婴幼儿喘息的诊治

婴幼儿喘息的诊治北京儿童医院赵顺英首次喘息诊断毛细（病毒感染性喘息）喘支哮喘首次发作肺炎支气管异物支气管畸形合并感染迁延或持续或反复喘息诊断首次病毒感染性喘息治疗不彻底哮喘胃食道反流气道畸形：气管-支气管软化、狭窄血管发育畸形:双主动脉弓等肺结核:肿大淋巴结压迫气道或支气管结核支气管异物免疫功能缺陷合并气道、肺部反复感染闭塞性细支气管炎*持续性细菌性支气管（细支气管）炎*气道狭窄支气管异物支气管畸形和血管压迫首次病毒感染性喘息治疗不彻底病毒感染性气道高反应持续合并感染:肺炎和持续性细菌性支气管炎平喘药物停用后反复哮喘早期考虑具有哮喘特征：发作性、可逆性，重复性喘息病情重：家族或个人过敏史除外其他引起喘息性疾病持续性细菌性支气管炎很多诊断名词：（1）慢性化脓性肺疾病（ChronicSuppurativeLungDisease）（2）持续性支气管内膜感染(PersistentEndobrobchialInfections)（3）迁延性支气管炎（ProtractedBronchitis）（4）慢性支气管炎（ChronicBronchitis）临床表现发病年龄：2岁以内常见诱因：急性上下呼吸道感染表现：持续性湿性咳嗽、喘息吸气相和呼气相粗痰鸣音而不是典型的喘鸣影像学表现可以正常最常见的异常表现为支气管壁增厚斑片片影可有支气管扩张支气管镜表现传导气道分泌物多，多呈脓性粘膜水肿气道闭塞支气管内膜炎肺泡灌洗液细胞学分析，中性粒细胞为主病原学肺炎链球菌、流感嗜血杆菌最常见卡他汉菌、其他链球菌G-杆菌并存疾病哮喘同时存在哮喘而导致诊断过程复杂化治疗流感嗜血杆菌、肺炎链球菌等治疗疗程3-6周WheezeinpreschoolageisassociatedwithpulmonarybacterialinfectionandresolvesafterantibiotictherapyBACKGROUND:NeonateswithairwayscolonizedbyHaemophilusinfluenzae,StreptococcuspneumoniaeorMoraxellacatarrhalisareatincreasedriskforrecurrentwheezewhichmayresembleasthmaearlyinlife.Itisnotclearwhetherchroniccolonizationbythesepathogensiscausativeforseverepersistentwheezeinsomepreschoolchildrenandwhetherthesechildrenmightbenefitfromantibiotictreatment.Weassessedtherelevanceofbacterialcolonizationandchronicairwayinfectioninpreschoolchildrenwithseverepersistentwheezingandevaluatedtheoutcomeoflong-timeantibiotictreatmentontheclinicalcourseinsuchchildren.METHODOLOGY/PRINCIPALFINDINGS:Preschoolchildren(n = 42)withseverepersistentwheezebutnosymptomsofacutepulmonaryinfectionwereinvestigatedbybronchoscopyandbronchoalveolarlavage(BAL).DifferentialcellcountsandmicrobiologicalandvirologicalanalyseswereperformedonBALsamples.Patientsdiagnosedwithbacterialinfectionweretreatedwithantibioticsfor2-16weeks(n = 29).Ofthe42childrenwithseverewheezing,34(81%)showedaneutrophilicinflammationand20(59%)ofthissubgrouphadelevatedbacterialcounts(≥10⁴colonyformingunitspermilliliter)suggestinginfection.Haemophilusinfluenzae,StreptococcuspneumoniaeandMoraxellacatarrhaliswerethemostfrequentlyisolatedspecies.Aftertreatmentwithappropriateantibiotics92%ofpatientsshowedamarkedimprovementofsymptomsuponfollow-upexamination.CONCLUSIONS/SIGNIFICANCE:Chronicbacterialinfectionsarerelevantinasubgroupofpreschoolchildrenwithpersistentwheezingandsuchchildrenbenefitsignificantlyfromantibiotictherapy.PLoSOne.2011;6(11):e27913.Epub2011Nov29.闭塞性细支气管炎（BronchiolitisObliterans)北京儿童医院赵顺英定义闭塞性细支气管炎（Bronchiolitisobliterans）是与细支气管炎症性损伤相关，导致管腔闭塞的慢性气流阻塞综合征。