Table of Contents

HK J Paediatr (New Series)
Vol 14. No. 4, 2009

HK J Paediatr (New Series) 2009;14:260-274

35th C. Elaine Field Memorial Lecture

Severe Therapy Resistant Asthma in Children
兒童嚴重難治性哮喘

A Bush


Abstract

Most children with asthma respond to low doses of inhaled corticosteroids, but a few remain symptomatic despite being prescribed the routine usual asthma medications. The first steps are to ensure the diagnosis is correct, and that the inhaled medications are being given with an appropriate device. If the child continues to be symptomatic, with any or all of chronic symptoms, acute exacerbations, the need for regular oral corticosteroids, or persistent airflow limitation, then they are considered to have problematic, severe asthma. The next step is to perform a detailed evaluation, including a nurse-lead home visit, to determine if the child has difficult to treat asthma, which improves if the basics are got right, or severe, therapy resistant asthma, which latter group would be candidates for cytokine specific therapies. If severe, therapy resistant asthma is the likely issue, then detailed invasive investigation is performed, including a bronchoscopy, bronchoalveolar lavage and endobronchial biopsy, and trial of adherence with a single intramuscular injection of depot triamcinolone. After detailed phenotyping, an individualised treatment plan is determined. Future work will determine the roles of proximal and distal inflammation, as well as the relative importance of intramural (mucosal) and intraluminal infection. The stability of paediatric asthma phenotypes over time is more variable than those of adults, and the implications of a change of phenotype are yet to be determined.

絕大部份的哮喘患兒對於低劑量皮質醇吸入性治療均有治療反應,但有一些病人在經過常規抗哮喘藥物治療後症狀仍無法得到控制。對於這類病人,首先應確定診斷是否正確,以及藥物是否經過適當的方法與裝置進行吸入性治療。若患兒症狀仍未緩解,並出現任何慢性症狀,或急性病情惡化,需要定時服用皮質醇或持續氣流受限時,均需考慮患兒是否存在嚴重哮喘。此後,需進行詳細的評估,包括需進行護士家訪,從而確定患兒出現以上這些情況是由於接受治療困難,還是因為存在嚴重的治療抵抗性哮喘。前者的情況將可得到改善,若屬於後者則考慮可能需接受特異性細胞因數治療。同時,如果考慮存在嚴重治療抵抗性難治性哮喘的可能,則還需要進行一系列詳細的侵入性檢查,包括支氣管鏡、支氣管肺泡灌洗、支氣管鏡活檢以及肌肉注射氟氫強的松龍試驗。經過詳細的疾病表型分析之後,將進一步制訂針對個別患童的治療計劃。今後還將可以確定以及判斷近端或遠端炎症,以及粘膜內或腔內感染的情況及意義。隨著時間推移,兒童哮喘表型較成人多變,而此種改變的意義尚未明確。

Keyword : Allergen exposure; Endobronchial biopsy; Induced sputum; Nitric oxide; Omalizumab; Steroid resistance

關鍵詞:變應原暴露、支氣管內鏡活檢、誘導痰、一氧化氮、Omalizumab藥、激素抵抗

 
 

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