【摘要】：嬰幼兒喘息是全世界范圍內(nèi)兒童常見的臨床癥候群，反復(fù)發(fā)作的嬰幼兒喘息多與急性呼吸道病毒感染有關(guān)，基于喘息臨床表型而制定個體化治療策略，是達(dá)到喘息/哮喘最優(yōu)化臨床控制的關(guān)鍵。大多數(shù)哮喘兒童的首次喘息癥狀發(fā)生在學(xué)齡前期，但約50%左右的喘息到6歲時可完全緩解，與呼吸道病毒感染高峰年齡一致，對病毒感染與嬰幼兒喘息之間關(guān)系的深入了解，有助于認(rèn)識感染與變態(tài)反應(yīng)相關(guān)炎癥之間內(nèi)在的免疫學(xué)機(jī)制，能夠幫助大家更好地理解嬰幼兒喘息與哮喘的異同點，最終達(dá)到哮喘的個體化治療方案推行。已證實誘發(fā)嬰幼兒喘息急性發(fā)作最常見的病毒是RSV，與年長兒和成人不同。病毒感染相關(guān)的嬰幼兒喘息因其與支氣管哮喘的密切相關(guān)性而日益受到重視，反復(fù)發(fā)作的喘息是哮喘的高危因素，患有反復(fù)喘息的嬰幼兒，哮喘的發(fā)生率是沒有喘息癥狀兒童的5～10倍。因此，觀察喘息嬰幼兒病情發(fā)展變化特點，并進(jìn)行準(zhǔn)確的評估及早期干預(yù)性治療，是降低哮喘發(fā)病率、提高兒童健康水平的有效措施之一。但是，始終困擾臨床醫(yī)生的問題是目前臨床缺乏嬰幼兒哮喘早期診斷的標(biāo)準(zhǔn)，也沒有提示早期治療必要性的客觀依據(jù)，究其根源，是缺乏對嬰幼兒慢性氣道炎癥及功能評價的行之有效的臨床判定方法。 近年來，哮喘患病率呈明顯上升趨勢，嚴(yán)重影響著兒童的身心健康。嗜酸細(xì)胞被認(rèn)為是哮喘的主要效應(yīng)細(xì)胞，嗜酸性粒細(xì)胞炎癥反應(yīng)是哮喘的基本特征，已證實嗜酸性粒細(xì)胞炎癥是哮喘加重的很好的預(yù)測指標(biāo)，并且認(rèn)為嗜酸性粒細(xì)胞對病毒感染無反應(yīng)。然而，有研究揭示嗜酸性粒細(xì)胞可以促進(jìn)病毒清除和增強宿主的防御能力，提出了嗜酸性粒細(xì)胞可以在獲得性免疫反應(yīng)不足的情況下在某種程度上激發(fā)原發(fā)性宿主抗病毒防御反應(yīng)。已有國內(nèi)外許多研究證實，哮喘患兒痰液細(xì)胞分型能客觀反映氣道炎癥變化，但與成人哮喘不同，兒童哮喘不具有兩種特有的穩(wěn)定炎癥表型，即嗜酸性粒細(xì)胞和非嗜酸性粒細(xì)胞型，雖然在成人依據(jù)這兩種表型而制定的哮喘治療策略在臨床工作中都獲得了成功，但是，兒童哮喘的診斷遠(yuǎn)比成人復(fù)雜，兒童哮喘治療方案的確定也較成人有很大不同。人們越來越認(rèn)識到針對哮喘兒童采用單一的治療方法不太可能獲得臨床成功，因為有一大群“兒童哮喘”并不是真正意義上的哮喘，而一部分被當(dāng)成呼吸道反復(fù)感染而治療的患者卻極有可能是被忽視的哮喘，因此，確定兒童哮喘和/或喘息性疾病的臨床表型，可以為兒童喘息相關(guān)性疾病提供潛在的治療目標(biāo)和更個性化的治療方法。因此，我們采用液基薄層細(xì)胞制片技術(shù)研究哮喘的高危人群，即具有特應(yīng)性體質(zhì)的反復(fù)發(fā)作喘息的嬰幼兒，采集誘導(dǎo)痰液進(jìn)行痰炎癥細(xì)胞表型檢測，并按病情嚴(yán)重程度研究結(jié)果進(jìn)行了比較。參照以往研究結(jié)果，擬定痰液EOS%＞2.5%為痰液EOS增高，痰液NEU%＞54%為NEU增高，結(jié)合兩者將研究對象分為4組:①嗜酸性粒細(xì)胞型（EOS%＞2.5%）；②中性粒細(xì)胞型（NEU%＞54%）；③少中性粒細(xì)胞型（NEU%≤54%+EOS%≤2.5%）；④混合粒細(xì)胞型（EOS%＞2.5%+NEU%＞54%）。同時對反復(fù)喘息患者進(jìn)行氣道炎癥標(biāo)志物血清EDN水平檢測，及嬰幼兒潮氣肺功能檢測，并對比孟魯司特鈉干預(yù)性治療前后嬰幼兒喘息氣道炎癥指標(biāo)及肺功能的變化，以期探討嬰幼兒喘息與哮喘之間發(fā)病機(jī)制的異同，對嬰幼兒哮喘做到早期診斷、合理治療，提高兒童的健康水平。 本研究聯(lián)合應(yīng)用液基薄層細(xì)胞制片技術(shù)、血清EDN酶聯(lián)免疫吸附測定及嬰幼兒潮氣肺功能檢測技術(shù)，對反復(fù)喘息嬰幼兒臨床表現(xiàn)、氣道炎癥表型及氣道功能進(jìn)行綜合評價，以期證實嬰幼兒喘息不同于典型哮喘的發(fā)病機(jī)制及其與哮喘密切相關(guān)的共同特征，以期發(fā)現(xiàn)嬰幼兒喘息的治療折點并探索早期治療的重要性。 