婴幼儿喘息的诊治市公开课特等奖市赛课微课一等奖课件

婴幼儿喘息诊治北京儿童医院赵顺英第1页首次喘息诊疗毛细（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第2页迁延或连续或重复喘息诊疗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效缺点合并气道、肺部重复感染闭塞性细支气管炎*连续性细菌性支气管（细支气管）炎*第3页气道狭窄

支气管异物支气管畸形和血管压迫第4页

首次病毒感染性喘息治疗不彻底

病毒感染性气道高反应连续合并感染:肺炎和连续性细菌性支气管炎平喘药品停用后重复

第5页哮喘早期考虑

含有哮喘特征：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它引发喘息性疾病第6页连续性细菌性支气管炎

很多诊疗名词：（1）慢性化脓性肺疾病（ChronicSuppurativeLungDisease）（2）连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）第7页临床表现发病年纪：2岁以内常见诱因：急性上下呼吸道感染表现：连续性湿性咳嗽、喘息

吸气相和呼气相粗痰鸣音而不是经典喘鸣第8页影像学表现

能够正常最常见异常表现为支气管壁增厚斑片片影可有支气管扩张第9页支气管镜表现

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，中性粒细胞为主第10页病原学肺炎链球菌、流感嗜血杆菌最常见卡他汉菌、其它链球菌G-杆菌第11页并存疾病

哮喘同时存在哮喘而造成诊疗过程复杂化第12页治疗流感嗜血杆菌、肺炎链球菌等治疗疗程3-6周第13页

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(≥10⁴colonyformingunitspermilliliter)suggestinginfection.Haemophilusinfluenzae,StreptococcuspneumoniaeandMoraxellacatarrhaliswerethemostfrequentlyisolatedspecies.Aftertreatmentwithappropriateantibiotics92%ofpatientsshowedamarkedimprovementofsymptomsuponfollow-upexamination.CONCLUSIONS/SIGNIFICANCE:Chronicbacterialinfectionsarerelevantinasubgroupofpreschoolchildrenwithpersistentwheezingandsuchchildrenbenefitsignificantlyfromantibiotictherapy.

PLoSOne.;6(11):e27913.EpubNov29.第14页闭塞性细支气管炎

（BronchiolitisObliterans)北京儿童医院赵顺英第15页定义闭塞性细支气管炎（Bronchiolitisobliterans）是与细支气管炎症性损伤相关，造成管腔闭塞慢性气流阻塞综合征。

也可发生于支气管,出现闭塞、扩张

第16页病因★毒气吸入★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

肺炎支原体第17页★结缔组织病、组织器官移植：本身免疫性溶血、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）★药品、肿瘤★特发性狭窄性为主第18页症状咳嗽、喘息

气促、呼吸困难

运动不耐受、重复呼吸道感染

短暂症状改进期后加重、连续体征喘鸣音

“crackles”临床表现第19页试验室检验血气分析肺功效影像学电子支气管镜检验肺通气灌注扫描第20页试验室检验－肺功效（续）用来诊疗小气道疾病方法世界心肺移植协会1993年提议、年修订BO临床分级，被广泛用于描述BO可用于BO疗效观察提议用所测值占预计值百分数来表示第21页试验室检验－肺功效（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容量流速第22页试验室检验－胸片无特异性改变两肺过分充气随病情进展，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第23页试验室检验－肺CTHRCT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能更加好地显示小气道病变第24页BO临床诊疗(1)急性感染或急性肺损伤后6周以上重复或连续气促，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线片多为过分通气；(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)肺功效示阻塞性通气功效障碍；(5)胸部x线片为单侧透明肺;⑥排除其它阻塞性疾病，如哮喘、先天纤毛运动功效障碍、囊性纤维化、异物吸入、先天发育异常、结核、艾滋病和其它免疫功效缺点等。第25页治疗激素大环内酯类孟鲁司特支气管扩张剂：对有反应病人抗生素：合并感染时应用，常感染第26页儿科治疗激素（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，肺炎链球菌多见防止再次打击很主要！

第27页儿科治疗孟鲁司特

文件报道对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第28页学龄前期重复喘息表型

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,表型评价第29页学龄前期重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喘息:诱因各种,有家族和个人过敏史第30页学龄前期重复喘息表型分类Episodicwheezingisdefinedaswheezingindiscreteepisodesof2to4weeksinduration,withthechildbeingwellinbetweenepisodes.Thetriggerisusuallyaviralinfection.Inunremittingwheezing,thechildhasdistinctepisodesofwheezingbutbetweenthesesevereepisodesalsohasintermittentsymptoms,suchascoughingorwheezingatnightorinresponsetoexercise,crying,laughter,mist,orcoldair.Viralinfectionsarealsothemostcommoncausesofthesesevereepisodes,buttheymaypersistinthepresenceofothertriggers,suchaspassivesmoking,allergenexposure,orairpollution.Consequently,thiswheezingphenotypehasalsobeentermedmultitriggerwheezing.Thewheezingphenotypescansometimesbehardtodistinguishandcanchangeaschildrengrowolder:第31页学龄前期重复喘息表型分类Episodicwheezingisusuallynotassociatedwithatopyandrarelyprogressestoasthma.Incontrast,unremittingwheezinginchildrenofpreschoolageisoftenassociatedwithatopicsensitizationasearlyasthefirstyearoflife.childrenoftenhaveallergiestofoodssuchashen’seggsandcow’smilk.Manyofthesechildrenhaveatopicdermatitisorsensitizationtoindoorallergens,withsubsequentdevelopmentofimpairedlungfunction.Bythetimetheyareinschool,wecalltheirdiseaseasthma.第32页学龄前期重复喘息治疗发作性（病毒诱发性喘息）:孟鲁司特不能缓解喘息（多原因相关）：吸入激素（ICS）或孟鲁司特第33页第34页

Asimpletooltoidentifyinfantsathighriskofmildtoseverechildhoodasthma:thepersistentasthmapredictivescore

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

第35页

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