今日の臨床サポート

咳・喘鳴・呼吸困難(小児科)

著者: 川越信 かわごえ小児科クリニック

監修: 五十嵐隆 国立成育医療研究センター

著者校正済:2021/11/24
現在監修レビュー中
参考ガイドライン:
  1. 日本小児呼吸器学会、小児の咳嗽診療ガイドライン2020
  1. 日本小児呼吸器学会 ほか、小児RSウイルス呼吸器感染症診療ガイドライン2021
  1. 日本小児呼吸器学会日本小児感染症学会:小児呼吸器感染症診療ガイドライン2017
  1. 日本呼吸器学会:咳嗽・喀痰の診療ガイドライン 2019
患者向け説明資料

概要・推奨   

  1. 小児における急性咳嗽の原因の多くはウイルス性上気道炎であり、特に検査を必要としない(推奨度1)。
  1. 夜間咳嗽があるかを問診することは大切である(推奨度2)。
  1. 肺炎の重症度を評価するのに役立つ臨床指標は多呼吸の有無である(推奨度2)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
川越信 : 未申告[2021年]
監修:五十嵐隆 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 小児の咳嗽診療ガイドライン2020、小児RSウイルス呼吸器感染症診療ガイドライン2021を参考に定期レビューを行った(変更なし)

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 咳・喘鳴(ぜんめい)の原因は多岐にわたる。
  1. 呼吸困難のフローチャート:アルゴリズム
  1. 上気道閉塞のフローチャート:アルゴリズム
  1. 幅広い年齢でみられる疾患:アルゴリズム
  1. 新生児・乳児期でみられる疾患:アルゴリズム
  1. 幼児期でみられる疾患:アルゴリズム
  1. 学童・思春期でみられる疾患:アルゴリズム
  1. 年齢・基礎疾患の有無を考慮し、病歴の詳細な聴取により鑑別診断を行い、検査は必要最低限とする。
  1. 小児慢性咳嗽の代表的疾患とフローチャート:アルゴリズム
  1. 吸気性喘鳴のフローチャート:アルゴリズム
  1. 呼気性喘鳴のフローチャート:アルゴリズム
  1. 呼吸器疾患以外の原因で症状を呈することを念頭に置きながら診療にあたる。
  1. 喘鳴・呼吸困難時には治療が優先される場合がある。
  1. 乳幼児では自覚症状を訴えることができないため、他覚的所見(多呼吸・陥没呼吸・呻吟など)に注意し重症度を評価する。
 
乳幼児で呼吸困難を疑う症状・所見

乳幼児では自覚症状を訴えることが難しく、他覚症状より呼吸状況を把握することが重要。
経過や児の様子について、家族からしっかり問診をとることも大切である。

出典

img1:  著者提供
 
 
 
  1. 肺炎の重症度を評価するのに役立つ臨床指標は多呼吸の有無である(推奨度2JS/CS)。(参考文献:[1][2]
  1. 肺炎の重症度評価は、日本小児呼吸器学会が示すガイドラインがある。
  1. システマティックレビューにおいて、肺炎の重症度評価には呼吸数は重要なことが示されている。
  1. 肺炎に限らず、呼吸器症状を診察する場合は呼吸数を測定することが大切である。
 
小児市中肺炎の重症度分類

肺炎以外でも呼吸障害の重症度評価には、呼吸数・努力呼吸の有無が臨床所見として大切である。

 
  1. 小児の咳嗽についてはエビデンスが乏しい(推奨度1G)。(参考文献:[3]
  1. 小児の咳嗽については疫学・診断・治療についてのエビデンスが乏しい。治療は咳嗽の原因に応じて行うべきであるが、原因不明のまま治療を行わざるえないこともある。その場合、治療の効果をフォローすることが大切である。咳嗽は小児ではありふれた主訴であるが、児だけでなく保護者のQOLに影響を及ぼす。保護者の不安をとることも大切である。
 
Summary of Recommendations

出典

img1:  Guidelines for evaluating chronic cough in pediatrics: ACCP evidence-based clinical practice guidelines.
 
