguyn khc v /hoc khng c bnh gan t trc, khng c tin s
lm dng ru hoc cc thuc gy c t bo gan):
- C th xy ra trong cc tun iu tr u tin.
- iu tr h tr chc nng gan. C th khng cn phi ngng thuc hoc thay i iu tr
v men gan c th t tr li mc bnh thng. Nu duy tr s dng thuc chng lao cn
phi theo di cht ch, pht hin cc du hiu gi sm trn lm sng (mt mi, suy
nhc, chn n, bun nn, au bng), xt nghim nh gi chc nng gan sau 3 5 ngy.
b) Men gan tng ln hn 5 ln v di 10 ln gii hn trn bnh thng (c km hoc
khng km triu chng lm sng) hoc ln hn 2,5 ln gii hn trn bnh thng c
km triu chng lm sng:
Cn nhc ngng ton b hoc mt s thuc lao gy c cho t bo gan gm Rifampicin,
Isoniazid, Pyrazinamid, iu tr h tr chc nng gan tch cc, nh gi tnh trng lm
sng chi tit v ton din, xc nh cc yu t tin lng xu: tng bilirubin v ri lon
cc yu t ng mu (nh lng fibrinogen v t l prothrompin).
c) Men gan tng ln hn 10 ln gii hn trn bnh thng:
- Cn phi ngng ton b thuc lao, ngi bnh c iu tr tch cc ti bnh vin, cn
kt hp vi chuyn khoa tiu ha. Nu bilirubin ton phn trong mu huyt thanh tng
km triu chng lm sng nng, cn xem xt mc can thip hoc iu tr bng thuc,
s dng bin php thay huyt tng, iu tr h tr gan tch cc ngi bnh suy gan
cp nng (Bilirubin ton phn > 250 mol/l).
- nh gi lm sng chi tit v ton din, xem xt cc yu t tin lng xu: tng bilirubin
v ri lon cc yu t ng mu (nh lng fibrinogen v t l prothrombin).
4.1.4. La chn phc iu tr lao

63
- Nu mc vim gan c kh nng e da tnh mng v cn nguyn khng phi do virut
hoc ngi bnh mc th lao nng m vic ngng tm thi vic iu tr lao l khng an
ton th cn nhc la chn phc iu tr lao gm cc thuc t c nguy c c vi gan
nh Streptomycin v Ethambutol, hoc kt hp vi mt thuc nhm Fluoroquinilone.
- Nu vic iu tr lao c th tm ngng th nn ch cho cc triu chng lm sng v xt
nghim nh gi chc nng gan v bnh thng, nn tin hnh s dng li cc thuc
chng lao. Thng iu tr t nht 3 thuc khng c vi gan n khi c th xc nh
c nguyn nhn gy vim gan v cn ko di thi gian iu tr cho ph hp. Nn bt
u s dng li tng thuc nghi ng mi thi im sau khi nng men gan gim
xung di 2 ln gii hn bnh thng trn ( ngi bnh c tin s b bnh gan, thi
im khuyn s dng li thuc khi nng men gan gim v gn mc gii hn bnh
thng).
Cc thuc ln lt c cn nhc ch nh s dng li: RMP/INH/PZA nu men gan khng
tng c th sau mi 3 ngy 1 tun iu tr.
Phc iu tr thay th ph thuc vo thuc no c th l nguyn nhn gy vim gan
v phi loi tr khi phc , c th cn nhc la chn phc sau cho ngi bnh
khng mc lao a khng:
- Nu vim gan lin quan n Rifampicin, phc ngh: 2SHE /10 HE.
- Nu khng th s dng INH, cn c cn nhc s dng phc 9 thng gm RMP,
PZA, EMB.
- Nu cn ngng iu tr PZA trong khi cha kt thc giai on tn cng th ko di iu
tr bng RMP, INH ti 9 thng.
- Nu c 2 thuc INH, RMP u khng th s dng li th phc khuyn co phi hp
SM, EMB v mt fluoroquinolon (c th ko di ti 18-24 thng).
4.2. Tc dng khng mong mun trn da mc va n nng (phn ng qu mn)
4.2.1. Biu hin lm sng: Pht ban c th km theo st.
4.2.2. Nguyn nhn: C th gp cc thuc vi mc thng gp xy ra nh sau:
Isoniazid<Rifampicin<Pyrazinamid<Ethionamid<Ethambutol<PAS<Streptomycin
Lu : tr em, tnh trng nhim virut (v d herpes simplex) thng cng gp pht ban nn
c th ln ln vi mt phn ng ca thuc.
4.2.3. X tr
- Trn tr em:
Ngng tt c cc loi thuc ang dng.
Kim tra cn nguyn virus (cc test xt nghim, cng thc mu...).
Nu l cn nguyn do nhim mt loi virus no th tip tc s dng li tt c cc
thuc lao.

64
 Nu loi tr cn nguyn nhim virus th theo di nguyn tc thay i liu ngi
ln, hiu chnh li liu theo tui v cn nng.
- Trn ngi ln:
Dng tt c cc thuc n khi ht phn ng.
4.2.3.1. Ch nh v chng ch nh gii mn cm
* Ch nh gii mn cm:
a) Thuc gy d ng l thuc khng th thay th bng thuc khc trong qu trnh iu tr
(iu tr c hiu).
b) Thuc gy d ng l thuc c hiu qu tt nht cho la chn liu php iu tr (first
line) v d: thuc iu tr lao, Cotrimoxazol cho ngi bnh HIV.
* Chng ch nh gii mn cm:
a) Ngi bnh c nguy c cao bnh phi hp: Hen ph qun (FEV1<70%), ang iu tr
bta blocke, tin s Shock phn v nng v bnh gan thn nng.
b) Chng ch nh tuyt i ngi bnh nng, phn ng c t bo min dch nng
hoc e da mng sng (hi chng Steven- Jhonson), hi chng Lyell, Dress.
4.2.3.2. Nhn dng thuc gy ADR v gii mn cm (xem ph lc 10)
u phi da trn yu t c th tng ngi bnh. Gii mn cm ch nn cn nhc sau
khi nh gi gia yu t nguy c/ li ch.
4.3. Tc dng khng mong mun trn thn
4.3.1. Biu hin:
- au tht lng t ngt, st, gim niu, v niu cp.
- Tng nng creatinin/huyt thanh trong 7-10 ngy u iu tr.
- S thiu ht magie, kali c th xy ra.
4.3.2. Nguyn nhn:
- Thng nguyn nhn gy c trn thn gp Kanamycin= Amikacin>Streptomycin, c
ch gy c l hy t bo ng thn cp.
- Ngoi ra c th gp phn ng suy thn cp do Rifampicin, thng him gp, theo c ch
min dch trung gian.
4.3.3. Yu t nguy c
- Nng Aminoglycosid/huyt thanh cao.
- S dng Aminoglycosid ko di.
- iu tr ngt qung hoc iu tr tht thng Rifampicin.
- S dng ng thi vi cc thuc c c vi thn.
- Bnh gan.

