Khoujah Danya, Naples James G, Silva Lucas Oliveira J E, Edlow Jonathan A, Gerberi Danielle J, Carpenter Christopher R, Bellolio Fernanda
Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA.
Department of Emergency Medicine, AdventHealth Tampa, Tampa, Florida, USA.
Acad Emerg Med. 2023 Apr 26. doi: 10.1111/acem.14739.
Canalith repositioning maneuvers (such as the Epley maneuver) are recommended by specialty guidelines for management of benign paroxysmal positional vertigo (BPPV) yet are frequently underutilized in the emergency department (ED).
We conducted a systematic review of systematic reviews to summarize the evidence of Epley maneuver for the treatment of posterior canal (pc) BPPV in any setting. We included systematic reviews of randomized controlled trials (RCTs) that compared Epley to control in adult patients with pc-BPPV. Titles, abstracts, and full texts were screened in duplicate. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to rate certainty of evidence. Odds ratios (OR) and 95% confidence intervals (CI) are reported. Meta-analysis of individual studies was conducted with random and fixed effects.
From 2,228 titles, 7 systematic reviews were selected for quality assessment. One review was of higher methodological quality, included only RCTs, and was the most current and comprehensive. Five of the 11 RCTs of the review, including 312 patients with pc-BPPV diagnosed by Dix-Hallpike, were relevant to our question. Meta-analysis of 4 RCTs (251 patients) showed the use of Epley (as compared to control) was associated with higher complete resolution of vertigo at 1 week (OR 7.19, CI 1.52 to 33.98, moderate certainty). Meta-analysis of 3 RCTs (195 patients) showed the use of Epley was associated with higher conversion to negative Dix-Hallpike at 1 week (OR 6.67, CI 1.52 to 33.98, moderate certainty). The number-needed-to-treat was 3. Meta-analysis of the outcomes at 1 month, and when observational studies were included, showed similar results. No serious adverse effects were reported.
Symptoms of pc-BPPV improve with the Epley maneuver. Emergency clinicians should become familiar with performing the Epley for BPPV. Further studies on ED implementation and clinician education of Epley are needed.
专科指南推荐采用耳石复位手法（如Epley手法）来治疗良性阵发性位置性眩晕（BPPV），但在急诊科（ED）中该方法的使用频率常常较低。
我们对系统评价进行了一项系统综述，以总结在任何环境下Epley手法治疗后半规管（pc）BPPV的证据。我们纳入了对成年pc - BPPV患者中Epley与对照进行比较的随机对照试验（RCT）的系统评价。标题、摘要和全文均进行了双人筛选。采用推荐分级、评估、制定与评价（GRADE）评估来评定证据的确定性。报告了比值比（OR）和95%置信区间（CI）。对个体研究进行了随机和固定效应的荟萃分析。
从2228个标题中，选择了7项系统评价进行质量评估。一项评价具有较高的方法学质量，仅纳入了RCT，且是最新和最全面的。该评价的11项RCT中有5项（包括312例经Dix - Hallpike诊断的pc - BPPV患者）与我们的问题相关。对4项RCT（251例患者）的荟萃分析显示，使用Epley手法（与对照相比）在1周时眩晕完全缓解率更高（OR 7.19，CI 1.52至33.98，中等确定性）。对3项RCT（195例患者）的荟萃分析显示，使用Epley手法在1周时Dix - Hallpike转为阴性的比例更高（OR 6.67，CI 1.52至33.98，中等确定性）。治疗所需人数为3。对1个月时的结果以及纳入观察性研究后的荟萃分析显示了相似的结果。未报告严重不良反应。
Epley手法可改善pc - BPPV的症状。急诊临床医生应熟悉为BPPV患者实施Epley手法。需要进一步研究Epley手法在急诊科的应用及对临床医生的培训。
