2006+AAP临床实践指南：毛细支气管炎的诊断与治疗

CLINICAL PRACTICE GUIDELINE Diagnosis and Management of Bronchiolitis Subcommittee on Diagnosis and Management of Bronchiolitis Endorsed by the American Academy of Family Physicians, the American College of Chest Physicians, and the American Thoracic Society. ABSTRACT Bronchiolitis is a disorder most commonly caused in infants by viral lower respi- ratory tract infection. It is the most common lower respiratory infection in this age group. It is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospasm. The American Academy of Pediatrics convened a committee composed of primary care physicians and specialists in the fields of pulmonology, infectious disease, emergency medicine, epidemiology, and medical informatics. The com- mittee partnered with the Agency for Healthcare Research and Quality and the RTI International-University of North Carolina Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to the diagnosis, management, and prevention of bronchiolitis. The resulting evidence report and other sources of data were used to formulate clinical practice guideline recommendations. This guideline addresses the diagnosis of bronchiolitis as well as various ther- apeutic interventions including bronchodilators, corticosteroids, antiviral and an- tibacterial agents, hydration, chest physiotherapy, and oxygen. Recommendations are made for prevention of respiratory syncytial virus infection with palivizumab and the control of nosocomial spread of infection. Decisions were made on the basis of a systematic grading of the quality of evidence and strength of recommen- dation. The clinical practice guideline underwent comprehensive peer review before it was approved by the American Academy of Pediatrics. This clinical practice guideline is not intended as a sole source of guidance in the management of children with bronchiolitis. Rather, it is intended to assist clini- cians in decision-making. It is not intended to replace clinical judgment or estab- lish a protocol for the care of all children with this condition. These recommen- dations may not provide the only appropriate approach to the management of children with bronchiolitis. INTRODUCTION THIS GUIDELINE EXAMINES the published evidence on diagnosis and acute manage- ment of the child with bronchiolitis in both outpatient and hospital settings, including the roles of supportive therapy, oxygen, bronchodilators, antiinflamma- tory agents, antibacterial agents, and antiviral agents and make recommendations to influence clinician behavior on the basis of the evidence. Methods of prevention www.pediatrics.org/cgi/doi/10.1542/ peds.2006-2223 doi:10.1542/peds.2006-2223 All clinical practice guidelines from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of care. Variations, taking into account individual circumstances, may be appropriate. KeyWord bronchiolitis Abbreviations CAM—complementary and alternative medicine LRTI—lower respiratory tract infection AHRQ—Agency for Healthcare Research and Quality RSV—respiratory syncytial virus AAP—American Academy of Pediatrics AAFP—American Academy of Family Physicians RCT—randomized, controlled trial CLD—chronic neonatal lung disease SBI—serious bacterial infection UTI—urinary tract infection AOM—acute otitis media SpO2—oxyhemoglobin saturation LRTD—lower respiratory tract disease PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2006 by the American Academy of Pediatrics 1774 AMERICAN ACADEMY OF PEDIATRICS Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children are reviewed, as is the potential role of complementary and alternative medicine (CAM). The goal of this guideline is to provide an evidence- based approach to the diagnosis, management, and pre- vention of bronchiolitis in children from 1 month to 2 years of age. The guideline is intended for pediatricians, family physicians, emergency medicine specialists, hos- pitalists, nurse practitioners, and physician assistants who care for these children. The guideline does not apply to children with immunodeficiencies including HIV, organ or bone marrow transplants, or congenital immunodeficiencies. Children with underlying respira- tory illnesses such as chronic neonatal lung disease (CLD; also known as bronchopulmonary dysplasia) and those with significant congenital heart disease are ex- cluded from the sections on management unless other- wise noted but are included in the discussion of preven- tion. This guideline will not address long-term sequelae of bronchiolitis, such as recurrent wheezing, which is a field with distinct literature of its own. Bronchiolitis is a disorder most commonly caused in infants by viral lower respiratory tract infection (LRTI). It is the most common lower respiratory infection in this age group. It is characterized by acute inflammation, edema