成人哮喘诊断的再评价
2017/08/08
摘要
重要性：尽管哮喘是一种慢性疾病，但成人哮喘的预期自发缓解率及诊断的稳定性是未知的。
目的：为确定在随机选择的成人现症哮喘患者中是否可以排除哮喘诊断，以及这些患者是否可以安全地停用哮喘药物。
设计，安排，受试者：2012年1月至2016年2月在加拿大的10个城市进行了一项前瞻性、多中心队列研究。采用随机数字拨号的方式来招募过去5年内被医生诊断为哮喘的成人受试者。长期使用口服激素和无法进行肺功能测定的受试者被排除。获得诊断医生的信息，以确定哮喘的诊断最初在社区是如何进行的。在电话筛选中符合入组标准的1026名潜在受试者中，有701（68.3%）同意进入研究。所有的受试者都进行家庭的峰流量和症状监测，评估肺功能和支气管激发试验，这些受试者每天使用的哮喘药物在4个观察周期内逐渐减少。对现症哮喘患者但最终被排除该诊断的受试者进行超过1年的重复支气管激发试验的临床随访。
暴露 医生诊断的哮喘确立在5年内。
主要终点和措施 主要终点是现症哮喘的受试者中被排除哮喘诊断的患者的百分比，排除的标准定义为在所有哮喘药物逐渐减少后无证据显示出现哮喘症状急性加重、可逆性气道阻塞及气道高反应性并且经胸科专家研究后建立了替代诊断。次要终点包括12个月后被排除哮喘诊断的受试者的比例和社区中那些进行了恰当的初始诊断检查的哮喘患者的比例。
结果：701名受试者（平均[SD]年龄，51 [16]岁；女性467 [67%]），613人完成了研究并且可以最终评估诊断为现症哮喘。613人现症哮喘中203个研究受试者被排除哮喘诊断（33.1%；95% CI，29.4% - 36.8%），12名受试者（2%）被发现有严重的心肺情况，之前在社区被误诊为哮喘。经过12个月的随访，181名受试者（29.5%，95% CI，25.9% - 33.1%）持续未表现哮喘的临床或实验室证据。与被确诊的哮喘患者相比，目前排除哮喘的受试者在初始诊断时不太可能在社区进行气流限制试验（分别为43.8%和55.6%，绝对差异，11.8%，95% CI，2.1% - 21.5%）。
结论和相关性 在医生诊断的成人哮喘患者中，33.1%的不使用日常哮喘药物或药物治疗的这部分患者是无法确诊哮喘的。这部分患者，重新评估哮喘的诊断可能是必要的。
Reevaluation of Diagnosis in Adults With Physician-Diagnosed Asthma
Shawn D. Aaron, MD; Katherine L. Vandemheen, MScN; J. Mark FitzGerald, MD; Martha Ainslie, MD; Samir Gupta, MD; Catherine Lemière, MD;Stephen K. Field, MD; R. Andrew McIvor, MD; Paul Hernandez, MD; Irvin Mayers, MD; Sunita Mulpuru, MD; Gonzalo G. Alvarez, MD;Smita Pakhale, MD; Ranjeeta Mallick, PhD; Louis-Philippe Boulet, MD; for the Canadian Respiratory Research Network
Abstract
IMPORTANCE Although asthma is a chronic disease, the expected rate of spontaneous remissions of adult asthma and the stability of diagnosis are unknown.
OBJECTIVE To determine whether a diagnosis of current asthma could be ruled out and asthma medications safely stopped in randomly selected adults with physician-diagnosed asthma.
DESIGN, SETTING, AND PARTICIPANTS A prospective, multicenter cohort study was conducted in 10 Canadian cities from January 2012 to February 2016. Random digit dialing was used to recruit adult participants who reported a history of physician-diagnosed asthma established within the past 5 years. Participants using long-term oral steroids and participants unable to be tested using spirometry were excluded. Information from the diagnosing physician was obtained to determine how the diagnosis of asthma was originally made in the community. Of 1026 potential participants who fulfilled eligibility criteria during telephone screening, 701(68.3%) agreed to enter into the study. All participants were assessed with home peak flow and symptom monitoring, spirometry, and serial bronchial challenge tests, and those participants using daily asthma medications had their medications gradually tapered off over 4 study visits. Participants in whom a diagnosis of current asthma was ultimately ruled out were followed up clinically with repeated bronchial challenge tests over 1 year.
