green 2009-12-3 11:11
不建議每天以生理食鹽水灌洗鼻腔
作者：Deborah Brauser
出處：WebMD醫學新聞
November 11, 2009（加州聖地牙哥）－根據一項發表在美國過敏、氣喘與免疫學會（ACAAI）2009年年會的新研究結果，罹患再發性鼻腔鼻竇炎（RS）的病患，長期每天使用生理食鹽水鼻腔灌洗（NSI）可能會增加急性感染機率達60%。許多與會者們稱這項研究是很重要的。
喬治城大學醫學院大學醫院小兒科與過敏/免疫臨床教授、同時也是維吉尼亞州Watergate與Burke過敏與氣喘研究中心醫療主任的Talal M. Nsouli醫師在座談會上發表這項研究結果。
Nsouli醫師向Medscape過敏與臨床免疫學表示，短期使用NSI是沒有問題的，過去研究證實這可以改善鼻腔黏膜纖毛清除。然而，即使經常使用NSI或是洗鼻器用於治療鼻竇疾病，但少有證據證實這是有效的。
在這項研究中，研究者們假設長期使用NSI可能降低鼻子黏液免疫層的保護，鼻子黏液免疫層保護力降低可能造成再發性RS。
為了測試這項理論，研究者收納了68位RS病患（年齡中位數為29.3歲），這些病患經常使用NSI；病患們繼續接受每天兩次的治療，接著在12個月間追蹤RS發作次數；於完成治療停用後，另外再追蹤12個月。
除此之外，還有一組收納24位病患的平行非介入控制組（年齡中位數為34.2歲），這些病患每天使用NSI達12個月，研究者也追蹤其RS發作次數。
所有病患都持續使用其過敏醫師與其他醫師所開立的藥物。
【停用後發作次數減少】
研究結果顯示，在使用NSI的階段，總共發生544次急性RS（每位病患每年平均發作8次），而在停用期時僅發作204次（每位病患每年平均發作3次），發作頻率顯著下降62.5%（P<0.001）。
同樣的，控制組的RS平均發作頻率比停止使用組高50%，這也達到統計上顯著差異（P<0.01）
Nsouli醫師解釋，因為鼻黏膜黏液的組成，是對抗感染的第一道呼吸道防線，當我們將好的黏液洗掉時，可能因而降低鼻黏液分泌的免疫保護作用。
Nsouli醫師繼續說道，以NSI治療壞的黏液，頭1個禮拜到10天是好的，且術後病患可以使用達6~8週。但是如果總是有壞的黏液，這代表那位病患感染了，而需要使用其他藥物治療。
他報告他的團隊接著將會進行一項較大型的研究。我們正期待有同樣結果的研究，而這將會增加統計力量。
基本論點是，長期使用NSI對病患們來說是有害的。Nsouli醫師的結論是，我們需要告訴病患，拿這些用具回來換咖啡和茶！
【總是提出問題】
ACAAI摘要審閱委員會主席、紐阿克新澤西醫學院的醫學臨床副教授John J. Oppenheimer醫師在關鍵研究發現記者會中指出，這是個簡單但重要的研究。Oppenheimer醫師並未參加這項研究。
Oppenheimer醫師表示，這些接受長期治療的病患，其預後比未使用任何治療的病患差。但是，這並不代表當你感冒時，這就不是個適當的治療。不過，每天使用這種治療可能並不如我們所想的會有良好的預後。
他附帶表示，這強化了我的想法，身為一位醫師，對我們來說經常問問題是很重要的。因為多年來，我們可能做了不需要的事情。
在同一個記者會上，過敏、氣喘與免疫學學誌主編Gailen D. Marshall醫師與其來自傑克森密蘇里大學醫學中心的過敏/免疫部門的同事表示，當病患感冒時，透過生理食鹽水清洗來擺脫鼻黏液困擾，仍是個好主意。
但是過與不及都是不好的，這篇摘要以比較清楚的方式強調，在接受這種治療時，可能需停止使用幾天，這提出了一個很好的論點。Marshell醫師並未參與這項研究。
他繼續說道，因為該項研究顯示這樣一個簡單的治療可能是有害的，我認為這是個很好的研究。但如果適當使用的話，這樣一個單純的治療也可以是非常好的。我認為多花幾分鐘對我們的病患做解釋，並告訴他們給予這些建議的理由為何，是很重要的。
當問到下一步應該是什麼時，Oppenheimer醫師回應：我認為我們強烈意識到需要取得同樣的證據。我對於重複研究結果看這之間是否有差異感到比較放心。但這是對的方向，這告訴我們有些經驗上合理的事，在現實生活中可能並非如此。
Nsouli醫師與Marshall醫師表示已無相關資金上的往來。Oppenheimer醫師擔任Glaxo、AstraZeneca、Schering, Merck、Novartis與Genentech等公司的顧問。
Daily Nasal Saline Irrigation Not Recommended for Long-Term Use
By Deborah Brauser
Medscape Medical News
November 11, 2009 (San Diego, California) — Daily long-term use of nasal saline irrigation (NSI) by patients with recurrent rhinosinusitis (RS) can increase the frequency of acute infection by as much as 60%, according to a new study presented here at the American College of Allergy, Asthma Immunology (ACAAI) 2009 Annual Scientific Meeting. Many called the study "important."
