王秀芳关于婴幼儿喘息的几个问题.ppt

,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,.,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,.,*,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,*,*,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,年幼儿童哮喘诊断及治疗,的几个问题,郑州大学第三附属医院儿科 王秀芳,1,.,儿童喘息,儿童呼吸系统疾病的常见症状,一组临床综合征，任何能导致气道狭窄的疾病均可有喘息,1/3,的儿童在,3,岁前至少发生过一次喘息,可为良性、自限性过程,或表示严重的呼吸系统疾病,反复喘息的儿童最有可能被诊断为哮喘,其他疾病也可表现为儿童期喘息,2,.,Slide,3,婴幼儿喘息和哮喘,婴幼儿喘息和哮喘的特点为,：,患病率增长最快,喘息发生率最高,就医率最高,-5,岁以下受累有,1300,万,住院率,-,比其他儿童高,3,倍,因喘息需门诊,300,万人次,/,年,因喘息需急诊,57,万人次,/,年,因喘息需处方,870,万张,/,年,Gentile et al 57 th,AAAAI meeting,2001,；,National Asthma Campaign.,Asthma J,2001N,76,80,84,88,92,96,00,年,英国每周新的哮喘病人数,(,每,100,000,一个年龄组,),0 4,岁,514,岁,15,岁,180,160,140,120,100,80,60,40,20,0,3,.,Slide,4,婴幼儿喘息的临床表现,呼吸短促伴胸骨下段凹陷,喂养困难、喂奶时喘鸣,反复,发作,喘,息,夜间觉醒、易疲劳,Gentile et al,;57thAAAAI Annual meeting 2001,4,.,婴幼儿喘息的鉴别诊断问题,5,.,年幼,儿童反复喘息的原因,结构异常,气管支气管软化症,血管压迫,/,血管环,气管狭窄,/,气管蹼,囊性病变,/,肿块,肿瘤,/,淋巴结肿大,心脏扩大,其他,6,.,功能性异常,哮喘,胃食管反流*,气道,异物,囊性纤维化,免疫缺陷,原发性纤毛运动障碍,支气管肺发育不良,闭塞性细支气管炎,肺水肿,声带功能障碍,间质性肺病,7,.,8,.,9,.,先天性气管软化,女岁月,生后月起反复咳嗽、喉中痰鸣、气喘,肺部可闻及喘鸣音曾次因咳嗽气喘住院治疗，平均每次住院时间达,5,天左右,按哮喘吸入治疗年，发作次数逐渐减少，仍有喘息发作,10,.,气管支气管造影：,1,名患有先天性气管狭窄的,7,岁男孩,图片：气管下段和两个主支气管狭窄，,临床：沙丁胺醇治疗无效,11,.,支气管占位,谭,XX,男岁,主诉：咳嗽一周，气喘五天,特点：发作时气急、呼吸困难、大汗、颈静脉怒张,两肺呼吸音低,有时可闻及痰鸣音、喘鸣音,外院诊为哮喘发作予普米克令舒、喘乐宁、甲强龙,吸氧等治疗有所缓解，但仍时有发作,入院,5,天后渐发作频繁，一周后出现极度吸气性呼吸困难,胸片及,CT:,两肺气肿改变,12,.,13,.,胸内巨大甲状腺肿压迫气管,胸片：显示右侧胸内有一个巨大的肿块，颈部和近端的胸内气管移位、狭窄,临床：出现喘鸣症状,14,.,支气管发育异常,15,.,支气管肺发育不良,16,.,、,闭塞性细支气管炎,17,.,年幼儿童哮喘的诊断问题,18,.,评估气道炎症的最可靠指标,支气管镜黏膜活检,支气管肺泡灌洗标本,19,.,呼出气一氧化氮（,FeNO,）,研究显示通过呼气流速控制或呼出气收集法进行,FeNO,检测可能对婴幼儿喘息的诊断及早期预测持续性喘息有一定意义,Moeller A,Diefenbacher C,Lehmann A,et al.Exhaled nitric oxidedistinguishes between subgroups of preschool children with respiratory symptoms J.Allergy Clin Immunol,2008,121(3):705,20,.,肺通气功能检查,常用于年幼儿童肺通气检查项目：,IOS,、,体描法、阻断法、潮气肺通气功能,确定准确、客观的年幼儿童气道阻塞可逆性的检测方法并制定其参考标准是今后我们的工作重点之一,21,.,5,岁以下儿童的哮喘症状多变、缺乏特异性。很难对哮喘的气流受限和气道炎症进行常规评估。