65
 - Tui cao.
- Gim huyt p.
- Gim th tch tun hon.
- C tin s suy gim chc nng thn.
- C bnh thn t trc.
- Ung th.
- i tho ng.
4.3.4. X tr
- Ngng s dng thuc nghi ng.
- Kim sot cc yu t nguy c c lin quan.
- Phc 2RHZ/4RH c th p dng iu tr cho ngi bnh lao c suy thn.
- Suy thn cp l mt chng ch nh xa hn ca Kanamycin, Amikacin, Streptomycin v
Rifampicin.
- Trng hp bnh lao nng nguy c cao, e da tnh mng: cn nhc li ch v nguy c,
c th s dng Streptomycin v Ethambutol, hiu chnh thuc lao theo thanh thi ca
creatinin.
- Trong phc iu tr ngi bnh a khng thuc c suy thn Ethionamide/
Prothionamide cng c u tin la chn (hiu chnh liu khi c suy thn nng).
4.4. au khp
- Tp 1
+ Nguyn nhn: Pyrazinamid >> Ethambutol > Isoniazid.
+ Biu hin lm sng: au khp chn, vai, u gi(thng mc nh).
+ X tr:
Khng bt buc phi dng thuc chng lao.
Liu thp NSAID c th s dng trong trng hp au nh.
Nu cc triu chng vn cn dai dng, cn nhc chuyn n chuyn khoa
xng khp nh gi.
- Tp 2 (b Gout)
Nguyn nhn: Pyrazinamid >> Ethambutol.
Biu hin lm sng:
Triu chng: au v sng cc khp: chn, vai, u gi
Triu chng thng l nng.
Du hiu: tng acid uric mu.
X tr:

66
 Thng thng, khng bt buc phi dng thuc chng lao.
Nu sng khp cp vn tn ti, m thanh ca khp khng t nhin v xt
nghim c tinh th urat th ngh n triu chng ca t gt cp.
iu tr
o S dng mt NSAID: indomethacin 50mg x 3-4 ln/ngy n khi gim bt
au, sau dng 25mg x 3-4 ln/ngy hoc ibuprofen 800mg ngy 3 ln
hoc naproxen 750mg/ln u v sau 250mg mi 8h.
o Colchicin c s dng nh mt tc nhn thay th NSAID
Liu: 0,5-1,2mg/ln u, sau 0,5-0,6mg mi 1-2h n khi au khp
gim hoc c biu hin bun nn, nn hoc tiu chy.
Triu chng au thng ht sau tng liu 4-8mg.
Liu ti a 8mg
S dng Corticoid gim dn liu c th c s dng trong trng hp cn
gt nng.
C th xy ra nhng t ti din trong qu trnh s dng phc c
Pyrazinamid hoc Ethambutol.
Cn nhc s dng d phng bng Colchicin vi liu 0,6mg: 1 - 2 ln/hng
ngy.
Tip tc s dng n khi dng s dng thuc gy triu chng au.
Cn nhc chuyn n chuyn khoa xng khp lng gi t gout cp.
4.5. St do thuc lao
- St do thuc lao thng xut hin li nhng ngi bnh c iu tr vi tun, c
bit ngi bnh c ci thin v vi khun hc v trn hnh nh Xquang. Tuy nhin cn
ch rng: st do bnh lao c th ko di ti 2 thng sau khi bt u iu tr.
- Khng c chun c bit cho ghi nhn du hiu st. Biu hin tng bch cu eosin c th
c hoc khng.
- Cn phn bit nguyn nhn nhim trng, bnh lao ang din bin xu hn, thuc iu tr
lao k cha liu, chn on nhm cn nguyn. St cng c th l biu hin ca hi
chng phc hi min dch (IRIS Immune reconstitution), c bit trn ngi bnh ng
nhim HIV.
- Cn ngng tm thi tt c cc thuc. Biu hin st do thuc s t ht trong vng 24gi
sau khi ngng thuc v s dng li thuc c th thc hin tng t nh phn x tr triu
chng pht ban.

67
 PHNG BNH LAO

1. Cc khi nim c bn
1.1. C ch ly truyn trong bnh lao: Bnh lao l bnh ly truyn qua ng h hp do
ht phi cc ht kh dung trong khng kh c cha vi khun lao, cc ht kh dung c cha vi
khun lao c sinh ra khi ngi mc lao phi trong giai on tin trin ho, khc, ht hi
(ht kh dung c ng knh khong 1 5 micromet bay l lng trong khng kh khong t
vi gi n 24 gi). Kh nng ly lan gim mnh sau iu tr t 2 4 tun, do vy pht hin
v iu sm bnh lao s lm gim ly lan trong cng ng.
1.2. Nhim lao: l tnh trng c vi khun lao trong c th nhng khng sinh trng c do
s khng ch ca h thng min dch, vi khun tn ti trong c th nhng khng hot ng
v c th hot ng sau ny khi sc khng ca c th suy gim. Ngi nhim lao khng
c biu hin lm sng ca bnh lao, s lng vi khun lao t, c th pht hin tnh trng
nhim lao thng qua cc xt nghim min dch hc nh phn ng Mantoux, hoc xt nghim
IGRA (xt nghim trn c s gii phng interferon gamma)
1.3. Bnh lao: Lao l mt bnh truyn nhim do vi khun lao (Mycobacterium tuberculosis)
gy nn. Bnh lao c th gp tt c cc b phn ca c th, trong lao phi l th lao ph
bin nht (chim 80 85%) v l ngun ly chnh cho ngi xung quanh. Ngi bnh c
cc du hiu ca bnh lao, s lng vi khun ngi bnh lao nhiu hn vi s lng vi
khun ngi nhim lao
1.4. Nguy c chuyn t nhim lao sang bnh lao: Khong 10% trong sut cuc i
nhng ngi khe mnh c h thng min dch bnh thng b nhim lao t lc nh s
chuyn thnh bnh lao. Vi nhng ngi suy gim min dch nh ng nhim HIV th nguy
c chuyn t nhim lao sang bnh lao hot ng s tng ln rt cao, khong 10% /nm
1.5. Mt s yu t lin quan n s ly truyn bnh lao:
- S tp trung ca cc ht kh dung trong khng kh b chi phi bi s lng vi khun
do ngi bnh ho khc ra v s thng kh ti khu vc phi nhim.
- Thi gian tip xc vi cc ht kh dung b nhim vi khun lao
- Trng thi gn vi ngun cc ht kh dung mang vi khun lao
- H thng min dch suy gim: HIV, tiu ng, v suy dinh dng
- Nhng ngi s dng thuc l, ru c th lm gia tng nguy c nhim lao v bnh
lao.
- Cc yu t mi trng: Khng gian cht hp, thng kh khng y , ti lu thng
khng kh c cha cc ht kh dung cha vi khun lao
2. Phng bnh lao
Phng bnh lao l p dng cc bin php nhm:
Gim nguy c nhim vi khun lao

