中国哮喘联盟

日常诊疗中慢性阻塞性肺病诊断和控烟支持:证据和实践的差异

2018/01/19

   摘要

   目的:回顾澳洲初级诊疗机构中慢性阻塞性肺病(COPD)诊断准确率,并描述其中吸烟者戒烟经验和偏好。
   设计、场所和受试者:年龄≥40岁的COPD患者受邀参与研究,且在既往一年中在墨尔本全科诊所随访至少2次以上,当前或既往吸烟者,吸烟指数≥10包·年,或正在接受COPD治疗。完成问卷调查,如条件允许,进行肺功能测定(FEV1/FEV6),评价健康相关生活质量,呼吸困难和临床症状。
   结果:41个医疗点中1050名患者纳入基线筛选(2015年2月至2017年4月)。其中245名受试者接受COPD治疗,130名(53.1%)患者满足肺功能诊断标准(应用支气管扩张剂后FEV1/FVC < 0.7),或临床相关。在37%未确诊COPD病例中,9.8%患者无明确的结果。临床筛选和肺功能检查发现142例新发COPD病例(17.6%受试者之前诊断不明确;95%CI:15.1-20.5%)。690名受试者(65.7%)为当前吸烟者,其中360名受试者在既往12个月内尝试戒烟;286名受试者(尝试戒烟者中81%)表示戒烟存在困难。尼古丁依赖治疗(205名受试者,57.4%)和伐尼克兰(110名受试者,30.8%)则是选择最多的治疗药物,药物副作用也较多。催眠治疗则是应用最多的非药物治疗方法(62名吸烟者,17%);电子烟为38名吸烟者(11%)所使用。187名当前吸烟者(27.6%)表示打算使用电子烟进行戒烟。
   结论:COPD被误诊或漏诊。病例检查和肺功能测试可以提高诊断率。药物戒烟副作用和戒烟困难较为常见。医务人员应注重证据依赖的戒烟手段并密切关注戒烟困难和辅助戒烟措施的副作用。

 

(上海交通大学医学院附属瑞金医院呼吸与危重症医学科 周剑平 万欢英 摘译)

(Med J Aust. 2018 Jan 15;208(1):29-34.)

 

 

Diagnosing COPD and supporting smoking cessation in general practice: evidence-practice gaps.

 

Med J Aust. 2018 Jan 15;208(1):29-34.

Liang J et al.
 
Abstract
OBJECTIVE:To review the accuracy of diagnoses of chronic obstructive pulmonary disease (COPD) in primary care in Australia, and to describe smokers' experiences with and preferences for smoking cessation.
DESIGN, SETTING AND PARTICIPANTS:Patients were invited to participate if they were at least 40 years old and had visited participating general practice clinics in Melbourne at least twice during the previous 12 months, reported being current or ex-smokers with a smoking history of at least 10 pack-years, or were being managed for COPD. Interviews based on a structured questionnaire and case finding (FEV1/FEV6 measurement) were followed, when appropriate, by spirometry testing and assessment of health-related quality of life, dyspnoea and symptoms.
RESULTS:1050 patients attended baseline interviews (February 2015 - April 2017) at 41 practices. Of 245 participants managed for COPD, 130 (53.1%) met the spirometry-based definition (post-bronchodilator FEV1/FVC < 0.7) or had a clinical correlation; in 37% of cases COPD was not confirmed, and no definitive result was obtained for 9.8% of patients. Case finding and subsequent spirometry testing identified 142 new COPD cases (17.6% of participants without prior diagnosis; 95% CI, 15.1-20.5%). 690 participants (65.7%) were current smokers, of whom 360 had attempted quitting during the previous 12 months; 286 (81.0% of those attempting to quit) reported difficulties during previous quit attempts. Nicotine replacement therapy (205, 57.4%) and varenicline (110, 30.8%) were the most frequently employed pharmacological treatments; side effects were common. Hypnotherapy was the most popular non-pharmacological option (62 smokers, 17%); e-cigarettes were tried by 38 (11%). 187 current smokers (27.6%) would consider using e-cigarettes in future attempts to quit.
CONCLUSIONS:COPD was both misdiagnosed and missed. Case finding and effective use of spirometry testing could improve diagnosis. Side effects of smoking cessation medications and difficulties during attempts to quit smoking are common. Health professionals should emphasise evidence-based treatments, and closely monitor quitting difficulties and side effects of cessation aids.
 


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