哮喘儿童吸入性糖皮质激素规范治疗停药后复发相关因素的分析

Analysis of the related factors of relapse after withdrawal of inhaled glucocorticoid in asthmatic children

目的探讨哮喘儿童经规范应用吸入性糖皮质激素(ICS)停药后复发情况及相关因素分析,以便采取相应的有效措施,降低其复发率。方法选择2014年1月至2015年12月就诊于天津医科大学第二医院儿科的4~14岁的经规范治疗后(符合中国儿童哮喘诊断与治疗指南)停用ICS的哮喘患儿共104例,其中男70例,女34例。以问卷调查的形式,从首次喘息开始追溯,并自停药后随访观察≥1年,探寻停用哮喘控制药物后复发的原因,并分析相关的危险因素。结果 104例患儿中有64例于停用ICS后出现哮喘复发,复发率为61.54%;不同性别复发为男43例,女21例,性别复发率比较差异无统计学意义(P>0.05)。6岁前发病的哮喘患儿复发率明显高于哮喘发病时间≥6岁的患儿(P<0.05)。ICS应用疗程6~11个月、12~24个月、25~36个月、>36个月的患儿哮喘复发率分别为91.67%、62.26%、62.50%、33.33%,疗程6~11个月组的复发率高于12~24个月、36个月组(P<0.05),疗程>36个月组复发率低于6~11个月、25~36个月组(P<0.05)。停药前稳定期(指哮喘临床缓解时间)<4个月、4~7个月、8~11个月、≥12个月的复发率分别为90.91%、72.22%、72.73%、51.56%,稳定期<4个月组的复发率高于稳定期≥12个月组(P<0.05),稳定期≥12个月组复发率低于稳定期<4个月组(P<0.05)。轻、中、重度哮喘的复发率分别为34.62%、56.60%、80%,中度组复发率略高于轻度组,但差异无统计学意义(P>0.05),重度组复发率高于轻度组和中度组(P<0.05)。合并过敏性鼻炎的患儿83例(80.00%),复发率为68.67%,未合并过敏性鼻炎的患儿21例,复发率为33.33%,两组比较差异有统计学意义(P<0.05)。合并鼻窦炎复发率为83.33%,未合并鼻窦炎复发率为58.69%,两组比较差异无统计学意义(P>0.05)。复发诱因有上呼吸道感染、运动、过敏原暴露、大笑、天气变化和雾霾等,其中以上呼吸道感染最多。结论哮喘儿童停用ICS后复发与发病年龄、ICS疗程、病情严重程度、停药前稳定期、共患过敏性鼻炎及鼻窦炎密切相关。复发的最主要触发因素为上呼吸道感染和过敏原暴露。延长ICS疗程可以降低哮喘的复发率,注重治疗共存病如过敏性鼻炎及鼻窦炎等有益于降低哮喘复发的风险。

Objective To explore the relapse and related factors of relapse after withdrawal of standard inhaled corticosteroids（ ICS） in children with asthma,so as to take effective measures to reduce the recurrence rate. Methods A total of 104 asthmatic children aged 4 - 14 years and treated with ICS after the standardized treatment（ according to China asthma diagnosis and Treatment Guide） were discontinued from January 2014 to December 2015 in the pediatric department of Second Hospital of Tianjin Medical University were selected,including 70 males and 34 females. In the form of questionnaire survey,from the first wheezing began to trace,the children were followed more than 1 year. The cause of recurrence after stopped down their asthma controller medication and the related risk factors were analyzed. Results Among the 104 children,64 cases had asthma recurrence after stopping ICS. The recurrence rate was 61. 54%,including 43 males and 21 females,and there was no significant difference between the two groups（ P〈0. 05）. The recurrence rate of the group that the onset of asthma 6 years was significantly higher than that of the other groups（ P〈0. 05）. The recurrence rates of the application of ICS for 6 - 11 months,12 - 24 months,25 - 36 months and 36 months were respectively91. 67%,62. 26%,62. 50% and 33. 33%. The recurrence rate of 6 - 11 months group was significantly higher than those of 12 - 24 mouths group and 36 months group（ P〈0. 05）; the recurrence rate of 36 months groups was significantly lower than those of 6 - 11 mouths group and 25 - 36 months group（ P〈0. 05）. The lengths of the asthma stability prior to stopping down asthma medication were 4 months,4 - 7 months,8 - 11 months and ≥12 months,and the recurrence rates were respectively 90. 91%,72. 22%,72. 73% and 51. 56%. The recurrence rate of 4 months group was significantly higher than that of ≥12 months group（ P〈0. 05）; the recurrence rate of 12 months group was lower than that of 4 months group（ P〈0. 05）. The recurrence rates in mild,moderate and severe asthma groups were respectively34. 62%,56. 60% and 80%. The recurrence rate in moderate group was higher than that of mild group,but the difference was not statistically significant（ P〈0. 05）,and the recurrence rate in severe group was significantly higher than those of mild group and moderate group（ P〈0. 05）. The relapse rate of severe asthma groups was significantly higher than those of mild group and moderate group（ P〈0. 05）. There were 83 cases of children complicated with allergic rhinitis,the recurrence rate was 68. 67%,and there were 21 cases of children without allergic rhinitis,the recurrence rate was 33. 33%,there was significant difference in the recurrence rate between the two groups（ P〈0. 05）. The recurrence rate of children with sinusitis（ 83. 33%） was slightly higher than that of the children without sinusitis（ 58. 69%）,but there was no significant difference between the two groups（ P〈0. 05）. The triggers of recurrence of asthma included upper respiratory infection,exercise,allergen exposure,laughter,weather change and haze,and upper respiratory infection accounted for the highest proportion. Conclusion The relapse of asthma children after withdrawal of ICS is closely related to the age of onset of asthma,the course of application of ICS,the severity of the disease,the stable period before stopping ICS,coexisting diseases,such as allergic rhinitis and sinusitis. The main trigger factors of recurrence are upper respiratory infection and allergen exposure. Prolonged ICS treatment can reduce the recurrence rate of asthma. Treatment of coexisting diseases,such as allergic rhinitis and sinusitis,should be paid atlention to,which is beneficial to reducing the risk of recurrence of asthma.