68
 Gim nguy c chuyn t nhim lao sang bnh lao
2.1. Gim nguy c nhim vi khun lao
Kim sot nhim khun lao l s kt hp cc bin php nhm hn ch ti thiu nguy c lan
truyn ca bnh lao trong cng ng.
2.1.1. Kim sot v sinh mi trng
- Gim m cc ht nhim khun trong khng kh bng thng gi tt:
+ Ca i v ca s ca bung khm, khu ch v bung bnh cn c m cho thng
gi t nhin hoc dng qut in ng chiu lm long cc ht nhim khun v
y vi khun ra ngoi, di nh nng mt tri vi khun lao s d b tiu dit.
+ B tr v tr lm vic hp l theo chiu thng gi: Khng khng kh i t ngi
bnh n cn b y t. (S bung khm bnh xem ph lc 15)
- Thay i hnh vi ca ngi bnh (v sinh h hp) nhm lm gim cc ht nhim khun
ra mi trng:
+ Dng khu trang hoc t nht c khn che ming khi tip xc ni chuyn vi ngi
khc (cn b y t), khi ht hi, ho.
+ Khc m vo giy hoc ca cc, b ng ni quy nh, ra tay x phng thng
xuyn.
+ Ly m xt nghim ng ni quy nh, tt nht l ngoi tri, mi trng thng
thong. Nu khng, cn ni c thng gi tt, t kh nng tip xc ca nhn vin y t
v ngi khc. Khng nn t ni ly m nhng phng nh ng kn hoc nh v
sinh.
2.1.2. S dng phng tin phng h c nhn cho nhn vin y t
Khu trang thng thng t c tc dng bo v nhim vi khun lao. Nhng ni c nguy c
ly nhim cao cn eo khu trang bo v h hp t tiu chun nh loi N95 hoc tng
ng tr ln.
2.1.3. Gim tip xc ngun ly
- Cch ly: Nn c ni chm sc iu tr ring cho ngi bnh lao phi AFB (+), c bit
vi ngi bnh lao a khng thuc.
- Trong cc c s c bit nh tri giam, c s cai nghin, c s gio dc, trng gio
dng, c s bo tr x hi c kh nng ly nhim rt cao, cn cch ly tha ng nhng
ngi bnh iu tr mi trnh c cc v dch nghim trng.
- Nhn vin y t cn tun th quy trnh khm, chm sc ngi bnh: khi khm, hi bnh,
thc hin t vn ngi bnh quay lng li. Thn thin qua hnh ng, c ch, li ni
ch khng nht thit phi tip xc trc tip.
- bo v cho ngi nhim HIV n khm: cn xc nh nhng ngi nghi lao (ho khc)
hng dn h dng khu trang, giy che ming, chuyn n khu ch ring hoc phng
cch ly (nu c) v u tin khm trc gim thi gian tip xc.

69
2.2. Gim nguy c chuyn t nhim lao sang bnh lao
2.2.1. Tim vc xin BCG (Bacille Calmette-Gurin): do Chng trnh Tim chng m rng
thc hin nhm gip cho c th hnh thnh min dch chng li bnh lao khi b nhim lao.
c tc dng cn:
- Tim ng k thut, ng liu lng
- Vacxin phi c bo qun ng, m bo cht lng trong ton b dy truyn n tng
liu s dng cho tr
Ch nh tim vacxin BCG:
- i vi tr khng nhim HIV c tin hnh cho tr s sinh v tr di 1 tui
- i vi tr nhim HIV khng c triu chng ca bnh HIV/AIDS
Chng ch nh tuyt i:
- Tr suy gim min dch bm sinh
- Nhim HIV c triu chng lm sng ca bnh HIV/AIDS
Chng ch nh tng i:
- Tr non thiu thng.
- ang nhim khun cp tnh.
- Sau mt bnh cp tnh, nhim virus cm, si.
Liu lng v phng php:
- ng tim: Tim trong da
- Liu lng: 0,05mg tng ng 1/10ml dung dch, ti v tr tim ni vt sn ng knh
4-5mm
- V tr tim: Vng gia 1/3 trn v 2/3 di, mt ngoi chch sau cnh tay tri, pha di
vng c delta
Din bin: Sau khong 3 n 4 tun ti ch tim s c mt nt sng nh, r dch trong vi
tun ri kn ming ng vy. Khi vy rng s li mt so nh, mu trng, c th hi lm
Bin chng tim BCG:
- Nt lot to (ng knh 5 8 mm) lm m v ko di, c th dng dung dch Isoniazid
(INH) 1%, bt Isoniazid (INH) hoc Rifampicin ti ch
- Vim hch: t l di 1%, thng xut hin trong 6 thng sau tim, sng hch nch hoc
hch thng n cng bn tim, hch mm, di ng, sng chm v v, c th r ko di
trong vi thng ri lnh t nhin. Khi hch nhuyn ha c th chch v ra sch, rc bt
Isoniazid (INH) hoc Rifampicin ti ch. Khng cn dng thuc chng lao ng lao
ton thn.
- nhng tr pht trin thnh bnh BCG th cn nh gi tnh trng min dch v iu tr
thuc lao hng th nht (tr Pyrazinamid) v c th iu tr phu thut phi hp.

70
2.2.2. iu tr lao tim n bng INH:
- i tng:
+ Tt c nhng ngi nhim HIV (ngi ln) c sng lc hin khng mc bnh
lao.
+ Tr em di 5 tui v tr 0-14 tui c HIV sng cng nh vi ngi bnh lao phi,
nhng tr ny c xc nh khng mc lao.
- Phc :
+ Ngi ln: Isoniazid (INH) liu dng 300 mg/ngy, ung mt ln hng ngy trong 9
thng, phi hp Vitamin B6 liu lng 25mg hng ngy.
+ Tr em: Isoniazid (INH) liu dng 10 mg/kg/ngy, ung mt ln vo mt gi nht
nh (thng ung trc ba n 1 gi), ung hng ngy trong 6 thng (tng s 180
liu INH).
- Theo di nh gi:
i vi ngi ln:
Cp thuc hng thng v nh gi vic dng thuc t nht 01 thng/ln. Nu ngi bnh
b tr, s liu b tr t hn 50% tng liu th c th b sung cho . Nu s liu b qu
50% tng liu th nn bt u iu tr t u sau b tr
i vi tr em:
+ Ti khm 1ln/thng. Khi ti khm phi cn tr, nh gi s tun th iu tr v tm
du hiu tc dng ngoi mun ca thuc lao nh: vng da, vng mt,
+ iu chnh liu iu tr theo cn nng hng thng
+ Nu tr xut hin cc triu chng nghi lao trong khi ang iu tr lao tim n, chuyn
tr ln tuyn qun/huyn khm pht hin bnh lao. Nu xc nh tr khng mc lao,
tip tc iu tr liu trnh.
+ Nu tr b thuc lin tc trn 2 thng, mun tip tc phi ng k iu tr li t u.
nh gi kt qu lao tim n tr em:
+ Hon thnh iu tr: ung thuc 6 thng lin tc hoc ung 180 liu thuc INH
trong thi gian khng qu 9 thng.
+ B iu tr l khng ung thuc lin tc t 2 thng tr ln.
- Tc dng ph:
+ Nh: Vim thn kinh ngoi vi. X l bng Vitamin B6 liu lng 100mg/ngy
+ Nng: tn thng gan (vng da, chn n, men gan tng cao). X tr: ngng INH v
chuyn n cc c s y t iu tr.
3. Thc hin phng ly nhim trong c s y t
Cc c s y t phi thc hin y Quy ch kim sot nhim khun bnh vin v Hng
dn kim sot ly nhim lao ti cc c s y t
71
- Lnh o cn quan tm, c k hoch, quy trnh v phn cng ngi ph trch d phng
ly nhim lao ti n v. cn u t thch hp cc iu kin cn thit phc v k hoch v
quy trnh d phng ly nhim cho nhn vin y t v cho ngi bnh ti n v.
- K hoch v quy trnh cn c ph bin rng ri cho nhn vin t cc bc qun l
ngi bnh, ly bnh phm, tun th quy trnh v sinh v phi c cng khai di dng
bng biu, bin bo d thy, d thc hin v khuyn khch mi nhn vin tham gia kim
tra gim st, gp .
- nh k, ngi ph trch d phng ly nhim bo co vi lnh o v thc hin k
hoch v tham mu v cc im cn thc hin ci thin cht lng cng tc d phng
ly nhim trong n v.
4. D phng ly nhim h gia nh
- Ngi bnh phi tun th iu tr lao theo ng hng dn ca thy thuc t hiu
qu iu tr, trnh nguy c ly nhim (c bit l khi cn ho khc ra vi khun lao, c xt
nghim m AFB dng tnh)
- Trnh ly nhim lao cho ngi xung quanh:
+ Dng khu trang hoc t nht c khn che ming khi tip xc ni chuyn vi ngi
khc, khi ht hi, ho.
+ Khng khc nh ba bi, khc m vo khn giy ri t, ra tay x phng thng
xuyn.
- m bo v sinh mi trng ni ca ngi bnh: Thng kh t nhin (ca ra vo, ca
s, thong), c nh nng.
- Thng xuyn phi nng dng c nhn, chiu, chn, mn.

