噴霧狀腎上腺素對嬰兒急性細支氣管炎沒有幫助


  July 2, 2003 - 根據一項發表在July 3出刊的New England Journal of Medicine的多中心隨機雙盲試驗研究指出,噴霧狀腎上腺素對嬰兒急性細支氣管炎而言是沒有幫助的。
  
  澳大利亞皇家兒童醫院的的Claire Wainwright, MB, BS, MD表示,對嬰兒細支氣管炎的治療主要是支持性的,所以支氣管擴張劑的作用是具有爭議的。
  
  在澳大利亞四家醫院的194名嬰兒細支氣管炎患者中,1%噴霧狀腎上腺或常規saline治療組在住院長短和嬰兒準備出院時間方面沒有顯著不同,但是,需要輔助吸氧和靜脈點滴腎上腺治療組嬰兒準備出院時間顯著變長(P = .02)。
  
  入院時需要吸氧是疾病嚴重評分、住院長短以及嬰兒準備出院時間等的最強預測因子(P < .001),雖然每次4-mL腎上腺治療後心率顯著增加,但是呼吸頻率、血壓或呼吸費力評分等沒有明顯改變,作者強調,因為腎上腺治療組病情較嚴重的嬰兒更多,這個不同可能影響腎上腺的效果。 
  
  作者表示,這項試驗反映了第三期照顧和區域醫院兩者臨床實踐的現實,我們的結果因此可運用在絕大多數住院急性細支氣管炎嬰兒患者,來自這項試驗的證據清楚指出,從短期或長期臨床相關結果來講,噴霧狀腎上腺素對嬰兒急性細支氣管炎沒有什麼幫助。
  
  哈佛大學醫學院的Mary Ellen B. Wohl, MD和Victor Chernick, MD在編者按中指出,沒有支氣管擴張劑可縮短使用albuterol 或epinephrine治療的嬰兒住院時間,因此不推薦支氣管擴張劑的使用。
  
  他們同時指出,與albuterol比較,腎上腺素並不能減少通道阻力及改善臨床評分,我們推測使用alpha-adrenergic 鼻滴劑可能獲得同樣的好處,特別是餵食前,這不是更簡單嗎?

Nebulized Epinephrine Not Help

By Laurie Barclay, MD
Medscape Medical News

July 2, 2003 — Nebulized epinephrine is not helpful for infants with acute bronchiolitis, according to the results of a multicenter, randomized, double-blind trial published in the July 3 issue of the New England Journal of Medicine.

"The treatment of infants with bronchiolitis is largely supportive," write Claire Wainwright, MB, BS, MD, from Royal Children's Hospital in Brisbane, Australia, and colleagues. "The role of bronchodilators is controversial."

Among 194 infants with bronchiolitis admitted to four Australian hospitals, length of hospital stay and the time until the infant was ready for discharge were not significantly different in those treated with 1% nebulized epinephrine or with normal saline. However, the time until the infant was ready for discharge was significantly longer in the epinephrine group (P = .02) among infants requiring supplemental oxygen and intravenous fluids.

The need for supplemental oxygen at admission was the strongest predictor of illness severity score, length of stay, and the time until the infant was ready for discharge (P < .001). Although heart rate increased significantly after each 4-mL treatment with epinephrine, there were no significant changes in respiratory rate, blood pressure, or respiratory effort scores.

Because more infants with moderately severe illness were assigned to the epinephrine group, this difference could have influenced the apparent effect of epinephrine, the authors note.

"This trial mirrors the reality of clinical practice in both tertiary care and district hospitals, and our results are therefore applicable to the majority of hospitalized infants with acute broncholitis," the authors write. "The evidence from this trial points clearly to a lack of benefit, in either short-term or long-term clinically relevant outcomes, of nebulized epinephrine in infants hospitalized with acute bronchiolitis."

In an accompanying editorial, Mary Ellen B. Wohl, MD, and Victor Chernick, MD, from Harvard Medical School in Boston, Massachusetts, point out that no bronchodilator reduces length of stay and that treatment of hospitalized infants with either albuterol or epinephrine therefore cannot be recommended.

"However, epinephrine does reduce airway resistance and improves the clinical score as compared with albuterol," they write. "We speculate that the same benefits might be achieved by the administration of alpha-adrenergic nose drops, particularly before feeding. How simple."

N Engl J Med. 2003;349:27-35, 82-83

Reviewed by Gary D. Vogin, MD

    
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