青少年和成人哮喘管理：国家哮喘教育和预防计划2020年哮喘指南更新
2020/12/17
摘要
重要性：哮喘是世界范围内的一个主要公共卫生问题，这与其高发病率、死亡率以及劳动力丧失造成的经济成本有关。美国国家哮喘教育和预防计划发布了2020年哮喘指南更新，其中包括对哮喘患者治疗的最新循证建议。
目的：报告青少年和成人哮喘临床治疗的6个主题的最新建议：（1）间歇应用吸入糖皮质激素（ICS）；（2）长效毒蕈碱拮抗剂附加治疗；（3）呼出气一氧化氮；（4）室内过敏原脱敏；（5）免疫治疗；（6）支气管热成形术。
证据回顾：根据2014年的需求评估结果，国家心肺血液咨询委员会选择了6个主题来更新2007年哮喘指南。美国医疗保健研究与质量局根据截至2017年3月至4月的文献检索，对这6个主题进行了系统综述。综述更新至2018年10月，由一个专家小组（n=19），包括哮喘内容专家、初级保健临床医生、宣传和实施专家以及卫生政策专家，使用GRADE方法制定了19项新建议。本特别通讯报告了关于12岁以上人群的17项建议。
研究结果：在选定的20572篇参考文献中，475篇被纳入6个系统综述中，这形成了建议的证据基础。与2007年的指南相比：第1级（间歇性哮喘）治疗[按需使用短效β2激动剂(SABA)进行急救治疗]没有变化；第2级（轻度持续性哮喘）治疗，建议每日小剂量使用ICS必要时加用SABA或按需联合使用ICS和SABA；福莫特罗及ICS联合制剂（单一维持和缓解治疗）首选用于中度持续性哮喘，包括第3级（低剂量ICS-福莫特罗治疗）和第4级（中剂量ICS-福莫特罗治疗）的每日或按需治疗；对于哮喘症状的恶化，不建议仅短期增加ICS剂量；对于第5级（中重度持续性哮喘）使用ICS-福莫特罗治疗不能控制的哮喘患者，推荐使用长效毒蕈碱拮抗剂；呼出气一氧化氮检测推荐用于辅助诊断和监测症状，但其不能单独用于哮喘的诊断和监测；过敏原脱敏治疗仅建议用于有过敏原暴露及有相关致敏或症状的患者，当使用时，应有明确的致敏原并包含多种过敏原特异性脱敏策略；皮下免疫治疗被推荐作为标准药物治疗的一种辅助手段，用于有症状及对特定过敏原致敏的患者，舌下腺免疫治疗不推荐用于哮喘；支气管热成形术不建议作为常规治疗，其应作为正在进行的研究工作的一部分。
结论与相关性：哮喘是一种常见病，在全球范围内造成了巨大的人力和经济损失。虽然没有治愈或明确的预防手段，但有效的治疗是可行的。使用2020年哮喘指南更新版中的建议可以改善哮喘患者的健康状况。
Managing Asthma in Adolescents and Adults: 2020 Asthma Guideline Update From the National Asthma Education and Prevention Program
Michelle M Cloutier, Anne E Dixon, Jerry A Krishnan, Robert F Lemanske Jr, Wilson Pace, Michael Schatz
Abstract
Importance: Asthma is a major public health problem worldwide and is associated with excess morbidity, mortality, and economic costs associated with lost productivity. The National Asthma Education and Prevention Program has released the 2020 Asthma Guideline Update with updated evidence-based recommendations for treatment of patients with asthma.
Objective: To report updated recommendations for 6 topics for clinical management of adolescents and adults with asthma: (1) intermittent inhaled corticosteroids (ICSs); (2) add-on long-acting muscarinic antagonists; (3) fractional exhaled nitric oxide; (4) indoor allergen mitigation; (5) immunotherapy; and (6) bronchial thermoplasty.
Evidence review: The National Heart, Lung, and Blood Advisory Council chose 6 topics to update the 2007 asthma guidelines based on results from a 2014 needs assessment. The Agency for Healthcare Research and Quality conducted systematic reviews of these 6 topics based on literature searches up to March-April 2017. Reviews were updated through October 2018 and used by an expert panel (n = 19) that included asthma content experts, primary care clinicians, dissemination and implementation experts, and health policy experts to develop 19 new recommendations using the GRADE method. The 17 recommendations for individuals aged 12 years or older are reported in this Special Communication.
