嬰幼兒持續哮喘診斷的新指引


  【24drs.com】根據線上發表的一份文件以及8月1日的美國呼吸及重症醫學期刊,美國胸腔醫學會(ATS)發表了嬰幼兒持續哮喘診斷臨床實務指引。新版建議是針對小兒科醫師和小兒胸腔科醫師,對哮喘嬰幼兒的診斷評估提供臨床指引。
  
  印第安納波利斯Riley兒童醫院、印第安納大學醫學院Clement L. Ren醫師等人寫道,美國胸腔醫學會(ATS)小兒科會員的2009年調查中,這些會員認為所需的指引中,嬰幼兒哮喘是排名最高的議題之一。為了解決這個知識差距和興趣,ATS召集具有嬰幼兒哮喘臨床與研究經驗的小兒胸腔科醫師組成委員會,為嬰幼兒哮喘的診斷評估發展具有實證基礎的指引。
  
  這個委員會對醫師們常用於嬰幼兒哮喘的診斷檢測進行了證據綜合,不過僅限於針對那些有爭議性或者還未確定價值者,他們將嬰幼兒哮喘定義為24個月以下嬰幼童反覆或持續發生哮喘。
  
  不過,根據作者們表示,雖然哮喘在嬰幼兒相當普遍,有關發展指引的各相關資料仍闕如,我們找不到採用一致之病例定義和結果的任何大型臨床研究。為此,委員會特別強調,它的建議是有條件的,並且不打算建立護理標準。
  
  對於已有使用支氣管擴張劑、吸入型皮質類固醇、全身性作用皮質類固醇治療仍持續發作哮喘的嬰兒,委員會建議,醫師應考慮幾個診斷檢測,醫師應使用有彈性的纖維支氣管鏡檢查呼吸道,特別是因為有三分之一的哮喘嬰兒有解剖構造異常,不是傾向自限性就是可以用手術矯正。
  
  委員會建議採用支氣管肺泡灌洗以確認或排除這些患者的下呼吸道細菌感染,雖然他們承認,支氣管肺泡灌洗是患者須被鎮靜的一種侵入性方式,委員會指出,這項檢測的好處可能大於風險。
  
  醫師們應考慮以24小時食道pH 值監測取代上胃腸道攝影檢查或胃腸道閃爍成像,因為相較於後兩者,它的侵犯性較小且所需時間比較短,還可避免患者曝露於放射線。
  
  醫師們也應考慮影像透視吞嚥功能檢查,特別是發現有吞嚥功能障礙者,治療計畫包括改變餵食方式,可減少約90%的誤吸-持續哮喘的替代結果。
  
  對於沒有濕疹的持續哮喘嬰兒,儘管有標準治療,委員會建議,醫師不應該使用經驗性食品迴避法,因為證據顯示它對哮喘的頻率沒有影響,不過,他們建議須進一步研究,以探討食物迴避法對那些對於食物抗原為免疫球蛋白E陽性嬰幼兒的效益。
  
  另外,委員會也建議,需要進行研究以確認,對於已進行標準治療之持續哮喘嬰幼兒的管理,使用加量快速胸腹壓縮之肺功能測試是否比僅憑臨床評估更有效。
  
  因此,作者們強調,除了幫助小兒科通科或呼吸道專科醫師評估嬰幼兒復發或持續哮喘,這些指引也可幫助確認需要哪些研究,以改善這些患者的處置。
  
  作者們結論,考慮到嬰幼兒哮喘的發生頻率,在這個領域中,迫切需要進行更多嚴謹的研究。
  
  資料來源:http://www.24drs.com/
  
  Native link:New Guidelines on Diagnosing Persistent Wheeze in Infants

New Guidelines on Diagnosing Persistent Wheeze in Infants

By Nicola M. Parry, DVM
Medscape Medical News

The American Thoracic Society (ATS) has released clinical practice guidelines on diagnosing persistent wheeze in infants, according to a document published online and in the August 1 issue of the American Journal of Respiratory and Critical Care Medicine. The new recommendations target pediatricians and pediatric pulmonologists and provide clinical guidance on the diagnostic evaluation of wheezing infants.

