儿童塑型性支气管炎诊疗进展

儿童塑型性支气管炎是一种较罕见的疾病,病因不明,起病隐匿,进展快,症状重,诊断和治疗难度大,病死率高.儿童塑型支气管炎被认为与某些疾病包括支气管哮喘、囊性纤维病、伴发急性胸部综合征的镰状细胞病、先天性心脏病以及各种呼吸道细菌性和病毒性感染有一定关系.关于儿童塑型性支气管炎的诊断和治疗目前仍较困难,临床医生应该警惕该病,做到早期诊断、早期治疗.     

塑型性支气管炎研究进展北大核心CSCD

塑型性支气管炎（plastic bronchitis or bronchial casts,PB）是一种罕见的、涉及多系统的临床综合征,其主要特征是支气管内形成树样管型,引发局部或广泛阻塞,导致急性致命性的呼吸窘迫。本病国内多见于感染相关性疾病,国外则报道先天性心脏病术后患者较多见。塑型性支气管炎的治疗是一项具有挑战性的问题,其病死率高,尚未出台有效的治疗方案。目前支气管镜作为急性期唯一能迅速缓解症状的治疗方法被国内外学者所认可,药物治疗方案多种多样,但尚无统一标准,支气管扩张剂、高渗盐水、白三烯调节剂、大环内酯类、糖皮质激素、黏液溶解剂、肝素、纤维溶解剂等治疗逐渐被提及并应用于临床。塑型性支气管炎发病机制尚不明确,临床表现多样,早期诊断及治疗尤为重要。     

保守治疗六例儿童塑型性支气管炎

目的探讨儿童塑型性支气管炎在不适于应用气管镜时的诊断和救治方法。方法总结我院2011年9月至2012年11月收治的6例儿童塑型性支气管炎病例。结果入院时主要诊断：支气管肺炎,气管异物,肺不张,胸腔积液,重症肺炎,急性呼吸窘迫综合征。收治时6例均有呼吸困难,病情危重,均需机械通气治疗。经肺CT及支气管腔内塑型性异物病理组织学切片明确诊断,气道内雾化、震荡排痰治疗排出树枝状痰栓后病情迅速好转。结论塑型性支气管炎是儿科急危重症,肺CT气道重建对早期诊断有重要意义,急诊做支气管镜取出痰栓是最佳选择,但在不适于应用气管镜或就诊医院小具备气管镜时,应用气管内雾化及震荡排痰治疗也能取得较好疗效。     

儿童塑型性支气管炎的临床特征及鉴别诊断

塑型性支气管炎(PB)是指内生性异物局部或广泛性堵塞支气管,导致部分或全部通气功能障碍的一种疾病。PB临床表现不具有特异性,常表现为咳嗽、进行性呼吸困难和难以改善的低氧血症;而经支气管镜取出塑型物后,呼吸困难及低氧血症可迅速缓解。现重点阐述PB的临床特征及鉴别诊断,旨在提高临床医师对该病的诊断水平。     

肺炎支原体塑型性支气管炎5例临床分析

目的分析肺炎支原体塑型性支气管炎临床特点。方法回顾分析5例肺炎支原体塑型性支气管炎患儿的临床资料。结果 5例患儿,男4例、女1例,均有咳嗽、高热,热程为5～13天;呼吸困难、呼吸衰竭3例;合并中毒性肝炎2例,中毒性脑病、中毒性心肌炎各1例,髂静脉及股静脉血栓1例。胸部影像学检查5例均有单侧肺不张伴肺实变。病程第4～10天经支气管镜检查见塑型物堵塞段支气管4例、主支气管1例,确诊为塑型性支气管炎,经2～4次支气管镜术钳取出塑型物,临床治愈出院。结论肺炎支原体肺炎伴呼吸困难、单侧肺不张/肺实变,需警惕塑型性支气管炎;支气管镜术对明确诊断、改善预后有重要作用。     

