任明星，薛國(guó)昌，沈琳娜，張黎雯，宋月娟，夏　歡，夏雪霞

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·臨床醫(yī)學(xué)·

雙歧桿菌三聯(lián)活菌散對(duì)特應(yīng)性體質(zhì)患兒毛細(xì)支氣管炎后再發(fā)喘息的預(yù)防作用

任明星，薛國(guó)昌，沈琳娜，張黎雯，宋月娟，夏歡，夏雪霞

[摘要]目的觀察雙歧桿菌三聯(lián)活菌散對(duì)特應(yīng)性體質(zhì)患兒毛細(xì)支氣管炎后再發(fā)喘息的預(yù)防作用，及對(duì)嗜酸性粒細(xì)胞(EOS)和轉(zhuǎn)化生長(zhǎng)因子β1(TGF-β1)水平的影響。方法經(jīng)監(jiān)護(hù)人知情同意，并簽署知情同意書后，采用數(shù)字表法將60例毛細(xì)支氣管炎患兒隨機(jī)分為治療組30例，常規(guī)治療組30例，并設(shè)健康對(duì)照組25例；常規(guī)治療組予毛細(xì)支氣管炎常規(guī)治療，治療組予常規(guī)治療外，加用雙歧桿菌三聯(lián)活菌散治療2個(gè)月。于急性期及口服雙歧桿菌三聯(lián)活菌散2月后檢測(cè)EOS和TGF-β1水平。結(jié)果(1)治療組患兒6月內(nèi)再次喘息發(fā)作次數(shù)(0.67±0.13)明顯少于常規(guī)治療組(1.27±0.17)，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。(2)治療組和常規(guī)治療組患兒急性期EOS[(0.72±0.13)×109/L和(0.70±0.13)×109/L]均高于健康對(duì)照組[(0.16±0.09)×109/L]，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；治療組和常規(guī)治療組患兒急性期TGF-β1[(1.20±0.13) ng/L和(1.22±0.11) ng/L]均低于健康對(duì)照組[(1.45±0.13) ng/L]，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)?？诜p歧桿菌三聯(lián)活菌散2月后，治療組EOS[(0.27±0.12)×109/L]低于常規(guī)治療組[(0.36±0.14)×109/L]，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。治療組TGF-β1水平[(1.41±0.09) ng/L]高于常規(guī)治療組[(1.34±0.10) ng/L]，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。結(jié)論口服雙歧桿菌三聯(lián)活菌散能降低特應(yīng)性體質(zhì)毛細(xì)支氣管炎患兒再發(fā)喘息次數(shù)并上調(diào)患兒EOS和TGF-β1水平。

[關(guān)鍵詞]毛細(xì)支氣管炎；雙歧桿菌三聯(lián)活菌散；嗜酸性粒細(xì)胞；轉(zhuǎn)化生長(zhǎng)因子β1

[作者單位]214062江蘇 無錫，蘇州大學(xué)附屬無錫市第九人民醫(yī)院兒科

毛細(xì)支氣管炎又稱喘憋性肺炎，是2歲以內(nèi)嬰幼兒最常見的下呼吸道感染。流行病學(xué)資料顯示毛細(xì)支氣管炎是嬰幼兒發(fā)展成為支氣管哮喘的高危因素，尤以特應(yīng)性體質(zhì)患兒為重，尚無特殊預(yù)防措施，目前已有報(bào)道應(yīng)用益生菌來防治兒童支氣管哮喘[1]。因毛細(xì)支氣管炎與支氣管哮喘有相似的免疫學(xué)異常表征[2]，本文采用雙歧桿菌三聯(lián)活菌散輔助治療特應(yīng)性體質(zhì)毛細(xì)支氣管炎患兒，觀察其對(duì)毛細(xì)支氣管炎后再發(fā)喘息的預(yù)防作用及對(duì)嗜酸性粒細(xì)胞(eosinophil, EOS)和轉(zhuǎn)化生長(zhǎng)因子β1(transforming growth factor-beta1, TGF-β1)水平的影響，現(xiàn)報(bào)道如下。

