嬰幼兒喘息的診治課件

嬰幼兒喘息的診治首次喘息診斷毛細(xì)（病毒感染性喘息）喘支哮喘首次發(fā)作肺炎支氣管異物

支氣管畸形合并感染遷延或持續(xù)或反復(fù)喘息診斷首次病毒感染性喘息治療不徹底哮喘胃食道反流氣道畸形：氣管-支氣管軟化、狹窄血管發(fā)育畸形:雙主動(dòng)脈弓等肺結(jié)核:腫大淋巴結(jié)壓迫氣道或支氣管結(jié)核支氣管異物免疫功能缺陷合并氣道、肺部反復(fù)感染閉塞性細(xì)支氣管炎*持續(xù)性細(xì)菌性支氣管（細(xì)支氣管）炎*氣道狹窄

支氣管異物支氣管畸形和血管壓迫

首次病毒感染性喘息治療不徹底

病毒感染性氣道高反應(yīng)持續(xù)合并感染:肺炎和持續(xù)性細(xì)菌性支氣管炎平喘藥物停用后反復(fù)

哮喘早期考慮

具有哮喘特征：發(fā)作性、可逆性，重復(fù)性喘息病情重：家族或個(gè)人過(guò)敏史除外其他引起喘息性疾病持續(xù)性細(xì)菌性支氣管炎

很多診斷名詞：（1）慢性化膿性肺疾?。–hronicSuppurativeLungDisease）（2）持續(xù)性支氣管內(nèi)膜感染(PersistentEndobrobchialInfections)（3）遷延性支氣管炎（ProtractedBronchitis）（4）慢性支氣管炎（ChronicBronchitis）臨床表現(xiàn)發(fā)病年齡：2歲以?xún)?nèi)常見(jiàn)誘因：急性上下呼吸道感染表現(xiàn)：持續(xù)性濕性咳嗽、喘息

吸氣相和呼氣相粗痰鳴音而不是典型的喘鳴影像學(xué)表現(xiàn)

可以正常最常見(jiàn)的異常表現(xiàn)為支氣管壁增厚斑片片影可有支氣管擴(kuò)張支氣管鏡表現(xiàn)

傳導(dǎo)氣道分泌物多，多呈膿性粘膜水腫氣道閉塞支氣管內(nèi)膜炎

肺泡灌洗液細(xì)胞學(xué)分析，中性粒細(xì)胞為主病原學(xué)肺炎鏈球菌、流感嗜血桿菌最常見(jiàn)卡他漢菌、其他鏈球菌G-桿菌并存疾病

哮喘同時(shí)存在哮喘而導(dǎo)致診斷過(guò)程復(fù)雜化治療流感嗜血桿菌、肺炎鏈球菌等治療療程3-6周

Wheezeinpreschoolageisassociatedwithpulmonarybacterialinfectionandresolves

afterantibiotictherapy

BACKGROUND:NeonateswithairwayscolonizedbyHaemophilusinfluenzae,StreptococcuspneumoniaeorMoraxellacatarrhalisareatincreasedriskforrecurrentwheezewhichmayresembleasthmaearlyinlife.Itisnotclearwhetherchroniccolonizationbythesepathogensiscausativeforseverepersistentwheezeinsomepreschoolchildrenandwhetherthesechildrenmightbenefitfromantibiotictreatment.Weassessedtherelevanceofbacterialcolonizationandchronicairwayinfectioninpreschoolchildrenwithseverepersistentwheezingandevaluatedtheoutcomeoflong-timeantibiotictreatmentontheclinicalcourseinsuchchildren.METHODOLOGY/PRINCIPALFINDINGS:Preschoolchildren(n?=?42)withseverepersistentwheezebutnosymptomsofacutepulmonaryinfectionwereinvestigatedbybronchoscopyandbronchoalveolarlavage(BAL).DifferentialcellcountsandmicrobiologicalandvirologicalanalyseswereperformedonBALsamples.Patientsdiagnosedwithbacterialinfectionweretreatedwithantibioticsfor2-16weeks(n?=?29).Ofthe42childrenwithseverewheezing,34(81%)showedaneutrophilicinflammationand20(59%)ofthissubgrouphadelevatedbacterialcounts(≥10?colonyformingunitspermilliliter)suggestinginfection.Haemophilusinfluenzae,StreptococcuspneumoniaeandMoraxellacatarrhaliswerethemostfrequentlyisolatedspecies.Aftertreatmentwithappropriateantibiotics92%ofpatientsshowedamarkedimprovementofsymptomsuponfollow-upexamination.CONCLUSIONS/SIGNIFICANCE:Chronicbacterialinfectionsarerelevantinasubgroupofpreschoolchildrenwithpersistentwheezingandsuchchildrenbenefitsignificantlyfromantibiotictherapy.

