AAP发新版阻塞性睡眠呼吸延期治疗指南

《儿科学》(Pediatrics)8月27日刊载的美国儿科物理学会(AAP)新版临床疗法简要同意，自为增殖腺扁桃体输精管的阻塞性排便排尿暂停综合征(OSAS)早产儿应住院疗法(Pediatrics 2012;130:576-84)。新版简要是由AAP的OSAS一个委员会对1999~2008年刊载的3166篇无关科学论文及2008~2011年刊载的简要类文章进自为综述后制订的。新版简要的均不可忽视同意如下：·对于轻度OSAS老年人患者，比如说是不适合接受开刀或已接受开刀且残留阻塞性排尿暂停的患者，鼻内荷尔蒙给制剂可更容易缓解症状。·同意临床医生可常规进自为OSAS筛查。可向老年人孩子询问几个难题。一是：孩子排便如何？二是：有打鼾现象吗？如有，则继续询问打鼾时是否诱发排尿困难。根据经验和病史，可对老年人进自为排便核对等进一步普遍性评估。·同意以下早产儿在扁桃体输精管后住院疗法：3岁以下；多导排便布核对若有重度OSAS；OSAS瓣膜出血；退化停滞；肥胖；颅面畸形、中枢神经系统身体疾病或当前发炎感染。·如果扁桃体输精管后OSAS体征和症状长时间共存，或如果尚未进自为扁桃体输精管，则同意进自为长时间浸润正压持续性(CPAP)疗法。小组专业人士表示，CPAP是最佳的二线疗法方案。·如果老年人或孩童经常打鼾或相符OSAS症状和体征，则同意进自为多导排便布核对或移至排便专科或牙医疗法。不过该同意尚未获得一个委员会专业人士和咨询医学物理学会的一致认可，因为现有的医疗保健资源无法对每例早产儿都开展此项核对。而且科学研究显示，在50%的情况下，即使病史若有OSAS，排便核对结果仍可能为出现异常。因此，一个折中的同意是，如果无法进自为多导排便布核对，可再考虑进自为其他治疗性核对，如日间录像带录制、日间血氧稍低推算出、午睡多导排便布核对或门诊多导排便布核对。小组专业人士道歉信与Philips Respironics等多家公司共存商业利益关系。By: DOUG BRUNK, Clinical Neurology News Digital NetworkAn updated clinical practice guideline from the American Academy of Pediatrics spells out which children with obstructive sleep apnea syndrome who undergo adenotonsillectomy should be admitted as inpatients."That’s really important because the vast majority of children he adenotonsillectomy on an outpatient basis," said Dr. Carole L. Marcus, who chaired a subcommittee that assembled the guideline, which was updated from a 2002 version and published online Aug. 27 in Pediatrics.Courtesy Dr. Carole L. MarcusAnother new component of the 10-page guideline, titled "Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome," includes an option for clinicians to prescribe intranasal steroids for a subset of children with obstructive sleep apnea syndrome (OSAS)."For children with mild obstructive sleep apnea – especially for those in whom surgery might be contraindicated, or in those who he already had surgery and he some residual obstructive apnea – intranasal steroids could be helpful," Dr. Marcus, who directs the Sleep Center at the Children’s Hospital of Philadelphia, said in an interview. "There are still a lot of unanswered questions [about this practice], one of the biggest being that all of the studies he been relatively short term, meaning weeks to months, not years. Does a child need just one course, or do they need to be on it for the rest of their lives? Those are studies that need to be done."To update the 2002 guideline, Dr. Marcus and 11 other members of the interdisciplinary AAP Subcommittee on Obstructive Sleep Apnea Syndrome reviewed 3,166 articles from the medical literature related to the diagnosis and management of OSAS in children and adolescents that were published during 1999-2008. Then subcommittee members "selectively updated this literature search for articles published from 2008 to 2011 specific to guideline categories." Of the 3,166 studies, 350 were used to formulate eight recommendations, termed "key action statements" (Pediatrics 2012;130:576-84).Since publication of the previous guideline, "there has been a huge amount of research done in this field," noted Dr. Marcus, who is also a professor of pediatrics at the University of Pennsylvania, Philadelphia. "Many of the initial studies we looked at for the first guideline were case series. Now people are doing well-structured studies and looking at some of the detailed outcomes such as neurocognitive findings."The first recommendation in the updated guideline advises clinicians to screen for OSAS during routine health maintenance visits, "because OSA in children is underdiagnosed," Dr. Marcus explained. "Parents don’t necessarily think of snoring as a sign of a serious disease. They might think it’s funny, but it’s actually a sign of illness."Knowing how busy pediatricians are, there are two questions that are crucial," she continued. "One is, ‘How does your child sleep?’ The other is, ‘Does your child snore?’ If you get a positive [response] to the snoring [question] you do need to go into more detail. The next question would be, ‘Is there labored breathing with the snoring?’ Your history will tell you which children need further objective evaluation, such as a sleep study."The guideline also recommends that the following subset of children be admitted as inpatients after tonsillectomy: those younger than age 3; those with severe OSAS on polysomnography; those with cardiac complications of OSAS; those with failure to thrive; those who are obese; and those with craniofacial anomalies, neuromuscular disorders, or a current respiratory infection.Another component to the guideline is the recommendation that clinicians refer patients for continuous positive airway pressure (CPAP) management if OSAS signs and symptoms persist after adenotonsillectomy or if adenotonsillectomy is not performed. Dr. Marcus described CPAP as "the best way to go as a second-line option. Since the previous guidelines came out, the prevalence of obesity in children has gone up even more dramatically. Therefore, there is a lot more OSA out there, and pediatricians will be seeing a lot more in children of all ages."One component of the guideline related to polysomnography proved difficult for the committee members and the consulting medical societies to reach consensus on. This recommendation states that clinicians should obtain a polysomnogram or refer the patient to a sleep specialist or otolaryngologist if the child or adolescent snores regularly or meets the symptoms and signs of OSAS."If one agrees that sleep studies are the only objective way to tell what’s going on, we just don’t he the resources in this country to study every child," Dr. Marcus said. "The literature is very strong showing that a history and physical exam could give you an idea of which children you should he an index of suspicion about, but do not tell you which children he sleep apnea. The vast number of children who he adenotonsillectomy for suspected OSA are hing it done without any sort of objective finding. The studies that he been done show that about 50% of the time, even with a history that seems indicative of OSA, the children will he normal sleep studies."Because of this quandary, the committee included a related recommendation, which reads that if polysomnography is not ailable, "then clinicians may order alternative diagnostic tests, such as nocturnal video recording, nocturnal oximetry, daytime nap polysomnography, or ambulatory polysomnography."Dr. Marcus said that further changes to the new guideline may be warranted pending the results of the Childhood Adenotonsillectomy Study for Children With OSAS (CHAT). Sponsored by the National Heart, Lung, and Blood Institute, the goal of this multicenter, randomized trial is to determine the effect of adenotonsillectomy surgery on OSAS in children. "That study has just been completed, but nothing has been published yet," said Dr. Marcus, who is one of CHAT’s investigators. "That might change things even more."There is a 44-page technical report that details the procedures the subcommittee members followed and the data they considered (Pediatrics 2012;130:e714-55).Dr. Marcus disclosed that she has received research support from Philips Respironics. Another subcommittee member, Dr. Did Gozal, disclosed hing research support from AstraZeneca and being a speaker for Merck.; Dr. Ann C. Halbower disclosed receiving research funding from Resmed; and Dr. Michael S. Schechter disclosed that he is a consultant to Genentech and Gilead, and that he has received research support from Mpex Pharmaceuticals, Vertex Pharmaceuticals, and other companie