Findings: From 20 572 identified references, 475 were included in the 6 systematic reviews to form the evidence basis for these recommendations. Compared with the 2007 guideline, there was no recommended change in step 1 (intermittent asthma) therapy (as-needed short-acting β2-agonists [SABAs] for rescue therapy). In step 2 (mild persistent asthma), either daily low-dose ICS plus as-needed SABA therapy or as-needed concomitant ICS and SABA therapy are recommended. Formoterol in combination with an ICS in a single inhaler (single maintenance and reliever therapy) is recommended as the preferred therapy for moderate persistent asthma in step 3 (low-dose ICS-formoterol therapy) and step 4 (medium-dose ICS-formoterol therapy) for both daily and as-needed therapy. A short-term increase in the ICS dose alone for worsening of asthma symptoms is not recommended. Add-on long-acting muscarinic antagonists are recommended in individuals whose asthma is not controlled by ICS-formoterol therapy for step 5 (moderate-severe persistent asthma). Fractional exhaled nitric oxide testing is recommended to assist in diagnosis and monitoring of symptoms, but not alone to diagnose or monitor asthma. Allergen mitigation is recommended only in individuals with exposure and relevant sensitivity or symptoms. When used, allergen mitigation should be allergen specific and include multiple allergen-specific mitigation strategies. Subcutaneous immunotherapy is recommended as an adjunct to standard pharmacotherapy for individuals with symptoms and sensitization to specific allergens. Sublingual immunotherapy is not recommended specifically for asthma. Bronchial thermoplasty is not recommended as part of standard care; if used, it should be part of an ongoing research effort.
重要性：哮喘是世界范围内的一个主要公共卫生问题，这与其高发病率、死亡率以及劳动力丧失造成的经济成本有关。美国国家哮喘教育和预防计划发布了2020年哮喘指南更新，其中包括对哮喘患者治疗的最新循证建议。
目的：报告青少年和成人哮喘临床治疗的6个主题的最新建议：（1）间歇应用吸入糖皮质激素（ICS）；（2）长效毒蕈碱拮抗剂附加治疗；（3）呼出气一氧化氮；（4）室内过敏原脱敏；（5）免疫治疗；（6）支气管热成形术。
证据回顾：根据2014年的需求评估结果，国家心肺血液咨询委员会选择了6个主题来更新2007年哮喘指南。美国医疗保健研究与质量局根据截至2017年3月至4月的文献检索，对这6个主题进行了系统综述。综述更新至2018年10月，由一个专家小组（n=19），包括哮喘内容专家、初级保健临床医生、宣传和实施专家以及卫生政策专家，使用GRADE方法制定了19项新建议。本特别通讯报告了关于12岁以上人群的17项建议。
研究结果：在选定的20572篇参考文献中，475篇被纳入6个系统综述中，这形成了建议的证据基础。与2007年的指南相比：第1级（间歇性哮喘）治疗[按需使用短效β2激动剂(SABA)进行急救治疗]没有变化；第2级（轻度持续性哮喘）治疗，建议每日小剂量使用ICS必要时加用SABA或按需联合使用ICS和SABA；福莫特罗及ICS联合制剂（单一维持和缓解治疗）首选用于中度持续性哮喘，包括第3级（低剂量ICS-福莫特罗治疗）和第4级（中剂量ICS-福莫特罗治疗）的每日或按需治疗；对于哮喘症状的恶化，不建议仅短期增加ICS剂量；对于第5级（中重度持续性哮喘）使用ICS-福莫特罗治疗不能控制的哮喘患者，推荐使用长效毒蕈碱拮抗剂；呼出气一氧化氮检测推荐用于辅助诊断和监测症状，但其不能单独用于哮喘的诊断和监测；过敏原脱敏治疗仅建议用于有过敏原暴露及有相关致敏或症状的患者，当使用时，应有明确的致敏原并包含多种过敏原特异性脱敏策略；皮下免疫治疗被推荐作为标准药物治疗的一种辅助手段，用于有症状及对特定过敏原致敏的患者，舌下腺免疫治疗不推荐用于哮喘；支气管热成形术不建议作为常规治疗，其应作为正在进行的研究工作的一部分。
结论与相关性：哮喘是一种常见病，在全球范围内造成了巨大的人力和经济损失。虽然没有治愈或明确的预防手段，但有效的治疗是可行的。使用2020年哮喘指南更新版中的建议可以改善哮喘患者的健康状况。
(中日友好医院呼吸与危重症医学科 顾宪民 摘译 林江涛 审校)
(JAMA. 2020 Dec 3. doi: 10.1001/jama.2020.21974.)
