AAAAI 2009:咳嗽時嘔吐可能是小孩氣喘的症狀之一


  March 16, 2009(華盛頓特區) — 華盛頓特區Walter Reed陸軍醫學中心的一個研究團隊認為,咳嗽後嘔吐是兒童氣喘的一個可能徵兆。
  
  主要研究者、Walter Reed陸軍醫學中心過敏免疫科Joseph Turbyville醫師於美國哮喘、過敏症及免疫學學會2009年會中的海報發表時向Medscape Allergy & Clinical Immunology表示,若的確如此,治療應更針對呼吸道管理而非抑制咳嗽。
  
  研究者於兩週內向Walter Reed陸軍醫學中心小兒科與過敏門診的2-17歲小孩家長發放共780份問卷,問題是有關於年紀、性別、之前的百日咳診斷、呼吸道感染的頻率、胃食道逆流(GERD)以及之前的氣喘診斷。
  
  共回收了500份問卷,完成評估的小孩有144名。
  
  醫師診斷氣喘的比率有23%,共33名小孩,其中,48%有咳嗽後嘔吐病史。
  
  37個小孩有疑似氣喘的指標,但是沒有正式診斷,這些指標包括哮喘、胸悶、復發呼吸道感染與鼻竇炎、夜間咳嗽;這些人之中有49%出現咳嗽後嘔吐。
  
  有74名小孩未出現氣喘,其中有11%曾有出現咳嗽後嘔吐。
  
  Turbyville醫師報告指出,不論是有氣喘或者疑似氣喘,出現咳嗽後嘔吐的比率都顯著比無氣喘小孩更多(P < .0005)。
  
  他解釋,我們認為是單純的機械式反應。橫膈變平,壓迫胃部且產生壓力,引起胃排空。另一個可能是,氣道阻塞將空氣壓入食道。這些小孩的氣管-食道接合處有很明顯的阻塞。
  
  Turbyville醫師指出,這種機械式解釋也可以用來解釋GERD與阻塞性睡眠呼吸中止的關係。
  
  Turbyville醫師結論表示,我們的發現若經證實,將引領我們朝向使用長效乙型致效劑與抗發炎劑治療,而不用止咳劑;如果小孩咳嗽後嘔吐,則咳嗽可能是氣喘徵兆而非呼吸道感染。
  
  喬治亞州過敏與氣喘照護中心的過敏專家Andy Nish醫師在Turbyville醫師發表之後,應Medscape Allergy & Clinical Immunology之邀發表評論時表示,這些發現讓我們於考量氣喘診斷時多了一個線索。
  
  Nish醫師觀察發現,很難指明哪一種咳嗽會繼續變成支氣管痙攣。我們必須觀察全貌,是否正有哮喘、胸悶,是否增加運動或者有壓力、是否有抽菸或曝露於二手菸等等。
  
  他表示,我們需進行完整的體檢,包括肺功能測試,聽診肺部有無哮喘或氣流減少、檢查吸氣/吐氣比率的變化、尖峰流速的變化、必要時進行胸部X光檢查等等。
  
  Nish醫師建議,出現咳嗽後嘔吐應提高你的警覺,進行追蹤檢查,特別是肺功能檢查,最好是出現咳嗽後嘔吐後立即檢查。
  
  美國哮喘、過敏症及免疫學學會(AAAAI)2009年會:海報 17。發表於2009年3月14日。

AAAAI 2009: Vomiting With Cough a Symptom of Asthma in Children

By Martha Kerr
Medscape Medical News

March 16, 2009 (Washington, DC) — A team at Walter Reed Army Medical Center in Washington, DC, believes that posttussive emesis is a probable sign of asthma in children.

If that is the case, then treatment should be directed more toward airway management than toward suppression of cough, principal investigator Joseph Turbyville, MD, from the Department of Allergy and Immunology at Walter Reed Army Medical Center, told Medscape Allergy & Clinical Immunology during poster sessions here at the American Academy of Asthma, Allergy and Immunology (AAAAI) 2009 Annual Meeting.

The investigators distributed 780 questionnaires during a 2-week period to parents of children aged 2 to 17 years attending the pediatric and allergy clinics at Walter Reed. Questions pertained to age, sex, previous diagnosis of pertussis, frequency of respiratory infections, gastroesophageal reflux (GERD), and a prior diagnosis of asthma.

Five hundred questionnaires were returned and evaluations of 144 children were completed.

The prevalence of physician-diagnosed asthma was 23%, occurring in 33 children. Of those, 48% reported a history of posttussive emesis.

There were 37 children who had "surrogate markers suggestive of asthma," but had not been given a formal diagnosis. Surrogate markers included wheeze, chest tightness, recurrent respiratory infections and sinusitis, and nighttime cough. Posttussive emesis was reported in 49% of this group.

No evidence of asthma was seen in 74 children, of whom 11% reported a history of posttussive emesis.

Posttussive emesis, either with asthma or a suspicion of asthma, was significantly more prevalent than in children without asthma (P < .0005), Dr. Turbyville reported.

"We think it's a simple, mechanical thing," he explained. "There is a flattening of the diaphragm, which compromises the stomach and puts pressure on it, causing it to empty.

"Another possibility is that the airway obstruction pushes air into the esophagus. There is a significant obstruction at the tracheal-esophageal junction in these kids," he said.

"The mechanical explanation would also explain the link with GERD and obstructive sleep apnea," Dr. Turbyville added.

"Our finding, if it is confirmed, would lead us toward treatment with a long-acting beta-agonist and anti-inflammatory agents rather than an antitussive agent," Dr. Turbyville concluded. "The cough may signal asthma rather than a respiratory infection if the child is vomiting with it."

"These findings give us one more clue to think about when considering a diagnosis of asthma," Andy Nish, MD, an allergist with Allergy and Asthma Care Center in Gainesville, Georgia, commented in an interview with Medscape Allergy & Clinical Immunology after Dr. Turbyville's presentation.

"It can be hard to sort out a cough and whether it has segued into bronchospasm," Dr. Nish observed. "We have to look at the whole ball of wax...whether there is wheezing, chest tightness, if it increases on exercise or with stress, whether there is smoke exposure, and so on.

"We need to do a complete physical examination, with pulmonary function testing...listening to the lungs for wheezing or decreased airflow, checking changes in the inspiration/expiration ratio, peak flow changes, possibly a chest x-ray, and so on," he said.

"The presence of posttussive emesis should raise your level of suspicion, and you should conduct follow-up testing, specifically pulmonary function tests, sooner rather than later, if posttussive emesis is present," Dr. Nish advised.

American Academy of Asthma, Allergy and Immunology (AAAAI) 2009 Annual Meeting: Poster 17. Presented March 14, 2009.

    
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