平衡多数和少数的需求：成人哮喘指南的下一步是什么？
2021/03/22
摘要
哮喘与许多其他慢性疾病不同，其大多数关键的治疗决策都是在非专家环境下做出的，如全科医生手术室和急诊室。初级医疗的哮喘诊断依赖于特征性症状的识别和哮喘发作的发生，有时会以基本的肺功能检测作为补充。当前的疾病管理以症状评估和气流阻塞的简单肺功能测量为指导，很少进行个性化治疗。这种方式是有缺陷的，因为症状的特异性不够并且可变气流阻塞的敏感性较低，这意味着往往很难有把握地排除哮喘的诊断。此外，即使诊断正确，炎症、气流阻塞和症状之间的分离意味着，基于症状的全面的哮喘阶梯治疗在相当大比例的患者中不太可能成功。因此，有效的治疗方法使用效率低下，结果往往比实际情况更糟。我们建议采用一种新的综合方法，治疗的选择取决于对关键的可治疗的机制特征的客观评估，而不是使用基于人群或个性化的方法来诊断和治疗。
Balancing the needs of the many and the few: where next for adult asthma guidelines.
Dominick E Shaw, Liam G Heaney, Mike Thomas, Richard Beasley, Peter G Gibson, Ian D Pavord.
Abstract
Asthma differs from many other chronic conditions in that most key management decisions are made in non-specialist settings, such as general practitioner surgeries and accident and emergency departments. Diagnosis in primary care relies on recognition of a characteristic pattern of symptoms and the occurrence of asthma attacks, sometimes supplemented by basic lung function tests. Ongoing management is guided by the assessment of symptoms and simple lung function measures of airflow obstruction, with little attempt made to personalise management. This approach is flawed because the inadequate specificity of symptoms, as well as the low sensitivity of variable airflow obstruction, means that a diagnosis of asthma is often difficult to exclude with confidence. Moreover, even if diagnosed correctly, dissociation between inflammation, airflow obstruction, and symptoms means that a generalised stepwise approach to managing asthma on the basis of symptoms is unlikely to be successful in a substantial proportion of patients. As a result, effective treatments are used inefficiently, and outcomes are often worse than they could be. Rather than use of either a population-based or personalised approach for the diagnosis and management of asthma, we recommend a new combined approach, in which treatment decisions are driven by objective assessment of key treatable mechanistic traits.
哮喘与许多其他慢性疾病不同，其大多数关键的治疗决策都是在非专家环境下做出的，如全科医生手术室和急诊室。初级医疗的哮喘诊断依赖于特征性症状的识别和哮喘发作的发生，有时会以基本的肺功能检测作为补充。当前的疾病管理以症状评估和气流阻塞的简单肺功能测量为指导，很少进行个性化治疗。这种方式是有缺陷的，因为症状的特异性不够并且可变气流阻塞的敏感性较低，这意味着往往很难有把握地排除哮喘的诊断。此外，即使诊断正确，炎症、气流阻塞和症状之间的分离意味着，基于症状的全面的哮喘阶梯治疗在相当大比例的患者中不太可能成功。因此，有效的治疗方法使用效率低下，结果往往比实际情况更糟。我们建议采用一种新的综合方法，治疗的选择取决于对关键的可治疗的机制特征的客观评估，而不是使用基于人群或个性化的方法来诊断和治疗。
(中日友好医院呼吸与危重症医学科 顾宪民 摘译 林江涛 审校)
(Lancet Respir Med. 2021 Feb 24;S2213-2600(21)00021-7. doi: 10.1016/S2213-2600(21)00021-7.)
(Lancet Respir Med. 2021 Feb 24;S2213-2600(21)00021-7. doi: 10.1016/S2213-2600(21)00021-7.)
Balancing the needs of the many and the few: where next for adult asthma guidelines.
Dominick E Shaw, Liam G Heaney, Mike Thomas, Richard Beasley, Peter G Gibson, Ian D Pavord.
Abstract
Asthma differs from many other chronic conditions in that most key management decisions are made in non-specialist settings, such as general practitioner surgeries and accident and emergency departments. Diagnosis in primary care relies on recognition of a characteristic pattern of symptoms and the occurrence of asthma attacks, sometimes supplemented by basic lung function tests. Ongoing management is guided by the assessment of symptoms and simple lung function measures of airflow obstruction, with little attempt made to personalise management. This approach is flawed because the inadequate specificity of symptoms, as well as the low sensitivity of variable airflow obstruction, means that a diagnosis of asthma is often difficult to exclude with confidence. Moreover, even if diagnosed correctly, dissociation between inflammation, airflow obstruction, and symptoms means that a generalised stepwise approach to managing asthma on the basis of symptoms is unlikely to be successful in a substantial proportion of patients. As a result, effective treatments are used inefficiently, and outcomes are often worse than they could be. Rather than use of either a population-based or personalised approach for the diagnosis and management of asthma, we recommend a new combined approach, in which treatment decisions are driven by objective assessment of key treatable mechanistic traits.
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确定持续性哮喘和COPD的最佳药物依从性
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哮喘的遗传学和基因组学指导药物靶点发现的前景
