概述

• 反复喘息是婴幼儿常见的呼吸道疾病
• 目前临床缺乏标准化的诊断和治疗方案
• 本指南旨在为临床医生提供标准化方案，提高诊断准确性和治疗效果

反复喘息定义

• 喘息是气流通过狭窄气道产生的连续、粗糙声音
• 本指南中，婴幼儿指29天至3岁儿童，反复喘息指3次以上喘息发作，每次间隔至少7天
• GINA 2025定义5岁以下儿童反复喘息为过去12个月内至少2次急性喘息发作
• 持续4周以上未缓解的喘息为持续性喘息

反复喘息分类

根据症状发作表现分类

• 发作性病毒相关性喘息：多由呼吸道病毒感染触发，感染控制后症状完全缓解，发作间期无症状
• 多触发因素喘息：除病毒感染外，运动、哭闹、过敏原暴露等也可诱发，发作间期也可能有症状
• 未分类喘息：不符合前两种类型，主要由潜在呼吸道疾病引起

根据起病年龄及病程分类

• 早期短暂性喘息：3岁前起病，3岁后明显减少，6岁左右缓解
• 早期持续性喘息：3岁前起病，持续至6岁以后
• 晚期起病喘息：3岁后起病，持续至6岁以后，超出本指南范围

根据特应性分类

• 过敏性喘息：多数发展为过敏性哮喘
• 非过敏性喘息：多数由呼吸道感染诱发，上学年龄前多可缓解

反复喘息严重程度分级

• 根据发作时症状严重程度分为轻度和重度
• 根据发作频率分为频繁发作（每季度3次以上）和间歇发作（每季度2次以下）

反复喘息病因

• 可由呼吸系统和非呼吸系统疾病引起
• 常见病因包括病毒诱发的喘息、婴幼儿哮喘和迁延性细菌性支气管炎等
• 少见病因包括支气管肺发育不良、闭塞性细支气管炎、气道发育异常等

临床信息要点

病史采集要点

• 首次喘息发作年龄
• 喘息发作或加重的触发因素
• 喘息发作的节律性
• 喘息发作的严重程度
• 伴随症状
• 喘息与喂养的关系
• 喘息与体位的关系
• 对药物的反应
• 其他全身症状
• 既往病史
• 个人和家族史，特别是过敏和哮喘相关信息

体格检查要点

• 区分喘息是呼气性还是吸气性
• 注意精神状态、呼吸频率、心率、缺氧体征等
• 不对称呼吸音可能提示单侧气道阻塞
• 固定细湿啰音可能提示肺炎
• 注意肺外体征，如杵状指、肝脾肿大等

提示罕见或严重疾病的病史和体格检查发现

• 生长发育迟缓
• 新生儿期或婴儿早期起病
• 对哮喘药物反应不佳
• 呕吐伴呼吸道症状
• 与常见触发因素无关的喘息发作
• 检查发现明显肺部或心脏体征
• 杵状指/趾
• 严重低氧血症

常用实验室和辅助检查

嗜酸性粒细胞计数

• 推荐对反复喘息婴幼儿进行血常规嗜酸性粒细胞计数
• 升高与过敏性哮喘诊断、未来哮喘发生概率及急性发作频率增加相关
• 可作为吸入糖皮质激素治疗反应的生物标志物

过敏原检测

• 推荐对反复喘息婴幼儿进行过敏原检测
• 早期吸入性过敏原致敏是喘息和哮喘发生的高危因素
• 有助于判断ICS治疗效果
• 婴幼儿早期食物过敏增加儿童期哮喘风险

胸部影像学检查

• 推荐常规进行胸部X线检查
• 若X线检查不能充分解释症状或标准化药物治疗反应不佳，建议进行胸部CT检查
• 怀疑血管畸形导致气管受压时，需进行增强胸部CT血管造影

肺功能检查

• 推荐对反复喘息婴幼儿进行肺功能检查
• 有助于诊断和预后评估，但3岁以下儿童受年龄限制，准确性较差

呼出气一氧化氮检测

• 推荐对疑似哮喘的反复喘息婴幼儿进行呼出气一氧化氮检测
• 对婴幼儿哮喘早期诊断有重要参考价值，但国内临床应用尚不广泛

呼吸道病原体检测

• 推荐在反复喘息急性加重期检测呼吸道病毒
• 怀疑细菌、支原体或衣原体感染时，推荐进行呼吸道分泌物细菌培养或非典型病原体核酸检测

24小时食管pH监测

• 怀疑胃食管反流时，推荐进行24小时食管pH监测
• 有助于诊断和治疗

支气管镜检查

• 对药物治疗无效的反复喘息婴幼儿，推荐进行支气管镜检查
• 有助于鉴别病因

吞咽功能评估

• 对有吞咽功能障碍高危因素的反复喘息婴幼儿，推荐进行吞咽功能评估
• 有助于减少呛吸导致的反复下呼吸道感染和喘息

基因检测

• 怀疑单基因疾病时，可选择性考虑进行基因筛查
• 对诊断有重要价值，但不作为常规检查

病因诊断

病毒诱发的喘息/急性哮喘性支气管炎

• 主要影响2岁以下婴幼儿
• 由RSV、RV等病毒引起的急性下呼吸道感染
• 症状包括发热、鼻塞、咳嗽、喘息等
• 病程一般<10天，每年发作2 - 3次，3岁后发作减少

