高滲透食鹽水對細支氣管炎兒童執行蒸氣吸入之成效探討: 隨機對照試驗之統合分析Effectiveness of steam inhalation with 3% Hypertonic Saline among bronchiolitis children: A meta-analysis of randomized controlled trials

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2019-08-31 已刊登
新刊登 綜 整 預防/治療/介入類型

作  者

謝佳妏 蘇慧娟* 林步鴻 陳可欣 陳杰峰

實證知識類別

A 類:實證健康照護綜整

PICO

治療/預防性問題

治療/介入措施

兒科醫學 Pediatrics

科別

  • 嬰幼兒及兒童照護 Infant and Child Care

中文關鍵詞

細支氣管炎 兒童 高滲透食鹽水 蒸氣吸入 住院天數 呼吸嚴重程度 治療效果

英文關鍵詞

bronchiolitis children hypertonic saline vapor treatment length of hospital stay efficacy safety

機構名稱

臺北市立萬芳醫院-委託財團法人臺北醫學大學辦理

申請單位

護理部

中文摘要

形成臨床提問:
細支氣管炎是兩歲以下兒童最常見的下呼吸道感染疾病之一,是兒童出生後第一年住院的主要原因之一,其感染時間可持續十幾天至三週,發生期間年幼的兒童特別容易因氣管阻塞產生呼吸困難的情形。根據 2014 年美國兒科學會(American Academy of Pediatrics) 細支氣管炎照護指引,蒸氣治療是最常被使用的治療方式之一,其有助於稀釋呼吸道分泌物、促進痰液排出。但臨床上用於蒸氣吸入之溶液濃度存有差異。高滲透 (3%) 食鹽水的作用機轉為利用霧化誘導水分子滲透到肺部黏膜層,提高黏膜纖毛清除功能,以減少氣道水腫的產生。因此,本研究目的為探討高滲透食鹽水對細支氣管炎兒童執行蒸氣吸入之成效及安全性。
文獻搜尋的方法與分析:
依據實證護理五大步驟,以PICO架構設定搜尋關鍵字及同義字,包括”child*”, “pediatric*”, “bronchiolitis”, “hypertonic”, “saline”, “safety”, “effect*”,並利用自然語彙 (free text) 及Mesh term找出廣義的詞彙,搜尋Cochrane Library, Pubmed, Embase, Clinicalkey以及華藝圖書館等資料庫,文獻搜尋期間至2019年7月,沒有語言限制。後續由兩位研究者獨立進行文章篩選、以Cochrane risk of bias (RoB) 2.0與GRADE進行文獻風險偏差及證據等級評估,並以Review Manager 5.3 (The Nordic Cochrane Centre, Copenhagen, Denmark, 2014) 及GRADE (Grading of Recommendations, Assessment, Development and Evaluation) profiler 3.6 軟體進行統合分析及證據體的證據等級判定。
文獻的品質評讀:
經篩選後納入19篇隨機對照試驗,共2,854位受試者。文獻整體評估結果:由於資料缺失及評估者無法盲化,故RoB評估結果為「一些擔憂」(some concern),而GRADE評核系統之整體證據品質為中等級。研究結果顯示:相較於使用生理食鹽水進行蒸氣吸入,使用高滲透食鹽水進行蒸氣治療者,其住院天數減少0.74天 (95% CI -1.2, -0.3, I²= 69%)、臨床呼吸嚴重程度分數 (clinical severity score, CSS) (MD -1.1, 95% CI -1.7, -0.6) 及呼吸窘迫評估分數 (respiratory distress assessment instrument, RDAI) 皆有顯著改善 (MD -0.6, 95% CI -0.9, -0.2)。因納入試驗的兒童年齡、呼吸症狀嚴重度、呼吸嚴重度評估工具及施測時間不同,故呈現異質性。納入研究中未報告任何嚴重不良反應事件。
結論與建議:
細支氣管炎兒童使用高滲透食鹽水執行蒸氣吸入較生理食鹽水更能縮短住院天數、顯著改善呼吸嚴重程度及呼吸窘迫分數。建議臨床上可用於進行蒸氣吸入,以達到更好的治療效果。

英文摘要

Ask an answerable question (PICO):
Acute bronchiolitis is the most common lower respiratory infection in children, and is a major cause for hospitalization in children in the first year after birth. The pathogenesis of bronchiolitis included mucosal inflammation and swelling. The infection can last 2–3 weeks, and it is particularly prone to dyspnea among children under two years old. According to the 2014 American Academy of Pediatrics Bronchiolitis guideline, vapor treatment is one of the most commonly used treatments, which helps to dilute respiratory secretions and promote sputum excretion. However, the effectiveness and clinical application of different concentration of the solution for vapor inhalation is still controversial. Inhaled hypertonic saline (HS) has recently been shown to be a favorable therapy, because of its facility to draw fluid from the submucosa and adventitial spaces, decreasing airway edema. The aim of this systematic review and meta-analysis was to evaluate the efficacy and safety of HS in the implementation of vapor treatment among children with bronchiolitis.
The Method and Analysis of Literature Review:
In total, 2854 children from 19 publications were included. All studies compared HS against a NS or placebo. The risk of bias was “some concern” using RoB 2.0, and “moderate” based on GRADE methodology. The risk of bias was rising from blinding of participants and personnel and incomplete outcome data. Compared to the control group, the HS group exhibited significantly decreased the length of hospital stay 0.74 days (95% CI -1.2, -0.3, I²= 69%), reducing the level of clinical severity score (CSS) (MD -1.1, 95% CI -1.7, -0.6), and the score of respiratory distress assessment instrument (RDAI) (MD -0.6, 95% CI -0.9, -0.2). A high heterogeneity was noted due to diversity of population, intervention (inhalation time and dose), assessment tools and the time point of measurement. No adverse events were reported in the included studies.
Critical Appraisal:
In total, 2854 children from 19 publications were included. All studies compared HS against a NS or placebo. The risk of bias was “some concern” using RoB 2.0, and “moderate” to“high” based on GRADE methodology. The risk of bias was rising from blinding of participants and personnel and incomplete outcome data. Compared to the control group, the HS group exhibited significantly decreased the length of hospital stay 0.74 days (95% CI -1.2, -0.3, I²= 69%), reducing the level of clinical severity score (CSS) (MD -1.1, 95% CI -1.7, -0.6), and the score of respiratory distress assessment instrument (RDAI) (MD -0.6, 95% CI -0.9, -0.2). A high heterogeneity was noted due to diversity of population, intervention (inhalation time and dose), assessment tools and the time point of measurement. No adverse events were reported in the included studies.
Conclusions and Recommendations:
We conclude that nebulized with 3% saline solution is effective in decreasing the length of hospital stay and the severity of symptoms as compared with 0.9% saline solution among children with acute bronchiolitis. Further rigor randomize controlled trails with large sample size are needed.