背景:过敏性支气管肺曲霉病(ABPA)经常使哮喘复杂化。迫切需要为儿童ABPA的管理制定循证指南。印度儿科学会(IAP)国家呼吸分会(NRC)的循证指南开发小组(EBGDG)解决了这一需求。
方法:EBGDG入围了与哮喘中ABPA管理相关的临床问题。对于每个问题,EBGDG进行了系统的,逐步寻找现有指南的证据,其次是系统评价,其次是初级研究。证据已经整理好了,批判性评价,和合成。EBGDG通过决策证据(EtD)框架工作,为了提出建议,使用建议评级评估,开发和评估(等级)方法。
结果:七个临床问题被优先考虑,并提出以下建议。(1)哮喘控制不佳的儿童应进行ABPA调查(有条件推荐,证据的适度确定性)。(2)低剂量类固醇治疗方案(前2周0.5mg/kg/d,随后逐渐逐渐减量)优于高剂量方案(有条件推荐,证据的确定性非常低)。(3)口服类固醇方案超过16周(包括逐渐减少),不应使用(有条件推荐,证据的确定性非常低)。(4)由于证据既不赞成也不反对,因此可以将抗真菌药添加到类固醇疗法中(有条件的建议,证据的确定性低)。(5)对于使用抗真菌药物的临床医生,EBGDG建议不要使用伏立康唑代替伊曲康唑(有条件推荐,证据的确定性非常低)。(6)没有循证推荐使用脉冲类固醇治疗而不是常规类固醇治疗。(7)不推荐使用生物制剂包括奥马珠单抗或dupilumab进行免疫治疗(有条件推荐,证据的确定性非常低)。
结论:这个基于证据的指南可以在不同的临床环境中被医疗保健提供者使用。
BACKGROUND: Allergic bronchopulmonary aspergillosis (ABPA) frequently complicates asthma. There is urgent need to develop evidence-based
guidelines for the management of ABPA in children. The Evidence Based
Guideline Development Group (EBGDG) of the Indian Academy of Pediatrics (IAP) National Respiratory Chapter (NRC) addressed this need.
METHODS: The EBGDG shortlisted clinical questions relevant to the management of ABPA in asthma. For each question, the EBGDG undertook a systematic, step-wise evidence search for existing
guidelines, followed by systematic reviews, followed by primary research studies. The evidence was collated, critically appraised, and synthesized. The EBGDG worked through the Evidence to Decision (EtD) framework, to formulate recommendations, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
RESULTS: Seven clinical questions were prioritized, and the following recommendations formulated. (1) Children with poorly controlled asthma should be investigated for ABPA (conditional recommendation, moderate certainty of evidence). (2) Low dose steroid therapy regimen (0.5 mg/kg/d for the first 2 wk, followed by a progressive tapering) is preferable to higher dose regimens (conditional recommendation, very low certainty of evidence). (3) Oral steroid regimens longer than 16 wk (including tapering), should not be used (conditional recommendation, very low certainty of evidence). (4) Antifungals may or may not be added to steroid therapy as the evidence was neither in favour nor against (conditional recommendation, low certainty of evidence). (5) For clinicians using antifungal agents, the EBGDG recommends against using voriconazole instead of itraconazole (conditional recommendation, very low certainty of evidence). (6) No evidence-based recommendation could be framed for using pulse steroid therapy in preference to conventional steroid therapy. (7) Immunotherapy with biologicals including omalizumab or dupilumab is not recommended (conditional recommendation, very low certainty of evidence).
CONCLUSIONS: This evidence-based
guideline can be used by healthcare providers in diverse clinical settings.