婴幼儿哮喘

• 诊断主要依靠临床线索，综合考虑哮喘危险因素、严重程度、对哮喘治疗的反应等
• 符合特定临床特征高度提示哮喘，可启动标准化哮喘治疗
• GINA 2025规定5岁以下儿童哮喘诊断需满足三个条件，不满足则诊断为“疑似哮喘”

迁延性细菌性支气管炎

• 主要表现为持续湿咳和反复喘息
• 诊断需满足临床和微生物学标准

治疗

急性加重期治疗

• ICS
  • Recommended for severe acute wheezing or suspected asthma (Strong)
  • Mild viral wheezing: no significant difference from placebo (Level A)
  • Severe viral wheezing: lower symptom scores, less need for systemic corticosteroids (Level A, B)
  • High - risk asthma children: more episode - free days, less systemic corticosteroids (Level A)
  • Adjust dosage based on severity and improvement
• Bronchodilators
  • SABA recommended (Strong)
  • Helps in specific cases (Level C)
  • Improves respiratory rate etc., no effect on admission or recurrence (Level A)
  • Suggest albuterol, adjust frequency; consider combination with ICS or ipratropium bromide
• Leukotriene receptor antagonists
  • Can be used (Weak)
  • Improves activity and symptom scores (Level B)
  • Effective in some cases (Level C)
  • Inform about potential adverse effects; off - label for <1 year
• Systemic corticosteroids
  • Not for mild, consider for severe (Weak)
  • Ineffective in most cases (Level A, B)
  • Consider for severe asthma - suggestive or non - responsive cases (Level B)
• Antimicrobial agents
  • Not routine, use for specific conditions (Strong)
  • Viral infections don't need antibiotics
  • Use for bacterial/atypical pathogen infections

缓解期治疗

• ICS maintenance therapy
  • Recommended for asthma, severe or frequent wheezing (Weak)
  • Different regimens for different cases
  • High - dose use has risks
• LTRA
  • Can be used for asthma or suspected asthma (Weak)
  • Moderately reduces symptoms, not effective for severe exacerbations (Level A)
  • ICS more effective than LTRA monotherapy (Level A)
  • Weigh benefits and risks, explain adverse effects

管理

Type 2 inflammatory disease

• Assess and manage (Strong)
• Characterized by elevated cytokines etc.
• Associated with allergic diseases
• Crucial for controlling symptoms and prognosis

环境评估

• Regular assessment and management (Strong)
• Risk factors: allergens, environment, passive smoking
• Preventive measures: reduce exposure, improve living conditions

营养评估

• Regular assessment and management (Strong)
• Obesity, food allergy, and other conditions related to wheezing
• Tailor to underlying etiology

长期随访计划

• Develop a plan (Strong)
• Asthma education for diagnosed children
• Follow - up for suspected cases
• Adjust management based on phenotype changes
• Pulmonary function follow - up and rehabilitation

诊断-治疗-评估-管理流程

• Follow “Evaluation–Diagnosis–Treatment–Re - evaluation–Re - diagnosis”
• Based on factors like severity, triggers, etc.

预防

免疫调节剂

• Can be adjunctive (Weak)
• Bacterial lysates beneficial (Level B, D)
• Other immunomodulators need more studies

维生素D

• Not recommended as adjunctive (Weak)
• Inconsistent evidence

益生菌

• Not recommended as adjunctive (Weak)
• No evidence for wheezing prevention

LTRAs

• Not routinely recommended (Strong)
• Consider for allergic rhinitis cases

抗组胺药

• Not recommended for prophylaxis (Strong)
• Insufficient evidence

预后

喘息表型

• Have predictive value but limited (Weak)
• Phenotypes can change over time

哮喘危险因素

• Assess to predict prognosis (Weak)
• Multiple high - risk factors

哮喘预测工具

• Combine methods for early identification (Strong)
• International and domestic methods, need improvement

呼吸道病毒感染与婴幼儿长期肺功能

呼吸道病毒感染

• RSV和RV感染与哮喘风险
  • Increase asthma risk in school - age children (Weak recommendation)
  • Highest risk for subsequent asthma in infants and toddlers, RV relatively higher (Evidence level: C)
  • RSV, RV or co - infection increases 6 - year asthma risk
• 病毒感染与反复喘息
  • Trigger recurrent wheezing, especially in atopic children
  • High virus detection rates in recurrent wheezing or asthma exacerbations (85%–95%)
  • RV - induced bronchiolitis more likely to cause recurrent wheezing (Evidence level: B) and increase rehospitalization risk

长期肺功能

• 反复喘息与肺功能损害
  • Recurrent wheezing in infants and toddlers impairs long - term pulmonary function (Strong recommendation)
  • Early recurrent wheezing leads to persistent impairment by 6 years and lower values at 16 years (Evidence level: A)
  • Lower FEV₁ and FEV₁/FVC ratio in those with history before 6 years, impairment may be established by 4 years or earlier (Evidence level: A)
• 喘息表型对肺功能的影响
  • Different phenotypes affect pulmonary function differently, persistent wheezing has most significant impact (Evidence level: B)
  • Different phenotypes have lower FEV₁ at 8 years, especially persistent wheezing
  • MTW shows significant abnormalities at 4 - 6 years, EVW less affected (Evidence level: C)

管理与未来研究

• 管理
  • Identify cause through history, examination, tests and follow - up
  • Implement etiology - specific and symptomatic treatment and prevention
• 未来研究
  • Focus on type 2 inflammatory mechanisms, risk factors, and interventions for asthma development
  • Long - term pulmonary function impact and outcomes
  • Clinical efficacy evaluation of RSV monoclonal antibodies and vaccines