阿司匹林激发试验在诊断非甾体抗炎药加重呼吸道疾病中的价值

The value of aspirin challenge tests in the diagnosis of non-steroidal anti-inflammatory drugs-exacerbated respiratory disease

目的:探究阿司匹林激发试验在诊断非甾体抗炎药加重呼吸道疾病(non-steroidal anti-inflammatory drugs-exacerbated respiratory disease,NERD)中的价值。方法:纳入2021年12月至2022年11月在四川大学华西医院过敏反应中心就诊,愿意接受NERD规范化诊断的慢性鼻窦炎伴鼻息肉(CRSwNP)伴/不伴哮喘的患者50例,其中男性22例,女性28例,年龄16~61岁。对患者实施NERD规范化诊断流程:(1)询问有无服用非甾体抗炎药(包括阿司匹林)后出现呼吸道症状加重的病史;(2)进行鼻腔阿司匹林激发试验(intranasal aspirin challenge,IAC);(3)进行口服阿司匹林激发试验(oral aspirin challenge,OAC)。上述步骤中,出现任何一项阳性,即可诊断为NERD。阳性者后续步骤不再进行,否则需进行到OAC。若OAC为阴性,则诊断为非NERD。所有患者均完成鼻腔鼻窦结局测试22(SNOT-22)评分、鼻内镜Lund-Kennedy评分,以及过敏原皮肤点刺试验、血常规及血清总免疫球蛋白E(tIgE)检测。采用SPSS 20.0软件进行统计学分析。结果:50例患者中,27例(27/50,54%)确诊为NRED。7例(7/50,14%)患者通过临床病史确诊;20例(20/50,40%)患者通过阿司匹林激发试验确诊,其中IAC阳性者17例(17/20,85%),OAC阳性者3例(3/20,15%)。进行IAC检测的43例患者中,仅2例(2/43,5%)出现哮喘急性发作。对比NERD组和非NERD组患者的临床特征,性别( P=0.001)、嗅觉减退( P=0.003)、反复鼻息肉手术史( P=0.028)、合并哮喘( P=0.013)、SNOT-22评分( P=0.004)、外周血嗜酸粒细胞百分率( P=0.043)的差异有统计学意义。 结论:仅通过病史诊断会造成NERD漏诊,有必要开展阿司匹林激发试验。IAC用于诊断NERD的准确性高、安全性良好,是诊断NERD的重要手段;若IAC阴性,需进一步进行OAC。

Objective To investigate the value of aspirin challenge tests in the diagnosis of non-steroidal anti-inflammatory drugs-exacerbated respiratory disease(NERD).Methods Fifty patients(22 males and 28 females;aged 16-61 years)who were diagnosed with chronic rhinosinusitis with nasal polyps(CRSwNP)with/without asthma,and underwent NERD standardized diagnosis in the Allergy Centre of West China Hospital,Sichuan University from December 2021 to November 2022 were included in the study.The first step was asking about the history of exacerbation respiratory symptoms after intake of any non-steroidal anti-inflammatory drug,including aspirin;the second step was performing intranasal aspirin challenge(IAC);and the third step was performing oral aspirin challenge(OAC).The diagnosis of NERD was made if any of the above steps was positive,and the subsequent steps were not performed,otherwise the diagnosis was made to OAC.If OAC was negative,the diagnosis was non-NERD.All patients completed the sino-nasal outcome test 22(SNOT 22)score,Lund-Kennedy score by nasal endoscopic,allergen skin prick test,blood routine and serum total IgE test.SPSS version 20.0 was used for statistical analysis.Results The diagnosis of NRED was confirmed in 27 patients(27/50,54%).Seven(7/50,14%)of them were diagnosed by clinical history and 20(20/50,40%)were diagnosed by aspirin challenge tests,of which 17(17/20,85%)were positive to IAC and 3(3/20,15%)to OAC.Of the 43 patients who underwent IAC testing,only 2(2/43,5%)developed asthma attacks during challenge.Comparing the clinical characteristics of patients in NERD and non-NERD group,there were significant differences between the two groups in gender(P=0.001),hyposmia(P=0.003),history of repeated CRSwNP surgeries(P=0.028),comorbid asthma(P=0.013),SNOT-22 score(P=0.004)and the percentage of peripheral blood eosinophil(P=0.043).Conclusions Patients may be underdiagnosed if the diagnosis of NERD is made only by medical history,and it is necessary to carry out aspirin challenge tests.IAC is an important means to diagnose NERD with high accuracy and good safety.However,If IAC is negative,further OAC is required.