最大呼气峰流速在儿童哮喘中的应用

目的　探讨最大呼气峰流速 (PEFR)在儿童哮喘诊治中的临床应用价值。方法　用呼气峰速仪测定 43例哮喘患儿急性发作期PEFR。测定缓解期PEFR个人最佳值 ,求出个体化PEFR下降率及警戒值 ,观察2 0例规范监测组和 2 3例非规范监测组个体化PEFR下降率与哮喘发作关系。结果　哮喘发作期时PEFR越低 ,临床表现越重。缓解期规范监测组根据个体化PEFR下降率变化指导预防用药 ,哮喘发作人数、次数及发病呈中、重度表现者分别为 15%、2 3 .5%、2 5% ;非规范监测组分别为 43 .5%、75.5%、76.9% ,两组比较均有显著性差异 (P均 <0 .0 1)。结论　PEFR可作为诊断儿童哮喘和病情严重程度分级依据 ,指导治疗。个体化PE FR下降率较PEFR变异率更灵敏反映病情变化 ,可作为哮喘发作警报 ,指导预防用药 ,以减少发作次数及利于肺功能恢复     

儿童支气管哮喘的诊断进展——2008 PRACTALL解读

5岁及以下儿童哮喘的诊断极为困难,因为诊断只能依靠临床判断、症状评价和体征分析。PRACTALL共识报告特别针对儿童哮喘制定,在诊断中强调了儿童哮喘的自然病史和病理生理特点、儿童喘息的不同类型、儿童哮喘的不同临床表型等,并推荐了不同年龄儿童哮喘的诊断、临床管理及监测的方法;强调诊断需要综合考虑,包括反复喘息的类型、特异体质病史、哮喘危险因素、长期随访、广泛鉴别诊断和观察对支气管舒张剂及抗炎治疗的反应。     

幼儿期支气管哮喘的临床特点及诊断策略

年长儿与成人期的支气管哮喘(哮喘)的诊断并不难,但幼儿期哮喘由于其特殊的生理解剖和免疫特点,并且致喘因素复杂,容易导致诊断不足或过度诊断.目前关于幼儿期哮喘的诊断在全球范围内仍然没有统一的标准,一直是儿科医学界的难点和热点问题.文章总结了幼儿期哮喘诊断的历程及概念,分析幼儿气道生理解剖免疫及临床特点,综合近年来GINA及各国指南对幼儿喘息的诊断观点,探讨幼儿期哮喘的临床特点及诊断策略,以期引起更广泛的关注.     

规范化管理教育对哮喘患儿肺功能的影响

目的探讨规范化管理教育对哮喘患儿肺功能的影响。方法在儿科哮喘门诊就诊或住院的哮喘患儿110例,随机分为管理组和非管理组各55例。对管理组患儿家长和学龄患儿进行哮喘及其药物基本知识教育,根据病情吸入不同剂量的布地奈德或丙酸倍氯米松(必可酮),定期随诊,适时升级或降级治疗;对照组仅进行发作期治疗。观察1年,对两组治疗前后临床疗效及肺功能进行比较。结果1年后管理组总有效率高于对照组(P<0.05);管理组患儿各项肺功能指标升高,与对照组比较差异有显著性(P<0.05),对照组观察前后各项指标比较差异无显著性(P均<0.05);管理组患儿1年内哮喘发作次数及治疗费用较观察前明显减少(P<0.05),对照组观察前后两项指标比较差异无显著性(P均>0.05)。结论对哮喘患儿进行规范化管理教育后患儿临床症状得到控制,肺功能显著改善,值得推广应用。     

Regional variation in the diagnosis of asthma among preschool‐age children

To study potential regional variation in asthma diagnostics, we retrospectively analyzed the management of 800 acutely wheezing preschool‐age children in two university clinics in Finland. Multivariate modelling indicated that the place of treatment was a strong independent predictor of asthma diagnosis during acute symptoms. Similar regional preferences in diagnostic activity may exist in other countries.     

