2015芬蘭兒童喉炎、哮喘支氣管炎、細支管治療指引

1、Finnishguidelinesforthetreatmentoflaryngitis,wheezingbronchitisandbronchiolitisinchildren芬蘭兒童喉炎、氣喘支氣管炎、細支氣管炎治療指南TerhiTapiainen(terhi.tapiainenoulu.fi)1,2,JanneAittoniemi3,JohannaImmonen4,HeliJylkk?a5,TuulaMeinander6,KirsiNuolivirta7,VillePeltola8,EevaSalo9,RaijaSeuri10,Satu-MaariaWalle11,MattiKorppi

2、121.DepartmentofPediatricsandAdolescence,OuluUniversityHospital,Oulu,Finland.芬蘭奧盧大學附屬醫(yī)院兒童和青少年門診1 .PEDEGOResearchUnit-ResearchUnitforPediatrics,Dermatology,ClinicalGenetics,ObstetricsandGynecology,andMedicalResearchCenter,UniversityofOulu,Oulu,Finland.芬蘭奧盧大學PEDEGO(兒科、皮膚科、臨床遺傳學、婦產(chǎn)科)研究中心和醫(yī)學研究中心.FimlabL

3、aboratories,Tampere,Finland2 .芬蘭坦佩雷Fimlab實驗室.TerveystaloPediatricClinic,Kuopio,Finland3 .芬蘭庫奧皮奧Terveystalo兒科診所.DepartmentofPediatrics,UniversityofTampere,Tampere,Finland,4 .芬蘭坦佩雷大學兒科系DepartmentofInternalMedicine,TampereUniversityHospitalandtheFinnishMedicalSocietyDuodecimo,Tampere,Finland6.芬蘭坦佩雷大學附屬

4、醫(yī)院內(nèi)科門診和芬蘭坦佩雷Duodecimo醫(yī)學會7.SeineajokiCentralHospital,Sein?ajoki,Finland7 .芬蘭Seinaejoki中心醫(yī)院.DepartmentofPediatrics,TurkuUniversityHospitalandUniversityofTurku,Turku,Finland.芬蘭圖爾庫大學及其附屬醫(yī)院兒科門診8 DepartmentofPediatrics,HelsinkiUniversityHospital,Helsinki,Finland9 芬蘭赫爾辛基大學附屬醫(yī)院兒科門診.HUSImaging,Children0sHosp

5、ital,HelsinkiUniversityHospital,Helsinki,Finland.芬蘭赫爾辛基大學附屬醫(yī)院、兒童醫(yī)院溶血性尿毒綜合征成像10 .EspoonlahtiHealthCareCenter,Espoo,Finland.芬蘭埃斯波EspoonlahtD1生保健中心11 .DepartmentofPediatrics,TampereUniversityHospitalandUniversityofTampere,Tampere,Finland12 .芬蘭坦佩雷大學及其附屬醫(yī)院兒科門診Keywords關鍵詞Bronchiolitis,Bronchitis,Cough,Lar

6、yngitis,Wheezingbronchitis細支氣管炎、支氣管炎、咳嗽、喉炎、哮喘支氣管炎CorrespondenceTTapiainen,MD,PhD,DepartmentofPediatrics,OuluUniversityHospital,P.O.Box23,90029Oulu,FinlandTel:+35883155185|Fax:+35883155559|Email:terhi.tapiainenoulu.fiReceived13January2015;revised22June2015;accepted17August2015.DOI:10.1111/apa.13162通信

7、地址：芬蘭奧盧大學附屬醫(yī)院兒科醫(yī)學博士、哲學博士Tapiainen先生郵政編碼：23,90029電話：+35883155185|傳真：+35883155559郵箱：terhi.tapiainenoulu.收稿日期：2015.1.13修訂日期：2015.6.22批準日期：2015.8.17（非專業(yè)人士翻譯，供參考，孫桂華，QQ:479327458）ABSTRACT摘要Evidence-basedguidelinesareneededtoharmoniseandimprovethediagnosticsandtreatmentofchildren'slowerrespiratorytrac