1對(duì)象與方法

1.1研究對(duì)象

2013年5月至2014年12月我院收治的毛細(xì)支氣管炎住院患兒，診斷標(biāo)準(zhǔn)參照《兒科學(xué)》第8版[3]，且符合特應(yīng)性體質(zhì)的診斷標(biāo)準(zhǔn)[4]。入組前無糖皮質(zhì)激素治療史,無先天性心臟病、肝腎功能不全及其他疾病史，胸部X線檢查無片狀浸潤(rùn)影。共60例，其中男33例，女27例，年齡3～20個(gè)月。經(jīng)監(jiān)護(hù)人知情同意并簽署知情同意書，采用數(shù)字表法，隨機(jī)抽樣分為2組，治療組30例，常規(guī)治療組30例。另選取同期我院兒童保健門診健康體檢兒童25例作為健康對(duì)照組，年齡3～20個(gè)月，男18例，女12例。治療組、常規(guī)治療組和健康對(duì)照組的一般情況間差異無統(tǒng)計(jì)學(xué)意義(P>0.05) ，有可比性。

1.2方法

1.2.1治療方法治療組和常規(guī)治療組均給予常規(guī)治療，用藥及療程無差異，具有可比性。治療組入院后即加服雙歧桿菌三聯(lián)活菌散(商品名：培菲康；上海信誼藥廠有限公司生產(chǎn)；規(guī)格：每包2 g，每克含雙歧桿菌、乳酸桿菌和腸球菌活菌數(shù)不低于1.0×107cfu；批號(hào)：國(guó)藥準(zhǔn)字S10970104)，1 g，2次/d，溫水沖服，療程共2個(gè)月。

1.2.2標(biāo)本采集所有患兒于入院時(shí)(急性期)及口服雙歧桿菌三聯(lián)活菌散2個(gè)月后(療程結(jié)束時(shí))抽取空腹靜脈血3 ml，3 000 r/min(r=1.5 cm)，離心10 min，留取血清-70 ℃凍存?zhèn)錅y(cè)。對(duì)照組兒童采血及保存同上。

1.2.3檢測(cè)方法外周血EOS計(jì)數(shù)常規(guī)采集無名指指端血，由本院檢驗(yàn)科實(shí)驗(yàn)室計(jì)數(shù)。TGF-β1采用雙抗體夾心ELISA 法，試劑盒購(gòu)自美國(guó)R&D公司，嚴(yán)格按說明書操作。

1.2.4臨床療效觀察記錄2組患兒急性期病程、喘息再次發(fā)作次數(shù)及可能出現(xiàn)的不良反應(yīng)。隨訪6個(gè)月。

1.3統(tǒng)計(jì)學(xué)處理

使用SPSS 16.0統(tǒng)計(jì)軟件進(jìn)行統(tǒng)計(jì)分析。計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示，2組間比較采用t檢驗(yàn)，多組間比較采用單因素方差分析，多重比較采用LSD法。計(jì)數(shù)資料采用χ2檢驗(yàn)。P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

2結(jié)果

治療組和常規(guī)治療組患兒急性期病程及6月內(nèi)再次喘息發(fā)作次數(shù)的比較，治療組急性期病程與對(duì)照組比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)；治療組6月內(nèi)再次喘息發(fā)作次數(shù)明顯少于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。見表1。治療組和對(duì)照組患兒急性期EOS均高于健康對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；治療組和對(duì)照組患兒急性期TGF-β1均低于健康對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)?？诜p歧桿菌三聯(lián)活菌散2個(gè)月后，治療組EOS低于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。治療組TGF-β1水平高于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。見表2。全部病例無皮疹、腹瀉、嘔吐等不良反應(yīng)。

表1治療組和常規(guī)治療組患兒急性期病程及6個(gè)月內(nèi)

再次喘息發(fā)作次數(shù)的比較

表2　3組EOS、TGF-β1水平比較

注：與健康對(duì)照組比較aP<0.05，與常規(guī)治療組比較bP<0.05。EOS為嗜酸性粒細(xì)胞，TGF-β1為轉(zhuǎn)化生長(zhǎng)因子