小儿重症甲型H1N1流感合并塑型性支气管炎四例分析并文献复习

目的 分析小儿重症甲型流感(甲流)合并塑型性支气管炎的诊治特点.方法 对2016年1月至3月北京儿童医院PICU收治的4例危重症甲流合并塑型性支气管炎患儿的临床表现、支气管镜检查、治疗经过和转归进行回顾性分析.结果 本组4例甲流患儿均为危重病例,急性起病,迅速出现呼吸衰竭,均进行机械通气支持,从发病到实施纤维支气管镜(纤支镜)灌洗时间为入院第2天;所有患儿均使用纤支镜析出白色胶冻样痰栓,呈支气管树样;并在经纤支镜析出痰栓及呼吸机治疗后,病情明显好转.结论 塑型性支气管炎是一种潜在危及生命的疾病,危重症甲流患儿易并发塑型性支气管炎,在甲流流行季节,临床上出现急性起病、短期内进行性呼吸困难,伴肺不张或实变时,应注意本病,如果对常规治疗反应不佳,应尽早施行纤支镜检查治疗.     

塑型性支气管炎研究进展

塑型性支气管炎是一组涉及多系统的临床综合征,其特征是形成大分支的黏液样支气管管型,可引起急性呼吸困难甚至呼吸衰竭,多见于儿童先天性心脏病术后及各种肺部炎性疾病,发病机制尚不明确,临床表现多样,早期诊断尤其重要,应用气管镜将其内生物取出是目前最有效的治疗方法.     

63例儿童流行性感冒合并塑型性支气管炎的临床特征分析

目的 研究儿童流行性感冒（简称流感）合并塑型性支气管炎的临床特征。方法 回顾性分析63例流感合并塑型性支气管炎患儿的临床表现、实验室检查、影像学、治疗及转归特点。结果 63例患儿中,男52例（83%）,女11例（17%）,其中甲型流感42例,乙型流感21例。3~6岁儿童38例（60％）。15例（24%）有基础性疾病。主要的临床表现包括高热（90%）、咳嗽（95%）和气促（73%）。影像学检查显示肺不张24例（38%）。16例（25%）听诊无肺部啰音。入住重症监护室41例,呼吸机辅助通气32例。63例患儿均行纤维支气管镜检查及肺泡灌洗。好转60例,死亡3例。结论 儿童流感合并塑型性支气管炎以男性及学龄前儿童多见。对于有气促的流感患儿,即使胸部X线未提示肺不张或听诊无肺部啰音,也需要警惕合并塑型性支气管炎的可能。     

63例儿童流行性感冒合并塑型性支气管炎的临床特征分析

目的 研究儿童流行性感冒（简称流感）合并塑型性支气管炎的临床特征。方法 回顾性分析63例流感合并塑型性支气管炎患儿的临床表现、实验室检查、影像学、治疗及转归特点。结果 63例患儿中，男52例（83%），女11例（17%），其中甲型流感42例，乙型流感21例。3~6岁儿童38例（60％）。15例（24%）有基础性疾病。主要的临床表现包括高热（90%）、咳嗽（95%）和气促（73%）。影像学检查显示肺不张24例（38%）。16例（25%）听诊无肺部啰音。入住重症监护室41例，呼吸机辅助通气32例。63例患儿均行纤维支气管镜检查及肺泡灌洗。好转60例，死亡3例。结论 儿童流感合并塑型性支气管炎以男性及学龄前儿童多见。对于有气促的流感患儿，即使胸部X线未提示肺不张或听诊无肺部啰音，也需要警惕合并塑型性支气管炎的可能。     

