🧸 儿科学 · 第2课，共5课 · 7 min

哮吼、会厌炎和那把永远不该用的压舌板

Croup, Epiglottitis and the Tongue Blade You Never Use

🐕 凌晨2点犬吠样咳嗽就是哮吼，一剂dexamethasone就能治疗。一个安静、流口水、惊恐地身体前倾坐着的孩子是会厌炎，而好心护士伸手去拿的压舌板可能会让气道彻底关闭。

🐕 A barking cough at 2 a.m. is croup, and a dose of dexamethasone treats it. A silent, drooling, terrified child sitting forward is epiglottitis, and the tongue blade a well-meaning nurse reaches for can close the airway for good.

💡 核心要点

哮吼会发出犬吠样咳嗽，用类固醇治疗，静息时有喘鸣再加雾化epinephrine。会厌炎会流口水、身体前倾坐着，需要气道团队，永远不要用压舌板。RSV需要吸痰和接触预防措施。CF每一口食物都要配胰酶。

Croup barks and gets a steroid, plus nebulized epinephrine for stridor at rest. Epiglottitis drools, sits forward and gets an airway team, never a tongue blade. RSV gets suction and contact precautions. CF gets enzymes with every bite.

🧠 为什么重要

哮吼（CROUP，喉气管支气管炎）：由病毒引起，表现为犬吠样咳嗽、吸气性喘鸣、声音嘶哑和低热，夜间加重；用皮质类固醇（口服dexamethasone）治疗，静息时有喘鸣则用雾化吸入racemic epinephrine，同时让孩子由家长陪伴保持安静；凉雾或凉爽的夜晚空气可让孩子舒服些，但并不能治疗哮吼。会厌炎（EPIGLOTTITIS）：由细菌引起（经典病原为b型Haemophilus influenzae，如今因疫苗接种已罕见），表现为突发高热、四个D（drooling流口水、dysphagia吞咽困难、dysphonia发音困难、distress呼吸窘迫）、三脚架体位且无咳嗽；不要检查咽喉、不要用压舌板、不要让孩子平躺；让孩子保持安静、坐直并由家长陪伴，并准备在气道团队在场的情况下进行紧急插管。毛细支气管炎（BRONCHIOLITIS，通常由RSV引起）：婴儿出现喘息、呼吸急促、鼻翼扇动和肋间凹陷；支持性护理包括喂奶前吸鼻、补液、按需给氧和接触预防措施。百日咳（PERTUSSIS）：阵发性咳嗽伴吸气性鸡鸣样回声，采取飞沫预防措施，使用大环内酯类抗生素。囊性纤维化（CYSTIC FIBROSIS）：分泌物黏稠、皮肤咸、脂肪泻和生长发育不良；进行胸部物理治疗、每餐和每次加餐都服用胰酶、高热量高蛋白饮食并补充脂溶性维生素，炎热天气时额外补盐。气道异物（FOREIGN BODY）：幼儿突然咳嗽或喘鸣；如果孩子不能咳嗽、哭喊或说话，则反复进行循环操作：5次背部拍击和5次胸部冲击适用于1岁以下儿童，年龄较大的儿童则给予5次背部拍击和5次腹部冲击。

CROUP (laryngotracheobronchitis): viral, with a barking cough, inspiratory stridor, hoarseness and low-grade fever, worse at night; treat with a corticosteroid (oral dexamethasone) and, for stridor at rest, nebulized racemic epinephrine, keeping the child calm with the parent; cool mist or cool night air may comfort the child but does not treat croup. EPIGLOTTITIS: bacterial (classically Haemophilus influenzae type b, now rare with vaccination), with sudden high fever, the four Ds (drooling, dysphagia, dysphonia, distress), a tripod position and no cough; DO NOT examine the throat, use a tongue blade or lay the child flat; keep the child calm, upright and with the parent, and prepare for emergency intubation with the airway team present. BRONCHIOLITIS (usually RSV): wheezing, tachypnea, nasal flaring and retractions in infants; supportive care with nasal suctioning before feeds, hydration, oxygen as needed, and contact precautions. PERTUSSIS: paroxysmal coughing with an inspiratory whoop, droplet precautions, macrolide antibiotics. CYSTIC FIBROSIS: thick secretions, salty skin, steatorrhea and failure to thrive; chest physiotherapy, pancreatic enzymes with every meal and snack, high-calorie high-protein diet with fat-soluble vitamins, and added salt in hot weather. FOREIGN BODY: sudden coughing or stridor in a toddler; if the child cannot cough, cry or speak, give repeated cycles of 5 back blows and 5 chest thrusts under age 1, or 5 back blows and 5 abdominal thrusts for older children.

