摘要
哮喘是兒童時期最常見的疾病，對居住在城市地區的低收入，少數民族兒童產生不成比例的不良影響。與哮喘發病率和死亡率相關的一係列風險因素例如：治療的不堅持，暴露於環境觸發因素，低收入家庭，暴露於慢性壓力，兒童心理問題，父母壓力，家庭功能障礙，肥胖症，缺乏身體活動和不健康的飲食。這些風險因素往往具有複雜的相互作用和相互關係。探索這些因素在哮喘發病率和死亡率中的相互關係的綜合研究是必要的，並且有助於通知臨床幹預。大量的研究集中在幹預措施，以改善哮喘患者的依從性，哮喘管理，哮喘症狀和生活質量。教育幹預措施與社會心理幹預措施(如行為，認知行為或家庭幹預)相結合，對學校，家庭和急診室提供護理是有益的，可以幫助解決獲得兒童和家庭護理的障礙。最近的另外一些研究已經探索了與兒科哮喘患者一起使用多學科協作綜合治療，提供了有希望的結果。綜合護理可以理想地處理在兒童哮喘中發揮作用的多種複雜的社會心理和健康因素，增加以患者為中心的護理，並促進協作的患者 - 提供者關係。在這方麵的進一步研究是必不可少的，將是有益的。
背景：哮喘是美國兒童中最常見的慢性疾病，估計影響了1060萬(14.5%)的兒童[1]，對受影響青年的身心健康產生了重大影響。 小孩的哮喘會給父母和家庭係統帶來很大的壓力和壓力。 大量的研究集中在兒童哮喘，探索疾病危險因素，依從性，兒童和護理人員心理問題的角色，家庭和環境壓力因素的影響以及哮喘和肥胖等健康因素之間的關係。 其他研究還探討了幹預措施，以減少哮喘青年的依從性問題，改善整體功能和哮喘管理。
環境風險因素
低收入城市少數民族青年受哮喘影響較大，因此低社會經濟地位兒童[2,3]和城市少數民族家庭[3,4]的哮喘患病率和疾病發病率較高。 患病率表明，非裔美國兒童的哮喘發病率高於拉丁裔或白人兒童[2]，波多黎各兒童的哮喘發病率高於其他拉丁裔兒童[3]。 此外，與哮喘白人兒童相比，非裔美國人和拉丁裔哮喘兒童的急診室訪視率和哮喘死亡率更高[5]。 一些研究表明，這些哮喘患病率的種族差異主要出現在低收入青年，而不是中低收入階層的少數兒童[6]。生活在低收入家庭的兒童往往體驗到壓力增加，如家庭衝突，暴力，低質量的家庭環境，危險的鄰居和汙染的空氣和水[7]，這被認為是哮喘的危險因素[8]。因此，與住房相關的壓力[9]，社區壓力源，如高犯罪率[10]，貧窮[11]，慢性家庭壓力[12]，暴露於煙草煙霧和汙染物[13]等社區壓力因素與增加哮喘症狀有關。作為解釋這種關係的一個途徑，暴露於慢性壓力與高度炎症反應有關，反過來又與哮喘症狀增加有關[12]。
此外，研究發現，居住在低收入家庭的兒童更可能經曆父母支持和參與的減少，花更多的時間看電視，更多地感受到他們的生活和生活環境缺乏控製[7]。 來自經濟困難家庭的兒童也可能獲得照料和較差的照顧質量[14]; 據估計，2-17歲的兒童中有41%沒有得到所需的精神衛生服務[1]。 因此，低收入的城市少數兒童已經增加了正確控製哮喘的障礙，包括增加暴露於環境觸發因素和減少獲得適當治療的機會[8]。此外，較低的父母教育與哮喘患病率較高，哮喘藥物依從性較低以及哮喘住院率較高有關[15]。 由於低收入家庭的父母受教育程度低於高收入家庭的父母，這也可以解釋低收入家庭與哮喘之間的關係。
堅持使用哮喘藥物
哮喘藥物治療能夠減少哮喘發病率，急診室訪視和住院治療，哮喘控製藥物依從性差與哮喘急性加重[16]，哮喘未控製[17,18]，哮喘發病率[19,20]和哮喘死亡率[21]相關。 然而，哮喘控製藥物往往在兒童中使用不足[22]，藥物不依從是一個重要的問題[23]，特別是在城市微小病患者[22]。 鑒於這些結果，改善藥物依從性的幹預對於降低哮喘發病率和死亡率是重要的。 此外，改善哮喘藥物依從性和隨之而來的改善哮喘控製可以導致生活質量的提高[24]。