and necrosis of epithelial cells lining small air- ways, increased mucus production, and bronchospasm. Signs and symptoms are typically rhinitis, tachypnea, wheezing, cough, crackles, use of accessory muscles, and/or nasal flaring.1 Many viruses cause the same con- stellation of symptoms and signs. The most common etiology is the respiratory syncytial virus (RSV), with the highest incidence of RSV infection occurring between December and March.2 Ninety percent of children are infected with RSV in the first 2 years of life,3 and up to 40% of them will have lower respiratory infection.4,5 Infection with RSV does not grant permanent or long- term immunity. Reinfections are common and may be experienced throughout life.6 Other viruses identified as causing bronchiolitis are human metapneumovirus, in- fluenza, adenovirus, and parainfluenza. RSV infection leads to more than 90 000 hospitalizations annually. Mortality resulting from RSV has decreased from 4500 deaths annually in 1985 in the United States2,6 to an estimated 510 RSV-associated deaths in 19976 and 390 in 1999.7 The cost of hospitalization for bronchiolitis in children less than 1 year old is estimated to be more than $700 million per year.8 Several studies have shown a wide variation in how bronchiolitis is diagnosed and treated. Studies in the United States,9 Canada,10 and the Netherlands11 showed variations that correlated more with hospital or individ- ual preferences than with patient severity. In addition, length of hospitalization in some countries averages twice that of others.12 This variable pattern suggests a lack of consensus among clinicians as to best practices. In addition to morbidity and mortality during the acute illness, infants hospitalized with bronchiolitis are more likely to have respiratory problems as older chil- dren, especially recurrent wheezing, compared with those who did not have severe disease.13–15 Severe dis- ease is characterized by persistently increased respiratory effort, apnea, or the need for intravenous hydration, supplemental oxygen, or mechanical ventilation. It is unclear whether severe viral illness early in life predis- poses children to develop recurrent wheezing or if in- fants who experience severe bronchiolitis have an un- derlying predisposition to recurrent wheezing. METHODS To develop the clinical practice guideline on the diagno- sis and management of bronchiolitis, the American Academy of Pediatrics (AAP) convened the Subcommit- tee on Diagnosis and Management of Bronchiolitis with the support of the American Academy of Family Physi- cians (AAFP), the American Thoracic Society, the Amer- ican College of Chest Physicians, and the European Re- spiratory Society. The subcommittee was chaired by a primary care pediatrician with expertise in clinical pul- monology and included experts in the fields of general pediatrics, pulmonology, infectious disease, emergency medicine, epidemiology, and medical informatics. All panel members reviewed the AAP Policy on Conflict of Interest and Voluntary Disclosure and were given an opportunity to declare any potential conflicts. The AAP and AAFP partnered with the AHRQ and the RTI International-University of North Carolina Evi- dence-Based Practice Center (EPC) to develop an evi- dence report, which served as a major source of infor- mation for these practice guideline recommendations.1 Specific clinical questions addressed in the AHRQ evi- dence report were the (1) effectiveness of diagnostic tools for diagnosing bronchiolitis in infants and children, (2) efficacy of pharmaceutical therapies for treatment of bronchiolitis, (3) role of prophylaxis in prevention of bronchiolitis, and (4) cost-effectiveness of prophylaxis for management of bronchiolitis. EPC project staff searched Medline, the Cochrane Collaboration, and the Health Economics Database. Additional articles were identified by review of reference lists of relevant articles and ongoing studies recommended by a technical expert advisory group. To answer the question on diagnosis, both prospective studies and randomized, controlled tri- als (RCTs) were used. For questions related to treatment and prophylaxis in the AHRQ report, only RCTs were considered. For the cost-effectiveness of prophylaxis, studies that used economic analysis were reviewed. For all studies, key inclusion criteria included outcomes that were both clinically relevant and able to be abstracted. Initially, 744 abstracts were identified for possible inclu- sion, of which 83 were retained for systematic review. Results of the literature review were presented in evi- dence tables and published in the final evidence report.1 PEDIATRICS Volume 118, Number 4, October 2006 1775 An additional literature search of Medline and the Cochrane Database of Systematic Reviews was per- formed