72
 PH LC
PH LC 1
HNG DN LY M LM XT NGHIM

m ly t tn thng trong phi Khng khc m t mi hoc ming

Vn cht np

1. Ht vo tht su
2. Th ra tht mnh
3. Ht vo tht su, th ra tht mnh (ln 2)
4. Ht su, th mnh ln 3, ho khc tht su t trong phi
5. t cc m ( m np) vo st ming, nh m vo y cc. Vn cht np.
6. Np cc m v phiu xt nghim cho ngi hng dn (NVYT). Khng t
cc m ln phiu xt nghim.
Lu : Nu lng m qu t (< 2ml) v khng c cht nhy m, lm li cc
bc trn c mu m t cht lng.

Bnh phm m Bnh phm m

Bnh phm m

t tiu chun t tiu chun khng t tiu chun

m t tiu chun s chn on bnh chnh xc!

73
 PH LC 2
S quy trnh chn on lao phi AFB(-)
Tt c cc ngi bnh nghi lao

Xt nghim m tm AFB Chp Xquang phi

Kt qu m tnh 2 mu m

C triu chng nghi lao iu tr khng sinh ph rng,

(khng dng thuc chng lao v nhm Fluoquinolone)

Triu chng khng Triu chng

thuyn gim thuyn gim

Xt nghim li 2
mu m

1 mu C 2 mu
dng tnh vn m tnh

Lao phi AFB(+) Lao phi AFB(-) Bnh h hp khng lao

Xquang phi v Hi chn thy thuc

Chuyn khoa, cc XN h tr
Lu : iu tr th bng khng sinh ph rng khi cc triu chng nghi lao (ho khc m ko di, st tht
thng) cn tn ti. Khng s dng nhm Fluoquinolone v nhm thuc ny c tc dng vi vi khun lao
do vy khng phn bit c gia vim do lao hay vi khun khc. Nu quyt nh iu tr lao cn iu tr
ht cng thc v thi gian tun th nguyn tc c kim sot trc tip.

74
 PH LC 3
S chn on lao khng thuc
(p dng trn cc i tng nghi lao khng thuc)
Nghi MDR

Xpert MTB/RIF

TB+/R+ TB+/R- TB-/R- TB+/R cha xc Bo li

nh

iu tr phc 4 iu tr
Hain test hng 1 v 2 lao phc Hi chn
KS hng 1 v 2 I, II,
Nhc li Gene
Xpert

iu chnh phc da vo
kt qu KS

Phc MDR-TB Phc Pre XDR

hoc XDR-TB

Khng m ha m sau 4 thng

KS hng hai chn

on XDR 75
 PH LC 4
S quy trnh chn on lao phi ngi HIV(+) khng c du hiu nng
NGI NHIM HIV NGHI LAO v KHNG C DU HIU NGUY HIM a

Xt nghim m tm AFB
Chp Xquang phi

AFB dng tnhb AFB m tnhc

iu tr lao, CPTd C kh nng Cy mf, GeneXpert,nh

iu tr ARV mclao gi lm sng, Xquang

t kh nng mc lao

iu tr PCP h iu tr khng sinh ph rng g

nh gi HIVe CPTd,nh gi HIVe

p ngj Khng/t p ng p ngj

nh gi li chn on lao

Ch thch:
a Ngi bnh n khng c du hiu nng (t i li c, khng kh th, khng st cao, mch
di 120/pht).
b Lao phi AFB(+) khi c t nht mt ln dng tnh,
c AFB m tnh khi c 2 mu m AFB(-).
d CPT: iu tr d phng bng Cotrimoxazol.
e nh gi HIV bao gm: phn loi lm sng, xt nghim m CD4 v xem xt iu tr
HIV/AIDS (bao gm c ART).
f Ch mt s ni c iu kin nui cy. Phim chp X-quang sn c t ln khm u tin,
nu c phim chp cc ln trc y so snh cng tt. Ngi bnh c nh gi k v
lm sng v X-quang phi chn on xc nh hoc loi tr.
g Khng sinh ph rng (tr nhm Quinolon)
h PCP: Vim phi do Pneumocystis carinii cn gi l Pneumocystis jiroveci
i nh gi li theo quy trnh nu triu chng ti xut hin.
76
 PH LC 5
S quy trnh chn on lao phi ngi HIV (+) c du hiu nng

NGI NHIM HIV NGHI LAO v C DU HIU NGUY HIM a

Chuyn ln tuyn trn Khng th chuyn ngay

Khng sinh tim ph rngb Khng sinh tim ph rngb

XN AFB v cy m, iu tr PCP
Xquang phiC XN AFB, Xquang phic

Khng lao Lao AFB dngd AFB md

Chm sc, iu tr lao/HIV Ci thin sau 3- Khng ci thin

5 ngy sau 3-5 ngy

Lng gi li Kh nng nh gi li kh Bt uiu trlao

cc bnh lin khng mc lao nng chn on Kt thc khng sinh
quanHIV laoe Chuyn chm sc
iu tr lao /HIV

Ch thch:
a Du hiu nguy him bao gm mt trong cc du hiu sau: nhp th >30/pht, st
>39oC, mch >120/pht v khng t i li c.
b Khng sinh ph rng tr nhm Quinolon.
c Cc xt nghim ny cn c thc hin sm tng tc chn on.
d AFB dng tnh c xc nh khi c t nht mt ln dng tnh, AFB m tnh - khi
c 2 hay nhiu hn cc mu AFB m tnh.
e Lng gi li lao bao gm xt nghim AFB v lng gi lm sng.

