激发试验论文：支气管激发试验在慢性咳嗽病因诊断价值中的探讨.doc

激发试验论文：支气管激发试验在慢性咳嗽病因诊断价值中的探讨【中文摘要】研究咳嗽是内科患者常见症状,慢性咳嗽表现单一,临床诊断病因和治疗难度较大,咳嗽的诊治不力将导致：抗菌药物的滥用；因诊断不清而反复进行各种检查；既增加了患者痛苦,又加重了其经济负担。用强迫震荡技术判断哮喘患者支气管激发试验是可靠的已经得到证实,但对其诊断哮喘的特异性及诊断标准方面尚需要进一步探讨。用Astograph法测定慢性咳嗽患者的气道反应性,并探讨其在慢性咳嗽病因诊断中的临床价值。研究方法中华医学会呼吸病学分会哮喘学组2009年咳嗽的诊断与治疗指南提出慢性咳嗽的诊断标准：(1)咳嗽时间8周；(2)以咳嗽为主或为惟症状；(3)胸部X线检查正常。本研究共收集了自2010年3月至2010年9月期间以咳嗽为主诉242例患者,失访11例,231例患者入选,失访11例患者同纳入研究的231例患者相比,在年龄、性别、疾病情况等方面无显著差异。研究方案经过医院临床医学伦理委员会批准,并取得所有受试者的知情同意。操作方法参照肺功能检查实用指南。1.受试者先测身高、体重,并练习至能熟练掌握配合肺功能检查要领。采用德国耶格公司MasterScreen-PFT肺功能仪进行常规肺通气功能测定,测定3次,误差低于5%,取其最佳值；应用日本CHEST公司Astograph Jupiter-21气道反应性测定仪进行支气管激发试验检测,同时记录最小诱发累积剂量(Dmin),以呼吸阻力增加到基础呼吸阻力(Rrs cont)的2倍且Dmin15做为阳性标准,支气管激动剂为乙酰甲胆碱。2.根据自愿的原则,对15名Astograph法阳性患者应用德国耶格公司生产的APS气雾激发系统再进行标准激发试验,标准激发试验前后用脉冲震荡法(Impulse Oscillomety, IOS)测定呼吸阻抗,该测定与Astographa法激发试验间隔24小时,为避免深呼吸对试验结果的影响,按照吸入乙酰甲胆碱(Mch)、测定呼吸阻抗、第1秒用力呼气量(FEV1)及呼气峰流量(PEF)、再重复以上过程的顺序测定,测定结束后给予沙丁胺醇。3.记录随访患者就诊至诊断治疗半年内病情或疗效变化。结果1.231例患者中支气管激发试验(BPT)阳性117例,阴性114例,阳性率50.6%,不同性别组BPT阳性率和CVA百分比无显著差异(P0.05),结合进一步检查及治疗效果,确诊为咳嗽变异型哮喘(CVA)110例,小于30岁年龄组CVA比例最高,占慢性咳嗽病因的68.6%,BPT诊断CVA的特异度为94.0%,60岁组CVA比例最低,为23.1%；其余7例BPT阳性慢性咳嗽患者中5例为感染后咳嗽,2例为0级慢性阻塞性肺病(COPD)患者；114例BPT阴性的咳嗽患者分别是上气道咳嗽综合征(UACS)、嗜酸粒细胞性支气管炎(EB)、胃食管反流性咳嗽(GERC)、服用血管紧张素转化酶抑制剂(ACEI)类药物和不明原因者,其中UACS组41例(17.7%),EB组25例(10.8%),GERC组24例(10.4%),ACEI组22例(9.5%),病因未明2例(0.9%)。2.分别以Dmin值为1unit、3unit、6unit、15unit为临界值,其诊断哮喘的敏感性、特异性不同,以Dmin6unit作为阳性标准时诊断哮喘的敏感性为74.1%,特异性为90.5%。3.IOS测定15例患者,支气管激发试验(BPT)均阳性,经随访证实哮喘患者10例,非哮喘患者5例,标准激发试验前哮喘组(10例)与非哮喘组(5例)患者基础呼吸阻力：脉冲频率为5Hz、20Hz的气道粘性阻力(R5、R20)、周边弹性阻力(X5),及第一秒用力呼气量(FEV1)、呼气峰流速(PEF)间的差异均无统计学意义(P0.05)；标准激发试验后哮喘组(10例)与非哮喘组(5例)患者基础呼吸阻力：脉冲频率为5Hz时的气道粘性阻力(R5)、第一秒用力呼气量(FEV1)、呼气峰流速(PEF)与激发试验前比较均有统计学意义,哮喘组Dmin值也明显低于非哮喘组。4.BPT阳性的三组患者中,Dmin和Cmin不同,CVA组最著小于COPD组和感染后咳嗽组(P0.05) both in Asthma group (10 cases) and non-asthmatic group (5 cases). After the standard provocative test there was a significant difference in R5, FEV1, PEF both in Asthma group (10 cases) and non-asthmatic group (5 cases). Dmin value in asthma group is much lower in non-asthmatic group.4. CVA, postinfectious cough and COPD are the three main causes of chronic cough with positive BPT, but they also have their own characteristics. CVA group had an evident lower Dmin and Cmin than the other two groups(P0.001). There was also a significant difference in the appearance of dose-resistance curve, mainly in the increasing rate of airway resistance. In CVA group, the resistance increased in a dynamic type, but fell rapidly after inhalation of bronchodilators, and the dose-resistance curve looked like an isosceles triangle, however, in COPD and postinfectious goup, the resistance increased slowly, especially in the postinfectious goup, it even showed an appearance similar to BPT negative curve.Conclusion1. Astograph and IOS were the same predictive value in BPT. Astograph method helps to diagnose the cause of airway hyperresponsiveness.2. BPT was highly specific to CVA diagnosis, thus, developing CVA screening in chronic cough patients could help to make a correct diagnosis as well as give a precise treatment as early as possible, so that cut off its way towards a characteristic asthma.3. A great variety of factors can lead to chronic cough, and two or more factors may exist in one single patient at the same time, thus, careful follow up should be payed more attention during the etiological diagnosis of chronic cough, and if the therapy is not curative, it is necessary to alter the treatment timely.【关键词】激发试验 慢性咳嗽 咳嗽变异型哮喘【英文关键词】Bronchial provocatio