今日の臨床サポート

急性気管支炎・急性細気管支炎

著者: 原永修作 琉球大学病院 総合臨床研修・教育センター

監修: 藤田次郎 琉球大学医学部

著者校正/監修レビュー済:2021/03/17
参考ガイドライン:
  1. 日本呼吸器学会:咳嗽・喀痰の診療ガイドライン 2019
  1. 日本感染症学会:気道感染症の抗菌薬適正使用に関する提言
患者向け説明資料

概要・推奨   

  1. インフルエンザワクチン接種は健常成人においてすぐれた予防効果を示す(推奨度2)
  1. 急性気管支炎ではほとんどの症例がウイルスによる感染のため、抗菌薬の投与は推奨されない(推奨度3)
  1. 健常人の急性気管支炎では気管支拡張薬(β2刺激薬)の効果は乏しいため、ルーチンでの使用は推奨されない(推奨度3)
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要と
  1. 急性細気管支炎におけるβ2刺激薬の投与は臨床経過を短縮するが、酸素化や入院率の改善にはつながらない(推奨度3)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧に
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
原永修作 : 特に申告事項無し[2021年]
監修:藤田次郎 : 講演料(塩野義製薬(株),杏林製薬(株),第一三共(株))[2021年]

改訂のポイント:
  1. 新たに発表された咳嗽と喀痰に関する診療ガイドラインや気道感染症の抗菌薬適正使用に関する提言を反映した内容とした。
  1. 感染性咳嗽の鑑別のフローチャートを急性咳嗽を呈する成人患者への対応のフローチャートへ変更した。

病態・疫学・診察

疾患情報(疫学・病態)  
急性気管支炎:[1][2][3][4]
  1. 急性気管支炎は日常診療においてよくみられる疾患の1つである。急性気管支炎は自然軽快する気道感染による気管支の炎症である。
  1. 健常人の急性気管支炎の病原体はウイルスが最も多く、百日咳菌やマイコプラズマ、肺炎クラミドフィラなども病原体となり得るが、一般細菌はまれである。
  1. COPDや気管支拡張症、心不全などの基礎疾患がある場合は細菌感染の割合が増える。
  1. 急性気管支炎の患者は通常5日以上~3週間程度まで持続する咳嗽を認め、喀痰はみられる場合もある。
  1. 急性気管支炎の診断は病歴と身体所見によってなされ、画像診断や血液検査は不要である。
  1. インフルエンザや百日咳、マイコプラズマが原因である場合には抗原検査や抗体検査が有用である。
 
急性細気管支炎:[5]
  1. 急性細気管支炎は幼小児や基礎疾患のある成人に発症する細気管支レベルでの急性炎症である。
  1. 季節性の流行がみられる。
  1. respiratory syncytial(RS)ウイルスが原因としては多い。
  1. 近年、乳幼児や高齢者、基礎疾患のある成人でヒトメタニューモウイルスが原因となることが報告されている。
  1. 鼻汁、咳嗽、微熱に引き続いて呼吸困難や喘鳴を認める。
  1. 急性細気管支炎では呼吸状態の悪化により入院加療を要することがある。
  1. 治療は支持療法が主体である。
問診・診察のポイント  
急性気管支炎:
  1. 急性気管支炎では咳嗽や喀痰といった気道の炎症による症状や発熱などの全身症状がみられる。基礎疾患のない患者ではウイルス感染が主であり周囲に同症状の人がいることが多い。上気道炎と異なり咳嗽が5日以上持続することが多く、肺炎で認められる高熱や胸痛、聴診上のラ音は認められない。ウイルス感染でも気道の炎症により膿性痰を認めるため、膿性痰がみられても細菌感染とは限らない。一方、COPDや心不全などの基礎疾患がある場合には細菌感染の割合が増えてくるため注意が必要である。

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文献 

著者: R Gonzales, J F Steiner, M A Sande
雑誌名: JAMA. 1997 Sep 17;278(11):901-4.
Abstract/Text CONTEXT: Antibiotic use is associated with increased rates of antibiotic-resistant organisms. A previous study has shown that colds, upper respiratory tract infections, and bronchitis account for nearly one third of all antibiotic prescribing by ambulatory care physicians. How frequently antibiotics are prescribed for these conditions and for and by whom is not known.
OBJECTIVES: To measure antibiotic prescription rates and to identify predictors of antibiotic use for adults diagnosed as having colds, upper respiratory tract infections, and bronchitis in the United States.
DESIGN: Sample survey of practicing physicians participating in the National Ambulatory Medical Care Survey, 1992.
SETTING: Office-based physician practices.
SUBJECTS: Physicians (n=1529) completing patient record forms for adult office visits (n=28787).
MAIN OUTCOME MEASURES: Antibiotic prescriptions for colds, upper respiratory tract infections, and bronchitis.
RESULTS: Office visits for colds, upper respiratory tract infections, and bronchitis resulted in approximately 12 million antibiotic prescriptions, accounting for 21% of all antibiotic prescriptions to adults in 1992. A total of 51 % of patients diagnosed as having colds, 52% of patients diagnosed as having upper respiratory tract infections, and 66% of patients diagnosed as having bronchitis were treated with antibiotics. Female sex (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.05-2.62) and rural practice location (OR, 2.25; 95% CI, 1.33-3.80) were associated with greater antibiotic prescription rates, whereas black race (OR, 0.44; 95% CI, 0.21-0.93) was associated with lower antibiotic prescription rates. Patient age, Hispanic ethnicity, geographic region, physician specialty, and payment sources were not associated with antibiotic prescription rates in the bivariate analysis. Multivariate logistic regression analysis identified only rural practice location (adjusted OR, 2.58; 95% CI, 1.39-4.76) to be independently associated with more frequent antibiotic prescriptions for colds, upper respiratory tract infections, and bronchitis.
CONCLUSION: Although antibiotics have little or no benefit for colds, upper respiratory tract infections, or bronchitis, these conditions account for a sizable proportion of total antibiotic prescriptions for adults by office-based physicians in the United States. Overuse of antibiotics is widespread across geographical areas, medical specialties, and payment sources. Therefore, effective strategies for changing prescribing behavior for these conditions will need to be broad based.