🏥 真实场景

🚫 一名4岁儿童到院时发热、流口水、身体前倾、拒绝吞咽。一名实习护士拿起笔式手电和压舌板，想查看咽喉。护士长拦住她，让孩子留在母亲腿上，并呼叫麻醉科。在手术室外直视会厌可能引发完全性气道梗阻。考试的正确答案就是那个对咽喉什么都不做的选项。

🚫 A 4-year-old arrives febrile, drooling, leaning forward, refusing to swallow. A student nurse picks up a penlight and tongue depressor to look at the throat. The charge nurse stops her, keeps the child in the mother's lap, and calls anesthesia. Visualizing the epiglottis outside the operating room can trigger complete obstruction. The exam's correct answer is the one that does nothing to the throat.

📌 要点总结

哮吼：犬吠样咳嗽，夜间喘鸣；dexamethasone，静息喘鸣加racemic epinephrineCroup: barking cough, stridor at night; dexamethasone, plus racemic epinephrine for stridor at rest
会厌炎：流口水、三脚架体位、无咳嗽：不查咽喉，准备插管Epiglottitis: drooling, tripod, no cough: no throat exam, prepare for intubation
RSV：喂奶前吸鼻，接触预防措施；CF：每餐服用胰酶RSV: suction before feeds, contact precautions; CF: enzymes with every meal

📖 本课术语

哮吼 (Croup): 幼童的病毒性气道感染，伴犬吠样咳嗽和喘鸣，用dexamethasone治疗，静息时有喘鸣时用雾化epinephrine治疗。

会厌炎 (Epiglottitis): 会厌的细菌性肿胀，伴流口水和三脚架体位；绝不能检查咽喉。

✅ 自我测试

一名疑似会厌炎的儿童正在流口水，坐直并身体前倾。护士的哪项行为需要立即干预？A child with suspected epiglottitis is drooling and sitting upright leaning forward. Which action by a nurse requires immediate intervention?

用压舌板检查咽喉Inspecting the throat with a tongue blade
呼叫气道团队到床边Calling for the airway team to come to the bedside
保持病房安静并推迟非紧急操作Keeping the room quiet and deferring nonurgent procedures
让孩子坐直待在家长腿上Keeping the child upright in the parent's lap

答案: A · 用压舌板检查咽喉

检查咽喉可能诱发完全性气道梗阻；气道应由技术娴熟的人员在受控环境中建立。让孩子坐直待在家长腿上是正确的护理：这个体位有助于呼吸，保持安静能减少可能加重梗阻的哭闹。

Throat examination can precipitate complete airway obstruction; the airway is secured by skilled staff in a controlled setting. Keeping the child upright in the parent's lap is correct care: the position eases breathing, and staying calm limits crying that can worsen the obstruction.

对于在家中患哮吼并有轻度喘鸣的幼儿，哪项干预合适？Which intervention is appropriate for a toddler with croup and mild stridor at home?

让孩子保持安静并坐直Keep the child calm and upright
鼓励剧烈玩耍以松动分泌物Encourage vigorous play to loosen secretions
给予非处方镇咳药Give over-the-counter cough suppressants
让孩子仰卧平躺Place the child flat on the back

答案: A · 让孩子保持安静并坐直

保持安静和坐直有助于呼吸并降低氧需求，医务人员通常会开一剂口服dexamethasone；静息时喘鸣需要紧急就医。凉雾可起到安慰作用，但不能治疗哮吼。不建议幼儿使用镇咳药，平躺会加重呼吸困难，剧烈玩耍会增加氧需求。

Calm and upright eases breathing and lowers oxygen demand, and the provider usually prescribes one dose of oral dexamethasone; stridor at rest needs urgent care. Cool mist may comfort but does not treat croup. Cough suppressants are not recommended for young children, lying flat worsens breathing, and vigorous play raises oxygen demand.

一名患囊性纤维化的儿童正要吃午餐。护士应确保什么？A child with cystic fibrosis is about to eat lunch. What should the nurse ensure?

孩子随餐服用胰酶The child receives pancreatic enzymes with the meal
这餐低脂肪、低热量The meal is low in fat and calories
孩子避免吃盐The child avoids salt
饭后立即进行胸部物理治疗Chest physiotherapy is done immediately after eating

答案: A · 孩子随餐服用胰酶

每餐和每次加餐都服用胰酶有助于脂肪和蛋白质的吸收；CF饮食热量、脂肪和盐含量都高，胸部物理治疗在饭前进行。

Enzymes with every meal and snack allow fat and protein absorption; CF diets are high in calories, fat and salt, and chest physiotherapy is done before meals.

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