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.pptx

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,*,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（Chronic Suppurative Lung Disease）,（2）连续性支气管内膜感染(Persistent Endobrobchial Infections),（3）迁延性支气管炎（Protracted Bronchitis）,（4）慢性支气管炎（Chronic Bronchitis）,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,Wheeze in preschool age is associated with pulmonary bacterial infection and resolves after antibiotic therapy,BACKGROUND:,Neonates with airways colonized by Haemophilus influenzae,Streptococcus pneumoniae or Moraxella catarrhalis are at increased risk for recurrent wheeze which may resemble asthma early in life.It is not clear whether chronic colonization by these pathogens is causative for severe persistent wheeze in some preschool children and whether these children might benefit from antibiotic treatment.We assessed the relevance of bacterial colonization and chronic airway infection in preschool children with severe persistent wheezing and evaluated the outcome of long-time antibiotic treatment on the clinical course in such children.,METHODOLOGY/PRINCIPAL FINDINGS:,Preschool children(n=42)with severe persistent wheeze but no symptoms of acute pulmonary infection were investigated by bronchoscopy and bronchoalveolar lavage(BAL).Differential cell counts and microbiological and virological analyses were performed on BAL samples.Patients diagnosed with bacterial infection were treated with antibiotics for 2-16 weeks(n=29).,Of the 42 children with severe wheezing,34(81%)showed a neutrophilic inflammation and 20(59%)of this subgroup had elevated bacterial counts(10 colony forming units per milliliter)suggesting infection.Haemophilus influenzae,Streptococcus pneumoniae and Moraxella catarrhalis were the most frequently isolated species.After treatment with appropriate antibiotics 92%of patients showed a marked improvement of symptoms upon follow-up examination.,CONCLUSIONS/SIGNIFICANCE:,Chronic bacterial infections are relevant in a subgroup of preschool children with persistent wheezing and such children benefit significantly from antibiotic therapy.,PLoS One.,;6(11):e27913.Epub Nov 29.,第14页,闭塞性细支气管炎（Bronchiolitis Obliterans),北京儿童医院 赵顺英,第15页,定 义,闭塞性细支气管炎（Bronchiolitis obliterans）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-PF,25/PF,PTEF,Vi,Vi/kg,Ve,Ti,RR,PF/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;,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：12mg/kg.d 13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(Episodic wheezing):,不能缓解喘息(unremitting wheezing):,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,Episodic wheezing is defined as wheezing in discrete episodes of 2 to 4 weeks in duration,with the child being well in between episodes.The trigger is usually a viral infection.,In unremitting wheezing,the child has distinct episodes of wheezing but between these severe episodes also has intermittent symptoms,such as coughing or wheezing at night or in response to exercise,crying,laughter,mist,or cold air.Viral infections are also the most common causes of these severe episodes,but they may persist in the presence of other triggers,such as passive smoking,allergen exposure,or air pollution.Consequently,this wheezing phenotype has also,been termed multitrigger wheezing.,The wheezing phenotypes can sometimes be hard to distinguish,and can change as children grow older:,第31页,学龄前期重复喘息表型分类,Episodic wheezing is usually not associated with atopy and rarely progresses to asthma.,In contrast,unremitting wheezing in children of preschool,age is often associated with atopic sensitization,as early as the first year of life.children often have allergies to foods such as hens eggs and cows milk.Many of these children have atopic dermatitis or sensitization to indoor allergens,with subsequent development of impaired lung function.,By the time they are in school,we call their disease asthma.,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,A simple tool to identify infants at high risk of mild to severe childhood asthma:the persistent asthma predictive score,J Asthma.,;48(10):1015-21,Three parameters independently predicted persistent asthma:family history of asthma,personal atopic dermatitis,and multiple allergen sensitizations.,Based on these variables,the PAPS showed 42%sensitivity,90%specificity,67%positive predictive value,and 76%negative predictive value for the prediction of persistent asthma.,第35页,Daily or Intermittent Budesonide in Preschool Children with Recurrent Wheezing,N Engl J Med;365:1990-,BACKGROUND,Daily inhaled glucocorticoids are recommended for young children at risk for asthma exacerbations,as indicated by a positive value on the modified asthma predictive index(API)and an exacerbation in the preceding year,but concern remains about daily adherence and effects on growth.We compared daily therapy with intermittent therapy.,METHODS,We studied 278 children between the ages of 12 and 53 months who had positive values on the modified API,recurrent wheezing episodes,and at least one exacerbation in the previous year but a low degree of impairment.Children were randomly assigned to receive a budesonide inhalation suspension for 1 year as either an intermittent high-dose regimen(1 mg twice daily for 7 days,starting early during a predefined respiratory tract illness)or a daily low-dose regimen(0.5 mg nightly)with corresponding placebos.The primary outcome was the frequency of exacerbations requiring oral glucocorticoid therapy.,RESULTS,The daily regimen of budesonide did not differ significantly from the intermittent regimen with respect to the frequency of exacerbations,with a rate per patient-year for the daily regimen of 0.97(95%confidence interval CI,0.76 to 1.22)versus a rate of 0.95(95%CI,0.75 to 1.20)for the intermittent regimen(relative rate in the intermittent-regimen group,0.99;95%CI,0.71 to 1.35;P=0.60).There were also no significant between-group differences in several other measures of asthma severity,including the time to the first exacerbation,or adverse events.The mean exposure to budesonide was 104 mg less with the intermittent regimen than with the daily regimen.,CONCLUSIONS,A daily low-dose regimen of budesonide was not superior to an intermittent high-dose regimen in reducing asthma exacerbations.Daily administration led to greater exposure to the drug at 1 year.,第36页,气道重塑何时发生?,年幼儿气道炎症作为哮喘起源根本已经受到挑战,因为研究发觉在幼儿哮喘发病时，气道结构改变已经存在，但气道炎症相对缺乏,第37页,气道重塑何时发生？,在哮喘中观察到“气道重塑”与胎儿肺发育时在分支形成期气道构建类似，异常构建与哮喘发病相关,认为气道重塑为先天性，最少与气道炎症平行,第38页,儿童哮喘防治主要性,儿童哮喘病理改变处于可逆性功效性改变（量变）阶段，,必须预防发展到不可逆性器质性改变,（质变）阶段,对儿童哮喘要抓,“,三早,”,：,关注气道重塑,早诊疗、早治疗、早预防,第39页,谢 谢！,第40页,