我是如何做的：重症哮喘的诊断检查
2021/07/28
摘要
病例：一位56岁的男性，患有难治性哮喘，尽管接受了大剂量吸入糖皮质激素（ICS）和额外的控制性药物治疗，但在过去12个月内有4次哮喘发作的病史。他适合更高级的治疗选择吗？
回顾范围：我们在本文中回顾了一例疑似重症哮喘患者的临床评估，讨论了导致哮喘控制不佳的因素以及生物标志物如何协助疾病调查和分层。
我是如何做的：我们的多学科方法的关键组成部分是确认哮喘诊断和治疗依从性，评估任何合并症或混杂因素，并对患者患有何种类型的哮喘进行分层。肺活量测定与2型气道炎症关键生物标志物（血嗜酸性粒细胞计数和呼出的一氧化氮分数）的重复测量相结合，可确定疾病控制不佳是由不受控制的、抗ICS的2型气道炎症还是持续的气流阻塞所驱动。如果两种方式都没得到证据证实，就意味着患者的症状（包括慢性呼吸道感染和非哮喘原因）有另一种驱动因素。每种表型都代表了一种治疗特征，需要一个特定的有针对性的方法。关键的是，类固醇会带来副作用，他们的使用应该以炎症的客观证据为指导，而不仅仅是症状。
病例总结：在评估治疗依从性和排除相关共病后，患者被证实患有重症哮喘，并伴有ICS抵抗的2型气道炎症。我们将在下一部分（“我是如何做的”第2部分）思考额外的治疗方案。
How I do it. Work-up of severe asthma
Simon Couillard, David J Jackson, Michael E Wechsler, Ian D Pavord
Abstract
Case example: A 56-year-old gentleman has difficult to control asthma and a history of four exacerbations in the prior 12 months despite high-dose inhaled corticosteroids (ICS) and additional controller therapies. Is he suitable for more advanced therapeutic options?
Scope of review: We herein review the clinical assessment of a patient with suspected severe asthma, discuss factors contributing to poor asthma control and how biomarkers assist in disease investigation and stratification.
How i do it: The key components of our multidisciplinary approach are to confirm an asthma diagnosis and adherence to treatment, to assess any contributing comorbidities or confounding factors, and to stratify what type of asthma our patient has. The combination of spirometry and repeated measures of key biomarkers of type-2 airway inflammation - the blood eosinophil count and fractional exhaled nitric oxide - identifies whether poor disease control is driven by uncontrolled, ICS-resistant type-2 airway inflammation or ongoing airflow obstruction. A failure to elicit evidence of either suggests an alternative driver for the patient's symptoms including chronic airway infection and non-asthma causes. Each phenotype represents a treatable trait that requires a specific targeted approach. Critically, steroids can cause harm and their use should be guided by objective evidence of inflammation rather than symptoms alone.
Case conclusion: After assessment of treatment adherence and exclusion of relevant comorbidities, the patient was found to have severe asthma with ICS-resistant type-2 airway inflammation. We will consider additional treatment options at our next appointment (Part 2/2 of this How I Do It series).
病例：一位56岁的男性，患有难治性哮喘，尽管接受了大剂量吸入糖皮质激素（ICS）和额外的控制性药物治疗，但在过去12个月内有4次哮喘发作的病史。他适合更高级的治疗选择吗？
回顾范围：我们在本文中回顾了一例疑似重症哮喘患者的临床评估，讨论了导致哮喘控制不佳的因素以及生物标志物如何协助疾病调查和分层。
我是如何做的：我们的多学科方法的关键组成部分是确认哮喘诊断和治疗依从性，评估任何合并症或混杂因素，并对患者患有何种类型的哮喘进行分层。肺活量测定与2型气道炎症关键生物标志物（血嗜酸性粒细胞计数和呼出的一氧化氮分数）的重复测量相结合，可确定疾病控制不佳是由不受控制的、抗ICS的2型气道炎症还是持续的气流阻塞所驱动。如果两种方式都没得到证据证实，就意味着患者的症状（包括慢性呼吸道感染和非哮喘原因）有另一种驱动因素。每种表型都代表了一种治疗特征，需要一个特定的有针对性的方法。关键的是，类固醇会带来副作用，他们的使用应该以炎症的客观证据为指导，而不仅仅是症状。
病例总结：在评估治疗依从性和排除相关共病后，患者被证实患有重症哮喘，并伴有ICS抵抗的2型气道炎症。我们将在下一部分（“我是如何做的”第2部分）思考额外的治疗方案。
(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)
(Chest. 2021 Jul 12;S0012-3692(21)01325-8. doi: 10.1016/j.chest.2021.07.008.)
(Chest. 2021 Jul 12;S0012-3692(21)01325-8. doi: 10.1016/j.chest.2021.07.008.)
How I do it. Work-up of severe asthma
Simon Couillard, David J Jackson, Michael E Wechsler, Ian D Pavord
Abstract
Case example: A 56-year-old gentleman has difficult to control asthma and a history of four exacerbations in the prior 12 months despite high-dose inhaled corticosteroids (ICS) and additional controller therapies. Is he suitable for more advanced therapeutic options?
Scope of review: We herein review the clinical assessment of a patient with suspected severe asthma, discuss factors contributing to poor asthma control and how biomarkers assist in disease investigation and stratification.
How i do it: The key components of our multidisciplinary approach are to confirm an asthma diagnosis and adherence to treatment, to assess any contributing comorbidities or confounding factors, and to stratify what type of asthma our patient has. The combination of spirometry and repeated measures of key biomarkers of type-2 airway inflammation - the blood eosinophil count and fractional exhaled nitric oxide - identifies whether poor disease control is driven by uncontrolled, ICS-resistant type-2 airway inflammation or ongoing airflow obstruction. A failure to elicit evidence of either suggests an alternative driver for the patient's symptoms including chronic airway infection and non-asthma causes. Each phenotype represents a treatable trait that requires a specific targeted approach. Critically, steroids can cause harm and their use should be guided by objective evidence of inflammation rather than symptoms alone.
Case conclusion: After assessment of treatment adherence and exclusion of relevant comorbidities, the patient was found to have severe asthma with ICS-resistant type-2 airway inflammation. We will consider additional treatment options at our next appointment (Part 2/2 of this How I Do It series).
上一篇：
定义重症哮喘超级应答者：基于德尔菲法的发现
下一篇：
通过用力振荡技术评估的支气管舒张效应比肺量计测定可更敏感地识别出较差的哮喘控制
