兒童阻塞性睡眠呼吸中止症伴隨腺扁桃體肥大的治療

Abstract

研究背景 兒童阻塞性睡眠呼吸中止症盛行率約1- 4%，而腺扁桃體肥大是最常見的原因，因此扁桃體切除術為第一線的治療方法。然而並非所有的兒童都適合且願意接受扁桃體切除術，且部分的兒童在手術後仍有症狀。到目前為止，對於較輕微阻塞性睡眠呼吸中止症，且沒有需要早期進行手術的兒童，以及在進行手術後仍有症狀的患者其治療方式仍有爭議。 研究目的 我的研究分為兩部分. 第一部分是系統性文獻回顧以網絡統合分析的方式探討兒童睡眠呼吸中止症伴隨腺扁桃體肥大不同治療方法的效果。第二部分則是以系統性文獻回顧來看不同治療方法針對經由扁桃體切除術，但仍有症狀的兒童的治療效果。 材料與方法 本研究經由電子資料庫及其他來源進行系統性文獻回顧，選用隨機或非隨機分派對照試驗，來比較針對兒童睡眠呼吸中止症或經手術後仍有症狀的不同治療方法的效果。以夜間多項生理功能監測治療前後睡眠呼吸障礙指數和最低血氧飽和濃度的差值。以隨機效應模型進行成對和網絡統合分析，並以平均差異和95％信賴區間來表示。 研究結果 第一部分：共有10篇文獻（7隨機對照試驗，3 非隨機對照試驗）與837位患者進入網絡統合分析。在睡眠呼吸障礙指數改變的部分，扁桃體切除術加上咽成型術的效果最好，其次是只做扁桃體切除術，而不治療組和安慰劑組則是最差的，抗發炎藥物和抗菌劑治療的效果則介於中間。然而，對於最低血氧飽和度的變化，扁桃體切除術，不管是否有沒有加做咽成型術，皆可得到很好治療效果。而抗發炎藥物和抗菌劑的治療效果和沒有進行治療及安慰劑間則無統計學上的差異。 第二部分：只有1篇文獻符合標準。肌功能療法可顯著改善輕度至中度的殘餘睡眠呼吸中止症。 結論 鑑於目前的證據，扁桃體切除術對於兒童睡眠呼吸中止症是最有效的，若加做咽成型術可有效改善睡眠呼吸障礙指數，但對最低血氧飽和濃度來看，其效果不顯著。而在非手術治療選項中，抗發炎藥物和抗菌劑對於改善睡眠呼吸障礙指數的程度差不多，皆有其效果。然而，使用抗發炎藥物和抗菌劑治療時，他們可能只會減少睡眠呼吸障礙指數，但不能完全使最低血氧飽和濃度恢復正常，這代表患者在睡眠中仍可能有缺氧的情形。而在殘餘睡眠呼吸中止症的治療中，肌功能療法可顯著改善輕度至中度患者的症狀。基於本研究的文章品質和篇數有限，在解讀結果時應更加謹慎。

Background Obstructive sleep apnea (OSA) syndrome has occurred in 1- 4% of children. And the adenotonsillar hypertrophy is the most common cause of childhood OSA, so the adenotonsillectomy is the first-line treatment. However, adenotonsillectomy may not be suitable for all children, and residual OSA is estimated to occur in a significant proportion of children. So far, there is still considerable debate as to whether therapy is considered for children with milder OSA, who do not need early adenotonsillectomy and which approaches should be indicated for residual OSA. Objectives My study had two parts. Part I: we set out a systematic review and network meta-analysis to compare the efficacy of several interventions in improving OSA in children with adenotonsillar hypertrophy. Part II: we conducted a systematic review to compare the efficacy of several interventions in improving residual OSA after adenotonsillectomy. Materials and methods Electronic databases and other sources were searched for randomized or non-randomized controlled trials (RCTs or NRCTs) to identify studies comparing different available treatment with each other or no treatment/ placebo for OSA and residual OSA syndrome. Evaluation of difference between pretreatment and posttreatment of Apnea Hypopnea Index (AHI) and the lowest of arterial oxygen saturation (lowest SaO2) as measured by overnight polysomnography. Random-effects models were used to conduct the pairwise and network meta-analysis with mean differences and 95% confidence intervals calculated. Results In part I: 10 studies (7 RCTs, 3 NRCTs) with 837 patients were included in the network meta-analysis. Among the several therapies, we found adenotonsillectomy with pharyngoplasty to yield the greatest probability for change in AHI, followed by adenotonsillectomy only, then anti-inflammatory therapy and antimicrobial therapy. The no treatment and placebo group are the worst. However, for change in the lowest SaO2, adenotonsillectomy with or without pharyngoplasty are the better treatments. While the treatment effects of anti-inflammatory therapy and antimicrobial therapy had no statistically difference with no treatment and placebo. In part II: only 1 study was eligible for this review. The myofunctional therapy could improve in mild to moderate residual OSA significantly. Conclusions Given current evidence, adenotonsillectomy with pharyngoplasty and the adenotonsillectomy were more effective than other treatments for OSA syndrome in children. Addition of pharyngoplasty to traditional adenotonsillectomy may improve AHI, but in the lowest SaO2, its effect is nonsignificant. Among the non-surgical treatment option, the anti-inflammatory therapy and the anti-microbial therapy were more effective in change in AHI than no treatment and placebo groups. However, when using anti-inflammatory therapy and antimicrobial therapy, it may only result in reduction of AHI, but not in their complete cessation. So, the children may have continued to have hypoxia during sleep as before. For the children with residual OSA, the myofunctional therapy may be helpful. Given that the limited study quality and study numbers, when interpreting the results of this review should be with caution.