职业性哮喘的诊断方法比较
2007/04/13
特异性过敏原激发试验（SIC）是诊断职业性哮喘（OA）所必须的。如果某些情况下无法进行这一测定，是否有其他替代的方法帮助职业性哮喘的诊断呢？Jeremy Beach等通过网上搜寻电子版数据和临床观察、相关书籍、学术会议交流文献和与作者直接沟通的结果进行分析，并与SIC参考标准进行比较，得出了其他一些有助于诊断职业性哮喘的检查手段的敏感性和特异性以及各自的95％可信区间。
这些参与比较的文献类型包括临床观察、队列研究、横断面研究和病例报告。总共有77篇文献参与分析研究，结果表明，对于大分子量致敏原物质（HMW），与SIC相比，非特异性支气管激发试验（NSBP）、特异性过敏原皮肤点刺试验（SPT）和血清特异性IgE 的敏感性均> 73%，而特异性在血清特异性IgE 最高，与SIC相比为79.0%，（95% CI, 50.5 to 93.3%)。对于低分子量致敏原物质（LMW），与SIC相比，NSBP与SPT结合的敏感性最高，为 100%（95% CI, 74.1 to 100%)。而血清特异性IgE 和SPT有相似的特异性，分别为88.9%（95% CI, 84.7 to 92.1%）和86.2%（95% CI, 77.4 to 91.9%).对于HMW物质，如果结合两种指标，特异性就更高了，如与SIC相比，NSBP加SPT为82.5%（95% CI, 54.0 to 95.0%)、NSBP加特异性IgE为74.3%（95% CI, 45.0 to 91.0%)， 但两者结合的敏感性相对较低，与SIC相比，分别为60.6%和65.2%。
因此，作者认为在临床上无法行特异性过敏原激发试验时，结合NSBP和特异性过敏原皮肤点刺试验或血清特异性IgE检测的结果可以作为诊断职业性哮喘的手段。即如果NSBP的结果阳性，SPT或血清特异性IgE阳性可以增加职业性哮喘的可能性，但阴性结果也不能排除OA。
这些参与比较的文献类型包括临床观察、队列研究、横断面研究和病例报告。总共有77篇文献参与分析研究，结果表明，对于大分子量致敏原物质（HMW），与SIC相比，非特异性支气管激发试验（NSBP）、特异性过敏原皮肤点刺试验（SPT）和血清特异性IgE 的敏感性均> 73%，而特异性在血清特异性IgE 最高，与SIC相比为79.0%，（95% CI, 50.5 to 93.3%)。对于低分子量致敏原物质（LMW），与SIC相比，NSBP与SPT结合的敏感性最高，为 100%（95% CI, 74.1 to 100%)。而血清特异性IgE 和SPT有相似的特异性，分别为88.9%（95% CI, 84.7 to 92.1%）和86.2%（95% CI, 77.4 to 91.9%).对于HMW物质，如果结合两种指标，特异性就更高了，如与SIC相比，NSBP加SPT为82.5%（95% CI, 54.0 to 95.0%)、NSBP加特异性IgE为74.3%（95% CI, 45.0 to 91.0%)， 但两者结合的敏感性相对较低，与SIC相比，分别为60.6%和65.2%。
因此，作者认为在临床上无法行特异性过敏原激发试验时，结合NSBP和特异性过敏原皮肤点刺试验或血清特异性IgE检测的结果可以作为诊断职业性哮喘的手段。即如果NSBP的结果阳性，SPT或血清特异性IgE阳性可以增加职业性哮喘的可能性，但阴性结果也不能排除OA。
（汤葳 上海交通大学附属瑞金医院 200025 摘译）
（Chest. 2007; 131:569-578）
（Chest. 2007; 131:569-578）
A Systematic Review of the Diagnosis of Occupational Asthma*
Jeremy Beach, MBBS, MD; Kelly Russell, BSc; Sandra Blitz, MSc; Nicola Hooton, BSc; Carol Spooner, MSc; Catherine Lemiere, MD, MSc; Susan M. Tarlo, MB, BS, FCCP and Brian H. Rowe, MD, MSc, FCCP
Background: This study systematically reviews literature regarding the diagnosis of occupational asthma (OA) and compares specific inhalation challenge (SIC) testing with alternative tests.
Methods: Electronic databases and trials registries were searched; additional references were identified from bibliographic searches of included studies, hand searches of conferences, and author contacts. Various study designs (clinical trials, cohorts, cross-sectional, or case series) were included involving workers with suspected OA. All diagnostic tests were compared to a ’reference standard,’ and two researchers independently extracted 2 x 2 data. Pooled sensitivities and specificities (95% confidence intervals [CIs]) were derived.
Results: Seventy-seven studies were included. For high molecular weight (HMW) agents, the nonspecific bronchial provocation (NSBP) test, skin-prick test (SPT), and serum-specific IgE had sensitivities > 73% when compared to SIC. Specificity was highest for specific IgE vs SIC (79.0%; 95% CI, 50.5 to 93.3%). The highest sensitivity among low molecular weight asthmagens occurred between combined NSBP and SPT vs SIC (100%; 95% CI, 74.1 to 100%). When compared to SIC, specific IgE and SPT had similar specificities (88.9%; 95% CI, 84.7 to 92.1%; and 86.2%; 95% CI, 77.4 to 91.9%, respectively). For HMW agents, high specificity was demonstrated for positive NSBP tests and SPTs alone (82.5%; 95% CI, 54.0 to 95.0%) or when combined with specific IgE (74.3%; 95% CI, 45.0 to 91.0%) vs SIC. Sensitivity was somewhat lower (60.6% and 65.2%, respectively).
Conclusions: In appropriate clinical situations when SIC is not available, the combination of a NSBP test with a specific SPT or specific IgE may be an appropriate alternative to SIC in diagnosing OA. While positive results of single NSBP test, specific SPT, or serum-specific IgE testing would increase the likelihood of OA, a negative result could not exclude OA.
Key Words: asthma · diagnostic test · occupational · sensitivity · specificity
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