加拿大胸科学会2012年指南更新：学龄前儿童、学龄期儿童和成人哮喘的诊断和处理
2012/07/06
摘要
背景：2010年，加拿大胸科协会（CTS）出版了6岁及以上儿童和成人哮喘的诊断和处理共识摘要，其中更新了对哮喘的处理。CTS哮喘临床学会随后进行了对临床实践的正式更新。在首次更新中，主要关注之前指南中存在争议的问题和/或与之前指南存在的差异。
方法：本次更新中，主要正对4个关键主题：气道炎症的无创性检查在调整抗炎治疗中的作用；启动激素吸入（ICS）的辅助治疗以控制哮喘；单次吸入ICS/长效β2受体激动剂作为缓解治疗及同时作为缓解和控制治疗的作用；增加哮喘控制用药，作为哮喘急性失控自我处理的一部分。专家组成员遵循一定的编制程序，针对指南中特定的问题进行分析。此外，通过检索文献，寻找相关系统综述和随机对照试验。专家组对收集到的证据正式评价和分级，给出34个推荐。
结果：更新版的指南中，认为除了哮喘控制的标准检测之外，还需要纳入评价痰液嗜酸性粒细胞，来指导成人中度至重度哮喘的控制治疗。此外，对于哮喘控制较差的成人和儿童，采用何种辅助治疗作为ICS的补充，以及何种ICS剂量下开始辅助治疗等相关证据，支持2010年CTS共识摘要中的推荐措施。同时，对书面行动计划中控制用药的调整，提供了推荐方案。最后，对未来研究的方向进行了分析。
结论：本次临床实践指南是加拿大呼吸道疾病指南委员会新指南开发过程实施后，对CTS哮喘指南的首次更新。支持指南实施的工具和措施将不断得到发展，CTS也将继续对指南进行更新，以更好反应最新研究成果。
（林江涛 审校）
Can Respir J. 2012 Mar;19(2):127-64.
Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults.
Lougheed MD, Lemiere C, Ducharme FM, Licskai C, Dell SD, Rowe BH, Fitzgerald M, Leigh R, Watson W, Boulet LP; CanadianThoracic Society Asthma Clinical Assembly.
Abstract
BACKGROUND: In 2010, the Canadian Thoracic Society (CTS) published a Consensus Summary for the diagnosis and management of asthma in children six years of age and older, and adults, including an updated Asthma Management Continuum. The CTS Asthma Clinical Assembly subsequently began a formal clinical practice guideline update process, focusing, in this first iteration, on topics of controversy and⁄or gaps in the previous guidelines.
METHODS: Four clinical questions were identified as a focus for the updated guideline: the role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy; the initiation of adjunct therapy to inhaled corticosteroids (ICS) for uncontrolled asthma; the role of a single inhaler of an ICS/long-acting beta2-agonist combination as a reliever, and as a reliever and a controller; and the escalation of controller medication for acute loss of asthma control as part of a self-management action plan. The expert panel followed an adaptation process to identify and appraise existing guidelines on the specified topics. In addition, literature searches were performed to identify relevant systematic reviews and randomized controlled trials. The panel formally assessed and graded the evidence, and made 34 recommendations.
RESULTS: The updated guideline recommendations outline a role for inclusion of assessment of sputum eosinophils, in addition to standard measures of asthma control, to guide adjustment of controller therapy in adults with moderate to severe asthma. Appraisal of the evidence regarding which adjunct controller therapy to add to ICS and at what ICS dose to begin adjunct therapy in children and adults with poor asthma control supported the 2010 CTS Consensus Summary recommendations. New recommendations for the adjustment of controller medication within written action plans are provided. Finally, priority areas for future research were identified.
CONCLUSIONS: The present clinical practice guideline is the first update of the CTS Asthma Guidelines following the Canadian Respiratory Guidelines Committee’s new guideline development process. Tools and strategies to support guideline implementation will be developed and the CTS will continue to regularly provide updates reflecting new evidence.