PMID 9302241  JAMA. 1997 Sep 17;278(11):901-4.
著者: V Snow, C Mottur-Pilson, R Gonzales, American Academy of Family Physicians, American College of Physicians-American Society of Internal Medicine, Centers for Disease Control, Infectious Diseases Society of America
雑誌名: Ann Intern Med. 2001 Mar 20;134(6):518-20.
Abstract/Text
PMID 11255531  Ann Intern Med. 2001 Mar 20;134(6):518-20.
著者: R Gonzales, J G Bartlett, R E Besser, R J Cooper, J M Hickner, J R Hoffman, M A Sande, Centers for Disease Control and Prevention
雑誌名: Ann Emerg Med. 2001 Jun;37(6):720-7.
Abstract/Text The following principles of appropriate antibiotic use for adults with acute bronchitis apply to immunocompetent adults without complicating comorbid conditions, such as chronic lung or heart disease. The evaluation of adults with an acute cough illness or a presumptive diagnosis of uncomplicated acute bronchitis should focus on ruling out serious illness, particularly pneumonia. In healthy, nonelderly adults, pneumonia is uncommon in the absence of vital sign abnormalities or asymmetrical lung sounds, and chest radiography is usually not indicated. In patients with cough lasting 3 weeks or longer, chest radiography may be warranted in the absence of other known causes. Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of duration of cough. If pertussis infection is suspected (an unusual circumstance), a diagnostic test should be performed and antimicrobial therapy initiated. Patient satisfaction with care for acute bronchitis depends most on physician--patient communication rather than on antibiotic treatment.

PMID 11385346  Ann Emerg Med. 2001 Jun;37(6):720-7.
著者: Andrew Bush, Anne H Thomson
雑誌名: BMJ. 2007 Nov 17;335(7628):1037-41. doi: 10.1136/bmj.39374.600081.AD.
Abstract/Text
PMID 18007004  BMJ. 2007 Nov 17;335(7628):1037-41. doi: 10.1136/bmj.39・・・
著者: J E Wipf, B A Lipsky, J V Hirschmann, E J Boyko, J Takasugi, R L Peugeot, C L Davis
雑誌名: Arch Intern Med. 1999 May 24;159(10):1082-7.
Abstract/Text BACKGROUND: The reliability of chest physical examination and the degree of agreement among examiners in diagnosing pneumonia based on these findings are largely unknown.
OBJECTIVES: To determine the accuracy of various physical examination maneuvers in diagnosing pneumonia and to compare the interobserver reliability of the maneuvers among 3 examiners.
METHODS: Fifty-two male patients presenting to the emergency department of a university-affiliated Veterans Affairs medical center with symptoms of lower respiratory tract infection (cough and change in sputum) were prospectively examined. A comprehensive lung physical examination was performed sequentially by 3 physicians who were blind to clinical history, laboratory findings, and x-ray results. Examination findings by lung site and whether the examiner diagnosed pneumonia were recorded on a standard form. Chest x-ray films were read by a radiologist.
RESULTS: Twenty-four patients had pneumonia confirmed by chest x-ray films. Twenty-eight patients did not have pneumonia. Abnormal lung sounds were common in both groups; the most frequently detected were rales in the upright seated position and bronchial breath sounds. Relatively high agreement among examiners (kappa approximately 0.5) occurred for rales in the lateral decubitus position and for wheezes. The 3 examiners' clinical diagnosis of pneumonia had a sensitivity of 47% to 69% and specificity of 58% to 75%.
CONCLUSIONS: The degree of interobserver agreement was highly variable for different physical examination findings. The most valuable examination maneuvers in detecting pneumonia were unilateral rales and rales in the lateral decubitus position. The traditional chest physical examination is not sufficiently accurate on its own to confirm or exclude the diagnosis of pneumonia.