EXPOSURE Physician-diagnosed asthma established within the past 5 years.
MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of participants in whom a diagnosis of current asthma was ruled out, defined as participants who exhibited no evidence of acute worsening of asthma symptoms, reversible airflow obstruction,or bronchial hyperresponsiveness after having all asthma medications tapered off and after a study pulmonologist established an alternative diagnosis. Secondary outcomes included the proportion with asthma ruled out after 12 months and the proportion who underwent an appropriate initial diagnostic workup for asthma in the community.
RESULTS Of 701 participants (mean [SD] age, 51 [16] years; 467 women [67%]), 613 completed the study and could be conclusively evaluated for a diagnosis of current asthma.Current asthma was ruled out in 203 of 613 study participants (33.1%; 95% CI, 29.4%-36.8%).Twelve participants (2.0%) were found to have serious cardiorespiratory conditions that had been previously misdiagnosed as asthma in the community. After an additional 12 months of follow-up, 181 participants (29.5%; 95% CI, 25.9%-33.1%) continued to exhibit no clinical or laboratory evidence of asthma. Participants in whom current asthma was ruled out,compared with those in whom it was confirmed, were less likely to have undergone testing for airflow limitation in the community at the time of initial diagnosis (43.8% vs 55.6%,respectively; absolute difference, 11.8%; 95% CI, 2.1%-21.5%).
CONCLUSIONS AND RELEVANCE Among adults with physician-diagnosed asthma, a current diagnosis of asthma could not be established in 33.1% who were not using daily asthma medications or had medications weaned. In patients such as these, reassessing the asthma diagnosis may be warranted.
重要性：尽管哮喘是一种慢性疾病，但成人哮喘的预期自发缓解率及诊断的稳定性是未知的。
目的：为确定在随机选择的成人现症哮喘患者中是否可以排除哮喘诊断，以及这些患者是否可以安全地停用哮喘药物。
设计，安排，受试者：2012年1月至2016年2月在加拿大的10个城市进行了一项前瞻性、多中心队列研究。采用随机数字拨号的方式来招募过去5年内被医生诊断为哮喘的成人受试者。长期使用口服激素和无法进行肺功能测定的受试者被排除。获得诊断医生的信息，以确定哮喘的诊断最初在社区是如何进行的。在电话筛选中符合入组标准的1026名潜在受试者中，有701（68.3%）同意进入研究。所有的受试者都进行家庭的峰流量和症状监测，评估肺功能和支气管激发试验，这些受试者每天使用的哮喘药物在4个观察周期内逐渐减少。对现症哮喘患者但最终被排除该诊断的受试者进行超过1年的重复支气管激发试验的临床随访。
暴露 医生诊断的哮喘确立在5年内。
主要终点和措施 主要终点是现症哮喘的受试者中被排除哮喘诊断的患者的百分比，排除的标准定义为在所有哮喘药物逐渐减少后无证据显示出现哮喘症状急性加重、可逆性气道阻塞及气道高反应性并且经胸科专家研究后建立了替代诊断。次要终点包括12个月后被排除哮喘诊断的受试者的比例和社区中那些进行了恰当的初始诊断检查的哮喘患者的比例。
结果：701名受试者（平均[SD]年龄，51 [16]岁；女性467 [67%]），613人完成了研究并且可以最终评估诊断为现症哮喘。613人现症哮喘中203个研究受试者被排除哮喘诊断（33.1%；95% CI，29.4% - 36.8%），12名受试者（2%）被发现有严重的心肺情况，之前在社区被误诊为哮喘。经过12个月的随访，181名受试者（29.5%，95% CI，25.9% - 33.1%）持续未表现哮喘的临床或实验室证据。与被确诊的哮喘患者相比，目前排除哮喘的受试者在初始诊断时不太可能在社区进行气流限制试验（分别为43.8%和55.6%，绝对差异，11.8%，95% CI，2.1% - 21.5%）。
结论和相关性 在医生诊断的成人哮喘患者中，33.1%的不使用日常哮喘药物或药物治疗的这部分患者是无法确诊哮喘的。这部分患者，重新评估哮喘的诊断可能是必要的。
（中日友好医院呼吸与危重症医学科 李红雯 摘译 林江涛 审校）
(JAMA. 2017;317(3):269-279. doi:10.1001/jama.2016.19627January 17, 2017)
(JAMA. 2017;317(3):269-279. doi:10.1001/jama.2016.19627January 17, 2017)
Reevaluation of Diagnosis in Adults With Physician-Diagnosed Asthma
Shawn D. Aaron, MD; Katherine L. Vandemheen, MScN; J. Mark FitzGerald, MD; Martha Ainslie, MD; Samir Gupta, MD; Catherine Lemière, MD;Stephen K. Field, MD; R. Andrew McIvor, MD; Paul Hernandez, MD; Irvin Mayers, MD; Sunita Mulpuru, MD; Gonzalo G. Alvarez, MD;Smita Pakhale, MD; Ranjeeta Mallick, PhD; Louis-Philippe Boulet, MD; for the Canadian Respiratory Research Network