8、tinfections.Followingaprofessionalliteraturesearch,aninterdisciplinaryworkinggroupvaluatedandgradedtheavailableevidenceanconstructedguidelinesfortreatinglaryngitis,bronchitis,wheezingbronchitisandbronchiolitis.需制定循證指南來協(xié)調(diào)和改善兒童下呼吸道感染的診斷和治療。根據(jù)專業(yè)文獻研究，交叉學科工作組對現(xiàn)有證據(jù)(即喉炎、支氣管炎、氣喘支氣管炎、細支氣管炎治療指南)進行了評價和等級劃分。Con

9、clusion:Currentlyavailabledrugswerenoteffectiveinrelievingcoughsymptoms.Salbutamolinhalationscouldrelievethesymptomsofwheezingbronchitisandshouldbeadministeredviaaholdingchamber.Nebulisedadrenalineorinhaledororalglucocorticoidsdidnotreducehospitalisationratesorrelievesymptomsininfantswithbronchiolit

10、isandshouldnotberoutinelyused.結論：目前可用藥物不能有效緩解咳嗽癥狀。舒喘靈噴霧療法可以緩解哮喘支氣管炎的癥狀，并需通過儲藥腔來給藥。霧化吸入腎上腺素或吸入/口服糖皮質(zhì)激素并沒有降低住院率或緩解嬰兒毛細支氣管炎癥狀且不應經(jīng)常服用。INTRODUCTION弓I言Evidence-basedclinicalpracticeguidelinesforthetreatmentoflowerrespiratorytractinfections(LRTIs)inchildrenweredevelopedinFinlandin2013-2014.Theyweredevisedb

11、yanindependentinterdisciplinaryworkinggroup,establishedbytheFinnishMedicalSocietyDuodecimandtheFinnishPediatricSociety,thatincludedpaediatricinfectiousdiseasespecialists,generalpaediatricians,aclinicalmicrobiologist,apaediatricradiologistandageneralpractitioner.Thescopeoftheguidelineswasthetreatment

12、ofacutepaediatricLRTIs,excludingseverecasesrequiringhospitaladmissionorintensivecare.2013-201誨芬蘭開發(fā)了兒童下呼吸道感染治療臨床實踐循證指南，并由芬蘭醫(yī)學會和芬蘭兒科學會共同組建的交叉學科工作組對該指南進行修訂，交叉學科工作組由兒科傳染病專家、普通兒科醫(yī)生、兒科臨床微生物學家、兒科放射科醫(yī)生和全科醫(yī)生組成。指南范圍包括小兒急性下呼吸道感染治療，不包括需住院治療或需重癥監(jiān)護的重癥患者。Ourprofessionallibrarianperformedsystematicliteraturesearche

13、susingselectedtopicsandquestions,andthen,thegroupreviewedtheliteratureandevaluatedtheavailableevidence.Thelevelofevidencewasassessedandmarkedwithinguidelinestatementsforthemostcriticaldecisions.Thefollowingcategorylevelsfortheevidencewereused:levelAreferredtostrongevidencewithatleasttwoseparate,high

14、-qualitystudies;levelBreferredtomoderateevidencewithatleastonehigh-qualitystudy;andlevelCreferredtoweakevidencewithatleastonesatisfactorystudy.Ahigh-qualitystudywasdefinedasastudyperformedinanappropriatepopulationwithastrongstudydesign,suchasarandomisedcontrolledtrialwithanappropriateoutcomemeasure.