(JAMA. 2020 Dec 3. doi: 10.1001/jama.2020.21974.)
Managing Asthma in Adolescents and Adults: 2020 Asthma Guideline Update From the National Asthma Education and Prevention Program
Michelle M Cloutier, Anne E Dixon, Jerry A Krishnan, Robert F Lemanske Jr, Wilson Pace, Michael Schatz
Abstract
Importance: Asthma is a major public health problem worldwide and is associated with excess morbidity, mortality, and economic costs associated with lost productivity. The National Asthma Education and Prevention Program has released the 2020 Asthma Guideline Update with updated evidence-based recommendations for treatment of patients with asthma.
Objective: To report updated recommendations for 6 topics for clinical management of adolescents and adults with asthma: (1) intermittent inhaled corticosteroids (ICSs); (2) add-on long-acting muscarinic antagonists; (3) fractional exhaled nitric oxide; (4) indoor allergen mitigation; (5) immunotherapy; and (6) bronchial thermoplasty.
Evidence review: The National Heart, Lung, and Blood Advisory Council chose 6 topics to update the 2007 asthma guidelines based on results from a 2014 needs assessment. The Agency for Healthcare Research and Quality conducted systematic reviews of these 6 topics based on literature searches up to March-April 2017. Reviews were updated through October 2018 and used by an expert panel (n = 19) that included asthma content experts, primary care clinicians, dissemination and implementation experts, and health policy experts to develop 19 new recommendations using the GRADE method. The 17 recommendations for individuals aged 12 years or older are reported in this Special Communication.
Findings: From 20 572 identified references, 475 were included in the 6 systematic reviews to form the evidence basis for these recommendations. Compared with the 2007 guideline, there was no recommended change in step 1 (intermittent asthma) therapy (as-needed short-acting β2-agonists [SABAs] for rescue therapy). In step 2 (mild persistent asthma), either daily low-dose ICS plus as-needed SABA therapy or as-needed concomitant ICS and SABA therapy are recommended. Formoterol in combination with an ICS in a single inhaler (single maintenance and reliever therapy) is recommended as the preferred therapy for moderate persistent asthma in step 3 (low-dose ICS-formoterol therapy) and step 4 (medium-dose ICS-formoterol therapy) for both daily and as-needed therapy. A short-term increase in the ICS dose alone for worsening of asthma symptoms is not recommended. Add-on long-acting muscarinic antagonists are recommended in individuals whose asthma is not controlled by ICS-formoterol therapy for step 5 (moderate-severe persistent asthma). Fractional exhaled nitric oxide testing is recommended to assist in diagnosis and monitoring of symptoms, but not alone to diagnose or monitor asthma. Allergen mitigation is recommended only in individuals with exposure and relevant sensitivity or symptoms. When used, allergen mitigation should be allergen specific and include multiple allergen-specific mitigation strategies. Subcutaneous immunotherapy is recommended as an adjunct to standard pharmacotherapy for individuals with symptoms and sensitization to specific allergens. Sublingual immunotherapy is not recommended specifically for asthma. Bronchial thermoplasty is not recommended as part of standard care; if used, it should be part of an ongoing research effort.
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支气管热成形术减少了由多次呼吸氮冲洗技术测量的通气异质性
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小气道功能障碍作为严重嗜酸性粒细胞性哮喘生物治疗临床反应的预测指标和标志物：一项纵向观察性研究
