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目的监测支气管哮喘(简称哮喘)患者联合治疗过程中症状积分、气道反应性[(以比气道传导率下降35%的乙酰甲胆碱浓度(PC_(35)sGaw)为代表)]、第一秒用力呼气容积占预计值百分比(FEV_1占预计值%)和呼气峰流量占预计值百分比(PEF%)的动态变化,探讨上述指标对评估病情、调整治疗方案的指导意义。方法将65例轻至中度慢性持续期哮喘患者分为 A(22例)、B(22例)、C(21例)3组。初始治疗均为吸入糖皮质激素(ICS)+长效β_2受体激动剂(LABA)联合治疗[即沙美特罗/氟替卡松50μg/250μg、50μg/100μg]。A 组维持固定剂量不变,B 组根据哮喘症状积分和肺功能进行降级或停药,C 组根据症状积分、肺功能结合气道反应性进行降级或停药。定期随访18个月,记录哮喘症状积分,测定 FEV_1占预计值%、PEF%和 PC_(35)sGaw。比较3种疗法的哮喘控制率。结果 65例轻至中度哮喘患者中有46例按研究方案完成治疗和随访,其中 A、B、C 组分别为15、15、16例。哮喘患者症状积分、FEV_1占预计值%和 PEF%在治疗后1～3个月内明显改善,与治疗前比较差异有统计学意义(t 值分别为9.54、13.17、14.27、12.4、6.72、6.59、8.31、5.22、5.96,P 均<0.01)。继续治疗期间大多数患者症状积分、FEV_1占预计值%和 PEF%维持在一相对稳定水平,持续性改善不明显,但 B 组部分患者症状控制不良,肺功能指标有所下降。气道反应性在治疗1～3个月内迅速降低(A、B、C 组的 t 值分别为9.71、12.04、14.31,P 均<0.01),随后缓慢降低,治疗9个月后维持在较低水平。4例患者气道反应性阴转,其中1例在停药后又转为轻度阳性。疗程结束时 A 组哮喘控制率为93.3%。B 组有86.7%的患者降级治疗,40%停药,但有40%需要复治或重新升级治疗。疗程结束时 B 组哮喘控制率为53.3%,与 A 组比较差异有统计学意义(X~2=10.35,P<0.01)。C 组降级和停药的比例(62.5%、25%)低于 B 组,时间也晚于 B 组,但仅有1例需要复治,临床结束时哮喘控制率为93.8%(与 A 组相似),与 B 组比较差异有统计学意义(X~2=10.35,P<0.01)。结论(1)ICS 联合 LABA 治疗能够迅速控制哮喘患者症状,改善肺功能,降低气道反应性;(2)根据哮喘临床控制水平调整治疗方案可能导致降级和停药过早,哮喘易于复发;(3)PC_(35)sGaw 是反映哮喘气道炎症较为敏感的指标,可作为评价疗效、指导治疗方案调整的指标之一。
Objective To monitor symptom scores and airway responsiveness during the combined treatment of patients with bronchial asthma (asthma) [(35% of methacholine (PC_ (35) sGaw) One second forced expiratory volume as a percentage of predicted value (FEV_1 accounted for the expected value%) and peak expiratory flow as a percentage of expected value (PEF%) dynamic changes, to explore the above indicators for the assessment of the disease, adjust the treatment guideline. Methods 65 patients with mild to moderate chronic asthma were divided into A (22 cases), B (22 cases) and C (21 cases). The initial treatment consisted of inhaled glucocorticoid (ICS) plus long-acting beta-2 receptor agonist (LABA) [salmeterol / fluticasone 50 μg / 250 μg, 50 μg / 100 μg]. In Group A, the fixed dose was maintained. Group B was downgraded or discontinued based on asthma symptom scores and pulmonary function. Group C was downgraded or discontinued on the basis of symptom score, pulmonary function and airway responsiveness. The patients were followed up for 18 months on a regular basis. Asthma symptom scores were recorded and FEV_1 accounted for the predicted value, PEF% and PC_ (35) sGaw. Comparison of three kinds of treatment of asthma control rate. Results Of the 65 patients with mild to moderate asthma, 46 patients completed the treatment and follow-up according to the study plan, of which 15, 15 and 16 patients were in group A, B and C, respectively. Symptom scores of asthma patients, FEV_1 accounted for the predicted value and PEF% 1 to 3 months after treatment significantly improved, compared with before treatment was statistically significant (t values were 9.54,13.17,14.27,12.4,6.72,6.59 , 8.31,5.22,5.96, P <0.01). During the continuance of treatment, symptom scores of most patients remained unchanged at a stable level of FEV_1 and PEF%, but the improvement of symptoms was not obvious. However, some patients in group B had poor symptom control and decreased pulmonary function. Airway responsiveness decreased rapidly within 1 to 3 months (t = 9.71, 12.04 and 14.31 in group A, B and C, respectively, P <0.01), then decreased slowly and maintained at 9 Low level. Four patients had negative airway responsiveness, of which 1 was mildly positive after discontinuation. At the end of treatment, the control rate of asthma in group A was 93.3%. 86.7% of patients in Group B were downgraded and 40% discontinued, but 40% required retreatment or regrading. At the end of treatment, the control rate of asthma in group B was 53.3%, which was significantly different from that in group A (X ~ 2 = 10.35, P <0.01). The rate of demotion and discontinuation in group C was lower (62.5%, 25%) than in group B and later than in group B, but only one patient required retreatment and the clinical control rate of asthma was 93.8% at the end of the study (similar to group A ), There was significant difference with group B (X ~ 2 = 10.35, P <0.01). Conclusions (1) ICS combined with LABA treatment can rapidly control the symptoms of asthma patients, improve lung function and reduce airway responsiveness; (2) adjust the treatment regimen according to the clinical control level of asthma may lead to premature downgrading and asthma relapse; ( PC_ (35) sGaw is a more sensitive indicator of airway inflammation in asthma, which can be used as an indicator to evaluate the curative effect and guide the adjustment of treatment regimen.