儿童塑型性支气管炎的诊断与治疗

目的　报告 5例儿童塑型性支气管炎病例 ,并复习相关文献 ,总结诊断及治疗方法。方法　 2 0 0 1年5月至 2 0 0 3年 10月 ,对 5例年龄 9个月至 10岁 ,主诉为反复咳嗽、气促并出现急性呼吸窘迫的塑型性支气管炎患儿 ,给予支气管镜检及气道内异物取出术 ,配以反复纤维支气管气道内冲洗、呼吸机机械通气、胸部物理治疗、强化护理及吸痰等综合治疗。结果　 5例中 ,4例支气管镜检取出异物 ,1例为吸痰时吸出支气管状条形异物 ,经病理检查确诊。双侧支气管病变 1例 ,左侧支气管病变 2例 ,右侧支气管病变 1例 ,另 1例吸痰时可吸出。死亡 2例 ,其余 3例均痊愈出院。病理组织学分型按Seear方法 :Ⅰ型 3例 ,Ⅱ型 2例。结论　塑型性支气管炎是一种高危性疾病 ,确诊需依靠支气管镜检查和病理组织学检查。支气管镜异物取出术是唯一有效的治疗方法。气道护理和胸部物理治疗是重要的辅助治疗手段。     

布地奈德溶液雾化吸入治疗对喘息性支气管炎患儿呼吸道阻力的影响

目的研究布地奈德雾化溶液吸入治疗对喘息性支气管炎患儿呼吸道阻力（AR）的影响。方法喘息性支气管炎患儿56例随机分为A组（常规＋布地奈德雾化溶液吸入治疗）和B组（常规治疗）,同时选取同期保健门诊同年龄组正常幼儿30例为对照组。应用Microloop肺功能仪加载的MicroRint传感器分别对各组儿童治疗前后的AR进行监测。结果喘息性支气管炎患儿急性期与对照组相比,AR明显增高（P〈0.01）;治疗2周后,A、B组AR均显著降低（Pa〈0.001）;但A组AR降低程度更明显,与对照组相比无明显差异;B组AR仍高于对照组。结论喘息性支气管炎患儿急性期AR明显升高;加用布地奈德雾化溶液吸入治疗可迅速减低患儿AR,缩短病程。     

Measuring the quality of antibiotic prescribing for upper respiratory infections and bronchitis in 5 US health plans

OBJECTIVE: To develop and test the validity of a quality-of-care performance measure that examines antibiotic prescribing rates in children diagnosed as having upper respiratory infection (URI) or bronchitis. DESIGN AND METHODS: The measure developed examines the annual rate of antibiotic prescribing to children aged 3 months to 18 years with an episode of URI or bronchitis. Administrative data from 5 US health plans were used to identify episodes of URI or bronchitis using International Classification of Diseases, Ninth Revision, codes 460, 465, 466, and 490. Pharmacy data (National Drug Codes) were used to determine whether antibiotics were prescribed for the URI or bronchitis episode. Medical record abstractions were performed on a random sample of 465 cases to assess percentage agreement with pharmacy claims data for antibiotic prescribing. RESULTS: For the 84,166 children and adolescents aged 3 months to 18 years who had at least 1 episode of URI or bronchitis during the measurement year, 31% received antibiotics. Prescribing rates for URI and/or bronchitis varied widely among the 5 participating health plans (2%-75%; P < .001). Inappropriate antibiotic prescribing occurred most frequently for bronchitis episodes, with 4 of 5 health plans prescribing antibiotics in 60% of such cases (range, 60%-80%). Percentage agreement between administrative and medical records data for antibiotic prescribing was 88%. CONCLUSIONS: This quality measure is feasible to implement at the health plan level and validly assesses antibiotic prescribing rates using administrative data. Improvements in adhering to judicious use guidelines for antibiotic prescribing in children with URI and bronchitis are warranted.     

IgG subclass specific antibody response in recurrent bronchitis.

