非典型主诉支气管哮喘临床诊断学特征及误诊分析

Clinical diagnostic characteristics and misdiagnosis analysis of bronchial asthma with atypical chief complaints

目的分析以不典型症状为主诉的支气管哮喘患者的临床特点及误诊原因,提高对哮喘疾病的认识和诊治水平。方法回顾收集2015年1月至2016年1月海军军医大学附属长海医院呼吸科门诊诊治的6例被误诊的以不同不典型主诉就诊的支气管哮喘患者临床资料,情景再现式介绍每位患者的诊治经过及心理表现,总结患者具有诊断价值的临床特征并对其误诊原因进行分析。结果 6例支气管哮喘患者平均年龄(41.50±17.50)岁,分别以心悸、单纯胸闷、全身不适、胸痛、咽部哽咽感、慢性咳嗽为主诉,病程中均无出现喘息,查体无异常。1例患者胸部CT平扫提示双侧支气管壁增厚,5例有过敏体质,4例患者合并过敏性鼻炎或湿疹病史,5例尘螨过敏原皮肤点刺试验阳性,呼出气一氧化氮(FeNO)中位值为33.5 ppb(16~176 ppb)(1 ppb=1×10^(-9)mol/L)。6例患者通气功能在正常范围,2例支气管激发试验阳性,4例存在可变性呼气气流受限。6例患者均诊断为轻度支气管哮喘,中位误诊时间为9个月(3~24个月)。在经过吸入性糖皮质激素/β_2受体激动剂和(或)白三烯受体调节剂抗哮喘治疗后病情显著缓解,中位起效时间为6 d(2~7 d),治疗前、后哮喘控制评分分别为(17.00±1.58)分和(24.20±1.09)分,差异具有统计学意义(t=8.37,P=0.001)。结论以不典型症状为主诉的哮喘患者大多伴有过敏体质并伴随胸闷、气短这两种典型哮喘症状,对抗炎治疗反应良好,但容易漏诊误诊。增强对哮喘存在不典型症状及表达异质性的意识,仔细深入地采集病史,综合应用多种辅助检查和科学合理地诊断性治疗是及早正确诊断、避免误诊漏诊的关键措施。

Objective To analyze the clinical characteristics and causes of misdiagnosis of asthmatic patients complained with atypical symptoms and improve the diagnosis and treatment of asthma.Methods The clinical data of 6 misdiagnosed asthmatic patients with diverse atypical complaints who were treated in outpatient department of respiratory medicine in Changhai Hospital from January 2015 to January 2016 were reviewed retrospectively.The doctor-visiting experience and psychological performance of each patient were introduced by scene reappearance.The clinical features with diagnostic value and the causes of misdiagnosis were summarized.Results Six cases with mean age of(41.50±17.50)years old,chiefly complained of cardiac palptations,chest tightness,general malaise,chest pain,throat chokes,chronic cough respectively and showed no typical wheeze sign and no abnormality in their physical examination.One case showed the bilateral bronchial wall thickening in thoracic CT scan,5 cases had atopic history,4 cases suffered co-morbidity of allergic rhinitis or eczema,5 cases got dust mite allegen-positive result through skin prick test.The median value of fractional exhaled nitric oxide(FeNO)was 33.5 ppb(16-176 ppb).Two cases were diagnosed by positive bronchial provocation test and 4 cases were confirmed by variable expiratory airflow limitation.The median course of misdiagnosis was 9 months(3-24 months).All patients were in the mild asthma category and relieved significantly by anti-asthmatic treatment of inhaling corticosteroid andβ2-adrenergic receptor agonist combined with/without leukotriene antagonist.The median onset time was 6 days(2-7 days).The asthma control test(ACT)score after 4 weeks treatment(24.20±1.09)was significantly higher than that before treatment(17.00±1.58;t=8.37,P=0.001).Conclusions Asthma patients with atypical chief complaints are mostly accompanied by atopy history and two kinds of typical asthmatic symptoms including chest tightness and shortness of breath.These patients,well responding to regular anti-asthmatic treatment,are easy to be underdiagnosed or misdiagnosed due to the existing of atypical symptoms and heterogeneity in expression from patients.Enhancing the awareness of this heterogeneity,comprehensive medical history collection,utilizing the special auxiliary tests and reasonable empirical treatment are the key measures to make the correct diagnosis timely and effectively.