初级保健机构COPD和哮喘鉴别诊断的困难
2012/07/06
摘要
背景：慢性阻塞性肺疾病（COPD）和哮喘的治疗必须基于正确的诊断。然而，初级保健机构接受吸入治疗的患者，基于当前的指南，可能并未得到准确诊断。
目的：为了分析吸入治疗患者的特征，对初级机构中鉴别诊断工具的一致性和激素吸入（IC）治疗的充分性进行研究。
设计和研究机构：对西班牙巴塞罗那10个初级保健中心进行横断面、多中心、非干预研究
方法：采用IC治疗的、年龄>40岁的慢性呼吸疾病患者入选。对社会人口统计学和临床信息进行分析，同时通过支气管扩张剂测试（BDT）检测用力肺活量。哮喘和COPD诊断的准确性采用两个鉴别诊断问卷调查评价。
结果：基础状态下，全科医生对328名患者进行诊断，64.8%诊断为COPD、15.4%为哮喘、19.8%的诊断不确定。肺活量检测显示，基于GOLD分类，40%的患者存在中度-严重气流受阻，第1秒用力呼气体积平均可逆性为8.4%；18.6%的患者BDT阳性；39.8%的患者支气管扩张剂后FEV1/用力肺活量>0.7。不同鉴别诊断工具的一致性成中等水平（临床诊断 vs 肺活量检测 和 两个问卷调查间）、较低水平（临床诊断 vs 问卷调查）和非常低（肺活量检测 vs 鉴别诊断）。诊断为COPD的患者中，71.4%的患者采用IC治疗，12%的诊断为哮喘的患者并未接受IC治疗。
结论：初级保健机构的医生能诊断大部分的COPD和哮喘患者。与症状和BDT中的肺活量检测相比，两个问卷调查不能更好的鉴别诊断COPD和哮喘。误诊可能会导致治疗不充分。
（刘国梁 审校）
Br J Gen Pract. 2012 Feb;62(595):68-75.
Difficulties in differential diagnosis of COPD and asthma in primary care.
Miravitlles M, Andreu I, Romero Y, Sitjar S, Altés A, Anton E.
Source
Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Ciber de Enfermedades Respiratorias (CIBERES), Hospital Clinic, Barcelona, Spain.
Abstract
BACKGROUND:Chronic obstructive pulmonary disease (COPD) and asthma treatment must be based on appropriate diagnosis. However, patients receiving inhaled therapy in primary care may not be accurately diagnosed according to current guidelines.
AIM: To analyse the characteristics of patients treated with inhaled medication, the concordance of tools for differential diagnosis, and the adequacy of prescription of inhaled corticosteroids (ICs) in primary care.
DESIGN AND SETTING: Cross-sectional, multicentre, non-interventional study conducted in 10 primary care centres in Barcelona, Spain.
METHOD: Patients with chronic respiratory disease, aged >40 years were treated with ICs. They provided sociodemographic and clinical information and performed forced spirometry with a bronchodilator test (BDT). The diagnostic accuracy of asthma and COPD diagnoses were tested using two differential diagnosis questionnaires.
RESULTS: A total of 328 patients were initially classified as having COPD (64.8%), asthma (15.4%), or indeterminate (19.8%) by their GPs. After spirometry, 40% of patients had moderate-severe airflow obstruction according to the GOLD classification; mean reversibility of forced expiratory volume in 1 second (FEV1) was 8.4%; 18.6% had a positive BDT; and 39.8% had post-bronchodilator FEV1/forced vital capacity >0.7. Concordance of the differential diagnosis tools was moderate (clinical diagnosis versus spirometry and between the two questionnaires), low (clinical diagnosis versus questionnaires), and very low (spirometry versus differential diagnosis). Of the patients diagnosed with COPD, 71.4% were treated with ICs, and 12% of those classified as having asthma were not receiving ICs.
CONCLUSION: Most patients can be classified as having COPD or asthma by primary care physicians. The use of the two questionnaires did not provide a better differential diagnostic compared with symptoms and spirometry with a BDT. Misdiagnosis may lead to inadequate treatment.
