在之前已有诊断的成人中 许多并未确认气喘


  【24drs.com】根据发表于1月17日JAMA期刊的一篇加拿大研究,在已有医生诊断气喘的成年人中,很多人在重新评估时并未确认气喘。
  
  加拿大安大略渥太华大学、渥太华医院研究中心Shawn Aaron医师等人写道,曾有医师诊断气喘的成年人中,33.1%在目前并未确认气喘诊断,这些人并未每天使用气喘药物或者是已经停药,对于这类患者,可能需要重新评估气喘诊断。
  
  作者们推测,这些患者可能是已经经历自发性缓解或者是可能被误诊。
  
  目前的指引建议,透过测试可逆气流限制来诊断气喘,以及透过测试呼气气流确认阳性结果。不过,疾病的可变表现及其复发和缓解之过程可能会使诊断复杂化,从而可能导致社区的许多医生根据经验诊断和治疗气喘。
  
  这篇研究包括了随机取样的701名自我报告表示在5年内曾有医师诊断气喘之成人,是透过电话在加拿大的10大都会区域筛选,研究者也运用来自主治医师的信息确认如何做出第一次诊断。
  
  然后,研究人员藉由连续监测症状、居家尖峰流量、肺量计(测量肺功能)以及验证支气管激发试验确认或排除气喘。
  
  使用预先定义之协议,让阴性检测结果的参加者逐渐减少药物,一年后再度进行支气管激发试验以追踪。
  
  必要时,由一名研究肺部专家评估患者并确认气喘或指定替代之诊断。
  
  共纳入完成研究的613名患者(平均年龄51岁; 67%是女性)进行分析。
  
  研究排除了203名参与者的气喘(33.1%; 95%信赖区间[CI], 29.4% - 36.8%),大多数参与者有良性的替代诊断;不过,12人(2.0%)有严重的心肺疾病,却被误诊为气喘。
  
  与确诊的气喘患者相比,被排除气喘者比较不可能是使用气流限制测试而被初次诊断(分别是43.8% vs 55.6%;绝对差异为11.8%; 95% CI, 2.1% - 21.5%)。
  
  另有获得530名患者的医师初次诊断信息,其中269人(50.8%)已经进行了验证气流限制测试,其余的人则是根据症状和/或身体检查结果而被诊断。
  
  被排除气喘者,超过90%安全地停用气喘药物达一年,其中181人(29.5%; 95% CI, 25.9% - 33.1%)仍然没有气喘的临床或检验证据。
  
  作者认为这些结果有两个可能的解释:参与者可能经历了气喘的自发缓解,或者,他们被误诊了。
  
  作者们也指出,被排除气喘的患者有35.0%每天使用气喘药物,这对他们并无好处,作者们表示,还使他们不必要地暴露于不利的药物作用之下,且增加医疗成本。
  
  来自麻州波士顿大学医学院的Helen Hollingsworth医师和George O'Connor医师在编辑评论写道,这些结果提供了两个重要的见解,有助于临床管理;O'Connor医师也是JAMA的副编辑。
  
  首先,成人气喘可能会变成慢性,而某些患者可能并不需要无限期的治疗;其次,呼气气流测试是必不可少的气喘诊断,以避免误诊和不必要的治疗。
  
  他们写道,虽然这些结果认为,某些患者可以安全地减少他们的气喘药物,他们也支持更频繁地使用生理测试来指导气喘管理。
  
  他们也指出,研究结果不能一般化到各种严重度之气喘,该研究排除了长期使用口服皮质类固醇的患者,只有45%的参与者有每天使用气喘药物;因此,该研究并未纳入许多中度到重度气喘的患者。
  
  然而,编辑们总结指出,Aaron等人的研究是重要的提醒,除了检查气喘的症状和治疗,试图了解该气喘诊断是否依旧适当,是临床照护的重要部分。
  
  资料来源:http://www.24drs.com/
  
  Native link:Asthma Not Confirmed in Many Previously Diagnosed Adults
  

Asthma Not Confirmed in Many Previously Diagnosed Adults

By Veronica Hackethal, MD
Medscape Medical News

In a substantial number of adults with physician-diagnosed asthma, asthma was not confirmed on revaluation, according to a Canadian study published in the January 17 issue of JAMA.