呼气峰值流量在儿童哮喘诊断及管理中的应用进展

呼气峰值流量（peak expiratory flow,PEF）是一种简单、可靠、低成本的肺功能检查方法。PEF可反映呼气气流受限情况,其变异率可判断气流受限有无可逆性,为儿童哮喘的诊断提供客观依据。短期监测PEF可协助管理哮喘急性发作、查找诱发因素、评估治疗效果等。长期监测PEF有助于哮喘控制的评估及预警急性发作,适用于重度哮喘患儿。该文就儿童PEF的检查方法、影响因素、结果判读,以及在儿童哮喘诊断和管理中的应用进展进行综述,为儿童PEF的临床应用提供参考。     

The value of FeNO measurement in asthma management: the motion against FeNO to help manage childhood asthma--reality bites

Since exhaled nitric oxide (FeNO) was first demonstrated to be raised in asthmatic patients in the early 1990s, there has been a strong interest in its potential role in the diagnosis and management of asthma. This culminated in 2003 when the US Food and Drug Administration cleared the NIOX nitric oxide analyser for clinical application in patients with asthma. The interest in FeNO is based on the assumptions that FeNO is a marker of asthma and asthma control, and that it reflects eosinophilic airway inflammation. However, the literature remains unconvincing and inconclusive. Furthermore, studies which have management algorithms that include FeNO as a guide to asthma treatment have failed to observe any improvement in asthma control compared with the use of standard asthma guidelines. At present, the cost of including FeNO in management guidelines far outweighs any potential benefits.     

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??Objective To explore the change of exhaled nitric oxide ??eNO?? in children from community and its importance in asthma management. Methods The study was conducted from October 2011 to December 2011. Totally 133 non-asthmatic children and 94 asthmatic children aged 7~12 years old from elementary schools in Beijing Xicheng District were included in the study. The eNO?? skin prick test ??SPT???? lung function and physical examination were carried out and information of medical history was collected in all children. The eNO level between non-asthmatic children and asthmatic children?? and its association with atopy?? rhinitis?? lung function and asthma control were analyzed. Results eNO levels of non-asthmatic children and asthmatic children were 11.63±1.88 ppb?? and 19.68±2.31 ppb respectively and the difference between them was statistically significant ??P<0.01??. In non-asthmatic children?? the level of eNO in children with rhinitis was significantly higher than in children without rhinitis ???17.49±2.02??×10-9 vs. ??10.42±1.76??×10-9?? P<0.01?? and eNO level in atopic children was higher than non-atopic children ???23.06±2.18??×10-9 vs. ??9.60±1.66??×10-9?? P<0.01??. In asthmatic children?? the difference in eNO level was not significant in children with rhinitis and without rhinitis ???19.58±2.34??×10-9 vs. ??20.09±2.25??×10-9??? but the eNO levels in atopic children ??23.06±2.18??×10-9 was significantly higher than non-atopic children ???8.75±1.86??×10-9?? P<0.01??. The level of eNO of uncontrolled asthmatic children was significantly higher than controlled asthmatic children ???25.09±2.31??×10-9 vs. ??17.21±2.22??×10-9?? P<0.05??. There was no significant difference in eNO level between children who used and those who did not use inhaled corticosteroid. The eNO level was not related to lung function parameters either in non-asthmatic or in asthmatic children. Conclusion The eNO level increases significantly in children with asthma or rhinitis and is associated with asthma control status. Atopy is an important factor on eNO level as well. Measuring eNO level would help improve the diagnosis of asthma and atopy and management of asthma and rhinitis in children from community.     