15、Theguidelinedocumentwaspeer-reviewedby14expertsandcliniciansbeforeitwaspublishedintheFinnishCurrentCareGuidelinesseriesin2014.TheprocessisdescribedindetailontheCurrentCareGuidelineWebpages(www.kaypahoito.fi).由我們專業(yè)的圖書管理員利用所選標題和問題進行系統(tǒng)文獻搜索，然后由交叉工作組對文獻進行評審并對現(xiàn)有證據(jù)進行評價。指南說明對最重要決定的證據(jù)等級進行了評估和劃分。證據(jù)等級種類如下：A級指有

16、力證據(jù)，要求至少有兩個獨立的高質(zhì)量研究；B級指中等證據(jù)，要求至少有一個高質(zhì)量研究；C級指弱證據(jù)，要求至少有一個令人滿意的研究。高質(zhì)量研究是指對適度人群所開展的帶強烈研究設計的研究，如具有適當檢測指標的隨機受控試驗。2014年，在芬蘭現(xiàn)行護理指南系列一書發(fā)表該篇指南文獻前，由14位同行專家和臨床醫(yī)生對該指南進行了評審。詳細過程請登錄www.kaypahoito.fi,查看網(wǎng)頁版現(xiàn)行護理指南。KeyNotes關鍵詞_Aninterdisciplinaryworkinggroupconstructedguidelinestoharmoniseandimprovethetreatmentofchild

17、ren'slowerrespiratorytractinfections.通過由交叉學科工作組創(chuàng)建的指南來協(xié)調(diào)和改善治療兒童下呼吸道感染的治療。Ourreviewfoundthatcurrentlyavailabledrugswerenoteffectiveinrelievingcoughsymptoms,butsalbutamolinhalationscouldrelievethesymptomsofwheezingbronchitis通過審查，我們發(fā)現(xiàn)目前可用藥物不能有效緩解咳嗽癥狀，但吸入舒喘靈可以緩解哮喘支氣管炎癥狀_Nebulisedadrenalineorinhaledor

18、oralglucocorticoidsdidnotreducehospitalisationratesorrelievesymptomsininfantswithbronchiolitisandshouldnotbeenroutinelyused.documentincludedapproximately200referencesandmorethan50linkedsupplementaryWebpagespresentingthesystematicliteraturereviewforeachstatement.Thisformedthefirstpartofthesummarydocu

19、ment.Thesecondpartpresentedthetreatmentofpneumoniaandpertussisinchildren(1).Thedetailedsearchdescriptionbytheprofessionallibrarianispresented(TablesS1S2).霧化吸入腎上腺素、吸入或口服糖皮質(zhì)激素并不能降低住院率或緩解嬰兒細支氣管炎癥狀，且不應經(jīng)常服用。該文獻所列入的參考資料約200篇，50多個鏈接補充網(wǎng)頁，對每種論述進行了系統(tǒng)地文獻評審，并將其作為摘要的第一部分。摘要第二部分講述了兒童肺炎和百日咳治療(1)。專業(yè)圖書館理員檢索詳細描述見表S1-

20、S2。Thispaperpresentstheavailableevidenceandthenewguidelinesfortreatinglaryngitis,wheezingbronchitisandbronchiolitisinchildreninFinland.Theevidence-basedstatements,whichappearinitalicsinthispaper,arepresentedandthereasoningbehindtherecommendationsisdiscussed.Table1summarisestherecommendationsfortheus

21、eofantimicrobials,glucocorticoidsandsympathomimetics.Inadditiontothepresentationofnewguidelines,wehavediscussedrelevantnewstudiespublishedsince2014andexplainedtheireffectonthepresentguidelines.本篇文章講述了有關芬蘭兒童喉炎、哮喘支氣管炎和毛細支氣管炎治療的現(xiàn)有證據(jù)和新指南。文章中的循證論述采用斜體字，并對所做建議的背后原因進行了討論。表1歸納了建議服用的抗菌素、糖皮質(zhì)激素和擬交感神經(jīng)藥。除指南外，我們還

22、對自2014年以來所發(fā)表的相關新研究進行了討論，并就其對當前指南的影響進行了闡釋。AETIOLOGYANDDIAGNOSTICSOFRESPIRATORYVIRUSES呼吸道病毒病原及其診斷AllknownrespiratoryvirusesarecapableofcausingdifferentLRTIssuchaslaryngitis,wheezingbronchitis,bronchiolitisorpneumonia.ThemostimportantvirusescausingLRTIsinchildrenarerhinoviruses,therespiratorysyncytialv