也可发生于支气管,出现闭塞、扩张病因★毒气的吸入★感染病毒：腺病毒、流感病毒、麻疹病毒细菌：金葡菌、B族溶血性链球菌、肺炎链球菌肺炎支原体★结缔组织病、组织器官移植：自身免疫性溶血、骨髓移植、心肺移植、类风湿性关节炎、渗出性多形性红斑★其它：支气管肺发育不良（BPD）先天性心脏病、囊性纤维化★吸入：异物吸入胃-食管返流（GER）★药物、肿瘤★特发性狭窄性为主症状咳嗽、喘息气促、呼吸困难运动不耐受、反复呼吸道感染短暂的症状改善期后加重、持续体征•喘鸣音•“crackles”临床表现实验室检查•血气分析•肺功能•影像学•电子支气管镜检查•肺通气灌注扫描实验室检查－肺功能（续）•用来诊断小气道疾病的方法•世界心肺移植协会1993年提议、2002年修订BO临床分级，被广泛用于描述BO•可用于BO疗效的观察•建议用所测值占预计值的百分数来表示实验室检查－肺功能（续）正常婴儿TBFV环BO婴儿TBFV环升枝陡，高峰前移，峰值较高，降枝凹陷潮气流速容量环（TBFV）特点%V-PF25/PFPTEFViVi/kgVeTiRRPF/Ve容量流速实验室检查－胸片•无特异性改变•两肺过度充气•随病情进展，出现斑片状肺泡浸润影，呈毛玻璃样，边缘不清•可有单侧透明肺实验室检查－肺CT•HRCT征象：马赛克灌注征支气管扩张支气管壁增厚气体捕捉征•呼气相CT：较吸气相CT能更好地显示小气道病变BO的临床诊断(1)急性感染或急性肺损伤后6周以上的反复或持续气促，喘息或咳嗽、喘鸣，对支气管扩张剂无反应；(2)临床表现与胸部x线片轻重程度不符，临床床症状重，胸部x线片多为过度通气；(3)肺CT显示支气管壁增厚，支气管扩张，肺不张，马赛克灌注征、小叶中心行结节；(4)肺功能示阻塞性通气功能障碍；(5)胸部x线片为单侧透明肺;⑥排除其他阻塞性疾病，如哮喘、先天纤毛运动功能障碍、囊性纤维化、异物吸入、先天发育异常、结核、艾滋病和其他免疫功能缺陷等。治疗激素大环内酯类孟鲁司特支气管扩张剂：对有反应的病人抗生素：合并感染时应用，常感染儿科治疗激素（泼尼松）足量：1~2mg/kg.d1~3个月，必要时冲击。维持：1年以上大环内酯类小剂量红霉素、阿奇霉素抗生素：常合并感染，肺炎链球菌多见避免再次打击很重要！儿科治疗孟鲁司特文献报道对BO有效主要机制为抑制平滑肌增殖为抑制肌成纤维细胞活化临床使用学龄前期反复喘息表型发作性喘息(Episodicwheezing):不能缓解喘息(unremittingwheezing):未分类喘息:几周评价治疗反应,表型评价学龄前期反复喘息表型发作性喘息:诱因通常为病毒,发作间歇期正常,常无家族和个人过敏史不能缓解的喘息:诱因多种,有家族和个人过敏史学龄前期反复喘息表型分类Episodicwheezingisdefinedaswheezingindiscreteepisodesof2to4weeksinduration,withthechildbeingwellinbetweenepisodes.Thetriggerisusuallyaviralinfection.Inunremittingwheezing,thechildhasdistinctepisodesofwheezingbutbetweenthesesevereepisodesalsohasintermittentsymptoms,suchascoughingorwheezingatnightorinresponsetoexercise,crying,laughter,mist,orcoldair.Viralinfectionsarealsothemostcommoncausesofthesesevereepisodes,buttheymaypersistinthepresenceofothertriggers,suchaspassivesmoking,allergenexposure,orairpollution.Consequently,thiswheezingphenotypehasalsobeentermedmultitriggerwheezing.Thewheezingphenotypescansometimesbehardtodistinguishandcanchangeaschildrengrowolder:学龄前期反复喘息表型分类Episodicwheezingisusuallynotassociatedwithatopyandrarelyprogressestoasthma.Incontrast,unremittingwheezinginchildrenofpreschoolageisoftenassociatedwithatopicsensitizationasearlyasthefirstyearoflife.childrenoftenhaveallergiestofoodssuchashen’seggsandcow’smilk.Manyofthesechildrenhaveatopicdermatitisorsensitizationtoindoorallergens,withsubsequentdevelopmentofimpairedlungfunction.Bythetimetheyareinschool,wecalltheirdiseaseasthma.学龄前期反复喘息治疗发作性（病毒诱发性喘息）:孟鲁司特不能缓解喘息（多因素有关）：吸入激素（ICS）或孟鲁司特Asimpletooltoidentifyinfantsathighriskofmildtoseverechildhoodasthma:thepersistentasthmapredictivescoreJAsthma.2011;48(10):1015-21Threeparametersindependentlypredictedpersistentasthma:familyhistoryofasthma,personalatopicdermatitis,andmultipleallergensensitizations.