The IgG subclass specific immune response against pneumococcal type 3 polysaccharide antigen before and after immunisation in healthy children and children with recurrent bronchitis was studied. Recurrent bronchitis was defined as three or more episodes a year, during at least two consecutive years, of bronchopulmonary infection, productive cough with or without fever, and/or diffuse rales by physical examination. Twenty five patients and 15 healthy children were selected. The patient group had lower concentrations of IgG1 and IgG2 specific pneumococcal antibodies compared with healthy children, regardless of whether or not the total IgG2 concentration was low. The children with recurrent bronchitis showed a greater increase in IgG1 and IgG2 antibodies after immunisation than the controls. It is concluded that children with recurrent bronchitis show a decreased humoral immune response to pneumococcal type 3 polysaccharide antigen. This finding suggests that a defect in the humoral immune response against polysaccharide antigens is an important cause of recurrent bronchitis in childhood.     

Cast bronchitis in infants and children

Seventy-two children (age range, 3 months to 5.5 years) with a clinical diagnosis of obstructive bronchitis (asthmatoid or spastic bronchitis or bronchiolitis) were found to have bronchial casts in the gastric fluid, and in 2 additional cases casts were spontaneously expectorated in the bronchial exudate. Cast bronchitis had a long-term course of 10 to 24 months in 65 of the 74 patients. Common radiologic findings included bronchi presumably filled with secretions, areas of atelectasis, and lung emphysema of varying degrees. Cast bronchitis did not appear to be associated with eosinophilia and elevated serum IgE levels. Therefore, an extrinsic allergic mechanism is not likely involved in the pathogenesis of the condition. Bronchial casts had varying consistencies; although they were usually soft, they were sometimes rather hard. They were hollow, often ramified, and white and measured from 0.5 to 2 cm in length. Histologically, they consisted of metaplastic squamous epithelium with a varying degree of inflammatory cells and noncellular material. Some differences in biochemical composition were observed between bronchial casts and bronchial exudate of acute catarrhal bronchitis. No viruses could be isolated in 11 cast specimens. Our results suggest that cast formation is mainly related to the metaplastic transformation of the bronchial epithelium and that this metaplasia may play an important pathophysiologic role in certain infants and children with obstructive bronchitis.     

Involuntary smoking and incidence of respiratory illness during the first year of life

A prospective study of 1,144 infants and their families was performed. Smoking and family histories were evaluated with respect to the incidence of lower respiratory disease during the first year of life. It was found that (1) tracheitis and bronchitis occurred significantly more frequently in infants exposed to cigarette smoke in the home, (2) maternal smoking imposed greater risks upon the infant than paternal smoking, (3) occurrence of neither tracheitis nor bronchitis showed a consistent relationship to the number of cigarettes smoked, (4) a family history that was positive for respiratory illness (chronic cough or bronchitis) significantly influenced the incidence of bronchitis, (5) too few cases of laryngitis and pneumonia were seen to warrant any opinions regarding the adverse influence of either smoking or a family history that was positive for respiratory illness, and (6) occurrence of bronchiolitis was not affected by the presence of a smoker nor influenced by a family history that was positive for respiratory illness. It is concluded that passive smoking is dangerous to the health of infants and that infants born to families with a history that is positive for respiratory illness (chronic cough or bronchitis) are at risk of developing bronchitis.     

儿童不同呼吸系统疾病气道反应性特点及其临床价值

目的探讨儿童支气管哮喘、咳嗽变异性哮喘(CVA)和支气管炎等不同呼吸系统疾病气道反应性特点及其临床价值。方法应用Astograph法气道反应性测定技术,对42例哮喘患儿、38例咳嗽变异性哮喘(CVA)患儿、36例支气管炎患儿及30例健康儿童进行气道反应性测定;分别对反映气道敏感性和气道反应性的Dmin、SGrs、PD35等各指标进行统计学分析和评估。结果哮喘组、CVA组和支气管炎组患儿的Dmin、SGrs、PD35等指标均低于健康对照组,差异有统计学意义(P<0.05),哮喘组、CVA组与支气管炎组患儿之间比较,差异也有统计学意义(P<0.05),而哮喘组与CVA组患儿比较,差异无统计学意义(P>0.05)。结论哮喘病、CVA和支气管炎等不同呼吸系统疾病患儿的气道反应性及气道敏感性均高于健康儿童,而不同呼吸系统疾病患儿的气道反应性、气道敏感性变化也各不相同,以此可为鉴别诊断提供依据。     