"We have a serious problem with many patients who suffer with chronic sinus disease thinking that the best treatment is daily [NSI]. They think it isn't harmful and so use it all the time," said lead investigator Talal M. Nsouli, MD, clinical professor of pediatrics and allergy/immunology at Georgetown University Hospital School of Medicine and medical director at the Watergate and Burke Allergy and Asthma Research Centers in Virginia. He presented the results during a podium session.
Afterward, Dr. Nsouli told Medscape Allergy Clinical Immunology that he has no problems with the use of NSI over a short term, and that previous studies have shown that it can improve nasal mucociliary clearance. However, "despite the common use of [NSI], or neti pots, in the treatment of sinus disease over a long period of time, there has been little evidence to confirm its success."
For this study, the investigators hypothesized that the "long-term use of NSI may deplete the nose of its immune blanket of mucus, resulting in recurrent RS."
To test this theory, they enrolled 68 patients with RS (mean age, 29.3 years) who were regular users of NSI. Patients continued using the treatment twice a day every day and were then monitored for the frequency of RS episodes over 12 months. That was followed by an additional 12 months of monitoring during complete treatment discontinuation.
In addition, a parallel noninterventive control group, consisting of 24 patients (mean age, 34.2 years) using NSI daily for 12 months, had the frequency of their RS episodes monitored.
All patients continued taking the same medication previously prescribed to them by their allergists or other physicians.
Episodes Decreased at Discontinuation
Study results showed that 544 episodes of acute RS were experienced by the patients in the NSI phase (each patient averaging 8 episodes a year), with only 204 in the discontinuation phase (averaging 3 episodes per year), a statistically significant decrease in frequency of 62.5% (P?< .001).
Similarly, the control group's average frequency of RS was 50% higher than that found in the discontinuation group, which was also a statistically significant difference (P?< .001).
"This happens because nasal mucus acts as a first line of respiratory defense against infections due to its composition," explained Dr. Nsouli. "When we wash away the good mucus, we might be depleting nasal secretions from its immune elements."
"Treating bad mucus with [NSI] for 1 week to 10 days is fine and patients can use it for 6 to 8 weeks after surgery," continued Dr. Nsouli. "But if the bad mucus is present all the time, it means that that person has an infection and needs to be treated with other medication."
He reported that his team will next be conducting a larger study. "We're expecting to find the same results, but this will increase the power."
"The bottom line is that long-term use of [NSI] is harmful for patients. We need to tell them to go back to using these devices for coffee and tea!" concluded Dr. Nsouli.
Always Ask Questions
"This is a simple but important study," said ACAAI abstract review committee chair John J. Oppenheimer, MD, associate clinical professor of medicine at New Jersey Medical School in Newark, during a press conference on key research findings. Dr. Oppenheimer was not involved with this study.
"These patients had worse outcomes with the long-term treatment than when using nothing at all. This doesn't mean that this isn't an appropriate medication to consider when you have a cold. But using it daily may not have as good outcomes as we thought it did," said Dr. Oppenheimer.
He added that "it reinforces to me that, as doctors, it's always important for us to ask questions. Just because we may have done something for years doesn't necessarily make it right."
At the same press conference, Gailen D. Marshall, MD, PhD, editor-in-chief of the Annals of Allergy, Asthma and Immunology, from the Division of Allergy/Immunology at the University of Mississippi Medical Center in Jackson, said that "it is still a good idea to get rid of mucus through a saline wash when a patient has a cold."
"But as with anything else, you can overdo it. This abstract addresses that fact in a clear fashion and makes a good argument for maybe giving the treatment a 'drug holiday'." Dr. Marshall was also not involved with this study.
He continued: "I think this is a wonderful study because it points out the idea that simple things can be harmful. But simple things can also be very good if used in the proper context. I think it's important to take a few extra minutes to explain all of this to patients and to give them the rationale for our suggestions."
When asked what the next step should be, Dr. Oppenheimer replied: "I think we need to look at the same evidence acutely. I would feel more comforted to see it replicated to see if there are any differences. But it's the right direction and it tells us that sometimes something that makes sense empirically may not make sense in real practice."
Dr. Nsouli and Dr. Marshall have disclosed no relevant financial relationships. Dr. Oppenheimer reports being a consultant and doing research for Glaxo, AstraZeneca, Schering, Merck, Novartis, and Genentech.
American College of Allergy, Asthma Immunology (ACAAI) 2009 Annual Scientific Meeting: Abstract 32. Presented November?8, 2009.