23、irus(RSV),parainfluenzaviruses1W,theadenovirusgroupandinfluenzavirusesAandB.Someviruses,however,aremorelikelytocausespecificLRTIs(2).Rhinovirusesareparticularlyassociatedwithwheezingbronchitis,RSVwithbronchiolitisininfantsandparainfluenzaviruseswithlaryngitis.Accordingly,RSVisthemostimportantvirusth

24、atcauseswheezinginchildrenunderoneyearofageandrhinovirusesarethemostimportantinolderchildren(3).Allrespiratoryvirusesarecapableofcausingfebrileinfections(2),forinstancerhinovirusesareassociatedwithfeverin4050%ofchildrenwithrespiratorytractinfections,theparainfluenzavirusisassociatedwithfeverin60-80%

25、andinfluenzaAin90-95%.Themostimportantrecentlyrecognisedrespiratoryvirusesarethehumanmetapneumovirus,whichisassociatedwithbronchiolitis,andthehumanbocavirus,whichisassociatedwithwheezingbronchitis.Bacteriadonotusuallycauselaryngitis,bronchitis,bronchiolitisorwheezingbronchitisinchildren.Theaetiology

26、ofpneumoniaispresentedintheseparateguidelinedocumentfromthesamegroup（1）.所有已知呼吸道病毒均能導致不同的下呼吸道感染（LRTIs）,如喉炎、喘息性支氣管炎、細支氣管炎或肺炎。導致兒童下呼吸道感染的最重要病毒為鼻病毒、呼吸道合胞病毒（RSV）、副流感病毒1-4、重組腺病毒、A類和B類流感病毒。但有些病毒更有可能會導致特異性下呼吸道感染（2）。鼻病毒尤其與哮喘支氣管炎相關，RSV病毒與嬰兒細支氣管炎相關，副流感病毒則與喉炎相關。相應地，RSV是導致1歲以下兒童哮喘的最重要病毒，而鼻病毒則是導致大齡兒童哮喘的最重要原因（3）。所

27、有呼吸道病毒均能引發(fā)熱性傳染?。?）,例如鼻病毒會導致40-50%呼吸道感染兒童出現(xiàn)高燒，副流感病毒會導致60-80%呼吸道感染兒童出現(xiàn)高燒，A類流感病毒會導致90-95%呼吸道感染兒童出現(xiàn)高燒。最近確認的最重要呼吸道病毒是人類偏肺病毒和人類博卡病毒，人類偏肺病毒與細支氣管炎有關，而人類博卡病毒則與哮喘支氣管炎有關。細菌通常不會引發(fā)兒童喉炎、支氣管炎、細支氣管炎或哮喘支氣管炎。肺炎病原請見同組單獨指南文獻（1）。TestingofinfluenzaAandBvirusisrecommendedtoallchildrenwithLTRIsduringtheinfluenzaseasonifthe

28、durationoftheacutesymptomsis<48hours(levelB).Influenzacannotreliablybediagnosedbasedonclinicalsymptomsinchildren.Antiviraltreatmentagainstinfluenzaiseffectiveifthetreatmentisstartedwithin48hoursofthestartofthesymptoms(4).However,influenzavirustestingmaybebeneficialforpatientsadmittedtohospitaleve

29、nafter48hours.InfluenzavirustestingduringanLRTIislikelytodecreaseantimicrobialconsumption(5).在流感季節(jié)，如果急性癥狀持續(xù)時間低于48小日t(B級)，則建議對所有下呼吸道感染兒童進行A類和B類流感病毒檢測。不能根據(jù)兒童臨床癥狀對流感進行確診。如果在癥狀開始48內(nèi)即開始治療，則能有效地進行抗病毒治療。但即使是在癥狀開始48后，對入院病人進行流感病毒檢測也是有益的。對下呼吸道感染者進行流感病毒檢測有可能會降低抗菌消費(5)。TestingofRSVandotherrespiratoryvirusescanb

30、eperformedonchildrenwhoareadmittedtohospitalduetoanLRTI(levelB)(6,7).Respiratoryvirustestingmaydecreasetheuseofantimicrobialtreatmentafterhospitalisation(8).Wheezingbronchitisorbronchiolitisarerarelyassociatedwithabacterialinfectionofthelowerrespiratorytract.Nosocomialinfectionsmaybedecreasedwithact