PMID 10335685  Arch Intern Med. 1999 May 24;159(10):1082-7.
著者: P H Orr, K Scherer, A Macdonald, M E Moffatt
雑誌名: J Fam Pract. 1993 May;36(5):507-12.
Abstract/Text BACKGROUND: Acute bronchitis is a common clinical problem that causes considerable morbidity and presents both diagnostic and treatment dilemmas for the physician. An evaluation of all published randomized controlled trials of antibiotics in the treatment of acute bronchitis was conducted to (1) quantitatively assess methodologic rigor, (2) determine if effectiveness of antimicrobial therapy is known, and (3) analyze strengths and weaknesses of randomized controlled trials in family practice settings.
METHODS: A scoring system for the evaluation of randomized controlled trials was adapted for this study. Four raters, who were blinded to which journals published the studies and the type of antibiotic used in each study, assessed the six-randomized clinical trials for treatment of bronchitis identified through a literature search. The trials were rated according to criteria that measured internal validity.
RESULTS: Scores for internal validity ranged from 65.5 to 102.5 points with a maximum possible score of 120 points (54.6% to 85.4%). The two trials with the highest scores assessed doxycycline and showed no benefit from use of this antibiotic. Single trials that studied erythromycin and trimethoprim-sulfamethoxazole showed improvement in outcome from use of these drugs; however, of the six trials, these two studies ranked fourth and fifth for internal validity. Low scores resulted from small sample size, possible contamination with other treatment measures, and poor assessment of subjects' compliance with antibiotic regimen.
CONCLUSIONS: An evaluation of the current literature does not support antibiotic treatment for acute bronchitis. Further studies of this common illness are indicated. It is hoped that this critical review of randomized control trials will prove useful in the planning of future studies, in placing greater emphasis on methodologic rigor, and in giving greater consideration to the practical constraints of research in the family practice setting.

PMID 8482934  J Fam Pract. 1993 May;36(5):507-12.
著者: J J Smucny, L A Becker, R H Glazier, W McIsaac
雑誌名: J Fam Pract. 1998 Dec;47(6):453-60.
Abstract/Text BACKGROUND: Most clinicians prescribe antibiotics for acute bronchitis in spite of recommendations against this practice. Because the results of individual clinical trials have been mixed, we conducted a meta-analysis to determine whether antibiotics are effective treatment for acute bronchitis.
METHODS: We conducted a comprehensive search to identify all trials in which patients who had a diagnosis of acute bronchitis were randomly assigned to treatment with an antibiotic or placebo. Patient-oriented outcomes of importance that were reported in at least 3 studies were quantitatively summarized.
RESULTS: Nine studies met the inclusion criteria, but not all trials provided data for each outcome. Patients given antibiotics were less likely to have a cough (relative risk [RR] = 0.69; 95% confidence interval [CI], 0.49 -0.98) and be considered unimproved (RR = 0.51; 95% CI, 0.30-0.88) at a follow-up visit; but they were not less likely to have a productive cough (RR = 0.79; 95% CI, 0.60-1.03), activity limitations (RR = 0.59; 95% CI, 0.24-1.44), or feel ill (RR = 0.70; 95% CI, 0.31-1.58). Antibiotic-treated patients had a slightly shorter duration of productive cough (weighted mean difference [WMD] = -0.56 days; 95% CI, -1.09 to -0.04), but not of overall cough (WMD = -0.94; 95% CI, -2.08 to 0.21) or activity limitations (WMD = -0.49; 95% CI, -1.07 to 0.10). Patients treated with antibiotics did not report significantly more adverse effects (RR = 1.47; 95% CI, 0.82-2.65).
CONCLUSIONS: Antibiotics may be modestly effective for a minority of patients with acute bronchitis. It is not clear which patient subgroups might benefit, and the failure of some studies to report negative findings may have resulted in overestimates of the benefits of antibiotics. Antibiotics are not necessary for every patient with acute bronchitis.

PMID 9866671  J Fam Pract. 1998 Dec;47(6):453-60.
著者: R Chandran
雑誌名: Am Fam Physician. 2001 Jul 1;64(1):135-8.
Abstract/Text OBJECTIVES: People with acute bronchitis may show little evidence of bacterial infection. If effective, antibiotics could shorten the course of the disease. However, if they are not effective, the risk of antibiotic resistance may be increased. The objective of this review was to assess the effects of antibiotic treatment in patients with a clinical diagnosis of acute bronchitis.
SEARCH STRATEGY: The authors searched MEDLINE, Embase, reference lists of articles, personal collections up to 1996 and Sci-search from 1989 to 1996.
SELECTION CRITERIA: Randomized trials comparing any antibiotic therapy with placebo in acute bronchitis.
DATA COLLECTION AND ANALYSIS: At least two reviewers extracted data and assessed trial quality.
PRIMARY RESULTS: The results of eight trials involving 750 patients from eight years of age to 65 and older and including smokers and nonsmokers were included. The quality of the trials was variable. A variety of outcome measures was assessed. In many cases, only outcomes that showed a statistically significant difference between groups were reported. Overall, patients taking antibiotics had slightly better outcomes than those taking placebo. They were less likely to report feeling unwell at a follow-up visit (odds ratio, 0.42; 95 percent confidence interval [CI] 0.22 to 0.82), to show no improvement on physician assessment (odds ratio, 0.43; CI, 0.23 to 0.79) or to have abnormal lung findings (odds ratio, 0.33; CI, 0.13 to 0.86), and had a more rapid return to work or usual activities (weighted mean difference, 0.7 days earlier; CI, 0.2 to 1.3). Antibiotic-treated patients reported significantly more adverse effects (odds ratio, 1.64; CI, 1.05 to 2.57), such as nausea, vomiting, headache, skin rash or vaginitis.
REVIEWERS' CONCLUSIONS: Antibiotics appear to have a modest beneficial effect in the treatment of acute bronchitis, with a correspondingly small risk of adverse effects. The benefits of antibiotics may be overestimated in this analysis because of the tendency of published reports to include complete data only on outcomes found to be statistically significant.