幾個危險因素似乎會破壞兒童服藥依從性，包括男性，非亞裔，背景較大，家庭較大，診斷年齡較大[25]，生活在農村[22]，社會經濟地位較低[26]， 導致不遵守的因素通常可以分為有意或無意[27]。無意的因素包括導致藥物不被人們選擇之外的其他原因所吸收的障礙和障礙。 [28]缺乏父母的參與[28]，缺乏適當的藥物治療，不正確的吸入技術[26]，兒童心理障礙[29]，青春期遺忘[30]。 照顧者心理困擾，家庭功能問題[31] ，兒童和家庭對哮喘和哮喘藥物的認識不足，症狀識別有限，缺乏社區支持[24]。另外，哮喘和哮喘藥物對兒童和家庭的不良認知，有限的臨床表現以及缺乏社區支持也可能導致藥物不依從[24]。故意的因素包括對自己的疾病和藥物的信念，導致選擇不服用藥物[32]。故意的因素，如父母關心控製藥物(如副作用，安全性)和治療費用[33]，青少年的信念，藥物是不必要的或無益的[30]已被證明與較高不遵守。
哮喘患兒及其護理人員的心理功能
大多數研究表明，與健康同齡人相比，哮喘患兒表現出更多的行為問題[34]，並使焦慮和情感障礙等疾病內化[35]。哮喘與行為和情緒困難之間的關聯已經顯示出隨著哮喘嚴重程度的顯著增加[34]。 哮喘兒童的這些心理障礙與功能限製增加和哮喘管理較差有關。例如，即使在控製了哮喘嚴重程度之後，患有並發哮喘和內化障礙的兒童的功能障礙增加[35]，錯過上課時間[36]，使用控製藥物增加，肺功能較差，出現頻率增加 護理使用[37]，以及更高的治療不依從性，這反過來又與較差的健康結果相關[29]。
小孩的哮喘也會影響護理人員的調節，心理功能和壓力感受。哮喘患兒護理人員心理障礙的風險顯著增加反映在抑鬱[29,38]和焦慮[37]的增加。 哮喘兒童護理人員的這些心理障礙可能會導致哮喘管理方麵的問題。例如，父母壓力與較差的藥物依從性顯著相關，母親的抑鬱症狀與使用適當的吸入技術，較差的藥物依從性，較大的煙草煙霧暴露以及較低的控製其兒童哮喘的能力[39]。
健康和生活方式
最近的研究集中在諸如促進健康或威脅健康的生活方式行為(例如飲食，運動)等健康因素及其與哮喘患者的相關性。調查人員發現兒童人群中肥胖與哮喘之間存在正相關關係[40,41]。兒童和青少年的肥胖也與抑鬱和焦慮增加有關[42,43]。 在哮喘患兒中，肥胖已被發現與非受控哮喘[13,44]，哮喘嚴重程度[41,45]，緊急護理使用和皮質類固醇使用[46]相關。此外，肥胖對哮喘管理提出了挑戰，例如對哮喘控製藥物的反應性下降和生活質量下降[47]，超重的哮喘兒童與健康體重相比，發現汙染物暴露的負麵影響增加 哮喘患兒[13]。
哮喘患兒的體力活動水平較低，導致肥胖和心理健康問題。例如，哮喘患兒體力活動水平較低[48,49]，而較高水平的久坐活動參與度，如在計算機上花費的時間[50]。此外，體重超重的哮喘兒童比沒有哮喘的超重兒童顯著減少體育鍛煉的可能性[51]。不活動增加可能導致哮喘和肥胖之間的問題關係。例如，哮喘超重兒童觀看電視的時間增加與呼吸係統症狀的風險增加有關[52,53]，而體育鍛煉的增加與呼吸係統症狀的風險降低有關[53]。另外，有人認為體力活動減少導致哮喘發病率增加[54]。此外，數據表明，對於哮喘患兒，身體活動水平與心理健康之間存在正相關關係[48]。
同樣，飲食與體重有關，並影響哮喘。大多數吃西式飲食的兒童，其脂肪和加工食品含量較高，而哮喘患病率高於食用較少脂肪和加工食品的兒童[55]。 地中海飲食與哮喘症狀減輕有關[56]，建議堅持飲食健康對兒童哮喘有保護作用[57]。飲食與哮喘之間關係的一個可能的解釋是飲食對腸內微生物群的影響，進而影響腸內微生物群對免疫炎症反應的影響[58]。
心理幹預
對哮喘兒童進行一係列社會心理幹預，如教育計劃，行為幹預，認知行為療法，家庭幹預和/或基於社區的幹預。 關於心理幹預療效的研究是有限的，還沒有定論[59,60]，並且受到關於方法學問題的擔憂的困擾[60]。盡管存在這些問題，初步的證據表明，心理幹預可以改善哮喘患兒的生活質量和醫療效果。將教育與社會心理幹預相結合的幹預措施，如行為，認知行為和/或家庭幹預顯示出特別的前景[31]。
一些幹預措施，如自我管理培訓和教育，被認為是哮喘患者在整個治療過程中治療的重要組成部分。對這些項目的研究已經發現哮喘患兒有益，包括提高對疾病管理的認識和信心[61,62]，改善依從性[23,63]，改善哮喘症狀[64]，改善肺功能[65] 減少急診室訪問[65,66]，減少學校缺勤，減少活動限製[65]，提高生活質量[66]。然而，在獲得文化敏感，適齡的患者教育資料方麵，全球性差距巨大[67]。