31、ivecohortingofhospitalisedpatientsbasedonviraltesting.Wheezingassociatedwitharhinovirusinfectionisariskfactorforlaterasthmainchildren(3).Thesensitivityofpoint-of-careantigentestsislowerthanthatofpolymerasechainreaction（PCR）performedinlaboratory,buttheirsensitivityandspecificityindetectinginfluenzavi

32、rusesandRSVisrathergood（9）.Theaccuracyandfeasibilityofpoint-of-caretestsforotherrespiratoryvirusesthaninfluenzavirusesandRSVislargelyunknown.可對住院治療的下呼吸道感染（B級）（6,7）兒童進行RSV或其他呼吸道病毒檢測。呼吸道病毒檢測可減少住院后的抗菌處理。哮喘支氣管炎、細支氣管炎很少與下呼吸道細菌感染有關。根據(jù)病毒檢測，可減少住院病人活動集中院內(nèi)感染。鼻病毒感染引發(fā)的哮喘有可能會導致兒童后期哮喘（3）,床旁抗原檢測敏感度低于實驗室聚合酶鏈反應測試結果，

33、但其流感病毒和RSV敏感性和特異性檢測結果相當不錯（9）。除流感病毒和RSV病毒外，其他呼吸道病毒的大部分床旁檢測精確性和可行性還是未知。LARYNGITIS喉炎Laryngitiscanbeclassifiedintoupperrespiratorytractorlowerrespiratorytractinfections.OurworkinggroupdecidedtoincludelaryngitisinthepresentLRTIguidelineaslaryngealsymptomsarecausedbysubglotticoedema,dyspnoeaiscommonandlar

34、yngitiscanbetreatedwithdruginhalations.Typicalsymptomsoflaryngitisareinspiratorywheezingandabarkingcough.Bacterialtracheitisisrare,andepiglottitisisveryrareintheeraofHaemophilusinfluenzaeBimmunisation,buttheycanalsocauseinspiratorydifficultiesandshouldberememberedinthedifferentialdiagnostics.Theoccu

35、rrenceoflaryngitisishighestamongchildrenagedsixmonthstothreeyears.Thesedays,childrenwithlaryngitisaremainlytreatedinemergencydepartmentsandotheroutpatientclinicsandhospitalisationduetolaryngitisisrare.喉炎可分為上呼吸道感染和下呼吸道感染。由于喉部癥狀是由聲門下水腫引起的，因此我們工作組決定將喉炎納入當前的LRTI指南。呼吸困難是常見癥狀，可用藥物吸入來治療喉炎。喉炎典型的癥狀是吸氣哮鳴和犬吠樣咳

36、嗽。在接種B型流感嗜血桿菌疫苗的年代，細菌性氣管炎是罕見的，而會厭炎則非常罕見，但這兩種病也會導致吸氣困難，在鑒別診斷中，應記住這兩種罕見病。6個月一3歲大兒童喉炎發(fā)生率最高。目前，由于喉炎屬于罕見病，因此患喉炎兒童主要是在急診科和其他門診診所治療或住院治療。Mistisnoteffectiveinrelievingthesymptomsoflaryngitis(levelA)(10,11).Intworandomisedcontrolledtrials(RCTs),mistadministrationdidnotdecreaseclinicallyevaluatedsymptomsoflar

37、yngitis.Nebulisedracemicadrenalineiseffectiveinrelievingthesymptomsoflaryngitis(levelA)(12).Theeffectisshorttermandlastsforonetotwohours.Nebulisedlevo-adrenaline,anisomerusedinsystemicadrenalineproducts,wasusedinonesmallstudy.Therewasnostatisticallysignificantdifferenceinsymptomscoresbetweenchildren