Br J Gen Pract. 2012 Feb;62(595):68-75.
背景：慢性阻塞性肺疾病（COPD）和哮喘的治疗必须基于正确的诊断。然而，初级保健机构接受吸入治疗的患者，基于当前的指南，可能并未得到准确诊断。
目的：为了分析吸入治疗患者的特征，对初级机构中鉴别诊断工具的一致性和激素吸入（IC）治疗的充分性进行研究。
设计和研究机构：对西班牙巴塞罗那10个初级保健中心进行横断面、多中心、非干预研究
方法：采用IC治疗的、年龄>40岁的慢性呼吸疾病患者入选。对社会人口统计学和临床信息进行分析，同时通过支气管扩张剂测试（BDT）检测用力肺活量。哮喘和COPD诊断的准确性采用两个鉴别诊断问卷调查评价。
结果：基础状态下，全科医生对328名患者进行诊断，64.8%诊断为COPD、15.4%为哮喘、19.8%的诊断不确定。肺活量检测显示，基于GOLD分类，40%的患者存在中度-严重气流受阻，第1秒用力呼气体积平均可逆性为8.4%；18.6%的患者BDT阳性；39.8%的患者支气管扩张剂后FEV1/用力肺活量>0.7。不同鉴别诊断工具的一致性成中等水平（临床诊断 vs 肺活量检测 和 两个问卷调查间）、较低水平（临床诊断 vs 问卷调查）和非常低（肺活量检测 vs 鉴别诊断）。诊断为COPD的患者中，71.4%的患者采用IC治疗，12%的诊断为哮喘的患者并未接受IC治疗。
结论：初级保健机构的医生能诊断大部分的COPD和哮喘患者。与症状和BDT中的肺活量检测相比，两个问卷调查不能更好的鉴别诊断COPD和哮喘。误诊可能会导致治疗不充分。
（刘国梁 审校）
Br J Gen Pract. 2012 Feb;62(595):68-75.
Difficulties in differential diagnosis of COPD and asthma in primary care.
Miravitlles M, Andreu I, Romero Y, Sitjar S, Altés A, Anton E.
Source
Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Ciber de Enfermedades Respiratorias (CIBERES), Hospital Clinic, Barcelona, Spain.
Abstract
BACKGROUND:Chronic obstructive pulmonary disease (COPD) and asthma treatment must be based on appropriate diagnosis. However, patients receiving inhaled therapy in primary care may not be accurately diagnosed according to current guidelines.
AIM: To analyse the characteristics of patients treated with inhaled medication, the concordance of tools for differential diagnosis, and the adequacy of prescription of inhaled corticosteroids (ICs) in primary care.
DESIGN AND SETTING: Cross-sectional, multicentre, non-interventional study conducted in 10 primary care centres in Barcelona, Spain.
METHOD: Patients with chronic respiratory disease, aged >40 years were treated with ICs. They provided sociodemographic and clinical information and performed forced spirometry with a bronchodilator test (BDT). The diagnostic accuracy of asthma and COPD diagnoses were tested using two differential diagnosis questionnaires.
RESULTS: A total of 328 patients were initially classified as having COPD (64.8%), asthma (15.4%), or indeterminate (19.8%) by their GPs. After spirometry, 40% of patients had moderate-severe airflow obstruction according to the GOLD classification; mean reversibility of forced expiratory volume in 1 second (FEV1) was 8.4%; 18.6% had a positive BDT; and 39.8% had post-bronchodilator FEV1/forced vital capacity >0.7. Concordance of the differential diagnosis tools was moderate (clinical diagnosis versus spirometry and between the two questionnaires), low (clinical diagnosis versus questionnaires), and very low (spirometry versus differential diagnosis). Of the patients diagnosed with COPD, 71.4% were treated with ICs, and 12% of those classified as having asthma were not receiving ICs.
CONCLUSION: Most patients can be classified as having COPD or asthma by primary care physicians. The use of the two questionnaires did not provide a better differential diagnostic compared with symptoms and spirometry with a BDT. Misdiagnosis may lead to inadequate treatment.
Br J Gen Pract. 2012 Feb;62(595):68-75.