PMID 11456430  Am Fam Physician. 2001 Jul 1;64(1):135-8.
著者: R Gonzales, J F Steiner, A Lum, P H Barrett
雑誌名: JAMA. 1999 Apr 28;281(16):1512-9.
Abstract/Text CONTEXT: The emergence and spread of antibiotic-resistant Streptococcus pneumoniae in US communities is due, in part, to the excessive use of antibiotics for acute respiratory tract infections.
OBJECTIVE: To decrease total antibiotic use for uncomplicated acute bronchitis in adults.
DESIGN: Prospective, nonrandomized controlled trial, including baseline (November 1996-February 1997) and study (November 1997-February 1998) periods.
SETTING: Four selected primary care practices belonging to a group-model health maintenance organization in the Denver, Colo, metropolitan area.
PARTICIPANTS: Consecutive adults diagnosed as having uncomplicated acute bronchitis. A total of 2462 adults were included at baseline and 2027 adults were included in the study. Clinicians included 56 physicians, 28 physician assistants or nurse practitioners, and 9 registered nurses.
INTERVENTION: The full intervention site received household and office-based patient educational materials, as well as a clinician intervention consisting of education, practice-profiling, and academic detailing. A limited intervention site received only office-based educational materials, and control sites provided usual care.
MAIN OUTCOME MEASURE: Antibiotic prescriptions for uncomplicated acute bronchitis during baseline and study periods.
RESULTS: Antibiotic prescription rates for uncomplicated acute bronchitis were similar at all 4 sites during the baseline period. During the study period, there was a substantial decline in antibiotic prescription rates at the full intervention site (from 74% to 48% [P = .003]), but not at the control and limited intervention sites (78% to 76% [P = .81] and 82% to 77% [P = .68], respectively). Compared with control sites, changes in nonantibiotic prescriptions (inhaled bronchodilators, cough suppressants, and analgesics) were not significantly different for intervention sites. Return office visits (within 30 days of the incident visit) for bronchitis or pneumonia did not change significantly for any of the sites.
CONCLUSIONS: Antibiotic treatment of adults diagnosed as having uncomplicated acute bronchitis can be safely reduced using a combination of patient and clinician interventions.

PMID 10227321  JAMA. 1999 Apr 28;281(16):1512-9.
著者: Jennifer Evertsen, Dennis J Baumgardner, Ann Regnery, Indrani Banerjee
雑誌名: Prim Care Respir J. 2010 Sep;19(3):237-41. doi: 10.4104/pcrj.2010.00024.
Abstract/Text AIMS: To understand which clinical criteria physicians use to diagnose pneumonia compared to bronchitis and upper respiratory tract infection (URTI).
METHODS: Retrospective chart review of adults diagnosed with pneumonia, bronchitis, or URTI.
RESULTS: Logistic regression analysis identified rales, a temperature > 100 degrees F (37.8 degrees C), chest pain, dyspnoea, rhonchi, heart rate, respiratory rate, and rhinorrhoea, as the best explanation for the variation in diagnosis of pneumonia compared to either of the alternative diagnoses (R2 = 59.3), with rales and a temperature > 100 degrees F explaining 30% of the variation. Rales, chest pain, and a temperature > 100 degrees F best predicted the ordering of a chest x-ray (R2 = 20.0). However, 35% (59/175) of patients diagnosed with pneumonia had a negative chest x-ray. Abnormal breath sounds were the best predictors for prescribing antibiotics (R2 = 38%). A significant number of patients with acute bronchitis (93% excluding sinusitis) and URTI (42%) were given antibiotics.
CONCLUSIONS: The presence of abnormal breath sounds and a temperature > 100 degrees F were the best predictors of a diagnosis of pneumonia.

PMID 20490437  Prim Care Respir J. 2010 Sep;19(3):237-41. doi: 10.4104・・・
著者: Lorne A Becker, Jeffrey Hom, Miguel Villasis-Keever, Johannes C van der Wouden
雑誌名: Cochrane Database Syst Rev. 2011 Jul 6;(7):CD001726. doi: 10.1002/14651858.CD001726.pub4. Epub 2011 Jul 6.
Abstract/Text BACKGROUND: There are no clearly effective treatments for the cough of acute bronchitis. Beta2-agonists are often prescribed, perhaps because clinicians suspect many patients also have reversible airflow restriction contributing to the symptoms.
OBJECTIVES: To determine whether beta2-agonists improve acute bronchitis symptoms in patients with no underlying pulmonary disease.
SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2011, issue 1 which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE (January 1966 to February week 1, 2011) and EMBASE (1974 to February 2011).
SELECTION CRITERIA: Randomised controlled trials (RCTs) in which patients (adults, or children over two years of age) with acute bronchitis or acute cough and without known pulmonary disease were allocated to beta2-agonist versus placebo, no treatment or alternative treatment.
DATA COLLECTION AND ANALYSIS: Three review authors independently selected outcomes and extracted data while blinded to study results. Two review authors independently assessed each trial for risk of bias. We analysed trials in children and adults separately.
MAIN RESULTS: Two trials in children (n = 109) with no evidence of airway obstruction did not find any benefits from oral beta2-agonists. Five trials in adults (n = 418) had mixed results but overall summary statistics did not reveal any significant benefits from oral (three trials) nor inhaled (two trials) beta2-agonists. There were no significant differences in daily cough scores nor in the percentage of adults still coughing after seven days (control group 73%; risk ratio (RR) 0.77, 95% confidence interval (CI) 0.54 to 1.09). in one trial, subgroups with evidence of airflow limitation had lower symptom scores if given beta2-agonists. The trials that noted quicker resolution of cough with beta2-agonists were those with a higher proportion of wheezing patients at baseline. Adults given beta2-agonists were more likely to report tremor, shakiness or nervousness (RR 7.94, 95% CI 1.17 to 53.94; number needed to treat to harm (NNTH) 2.3).
AUTHORS' CONCLUSIONS: There is no evidence to support the use of beta2-agonists in children with acute cough who do not have evidence of airflow obstruction. There is also little evidence that the routine use of beta2-agonists is helpful for adults with acute cough. These agents may reduce symptoms, including cough, in people with evidence of airflow obstruction. However, this potential benefit is not well-supported by the available data and must be weighed against the adverse effects associated with their use.

