AAP发新版阻塞性睡眠呼吸暂停治疗读物

《儿科学》(Pediatrics)8月27日出版的美国儿科该学会(AAP)新版病理化疗简要表示同意，行增殖腺扁桃体结扎的阻塞性新陈代谢新陈代谢延后综合征(OSAS)脑瘤应康复(Pediatrics 2012;130:576-84)。新版简要是由AAP的OSAS比如说委员会对1999~2008年出版的3166篇相关论文及2008~2011年出版的简要类文章顺利完成综述后制订的。新版简要的部分举足轻重表示同意如下：·对于轻度OSAS学龄前患者，比如说是不适合拒绝接受开刀或已拒绝接受开刀且残留阻塞性新陈代谢延后的患者，鼻内荷尔蒙给药可有助于加重患者。·表示同意病理内科医生可常规顺利完成OSAS筛查。可向学龄前父母告诉几个问题。一是：孩子们新陈代谢如何？二是：有打鼾现象吗？如有，则继续告诉打鼾时是否眩晕新陈代谢困难。根据经验和躁郁症，可对学龄前顺利完成新陈代谢安全检查等进一步普遍性评估。·表示同意以下脑瘤在扁桃体结扎后康复：3岁以下；多导新陈代谢平面图安全检查示意重度OSAS；OSAS心脏中风；发育停滞；肥胖；颅面畸形、神经肌肉结核病或这两项消化道感染。·如果扁桃体结扎后OSAS病症和患者不间断长期存在，或如果尚未顺利完成扁桃体结扎，则表示同意顺利完成不间断气道正压通气(CPAP)化疗。小组专家暗示，CPAP是最佳的二线化疗方案。·如果学龄前或儿童经常打鼾或不符OSAS患者和病症，则表示同意顺利完成多导新陈代谢平面图安全检查或转到新陈代谢外科或外科化疗。不过该表示同意尚未获得比如说委员会专家和咨询医学该学会的一致认可，因为现有的医疗人力不会对每例脑瘤都开展此项安全检查。而且研究显示，在50%的情况下，即使躁郁症示意OSAS，新陈代谢安全检查结果仍可能为也就是说。因此，一个折中的表示同意是，如果不会顺利完成多导新陈代谢平面图安全检查，可考虑顺利完成其他诊断性安全检查，如夜晚图片录音室、夜晚血氧饱和度测定、午睡多导新陈代谢平面图安全检查或门诊多导新陈代谢平面图安全检查。小组专家声明与Philips Respironics等多家公司长期存在利益间的关系。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