中国呼吸与危重监护杂志

中国呼吸与危重监护杂志

肺功能监测是否在哮喘当前控制评估中起重要作用?

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目的 2009 年版全球哮喘防治创议(GINA)中哮喘控制包括哮喘当前临床控制和未来风险。2015 年版 GINA 指南将哮喘“当前临床控制”更名为哮喘“症状控制”,且将肺功能从其中剥离出来,评估内容仅包括日间症状、夜间症状、缓解药物使用及活动受限四个方面。本研究旨在评价 2009 年版和 2015 年版 GINA 哮喘控制标准在评估哮喘当前控制间的一致性,并探索肺功能监测是否在哮喘当前控制评估中起重要作用。 方法 采用横断面研究设计,纳入 138 例稳定期哮喘患者。分别应用 2009 版和 2015 版 GINA 哮喘控制评估标准,比较同一控制水平组间的人口学资料、临床特征、肺功能、过去 12 个月哮喘急性发作、外周血细胞分类计数及诱导痰细胞计数等情况。采用 Kappa 检验评价两版标准的一致性。采用 Spearman 相关分析比较不同版本 GINA 哮喘控制水平与过去 12 个月哮喘急性发作间的相关性,亦分析肺功能与过去 12 个月哮喘急性发作情况之间的相关性。 结果 基于 2009 版 GINA 哮喘控制评估标准,138 例受试者分为未控制组 52 例、部分控制组 58 例、控制组 28 例。而以 2015 版 GINA 哮喘控制评估标准,则分为未控制组 33 例、部分控制组 59 例、控制组 46 例。Kappa 检验结果显示两标准呈中等一致性(Kappa=0.595,P<0.001)。与 2009 版比较,2015 版评估的控制组哮喘患者肺功能更差 [FEV1%pred:(89.9±12.9)% vs. (79.9±18.2)%,P=0.013],2015 版评估的部分控制组患者哮喘控制水平更差,其中 ACQ-6 评分(0.8±0.7 vs. 1.1±0.7,P=0.028)和 ACT 评分(20.7±2.5 vs. 19.4±2.5,P=0.007)差异均有统计学意义。两版哮喘控制标准均与过去 12 个月哮喘急性发作情况相关(2009 版:r=–0.212;2015 版:r=–0.268),且与 2015 年版 GINA 版标准关系更为密切。同一控制水平组间未发现在诱导痰、外周血炎症细胞分类计数和 IgE 水平的差异。 结论 2009 版与 2015 版 GINA 哮喘控制评估标准间存在中等程度一致性。相较于 2009 版,经肺功能监测缺如的 2015 版 GINA 评估为控制组的哮喘患者存在更差的肺功能,部分控制组则存在更差的哮喘控制得分,2015 年版 GINA 哮喘控制标准与哮喘急性发作间关系更为密切。因此,研究支持 2015 年版 GINA 哮喘控制标准在哮喘当前控制临床评估的应用。

Objective Since 2009, assessment of asthma control in Global Initiative for Asthma (GINA) includes current clinical control and future risk. " Current clinical control” is replaced by " symptom control” in GINA 2015, and lung function is excluded from assessment of current clinical control. This study was designed to investigate the agreement in current asthma control assessment between GINA 2009 and 2015, and to explore whether FEV1 monitoring plays an important role in this context. Methods A cross-sectional study was conducted among patients with stable asthma (n=138). The levels of asthma control were graded by GINA 2009 and GINA 2015, respectively. Demographic data, spirometry, exacerbations in the past 12 months, peripheral blood cells, induced sputum were collected. Kappa coefficient was used to measure the agreement of the two asthma control tools. Association of the asthma control levels using the two tools with the exacerbations in the past 12 months was examined by Spearman correlations. Additionally, associations of lung function with the exacerbations in the past 12 months were analyzed. Results Agreement in assessing current asthma control between GINA 2009 and 2015 was moderate (Kappa=0.595, P<0.001). Compared with GINA 2009, the patients with well-controlled asthma assessed by GINA 2015 had worse FEV1%pred [(89.9±12.9)% vs. (79.9±18.2)%, P=0.013], the partly controlled subjects assessed by GINA 2015 had worse asthma control scores in ACQ-6 score (0.8±0.7 vs. 1.1±0.7, P=0.028) and ACT score (20.7±2.5 vs. 19.4±2.5, P=0.007). Furthermore, asthma control levels assessed by either GINA 2015 or 2009 were related to exacerbations in the past 12 months and stronger relationship was presented in GINA 2015 (r=–0.268 for GINA 2015 vs. r=–0.212 for GINA 2009, respectively). In addition, there were no differences in cell counts in induced sputum or peripheral blood or IgE level in peripheral blood in patients with different asthma control levels assessing by GINA 2009 and 2015. Conclusions Our study indicates that it has a moderate agreement of assessing current asthma control between GINA 2015 and 2009. Compared with GINA 2009, absence of FEV1 monitoring from GINA 2015 would result in worse lung function in well-controlled asthma and worse asthma control scores in partly controlled asthma. Addition of FEV1 monitoring to GINA 2015 would weaken the relationship between current asthma control and future asthma outcomes, although it didn't reach statistical significance. Our study supports that GINA 2015 lacking lung function monitoring in current asthma control assessment is applicable in clinical practice.

