对医生曾经诊断的成人哮喘患者重新评估其诊断
2017/12/13
摘要
重要性：虽然哮喘是一种慢性疾病，但成人支气管哮喘的预期自发缓解率以及诊断的稳定性尚不清楚。
目的：为了明确随机选择的医生曾经诊断哮喘的成人中当前哮喘是否被排除以及哮喘药物能否安全停止。
设计、研究地点及受试者：2012年1月至2016年2月在加拿大的10个城市进行的一个前瞻性多中心队列研究。随机拨号用于招募过去5年内报道有医生诊断哮喘病史的成人受试者。长期口服激素以及不能耐受肺功能检测的受试者被排除。获取来自诊断医生的相关信息以确定社区如何初步诊断哮喘。在电话筛选中完全符合标准的1026例潜在受试者中，701例（68.3%）同意参加该研究。所有受试者均评估其家庭峰值流速以及症状监测，肺功能检测，连续支气管激发试验以及这些受试者日常使用的哮喘药物，且他们使用的药物在4次随访中用量逐渐减少。最终当前哮喘诊断被排除的受试者进行临床随访1年并进行反复的支气管激发试验。
暴露：过去5年内医生确诊的哮喘。
主要结局指标和测量：主要结局指标是当前哮喘诊断被排除的受试者百分比，定义为所有哮喘药物减少后无哮喘症状的急性加重，无可逆的气流阻塞，亦无支气管高反应性的证据，且该研究肺科专家确立了其它替代诊断。次要结局指标包括12个月后被排除的哮喘百分比及社区中哮喘受试者得到初步正确诊断的百分比。
结果：701例受试者年龄（均数[标准差]），51（16）岁，467例女性[67%]613例完成了研究且可用于当前哮喘诊断的评估。613例研究受试者中203例被排除（33.1%；95%CI，29.4%-36.8%）当前哮喘。12例（2.0%）受试者被发现存在严重的心肺疾病而在社区被初始误诊为哮喘。增加12个月的随访后，181例受试者（29.5%；95% CI，25.9%-33.1%）仍未表现出哮喘的临床或试验室证据。被排除当前哮喘的受试者与那些被确诊的受试者相比，他们在社区最初诊断时进行气流受限检测的可能性更小（百分比分别为43.8% vs 55.6%；绝对值差异，11.8%； 95% CI，2.1%-21.5%）。
结论与相关性：在医生诊断哮喘成人中，当前哮喘不能被确诊的受试者占33.1%，他们没有使用日常哮喘药物或者已经完全停药。在这些受试者中，可能需要重新评估哮喘诊断。
Reevaluation of Diagnosis in Adults With Physician-Diagnosed Asthma
Shawn D. Aaron; Katherine L. Vandemheen,; J. Mark FitzGerald; Martha Ainslie; Samir Gupta; Catherine Lemière; Stephen K. Field; R. Andrew McIvor; Paul Hernandez; Irvin Mayers; Sunita Mulpuru; Gonzalo G. Alvarez; Smita Pakhale; Ranjeeta Mallick; Louis-Philippe Boulet; for the Canadian Respiratory Research Network
JAMA. 2017; 317(3):269-279 .
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 Information from the diagnosing physician was obtained to determine how the diagnosis of asthma was originally made in the community.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：虽然哮喘是一种慢性疾病，但成人支气管哮喘的预期自发缓解率以及诊断的稳定性尚不清楚。
目的：为了明确随机选择的医生曾经诊断哮喘的成人中当前哮喘是否被排除以及哮喘药物能否安全停止。
设计、研究地点及受试者：2012年1月至2016年2月在加拿大的10个城市进行的一个前瞻性多中心队列研究。随机拨号用于招募过去5年内报道有医生诊断哮喘病史的成人受试者。长期口服激素以及不能耐受肺功能检测的受试者被排除。获取来自诊断医生的相关信息以确定社区如何初步诊断哮喘。在电话筛选中完全符合标准的1026例潜在受试者中，701例（68.3%）同意参加该研究。所有受试者均评估其家庭峰值流速以及症状监测，肺功能检测，连续支气管激发试验以及这些受试者日常使用的哮喘药物，且他们使用的药物在4次随访中用量逐渐减少。最终当前哮喘诊断被排除的受试者进行临床随访1年并进行反复的支气管激发试验。
暴露：过去5年内医生确诊的哮喘。
主要结局指标和测量：主要结局指标是当前哮喘诊断被排除的受试者百分比，定义为所有哮喘药物减少后无哮喘症状的急性加重，无可逆的气流阻塞，亦无支气管高反应性的证据，且该研究肺科专家确立了其它替代诊断。次要结局指标包括12个月后被排除的哮喘百分比及社区中哮喘受试者得到初步正确诊断的百分比。
结果：701例受试者年龄（均数[标准差]），51（16）岁，467例女性[67%]613例完成了研究且可用于当前哮喘诊断的评估。613例研究受试者中203例被排除（33.1%；95%CI，29.4%-36.8%）当前哮喘。12例（2.0%）受试者被发现存在严重的心肺疾病而在社区被初始误诊为哮喘。增加12个月的随访后，181例受试者（29.5%；95% CI，25.9%-33.1%）仍未表现出哮喘的临床或试验室证据。被排除当前哮喘的受试者与那些被确诊的受试者相比，他们在社区最初诊断时进行气流受限检测的可能性更小（百分比分别为43.8% vs 55.6%；绝对值差异，11.8%； 95% CI，2.1%-21.5%）。
结论与相关性：在医生诊断哮喘成人中，当前哮喘不能被确诊的受试者占33.1%，他们没有使用日常哮喘药物或者已经完全停药。在这些受试者中，可能需要重新评估哮喘诊断。
(吕燕1 张红萍1 王刚1 四川大学华西医院中西医结合科呼吸病组 610041 摘译)
（JAMA. 2017; 317(3):269-279）
（JAMA. 2017; 317(3):269-279）
Reevaluation of Diagnosis in Adults With Physician-Diagnosed Asthma
Shawn D. Aaron; Katherine L. Vandemheen,; J. Mark FitzGerald; Martha Ainslie; Samir Gupta; Catherine Lemière; Stephen K. Field; R. Andrew McIvor; Paul Hernandez; Irvin Mayers; Sunita Mulpuru; Gonzalo G. Alvarez; Smita Pakhale; Ranjeeta Mallick; Louis-Philippe Boulet; for the Canadian Respiratory Research Network
JAMA. 2017; 317(3):269-279 .
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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寡细胞型稳定期哮喘患者的临床、功能及气道炎症特点：不同痰表型的比较
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根据吸烟状态，饮食质量和成人哮喘症状变化的一项纵向研究