 Chest. 2006 Jan;129(1 Suppl):260S-283S. ・・・
問診・診察のポイント  
  1. 診察室に入ってくる様子、呼吸様式など視診により緊急性の有無を判断する。

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文献 

著者: Ann Van den Bruel, Tanya Haj-Hassan, Matthew Thompson, Frank Buntinx, David Mant, European Research Network on Recognising Serious Infection investigators
雑誌名: Lancet. 2010 Mar 6;375(9717):834-45. doi: 10.1016/S0140-6736(09)62000-6. Epub 2010 Feb 2.
Abstract/Text BACKGROUND: Our aim was to identify which clinical features have value in confirming or excluding the possibility of serious infection in children presenting to ambulatory care settings in developed countries.
METHODS: In this systematic review, we searched electronic databases (Medline, Embase, DARE, CINAHL), reference lists of relevant studies, and contacted experts to identify articles assessing clinical features of serious infection in children. 1939 potentially relevant studies were identified. Studies were selected on the basis of six criteria: design (studies of diagnostic accuracy or prediction rules), participants (otherwise healthy children aged 1 month to 18 years), setting (ambulatory care), outcome (serious infection), features assessed (assessable in ambulatory care setting), and sufficient data reported. Quality assessment was based on the Quality Assessment of Diagnostic Accuracy Studies criteria. We calculated likelihood ratios for the presence (positive likelihood ratio) or absence (negative likelihood ratio) of each clinical feature and pre-test and post-test probabilities of the outcome. Clinical features with a positive likelihood ratio of more than 5.0 were deemed red flags (ie, warning signs for serious infection); features with a negative likelihood ratio of less than 0.2 were deemed rule-out signs.
FINDINGS: 30 studies were included in the analysis. Cyanosis (positive likelihood ratio range 2.66-52.20), rapid breathing (1.26-9.78), poor peripheral perfusion (2.39-38.80), and petechial rash (6.18-83.70) were identified as red flags in several studies. Parental concern (positive likelihood ratio 14.40, 95% CI 9.30-22.10) and clinician instinct (positive likelihood ratio 23.50, 95 % CI 16.80-32.70) were identified as strong red flags in one primary care study. Temperature of 40 degrees C or more has value as a red flag in settings with a low prevalence of serious infection. No single clinical feature has rule-out value but some combinations can be used to exclude the possibility of serious infection-for example, pneumonia is very unlikely (negative likelihood ratio 0.07, 95% CI 0.01-0.46) if the child is not short of breath and there is no parental concern. The Yale Observation Scale had little value in confirming (positive likelihood ratio range 1.10-6.70) or excluding (negative likelihood ratio range 0.16-0.97) the possibility of serious infection.
INTERPRETATION: The red flags for serious infection that we identified should be used routinely, but serious illness will still be missed without effective use of precautionary measures. We now need to identify the level of risk at which clinical action should be taken.
FUNDING: Health Technology Assessment and National Institute for Health Research National School for Primary Care Research.

Copyright 2010 Elsevier Ltd. All rights reserved.
PMID 20132979  Lancet. 2010 Mar 6;375(9717):834-45. doi: 10.1016/S0140・・・
著者: Anne B Chang, William B Glomb, )
雑誌名: Chest. 2006 Jan;129(1 Suppl):260S-283S. doi: 10.1378/chest.129.1_suppl.260S.
Abstract/Text OBJECTIVES: To review relevant literature and present evidence-based guidelines to assist general and specialist medical practitioners in the evaluation and management of children who present with chronic cough.
METHODOLOGY: The Cochrane, MEDLINE, and EMBASE databases, review articles, and reference lists of relevant articles were searched and reviewed by a single author. The date of the last comprehensive search was December 5, 2003, and that of the Cochrane database was November 7, 2004. The authors' own databases and expertise identified additional articles.
RESULTS/CONCLUSIONS: Pediatric chronic cough (ie, cough in children aged <15 years) is defined as a daily cough lasting for >4 weeks. This time frame was chosen based on the natural history of URTIs in children and differs from the definition of chronic cough in adults. In this guideline, only chronic cough will be discussed. Chronic cough is subdivided into specific cough (ie, cough associated with other symptoms and signs suggestive of an associated or underlying problem) and nonspecific cough (ie, dry cough in the absence of an identifiable respiratory disease of known etiology). The majority of this section focuses on nonspecific cough, as specific cough encompasses the entire spectrum of pediatric pulmonology. A review of the literature revealed few randomized controlled trials for treatment of nonspecific cough. Management guidelines are summarized in two pathways. Recommendations are derived from a systematic review of the literature and were integrated with expert opinion. They are a general guideline only, do not substitute for sound clinical judgment, and are not intended to be used as a protocol for the management of all children with a coughing illness. Children (aged <15 years) with cough should be managed according to child-specific guidelines, which differ from those for adults as the etiologic factors and treatments for children are sometimes different from those for adults. Cough in children should be treated based on etiology, and there is no evidence for using medications for the symptomatic relief of cough. If medications are used, it is imperative that the children are followed up and therapy with the medications stopped if there is no effect on the cough within an expected time frame. An evaluation of the time to response is important. Irrespective of diagnosis, environmental influences and parental expectations should be discussed and managed accordingly. Cough often impacts the quality of life of both children and parents, and the exploration of parental expectations and fears is often valuable in the management of cough in children.