Can Respir J. 2012;19(2):127-64.
背景：2010年，加拿大胸科协会（CTS）出版了6岁及以上儿童和成人哮喘的诊断和处理共识摘要，其中更新了对哮喘的处理。CTS哮喘临床学会随后进行了对临床实践的正式更新。在首次更新中，主要关注之前指南中存在争议的问题和/或与之前指南存在的差异。
方法：本次更新中，主要正对4个关键主题：气道炎症的无创性检查在调整抗炎治疗中的作用；启动激素吸入（ICS）的辅助治疗以控制哮喘；单次吸入ICS/长效β2受体激动剂作为缓解治疗及同时作为缓解和控制治疗的作用；增加哮喘控制用药，作为哮喘急性失控自我处理的一部分。专家组成员遵循一定的编制程序，针对指南中特定的问题进行分析。此外，通过检索文献，寻找相关系统综述和随机对照试验。专家组对收集到的证据正式评价和分级，给出34个推荐。
结果：更新版的指南中，认为除了哮喘控制的标准检测之外，还需要纳入评价痰液嗜酸性粒细胞，来指导成人中度至重度哮喘的控制治疗。此外，对于哮喘控制较差的成人和儿童，采用何种辅助治疗作为ICS的补充，以及何种ICS剂量下开始辅助治疗等相关证据，支持2010年CTS共识摘要中的推荐措施。同时，对书面行动计划中控制用药的调整，提供了推荐方案。最后，对未来研究的方向进行了分析。
结论：本次临床实践指南是加拿大呼吸道疾病指南委员会新指南开发过程实施后，对CTS哮喘指南的首次更新。支持指南实施的工具和措施将不断得到发展，CTS也将继续对指南进行更新，以更好反应最新研究成果。
（林江涛 审校）
Can Respir J. 2012 Mar;19(2):127-64.
Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults.
Lougheed MD, Lemiere C, Ducharme FM, Licskai C, Dell SD, Rowe BH, Fitzgerald M, Leigh R, Watson W, Boulet LP; CanadianThoracic Society Asthma Clinical Assembly.
Abstract
BACKGROUND: In 2010, the Canadian Thoracic Society (CTS) published a Consensus Summary for the diagnosis and management of asthma in children six years of age and older, and adults, including an updated Asthma Management Continuum. The CTS Asthma Clinical Assembly subsequently began a formal clinical practice guideline update process, focusing, in this first iteration, on topics of controversy and⁄or gaps in the previous guidelines.
METHODS: Four clinical questions were identified as a focus for the updated guideline: the role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy; the initiation of adjunct therapy to inhaled corticosteroids (ICS) for uncontrolled asthma; the role of a single inhaler of an ICS/long-acting beta2-agonist combination as a reliever, and as a reliever and a controller; and the escalation of controller medication for acute loss of asthma control as part of a self-management action plan. The expert panel followed an adaptation process to identify and appraise existing guidelines on the specified topics. In addition, literature searches were performed to identify relevant systematic reviews and randomized controlled trials. The panel formally assessed and graded the evidence, and made 34 recommendations.
RESULTS: The updated guideline recommendations outline a role for inclusion of assessment of sputum eosinophils, in addition to standard measures of asthma control, to guide adjustment of controller therapy in adults with moderate to severe asthma. Appraisal of the evidence regarding which adjunct controller therapy to add to ICS and at what ICS dose to begin adjunct therapy in children and adults with poor asthma control supported the 2010 CTS Consensus Summary recommendations. New recommendations for the adjustment of controller medication within written action plans are provided. Finally, priority areas for future research were identified.
CONCLUSIONS: The present clinical practice guideline is the first update of the CTS Asthma Guidelines following the Canadian Respiratory Guidelines Committee’s new guideline development process. Tools and strategies to support guideline implementation will be developed and the CTS will continue to regularly provide updates reflecting new evidence.
Can Respir J. 2012;19(2):127-64.
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