PMID 21735384  Cochrane Database Syst Rev. 2011 Jul 6;(7):CD001726. do・・・
著者: J J Smucny, C A Flynn, L A Becker, R H Glazier
雑誌名: J Fam Pract. 2001 Nov;50(11):945-51.
Abstract/Text OBJECTIVE: Our goal was to determine whether beta2-agonists improve the symptoms of acute bronchitis or acute cough in patients who do not have underlying pulmonary disease.
STUDY DESIGN: We performed a systematic review including meta-analysis.
DATA SOURCES: We included randomized controlled trials comparing beta2-agonists with placebo or alternative therapies identified from the Cochrane Library, MEDLINE, EMBASE, conference proceedings, Science Citation Index, the System for Information on Grey Literature in Europe, and letters to manufacturers of beta2-agonists.
OUTCOMES MEASURED: We measured duration, persistence, severity or frequency of cough, productive cough, and night cough; duration of activity limitations; and adverse effects.
RESULTS: Two trials in children with cough and no obvious airway obstruction did not find any benefits from beta2-agonists. Five trials in adults with cough and with or without airway obstruction had mixed results, but summary statistics did not reveal any significant benefits from beta2-agonists. Studies that enrolled more wheezing patients were more likely to show benefits from beta2-agonists, and in one study only patients with evidence of airflow limitation were more likely to benefit. Patients given beta2-agonists were more likely to report tremor, shakiness, or nervousness than those in the control groups.
CONCLUSIONS: There is no evidence to support using beta2-agonists in children with acute cough and no evidence of airflow obstruction. There is little evidence that the routine use of beta2-agonists for adults with acute cough is helpful. These agents may reduce symptoms, including cough, in patients with evidence of airflow obstruction, but this potential benefit is not well-supported by the available data and must be weighed against the adverse effects associated with beta2-agonists.

PMID 11711010  J Fam Pract. 2001 Nov;50(11):945-51.
著者: B Littenberg, M Wheeler, D S Smith
雑誌名: J Fam Pract. 1996 Jan;42(1):49-53.
Abstract/Text BACKGROUND: Beta-agonist agents have been used for bronchospasm and cough in a variety of settings. We sought to evaluate the efficacy of oral albuterol for acute cough in ambulatory adults.
METHODS: We performed a prospective, randomized, controlled, double-blind clinical trial comparing albuterol 4 mg by mouth three times daily for 7 days with placebo in 104 adults. Subjects had cough of less than 4 weeks' duration and no evidence of pneumonia, asthma, or chronic obstructive pulmonary disease. All subjects were enrolled at the walk-in clinic of a rural academic medical center.
RESULTS: There was no significant difference between treated and control subjects in any measure of efficacy including cough severity score, reduction in sleepless nights, utilization of health care, or return to full activity. There were significantly more reports of "shakiness" and "nervousness" among albuterol-treated subjects than among controls.
CONCLUSIONS: Oral albuterol should not be used in unselected patients with acute, nonspecific cough.

PMID 8537805  J Fam Pract. 1996 Jan;42(1):49-53.
著者: L Pavesi, S Subburaj, K Porter-Shaw
雑誌名: Chest. 2001 Oct;120(4):1121-8.
Abstract/Text STUDY OBJECTIVE: The purpose of the meta-analysis was to understand the antitussive effect of treatment with dextromethorphan hydrobromide, 30 mg, vs placebo over a 3-h treatment period in patients with cough due to uncomplicated upper respiratory tract infection (URTI), and to show that the computerized system for acquisition and analysis of cough sound was consistent and reproducible across the individual studies.
STUDY DESIGN: The six studies used for the meta-analysis were randomized, double-blind, parallel-group, single-dose, placebo-controlled studies with a 3-h postdose cough evaluation period.
SETTING: One study was conducted in Durban, South Africa, and five studies were conducted in Bombay, India. Four studies took place in clinics, and two studies were in-home studies.
PATIENTS: Seven hundred ten adult patients with cough due to uncomplicated URTI who were otherwise healthy and who satisfied the inclusion/exclusion criteria for the meta-analysis.
MEASUREMENTS AND RESULTS: For each patient, a standard baseline was calculated pretreatment, then a 3-h continuous cough recording was made after treatment was initiated. Five efficacy variables were measured in 30-min intervals: cough bouts, cough components, cough effort, cough intensity, and cough latency. The meta-analysis showed consistent results across most of the studies for each of the efficacy variables. It demonstrated significantly greater overall reductions in cough bouts, cough components, and cough effort, and an increase in cough latency for patients treated with dextromethorphan hydrobromide, 30 mg, vs those treated with placebo.
CONCLUSION: The results of a meta-analysis of the six clinical studies show that the antitussive effect of a single dose of dextromethorphan hydrobromide, 30 mg, has been established. The consistent nature of the results shows that the computerized cough acquisition and analysis system is a valid and reproducible methodology for evaluating cough associated with URTI.