PMID 16428719  Chest. 2006 Jan;129(1 Suppl):260S-283S. doi: 10.1378/ch・・・
著者: P Munyard, A Bush
雑誌名: Arch Dis Child. 1996 Jun;74(6):531-4.
Abstract/Text A new multiparametric device (RBC-7) was used for recording cough in ambulatory children over a 24 hour period. The number of coughs and the pattern of coughing can easily be studied with the aid of a personal computer and dedicated computer software. Forty one 'normal' children were recorded, identified from a primary school with the aid of a questionnaire. They were free from any respiratory infection for one month, and had a normal examination and spirometry immediately before recording. Cough frequency was 11.3, range 1 to 34, cough episodes per 24 hours. This was unaffected by passive smoking or the presence of furry pets in the home. Nocturnal and prolonged coughing was unusual in these children. The device was highly acceptable to the children, and no adverse effects were reported. Such objective data on cough outside the laboratory setting are unique, help to determine what is normal, and may help in the diagnosis and assessment of many respiratory diseases.

PMID 8758131  Arch Dis Child. 1996 Jun;74(6):531-4.
著者: J M Marchant, I B Masters, S M Taylor, A B Chang
雑誌名: Thorax. 2006 Aug;61(8):694-8. doi: 10.1136/thx.2005.056986. Epub 2006 May 2.
Abstract/Text BACKGROUND: Paediatricians rely on cough descriptors to direct them to the level of investigations needed for a child presenting with chronic cough, yet there is a lack of published data to support this approach. A study was undertaken to evaluate (1) whether historical cough pointers can predict which children have a specific cause for their cough and (2) the usefulness of chest radiography and spirometry as standard investigations in children with chronic cough.
METHODS: This was a prospective cohort study of children referred to a tertiary hospital with a cough lasting >3 weeks between June 2002 and July 2004. All included children completed a detailed history and examination using a standardised data collection sheet and followed a pathway of investigation until a diagnosis was made.
RESULTS: In 100 consecutively recruited children of median age 2.8 years, the best predictor of specific cough observed was a moist cough at the time of consultation with an odds ratio (OR) of 9.34 (95% CI 3.49 to 25.03). Chest examination or chest radiographic abnormalities were also predictive with OR 3.60 (95% CI 1.31 to 9.90) and 3.16 (95% CI 1.32 to 7.62), respectively. The most significant historical pointer for predicting a specific cause of the cough was a parental history of moist cough (sensitivity 96%, specificity 26%, positive predictive value 74%).
CONCLUSIONS: The most useful clinical marker in predicting specific cough is the presence of a daily moist cough. Both chest examination and chest radiographic abnormalities are also useful in predicting whether children have a specific cause of their cough.

PMID 16670171  Thorax. 2006 Aug;61(8):694-8. doi: 10.1136/thx.2005.056・・・
著者: S M Smith, K Schroeder, T Fahey
雑誌名: Cochrane Database Syst Rev. 2008 Jan 23;(1):CD001831. doi: 10.1002/14651858.CD001831.pub3. Epub 2008 Jan 23.
Abstract/Text BACKGROUND: Acute cough due to upper respiratory tract infection (URTI) is a common symptom. Non-prescription over-the-counter (OTC) medicines are frequently recommended as a first-line treatment, but there is little evidence as to whether these drugs are effective.
OBJECTIVES: To assess the effects of oral OTC cough preparations for acute cough.
SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4); MEDLINE (January 1966 to January Week 1, 2007); EMBASE (January 1974 to January 2007); and the UK Department of Health National Research Register (June 2007).
SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing oral OTC cough preparations with placebo in children and adults suffering from acute cough in ambulatory settings. We considered all cough outcomes and second outcomes of interest were adverse effects.
DATA COLLECTION AND ANALYSIS: Two review authors independently screened potentially relevant citations and independently extracted data and assessed study quality. Quantitative analysis was performed where appropriate.
MAIN RESULTS: Twenty five trials (17 in adults, 8 in children) involving 3492 people (2876 adults and 616 children) were included. RESULTS OF STUDIES IN ADULTS: Six trials compared antitussives with placebo and had variable results. Two trials compared the expectorant, guaifenesin with placebo, one indicated significant benefit whereas the other did not. One trial found that a mucolytic reduced cough frequency and symptom scores. Two studies examined antihistamine-decongestant combinations and found conflicting results. Three studies compared other combinations of drugs with placebo and indicated some benefit in reducing cough symptoms. Three trials found antihistamines were no more effective than placebo in relieving cough symptoms. RESULTS OF STUDIES IN CHILDREN: Antitussives (two studies), antihistamines (two studies), antihistamine decongestants (two studies) and antitussive/bronchodilator combinations (one study) were no more effective than placebo. No studies using expectorants met our inclusion criteria. The results of one trial favoured active treatment with mucolytics over placebo. One trial tested two paediatric cough syrups and both preparations showed a 'satisfactory response' in 46% and 56% of children compared to 21% of children in the placebo group.
AUTHORS' CONCLUSIONS: There is no good evidence for or against the effectiveness of OTC medicines in acute cough. The results of this review have to be interpreted with caution due differences in study characteristics and quality. Studies often showed conflicting results with uncertainty regarding clinical relevance. Higher quality evidence is needed to determine the effectiveness of self-care treatments for acute cough.

