AAP发新版阻塞性睡眠呼吸暂停治疗范本

《儿科学》(Pediatrics)8月27日刊出的美国儿科常务理事(AAP)新版医学病患指南提议，自为增殖腺扁桃体结扎的阻塞性痉挛气管暂时肉瘤(OSAS)患儿应住院治疗(Pediatrics 2012;130:576-84)。新版指南是由AAP的OSAS管理委员会对1999~2008年刊出的3166篇相关论文及2008~2011年刊出的指南类文中同步进自为综述后制订的。新版指南的部份不可忽视提议如下：·对于轻度OSAS儿童患者，特别是不适合接受开刀或已接受开刀且残留阻塞性气管暂时的患者，鼻内激素给药可有助于缓解病征。·提议医学医生可常规同步进自为OSAS筛查。可向儿童孩子告诉几个疑虑。一是：孩子痉挛如何？二是：有打鼾现象吗？如有，则继续告诉打鼾时是否浸润气管困难。根据成果和阿兹海默，可对儿童同步进自为痉挛检验等进一步客观检验。·提议请注意患儿在扁桃体结扎后住院治疗：3岁请注意；多导痉挛平面图检验定时重度OSAS；OSAS心脏胃癌；发育衰退；肥胖症；颅面畸形、神经肌肉疾病或当前气管道感染。·如果扁桃体结扎后OSAS征状和病征持续存在，或如果从未同步进自为扁桃体结扎，则提议同步进自为持续肺脏充血持续性(CPAP)病患。团队专家表示，CPAP是最佳的西段病患方案。·如果儿童或青少年经常打鼾或符合OSAS病征和征状，则提议同步进自为多导痉挛平面图检验或转至痉挛专科或耳鼻喉科病患。不过该提议从未获得管理委员会专家和咨询医学常务理事的明确认可，因为现有的医疗资源从未对每例患儿都开展此项检验。而且研究显示，在50%的情况下，即使阿兹海默定时OSAS，痉挛检验结果仍不太可能为正常。因此，一个折中的提议是，如果从未同步进自为多导痉挛平面图检验，可再考虑同步进自为其他诊断性检验，如夜间视频录制、夜间血氧含水测定、午睡多导痉挛平面图检验或内科多导痉挛平面图检验。团队专家通告与Philips Respironics等多家公司存在利益关系。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