"Among adults with physician-diagnosed asthma, a current diagnosis of asthma could not be established in 33.1% who were not using daily asthma medications or had medications weaned. In patients such as these, reassessing the asthma diagnosis may be warranted," Shawn Aaron, MD, from the Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada, and colleagues write.

These patients may have experienced spontaneous remission or may have been misdiagnosed, the authors speculate.

Current guidelines recommend diagnosing asthma by testing for reversible airflow limitation and confirming positive results by testing expiratory airflow. However, the variable presentation of the disorder and its relapsing and remitting course can complicate diagnosis and may lead many physicians in the community to diagnose and treat asthma empirically.

The study included 701 adults randomly sampled and screened via telephone in Canada's 10 largest metropolitan areas who had self-reported having physician-diagnosed asthma within the last 5 years. Researchers used information from treating physicians to confirm how diagnoses were first made.

Researchers then confirmed or ruled out asthma with serial monitoring of symptoms, home peak flow, spirometry (a measure of lung function), and confirmatory bronchial challenge tests.

Participants with negative tests had their medications tapered off, using a predefined protocol, and were followed with repeat bronchial challenge tests for 1 year.

A study pulmonologist evaluated patients and confirmed asthma or assigned alternative diagnoses when necessary.

The analysis included 613 patients (mean age, 51 years; 67% women) who completed the study.

The study ruled out asthma in 203 participants (33.1%; 95% confidence interval [CI], 29.4% - 36.8%). Most participants had benign alternative diagnoses; however, 12 (2.0%) had serious cardiorespiratory conditions that had been misdiagnosed as asthma.

Compared with those with confirmed asthma, those in whom asthma was ruled out were less likely to have received initial diagnoses using airflow limitation testing (43.8% vs 55.6%, respectively; absolute difference, 11.8%; 95% CI, 2.1% - 21.5%).

Information from physicians on initial diagnoses was available for 530 of the patients, of whom 269 (50.8%) had had confirmatory airflow limitation testing. The remainder received their diagnoses on the basis of symptoms and/or physical exam findings.

More than 90% of participants whose asthma was ruled out safely stopped asthma medication for 1 year. Of these, 181 participants (29.5%; 95% CI, 25.9% - 33.1%) still had no clinical or laboratory evidence of asthma.

The authors suggest two possible explanations for these results: participants may have experienced spontaneous remission of asthma, or they may have been misdiagnosed.

The authors also point out that 35.0% of patients in whom asthma was ruled out were using daily asthma medications, which would have done them no good. It would also have exposed them unnecessarily to adverse medication effects and increased cost, the authors say.

"These results provide 2 important insights that inform clinical management," write Helen Hollingsworth, MD, and George O'Connor, MD, both from Boston University School of Medicine in Massachusetts, in an accompanying editorial. Dr O'Connor is also associate editor of JAMA.

First, adult asthma may not become chronic and may not require indefinite treatment in some patients. Second, expiratory airflow testing is "essential" for asthma diagnosis to avoid misdiagnosis and unnecessary treatment.

"[A]lthough these results suggest that some patients can safely reduce their asthma medications, they also support more frequent use of physiological testing to guide asthma management," they write.

They also note that the findings may not generalize across the range of asthma severity. The study excluded people receiving long-term oral corticosteroids, and just 45% of participants used daily asthma medications; therefore, the study may have excluded many people with moderate to severe asthma.

Nevertheless, the editorialists conclude, "The study by Aaron and colleagues is an important reminder that in addition to reviewing asthma symptoms and treatment, trying to understand if the diagnosis of asthma is still appropriate is an important part of clinical care."

One or more authors reports honoraria and other fees, advisory board or other membership, grants, and/or consulting for one or more of the following: Boehringer Ingelheim Canada, GlaxoSmithKline, Teva, AstraZeneca, Methapharm, Canadian Thoracic Society, Novartis, Synertec, Grifols, Roche, Actelion, Bayer, CSL Behring, Prometic.Altair, Amgen, Asmacure, Boston Scientific, Genentech, Ono Pharma, Schering, Wyeth, Merck, Global Initiative for Asthma, and/or Laval University. Dr O'Connor reports consulting for AstraZeneca and grants from Janssen Pharmaceuticals and the National Institutes of Health. Dr Hollingsworth has disclosed no relevant financial relationships.

JAMA. 2017;317(3):262-263, 269-279.

    
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