PMID 11591548  Chest. 2001 Oct;120(4):1121-8.
著者: Mike Purdon, Sherry Dodson, Harold A Williamson
雑誌名: J Fam Pract. 2003 Jan;52(1):69-70.
Abstract/Text
PMID 12540317  J Fam Pract. 2003 Jan;52(1):69-70.
著者: American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis
雑誌名: Pediatrics. 2006 Oct;118(4):1774-93. doi: 10.1542/peds.2006-2223.
Abstract/Text Bronchiolitis is a disorder most commonly caused in infants by viral lower respiratory tract infection. It is the most common lower respiratory infection in this age group. It is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospasm. The American Academy of Pediatrics convened a committee composed of primary care physicians and specialists in the fields of pulmonology, infectious disease, emergency medicine, epidemiology, and medical informatics. The committee partnered with the Agency for Healthcare Research and Quality and the RTI International-University of North Carolina Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to the diagnosis, management, and prevention of bronchiolitis. The resulting evidence report and other sources of data were used to formulate clinical practice guideline recommendations. This guideline addresses the diagnosis of bronchiolitis as well as various therapeutic interventions including bronchodilators, corticosteroids, antiviral and antibacterial agents, hydration, chest physiotherapy, and oxygen. Recommendations are made for prevention of respiratory syncytial virus infection with palivizumab and the control of nosocomial spread of infection. Decisions were made on the basis of a systematic grading of the quality of evidence and strength of recommendation. The clinical practice guideline underwent comprehensive peer review before it was approved by the American Academy of Pediatrics. This clinical practice guideline is not intended as a sole source of guidance in the management of children with bronchiolitis. Rather, it is intended to assist clinicians in decision-making. It is not intended to replace clinical judgment or establish a protocol for the care of all children with this condition. These recommendations may not provide the only appropriate approach to the management of children with bronchiolitis.

PMID 17015575  Pediatrics. 2006 Oct;118(4):1774-93. doi: 10.1542/peds.・・・
著者: Anne M Gadomski, Melissa Brower
雑誌名: Cochrane Database Syst Rev. 2010 Dec 8;(12):CD001266. doi: 10.1002/14651858.CD001266.pub2. Epub 2010 Dec 8.
Abstract/Text BACKGROUND: Bronchiolitis is an acute, viral lower respiratory tract infection affecting infants and often treated with bronchodilators.
OBJECTIVES: To assess the effects of bronchodilators on clinical outcomes in infants with acute bronchiolitis.
SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 1) which contains the Acute Respiratory Infections Group's Specialized Register, MEDLINE (1966 to March week 2 2010) and EMBASE (2003 to March 2010).
SELECTION CRITERIA: Randomized controlled trials (RCTs) comparing bronchodilators (other than epinephrine) with placebo for bronchiolitis.
DATA COLLECTION AND ANALYSIS: Two authors assessed trial quality and extracted data. Unpublished data were obtained from trial authors.
MAIN RESULTS: We included 28 trials (1912 infants) with bronchiolitis. In 10 inpatient and 10 outpatient studies, oxygen saturation did not improve with bronchodilators (mean difference (MD) -0.45, 95% confidence interval (CI) -0.96 to 0.05, n = 1182). Outpatient bronchodilator treatment did not reduce the rate of hospitalization (12% in bronchodilator group versus 16% in placebo, odds ratio (OR) 0.78, 95% CI 0.47 to 1.29, n = 650). Inpatient bronchodilator treatment did not reduce the duration of hospitalization (MD 0.06, 95% CI -0.27 to 0.39, n = 349). In seven inpatient and eight outpatient studies, average clinical score decreased slightly with bronchodilators (standardized mean difference (SMD) -0.37, 95% CI -0.62 to -0.13, n = 1006).Oximetry and clinical score outcomes showed significant heterogeneity. Including only studies at low risk of bias significantly reduced heterogeneity measures for oximetry (I(2) statistic = 17%) and average clinical score (I(2) statistic = 26%), while having little impact on the overall effect size of oximetry (MD -0.38, 95% CI -0.75 to 0.00, P = 0.05) and average clinical score (SMD -0.26, 95% CI -0.44 to -0.08, P = 0.005).Effect estimates for outpatients were slightly larger than for inpatients for oximetry (outpatients MD -0.57, 95% CI -1.13 to 0.00 versus inpatients MD -0.29, 95% CI -1.10 to 0.51) and average clinical score (outpatients SMD -0.49, 95% CI -0.86 to -0.11 versus inpatients SMD -0.20, 95% CI -0.43 to 0.03). Adverse effects included tachycardia and tremors.
AUTHORS' CONCLUSIONS: Bronchodilators do not improve oxygen saturation, do not reduce hospital admission after outpatient treatment, do not shorten the duration of hospitalization and do not reduce the time to resolution of illness at home. The small improvements in clinical scores for outpatients must be weighed against the costs and adverse effects of bronchodilators.