Abstract
IMPORTANCE Although asthma is a chronic disease, the expected rate of spontaneous remissions of adult asthma and the stability of diagnosis are unknown.
OBJECTIVE To determine whether a diagnosis of current asthma could be ruled out and asthma medications safely stopped in randomly selected adults with physician-diagnosed asthma.
DESIGN, SETTING, AND PARTICIPANTS A prospective, multicenter cohort study was conducted in 10 Canadian cities from January 2012 to February 2016. Random digit dialing was used to recruit adult participants who reported a history of physician-diagnosed asthma established within the past 5 years. Participants using long-term oral steroids and participants unable to be tested using spirometry were excluded. Information from the diagnosing physician was obtained to determine how the diagnosis of asthma was originally made in the community. Of 1026 potential participants who fulfilled eligibility criteria during telephone screening, 701(68.3%) agreed to enter into the study. All participants were assessed with home peak flow and symptom monitoring, spirometry, and serial bronchial challenge tests, and those participants using daily asthma medications had their medications gradually tapered off over 4 study visits. Participants in whom a diagnosis of current asthma was ultimately ruled out were followed up clinically with repeated bronchial challenge tests over 1 year.
EXPOSURE Physician-diagnosed asthma established within the past 5 years.
MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of participants in whom a diagnosis of current asthma was ruled out, defined as participants who exhibited no evidence of acute worsening of asthma symptoms, reversible airflow obstruction,or bronchial hyperresponsiveness after having all asthma medications tapered off and after a study pulmonologist established an alternative diagnosis. Secondary outcomes included the proportion with asthma ruled out after 12 months and the proportion who underwent an appropriate initial diagnostic workup for asthma in the community.
RESULTS Of 701 participants (mean [SD] age, 51 [16] years; 467 women [67%]), 613 completed the study and could be conclusively evaluated for a diagnosis of current asthma.Current asthma was ruled out in 203 of 613 study participants (33.1%; 95% CI, 29.4%-36.8%).Twelve participants (2.0%) were found to have serious cardiorespiratory conditions that had been previously misdiagnosed as asthma in the community. After an additional 12 months of follow-up, 181 participants (29.5%; 95% CI, 25.9%-33.1%) continued to exhibit no clinical or laboratory evidence of asthma. Participants in whom current asthma was ruled out,compared with those in whom it was confirmed, were less likely to have undergone testing for airflow limitation in the community at the time of initial diagnosis (43.8% vs 55.6%,respectively; absolute difference, 11.8%; 95% CI, 2.1%-21.5%).
CONCLUSIONS AND RELEVANCE Among adults with physician-diagnosed asthma, a current diagnosis of asthma could not be established in 33.1% who were not using daily asthma medications or had medications weaned. In patients such as these, reassessing the asthma diagnosis may be warranted.
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