AAP发新版阻塞性睡眠呼吸终止治疗指南

《儿科学》(Pediatrics)8月27日刊载的美国儿科学亦会(AAP)新版病理治疗Guide同意，行增殖腺扁桃体抽脂的阻塞性失眠颤动暂停综合征(OSAS)患者不宜患病(Pediatrics 2012;130:576-84)。新版Guide是由AAP的OSAS委员亦会对1999~2008年刊载的3166篇相关篇评论及2008~2011年刊载的Guide类评论顺利完成综述后制订的。新版Guide的均重要同意如下：·对于轻度OSAS幼儿患者，同样是不简便不感兴趣治疗或已不感兴趣治疗且移出阻塞性颤动暂停的患者，鼻内激素给解毒可有助于缓解疼痛。·同意病理牙医可常规顺利完成OSAS筛查。可向幼儿祖父母追问几个问题。一是：孩子们失眠如何？二是：有打鼾周期性吗？如有，则继续追问打鼾时前提伴有颤动困难。根据知识和病史，可对幼儿顺利完成失眠核查等进一步客观性评估。·同意不限患者在扁桃体抽脂后患病：3岁不限；多导失眠由此可知核查示意重度OSAS；OSAS肝脏中风；发育困难重重；成年人；颅面畸形、神经肌肉癌症或意味着颤动道病毒。·如果扁桃体抽脂后OSAS体征和疼痛过后存在，或如果未有顺利完成扁桃体抽脂，则同意顺利完成过后气道正压合上(CPAP)治疗。团队研究员表示，CPAP是最佳的二线治疗方案。·如果幼儿或少年幼儿经常打鼾或不符OSAS疼痛和体征，则同意顺利完成多导失眠由此可知核查或转至失眠专科或耳鼻喉科治疗。不过该同意未有获得委员亦会研究员和咨询病理学学亦会的相反认可，因为现有的医疗天然资源能够对每例患者都开展此项核查。而且研究显示，在50%的前提，即使病史示意OSAS，失眠核查结果仍可能为情况下。因此，一个折中的同意是，如果能够顺利完成多导失眠由此可知核查，可慎重考虑顺利完成其他诊断性核查，如夜间视频写歌、夜间血氧低浓度测定、午睡多导失眠由此可知核查或门诊多导失眠由此可知核查。团队研究员刊载声明与Philips Respironics等多家新公司存在利益集团关系。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