婴幼儿持续哮喘诊断的新指引


  【24drs.com】根据在线发表的一份文件以及8月1日的美国呼吸及重症医学期刊,美国胸腔医学会(ATS)发表了婴幼儿持续哮喘诊断临床实务指引。新版建议是针对小儿科医师和小儿胸腔科医师,对哮喘婴幼儿的诊断评估提供临床指引。
  
  印第安纳波利斯Riley儿童医院、印第安纳大学医学院Clement L. Ren医师等人写道,美国胸腔医学会(ATS)小儿科会员的2009年调查中,这些会员认为所需的指引中,婴幼儿哮喘是排名最高的议题之一。为了解决这个知识差距和兴趣,ATS召集具有婴幼儿哮喘临床与研究经验的小儿胸腔科医师组成委员会,为婴幼儿哮喘的诊断评估发展具有实证基础的指引。
  
  这个委员会对医师们常用于婴幼儿哮喘的诊断检测进行了证据综合,不过仅限于针对那些有争议性或者还未确定价值者,他们将婴幼儿哮喘定义为24个月以下婴幼童反覆或持续发生哮喘。
  
  不过,根据作者们表示,虽然哮喘在婴幼儿相当普遍,有关发展指引的各相关资料仍阙如,我们找不到采用一致之病例定义和结果的任何大型临床研究。为此,委员会特别强调,它的建议是有条件的,并且不打算建立护理标准。
  
  对于已有使用支气管扩张剂、吸入型皮质类固醇、全身性作用皮质类固醇治疗仍持续发作哮喘的婴儿,委员会建议,医师应考虑几个诊断检测,医师应使用有弹性的纤维支气管镜检查呼吸道,特别是因为有三分之一的哮喘婴儿有解剖构造异常,不是倾向自限性就是可以用手术矫正。
  
  委员会建议采用支气管肺泡灌洗以确认或排除这些患者的下呼吸道细菌感染,虽然他们承认,支气管肺泡灌洗是患者须被镇静的一种侵入性方式,委员会指出,这项检测的好处可能大于风险。
  
  医师们应考虑以24小时食道pH 值监测取代上胃肠道摄影检查或胃肠道闪烁成像,因为相较于后两者,它的侵犯性较小且所需时间比较短,还可避免患者曝露于放射线。
  
  医师们也应考虑影像透视吞咽功能检查,特别是发现有吞咽功能障碍者,治疗计画包括改变餵食方式,可减少约90%的误吸-持续哮喘的替代结果。
  
  对于没有湿疹的持续哮喘婴儿,尽管有标准治疗,委员会建议,医师不应该使用经验性食品回避法,因为证据显示它对哮喘的频率没有影响,不过,他们建议须进一步研究,以探讨食物回避法对那些对于食物抗原为免疫球蛋白E阳性婴幼儿的效益。
  
  另外,委员会也建议,需要进行研究以确认,对于已进行标准治疗之持续哮喘婴幼儿的管理,使用加量快速胸腹压缩之肺功能测试是否比仅凭临床评估更有效。
  
  因此,作者们强调,除了帮助小儿科通科或呼吸道专科医师评估婴幼儿复发或持续哮喘,这些指引也可帮助确认需要哪里些研究,以改善这些患者的处置。
  
  作者们结论,考虑到婴幼儿哮喘的发生频率,在这个领域中,迫切需要进行更多严谨的研究。
  
  资料来源: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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