不建议每天以生理食盐水灌洗鼻腔


  【24drs.com】November 11, 2009(加州圣地牙哥)-根据一项发表在美国过敏、气喘与免疫学会(ACAAI)2009年年会的新研究结果,罹患再发性鼻腔鼻窦炎(RS)的病患,长期每天使用生理食盐水鼻腔灌洗(NSI)可能会增加急性感染机率达60%。许多与会者们称这项研究是很重要的。
  
  乔治城大学医学院大学医院小儿科与过敏/免疫临床教授、同时也是维吉尼亚州Watergate与Burke过敏与气喘研究中心医疗主任的Talal M. Nsouli医师在座谈会上发表这项研究结果。
  
  Nsouli医师向Medscape过敏与临床免疫学表示,短期使用NSI是没有问题的,过去研究证实这可以改善鼻腔黏膜纤毛清除。然而,即使经常使用NSI或是洗鼻器用于治疗鼻窦疾病,但少有证据证实这是有效的。
  
  在这项研究中,研究者们假设长期使用NSI可能降低鼻子黏液免疫层的保护,鼻子黏液免疫层保护力降低可能造成再发性RS。
  
  为了测试这项理论,研究者收纳了68位RS病患(年龄中位数为29.3岁),这些病患经常使用NSI;病患们继续接受每天两次的治疗,接著在12个月间追踪RS发作次数;于完成治疗停用后,另外再追踪12个月。
  
  除此之外,还有一组收纳24位病患的平行非介入控制组(年龄中位数为34.2岁),这些病患每天使用NSI达12个月,研究者也追踪其RS发作次数。
  
  所有病患都持续使用其过敏医师与其它医师所开立的药物。
  
  【停用后发作次数减少】
  研究结果显示,在使用NSI的阶段,总共发生544次急性RS(每位病患每年平均发作8次),而在停用期时仅发作204次(每位病患每年平均发作3次),发作频率显著下降62.5%(P<0.001)。
  
  同样的,控制组的RS平均发作频率比停止使用组高50%,这也达到统计上显著差异(P<0.01)
  
  Nsouli医师解释,因为鼻黏膜黏液的组成,是对抗感染的第一道呼吸道防线,当我们将好的黏液洗掉时,可能因而降低鼻黏液分泌的免疫保护作用。
  
  Nsouli医师继续说道,以NSI治疗坏的黏液,头1个礼拜到10天是好的,且术后病患可以使用达6~8周。但是如果总是有坏的黏液,这代表那位病患感染了,而需要使用其它药物治疗。
  
  他报告他的团队接著将会进行一项较大型的研究。我们正期待有同样结果的研究,而这将会增加统计力量。
  
  基本论点是,长期使用NSI对病患们来说是有害的。Nsouli医师的结论是,我们需要告诉病患,拿这些用具回来换咖啡和茶!
  
  【总是提出问题】
  ACAAI摘要审阅委员会主席、纽阿克新泽西医学院的医学临床副教授John J. Oppenheimer医师在关键研究发现记者会中指出,这是个简单但重要的研究。Oppenheimer医师并未参加这项研究。
  
  Oppenheimer医师表示,这些接受长期治疗的病患,其预后比未使用任何治疗的病患差。但是,这并不代表当你感冒时,这就不是个适当的治疗。不过,每天使用这种治疗可能并不如我们所想的会有良好的预后。
  
  他附带表示,这强化了我的想法,身为一位医师,对我们来说经常问问题是很重要的。因为多年来,我们可能做了不需要的事情。
  
  在同一个记者会上,过敏、气喘与免疫学学志主编Gailen D. Marshall医师与其来自杰克森密苏里大学医学中心的过敏/免疫部门的同事表示,当病患感冒时,透过生理食盐水清洗来摆脱鼻黏液困扰,仍是个好主意。
  
  但是过与不及都是不好的,这篇摘要以比较清楚的方式强调,在接受这种治疗时,可能需停止使用几天,这提出了一个很好的论点。Marshell医师并未参与这项研究。
  
  他继续说道,因为该项研究显示这样一个简单的治疗可能是有害的,我认为这是个很好的研究。但如果适当使用的话,这样一个单纯的治疗也可以是非常好的。我认为多花几分钟对我们的病患做解释,并告诉他们给予这些建议的理由为何,是很重要的。
  
  当问到下一步应该是什么时,Oppenheimer医师回应:我认为我们强烈意识到需要取得同样的证据。我对于重复研究结果看这之间是否有差异感到比较放心。但这是对的方向,这告诉我们有些经验上合理的事,在现实生活中可能并非如此。
  
  Nsouli医师与Marshall医师表示已无相关资金上的往来。Oppenheimer医师担任Glaxo、AstraZeneca、Schering, Merck、Novartis与Genentech等公司的顾问。

Daily Nasal Saline Irrigation Not Recommended for Long-Term Use

By Deborah Brauser
Medscape Medical News

November 11, 2009 (San Diego, California) — Daily long-term use of nasal saline irrigation (NSI) by patients with recurrent rhinosinusitis (RS) can increase the frequency of acute infection by as much as 60%, according to a new study presented here at the American College of Allergy, Asthma & Immunology (ACAAI) 2009 Annual Scientific Meeting. Many called the study "important."