研究結(jié)果如下： 1嬰幼兒喘息與呼吸道病毒感染密切相關(guān)，7種常見呼吸道病毒病原篩查發(fā)現(xiàn)約76.0%的喘息患兒鼻咽抽吸物中可檢出呼吸道病毒，其中單一感染RSV為主要病毒（占48.0%），副流感病毒1、2、3占16.0%，流感病毒A、B占4.5%，腺病毒占7.5%，混合感染常占9.0%，并可見三重病毒感染者，僅15.0%的患兒未檢出病毒病原體。 2890例患者共采集合格痰液標(biāo)本867例，其中至少表現(xiàn)為一種炎癥細(xì)胞型為504例（占58.1%），分別為中性粒細(xì)胞型(占65.2%)，嗜酸細(xì)胞型(占30.6%)，混合細(xì)胞型(占4.2%)。中性粒細(xì)胞型是嬰幼兒炎癥細(xì)胞型的主要類型，嗜酸性粒細(xì)胞型在重癥組更具有優(yōu)勢，與輕癥組相比差異有統(tǒng)計學(xué)意義（P＜0.05）。重癥組誘導(dǎo)痰液標(biāo)本炎癥細(xì)胞計數(shù)顯示更高計數(shù)值，與輕癥組相比，中性粒細(xì)胞和嗜酸性粒細(xì)胞差異均有顯著性（P＜0.05）。 3血清EDN水平在不同炎癥細(xì)胞組有差異，以嗜酸細(xì)胞型組為最高（112.6±41.2）μg/l，其次依次為混合性細(xì)胞組（104.8±39.4）μg/l、中性粒細(xì)胞組（88.2±36.6）μg/l和少中性粒細(xì)胞型（60.9±34.6）μg/l，各組間血清EDN水平差異有統(tǒng)計學(xué)意義（P＜0.05）。 4雖然外周血嗜酸細(xì)胞計數(shù)在各炎癥組中并沒有顯著差異，但血清EDN水平顯示與外周血嗜酸細(xì)胞增高有顯著正相關(guān)性（γ=0.781，P＜0.05）。 5潮氣肺功能提示反復(fù)喘息兒童潮氣量減低，低潮氣量與血清EDN水平增高相關(guān)（γ=0.499，P＜0.05）。 6嬰幼兒喘息發(fā)作期患兒呼吸頻率比同齡對照組明顯增快，潮氣量明顯減少，反映氣道阻塞的指標(biāo)TPTEF/TE和VPEF/VE也低于對照組，差異均有顯著性(P＜0.05)。緩解期患兒呼吸頻率下降，VT/kg、TPTEF和VPEF、TPTEF/TE、VPEF/VE均明顯回升，治療前后各項指標(biāo)差異均有顯著性(P＜0.05)；緩解期VT/kg與對照組無明顯差異(P＞0.05)，但TPTEF/TE、VPEF/VE差異顯著(P＜0.05)。 7應(yīng)用孟魯司特鈉治療106例患者12周臨床癥狀改善42.5%（45/106），治療后4周、12周時患兒喘息、咳嗽、活動后咳嗽/喘息（活動力）、潮氣肺功能等與基礎(chǔ)值相比差異均有統(tǒng)計學(xué)意義（P＜0.05），與對照組相比，兩組在喘息發(fā)作次數(shù)、年平均住院天數(shù)、年均使用β2AG天數(shù)、肺功能改善等方面相比均有統(tǒng)計學(xué)差異（P＜0.05），經(jīng)隨訪2年治療組11例（占10.4%）診斷為哮喘，對照組19例（占39.6%），兩組差異有統(tǒng)計學(xué)意義（χ2=38.3967，P＜0.05）。 8在3個月的治療觀察結(jié)束時（觀察終點），未予孟魯司特鈉治療組嗜酸細(xì)胞型喘息患者血清EDN水平較相比治療組顯著增高的（P＜0.05），且較初始水平相比明顯增高（P＜0.05）；而治療組血清EDN水平較治療前顯著下降（P＜0.05）。 9治療前喘息患兒潮氣量明顯減少，反映氣道阻塞的指標(biāo)TPTEF/TE和VPEF/VE明顯減低。經(jīng)12周孟魯司特鈉治療后，治療組患兒PTEF(ml/s)、VT/kg、TPTEF和VPEF、TPTEF/TE、VPEF/VE均明顯回升，治療前后各項指標(biāo)差異均有顯著性(P0.05)；與對照組相比有顯著性(P0.05)，而未經(jīng)治療者，12周后PTEF(ml/s)也有改善(P0.05)，但TPTEF/TE、VPEF/VE差異顯著下降，觀察前后無明顯變化，差異無統(tǒng)計學(xué)意義(P0.05)。 本研究應(yīng)用DFA方法對嬰幼兒喘息進(jìn)行常見7種呼吸道病毒進(jìn)行篩查，并首次采用液基薄層細(xì)胞制片技術(shù)對患者進(jìn)行炎癥分型，并用EDN作為氣道炎癥標(biāo)志物作為評價，同時應(yīng)用潮氣肺功能對嬰幼兒阻塞性氣道疾病進(jìn)行診斷及預(yù)后評估，，發(fā)現(xiàn)嬰幼兒喘息與成人典型哮喘相比炎癥分型不同且不穩(wěn)定，嗜酸細(xì)胞活化很難及早發(fā)現(xiàn)，所以嗜酸細(xì)胞活化的標(biāo)志物因其更敏感，可以作為非侵襲性氣道功能評價的標(biāo)記物，而潮氣肺功能動態(tài)監(jiān)測及評估氣道功能值得推廣。孟魯司特鈉能夠阻斷嗜酸細(xì)胞脫顆粒，是嬰幼兒喘息早期干預(yù)性治療的有效地可選方案。