in July 2004 by using search terms submitted by the members of the Subcommittee on the Diagnosis and Management of Bronchiolitis. The methodologic quality of the research was appraised by an epidemiologist be- fore consideration by the subcommittee. The evidence-based approach to guideline develop- ment requires that the evidence in support of a policy be identified, appraised, and summarized and that an ex- plicit link between evidence and recommendations be defined. Evidence-based recommendations reflect the quality of evidence and the balance of benefit and harm that is anticipated when the recommendation is fol- lowed. The AAP policy statement “Classifying Recom- mendations for Clinical Practice Guidelines”16 was fol- lowed in designating levels of recommendation (Fig 1; Table 1). A draft version of this clinical practice guideline un- derwent extensive peer review by committees and sec- tions within the AAP, American Thoracic Society, Euro- pean Respiratory Society, American College of Chest Physicians, and AAFP, outside organizations, and other individuals identified by the subcommittee as experts in the field. Members of the subcommittee were invited to distribute the draft to other representatives and commit- tees within their specialty organizations. The resulting comments were reviewed by the subcommittee and, when appropriate, incorporated into the guideline. This clinical practice guideline is not intended as a sole source of guidance in the management of children with bronchiolitis. Rather, it is intended to assist clini- cians in decision-making. It is not intended to replace clinical judgment or establish a protocol for the care of all children with this condition. These recommendations may not provide the only appropriate approach to the management of children with bronchiolitis. All AAP guidelines are reviewed every 5 years. Definitions used in the guideline are: ● Bronchiolitis: a disorder most commonly caused in infants by viral LRTI; it is the most common lower respiratory infection in this age group and is charac- terized by acute inflammation, edema and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospasm. ● CLD, also known as bronchopulmonary dysplasia: an infant less than 32 weeks’ gestation evaluated at 36 weeks’ postmenstrual age or one of more than 32 weeks’ gestation evaluated at more than 28 days but less than 56 days of age who has been receiving sup- plemental oxygen for more than 28 days.17 ● Routine: a set of customary and often-performed pro- cedures such as might be found in a routine admission order set for children with bronchiolitis. ● Severe disease: signs and symptoms associated with poor feeding and respiratory distress characterized by tachypnea, nasal flaring, and hypoxemia. ● Hemodynamically significant congenital heart disease: children with congenital heart disease who are receiv- ing medication to control congestive heart failure, have moderate to severe pulmonary hypertension, or have cyanotic heart disease. RECOMMENDATION 1a Clinicians should diagnose bronchiolitis and assess disease se- verity on the basis of history and physical examination. Clini- cians should not routinely order laboratory and radiologic studies for diagnosis (recommendation: evidence level B; diag- nostic studies with minor limitations and observational studies with consistent findings; preponderance of benefits over harms and cost). RECOMMENDATION 1b Clinicians should assess risk factors for severe disease such as age less than 12 weeks, a history of prematurity, underlying cardiopulmonary disease, or immunodeficiency when making decisions about evaluation and management of children with bronchiolitis (recommendation: evidence level B; observational studies with consistent findings; preponderance of benefits over harms). The 2 goals in the history and physical examination of infants presenting with cough and/or wheeze, particu- larly in the winter season, are the differentiation of infants with probable bronchiolitis from those with other disorders and the estimation of the severity of illness. Most clinicians recognize bronchiolitis as a con- stellation of clinical symptoms and signs including a viral upper respiratory prodrome followed by increased respi- FIGURE 1 Integrating evidence quality appraisal with an assessment of the anticipated balance between benefits and harms if a policy is carried out leads to designation of a policy as a strong recommendation, recommendation, option, or no recommendation. 