77
 PH LC 6

S HNG DN QUY TRNH CHN ON

BNH LAO PHI TR EM

Tr c triu chng h hp nghi ng lao phi

XN bnh phm: AFB(-) hoc khng XN AFB (+)

Chn on lm sng: - Hin ti c tip xc vi ngun ly (hoc c tin s

TX vi ngun ly trong vng 1 nm tr li). IU TR LAO
- Triu chng h hp nghi ng lao phi v XN HIV
- Xquang phi gi bnh lao phi

Chn on lao nu c t nht hai du hiu

Nu ch c mt trong ba du hiu trn
trn

Nu tr m, cho nhp vin c Nu tr khe, khm li sau 2-4

tip tc theo di tun

Tuyn qun/huyn c th p dng s ny chn on bnh lao tr em

78
 PH LC 7
S HNG DN QUY TRNH CHN ON
BNH LAO TR EM
C triu chng lm sngnghi lao phi, hoc
lao ngoi phi Mi ln khm cn lu
- C th chn on bnh khc
- Cn vo vin ngay hoc chuyn tuyn trn (1)

XN khng c bng chng VK/khng xn XN c bng chng vi khun

C tin s tip xc vi ngun ly trong vng

1 nm tr li (hoc lu hn vi lao Ng.ph).

Khng

Hnh nh tn thng Xquang

nghi lao
C

KHNG IU TR LAO v XN
C HIV

- Khm li theo quy nh

- Chuyn ngi bnh ln tuyn
Cn nhc cc chn on khc hoc trn nu bnh p ng km sau
Khm li sau 2 tun 2 thng iu tr lao

(1) Cc du hiu cn nhp vin

- Cc th lao phi v lao ngoi phi nng (Lao k, lao mng no, lao mng tim...).
- Suy dinh dng nng.
- Cc bnh kt hp khc nh thiu mu nng, vim gan, suy thn.
- Suy h hp, hn m.
(1) Cn xem xt chuyn ngi bnh nu:
- Khng chc chn vi chn on,.
- Cn c chm sc lin quan n HIV.
- Ngi bnh nng ln hoc c bin chng do lao hoc do thuc.

79
 PH LC 8
Liu lng thuc chng lao
Bng 1. Liu lng cc thuc chng lao theo cn nng

Hng ngy cho ngi ln Hng ngy cho tr em (*)

Loi Liu lng (khong cch liu) Liu lng (khong cch liu) tnh
Thuc tnh theo mg/kg cn nng theo mg/kg cn nng

Isoniazid 5 (4-6) Ti a 300mg 10 (1015) Ti a 300mg

Rifampicin 10 (8-12) 15 (1020)
Pyrazinamid 25 (20-30) 35 (3040)
Ethambutol 15 (15-20) 20 (1525)
Streptomycin 15 (12-18)
(*) Tr em c cn nng t 25kg tr ln dng thuc theo thang cn nng ca ngi ln
Bng 2. S lng vin, l thuc n l dng hng ngy cho ngi ln theo cn nng

Cn nng ca ngi bnh (kg)

25-39 40-54 55-70 >70
Giai on tn cng hng ngy S lng vin hoc l
H 100 mg (vin) 2 3 3 3
R 150 mg (vin) 2 3 4 5
Z 400 mg (vin) 2 3 4 5
E 400 mg (vin) 2 2 3 4
S 1g (l) 0,5 0,75 1 1
Giai on duy tr hng ngy
H 100mg (vin) 2 3 3 3
R 150 mg (vin) 2 3 4 5
E 400 mg(vin) 2 2 3 4
Giai on duy tr tun 3 ln
H 300 mg(vin) 1 2 2 3
R 150 mg(vin) 2 3 4 5
E 400mg(vin) 2 4 6 6
80
Bng 3. S vin hn hp liu c nh dng hng ngy cho ngi ln theo cn nng

Cn nng (kg)
Thuc hn hp liu c nh
25-39 kg 40-54 kg 55-70 kg >70 kg
Giai on tn cng hng ngy Svin

HRZE (vin) 2 3 4 5
(75mg+150mg+400mg+275mg)
HRZ (vin) 2 3 4 5
(75mg+150mg+400mg)

Giai on duy tr hng ngy

HR (75mg+150mg), vin 2 3 4 5
HE (150mg + 400mg), vin 1,5 2 3 3
Giai on duy tr - tun 3 ln
HR (150mg + 100mg) (vin)
2 3 4 5
HR (150mg + 150mg) (vin)

81
 PH LC 9
Phn loi mc nghim trng v hng x tr tc dng khng mong mun
ca thuc lao

ADR Thng s cn Mc 1 Mc 2 Mc 3 Mc 4
lm sng (nh ) (va) (nng) (nng e tnh
mng)
Gii hn hot
Cc biu hin Hot ng ca
Hot ng ca ng ca ngi
thong qua ngi bnh b hn
ngi bnh c b bnh rt nghim
hoc nh, hot ch ng k,
hn ch t nh n trng, c s h
ng ca thng cn n s
trung bnh, c th tr ng k can
ngi bnh tr gip, i hi
cn n mt vi s thip y t / liu
khng b hn can thip hoc
tr gip, khng yu php iu tr ng
ch, khng i iu tr bng
cu can thip iu k, yu cu phi
hi phi can thuc, c th phi
tr, hoc can thip nhp
thip hoc iu nhp vin
v iu tr mc vin hoc iu tr
tr bng thuc ti thiu cp cu, tch cc.
Hgb 80-94 g/l 70-79 g/l 65-69g/l <65 g/l
Gim tiu cu 100.000 50.000 25.000 < 25.000/mm
Gim tiu
124.999/mm 99.999/mm 49.999/mm
cu, thiu
mu tn Gim bch 2.000 1.500 1.999/mm 1.000 1.400/mm <1.000/mm
huyt, cu 2.500/mm
gim bch
Gim 1 -2 g/l 0,75 0,99 g/l 0,5 0,74 g/l < 0,5g/l
cu, ri
fibrinogen
lon ng
mu Gim 1,1 1,25 ln 1,26- 1,5 ln bnh 1,51 3,0 ln >3,0 ln bnh
Prothrombin bnh thng thng bnh thng thng
(PT)
1,25-2,5 ln
>2,5-5,0 ln gii >5,0-10,0 ln gii >10,0 ln gii
Tng AST AST (SGOT) gii hn bnh
hn bnh thng hn bnh thng hn bnh thng
thng
1,25-2,5 ln
>2,5-5,0 ln gii >5,0-10,0 ln gii >10,0 ln gii
Tng ALT ALT (SGPT) gii hn bnh
hn bnh thng hn bnh thng hn bnh thng
thng
1,25-2,5 ln
>2,5-5,0 ln gii >5,0-10,0 ln gii >10,0 ln gii
Tng GGT GGT gii hn bnh
hn bnh thng hn bnh thng hn bnh thng
thng

Tng >1,0-1,5 ln
>1,5-2,5 ln gii >2,5-5 ln gii hn >5,0 ln gii hn
bilirubin Bilirubin gii hn bnh
huyt thanh hn bnh thng bnh thng bnh thng
thng

82
 >1,0-1,5 ln
Tng >1,5-3,0 ln gii >3,0-6,0 ln gii >6,0 ln gii hn
Creatinine gii hn bnh
creatinine hn bnh thng hn bnh thng bnh thng
thng
3,0-3,4 meq/l 2,5-2,9 meq/l 2,0-2,4 meq/l <2,0 meq/l
H Kali hoc
Kali hoc hoc hoc
mu
3,0-3,4 mmol/l 2,5-2,9 mmol/l 2,0-2,4 mmol/l <2,0 mmol/l
ADR Thng s Mc 1 Mc 2 Mc 3 Mc 4
lm sng (nh ) (va) (nng) (nng e tnh
mng)