38、receivingnebulisedracemicadrenalineandlevo-adrenaline,butthesamplesizeofthestudywastoosmalltoconfirmequalefficacy.Oralglucocorticoidsareeffectiveinrelievingthesymptomsoflaryngitis(levelA)(13).Differentdosesofglucocorticoidsappeartobeequallybeneficialandoralglucocorticoidsaseffectiveasintramusculargl

39、ucocorticoids.Possibledrugalternativesincludeasingleoraldoseofbetamethasone0.25.4mg/kg（Betapred_,watersolubletablets）ordexamethasone0.1-8.6mg/kg.Nebulisedbudesonide（2mg）mayprovideadditionalefficacyinchildrentreatedwithsystemicglucocorticoids（14）.霧化并不能有效緩解喉炎癥狀（A級）（10、11）。在兩組隨機控制試驗中，霧化并不能降低喉炎的臨床評估癥狀。霧

40、化吸入外消旋腎上腺素可有效緩解喉炎（A級）癥狀（12）。效果持續(xù)時間較短，為1-2小時。另一小型研究則采用霧化吸入左旋腎上腺素（全身腎上腺素產(chǎn)品所采用的一種異構體）來治療兒童喉炎。兩組兒童癥狀等級評分并沒有顯著的統(tǒng)計差異，但由于進養(yǎng)量太小，因此無法確認等效性?？诜瞧べ|(zhì)激素能有效緩解喉炎的癥狀（A級）（13）。即使糖皮質(zhì)激素劑量不同，但似乎同樣有益，而且口服糖皮質(zhì)激素和肌內(nèi)糖皮質(zhì)激素治療效果一樣。可選備用藥品包括單次口服倍他米松0.25-0.4毫克/千克（倍他米松鈉水溶性片劑）或地塞米松0.15-0.6毫克/千克。對于采用全身糖皮質(zhì)激素治療的兒童，霧化吸入布地奈德（2毫克）可提高治療功效（14

41、）。ACUTEBRONCHITIS急性支氣管炎Acutecoughinchildrenisusuallycausedbyviralrespiratoryinfections.Thedurationofcoughisusuallylessthanthreeweeks,butin10%ofcases,thecoughmaycontinuelonger.Antimicrobialsareineffectiveintreatingcoughinchildren.Antitussivedrugs(15-21)andbeta-sympathomimeticagents(18,22)areineffecti

42、veinrelievingacutecoughinchildrenandmaycauseseriousadverseevents(levelA).ThisisinlinewithanearlierstatementbytheU.S.FoodandDrugAdministrationrecommendingthatantitussivesshouldnotbeusedforinfantsduetoseriousadverseevents.HoneymayrelieveacutenocturnalcoughduringanLRTIinchildrenolderthanoneyearofage(le

43、velC)(2326).DosingofhoneyinRCTshasrangedfromasingledoseofafewmillilitresto10ggivenorallyapproximately30minutesbeforesleepinchildrenwithanacuteviralLRTI.Honeyshouldnotbegiventoinfantsyoungerthanoneyearofageduetotheriskofinfantbotulism.Chronicwetcough,whichisalsocalledpresumedprotractedbacterialbronch

44、itisintheliteratureandlastsforseveralweeks,isalessfrequentconditioninchildrenthanacutebronchitis.Morecommonly,achildsuffersfromrecurrentviralLRTIsandisasymptomaticbetweenLRTIepisodes.Ifchronicbacterialbronchitisissuspectedinchildren,otherdiagnosessuchastuberculosis,foreignbodyaspiration,cysticfibros

45、isorprimaryimmunodeficiencyshouldbeexcluded.Antimicrobialtreatmentmaybeeffectiveintreatingchronicwetcoughinchildren(levelC)(27-29).兒童急性咳嗽通常是由病毒性呼吸道感染引起的咳嗽持續(xù)時間通常不超過三周，但有10%兒童病人咳嗽持續(xù)時間會更長。抗菌藥物不能有效治療兒童咳嗽。鎮(zhèn)咳藥（15-21）和（3-擬交感神經(jīng)藥物（18-22）不能有效緩解兒童急性咳嗽，且可能會導致嚴重不良事件發(fā)生。對于年齡超過1歲的下呼吸道感染兒童患者（C級）（23-26）,在隨機控制試驗中（RCT）