3討論

毛細(xì)支氣管炎患兒氣道炎癥是氣道內(nèi)炎性細(xì)胞釋放的多種細(xì)胞因子、炎性遞質(zhì)與氣道內(nèi)細(xì)胞受體共同作用的結(jié)果，臨床表現(xiàn)為反復(fù)喘息發(fā)作和呼吸道高反應(yīng)性，長(zhǎng)期隨訪觀察發(fā)現(xiàn)約30%的患兒發(fā)展成為哮喘，尤其是特應(yīng)性體質(zhì)的患兒[5-6]。益生菌是指當(dāng)足量補(bǔ)充時(shí)，對(duì)宿主健康有益的活的微生物。目前大量動(dòng)物實(shí)驗(yàn)表明應(yīng)用益生菌可抑制哮喘模型小鼠氣道高反應(yīng)性和過敏性氣道炎癥反應(yīng)，并與Th1/Th2平衡和Th17細(xì)胞/調(diào)節(jié)性T細(xì)胞(Treg)平衡關(guān)系密切[7-8]。本研究發(fā)現(xiàn)治療組6月內(nèi)再次喘息發(fā)作次數(shù)明顯少于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義。因此筆者認(rèn)為較長(zhǎng)時(shí)間(2個(gè)月)口服雙歧桿菌三聯(lián)活菌散可能有預(yù)防毛細(xì)支氣管炎喘息再次發(fā)作的作用。

嗜酸性粒細(xì)胞是參與I型變態(tài)反應(yīng)的主要細(xì)胞之一，第一次接觸過敏原時(shí)機(jī)體產(chǎn)生的免疫球蛋白IgE與嗜酸性粒細(xì)胞結(jié)合并使之致敏，當(dāng)再次接觸相同的過敏原時(shí)，這些致敏的嗜酸性粒細(xì)胞就會(huì)在趨化因子的作用下通過血管內(nèi)皮細(xì)胞向炎性區(qū)域趨化并釋放出大量的炎性介質(zhì)，并拌有炎性細(xì)胞浸潤(rùn)、氣道上皮損傷、纖毛脫落、腺體增生、黏液高分泌、平滑肌增生使氣道處于高反應(yīng)狀態(tài)。TGF-β1主要由淋巴細(xì)胞和單核細(xì)胞產(chǎn)生，是一個(gè)多效性細(xì)胞因子，在哮喘中不僅能促進(jìn)機(jī)體對(duì)過敏原的免疫耐受，而且在不可逆的氣道重構(gòu)中也發(fā)揮著重要作用[9]。動(dòng)物實(shí)驗(yàn)表明大鼠氣道可通過旁分泌等方式分泌TGF-β1，從而介導(dǎo)T調(diào)節(jié)細(xì)胞抑制氣道炎癥高反應(yīng)[10]。TGF-β1作為一種免疫應(yīng)答負(fù)性調(diào)控因子，可抑制淋巴細(xì)胞增殖及功能，并抑制巨嗜細(xì)胞激活，可能具有關(guān)閉免疫應(yīng)答信號(hào)的作用[11]。本研究發(fā)現(xiàn)治療組、對(duì)照組患兒急性期EOS水平高于健康對(duì)照組，TGF-β1水平低于健康對(duì)照組，這與文獻(xiàn)報(bào)道的一致，提示EOS和TGF-β1參與了毛細(xì)支氣管炎的發(fā)病機(jī)制。

本研究還發(fā)現(xiàn)口服雙歧桿菌三聯(lián)活菌散2個(gè)月后治療組患兒IgE水平低于對(duì)照組，TGF-β1水平高于對(duì)照組，差異均有統(tǒng)計(jì)學(xué)意義。這表明長(zhǎng)期(2個(gè)月)口服雙歧桿菌三聯(lián)活菌散有下調(diào)EOS，上調(diào)TGF-β1的作用。其機(jī)制可能有：(1)雙歧桿菌三聯(lián)活菌散誘導(dǎo)Th1細(xì)胞活性，抑制Th2細(xì)胞活性，使B細(xì)胞產(chǎn)生IgE減少，導(dǎo)致肥大胞脫顆粒和釋放嗜酸細(xì)胞陽(yáng)離子蛋白等堿性蛋白減少，從而下調(diào)嗜酸性粒細(xì)胞。 (2)誘導(dǎo)Treg細(xì)胞分化，進(jìn)而上調(diào)TGF-β1水平。TGF-β1主要由Treg細(xì)胞分泌。Feleszko等[12]發(fā)現(xiàn)鼠李糖乳酸桿菌GG(lactobacillus rhanmosus GG，LGG)能夠抑制哮喘主要是通過增加Treg數(shù)量完成的。Martinez等[13]給患有過敏性疾病患兒服用含有乳酸桿菌gassed CECT5714和乳酸桿菌coryniformis CECT571l的奶制品，每天至少1×106cfu/g，持續(xù)3個(gè)月，結(jié)果發(fā)現(xiàn)Treg數(shù)量增加，血清IgE含量下降。