Bun nn Nh hoc Kh chu va phi, Lng nc u Yu cu nhp

thong qua, lng nc vo vo khng ng vin
duy tr lng gim ng k, hn k, yu cu truyn
nc vo hp ch mt s hot dch tnh mch
l ng
Nn 1 ln trong 24h 2-5 ln trong 24h >6 ln trong 24h Hu qu sinh l
hoc cn truyn yu cu nhp vin
dch tnh mch hoc yu cu dinh
dng ngoi rut
Tiu ha
Tiu chy Nh hoc Va phi hoc dai >7 ln, phn Sc h huyt p
thong qua: 3- dng: 5-7 ln, phn lng/ngy hoc hoc hu qu sinh
4 ln, phn lng/ngy hoc tiu tiu chy mu l, yu cu nhp
lng/ngy hoc chy ko di trn 1 hoc h huyt p vin
tiu chy nh tun t th hoc mt
ko di < 1 cn bng in gii
tun hoc yu cu
truyn dch tnh
mch > 2 ln
Lo u va phi Thay i tm trng Ri lon tm thn
nng, yu cu iu
Lo u nh hoc hoc trm cm, yu cp tnh, yu cu
Bnh tm
Tm thn cu iu tr, thay tr, hoc nh t nhp vin, hoc
thn trm cm
i trong sinh hot t, nh gy g c ch/c gng t
bnh thng t hoc o gic
au nh khng au va phi, mt au nng, au au khng lm g
gy nh hng cm gic v/hoc v/hoc mt cm c
ti chc nng au nh hng ti gic lm nh
au khp chc nng nhng hng ti hot
Xng khng nh hng ng sng thng
khp ti hot ng sng ngy
thng ngy
au nh vi au va phi vi au nng vi Cng v/hoc
vim, ban vim, ban hoc vim, ban hoc mt kh nng vn
83
 hoc sng sng khp, nh sng khp, nh ng khp.
khp nhng hng ti chc hng ti hot
khng nh nng nhng khng ng sng thng
Vim khp hng ti chc nh hng ti hot ngy
nng ng sng thng
ngy
Phn ng Ban chm khu Ban chm, nt sn Ban chm, nt sn Cc tn thng
ca da- ni tr ri rc hoc ban ri rc hoc ban lan rng hoc
ban dng si dng si vi cc ton thn hoc
nt phng nc hi chng
hoc tn thng Stevens- Jhonson,
lot b mt ca hoc hi chng
nim mc gii hn Lyell, DRESS,
ti mt v tr AGEP...

Phn ng d Ni my ay Ni my ay khu Ni my ay ton Shock phn v

Phn ng
ng ton thn khu tr nhng tr nhng cn ch thn hoc ph hoc co tht ph
d ng
cp tnh khng cn ch nh can thip y mch cn ch nh qun nng e da
nh can thip khoa hoc ph can thip y khoa tnh mng hoc
y khoa mch nh khng hoc b co tht ph ph thanh qun,
cn ch nh can qun nh tn thng vim
thip y khoa cu thn/ hi
chng thn h,
vin mch, Lupus
St 37,70C- 38,60C 38,8 0C - 39,30C 39,40C 40,50C >40,50C

84
 PH LC 10
Nhn dng thuc gy tc dng khng mong mun v gii mn cm
Nhn dng thuc gy ADR: Bt u s dng li tng thuc mi 4 ngy (cn nhc tham kho liu
th thch theo khuyn co bng1)
Bng 1:
Hng dn th thch liu
Thuc Liu th thch
Ngy 1 Ngy 2
Isoniazid 50mg 300mg
Rifampicin 75mg 300mg
Pyrazinamid 250mg 1g
Ethionamid 125mg 375mg
Cycloserin 125mg 250mg
Ethambutol 100mg 500mg
PAS 1g 5g
- Bt u vi INH liu 50mg s dng trong ngy u, nu cc biu hin ADR nng ln th
bt u thay i liu bng 1/10 liu ca ngy 1 nh lit k bng 1 (v d: INH 5mg).
- Nu ADR khng xy ra sau s dng liu ngy u tin th tng liu INH ln 300mg
ngy th 2.
- Nu ADR khng xy ra sau ngy dng thuc th 2 th tip tc s dng INH liu 300mg
mi ngy tip theo.
- Tip tc thm cc thuc khc theo nguyn tc v liu l thuyt nh bng 1 sau mi 4
ngy.
Nu cc triu chng ADR nng ln, bt u liu thay i bng 1/10 liu ca ngy 1
nh lit k bng 1.
Nu liu ngy th 2 thp hn liu khuyn co da trn cn nng ca ngi bnh th
tng liu tng ng ngy th 3.
- Nu nh ADR vn xy ra trong sut qu trnh thay i liu v thuc gy ADR khng th
tip tc dng, th vic gii mn cm thuc l cn thit. Vi thuc chng lao tim vic gii
mn cm ch thc hin sau khi nhn bit thuc gy d ng bng test kch thch (Drug
Provocation Test: DPT).

85
Gii mn cm ch nn cn nhc sau khi nh gi gia yu t nguy c/ li ch v c
bit lu yu t c th trn tng ngi bnh.
Ch nh:
Thuc gy d ng l thuc khng th thay th bng thuc khc trong qu trnh iu tr
(iu tr c hiu).
Thuc gy d ng l thuc c hiu qu tt nht cho la chn liu php iu tr (first
line) v d: Thuc iu tr lao, Cotrimoxazol cho ngi bnh HIV).
Chng ch nh:
Ngi bnh c nguy c cao bnh phi hp: Hen ph qun (FEV1<70%), tin s
Shock phn v nng v bnh gan thn nng.
Chng ch nh tuyt i ngi bnh nng, phn ng c t bo min dch nng
hoc e da mng sng (hi chng Steven - Jhonson), hi chng Lyell, Dress.
Phng php gii mn cm:
Liu khi u thp hn 1/10 liu iu tr hoc thp hn liu thp nht gy phn ng
d ng.
Thng thng l 1/10.000 1/100 liu iu tr.
i vi ngi bnh c tin s Hen ph qun: 1/1.000.000 1/10.000.
Tng liu gp i sau mi 15 20 pht, ko di vi gi cho n khi t liu iu tr.
Mt s cch gii mn cm thng c s dng hin nay:
- Cch thng dng:
Khi u vi liu nh liu ngy th nht c lit k trong Bng 1.
Nu c phn ng xy ra trong ngy u tin sau s dng thuc ny th bt u gii
mn cm vi liu bng 1/10 liu ngy u.
Mi ngy tng liu ln gp i (dng 2 ln/ngy) cho n khi t c liu khuyn
co s dng.
Duy tr liu khuyn co (2 ln/ngy) ny trong 3 ngy, sau s dng tng liu l 1
ln/ngy (v d: duy tr 3 ngy liu INH 150mg x 2ln/ngy x 3 ngy, sau tip tc
iu tr cc ngy sau l 300mg/1 ln mi ngy).
Nu phn ng pht trin trong sut thi gian gii mn cm th gim liu n liu cao
nht trc kia m khng gy ra phn ng v bt u tng dn tng lng nh liu.
- Gii mn cm nhanh: To ra tnh trng dung np thuc tm thi vi thuc gy ra phn
ng qu mn. Nhc li tng liu nh v tng dn liu d nguyn gy d ng v sau mi
khong thi gian c nh v thc hin liu v khong cch tng liu da trn lng gi triu
chng tng c th ngi bnh. Gii mn cm ch nn thc hin theo m hnh mt (mt y
t, mt BN), c kinh nghim cp cu v y phng tin cp cu.