"In a 2009 survey of Pediatrics Assembly members of the American Thoracic Society (ATS), infantile wheezing was one of the highest ranked topics for which members desired a guideline," Clement L. Ren, MD, from the Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, and colleagues write. "To address this knowledge gap and interest, the ATS convened a committee of pediatric pulmonologists with clinical and research experience in infantile wheezing to develop evidence-based guidelines for the diagnostic evaluation of infantile wheezing."

The committee conducted an evidence synthesis of diagnostic tests that clinicians typically use in the management of wheezing infants but restricted it to those that are considered to be of controversial or uncertain value. They defined infantile wheezing as recurrent or persistent episodes of wheezing in infants younger than 24 months.

However, according to the authors, although wheezing is widespread and common in infants, data were lacking in all areas of the guidelines' development: "[W]e were unable to find any large clinical studies that utilized consistent case definitions and outcomes." For this reason in particular, the committee emphasizes that its recommendations are conditional and are not intended to establish a standard of care.

For infants with wheezing that persists despite standard treatment with bronchodilators, inhaled corticosteroids, or systemic corticosteroids, the committee suggests several diagnostic tests that clinicians should consider. Clinicians should use flexible fiberoptic bronchoscopy to conduct an airway survey, in particular because about one third of wheezing infants have been shown to have an anatomic abnormality that either tends to be self-limiting or can be corrected surgically.

The committee recommends use of bronchoalveolar lavage to confirm or exclude bacterial infection of the lower airway in these patients. Although they acknowledge that bronchoalveolar lavage is an invasive procedure that requires the patient to be sedated, the committee notes that the benefits of this test probably outweigh its risks.

Clinicians should consider 24-hour esophageal pH monitoring instead of an upper gastrointestinal series or gastrointestinal scintigraphy because it is less invasive and less time-consuming than the latter two tests and avoids exposing the patient to radiation.

Clinicians should also consider a video-fluoroscopic swallowing function study, especially because if swallowing dysfunction is identified, the treatment plan involves changes in feeding that lead to approximately 90% reduction in aspiration, which is a surrogate outcome for persistent wheezing.

For infants without eczema who have persistent wheezing despite standard therapy, the committee recommends clinicians should not use empiric food avoidance, because the evidence suggests it has no effect on the frequency of wheezing. However, they do recommend the need for further studies to investigate the benefit of food avoidance in a subgroup of these infants who are immunoglobulin E-positive to food antigens.

In addition, the committee also recommends the need for research to determine whether pulmonary function testing using raised-volume rapid thoracoabdominal compression is more beneficial than clinical assessment alone for managing infants who have persistent wheezing despite standard therapy.

The authors therefore emphasize that, as well as helping the pediatric generalist or respiratory specialist to evaluate infants with recurrent or persistent wheeze, these guidelines will also help identify what research is needed to improve the management of this patient population.

"Given the frequency with which infantile wheezing occurs, there is an urgent need for more rigorous research to be conducted in this field," the authors conclude.

One coauthor received conference travel support from Allergopharma Turkey and GlaxoSmithKline. Another coauthor was previously employed by MannKind Corp. and has been an employee of Regeneron Pharmaceuticals since January 2016. Another coauthor was on an advisory committee for Vertex Pharmaceuticals, was a consultant for Vertex Pharmaceuticals and Eli Lilly and Co, and was a speaker for ABCOMM in an activity supported by Gilead. Another coauthor was a speaker for GlaxoSmithKline and Merck Sharp Dohme and also received conference travel support from Allergopharma, GlaxoSmithKline, and Nutricia. Another coauthor was a speaker and was on a data safety and monitoring board for Chiesi, received conference travel support from Lusofarmaco, was on an advisory committee and was a speaker for Novartis, was a speaker for Sigma-Tau, and participated in meetings sponsored by CareFusion, Cosmed, Italchimici, Stewart Italia, and Valeas. The remaining authors have disclosed no relevant financial relationships.

Am J Resp Crit Care Med. 2016;194:356-373.

    
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