嬰幼兒喘息的診治市公開課特等獎市賽課微課一等獎?wù)n件

嬰幼兒喘息診治北京兒童醫(yī)院趙順英第1頁首次喘息診療毛細（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第2頁遷延或連續(xù)或重復(fù)喘息診療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效缺點合并氣道、肺部重復(fù)感染閉塞性細支氣管炎*連續(xù)性細菌性支氣管（細支氣管）炎*第3頁氣道狹窄

支氣管異物支氣管畸形和血管壓迫第4頁

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)連續(xù)合并感染:肺炎和連續(xù)性細菌性支氣管炎平喘藥品停用后重復(fù)

第5頁哮喘早期考慮

含有哮喘特征：發(fā)作性、可逆性，重復(fù)性喘息病情重：家族或個人過敏史除外其它引發(fā)喘息性疾病第6頁連續(xù)性細菌性支氣管炎

很多診療名詞：（1）慢性化膿性肺疾?。–hronicSuppurativeLungDisease）（2）連續(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）第7頁臨床表現(xiàn)發(fā)病年紀：2歲以內(nèi)常見誘因：急性上下呼吸道感染表現(xiàn)：連續(xù)性濕性咳嗽、喘息

吸氣相和呼氣相粗痰鳴音而不是經(jīng)典喘鳴第8頁影像學(xué)表現(xiàn)

能夠正常最常見異常表現(xiàn)為支氣管壁增厚斑片片影可有支氣管擴張第9頁支氣管鏡表現(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

肺泡灌洗液細胞學(xué)分析，中性粒細胞為主第10頁病原學(xué)肺炎鏈球菌、流感嗜血桿菌最常見卡他漢菌、其它鏈球菌G-桿菌第11頁并存疾病

哮喘同時存在哮喘而造成診療過程復(fù)雜化第12頁治療流感嗜血桿菌、肺炎鏈球菌等治療療程3-6周第13頁

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.;6(11):e27913.EpubNov29.第14頁閉塞性細支氣管炎

（BronchiolitisObliterans)北京兒童醫(yī)院趙順英第15頁定義閉塞性細支氣管炎（Bronchiolitisobliterans）是與細支氣管炎癥性損傷相關(guān)，造成管腔閉塞慢性氣流阻塞綜合征。

也可發(fā)生于支氣管,出現(xiàn)閉塞、擴張

第16頁病因★毒氣吸入★感染

病毒：腺病毒、流感病毒、麻疹病毒

細菌：金葡菌、B族溶血性鏈球菌、肺炎鏈球菌

肺炎支原體第17頁★結(jié)締組織病、組織器官移植：本身免疫性溶血、骨髓移植、心肺移植、類風(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）★藥品、腫瘤★特發(fā)性狹窄性為主第18頁癥狀咳嗽、喘息

氣促、呼吸困難

運動不耐受、重復(fù)呼吸道感染

短暫癥狀改進期后加重、連續(xù)體征喘鳴音

“crackles”臨床表現(xiàn)第19頁試驗室檢驗血氣分析肺功效影像學(xué)電子支氣管鏡檢驗肺通氣灌注掃描第20頁試驗室檢驗－肺功效（續(xù)）用來診療小氣道疾病方法世界心肺移植協(xié)會1993年提議、年修訂BO臨床分級，被廣泛用于描述BO可用于BO療效觀察提議用所測值占預(yù)計值百分數(shù)來表示第21頁試驗室檢驗－肺功效（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%V-PF25/PFPTEFViVi/kgVeTiRRPF/Ve容量流速第22頁試驗室檢驗－胸片無特異性改變兩肺過分充氣隨病情進展，出現(xiàn)斑片狀肺泡浸潤影，呈毛玻璃樣，邊緣不清可有單側(cè)透明肺第23頁試驗室檢驗－肺CTHRCT征象：馬賽克灌注征支氣管擴張支氣管壁增厚氣體捕捉征呼氣相CT：較吸氣相CT能更加好地顯示小氣道病變第24頁BO臨床診療(1)急性感染或急性肺損傷后6周以上重復(fù)或連續(xù)氣促，喘息或咳嗽、喘鳴，對支氣管擴張劑無反應(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線片多為過分通氣；(3)肺CT顯示支氣管壁增厚，支氣管擴張，肺不張，馬賽克灌注征、小葉中心行結(jié)節(jié)；(4)肺功效示阻塞性通氣功效障礙；(5)胸部x線片為單側(cè)透明肺;⑥排除其它阻塞性疾病，如哮喘、先天纖毛運動功效障礙、囊性纖維化、異物吸入、先天發(fā)育異常、結(jié)核、艾滋病和其它免疫功效缺點等。第25頁治療激素大環(huán)內(nèi)酯類孟魯司特支氣管擴張劑：對有反應(yīng)病人抗生素：合并感染時應(yīng)用，常感染第26頁兒科治療激素（潑尼松）足量：1~2mg/kg.d1~3個月，必要時沖擊。維持：1年以上大環(huán)內(nèi)酯類小劑量紅霉素、阿奇霉素

抗生素：常合并感染，肺炎鏈球菌多見防止再次打擊很主要！

第27頁兒科治療孟魯司特

文件報道對BO有效主要機制為抑制平滑肌增殖為抑制肌成纖維細胞活化臨床使用第28頁學(xué)齡前期重復(fù)喘息表型

發(fā)作性喘息(Episodicwheezing):不能緩解喘息(unremittingwheezing):未分類喘息:幾周評價治療反應(yīng),表型評價第29頁學(xué)齡前期重復(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,常無家族和個人過敏史不能緩解喘息:誘因各種,有家族和個人過敏史第30頁學(xué)齡前期重復(fù)喘息表型分類Episodicwheezingisdefinedaswheezingindiscreteepisodesof2to4weeksinduration,withthechildbeingwellinbetweenepisodes.Thetriggerisusuallyaviralinfection.Inunremittingwheezing,thechildhasdistinctepisodesofwheezingbutbetweenthesesevereepisodesalsohasintermittentsymptoms,suchascoughingorwheezingatnightorinresponsetoexercise,crying,laughter,mist,orcoldair.Viralinfectionsarealsothemostcommoncausesofthesesevereepisodes,buttheymaypersistinthepresenceofothertriggers,suchaspassivesmoking,allergenexposure,orairpollution.Consequently,thiswheezingphenotypehasalsobeentermedmultitriggerwheezing.Thewheezingphenotypescansometimesbehardtodistinguishandcanchangeaschildrengrowolder:第31頁學(xué)齡前期重復(fù)喘息表型分類Episodicwheezingisusuallynotassociatedwithatopyandrarelyprogressestoasthma.Incontrast,unremittingwheezinginchildrenofpreschoolageisoftenassociatedwithatopicsensitizationasearlyasthefirstyearoflife.childrenoftenhaveallergiestofoodssuchashen’seggsandcow’smilk.Manyofthesechildrenhaveatopicdermatitisorsensitizationtoindoorallergens,withsubsequentdevelopmentofimpairedlungfunction.Bythetimetheyareinschool,wecalltheirdiseaseasthma.第32頁學(xué)齡前期重復(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（多原因相關(guān)）：吸入激素（ICS）或孟魯司特第33頁第34頁

Asimpletooltoidentifyinfantsathighriskofmildtoseverechildhoodasthma:thepersistentasthmapredictivescore

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

第35頁

DailyorIntermittentBudesonide

inPreschoolChildren

withRecurrentWheezing

NEnglJMed;365:1990-BACKGROUNDDailyinhaledglucocorticoidsarerecommendedforyoungchildrenatriskforasthmaexacerbations,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)fortheinte