PMID 21154348  Cochrane Database Syst Rev. 2010 Dec 8;(12):CD001266. d・・・
著者: G Flores, R I Horwitz
雑誌名: Pediatrics. 1997 Aug;100(2 Pt 1):233-9.
Abstract/Text OBJECTIVE: To evaluate the efficacy of beta2-agonists in bronchiolitis.
DESIGN: Critical review and meta-analysis of randomized controlled trials of inhaled beta2-agonists.
RESULTS: Three inpatient and five outpatient studies were identified. Inpatient studies (82 patients) were characterized by wide variability in therapeutic regimens and measurement of outcomes. Several problems were identified in the selection and specification of patients, such as failure to assess the prestudy duration of illness or to exclude patients already taking bronchodilators. Meta-analysis was not possible for inpatient trials due to the great variability in study outcomes, timing of outcome assessment, and drug regimens. Results of inpatient trials were contradictory: one found significant reductions in the clinical score and a shorter hospital stay with treatment, whereas two others found only significant oxygen desaturations. Outpatient studies (251 patients) examined immediate changes in physiologic measures and clinical scores after two treatments, but have not examined the effects of the longer-term regimen customarily used by clinicians. Meta-analysis revealed that short-term beta2-agonist therapy had no impact on the hospitalization rate or respiratory rate, and had a statistically significant but clinically insignificant impact on oxygen saturation and heart rate. The diversity of scoring systems precluded pooling of clinical score data.
CONCLUSIONS: Despite eight clinical trials, conclusive evidence for the efficacy of beta2-agonist therapy for bronchiolitis remains unavailable. Well-designed inpatient trials are needed. Meta-analysis of outpatient studies does not support the use of beta2-agonist therapy for bronchiolitis, but investigators have not studied the outcomes and the long-term outpatient regimen customarily used by clinicians.

PMID 9240805  Pediatrics. 1997 Aug;100(2 Pt 1):233-9.
著者: A M Gadomski, R Lichenstein, L Horton, J King, V Keane, T Permutt
雑誌名: Pediatrics. 1994 Jun;93(6 Pt 1):907-12.
Abstract/Text OBJECTIVE: To examine the efficacy of albuterol (0.15 mg/kg per dose) in the management of bronchiolitis.
DESIGN: Randomized, double-blind, placebo-controlled outpatient clinical trial utilizing four study groups: neubulized albuterol, nebulized saline, oral albuterol, and oral placebo.
SETTING: Pediatric emergency department and outpatient clinic at University of Maryland in Baltimore.
PATIENTS: Eighty-eight infants (median age 5.5 months) being treated for their first episode of wheezing were randomly assigned to nebulized albuterol (n = 22), nebulized saline (n = 23), oral albuterol (n = 19), oral placebo (n = 24).
INTERVENTIONS: The nebulized groups received two nebulizations 30 minutes apart, whereas the oral groups received one oral dose.
MAIN OUTCOME MEASURES: Respiratory and heart rates, clinical score, oxygen saturation (Spo2), and the infant's state, ie, asleep, awake, or feeding, were recorded at baseline and at 30 and 60 minutes after treatment.
RESULTS: Randomization produced equivalent groups in terms of demographics and baseline measures. There were no statistically significant differences in any outcomes among the four treatments, except for oral albuterol, which produced an increase in heart rate (15 beats per minute, P = .005). No differences in the need for additional treatment or hospitalization were observed. Change in the state of the infant during the trial had significant effects on respiratory rate and clinical score.
CONCLUSIONS: Albuterol is as effective as oral placebo in the management of bronchiolitis. Past studies supporting the use of albuterol did not control for effects of change in state of the infant and did not use a truly inactive placebo group. This study underscores the importance of these design components in measuring the efficacy of albuterol in infants.

PMID 8190575  Pediatrics. 1994 Jun;93(6 Pt 1):907-12.
著者: Howard M Corneli, Joseph J Zorc, Prashant Mahajan, Prashant Majahan, Kathy N Shaw, Richard Holubkov, Scott D Reeves, Richard M Ruddy, Baqir Malik, Kyle A Nelson, Joan S Bregstein, Kathleen M Brown, Matthew N Denenberg, Kathleen A Lillis, Lynn Babcock Cimpello, James W Tsung, Dominic A Borgialli, Marc N Baskin, Getachew Teshome, Mitchell A Goldstein, David Monroe, J Michael Dean, Nathan Kuppermann, Bronchiolitis Study Group of the Pediatric Emergency Care Applied Research Network (PECARN)
雑誌名: N Engl J Med. 2007 Jul 26;357(4):331-9. doi: 10.1056/NEJMoa071255.
Abstract/Text BACKGROUND: Bronchiolitis, the most common infection of the lower respiratory tract in infants, is a leading cause of hospitalization in childhood. Corticosteroids are commonly used to treat bronchiolitis, but evidence of their effectiveness is limited.
METHODS: We conducted a double-blind, randomized trial comparing a single dose of oral dexamethasone (1 mg per kilogram of body weight) with placebo in 600 children (age range, 2 to 12 months) with a first episode of wheezing diagnosed in the emergency department as moderate-to-severe bronchiolitis (defined by a Respiratory Distress Assessment Instrument score > or =6). We enrolled patients at 20 emergency departments during the months of November through April over a 3-year period. The primary outcome was hospital admission after 4 hours of emergency department observation. The secondary outcome was the Respiratory Assessment Change Score (RACS). We also evaluated later outcomes: length of hospital stay, later medical visits or admissions, and adverse events.
RESULTS: Baseline characteristics were similar in the two groups. The admission rate was 39.7% for children assigned to dexamethasone, as compared with 41.0% for those assigned to placebo (absolute difference, -1.3%; 95% confidence interval [CI], -9.2 to 6.5). Both groups had respiratory improvement during observation; the mean 4-hour RACS was -5.3 for dexamethasone, as compared with -4.8 for placebo (absolute difference, -0.5; 95% CI, -1.3 to 0.3). Multivariate adjustment did not significantly alter the results, nor were differences detected in later outcomes.
CONCLUSIONS: In infants with acute moderate-to-severe bronchiolitis who were treated in the emergency department, a single dose of 1 mg of oral dexamethasone per kilogram did not significantly alter the rate of hospital admission, the respiratory status after 4 hours of observation, or later outcomes. (ClinicalTrials.gov number, NCT00119002 [ClinicalTrials.gov].).