关键词: 2009 年版全球哮喘防治创议; 2015 年版全球哮喘防治创议; 肺功能监测; 当前哮喘控制

Key words: GINA 2009; GINA 2015; Forced expiratory volume in one second; Current asthma control

引用本文: 马利, 王霁, 康德英, 张红萍, 王蕾, 王刚. 肺功能监测是否在哮喘当前控制评估中起重要作用?. 中国呼吸与危重监护杂志, 2017, 16(4): 354-366. doi: 10.7507/1671-6205.201611038 复制

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1. Bousquet J, Clark TJ, Hurd S, et al. GINA guidelines on asthma and beyond. Allergy, 2007, 62(2):102-112.
2. Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2009. Available at: http://ginasthma.org.
3. Nathan RA, Sorkness CA, Kosinski M, et al. Development of the Asthma Control Test: a survey for assessing asthma control. J Allergy Clin Immunol, 2004, 113(1):59-65.
4. Juniper EF, O’Byrne PM, Guyatt GH, et al. Development and validation of a questionnair to measure asthma control. Eur Respir J, 1999, 14(4):902-907.
5. Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA)2015.Available at: http://ginasthma.org.
6. 中华医学会呼吸病学分会哮喘学组. 支气管哮喘防治指南(支气管哮喘的定义、诊断、治疗和管理方案). 中华结核和呼吸杂志, 2008, 31(3): 177-185.
7. Wang G, Zhou T, Wang L, et al. Relationship between current psychological symptoms and future risk of asthma outcomes: a 12-month prospective cohort study. J Asthma, 2011, 48(10): 1041-1050.
8. Novak N, Bieber T. Allergic and nonallergic forms of atopic diseases. J Allergy Clin Immunol, 2003, 112(2): 252-262.
9. Marks GB, Dunn SM, Woolcock AJ. A scale for the measurement of quality of life in adults with asthma. J Clin Epidemiol, 1992, 45(5): 461-472.
10. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J, 2005, 26(5):948-968.
11. 郑劲平, 主编. 肺功能学: 基础与临床. 广州: 广东科技出版社, 2007, 8.
12. 郑洁, 张欣, 郑静, 等. 肥胖与支气管哮喘控制水平及气道炎症表型的关系. 中国呼吸与危重监护杂志, 2015, 14(6):578-584.
13. Wang G, Baines KJ, Fu JJ, et al. Sputum mast cell subtypes relate to eosinophilia and corticosteroid response in asthma. Eur Respir J, 2016, 47(4):1121-1133.
14. Simpson JL, Phipps S, Baines KJ, et al. Elevated expression of the NLRP3 inflammasome in neutrophilic asthma. Eur Respir J, 2014, 43(4):1067-1076.
15. Simpson JL, McElduff P, Gibson PG. Assessment and reproducibility of non-eosinophilic asthma using induced sputum. Respiration, 2010, 79(2):147-151.
16. Meng XL, Rosenthal R, Rubin DB. Comparing correlated correlation coefficients. Psychol Bull, 1992, 111(1):172-175.
17. 吕媛, 易银沙. 关联相关系数的比较. 实用预防医学, 2001, 8(2): 157-158.
18. Bailey WC, Higgins DM, Richards BM, et al. Asthma severity: a factor analytic investigation. Am J Med, 1992, 93(3): 263-269.
19. Rosi E, Ronchi MC, Grazzini M, et al. Sputum analysis, bronchial hyperresponsiveness, and airway function in asthma: results of a factor analysis. J Allergy Clin Immunol, 1999, 103(2 Pt 1): 232-237.
20. Kerstjens HA, Brand PL, de Jong PM, et al. Influence of treatment on peak expiratory flow and its relation to airway hyperresponsiveness and symptoms. The Dutch CNSLD Study Group. Thorax, 1994, 49(11):1109-1115.
21. Jenkins CR, Thien FC, Wheatley JR, et al. Traditional and patient-centred outcomes with three classes of asthma medication. Eur Respir J, 2005, 26(1): 36-44.