由於擔心缺乏有效的幹預措施，尤其是處於不利背景的兒童，一些調查人員越來越重視探索以學校為基礎的急診室和家庭教育幹預措施。 當這些幹預措施包括父母時，結果表明家長對疾病管理的自我效能得到改善[68]。 緊急情況的房間幹預與增加的堅持和減少未來的緊急情況訪問有關[69]。 另外，研究發現，家庭幹預減少了哮喘症狀和緊急情況下的訪問[70,71]。
盡管有這些結果，但各個研究結果的綜合薈萃分析結果顯示，沒有額外幹預措施的教育幹預措施對於改善哮喘管理和健康結局是不夠的[72]。調查表明，將諸如行為或認知行為幹預等社會心理幹預措施納入哮喘教育項目，可減輕哮喘嚴重程度，減少急診室訪視[73]，減少兒童抑鬱症，減輕兒童壓力[74]，減少學校缺勤[73]，堅持不懈，減少親子衝突[75]。同樣，教育與家庭治療相結合，對兒童和父母有益，導致氣道炎症減輕，身體健康改善，心理健康得到改善。在哮喘管理和父母焦慮情緒方麵，父母也表現出增加的父母效能[76]。此外，一項研究發現，越來越多的父母監督增加了兒童藥物的依從性[77]。
對於超重兒科患者，提高幹預措施以提高身體活動水平，減少不健康的飲食行為[47]。例如，改善飲食攝入的行為幹預導致BMI下降和哮喘改善[78]，包括心理，營養和運動成分在內的幹預措施顯示BMI降低，哮喘控製改善，肺功能改善[79]。
綜合護理
考慮到影響哮喘發作和嚴重程度的複雜因素，應對這一挑戰需要將多個幹預措施組合在一起，以滿足個別兒童及其家庭的需求。最近的證據表明，全麵，協作，多學科護理(稱為綜合護理)的重要性，除了傳統的醫療護理外，還涉及精神健康，患者教育和家庭功能[80]。例如，國立衛生研究院的準則[81]特別強調了對心理並發症，心理社會壓力源和治療不依從的患者采用跨學科方法的益處。世界各地的機構正在努力通過綜合護理途徑來發展綜合護理，以治療哮喘[82]。因此，哮喘自我管理技能的綜合方法，包括社區參與方案設計，並重點關注家庭壓力，家庭關係[83,84]，家庭衝突，父母壓力，養育方式和兒童行為[ 84]可能對哮喘患兒產生更大的益處和結果。
提供整體護理的綜合護理項目已經證明哮喘症狀，哮喘管理方麵的感知能力，減少皮質類固醇使用以及改善護理人員和兒童的生活質量方麵有顯著改善[85,86]。特別是側重於特別解決治療障礙的幹預措施，如電話聯係，簡單幹預措施和父母解決問題，可以顯著提高初次任用和繼續參與治療[87]。 這些策略對青少年濫用藥物[88,89]，兒童心理健康[90]和注意力缺陷/多動障礙[91]顯示出有前景的有效性。
綜合護理可以根據患者的需要在多個設置中進行。作為谘詢聯絡服務的一部分，小兒心理學家經常在住院病人或三級護理診所就診，但是越來越多地被納入綜合護理小組[80,85]。行為健康從業者可以幫助醫療機構在醫療預約期間實施堅持促進幹預[93]。最後，早期幹預和預防保健運動[94,95]為初級保健機構[96]和校本保健中心[97,98]提供了多學科幹預的機會。由於兒童在學校(通常6-8小時)花費了大量時間，學校為藥物管理，父母支持和行為幹預提供了獨特的機會。基於校園幹預的研究已經發現，包括提高知識，自我效能和疾病管理[62]和改善哮喘控製[99]的好處。
結論
一係列環境，社會心理，行為和生活方式風險因素與哮喘惡化和發病率有關。這些風險因素具有複雜的相互作用和雙向關係(見圖1)。絕大多數的研究集中在孤立的一個或幾個這些因素。盡管經常出現這種罕見的焦點，研究中出現的幾個風險因素並不罕見，因此不管最初的重點如何，研究結果往往存在一些重疊。例如，對兒童風險因素的研究往往發現養育因素是相關的。鑒於風險因素之間複雜的相互作用，需要綜合研究探討所有或大部分因素在哮喘發病率和死亡率方麵的相互關係，並有助於通知臨床幹預。
因此，需要考慮個人，家族和環境風險因素之間相互作用的綜合治療方法。最近的研究已經強調了多學科，協作，綜合護理小兒哮喘患者的重要性，並取得了可喜的成果。 這種全麵的方法非常適合解決在兒童哮喘中發揮作用的多種複雜的，相互關聯的社會心理和健康/生活方式因素。 這種綜合護理方法對於增加以患者為中心的護理，共享決策以及家庭和提供者之間的合作關係也可能是有效的。 這方麵的進一步研究是必要的，將是有益的。
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