本研究發(fā)現(xiàn)治療組6個(gè)月內(nèi)再次喘息發(fā)作次數(shù)明顯少于對(duì)照組，因此，推測(cè)治療組6個(gè)月內(nèi)再次喘息發(fā)作次數(shù)少于對(duì)照組可能與上述機(jī)制有關(guān)，但需要進(jìn)一步擴(kuò)大樣本量及延長(zhǎng)隨訪時(shí)間。

[參考文獻(xiàn)]

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(本文編輯：張陣陣)

Effects of live trigeminal bifidobacterium, lactobacillus and enterococcus powder on the recurrence of wheezing in atopic children with bronchiolitis

Ren Mingxing, Xue Guochang, Shen Linna, Zhang Liwen, Song Yuejuan, Xia Huan, Xia Xuexia

(Department of Pediatrics, Nineth People′s Hospital of Wuxi, Affiliated to Suzhou University, Wuxi 214062, China)

[Abstract]ObjectiveTo observe the effects of live trigeminal bifidobacterium, lactobacillus and enterococcus powder on the recurrence of wheezing, and the levels of peripheral blood eosinophil (EOS) and serum transforming growth factor-beta 1(TGF-β1) in atopic children with bronchiolitis.Methods Sixty atopic children with bronchiolitis were randomly divided into the therapy group (30 cases) and the conventional treatment group (30 cases) and another 25 healthy children were recruited as the healthy control group. The conventional treatment group was given routine therapy, and the therapy group received live trigeminal bifidobacterium, lactobacillus and enterococcus, in addition to routine therapy for 2 months. The levels of EOS and TGF-β1 were detected at the acute stage and 2 months after receiving trigeminal bifidobacterium, lactobacillus and enterococcus.Results(1)The recurrent rate of wheezing after medication for the therapy group (0.67±0.13) was significantly lower than that for the conventional treatment group (1.27±0.17), with statistical significance (P<0.05).(2)The levels of EOS of the therapy group [(0.72±0.13)×109/L] and the conventional treatment group [(0.70±0.13)×109/L] at the acute stage were markedly higher than those of the healthy control group [(0.16±0.09)×109/L], also with statistical significance (P<0.05). The levels of TGF-β1 of the therapy group [(1.20±0.13) ng/L] and the conventional treatment group(1.22±0.11) at acute stage were all considerably lower than those of the control group [(1.45±0.13) ng/L], with statistical significance (P<0.05). The level of EOS in the therapy group [(0.27±0.12)×109/L] 2 months after medication of oral live trigeminal bifidobacterium, lactobacillus and enterococcus powder was lower than that in the conventional treatment group [(0.36±0.14)×109/L], also with statistical significance (P<0.05). The level of TGF-β1 of the therapy group [(1.41±0.09) ng/L] 2 months after medication was markedly higher than that of the conventional treatment group [(1.34±0.10) ng/L], also with statistical significance (P<0.05).ConclusionOral medication of live trigeminal bifidobacterium, lactobacillus and enterococcus powder for 2 months could obviously reduce the recurrent rate of wheezing within 6 months after the onset of bronchiolitis and could also up-regulate the levels of EOS and TGF-β1 in atopic children with bronchiolitis.

[Key words]Bronchiolitis; Live trigeminal bifidobacterium, lactobacillus and enterococcus powder; Eosinophil; Transforming growth factor-beta 1

(收稿日期：2015-10-11)

[中圖分類號(hào)]R735.2

[文獻(xiàn)標(biāo)識(shí)碼]A[DOI]10.3969/j.issn.1009-0754.2016.02.008

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