PMID 18253996  Cochrane Database Syst Rev. 2008 Jan 23;(1):CD001831. d・・・
著者: Diane E Pappas, J Owen Hendley, Frederick G Hayden, Birgit Winther
雑誌名: Pediatr Infect Dis J. 2008 Jan;27(1):8-11. doi: 10.1097/INF.0b013e31814847d9.
Abstract/Text BACKGROUND: Signs and symptoms of a common cold reported in young children are those perceived by caretakers. Objective signs include cough, fever, and sneezing. Subjective symptoms include nasal congestion, feverishness, headache, and sore throat. School-aged children may provide a more accurate picture of the symptom profile during colds because they can self-report.
METHODS: Using preprinted diary sheets listing common signs and symptoms, diaries were kept for school-aged children for 10 days after onset of a cold. Nasopharyngeal aspirates were analyzed for respiratory viruses and potential bacterial pathogens.
RESULTS: Out of 81 colds studied, the most common signs were cough and sneezing, although the most common symptoms were nasal congestion and runny nose. Other symptoms, including feverishness and headache, were each reported in 15% of children at onset. The majority of children (73%) continued to be symptomatic 10 days after onset. Rhinovirus was detected in 46% and 1 or more potential bacterial pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) in 29% of episodes. Symptom profiles for rhinovirus illnesses and those in which potential pathogenic bacteria were detected were not different from the rest.
CONCLUSION: The common cold in school-aged children is characterized by nasal congestion, cough, and runny nose. Signs and symptoms usually continue for at least 10 days.

PMID 18162930  Pediatr Infect Dis J. 2008 Jan;27(1):8-11. doi: 10.1097・・・
著者: Alastair D Hay, Andrew D Wilson
雑誌名: Br J Gen Pract. 2002 May;52(478):401-9.
Abstract/Text Professional and parental uncertainty regarding the natural history of cough and respiratory tract infection (R77) in pre-school children may in part be responsible for the high consultation, reconsultation, and antibiotic prescribing rates in this age group. The aim of the study was to review the evidence about the natural history of acute cough in children aged between 0 and 4 years presenting to primary care in terms of illness duration and complications. The study was a systematic review, with qualitative and quantitative data synthesis, of control and placebo arms of systematic reviews, randomised controlled trials (RCTs), and cohort studies set in primary care. Searches were done of MEDLINE (between 1966 and June 1998), EMBASE (between 1988 and September 1998), and the Cochrane Library databases, using the MeSH terms 'respiratory tract infection, 'cough, and 'bronchitis, and the textwords 'cough' 'bronchitis, and 'chest infection, limited to children aged between 0 and 4years, and English language articles. Eight RCTs and two cohort studies met the review criteria. At one week, 75% of children may have improved but 50% may be still coughing and/or have a nasal discharge. At two weeks up to 24% of children may be no better. Within two weeks of presentation, 12% of children may experience one or more complication, such as rash, painful ears, diarrhoea, vomiting, or progression to bronchitis/pneumonia. This review offers parents and clinicians more prognostic information about acute cough in pre-school children. Illness duration may be longer and complications higher than many parents and clinicians expect. This may help to set more realistic expectations of the illness and help parents to decide when and if to reconsult. This information may be useful to those designing patient information and self-help resources.

PMID 12014540  Br J Gen Pract. 2002 May;52(478):401-9.

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