46、,讓患急性病毒性下呼吸道感染的兒童在睡前30分鐘服用蜂蜜，單次口服劑量為幾毫升一10克。因存在嬰兒型肉毒中毒風險，一歲以下兒童不應服用蜂蜜。與急性支氣管炎兒童患者相比，兒童患慢性濕咳（醫(yī)學文獻也稱之為假定持久細菌性支氣管炎，持續(xù)時間為幾周）的情況并不常見。更為常見的是兒童復發(fā)性病毒性下呼吸道感染，且病發(fā)間無臨床癥狀。如兒童患有疑似慢性細菌性支氣管炎，則應排除其它診斷，如肺結核、異物吸入、囊性纖維化和原發(fā)性免疫缺陷病?？咕委煼捎行е委焹和詽窨龋–級）（27-29）。ACUTEWHEEZINGUNDERTHREEYEARSOFAGE三歲以下兒童急性哮喘Acutewheezinginchil

47、drenunderthreeyearsofagecoverstwoclinicalconditions,wheezingbronchitisandbronchiolitis,thataredifferentintermsofcausativeagents,clinicalsymptomsandoutcomes.However,intheliteratureweexamined,bothconditionswereoftenincludedtogetherinthesametrials.Thetermbronchiolitisisusedforchildrenunder24monthsofage

48、withwheezingintheUnitedStates,butinEurope,itisrestrictedtochildrenunder12monthsofageexperiencingtheirfirstwheezingepisode.TheEuropeandefinitionofbronchiolitisisusedinthisguideline.However,RSVbronchiolitisduringthefirstmonthsoflifediffersfromrhinovirusinducedwheezinginolderinfantswhoareunder12monthso

49、fage.Infuturetrials,RSVinfectionininfantsyoungerthansixmonthsofageandrhinovirus-inducedwheezingininfantsolderthansixmonthsofagewouldideallybeassessedseparately.3歲以下兒童急性哮喘包含兩種臨床狀況，即喘息性支氣管炎和細支氣管炎，就病原體、臨床癥狀和結果而言，這兩種狀況是不同的。然而在我們檢查的文獻中，這兩種狀況通常被納入相同試驗中。在美國，細支氣管炎用于2歲以下哮喘兒童患者，而在歐洲細氣支管炎則僅限于1歲以下第一次發(fā)哮喘的兒童。該指南采

50、用了歐洲細支氣管炎定義。但幾個月大初生兒RSV細支氣管炎與1歲以下較大兒童的鼻病毒哮喘是不同的。在未來試驗中，應對6個月以下嬰兒RSV感染和6個月以上鼻病毒哮喘分別進行評價。WHEEZINGBRONCHITIS喘支氣管炎Wheezingbronchitisismostfrequentlytriggeredbyarhinovirusandisdefinedaswheezinginchildrenaged12to36monthsduringacuterespiratoryviralinfectionorrepeatedwheezinginchildrenagedsixto12months.Rhin

51、ovirus-inducedwheezinginchildrenisaclearriskfactorforasthmainlaterchildhood(3).Theborderbetweenrepeatedepisodesofwheezingbronchitisandchildhoodasthmaissliding.Inmostcases,childrenwithwheezinggrowoutofthistendencybeforeschoolage,buttherearenoreliablemeanstoassess,earlyinlife,whowillstopandwhowillcont

52、inuewheezing.Riskfactorsforrecurrentwheezingarepassivesmoking,parentalasthma,atopicdiseaseinthechildandwheezingstartingwhenthechildismorethan12monthsofage.最易引發(fā)哮喘支氣管炎的是鼻病毒，哮喘支氣管炎是指1-3歲兒童因急性呼吸道病毒感染而出現(xiàn)的哮喘，或6-12個月大兒童反復性哮喘。鼻病毒哮喘有可能會導致兒童在童年后期出現(xiàn)哮喘。哮喘支氣管炎復發(fā)與兒童哮喘間的近似邊界正逐漸降低。大多數(shù)情況下，兒童在長大至學齡前，出現(xiàn)哮喘的趨勢會消失，但沒有可靠的