[Abstract]:Infantile wheezing is a common clinical syndrome in children worldwide. Repeated onset wheezing is associated with acute respiratory virus infection. An individualized treatment strategy based on a wheezing clinical phenotype is the key to optimal clinical control of wheezing / asthma. The first wheezing symptom in most children of asthma occurs in school. At the beginning of the age, about 50% of the wheezing can be completely relieved at the age of 6. It is consistent with the peak age of the respiratory virus infection. The deep understanding of the relationship between the virus infection and the infantile breather helps to understand the inherent immunological mechanism between infection and allergy related inflammation, which can help us to better understand the wheezing and asthma of infants. It has been proved that the most common virus that induces acute asthma attacks in infants is RSV, which is different from the older and adult. The asthma associated with virus infection is becoming more and more important because of its close correlation with bronchial asthma. Repeated attacks of wheezing are the high risk of asthma. The incidence of asthma in infants and young children with repeated wheezing is 5~10 times as high as that of children without wheezing symptoms. Therefore, it is one of the effective measures to reduce the incidence of asthma and improve the health level of children. The problem of birth is the standard for the lack of early diagnosis of infant asthma in clinical, and there is no objective basis for the necessity of early treatment. The root of this problem is the lack of effective clinical judgement on the evaluation of chronic airway inflammation and function in infants.