Survey of the use of complementary medicines and therapies in children with asthma

OBJECTIVE: To survey the frequency of use of complementary medicines (CM) and complementary therapies (CT) in asthmatic children. METHODOLOGY: A 3-month survey of asthmatic inpatients and outpatients of a teaching hospital respiratory paediatrician was undertaken. Parents answered a structured questionnaire about their past and present usage and opinions of CM and CT. Parents and the physician independently assessed overall asthma control. 'Users' and 'non-users' of CM and CT were compared for characteristics of asthma, usage of conventional medications and parental demographics. RESULTS: One hundred and seventy-four children with 331 parents were enrolled in the study. All of the children were on bronchodilators and 150 (86.2%) were on disodium cromoglycate or inhaled steroids. Control was assessed by a physician as good in 95 children (54.6%), fair in 65 (37.4%) and poor or very poor in 13 (7.5%). Ninety (51.7%) of the children had used at least one CM in their lifetime. Out of the 145 preparations used, 90 (62.1%) were in current use. Vitamins and minerals (53.2%) and herbal preparations (29%) were used most commonly. Only 47.8% of parents had told their doctors about the use of CM. Costs ranged from $A2-$A200 (median $A10) per month. Forty-three (24.7%) of the children had been taken to an alternative practitioner at a cost of $A25-$A400 (median $A40) per month. Users of CM and CT were significantly more likely than non-users to have persistent asthma (P < 0.02), be on high-dose inhaled or oral steroids (P < 0.05), to have poor or very poor control of symptoms (P < 0.04), and more frequent doctor visits (P < 0.05). They also had more adverse reactions to relieving bronchodilators (P < 0.02) and were significantly older than non-users (P < 0.02). The most common reasons for using CM and CT were dissatisfaction with conventional therapies and concerns about steroid side-effects. CONCLUSIONS: Health professionals should be aware of the high rates of usage of CM and CT in asthmatic children and of parental attitudes to conventional and alternative therapies.     

Epidemiological studies of the very high prevalence of asthma and related symptoms among school children in Costa Rica from 1989 to 1998

The aim of our study was to determine the prevalence of asthma and related respiratory symptoms in school children from Costa Rica during the last 10 years, from 1989 to 1998. Using nationally representative samples of school children from Costa Rica during the last 10 years we have performed three studies. Altogether 9931 children were investigated. The age groups: study I, 5–17 years (n = 2682), study II, 6–7 years (n = 2944), 13–14 years (n = 3200) and study III, 10 years (n = 1105). The diagnostic criteria for asthma used in these studies was as follows: study I (1989), diagnosis by a doctor in combination with the presence of four kinds of respiratory symptoms; studies II (1995) and III (1998), history of wheeze in the past 12 months. The two latter were part of the International Study of Asthma and Allergies in Childhood (ISAAC). A very high prevalence of a history of wheezing was found in the three studies (46.8%, 42.9%, and 45.1%) as well as a diagnosis of asthma (23.4%, 27.7% and 27.1%). The physician's diagnosis of asthma reported in the first study (23%) increased from 23.1 in study II to 27.7% in study III (p = 0.004). This increment could be a real increase in asthma prevalence, or be due to a better awareness about asthma. In study II the group of 6–7‐year‐olds had respiratory symptoms significantly more often than 13–14‐year‐olds (p < 0.001). Boys more often had a history of wheezing (p = 0.001), wheeze during the previous 12 months (p = 0.01) and an asthma diagnosis at the age of 6–7 years (p = 0.002) than girls, but girls had more respiratory symptoms than boys at the age of 13–14 years (p < 0.005). Wheezing in the past 12 months was more common for those living in urban areas aged 6–7 years (p = 0.04), and there was an increase of wheeze after exercise (p = 0.01). For the 13–14‐year‐olds the risk of wheezing was higher during the previous 12 months if they lived in temperate areas (<20°C) and at a high altitude (>1000 m). Living in a rural area and in a warm region (>20°C), increased the risk of dry cough during the previous 12 months in the group of 13–14‐year‐olds. In conclusion, Costa Rica is located in the tropics with a very high humidity, an enormous variety of flora and fauna and a very high prevalence of mite and cockroach allergens, which provide important risk factors that may explain the high prevalence of asthma and asthma‐related symptoms. Further possible factors, such as the change towards a more Western life style, resulting in fewer infections and parasitic diseases in the first years of life and changes in bedding material, may also be unresolved. Increased environmental pollution may add to the very high prevalence of asthma and related respiratory symptoms. The very extensive exposure to mites and cockroaches in bed material and in homes with poor ventilation may be an important factor, but many asthmatic children behave as non atopic, with a viral respiratory infection as a major precipitating factor.     