,建议采用包含喘息表型定义的症状描述性方法，以协助,5,岁及以下儿童哮喘的诊断,.,22,.,婴幼儿喘息的,临床表型,早期一过性喘息,早期持续性喘息,迟发性喘息（哮喘）,Global Initiative for Asthma:Global strategy for Asthma Management and Prevention 2009,23,.,临床表型,特点,早期一过性喘息 多见于早产和父母吸烟者,大多数患儿 在生后,3,岁之内喘息逐渐消失,。,早期起病的持续性喘息 与急性呼吸道病毒感染相关的反,复喘息，本人无特应症表现，,也无家族过敏性疾病史。,迟发性喘息,/,哮喘 典型的特应症背景，往往伴有湿疹,24,.,儿童喘息的自然进程,Age(Years),Wheezing Prevalence,Non-atopicwheezers,Transient earlywheezers,IgE-associatedwheeze/asthma,03611,Martinez.,J Allergy Clin Immunol,1999;104:S169-S174.,25,.,哮喘预测指数（,API,）对婴幼儿哮喘诊断的临床应用价值,26,.,Taussig LM,Wright AL,.Tucson childrens respiratory study:1980 to presentJ.J Allergy Clin Immunol,2003,111(4):661,哮喘的预测指数,(API),3,岁之前的喘息患儿过去,1,年内喘息,4,次,如果存在,1,个主要或,2,个次要危险因素提示预测指数阳性,主要危险因素：,父母有哮喘病史,经医生诊断的湿疹,次要危险因素：,外周血嗜酸粒细胞,4%,与感染无关的喘息,医生诊断的变应性鼻炎,27,.,Guilbert TW,Morgan WJ,Zeiger RS,et al.Atopic characteristics of childhood with recurrent wheezing at high risk for the development of childhood asthmaJ.J Allergy Clin Immunol,2004,114(6):1282,修订版哮喘的预测指数（,mAPI,）,3,岁之前的喘息患儿过去,1,年内喘息,4,次,如果存在,1,个主要或,2,个次要危险因素提示预测指数阳性,主要危险因素：,父母有哮喘病史,经医生诊断的湿疹,吸入性过敏原致敏,次要危险因素：,外周血嗜酸粒细胞,4%,与感染无关的喘息,食物型过敏原致敏,28,.,API,可预测,3,岁内,喘息儿发展为哮喘的风险,喘息患儿,年龄,OR,*,灵敏度,特异度,阳性预测值,阴性预测值,到,6,岁,9.8,27.5%,96.3%,47.5%,91.6%,到,8,岁,5.8,16.3%,96.7%,43.6%,88.2%,到,11,岁,4.3,15.0%,96.1%,42.0%,85.6%,到,13,岁,5.7,14.8%,97.0%,51.5%,84.2%,哮喘预测指数严格指标阳性的患儿在,6-13,岁发生哮喘的风险增加,4.3-9.8,倍,哮喘预测指数严格指标特异度均高于,95%,，即,95%,的严格指标阴性患儿在,6-13,岁不发生哮喘,Castro-Rodriguez JA,Holberg CJ,Wright AL,Martinez FD.A clinical index to define risk of asthma in young children with recurrent wheezing.Am J Respir Crit Care Med 2000;162:1403-6.,29,.,其他的哮喘预测指数,基于四项指标的评价体系（英国,2003,）,1.,哮喘家族史,2.,生后第,1,年鼻部症状,3.,生后第,2,年反复呼吸道感染,4.4,岁时对过敏原致敏的证据,如果符合,4,项指标，,10,岁时发生持续喘息的机会是,83%,如果,4,项指标都不符合，则,80%,为一过性喘息,Kurukulaaratchy RJ,Matteews S,Holgate ST,et al.Predieting persistent disease among children who wheeze during early life J.Eur Respir