肺功能检查技术如何在基层医疗卫生服务中更好地应用--附重点问题专家解答

Attaching Importance to the Application of Lung Function Examination Technology in Grassroots Medical and Health Institutions--Expert Answers to Key Questions

慢性呼吸系统疾病患病率持续上升,严重危害我国国民身体健康和生命安全。肺功能检查是慢性呼吸系统疾病重要的筛查和诊断技术,但长期以来未受到足够重视,特别是在我国基层医疗卫生机构。为什么要重视基层医疗卫生机构的肺功能检查:(1)慢性阻塞性肺疾病(以下简称慢阻肺)发病呈现高态势,预测至2060年死于慢阻肺及其相关疾病的人数将超过540万人/年,已成为严重影响我国国民健康的公共卫生问题之一;(2)肺功能检查是“金标准”,在基层医疗卫生机构开展肺功能检查,并通过早期强化治疗,可以延缓肺功能下降。那么全科医生团队进行肺功能检查的优势及可做工作有哪些呢?(1)全科医生团队扎根基层,给慢性病的长期随访管理带来了诸多便利,且“生物-心理-社会医学模式”更有利于其对患者进行健康照顾;(2)全科医生可通过采取形式多样的健康教育,增强居民对慢性呼吸系统疾病的防控意识,从而提高居民进行肺功能检查的依从性;(3)全科医生可发挥主观能动性,主动对辖区居民,特别是有危险因素的高危人群进行早期肺功能筛查,把握最佳治疗时机而从降低疾病负担;(4)开展家庭医生签约,为患者建立呼吸健康档案,对不同严重程度的慢阻肺患者进行分级管理,做到慢性病管理流程科学高效、随访及时到位、管理持续规范。但是基层医疗卫生机构肺功能检查现状不容乐观,因此特邀专家对部分重点问题进行解答。陈燕教授指出对于有以下危险因素的慢阻肺患者要考虑进行肺功能检查:存在呼吸困难、慢性咳嗽或咳痰史、反复发作的下呼吸道感染、慢阻肺家族史或儿童时期因素(如低出生体质量、儿童时期呼吸道感染)、有任意慢阻肺危险因素暴露史(如烟草烟雾、燃料燃烧和可吸入粉尘等)及年龄>40岁;对于具有以下危险因素的哮喘患者要考虑进行肺功能检查:过敏性鼻炎、胃食管反流病、慢阻肺、支气管扩张、吸烟、接触过敏原等环境触发因素和肥胖等;此外还要关注支气管扩张、特发性肺间质纤维化患者的肺功能检查。宋元林、盖晓燕教授在如何评价和改善肺功能质控方面指出:肺功能检查操作过程容易受到多方面因素干扰,凡是能影响呼吸频率、呼吸幅度和气体流速的生理、病理因素均可影响肺通气功能,而这些因素亦有可能来源于仪器设备、受试者或操作技术人员;并建议未来尽量采取智能化技术,内置定标和质控标准,以降低肺功能检查操作的复杂程度,使得基层医务人员能较快掌肺功能检查操作的要领。陈亚红教授对慢阻肺社区专病特色科室在基层呼吸系统疾病早期筛查干预能力提升项目建设中如何发挥示范作用指出:基层呼吸规范化建设项目、基层呼吸系统疾病早期筛查干预能力提升项目在推动基层呼吸疾病规范化防治、提升照护能力以及明确基层医疗卫生机构肺功能仪配备数量、质量等方面均取得了重大成果。期待本文可为基层医疗卫生机构的肺功能检查推进提供借鉴。

The prevalence of chronic respiratory diseases is increasing,seriously threatening the health and life safety of Chinese residents.Lung function tests are important screening and diagnostic means for chronic respiratory diseases,but have been insufficiently valued for a long time,especially in primary care.Great emphasis should be placed on the use of these tests in primary care,mainly due to the following two aspects:(1)The incidence of chronic obstructive pulmonary disease(COPD)remains high in China,and it is estimated that more than 5.40 million people will die of COPD and its related diseases per year by 2060.Chronic respiratory diseases have become a public health issue that seriously impairs the health of Chinese residents.(2)Lung function tests are the gold standard for diagnosing chronic respiratory diseases.Carrying out these tests in primary care is contributive to early detection and timely intensive treatment of chronic respiratory diseases,thereby delaying the decrease in lung functions.As the major healthcare providers,general practitioner(GP)teams have many advantages to implement lung function tests,and they can perform many tasks related to the tests:(1)Working in primary care is favorable for GP teams to implement long-term follow-up management for chronic diseases,and the biopsychosocial model used by them is beneficial to improving the quality of care for the patients.(2)GPs may carry out various types of heath education to enhance residents'awareness of chronic respiratory disease prevention and control to improve their adherence to lung function tests.(3)GPs may proactively perform early lung function tests for residents in their service area,especially those at high risk for chronic respiratory diseases,by which the optimal treatment time will be determined,then the disease burden will be reduced.(4)GP teams can provide contracted care services and creating a respiratory health file for chronic respiratory disease patients,and offer tiered management services to COPD patients according to the severity of their disease.In general,GPs should provide chronic respiratory disease patients with continuous and standardized services using a scientific and effective process,and timely and appropriate follow-up services.In view of the unsatisfactory implementation status of lung function tests in primary care,we invited a group of experts to give their opinions on some key questions.Professor CHEN Yan put forward recommendations on the target population to be screened:COPD patients with dyspnea,a history of chronic cough/expectoration,recurrent lower respiratory tract infection,a family history of COPD/childhood factors(such as low birth weight,childhood respiratory tract infection),a history of exposure to any COPD risk factors(including tobacco smoke,fumes from burning fuel and inhalable dust),or age>40 years;asthma patients with allergic rhinitis,gastroesophageal reflux disease,COPD,bronchiectasis,smoking,a history of exposure to allergens and other environmental triggers,or obesity.And bronchiectasis and idiopathic pulmonary interstitial fibrosis patients should also be concerned population for implementing lung function tests.In terms of assessing and improving the quality control in performing lung function tests,Professor SONG Yuanlin and Professor GAI Xiaoyan proposed that during the implementation of such tests,the respiratory rate,respiratory amplitude and respiratory gas flow rate associated with lung ventilation function of the examinees are easily influenced by the performance of instruments and equipment,and operating skills of technicians as well as individual physiological and pathological factors of examinees.And they put forward recommendations,for example,using smart spirometers with built-in calibration and quality control standards in lung function tests,to reduce the operational complexity,so that primary care workers can quickly grasp the essentials of performing lung function tests.During the discussion of a community COPD department playing a demonstration role in the construction of early screening and intervention of respiratory disease project in primary care,Professor CHEN Yahong pointed out the standardized respiratory disease prevention,diagnosis and management system and capacity building program in primary care,and capabilities improvement program for early screening and intervention for respiratory diseases in primary care,have greatly promoted the levels of standardized prevention,treatment and nursing care of respiratory diseases,and the determination of number and quality of spirometers equipped in primary care settings.It is hoped that this article will provide insights into the promotion of lung function tests in primary care.