53、方法來評估在童年早期，誰會停止或誰會繼續(xù)發(fā)生哮喘。哮喘復發(fā)風險因素包括被動吸煙、父母哮喘、兒童過敏性疾病和兒童哮喘始發(fā)時間大于1歲。TREATMENTOFWHEEZINGBRONCHITS喘支氣管炎治療Salbutamolinhalationsmayrelievethesymptomsofwheezingbronchitis(levelC)(30).Salbutamoladministeredviaaholdingchamber(spacer)islikelytobemoreeffectivethansalbutamoladministeredviaanebuliser(levelB)(31,

54、32).Thesideeffectscausedbysalbutamolappeartobemoreprevalentwhensalbutamolisadministeredusinganebuliserthanifitisadministeredusingaholdingchamber(31,32).Forthesereasons,mostwheezingbronchitisepisodesarecurrentlytreatedusingspacechambersinFinland.Oralbeta-sympathomimeticagentsareineffectiveandarenotre

55、commendedforthetreatmentofwheezingbronchitis(levelA)(33W5).Glucocorticoidinhalationsareineffectiveandarenotrecommendedforthepreventionofexpiratorywheezingepisodesinducedbyviralinfectionsinchildren（levelA）（3641）.Glucocorticoidinhalationsadministeredeithercontinuouslyorjustduringrespiratoryinfectionsw

56、ereineffectiveinpreventingwheezingepisodes.Childrenattendingglucocorticoidpreventiontrialshadsufferedfromtwoormorewheezingepisodes,butwereasymptomaticbetweentheepisodes,inotherwordschildrenwithpersistentasthmasymptomswerenotincludedinthestudies.吸入沙丁胺醇可緩解哮喘支氣管炎癥狀（C級）（30）。通過儲藥腔（間隔器）來給予沙丁胺醇其效果有可能比通過霧化器

57、（B級）（31,32）來給予沙丁胺醇更好。而且較使用儲藥腔而言，使用霧化器來給予沙丁胺醇其副作用似乎更為普遍（31,32）。因此在芬蘭，目前大部分喘息性支氣管炎均采用儲藥腔來治療。對于喘息性支氣管炎，口服B-擬交感神經(jīng)藥物沒有治療效果，不建議采用此方法來治療喘息性支氣管炎（A級）（33-35）。對于兒童呼氣哮鳴，吸入糖皮質(zhì)激素也無治療效果，因此不建議采用該方法來預防由病毒感染引起的兒童呼氣哮鳴（A級）（36-41）。無論是持續(xù)吸入糖皮質(zhì)激素還是僅在出現(xiàn)呼吸道感染時吸入糖皮質(zhì)激素對于預防哮喘均沒有效果。參與糖皮質(zhì)激素預防試驗的兒童經(jīng)歷了兩次或更多次哮喘發(fā)作，但發(fā)作間隙無臨床癥狀，換而言之，該研究

58、不包含有持續(xù)哮喘癥狀的兒童。BRONCHIOLITIS細支氣管炎BronchiolitisismostoftenseenininfantsundersixmonthsofageduringRSVepidemics.Crepitations(finecrackles)onchestauscultationarecharacteristicofbronchiolitis.Younginfantsmaypresentwithapnoea.Intotal,2W%ofchildrenarehospitalisedduetobronchiolitisduringtheirfirstyearoflife(4

59、2).Themortalityrateduetobronchiolitiswastwotothreeper100000duringthefirstyearoflifeintheUnitedKingdomandtheUnitedStatesinthe1990s(42).Riskfactorsforseverebronchiolitisarebeingyoungerthantwomonthsofage,prematurityandbronchopulmonarydysplasiainpreterminfants(42).Inaddition,childrenwithcongenitalheartdefects,eurologicaldiseasesorimmunodeficiencyarepronetoseverediseases.RSVisthemaincausativeagentofbronchiolitis.RSVepidemicsusedtofollowabia