Copyright 2007 Massachusetts Medical Society.
PMID 17652648  N Engl J Med. 2007 Jul 26;357(4):331-9. doi: 10.1056/NE・・・
著者: Mirta Mesquita, Jose A Castro-Rodríguez, Lizzette Heinichen, Esmilse Fariña, Ricardo Iramain
雑誌名: Allergol Immunopathol (Madr). 2009 Mar-Apr;37(2):63-7.
Abstract/Text BACKGROUND AND OBJECTIVE: The management of bronchiolitis is still controversial and to the best of our knowledge, no clinical trial with oral corticosteroids in outpatients has been carried out in developing countries. The objective was to compare the efficacy of a single dose of oral dexamethasone in infants with moderate to severe bronchiolitis presenting to an emergency department.
MATERIAL AND METHODS: A randomised, double-blind, placebo-controlled trial was conducted in Paraguay. At baseline, respiratory distress assessment instrument (RDAI), heart and respiratory rates, and transcutaneous haemoglobin oxygen saturation (SpO(2)) were recorded. Children received either a single dose of dexamethasone (0.5 mg/kg) or placebo; and then both groups received two nebulisations with adrenaline. Respiratory status was recorded again after the 1st and 4th hours. The primary outcome was RDAI improvement at the 4th hour; and the secondary was the hospital admission rate.
RESULTS: During 5 months, 80 (33.3 %) out of 240 infants who consulted with acute respiratory illness fulfilled the inclusion criteria. During the trial 15 were excluded, therefore, 65 infants (33 in the dexamethasone vs. 32 in the placebo group) finished the study. Baseline characteristics and respiratory status were similar between groups. There were no differences in RDAI, heart and respiratory rate and SpO(2) between groups after the 1st and 4th hours. The hospitalisation rate was similar between groups (21 % vs. 25 %, p = 0.9, respectively), independently of the virus identified.
CONCLUSIONS: Infants with moderate-severe bronchiolitis who were treated with a single dose of dexamethasone did not significantly alter the rate of hospitalisation or respiratory status.

PMID 19445861  Allergol Immunopathol (Madr). 2009 Mar-Apr;37(2):63-7.
著者: Tom Jefferson, Carlo Di Pietrantonj, Alessandro Rivetti, Ghada A Bawazeer, Lubna A Al-Ansary, Eliana Ferroni
雑誌名: Cochrane Database Syst Rev. 2010 Jul 7;(7):CD001269. doi: 10.1002/14651858.CD001269.pub4. Epub 2010 Jul 7.
Abstract/Text BACKGROUND: Different types of influenza vaccines are currently produced worldwide. Healthy adults are presently targeted mainly in North America.
OBJECTIVES: Identify, retrieve and assess all studies evaluating the effects of vaccines against influenza in healthy adults.
SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010, issue 2), MEDLINE (January 1966 to June 2010) and EMBASE (1990 to June 2010).
SELECTION CRITERIA: Randomised controlled trials (RCTs) or quasi-RCTs comparing influenza vaccines with placebo or no intervention in naturally-occurring influenza in healthy individuals aged 16 to 65 years. We also included comparative studies assessing serious and rare harms.
DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data.
MAIN RESULTS: We included 50 reports. Forty (59 sub-studies) were clinical trials of over 70,000 people. Eight were comparative non-RCTs and assessed serious harms. Two were reports of harms which could not be introduced in the data analysis. In the relatively uncommon circumstance of vaccine matching the viral circulating strain and high circulation, 4% of unvaccinated people versus 1% of vaccinated people developed influenza symptoms (risk difference (RD) 3%, 95% confidence interval (CI) 2% to 5%). The corresponding figures for poor vaccine matching were 2% and 1% (RD 1, 95% CI 0% to 3%). These differences were not likely to be due to chance. Vaccination had a modest effect on time off work and had no effect on hospital admissions or complication rates. Inactivated vaccines caused local harms and an estimated 1.6 additional cases of Guillain-Barré Syndrome per million vaccinations. The harms evidence base is limited.
AUTHORS' CONCLUSIONS: Influenza vaccines have a modest effect in reducing influenza symptoms and working days lost. There is no evidence that they affect complications, such as pneumonia, or transmission.WARNING: This review includes 15 out of 36 trials funded by industry (four had no funding declaration). An earlier systematic review of 274 influenza vaccine studies published up to 2007 found industry funded studies were published in more prestigious journals and cited more than other studies independently from methodological quality and size. Studies funded from public sources were significantly less likely to report conclusions favorable to the vaccines. The review showed that reliable evidence on influenza vaccines is thin but there is evidence of widespread manipulation of conclusions and spurious notoriety of the studies. The content and conclusions of this review should be interpreted in light of this finding.

PMID 20614424  Cochrane Database Syst Rev. 2010 Jul 7;(7):CD001269. do・・・

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