中国儿童支气管哮喘监测与治疗的调查

A survey in physicians in China on monitoring and treatment of childhood asthma national cooperation group on childhood bronchial asthma

目的了解中国医师对儿童支气管哮喘(简称哮喘)的认知、监测与治疗情况。方法通过发放调查问卷的形式,收集中国25个省市临床医生对儿童哮喘监测与治疗的相关资料,问卷为亚太儿科变态反应、呼吸及免疫学会(APAPARI)提供的统一标准问卷。结果本次调查收回来自中国25个省市的1863份问卷,其中填写完整问卷1676份,我们对其进行了统计分析。接受调查的医生中普通儿科医生占58%,儿科呼吸及变态反应科医生占22%,成人呼吸科和变态反应科医生占7%,其他科室医生占13%;其中三级医院医生占73%,二级医院医生占21%,一级医院医生占4%。医生在儿童哮喘监测过程中使用仪器监测的比例高于日记卡,大部分医生(67%)会使用1～2种仪器来监测哮喘,但仅有26%的医生经常使用日记卡监测。在治疗哮喘急性发作时,医生首选治疗的前三位分别是:每20min雾化吸入一次沙丁胺醇/特布他林(29%),临时雾化吸入一次沙丁胺醇/特布他林(22%)以及静脉注射皮质激素(12%)。儿科呼吸科及成人呼吸科医生更倾向于使用吸入糖皮质激素(ICS)治疗哮喘急性发作。医生选择最多的三种糖皮质激素依次为地塞米松(85%)、甲基强的松龙(84%)和氢化考的松(81%)。医生决定开始儿童哮喘维持治疗标准的前三位分别是症状的频率(91%),症状的严重性(87%)和严重的肺功能下降(85%)。在剂型上,医生更倾向于选择吸入型药物(89%)。总体而言,医生对于各年龄段的儿童哮喘维持治疗的药物选择基本一致。对于0～3岁儿童,ICS是首选(82%),其次是孟鲁司特(68%),再次是ICS加按需口服长效β2受体激动剂(LABA);对于4～6岁儿童,吸入LABA+ICS是首选(83%),其次是ICS(80%)和孟鲁司特(69%);对于6～16岁儿童,吸入LABA+ICS是首选(86%),其次是ICS(72%)和孟鲁司特(68%);对于4～16岁中、重度哮喘儿童,吸入LABA+ICS是医生的首选药物(89%)。结论中国城市医生对儿童哮喘的认知、监测、全球哮喘防治创议(GINA)方案的应用以及吸入激素的使用明显改善。今后哮喘防治工作应继续推广GINA方案,并逐步向非专科医生及城镇和社区等医疗机构推广。

Objective To investigate the approach (monitoring and treatment) of pediatricians and general physicians to childhood asthma in China.Methods A standardized questionnaire survey,which was constructed by APAPARI on monitoring and treating childhood asthma was send to physicians in 25 provinces and cities of China.Results 1863 questionnaires were received,of which 1676 were completed (89.96%).58% of the doctors were general pediatricians,22%were pediatric pulmonologists or pediatric allergists,7% were adult pulmonologists or allergists who also treat children,and 13%were others (non-specified).Working places were:73% in a tertiary hospital,21% in a secondary hospital,and 4% work in a first grade hospital.Most of the doctors (67%) used peak flow meter or spirometry to monitor childhood asthma,while 31% of them used diary cards.For treating acute asthma exacerbations,the first choice treatment was nebulized salbutamol /terbutaline every 20 mins (29%),the second choice was salbutamol inhalation with a spacer (22%) and the third choice was systemic corticosteroids (12%).Pediatric pulmonologists and pulmonologists tended to use ICS for acute asthma.The most frequently used systemic corticosteroids to treat acute asthma were dexamethasone (85%),methylprednisolone (84%) and hydrocortisone (81%).The criteria applied by doctors to start a maintenance therapy in asthmatic children were the frequency of symptoms (91%),severity of symptoms (87%) and whether or not there was asevere disturbance in lung function testing (85%).For the selection of drugs,doctors tended to choose ICS.Generally,the first choice of drugs used in maintenance treatment of asthma in young children (0-3y) were ICS (82%),the second was montelukast(68%),and the third was ICS plus oral LABA(necessarily) (60%),while in preschool and school children (4-16 y) the first choice was a LABA plus ICS (83%-86%),the second was ICS (72%-80%) and the third montelukast (68%-69%).For moderate to severe asthma,the first choice was ICS plus LABA(89%).Conclusions The awareness and recognition of childhood asthma,the implementation of GINA guidelines and the use of ICS have improved among the doctors of the cities in China.Nevertheless,dissemination of the GINA program among non-specialists and doctors in countries and communities must be continued and re-enforced.