86
 Gii mn cm nhanh vi INH tham kho theo bng di, thc hin liu v khong cch
tng liu da trn lng gi triu chng tng c th ngi bnh.
Thi gian Liu (mg)
8:00 0.1
8:15 0.5
8:30 1.0
Sng 8:45 2.0
9:00 4.0
9:30 8.0
10:00 16
10:30 32
11:30 50
1:30 100
Chiu 2:30 150
3:00 150
Ngy tip theo Tip tc 150mg mi 12h
Gii mn cm nhanh vi Rifampicin v Ethambutol tham kho theo bng di, thc hin
liu v khong cch tng liu da trn lng gi triu chng tng c th ngi bnh.
Thi gian bt u s dng Rifampicin (mg) Ethambutol (mg)
8:00 0.1 0.1
8:45 0.5 0.5
9:30 1.0 1.0
10:15 2.0 2.0
11:00 4.0 4.0
11:45 8.0 8.0
12:30 16 16
13:15 32 32
14:00 50 50
14:45 100 100
15:30 150 200
16:00 300 400
Ngy tip theo (6:00 sng) 300 hai ln/ngy 400 ba ln/ngy
87
 Corticoid c th c s dng nu vic gii mn cm l cp bch, c th:
o Lao nng.
o ADR nng.
o Qu mn vi nhiu hn mt thuc.
Ngi bnh nn s dng liu hng ngy sau khi hon tt qu trnh gii mn cm (khng
s dng phc 2 ln mi tun hoc 3 ln mi tun).

88
 PH LC 11
QUY TRNH CHP PHI THNG
MC TIU:
- Chun b c dng c v ngi bnh.
- Thao tc k thut ng quy trnh v nh gi c phim chp t tiu chun k thut.
CC BC TIN HNH:
I. CHUN B DNG C V NGI BNH
- Kim tra tnh trng hot ng ca my xquang.
- Dng phim, cassette c 30 x 40 cm hoc 35 x 35cm.
- Gi gi phim.
- H tn ngi bnh, du phi tri, ngy thng nm.
- Gi ngi bnh vo phng chp, tip xc, gii thch, hng dn ngi bnh bc l vng
cn chp, tho trang sc vng c nu c.
II. TIN HNH K THUT
- Phim t dc trn gi gi phim, c nh phn dc ca tia X vo gia phim theo chiu dc.
- Hng dn ngi bnh ng trc gi gi phim, mt ngi bnh quay v pha gi gi
phim, ngc ngi bnh p st phim, hai bn tay ngi bnh chng hng, khy tay gp, dng
sc xoay 2 vai v khy tay v pha trc mt trc ca vai v khy tay st phim.
- Mt ngi bnh hi nga v t ln mt trn ca cassette, chnh cnh trn ca cassette cao
hn mt trn ca vai 5cm, chnh trc ct sng lng vo gia phim theo chiu dc.
- Bng Xquang chiu ngang, vung gc vi phim.
- Tia trung tm khu tr vo im ngang t sng lng D6, ng ngang ca tia X qua ng
ni hai b trn ca hm nch. i vi ph n, ngi bnh to bo tia trung tm c th khu tr
ngang D8.
- Khong cch bng Xquang n phim l 1,5m, khu tr trm tia X, t tn ngi bnh, du P
hoc T, ngy thng nm.
- Cn dn ngi bnh ng im, gi nguyn t th.
- Tiu chun chp: ( ch mang tnh cht tham kho).

My Xquang KV mAs FFD ( cm) Li

Cao tn 65 - 70 8 150 - 180 c
Cao tn 65 - 70 5 150 - 180 khng
- Kim tra li cng thc, quan st ngi bnh, h ngi bnh ht su ht c nn th sau n
nt pht tia.
89
- Hng dn ngi bnh ra khi phng chp v a phim i trng.
III. NH GI KT QU
- Ly c ton b hai trng phi, trc ct sng lng vo gia phim theo chiu dc, khp
c n hai bn cn i, u trong ca hai xng n phi i xng qua gai sau ca ct sng
lng, c honh bn phi nm di u trong xng sn th 6 pha trc.
- Hai xng b vai c tch ra khi lng ngc, thy r c 3 t sng ngc u tin trn
phim.
- Phim c nt, tng phn, phim sch, khng b xc.
- Phim c h tn ngi bnh, du phi hoc tri, ngy thng nm chp.

90
 PH LC 12
QUY TRNH CHP PHI NGHING

MC TIU:
- Chun b c dng c v ngi bnh.
- Thao tc k thut ng quy trnh v nh gi c phim chp t tiu chun k thut.
CC BC TIN HNH:
I. CHUN B DNG C V NGI BNH
- Kim tra tnh trng hot ng ca my xquang.
- Dng phim, cassette c 30 x 40 cm hoc 35 x 35cm.
- Gi gi phim.
- H tn ngi bnh, du phi tri, ngy thng nm.
- Gi ngi bnh vo phng chp, tip xc, gii thch, hng dn ngi bnh bc l vng
cn chp, tho trang sc vng c nu c.
II. TIN HNH K THUT
- Phim t dc trn gi gi phim, c nh phn dc ca tia X vo gia phim theo chiu dc.
- Hng dn ngi bnh ng nghing hon ton trc gi gi phim, hai tay ngi bnh m
u, t thnh ngc bn cn chp st phim, cm ngi bnh hi nga.
- Chnh mt phng lng vung gc vi phim, chnh cnh trn ca cassette cao hn mt trn
ca vai 5cm.
- Bng Xquang chiu vung gc vi phim.
- Tia trung tm khu tr vo im ngang t sng lng 6, ng dc ca tia X i theo ng
nch sau v cch da lng 4 khot ngn tay, i vi ph n, ngi ln v to bo tia trung
tm c th khu tr vo ngang D8.
- Khong cch bng Xquang n phim l 1,5m, khu tr trm tia X, t tn ngi bnh, du P
hoc T, ngy thng nm.
- Cn dn ngi bnh ng im, gi nguyn t th.
- Tiu chun chp: ( ch mang tnh cht tham kho).

My Xquang KV mAs FFD ( cm) Li

Cao tn 75 80 15 150 c
Cao tn 75 80 8 150 khng
- Kim tra li cng thc, quan st ngi bnh, h ngi bnh ht su ht c nn th sau n
nt pht tia.
91
- Hng dn ngi bnh ra khi phng chp v a phim i trng.
III. NH GI KT QU
- Cc cung sau ca xng sn chng ln nhau.
- Cc vm honh pha trc nm ngang vi cung trc ca xng sn th 6.
- Hai vm honh phi r nt v u.
- Phim c nt, tng phn, phim sch, khng b xc.
- Phim c h tn ngi bnh, du phi hoc tri, ngy thng nm chp.

