肺功能监测是否在哮喘当前控制评估中起重要作用?

Does lung function monitoring play important roles in assessing current asthma control?

目的 2009年版全球哮喘防治创议(GINA)中哮喘控制包括哮喘当前临床控制和未来风险。2015年版GINA指南将哮喘"当前临床控制"更名为哮喘"症状控制",且将肺功能从其中剥离出来,评估内容仅包括日间症状、夜间症状、缓解药物使用及活动受限四个方面。本研究旨在评价2009年版和2015年版GINA哮喘控制标准在评估哮喘当前控制间的一致性,并探索肺功能监测是否在哮喘当前控制评估中起重要作用。方法采用横断面研究设计,纳入138例稳定期哮喘患者。分别应用2009版和2015版GINA哮喘控制评估标准,比较同一控制水平组间的人口学资料、临床特征、肺功能、过去12个月哮喘急性发作、外周血细胞分类计数及诱导痰细胞计数等情况。采用Kappa检验评价两版标准的一致性。采用Spearman相关分析比较不同版本GINA哮喘控制水平与过去12个月哮喘急性发作间的相关性,亦分析肺功能与过去12个月哮喘急性发作情况之间的相关性。结果基于2009版GINA哮喘控制评估标准,138例受试者分为未控制组52例、部分控制组58例、控制组28例。而以2015版GINA哮喘控制评估标准,则分为未控制组33例、部分控制组59例、控制组46例。Kappa检验结果显示两标准呈中等一致性(Kappa=0.595,P<0.001)。与2009版比较,2015版评估的控制组哮喘患者肺功能更差[FEV_1%pred:(89.9±12.9)%vs.(79.9±18.2)%,P=0.013],2015版评估的部分控制组患者哮喘控制水平更差,其中ACQ-6评分(0.8±0.7 vs.1.1±0.7,P=0.028)和ACT评分(20.7±2.5 vs.19.4±2.5,P=0.007)差异均有统计学意义。两版哮喘控制标准均与过去12个月哮喘急性发作情况相关(2009版:r=–0.212;2015版:r=–0.268),且与2015年版GINA版标准关系更为密切。同一控制水平组间未发现在诱导痰、外周血炎症细胞分类计数和Ig E水平的差异。结论 2009版与2015版GINA哮喘控制评估标准间存在中等程度一致性。相较于2009版,经肺功能监测缺如的2015版GINA评估为控制组的哮喘患者存在更差的肺功能,部分控制组则存在更差的哮喘控制得分,2015年版GINA哮喘控制标准与哮喘急性发作间关系更为密切。因此,研究支持2015年版GINA哮喘控制标准在哮喘当前控制临床评估的应用。

Objective Since 2009, assessment of asthma control in Global Initiative for Asthma （GINA） includes current clinical control and future risk. ＂Current clinical control＂ is replaced by ＂symptom control＂ in GINA 2015, and lung function is excluded from assessment of current clinical control. This study was designed to investigate the agreementin current asthma control assessment between GINA 2009 and 2015, and to explore whether FEV1 monitoring plays an important role in this context. Methods A cross-sectional study was conducted among patients with stable asthma （n=138）. The levels of asthma control were graded by GINA 2009 and GINA 2015, respectively. Demographic data, spirometry, exacerbations in the past 12 months, peripheral blood cells, induced sputum were collected. Kappa coefficient was used to measure the agreement of the two asthma control tools. Association of the asthma control levels using the two tools with the exacerbations in the past 12 months was examined by Spearman correlations. Additionally, associations of lung function with the exacerbations in the past 12 months were analyzed. Results Agreement in assessing current asthma control between GINA 2009 and 2015 was moderate （Kappa=0.595, P〈0.001）. Compared with GINA 2009, the patients with well-controlled asthma assessed by GINA 2015 had worse FEV1%pred [（89.9±12.9）% vs. （79.9±18.2）%, P=0.013], the partly controlled subjects assessed by GINA 2015 had worse asthma control scores in ACQ-6 score （0.8±0.7 vs. 1.1±0.7, P=0.028） and ACT score （20.7±2.5 vs. 19.4±2.5, P=0.007）. Furthermore, asthma control levels assessed by either GINA 2015 or 2009 were related to exacerbations in the past 12 months and stronger relationship was presented in GINA 2015 （r=-0.268 for GINA 2015 vs. r=-0.212 for GINA 2009, respectively）. In addition, there were no differences in cell counts in induced sputum or peripheral blood or IgE level in peripheral blood in patients with different asthma control levels assessing by GINA 2009 and 2015. Conclusions Our study indicates that it has a moderate agreement of assessing current asthma control between GINA 2015 and 2009. Compared with GINA 2009, absence of FEV1 monitoring from GINA 2015 would result in worse lung function in well-controlled asthma and worse asthma control scores in partly controlled asthma. Addition of FEV1 monitoring to GINA 2015 would weaken the relationship between current asthma control and future asthma outcomes, although it didn＇t reach statistical significance. Our study supports that GINA 2015 lacking lung function monitoring in current asthma control assessment is applicable in clinical practice,