1776 AMERICAN ACADEMY OF PEDIATRICS ratory effort and wheezing in children less than 2 years of age. Clinical signs and symptoms of bronchiolitis con- sist of rhinorrhea, cough, wheezing, tachypnea, and in- creased respiratory effort manifested as grunting, nasal flaring, and intercostal and/or subcostal retractions. Respiratory rate in otherwise healthy children changes considerably over the first year of life, decreas- ing from a mean of approximately 50 breaths per minute in term newborns to approximately 40 breaths per minute at 6 months of age and 30 breaths per minute at 12 months.18–20 Counting respiratory rate over the course of 1 minute may be more accurate than measurements extrapolated to 1 minute but observed for shorter peri- ods.21 The absence of tachypnea correlates with the lack of LRTIs or pneumonia (viral or bacterial) in infants.22,23 The course of bronchiolitis is variable and dynamic, ranging from transient events such as apnea or mucus plugging to progressive respiratory distress from lower airway obstruction. Important issues to assess include the impact of respiratory symptoms on feeding and hy- dration and the response, if any, to therapy. The ability of the family to care for the child and return for further care should be assessed. History of underlying conditions such as prematurity, cardiac or pulmonary disease, im- munodeficiency, or previous episodes of wheezing should be identified. The physical examination reflects the variability in the disease state and may require serial observations over time to fully assess the child’s status. Upper airway obstruction may contribute to work of breathing. Nasal suctioning and positioning of the child may affect the assessment. Physical examination findings of importance include respiratory rate, increased work of breathing as evidenced by accessory muscle use or retractions, and auscultatory findings such as wheezes or crackles. The evidence relating the presence of specific findings in the assessment of bronchiolitis to clinical outcomes is limited. Most studies are retrospective and lack valid and unbiased measurement of baseline and outcome vari- ables. Most studies designed to identify the risk of severe adverse outcomes such as requirement for intensive care or mechanical ventilation have focused on inpa- tients.24–26 These events are relatively rare among all children with bronchiolitis and limit the power of these studies to detect clinically important risk factors associ- ated with disease progression. Several studies have associated premature birth (less than 37 weeks) and young age of the child (less than 6–12 weeks) with an increased risk of severe disease.26–28 Young infants with bronchiolitis may develop apnea, which has been associated with an increased risk for prolonged hospitalization, admission to intensive care, and mechanical ventilation.26 Other underlying condi- tions that have been associated with an increased risk of progression to severe disease or mortality include hemo- dynamically significant congenital heart disease,26,29 chronic lung disease (bronchopulmonary dysplasia, cys- tic fibrosis, congenital anomaly),26 and the presence of an immunocompromised state.26,30 Findings on physical examination have been less con- sistently associated with outcomes of bronchiolitis. Tachypnea, defined as a respiratory rate of 70 or more breaths per minute, has been associated with increased risk for severe disease in some studies24,27,31 but not oth- TABLE 1 Guideline Definitions for Evidence-Based Statements Statement Definition Implication Strong recommendation A strong recommendation in favor of a particular action is made when the anticipated benefits of the recommended intervention clearly exceed the harms (as a strong recommendation against an action is made when the anticipated harms clearly exceed the benefits) and the quality of the supporting evidence is excellent. In some clearly identified circumstances, strong recommendations may be made when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present. Recommendation A recommendation in favor of a particular action is made when the anticipated benefits exceed the harms but the quality of evidence is not as strong. Again, in some clearly identified circumstances, recommendations may be made when high- quality evidence is impossible to obtain but the anticipated benefits outweigh the harms. Clinicians would be prudent to follow a recommendation but should remain alert to new information and sensitive to patient preferences. Option Options define courses that may be taken when either the quality of evidence is suspect or carefully performed studies have shown little clear advantage to one approach over another. Clinicians should consider the option in their decision-making, and patient preference may have a substantial role. No recommendation No recommendation indicates that there is a lack of pertinent published evidence and that the anticipated balance of benefits and harms is presently unclear. Clinicians should be alert to new published evidence that clarifies the balance of benefit versus harm. PEDIATRICS V