In recent years, the incidence of asthma is on the rise, which seriously affects the physical and mental health of children. Eosinophil is considered to be the main effect cell of asthma. Eosinophil inflammation is the basic characteristic of asthma. Eosinophil inflammation is a good predictor of asthma aggravation and is considered to be eosinophil. There is no response to viral infection. However, studies have revealed that eosinophils promote the clearance of viruses and enhance the defense ability of the host. It is suggested that eosinophils can stimulate the anti viral defense against the primary host to some extent under the condition of acquired immune response. Many studies have confirmed that children with asthma have been diagnosed with asthma. Phlegm cell typing can objectively reflect the changes in airway inflammation, but unlike adult asthma, children with asthma do not have two specific stable inflammatory phenotypes, eosinophils and non eosinophilic granulocytes. Although the asthma treatment strategy based on these two phenotypes in adults has been successful in clinical work, however, children The diagnosis of asthma is far more complex than that of adults, and the treatment for asthma is very different from that in adults. It is increasingly recognized that a single treatment for asthma children is not likely to be clinically successful because a large group of "child asthma" is not a true sense of asthma, and a part is treated as a respiratory tract. Patients treated with reinfection are highly likely to be neglected asthma. Therefore, the clinical phenotype of asthma and / or asthmatic disease in children can provide potential treatment targets and more individualized treatment for asthma related diseases in children. Therefore, we use liquid based thin layer cell technique to study high-risk groups of asthma, In the case of recurrent wheezing infants with atopic constitution, the sputum induced sputum was collected to detect the phlegm phenotype of phlegm cells, and the results were compared according to the severity of the disease. According to the previous research results, the sputum EOS% > 2.5% was increased in sputum EOS, and the sputum NEU% > 54% was higher in NEU, and the study object was divided into 4 groups. (1) Eosinophil type (EOS% > 2.5%); (2) neutrophils (NEU% > 54%); (3) neutrophils (NEU% < < 54%+EOS% < 2.5%); (EOS% > 2.5%+NEU% > 54%); (EOS% > 2.5%+NEU% > 54%). Serum EDN level of airway inflammation markers in patients with repeated wheezing, and detection of tidal lung function in infants and infants, and compared to montelukast The changes of airway inflammation index and lung function in infants and young children before and after intervention treatment are discussed in order to explore the similarities and differences between infant wheezing and asthma, early diagnosis, rational treatment and improvement of children's health.
This study combined with liquid based thin layer cell production, serum EDN enzyme linked immunosorbent assay and infant tidal lung function testing technology to evaluate the clinical manifestations, airway inflammation phenotypes and airway function of infants and young children with repeated wheezing, in order to confirm that infant wheezing is different from that of typical asthma and is closely related to asthma. The common characteristics are to find out the treatment points of infant wheezing and to explore the importance of early treatment.
The results of the study are as follows:
1 infantile wheezing is closely related to respiratory virus infection. 7 common respiratory virus pathogens screening found that about 76% of the nasopharyngeal aspirates in children with wheezing can detect respiratory virus, of which single infection RSV is the main virus (48%), parainfluenza virus 1,2,3 accounts for 16%, flow virus A, B account for 4.5%, adenovirus 7.5%, mixed infection often 9. %, and three cases of viral infection were found. Only 15% of children did not detect viral pathogens.
