儿童喘息与心肺血管疾病

Wheezing and cardiovascular abnormalities in children

喘息是儿童常见症状,约1/3的儿童在1岁内至少出现1次喘息.喘息最容易被认为与支气管哮喘（哮喘）相关,但并非所有的喘息均为哮喘,积极寻找引起喘息的病因,及时诊断及合理治疗至关重要.尤其是对于反复喘息、治疗不顺利的患儿,应注意少见、罕见原因,尤其是心肺血管疾病.心肺血管疾病引起患儿反复喘息的主要原因为呼吸道受压,而其中最常见的为血管环畸形.血管环畸形包括3大类：主动脉弓异常,迷走左肺动脉（左肺动脉起源异常/肺动脉吊带）及迷走无名动脉（无名动脉压迫综合征/头臂干压迫综合征）.其中主动脉弓异常主要由双主动脉弓、左右位主动脉弓及异常血管、韧带形成血管环以及颈位主动脉弓.另外其他可引起呼吸道受压的心肺血管疾病包括肺动脉瓣缺如、动脉瘤、心脏病等.对心肺血管疾病的诊断,影像学检查十分重要,首选胸部X线片.心脏超声,胸部CT和磁共振成像（MRI）三维血管重建对血管环畸形有诊断意义.心肺血管畸形易合并呼吸道发育畸形,所以在患儿病情允许的情况下,建议进行支气管镜检查以发现是否合并气管、支气管异常,如气管、支气管软化和狭窄等.支气管镜也是外科手术治疗前病情评估的手段之一.约10％的血管环畸形需要外科手术治疗.

Wheezing in children is a common problem.Approximately 30 percent of infants will have at least one wheezing episode.Although asthma is the condition most commonly associated with wheezing,the high prevalence of wheezing as a common presenting complaint requires consideration of a broad and age-dependent differential diseases.A high index of suspicion of cardiovascular anatomic anomalies should be maintained in infants and children with recurrent wheezing and minimal improvement despite reasonable treatment.Compression of the pediatric airway is a relatively common and often unrecognized complication of a variety of cardiovascular diseases.The most common congenital anomalies associated with airway compression are the vascular rings.Vascular ring abnormalities are aortic arches abnormalities,aberrant left pulmonary artery （pulmonary sling） or aberrant i nnominate artery （innominate artery syndrome）.Aortic arches abnormalities include double aortic arch,right/left sided aortic arch with ligamentum arteriosum and aberrant left subclavian artery or cervical aortic arch.Other rare reasons could cause the compression of airway are absent pulmonary valve,aneurysm,left atrial enlargement or massive cardiomegaly.Imaging techniques are usually required for diagnosis.First-tier evaluation of the child with recurrent wheeze should include a chest radiograph.Echocardiography,multi detector computed tomography （MDCT） or magnetic resonance imaging （MRI） are performed as the diagnostic pathway.Bronchoscopy is currently the techniques to assess the degree of bronchial malacia and narrowing in pre-operation.Treatment of these abnormalities usually is surgical.