22. Reddel HK, Bateman ED, Becker A, et al. A summary of the new GINA strategy: a roadmap to asthma control. Eur Respir J, 2015, 46(3): 579-582.
23. Li HL, He XL, Liang BM, et al. Anxiety but not depression symptoms are associated with greater perceived dyspnea in asthma during bronchoconstriction. Allergy Asthma Proc, 2015, 36(6):447-457.
24. Osborne ML, Pedula KL, O’Hollaren M, et al. Assessing future need for acute care in adult asthmatics: the Profile of Asthma Risk Study: a prospective health maintenance organization-based study. Chest, 2007, 132(4): 1151-1161.
25. Kitch BT, Paltiel AD, Kuntz KM, et al. A single measure of FEV1 is associated with risk of asthma attacks in long-term follow-up. Chest, 2004, 126(6):1875-1882.
26. Fuhlbrigge AL, Kitch BT, Paltiel AD, et al. FEV1 is associated with risk of asthma attacks in a pediatric population. J Allergy Clin Immunol, 2001, 107(1):61-67.
27. Melter EO, Busse WW, Wenzel SE, et al. Use of the Asthma Control Questionaire to predict future risk of asthma exacerbation. J Allergy Clin Immunol, 2011, 127(1):167-172.
28. McCoy K, Shade DM, Irvin CG, et al. Predicting episodes of poor asthma control in treated patients with asthma. J Allergy Clin Immunol, 2006, 118(6):1226-1233.
29. Schatz M, Zeiger RS, Yang SJ, et al. The relationship of asthma impairment determined by psychometric tools to future asthma exacerbations. Chest, 2012, 141(1):66-72.
30. Wei HH, Zhou T, Wang L, et al. Current asthma control predicts future risk of asthma exacerbation: a 12-month prospective cohort study. Chin Med J, 2012, 125(17):2986-2993.
31. Fitzpatrick S, Joks R, Silverberg JI. Obesity is associated with increased asthma severity and exacerbations, and increased serum immunoglobulin E in inner-city adults. Clin Exp Allergy, 2012, 42(5):747-759.
32. Bousquet J, Khaltaev N, Cruz AA, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA2LEN and AllerGen). Allergy, 2008, 63 Suppl 86:8-160.
33. Wechsler ME, Kelley JM, Boyd IO, et al. Active albuterol or placebo, sham acupuncture, or no intervention in asthma. N Engl J Med, 2011, 365(2): 119-126.
34. Lazarus SC, Boushey HA, Fahy JV, et al. Long-acting beta2-agonist monotherapy vs continued therapy with inhaled corticosteroids in patients with persistent asthma: a randomized controlled trial. JAMA, 2001, 285(20):2583-2593.
35. Bateman ED, Reddel HK, Eriksson G, et al. Overall asthma control: the relationship between current control and future risk. J Allergy Clin Immunol, 2010; 125(3): 600-608.
36. Pavord ID, Korn S, Howarth P, et al. Mepolizumab for severe eosinophilic asthma (DREAM): a multicenter, double-blind, placebo-controlled trial. Lancet, 2012, 380(9842): 651-659.
37. Haldar P, Pavord ID, Shaw DE, et al. Cluster analysis and clinical asthma phenotypes. Am J Respir Crit Care Med, 2008, 178(3): 218-224.
38. Volbeda F, Broekema M, Lodewijk ME, et al. Clinical control of asthma associates with measures of airway inflammation. Thorax, 2013, 68(1):19-24.