"We have a serious problem with many patients who suffer with chronic sinus disease thinking that the best treatment is daily [NSI]. They think it isn't harmful and so use it all the time," said lead investigator Talal M. Nsouli, MD, clinical professor of pediatrics and allergy/immunology at Georgetown University Hospital School of Medicine and medical director at the Watergate and Burke Allergy and Asthma Research Centers in Virginia. He presented the results during a podium session.

Afterward, Dr. Nsouli told Medscape Allergy & Clinical Immunology that he has no problems with the use of NSI over a short term, and that previous studies have shown that it can improve nasal mucociliary clearance. However, "despite the common use of [NSI], or neti pots, in the treatment of sinus disease over a long period of time, there has been little evidence to confirm its success."

For this study, the investigators hypothesized that the "long-term use of NSI may deplete the nose of its immune blanket of mucus, resulting in recurrent RS."

To test this theory, they enrolled 68 patients with RS (mean age, 29.3 years) who were regular users of NSI. Patients continued using the treatment twice a day every day and were then monitored for the frequency of RS episodes over 12 months. That was followed by an additional 12 months of monitoring during complete treatment discontinuation.

In addition, a parallel noninterventive control group, consisting of 24 patients (mean age, 34.2 years) using NSI daily for 12 months, had the frequency of their RS episodes monitored.

All patients continued taking the same medication previously prescribed to them by their allergists or other physicians.

Episodes Decreased at Discontinuation

Study results showed that 544 episodes of acute RS were experienced by the patients in the NSI phase (each patient averaging 8 episodes a year), with only 204 in the discontinuation phase (averaging 3 episodes per year), a statistically significant decrease in frequency of 62.5% (P?< .001).

Similarly, the control group's average frequency of RS was 50% higher than that found in the discontinuation group, which was also a statistically significant difference (P?< .001).

"This happens because nasal mucus acts as a first line of respiratory defense against infections due to its composition," explained Dr. Nsouli. "When we wash away the good mucus, we might be depleting nasal secretions from its immune elements."

"Treating bad mucus with [NSI] for 1 week to 10 days is fine and patients can use it for 6 to 8 weeks after surgery," continued Dr. Nsouli. "But if the bad mucus is present all the time, it means that that person has an infection and needs to be treated with other medication."

He reported that his team will next be conducting a larger study. "We're expecting to find the same results, but this will increase the power."

"The bottom line is that long-term use of [NSI] is harmful for patients. We need to tell them to go back to using these devices for coffee and tea!" concluded Dr. Nsouli.

Always Ask Questions

"This is a simple but important study," said ACAAI abstract review committee chair John J. Oppenheimer, MD, associate clinical professor of medicine at New Jersey Medical School in Newark, during a press conference on key research findings. Dr. Oppenheimer was not involved with this study.

"These patients had worse outcomes with the long-term treatment than when using nothing at all. This doesn't mean that this isn't an appropriate medication to consider when you have a cold. But using it daily may not have as good outcomes as we thought it did," said Dr. Oppenheimer.

He added that "it reinforces to me that, as doctors, it's always important for us to ask questions. Just because we may have done something for years doesn't necessarily make it right."

At the same press conference, Gailen D. Marshall, MD, PhD, editor-in-chief of the Annals of Allergy, Asthma and Immunology, from the Division of Allergy/Immunology at the University of Mississippi Medical Center in Jackson, said that "it is still a good idea to get rid of mucus through a saline wash when a patient has a cold."

"But as with anything else, you can overdo it. This abstract addresses that fact in a clear fashion and makes a good argument for maybe giving the treatment a 'drug holiday'." Dr. Marshall was also not involved with this study.

He continued: "I think this is a wonderful study because it points out the idea that simple things can be harmful. But simple things can also be very good if used in the proper context. I think it's important to take a few extra minutes to explain all of this to patients and to give them the rationale for our suggestions."

When asked what the next step should be, Dr. Oppenheimer replied: "I think we need to look at the same evidence acutely. I would feel more comforted to see it replicated to see if there are any differences. But it's the right direction and it tells us that sometimes something that makes sense empirically may not make sense in real practice."

Dr. Nsouli and Dr. Marshall have disclosed no relevant financial relationships. Dr. Oppenheimer reports being a consultant and doing research for Glaxo, AstraZeneca, Schering, Merck, Novartis, and Genentech.

American College of Allergy, Asthma & Immunology (ACAAI) 2009 Annual Scientific Meeting: Abstract 32. Presented November?8, 2009.

    
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