In 2890 cases, 867 cases of qualified sputum were collected. At least one inflammatory cell type was found in 504 cases (58.1%), which were neutrophil type (65.2%), eosinophil type (30.6%) and mixed cell type (4.2%). Neutrophil type was the main type of infantile inflammatory cell type, and eosinophil type was more in severe group. The difference was statistically significant compared with the light disease group (P < 0.05). The inflammatory cell count of the sputum specimens induced by the severe group showed a higher count value. Compared with the light disease group, there were significant differences in neutrophils and eosinophils (P < 0.05).
3 the level of serum EDN was different in the different inflammatory cells group, and the eosinophil group was the highest (112.6 + 41.2) mu g/l, followed by mixed cell group (104.8 + 39.4) mu g/l, neutrophils group (88.2 + 36.6) mu g/l and less neutrophil type (60.9 + 34.6) mu g/l, and the difference of serum level between each group was statistically significant (P < 0.05).
4 although there was no significant difference in the eosinophil count of peripheral blood in the inflammatory groups, there was a significant positive correlation between the serum EDN level and the increase of eosinophils in the peripheral blood (gamma =0.781, P < 0.05).
5 tidal pulmonary function indicates that tidal volume decreases in children with recurrent wheezing, and low tidal volume is associated with increased serum EDN level (gamma =0.499, P < 0.05).
6 the respiratory rate in children with wheezing attack was significantly faster than that in the same age control group, and the volume of tidal gas decreased significantly. The index of TPTEF/TE and VPEF/VE reflecting airway obstruction were also lower than those in the control group. The difference was significant (P < 0.05). The respiratory frequency of children in remission stage decreased, VT/kg, TPTEF and VPEF, TPTEF/TE, VPEF/VE all increased significantly, and all the fingers before and after treatment. There was no significant difference in VT/kg between remission group and control group (P > 0.05), but there was significant difference in TPTEF/TE and VPEF/VE between remission group and control group (P < 0.05).
7 the clinical symptoms of 106 patients with montelukast were improved by 42.5% (45/106), 4 weeks after treatment, 12 weeks of asthma, cough, coughing / wheezing (activity), and tidal gas and lung function, compared with the basic values (P < 0.05). Compared with the control group, the number of breathing attacks, the annual average hospitalization days, and the years were compared with the control group. There were statistically significant differences in the use of beta 2AG days and the improvement of lung function (P < 0.05). After 2 years of follow-up, 11 cases (10.4%) were diagnosed as asthma and 19 cases in the control group (39.6%). The two groups were statistically significant (x 2=38.3967, P < 0.05).
8 at the end of the 3 month treatment observation (observation point), the level of serum EDN in the patients with eosinophilic wheezing in the montelukast group was significantly higher than that in the treatment group (P < 0.05), and was significantly higher than the initial level (P < 0.05), while the serum level of EDN in the treatment group was significantly lower than that before the treatment (P < 0.05).
9 the tidal volume of children with wheezing before treatment was significantly reduced, and the index of TPTEF/TE and VPEF/VE of airway obstruction decreased obviously. After 12 weeks of montelukast treatment, PTEF (ml/s), VT/kg, TPTEF and VPEF, TPTEF/TE, VPEF/VE all increased significantly after 12 weeks of treatment (P0.05), and there was a significant difference compared with the control group (P) 0.05), but without treatment, PTEF (ml/s) was also improved after 12 weeks (P0.05), but the difference of TPTEF/TE and VPEF/VE decreased significantly. There was no significant change before and after observation, and there was no significant difference (P0.05).
In this study, the DFA method was used to screen 7 common respiratory viruses for infants and infants, and the liquid based thin layer cell technique was used for the first time to classify the patients, and EDN was used as a marker for airway inflammation. At the same time, the diagnosis and prognosis evaluation of the obstructive airway disease in infants and infants was evaluated by using the tidal lung function. Infant wheezing is different and unstable compared with adult asthma. Eosinophil activation is difficult to detect early. Therefore, the markers of eosinophil activation can be used as a marker for noninvasive airway function evaluation. Dynamic monitoring and assessment of airway function are worth promoting. Montelukast sodium. Blocking eosinophils degranulation is an effective alternative to early intervention in infants with wheezing.
【學(xué)位授予單位】：吉林大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2013
【分類號】：R725.6

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