普米克令舒治疗喘憋性肺炎的临床观察

目的 观察普米克令舒雾化吸入治疗流行性喘憋性肺炎的疗效.方法 将喘憋性肺炎患儿随机分为两组,治疗组98例,在常规治疗基础上加用普米克令舒(布地奈德),对照组58例,给予常规治疗,观察临床症状:咳嗽、气急、喘息、肺部哮鸣音.对结果采用卡方检验.结果 治疗组治疗前后病情明显改善,优于对照组,两组总有效率分别为93.8%,72.4%,治疗组明显优于对照组(x2=13.877,P=0.001).结论 普米克令舒雾化吸入治疗喘憋性肺炎疗效满意.     

Management of Plastic Bronchitis With Topical Tissue-type Plasminogen Activator

Plastic bronchitis or cast bronchitis is a rare disease of unclear etiology characterized by formation of airway casts that can lead to life-threatening airway obstruction. There is currently limited data regarding optimal treatment of plastic bronchitis. Several therapies have been suggested, but recurrences are common and mortality remains high. We report the case of a 6-year-old boy with refractory eosinophilic bronchial casts, unresponsive to low-dose systemic corticosteroids, inhaled corticosteroids, azithromycin, and dornase alfa, who was treated successfully and safely with direct instillation of tissue-type plasminogen activator (tPA) to the obstructing casts during flexible bronchoscopy and inhaled tPA. Our case illustrates that the current therapy for plastic bronchitis remains inadequate. To our knowledge, this case is the first to show that direct instillation of tPA can be used safely for treatment of this disease. The use of tPA via direct administration into the airways during bronchoscopy and via a nebulizer appeared to be a safe and effective therapy for plastic bronchitis and should be considered early in the course of the disease to prevent complications of severe airway obstruction.     

Long-term treatment of plastic bronchitis with aerosolized tissue plasminogen activator in a Fontan patient.

OBJECTIVE: To report the successful treatment of plastic bronchitis with aerosolized tissue plasminogen activator. DESIGN: Case report. PATIENTS: A 4-yr-old boy with congenital heart disease, who developed plastic bronchitis 33 months after a Fontan operation INTERVENTIONS: Long-term treatment with aerosolized tissue plasminogen activator. MEASUREMENTS AND MAIN RESULTS: We describe the case of a boy who developed recurrent episodes of life-threatening airway obstruction secondary to plastic bronchitis. Following the failure of multiple therapeutic interventions, his condition improved significantly with aerosolized tissue plasminogen activator. Several attempts to wean him off this treatment resulted in clinical deterioration. He has remained on long-term aerosolized tissue plasminogen activator. CONCLUSION: Treatment of plastic bronchitis with aerosolized tissue plasminogen activator may benefit patients in whom other therapies have failed.     

Regional blood flow and air level in the lung segments in recurrent and chronic bronchitis in children

Transbronchial regional electroplethysmography was employed to measure the blood flow and air content in 67 children aged 3-15 years. Of these, 44 children suffered from chronic bronchitis and 23 from bronchiectasis. Children with recurrent bronchitis examined during the inactive phase of the disease marked by clinicoendoscopic silence were used as controls. In children with chronic bronchitis who escaped bronchial deformity, the levels of the regional blood flow were similar to those seen in the controls. Meanwhile in diffuse deforming bronchitis the reduction of the blood flow was noted in the posterobasal segments on both sides. In local deformities and bronchiectasis the levels of the air content and blood flow were decreased in the affected area whereas in the adjacent part the blood flow was more intense as compared with the symmetrical part on the opposite side, which was likely to be connected with the irritative effect of the focus of lesion.