儿童过敏性结肠炎33例诊治分析

目的探讨儿童过敏性结肠炎(AC)的诊治特点。方法分析33例AC儿童的临床表现、结肠镜及病理学特点、相关的实验室检查及治疗情况。结果①AC以2岁以下儿童多见,共24例(占72.7%)。临床主要表现为腹泻28例(84.8%),便血25例(75.8%),其他还有腹痛、体重下降、腹胀、呕吐等。②内镜下表现为灶性红斑、粘膜变脆7例(21.2%),多发性小结节12例(36.4%),血管减少、多发浅表糜烂10例(30.3%),明显溃疡、表面渗出4例(12.1%),主要累及直肠24例(72.7%),乙状结肠28例(84.8%)。组织病理学主要表现为粘膜各层EOS浸润,以固有层轻中度浸润为主(94%)。③病史及辅助检查包括有:血红蛋白下降23例,外周血EOS增高8/20例。血清白蛋白下降5/33例,IgA下降6/10例,IgE增高6/18例。过敏原阳性9/18例,其中牛奶阳性3例,鱼虾、蟹阳性3例,鸡蛋阳性2例,豚草阳性1例。11例病儿有过敏性体质史。10例症状发作与进食食物明显有关(牛奶6例,鸡蛋2例,豆制品1例,动物肝脏1例),5例患儿母亲有明显进食牛奶及海鲜食物史。④患儿经住院治疗均缓解出院,平均住院时间(10.2±4.7)d。结论儿童AC临床表现及内镜特点各异;详细的病史、辅助检查、内镜检查结合多点粘膜活检有助于AC的诊断;停食可疑食物是治疗AC的关键。     

Time trend of asthma prevalence among school children in Taiwan: ISAAC phase I and III surveys.

The standardized International Study of Asthma and Allergies in Childhood (ISAAC) is a valid tool in assessing prevalence of asthma indices. In order to determine the time trends of childhood asthma in Taiwan, we compared data from nationwide ISAAC surveys from a very large sample of Taiwanese 12- to 15-year-old school children, using ISAAC core written and video questionnaires. The number of participants was 44,104 in 1995-96 (phase I) and 11,048 in 2001 (phase III). We found a general tendency towards an increase in lifetime prevalence of physician-diagnosed asthma and asthma symptoms between two surveys, more marked for girls than for boys. Most of the 12-month prevalence of asthma symptoms decreased among boys but stabilized among girls. When comparing different severity levels, we also noted that the decreasing trends of current symptoms were more marked with regard to severe symptoms than mild symptoms in both sexes. A combination of both improved awareness and management of asthma might in part explain this circumstance. Over the past decade in Taiwan, the lifetime prevalence of childhood asthma was increasing, more marked among girls; however, the 12-month prevalence of asthma symptoms was decreasing, mostly among boys. The exact reasons for such trends remain to be explored.     

Application and efficacy of the multi‐dose powder inhaler, Easyhaler®, in children with asthma

With powder inhalers, optimal performance is dependent on the inspiratory flow produced by the patient through the devices. The objective of this open, non‐randomized study was to evaluate the suitability of a new, multi‐dose, dry powder inhaler, the Easyhaler^®, for children with asthma. The peak inspiratory flow (PIF) through the Easyhaler (PIF_EH) was measured with a pneumotachograph in 120 asthmatic children aged 4–16 yr. The bronchodilatory effect of 0.2 mg salbutamol through the Easyhaler was compared with that of 0.2 mg salbutamol through a metered dose inhaler (MDI) with a spacer, in 15 children with obstruction. The mean PIF_EH was 56 l/min (range 22–83 l/min). The PIF_EH correlated significantly with age, height, and absolute peak expiratory flow (PEF), but not with the level of obstruction (PEF percentage of predicted, range 45–146%). Only four children (aged 5, 6, 10, and 16 yr) had PIF_EH values below 28 l/min, which has been shown in in vitro studies to be the threshold for effective use of the Easyhaler. In 15 children with PEF, < 85% of predicted bronchodilatory effects of 0.2 mg salbutamol through the Easyhaler and from an MDI‐cum‐spacer were equal. Most children aged 6–16 yr produce PIF values sufficient for the use of the Easyhaler. The gain of 0.2 mg salbutamol from the Easyhaler was equal to that from a new, unprimed, MDI with a spacer in children with asthma.     