PLoSOne.2011;6(11):e27913.Epub2011Nov29.閉塞性細(xì)支氣管炎

（BronchiolitisObliterans)北京兒童醫(yī)院趙順英定義閉塞性細(xì)支氣管炎（Bronchiolitisobliterans）是與細(xì)支氣管炎癥性損傷相關(guān)，導(dǎo)致管腔閉塞的慢性氣流阻塞綜合征。

也可發(fā)生于支氣管,出現(xiàn)閉塞、擴(kuò)張

病因★毒氣的吸入★感染

病毒：腺病毒、流感病毒、麻疹病毒

細(xì)菌：金葡菌、B族溶血性鏈球菌、肺炎鏈球菌肺炎支原體★結(jié)締組織病、組織器官移植：自身免疫性溶血、骨髓移植、心肺移植、類(lèi)風(fēng)濕性關(guān)節(jié)炎、滲出性多形性紅斑★其它：支氣管肺發(fā)育不良（BPD）先天性心臟病、囊性纖維化★吸入：異物吸入胃-食管返流（GER）★藥物、腫瘤★特發(fā)性狹窄性為主癥狀咳嗽、喘息

氣促、呼吸困難

運(yùn)動(dòng)不耐受、反復(fù)呼吸道感染

短暫的癥狀改善期后加重、持續(xù)體征喘鳴音

“crackles”臨床表現(xiàn)實(shí)驗(yàn)室檢查血?dú)夥治龇喂δ苡跋駥W(xué)電子支氣管鏡檢查肺通氣灌注掃描實(shí)驗(yàn)室檢查－肺功能（續(xù)）用來(lái)診斷小氣道疾病的方法世界心肺移植協(xié)會(huì)1993年提議、2002年修訂BO臨床分級(jí)，被廣泛用于描述BO可用于BO療效的觀察建議用所測(cè)值占預(yù)計(jì)值的百分?jǐn)?shù)來(lái)表示實(shí)驗(yàn)室檢查－肺功能（續(xù)）正常嬰兒TBFV環(huán)BO嬰兒TBFV環(huán)

升枝陡，高峰前移，峰值較高，

降枝凹陷潮氣流速容量環(huán)（TBFV）特點(diǎn)%V-PF25/PFPTEFViVi/kgVeTiRRPF/Ve容量流速實(shí)驗(yàn)室檢查－胸片無(wú)特異性改變兩肺過(guò)度充氣隨病情進(jìn)展，出現(xiàn)斑片狀肺泡浸潤(rùn)影，呈毛玻璃樣，邊緣不清可有單側(cè)透明肺實(shí)驗(yàn)室檢查－肺CTHRCT征象：馬賽克灌注征支氣管擴(kuò)張支氣管壁增厚氣體捕捉征呼氣相CT：較吸氣相CT能更好地顯示小氣道病變BO的臨床診斷(1)急性感染或急性肺損傷后6周以上的反復(fù)或持續(xù)氣促，喘息或咳嗽、喘鳴，對(duì)支氣管擴(kuò)張劑無(wú)反應(yīng)；(2)臨床表現(xiàn)與胸部x線片輕重程度不符，臨床床癥狀重，胸部x線片多為過(guò)度通氣；(3)肺CT顯示支氣管壁增厚，支氣管擴(kuò)張，肺不張，馬賽克灌注征、小葉中心行結(jié)節(jié)；(4)肺功能示阻塞性通氣功能障礙；(5)胸部x線片為單側(cè)透明肺;⑥排除其他阻塞性疾病，如哮喘、先天纖毛運(yùn)動(dòng)功能障礙、囊性纖維化、異物吸入、先天發(fā)育異常、結(jié)核、艾滋病和其他免疫功能缺陷等。治療激素大環(huán)內(nèi)酯類(lèi)孟魯司特支氣管擴(kuò)張劑：對(duì)有反應(yīng)的病人抗生素：合并感染時(shí)應(yīng)用，常感染兒科治療激素（潑尼松）足量：1~2mg/kg.d1~3個(gè)月，必要時(shí)沖擊。維持：1年以上大環(huán)內(nèi)酯類(lèi)小劑量紅霉素、阿奇霉素

