当前气道舒张标准低估老年哮喘的存在
2020/03/11
摘要
背景：哮喘在老年人中很常见，并且可以通过可变性气流受限得以证实，通常是在使用支气管扩张药物后测量肺功能进行评估。然而，许多临床上怀疑哮喘并存在气流受限的患者，使用支气管扩张剂药物后的气道舒张程度未达到或超出当前指南标准。试验调查延长从开始使用支气管扩张剂时至评估气道舒张反应时的时间长度是否会增强肺功能对老年哮喘患者的诊断。
方法：此研究为横断面研究。入组人群为不吸烟、年龄≥60岁的哮喘患者。人群特征为（1）使用支气管扩张剂后30min舒张试验阳性；（2）使用支气管扩张剂60min后舒张试验阳性；（3）舒张试验阴性，乙酰甲胆碱激发试验阳性。利用双变量分析和logistic回归多变量分析来评估与支气管扩张剂迟发反应相关的因素。
结果：该研究共计165名受试者。其中81例（49.1％）在使用支气管扩张剂后30min舒张试验阳性。25例（15.2％）支气管扩张剂后1h舒张试验阳性；59例（35.8％）舒张试验阴性性，但乙酰甲胆碱激发试验阳性。在多变量回归分析中，那些具有较高FEV1pred基线百水平，ACT评分较高同时出现活动后喘息和/或咳嗽的患者可能具有晚发气管舒张反应或气管舒张反应。
结论：研究表明，在老年疑似哮喘患者中，晚发的气道舒张反应更为常见。如果早期评估无明显舒张反应，肺功能实验室应考虑常规检查支气管扩张剂1h后的肺功能。
Current Bronchodilator Responsiveness Criteria Underestimate Asthma in Older Adults.
Cavallazzi RS, Polivka BJ, Beatty BL, Antimisiaris DE, Gopalraj RK, Vickers-Smith RA, Folz RJ.
Abstract
BACKGROUND: Asthma is common in older adults and is confirmed by demonstration of variable expiratory air-flow limitations, typically evaluated by spirometric assessment of bronchodilator responsiveness. However, many patients with clinically suspected asthma and documented air-flow obstruction do not exhibit a post-bronchodilator response that meets or exceeds current established guidelines. We investigated if extending the time from bronchodilator administration to assessment of bronchodilator response increases the yield of spirometry for the diagnosis of asthma in older adults.
METHODS: This was a cross-sectional study. The subjects were non-smokers, ≥ 60 y old, and with suspected asthma. Subjects were characterized as (1) those with a positive bronchodilator response on the 30-min post-bronchodilator spirometry, (2) those with a positive bronchodilator response on the 60-min post-bronchodilator spirometry, and (3) those without a positive bronchodilator response but with a positive methacholine challenge test. Factors associated with a late response to bronchodilator were evaluated by using bivariate analysis and by multivariate analysis by using a logistic regression model.
RESULTS: This study enrolled 165 subjects. Of these, 81 (49.1%) had a positive bronchodilator response on 30-min post-bronchodilator spirometry; 25 (15.2%) had a positive bronchodilator response on the 1h post-bronchodilator spirometry; and 59 (35.8%) had no positive bronchodilator response but had a positive methacholine challenge test. On multivariable regression analysis, those with a higher baseline percentage of predicted FEV1, higher scores on a standard asthma control test, and wheezing and/or cough after exercise were more likely to either have a late bronchodilator response or no bronchodilator response.
CONCLUSIONS: Our study showed that a late positive response to bronchodilator use was more common than previously presumed in older subjects with suspected asthma. Pulmonary function testing laboratories should consider routinely reassessing spirometry at 1 h after bronchodilator use if the earlier assessment did not reveal a significant response.