The relative importance of socio-economic status,parental smoking and air pollution (SO2) on asthma symptoms,spirometry and bronchodilator response in 11-year-old children

The aim of this study was to evaluate the relative contribution of several risk factors to the prevalence of allergic respiratory symptoms, and the positivity of the bronchodilator test with fenoterol, and to establish the relative importance of these factors on the variability of FVC, FEV₁, PEF, MEF₂₅, MEF₅₀ and MEF₇₅. A total of 340 11-year-old children attending school in polluted and non-polluted areas of the city of Cartagena, Spain, were studied. The polluted area had had an annual mean of 75 μg/m³ of SO₂ over the last 10 years and the non-polluted area had < 20 μg/m³ during this period. A questionnaire about allergic respiratory symptoms was completed by the parents. Specific questions about parental smoking habits and socio-economic level were included. Each child’s performance in spirometry before and after administration of 0.2 mg of inhaled fenoterol was evaluated. The only significant predictive variables in the logistic regression (for suffering any symptom or a positive bronchodilator response) were male sex for nasal symptoms (RR 1.37; p = 0.04) and housing near heavy traffic for eye symptoms (RR 1.45; p = 0.01). Living in the polluted area reduced the risk of a positive bronchodilator response (RR 0.61; p = 0.004). Maternal smoking, even though not statistically significant, tended to increased the risk of suffering any symptom (RR 1.26; p = 0.07) or of having a positive bronchodilator response (RR 1.23; p = 0.1). None of the risk factors studied was of significant importance in explaining the variability of spirometry results. Although none of the risk factors were specifically determinant to the symptom questions, bronchodilator test or spirometric measurements, having a mother who smokes seems more important than living in a polluted area if statistically non-significant trends are considered.     

Associations between home dampness and presence of molds with asthma and allergic symptoms among young children in the tropics

Existing literature has shown that home dampness increases indoor mold burden and is associated with increased allergic symptoms among young children in temperate environments. There is no report of any studies of similar nature in the tropics where conditions are characterized typically by high temperatures and humidity with rainfall throughout the year. To evaluate if there are associations between the prevalence of current asthma and allergic symptoms in young children (age 1.5-6 yr) with dampness and indoor mold in children's bedrooms in a tropical environment. A cross-sectional study adopting an expanded and modified ISAAC--International Study on Asthma and Allergies in Children--questionnaire for the evaluation of asthma and allergies was conducted on 6794 children (4759 responded--70%) attending 120 randomly selected daycare centers. Specific information on demographics, home dampness, and the visible presence of indoor molds were obtained. The prevalence ratios (PR) and 95% confidence interval (CI) were determined by Cox proportional hazard regression model with assumption of a constant risk period as recommended for cross-sectional studies. The calculated PRs were controlled for age, gender, ethnicity, socio-economic status, type of housing, maternal and paternal atopy, respiratory infections, environmental tobacco smoke (ETS) exposure, and food allergy. After adjusting for potential confounding effects, home dampness was observed to be significantly associated with current symptoms of rhinoconjunctivitis (adjusted PR 1.53, 95% CI: 1.00-2.33). The visible presence of mold was significantly associated with current symptoms of rhinitis (PR 1.55, 95% CI: 1.16-2.07) and rhinoconjunctivitis (PR 2.38, 95% CI: 1.51-3.75). Indoor dampness and mold in children's bedroom are important risk factors associated with allergic symptoms in young children in Singapore.