92
 PH LC 13
QUY TRNH CHP PHI T TH NH PHI N
T TH LORDOTIQUE
( Ngi bnh ng, tia chiu trc sau, chch bng ln pha trn)

MC TIU:
- Chun b c dng c v ngi bnh.
- Thao tc k thut ng quy trnh v nh gi c phim chp t tiu chun k thut.
CC BC TIN HNH:
I. CHUN B DNG C V NGI BNH
- Kim tra tnh trng hot ng ca my xquang.
- Dng phim, cassette c 30 x 40 cm hoc 35 x 35cm.
- Gi gi phim.
- H tn ngi bnh, du phi tri, ngy thng nm.
- Gi ngi bnh vo phng chp, tip xc, gii thch, hng dn ngi bnh bc l vng
cn chp, tho trang sc vng c nu c.
II. TIN HNH K THUT
- Phim t dc trn gi gi phim, c nh phn dc ca tia X vo gia phim theo chiu dc.
- Hng dn ngi bnh ng thng trc gi gi phim, mt quay v pha bng Xquang,
lng p st phim.
- Hai tay ngi bnh m gy, hai khy tay gp v a vo trong ti a.
- Cm ngi bnh hi nga, chnh cnh trn ca cassette cao hn mt trn vai 5 - 10cm,
chnh trc ct sng lng vo gia phim theo chiu dc.
- Bng Xquang chiu chch ln pha trn 1 gc t 300 n 400 so vi phng nm ngang
- Tia trung tm khu tr vo im gia thn xng c.
- Khong cch bng Xquang n phim l 1,5m, khu tr trm tia X, t tn ngi bnh, du P
hoc T, ngy thng nm.
- Cn dn ngi bnh ng im, gi nguyn t th.
- Tiu chun chp: ( ch mang tnh cht tham kho).

My Xquang KV mAs FFD ( cm) Li

Cao tn 70 12 150 c
Cao tn 70 8 150 khng

93
- Kim tra li cng thc, quan st ngi bnh, h ngi bnh ht su ht c nn th sau n
nt pht tia.
- Hng dn ngi bnh ra khi phng chp v a phim i trng.
III. NH GI KT QU
- Xng n c y ln cao ra khi lng ngc.
- Thy r nh phi, thy gia v chn rnh lin thy.
- Trc ct sng lng vo gia phim theo chiu dc.
- Phim c nt, tng phn, phim sch, khng b xc.
- Phim c h tn ngi bnh, du phi hoc tri, ngy thng nm chp.

94
 PH LC 14
HNH NH CA CC HNH THI TN THNG LAO
Nt:
Thm nhim:

95
Hang:

96
Hnh m do trn dch mng phi

97
Hnh nh trn kh mng phi

98
 PH LC 15

S bung khm bnh lao

QUT
Cas
Ca ra CBYT
vo
BN CHIU GI
CHIU GI

NB

Yu cu: (1) Din tch ti thiu 12m2

(2) m bo thng kh ti thiu 12 chu k trao i kh/gi.
(3) Thy thuc ngi cch ngi bnh ti thiu 1m.
Ghi ch: CBYT: Cn b Y t
NB: Ngi bnh

99
 PH LC 16
Hnh nh m t cc bc nhum hunh quang bng ha cht t pha
(nhum bng b kit lu ch nh thuc nhum kn vt dn, ty mu v nhum nn
chung 1 bc)

1. t tiu bn ln gi nhum. Xp cc tiu bn cch nhau t nht 1 cm

2. Ph y dung dch Auramine 0,1%. 15 pht

100
3. Ra tiu bn bng nc thng, nghing ro nc

4. Ph dung dch cn HCl 0,5%. 2 pht

101
5. Ra nc ri nghing tiu bn ro nc

102
6. Ph y dung dch xanh methylen 0,3%. 1 - 2 pht

7. Ra nc ri nghing tiu bn ro nc

103
8. kh t nhin hoc t ln my sy tiu bn

104
 TI LIU THAM KHO

1. American Thoracic Society, CDC, Infectious Diseases Society of America. Treatment of

tuberculosis, Am J Respir Crit Care Med Vol 167.pp 603-662, 2003.
2. Aberer & Kranke. Immunol Allergy Clin N Am 29. 567-584, 2009.
3. Australian Society for Microbiology (2004). Guidelines for Assuring Quality of Solid
Media used in Australis for the Cultivation of Medicallly Important Mycobacteria.
4. Van Deaun, A. Martin, J.C. Palomino (2010). Diagnosis of drug-resistant tuberculosis:
reliability and rapidity of detection. Int J Tuberc Lung Dis 14(2): 131 140.
5. B Y t - Chng trnh chng lao Quc gia Vit Nam. Hng dn qun l bnh lao. Nh
xut bn Y hc, 2009.
6. Chng trnh chng lao Quc gia Vit Nam. Hng dn k thut trong chn on v
iu tr bnh lao khng a thuc. Nm 2010.
7. Chng trnh chng lao Quc gia. Hng dn qui trnh thc hnh chun xt nghim vi
khun lao, 2012.
8. Chng trnh chng lao Quc gia. Hng dn duy tu bo dng trang thit b phng xt
nghim lao, 2010.
9. Chng trnh chng lao Quc gia - MSH. Qui trnh chuyn mu cho qun l v iu tr
bnh lao, 2011.
10. CDC. TB Program evaluation handbook, 2006.
11. Demonstration Project iLED. Training manual for Fluorescente Base AFB microscopy,
2008.
12. Guidelines EAACI. Allergy 2014;69:1026-45.
13. Hanscheid T, Ribeiro CM, Shapiro HM, Perlmutter NG. Fluorescence microscopy for
tuberculosis diagnosis. Lancet Infect Dis 2007; 7: 236-7.
14. International Union Agaist Tuberculosis and Lung Disease (IUATLD) technical guide:
sputum examination for tuberculosis by direct microscopy in low income countries. 5th
ed.Paris: IUATLD, 2006.
15. K.D. Mc carthy, * B. Metchock, * P. Monkongdee et al (2008). Mornitoring the
performance of mycobacteriologies laboratories: a proposal for standardized indicators.
Int J Tuberc Lung Dis 12(9): 1015 1020.
16. Nigeria NTP (2009). National standard operating procedure for laboratories, Nigeria
17. Naga P. Chalasani, et al on behalf of the Practice Parameters Committee of the American
College of Gastroenterology. Am J Gastroenterol 2014; 109:950966; American journal
and respiratory cristical care medecine vol 174 2006. An Official ATS Statement:
Hepatotoxicity of Antituberculosis Therapy

105
18. Procedure for culture of Mycobacteria using MGIT 960 technique, 2007.
19. Lawrence Flick Memorial Tuberculosis Clinic Philadelphia Tuberculosis Control
Program; November, 1998.
20. World Health Organization. 1998. Laboratory Service in tuberculosis Control: Part II,
Microscopy. WHO/TB/98.258.
21. WHO. Services in tuberclosis control. Part II: Microscopy. 1998.
22. WHO. Treatment of Tuberculosis Guidelines Fourth Edition. 2009.
23. WHO. Guidelines for the programmatic management of drug-resistant tuberculosis:
emergency update 2008, Geneva, 2008.
24. WHO (2003), WHO Toxicity Grading Scale of Determining The Severity of Adverse
Events.
25. T chc Y t Th gii khu vc Ty Thi Bnh Dng. m bo cht lng xt nghim
m trc tip trong chin lc DODS, 2003.
26. Toman K. Toman's tuberculosis case detection, treatment and monitoring, WHO, 2004.
27. Temple R. Hys law: predicting serious hepatotoxicity. Pharmacoepidemiol Drug Saf
2006;15:241243.

106