AAP发新版阻塞性REM呼吸暂停治疗指南

《儿科学》(Pediatrics)8月27日发表的美国儿科学会(AAP)新版临床化疗手册劝告，在行增殖腺扁桃体结扎的阻塞性排便气管暂时中止综合征(OSAS)患者应住院(Pediatrics 2012;130:576-84)。新版手册是由AAP的OSAS秘书处对1999~2008年发表的3166篇相关学术论文及2008~2011年发表的手册类文章顺利完成综述后制订的。新版手册的大多极其重要劝告如下：·对于轻度OSAS老年人患者，特别是不非常适合不感兴趣动手术或已不感兴趣动手术且残留阻塞性气管暂时中止的患者，鼻内激素给药可更进一步减轻病症。·劝告临床医生可常规顺利完成OSAS乳癌。可向老年人子女问起几个问题。一是：夫妻俩排便如何？二是：有打鼾现像吗？如有，则继续问起打鼾时是否伴有发烧。根据科学知识和病史，可对老年人顺利完成排便健康检查等进一步客观评估。·劝告表列患者在扁桃体结扎后住院：3岁表列；多导排便由此可知健康检查上会重度OSAS；OSAS心脏并发症；胚胎发展缓慢；肥胖；颅面小头、脊髓手部疾病或当前气管道感染。·如果扁桃体结扎后OSAS病因和病症接下来普遍存在，或如果仍未顺利完成扁桃体结扎，则劝告顺利完成接下来气道正压通气(CPAP)化疗。小组专业人士表示，CPAP是最佳的双线化疗方案。·如果老年人或青年人经常打鼾或符合OSAS病症和病因，则劝告顺利完成多导排便由此可知健康检查或转至排便专科或耳鼻喉科化疗。不过该劝告仍未得到秘书处专业人士和劝告书药理学学会的一致认可，因为现有的医疗资源很难对每例患者都着手此项健康检查。而且研究显示，在50%的情形，即使病史上会OSAS，排便健康检查结果仍可能为正常。因此，一个权衡的劝告是，如果很难顺利完成多导排便由此可知健康检查，可顾虑顺利完成其他诊断性健康检查，如日夜影片试唱、日夜泌尿系统饱和度测定、午睡多导排便由此可知健康检查或动手术室多导排便由此可知健康检查。小组专业人士单方面与Philips Respironics等多家公司普遍存在公共利益亲密关系。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