抗生素：常合并感染，肺炎鏈球菌多見(jiàn)避免再次打擊很重要！

兒科治療孟魯司特

文獻(xiàn)報(bào)道對(duì)BO有效主要機(jī)制為抑制平滑肌增殖為抑制肌成纖維細(xì)胞活化臨床使用學(xué)齡前期反復(fù)喘息表型

發(fā)作性喘息(Episodicwheezing):不能緩解喘息(unremittingwheezing):未分類(lèi)喘息:幾周評(píng)價(jià)治療反應(yīng),表型評(píng)價(jià)學(xué)齡前期反復(fù)喘息表型發(fā)作性喘息:誘因通常為病毒,發(fā)作間歇期正常,常無(wú)家族和個(gè)人過(guò)敏史不能緩解的喘息:誘因多種,有家族和個(gè)人過(guò)敏史學(xué)齡前期反復(fù)喘息表型分類(lèi)Episodicwheezingisdefinedaswheezingindiscreteepisodesof2to4weeksinduration,withthechildbeingwellinbetweenepisodes.Thetriggerisusuallyaviralinfection.Inunremittingwheezing,thechildhasdistinctepisodesofwheezingbutbetweenthesesevereepisodesalsohasintermittentsymptoms,suchascoughingorwheezingatnightorinresponsetoexercise,crying,laughter,mist,orcoldair.Viralinfectionsarealsothemostcommoncausesofthesesevereepisodes,buttheymaypersistinthepresenceofothertriggers,suchaspassivesmoking,allergenexposure,orairpollution.Consequently,thiswheezingphenotypehasalsobeentermedmultitriggerwheezing.Thewheezingphenotypescansometimesbehardtodistinguishandcanchangeaschildrengrowolder:學(xué)齡前期反復(fù)喘息表型分類(lèi)Episodicwheezingisusuallynotassociatedwithatopyandrarelyprogressestoasthma.Incontrast,unremittingwheezinginchildrenofpreschoolageisoftenassociatedwithatopicsensitizationasearlyasthefirstyearoflife.childrenoftenhaveallergiestofoodssuchashen’seggsandcow’smilk.Manyofthesechildrenhaveatopicdermatitisorsensitizationtoindoorallergens,withsubsequentdevelopmentofimpairedlungfunction.Bythetimetheyareinschool,wecalltheirdiseaseasthma.學(xué)齡前期反復(fù)喘息治療發(fā)作性（病毒誘發(fā)性喘息）:孟魯司特不能緩解喘息（多因素有關(guān)）：吸入激素（ICS）或孟魯司特

Asimpletooltoidentifyinfantsathighriskofmildtoseverechildhoodasthma:thepersistentasthmapredictivescore

JAsthma.2011;48(10):1015-21Threeparametersindependentlypredictedpersistentasthma:familyhistoryofasthma,personalatopicdermatitis,andmultipleallergensensitizations.Basedonthesevariables,thePAPSshowed42%sensitivity,90%specificity,67%positivepredictivevalue,and76%negativepredictivevalueforthepredictionofpersistentasthma.

DailyorIntermittentBudesonide

inPreschoolChildren

withRecurrentWheezing

NEnglJMed2011;365:1990-2001BACKGROUNDDailyinhaledglucocorticoidsarerecommendedforyoungchildrenatriskforasthmaexacerbations,asindicatedbyapositivevalueonthemodifiedasthmapredictiveindex(API)andanexacerbationintheprecedingyear,butconcernremainsaboutdailyadherenceandeffectsongrowth.Wecompareddailytherapywithintermittenttherapy.METHODSWestudied278childrenbetweentheagesof12and53monthswhohadpositivevaluesonthemodifiedAPI,recurrentwheezingepisodes,andatleastoneexacerbationinthepreviousyearbutalowdegreeofimpairment.Childrenwererandomlyassignedtoreceiveabudesonideinhalationsuspensionfor1yearaseitheranintermittenthigh-doseregimen(1mgtwicedailyfor7days,startingearlyduringapredefinedrespiratorytractillness)oradailylow-doseregimen(0.5mgnightly)withcorrespondingplacebos.Theprimaryoutcomewasthefrequencyofexacerbationsrequiringoralglucocorticoidtherapy.RESULTSThedailyregimenofbudesonidedidnotdiffersignificantlyfromtheintermittentregimenwithrespecttothefrequencyofexacerbations,witharateperpatient-yearforthedailyregimenof0.97(95%confidenceinterval[CI],0.76to1.22)versusarateof0.95(95%CI,0.75to1.20)fortheintermittentregimen(relativerateintheintermittent-regimengroup,0.99;95%CI,0.71to1.35;P=0.60).Therewerealsonosignificantbetween-groupdifferencesinseveraloth