J.2003,22(5):767,30,.,其他的哮喘预测指数,哮喘和螨过敏预防的队列研究（,PLAMA,）（荷兰,2009,）,独立性儿童哮喘预测的危险因素：,男童、过期产、父母教育水平、喘息频度、非感冒性喘息、吸入药物、呼吸道感染、湿疹,Caudri D,Wijga A,Schipper CM,et al.Predicting the long-term prognosis of children with symptoms suggestive of asthma at preschool ageJ.J Allergy Clin Immunol,2009,124(5):903,31,.,疑似为哮喘的低龄儿童喘息的治疗,32,.,大量研究资料显示长期规律的吸入糖皮质激素激素有助于控制婴幼儿喘息，但不能预防婴幼儿喘息发展为持续性喘息。,儿童支气管哮喘诊断和防治指南,（中国、,2008,）建议对,API,阳性的婴幼儿按哮喘治疗,Bisgard H,Hermansen MN,Loland L,et al.Intermittent Inhaled corticosteroids in infants with episodic wheezing【J】.NEnglishJM,的，,2006,354,（,19,）：,814,33,.,早期干预的措施,应用吸入型糖皮质激素,白三烯调节剂的作用,应针对,哮喘发生的危险因素制订早期干预措施，如积极控制环境污染、减少或避免父母吸烟、避免过敏原的暴露等,34,.,中华医学会儿科学分会呼吸学组,.,儿童支气管哮喘诊断与防治指南,中华儿科杂志,.2008;46:745-53,儿童哮喘需要维持治疗,儿童支气管哮喘诊断与防治指南,2008,中哮喘临床缓解期处理措施之一：,病情缓解后应继续使用长期控制药物，如使用最低有效维持量的,ICS,等,35,.,ICS用于,反复发作喘鸣及过去,1,年中发作喘鸣的,学龄前患,儿,每日应用,间歇应用,36,.,喘息婴,幼儿持,续与间歇应用吸入型皮质类激素,(MIST)试验,Zeiger RS for the CARE Network,NEJM 2011;365:1990-2001,37,.,MIST,方案：概述,治疗,时间,：52周,随机治疗组,夜,晚,使用，,呼吸道疾病期间除,外,呼吸道疾病期间,仅,使用,7天,每日低,剂,量,布地奈德,布地奈德,0.5 mg,下午使用,安慰剂上午使用,布地奈德,0.5 mg,下午使用,间歇,高剂量,布地奈德,安慰剂下午使用,布地奈德,1.0 mg,上午使用,1.0 mg,下午使用,队列(N=278)：1253月龄，频发,喘鸣,，,修订,版,API，过去1年,发作过喘鸣,，间歇性,发作,入组,：安慰剂,夜,晚,使用,+沙丁胺醇,需要时使用,(PRN),38,.,每日与间歇,ICS,治疗组至首次发作的时间相似,(Rate 0.95/person yr),(Rate 0.97/person yr),P,值,=0.87,0,50,100,150,200,250,300,350,400,0,20,40,60,80,100,B.,时间,(,天,),139,114,100,89,78,71,64,50,139,114,93,84,74,66,54,40,危险患者例数,间歇治疗,每日治疗,间歇治疗,(,比率,0.95/,人年,),每日治疗,(,比率,0.97/,人年,),未使用泼尼松龙的患者,%,39,.,每日,vs.,间歇,布地奈德,次要指标结果,无显著性差异,无发作天数,(EFD),婴幼儿生活质量,沙丁胺醇使用天数所占比例,(,约,5%),呼出气一氧化氮,(F,E,NO),水平,生长,但是，每日布地奈德治疗组患儿的累计剂量达到,104 mg,，或者说比间歇治疗组高,3.3,倍,40,.,从,MIST,试验获得的经验,对于喘鸣频发且过去,1,年中发作加重的,API,阳性的,学龄前患儿,尽管进行,ICS,治疗，但疾病负担仍然巨大,在呼吸道疾病早期（,Pre-empt),开始间歇高剂量布地奈德治疗，并持续,7,天，可能是每日低剂量布地奈德疗法的一种,替代治疗方案，,因为：,结果相似,用药频率较低,ICS,用药剂量较低,41,.,难治性重症哮喘的定义,42,.,郑州大学三附院小儿呼吸内科,呼吸一病区,呼吸二病区,儿童纤维支气管镜室,PICU,病区,儿童哮喘门诊,43,.,儿童哮喘门诊,雾化治疗室,肺功能室,免疫治疗室,44,.,国家继续教育项目,儿童呼吸系统疾病和呼吸治疗技术,2014.6.21-22,郑州,45,.,谢 谢,1/11/2025,46,.,