背景：哮喘在老年人中很常见，并且可以通过可变性气流受限得以证实，通常是在使用支气管扩张药物后测量肺功能进行评估。然而，许多临床上怀疑哮喘并存在气流受限的患者，使用支气管扩张剂药物后的气道舒张程度未达到或超出当前指南标准。试验调查延长从开始使用支气管扩张剂时至评估气道舒张反应时的时间长度是否会增强肺功能对老年哮喘患者的诊断。
方法：此研究为横断面研究。入组人群为不吸烟、年龄≥60岁的哮喘患者。人群特征为（1）使用支气管扩张剂后30min舒张试验阳性；（2）使用支气管扩张剂60min后舒张试验阳性；（3）舒张试验阴性，乙酰甲胆碱激发试验阳性。利用双变量分析和logistic回归多变量分析来评估与支气管扩张剂迟发反应相关的因素。
结果：该研究共计165名受试者。其中81例（49.1％）在使用支气管扩张剂后30min舒张试验阳性。25例（15.2％）支气管扩张剂后1h舒张试验阳性；59例（35.8％）舒张试验阴性性，但乙酰甲胆碱激发试验阳性。在多变量回归分析中，那些具有较高FEV1pred基线百水平，ACT评分较高同时出现活动后喘息和/或咳嗽的患者可能具有晚发气管舒张反应或气管舒张反应。
结论：研究表明，在老年疑似哮喘患者中，晚发的气道舒张反应更为常见。如果早期评估无明显舒张反应，肺功能实验室应考虑常规检查支气管扩张剂1h后的肺功能。
（中日友好医院呼吸与危重症医学科 张鑫 翻译 林江涛 审校）
（Respir Care. 2020 Feb 18. pii: respcare.07132. doi: 10.4187/respcare.07132. [Epub ahead of print]）
（Respir Care. 2020 Feb 18. pii: respcare.07132. doi: 10.4187/respcare.07132. [Epub ahead of print]）
Current Bronchodilator Responsiveness Criteria Underestimate Asthma in Older Adults.
Cavallazzi RS, Polivka BJ, Beatty BL, Antimisiaris DE, Gopalraj RK, Vickers-Smith RA, Folz RJ.
Abstract
BACKGROUND: Asthma is common in older adults and is confirmed by demonstration of variable expiratory air-flow limitations, typically evaluated by spirometric assessment of bronchodilator responsiveness. However, many patients with clinically suspected asthma and documented air-flow obstruction do not exhibit a post-bronchodilator response that meets or exceeds current established guidelines. We investigated if extending the time from bronchodilator administration to assessment of bronchodilator response increases the yield of spirometry for the diagnosis of asthma in older adults.
METHODS: This was a cross-sectional study. The subjects were non-smokers, ≥ 60 y old, and with suspected asthma. Subjects were characterized as (1) those with a positive bronchodilator response on the 30-min post-bronchodilator spirometry, (2) those with a positive bronchodilator response on the 60-min post-bronchodilator spirometry, and (3) those without a positive bronchodilator response but with a positive methacholine challenge test. Factors associated with a late response to bronchodilator were evaluated by using bivariate analysis and by multivariate analysis by using a logistic regression model.
RESULTS: This study enrolled 165 subjects. Of these, 81 (49.1%) had a positive bronchodilator response on 30-min post-bronchodilator spirometry; 25 (15.2%) had a positive bronchodilator response on the 1h post-bronchodilator spirometry; and 59 (35.8%) had no positive bronchodilator response but had a positive methacholine challenge test. On multivariable regression analysis, those with a higher baseline percentage of predicted FEV1, higher scores on a standard asthma control test, and wheezing and/or cough after exercise were more likely to either have a late bronchodilator response or no bronchodilator response.
CONCLUSIONS: Our study showed that a late positive response to bronchodilator use was more common than previously presumed in older subjects with suspected asthma. Pulmonary function testing laboratories should consider routinely reassessing spirometry at 1 h after bronchodilator use if the earlier assessment did not reveal a significant response.
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呼出气一氧化氮在重度哮喘管理中的临床应用
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临床中利用电子鼻分析呼出气体以评估难控制哮喘症状
