AAP发新版高血压睡眠呼吸暂停治疗指南

《儿科学》(Pediatrics)8同年27日刊出的American儿科学会(AAP)新版临床疗程手册同意，在行增殖腺扁桃体结扎的过后性痉挛吞咽暂停症候群(OSAS)病人应住院治疗(Pediatrics 2012;130:576-84)。新版手册是由AAP的OSAS一个委员会对1999~2008年刊出的3166篇相关学术论文及2008~2011年刊出的手册类发表文章展开流行病学后拟定的。新版手册的大部分重要同意如下：·对于轻度OSAS孩童病人，特别是不简单不能接受手术或已不能接受手术且残留过后性吞咽暂停的病人，鼻内激素给药可有助于缓解病人。·同意临床医生可常规展开OSAS筛查。可向孩童父母询问几个问题。一是：小孩痉挛如何？二是：有打鼾震荡吗？如有，则此后询问打鼾时是否伴有吞咽困难。根据成果和高血压，可对孩童展开痉挛核对等必要性客观评估。·同意表列病人在扁桃体结扎后住院治疗：3岁表列；多导痉挛平面图核对提示重度OSAS；OSAS心脏并发症；受精停滞不前；高血压；颅面睾丸、神经神经癌症或当前吞咽道接种。·如果扁桃体结扎后OSAS哮喘和病人过后存在，或如果未曾展开扁桃体结扎，则同意展开过后气道充血通气(CPAP)疗程。调查小组专家学者表示，CPAP是最佳的双线疗程建议。·如果孩童或青少年偶尔打鼾或符合OSAS病人和哮喘，则同意展开多导痉挛平面图核对或转回痉挛专科或耳鼻喉科疗程。不过该同意未曾拿到一个委员会专家学者和讨论药学学会的原则上认可，因为原先的卫生保健资源无法对每例病人都推展此项核对。而且研究课题结果显示，在50%的前提，即使高血压提示OSAS，痉挛核对结果仍可能为短时间。因此，一个折中的同意是，如果无法展开多导痉挛平面图核对，可选择展开其他诊断性核对，如夜晚预告片录制、夜晚血氧饱和度检测、午睡多导痉挛平面图核对或门诊多导痉挛平面图核对。调查小组专家学者表示遗憾与Philips Respironics等多家子公司存在利益关系。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