哮喘-慢性阻塞性肺疾病重叠综合征临床诊断的初步探讨

A preliminary study on the diagnosis of asthma-COPD overlap syndrome by different criteria

目的探讨慢性阻塞性肺疾病(简称慢阻肺)全球创议(GOLD)/哮喘全球创议(GINA)联合指南标准(简称GOLD/GINA标准)与西班牙慢阻肺指南标准(简称西班牙指南标准)诊断哮喘-慢阻肺重叠综合征(ACOS)的临床应用价值。方法连续入选稳定期慢阻肺门诊就诊患者,收集临床资料,进行肺功能测定及可逆试验,检测外周血嗜酸性粒细胞计数、血清总IgE水平、痰炎性细胞分类计数。分别根据GOLD/GINA标准和西班牙指南标准对ACOS做出诊断,比较ACOS在慢阻肺中的分布及其特征。结果在104例诊断明确的慢阻肺患者中,依据GOLD/GINA标准和西班牙指南标准分别诊断ACOS 24例(24/104,23.1%)和10例(10/104,9.6%),后者诊断的ACOS患者完全包含在前者诊断的患者中。GOLD/GINA标准最常符合的条目是活动和(或)情绪诱发的喘息、可变的气流受限、哮喘家族史及其他过敏性疾病史;作为可变性气流受限的客观指标,呼气流量峰值平均每日昼夜变异率≥10%的阳性率为45.8%(11/24),而气道舒张试验的阳性率为66.7%(16/24)。西班牙指南标准最常符合的条目为40岁以前哮喘病史、存在过敏性疾病、2次以上支气管舒张试验阳性。结论 GOLD/GINA标准诊断ACOS的敏感性较高,且不需要特殊实验室检查,更适合临床使用;而西班牙指南标准则比较严格,有可能导致诊断不足。

Objective To study the clinical application ofthe GOLD/GINA criteria and the Spanish guideline in the diagnosis of asthma-COPD overlap syndrome （ACOS）. Methods Patients with stable COPD were consecutively enrolled in the study. Clinical data were collected, lung function with bronchodilator test and peak expiratory flow （PEF） were performed, and peripheral blood eosinophils, total IgE, and sputum inflammatory cells were measured. Those overlap with asthma were identified by the 2 different criteria, and the prevalence and features of ACOS were compared. Results Among 104 cases of stable COPD, 24 （23.1%） and 10 （9.6%） were identified as ACOS by the GOLD/GINA criteria and the Spanish guideline, respectively; the latter 10 cases were all included in the former 24. For the GOLD/GINA criteria, the most common features were symptoms triggered by exercise or emotions, variable airflow limitation, family history of asthma, and other allergic conditions. Mean diurnal PEF variation~〉 10% was evident in 11 cases （45.8%, 11/24）, while bronchodilator test was positive in 16 cases （66.7%, 16/24）. For the Spanish guideline, the most common features were diagnosis of asthma before 40, other allergic diseases, positive bronchodilator test on 2 occasions. Conclusions The GOLD/GINA criteria may be more sensitive for the diagnosis of ACOS, and do not need sophisticated lab tests, which may be more applicable for clinical use. The Spanish guideline is restrictive, and therefore may lead to under-diagnosis.