Early Chronic Obstructive Pulmonary Disease or Early Detection of Mild Disease?
Early Chronic Obstructive Pulmonary Disease or Early Detection of Mild Disease?
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早期慢性阻塞性肺疾病或早期发现轻度疾病？
DOI：
10.1164/rccm.201802-0257le
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发表时间：
2018
影响因子：
24.7
通讯作者：
Bhatt,SuryaP
中科院分区：
文献类型：
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作者：
Bhatt,SuryaP
Martinez及其同事关于区分早期慢性阻塞性肺疾病（COPD）与轻度疾病的观点文章是关于这一重要主题的优秀而及时的论述（1）。临床医生和研究人员经常混淆轻度和早期气流阻塞。当观察到轻度疾病时，很难与早期疾病区分开来，唯一的区分因素是时间信息。作者提出了一些标准，试图区分早期和轻度疾病。虽然这些建议是实用的，但在为临床或研究目的调整“所需”标准方面存在一些问题。50岁以下的人应被视为患有早期疾病的建议没有时间因素，也没有考虑到大多数吸烟者在十几岁时开始吸烟，因此在他们四十多岁时已经积累了大量的吸烟负担。我们最近发现，吸烟持续时间与COPD指标的相关性比包年综合指数更强（2）。确定吸烟的发作是很容易的，因此，通过将那些在保守的吸烟发作10年内出现气流阻塞的患者称为早期COPD，可以很容易地包括时间成分。对于非吸烟相关的COPD，时间性很难确定，但较低的年龄阈值可能会有所帮助。此外，还有一些其他建议需要澄清。首先，作者建议使用支气管扩张剂后数值作为正常值下限（LLN）。不幸的是，可用的LLN值是使用支气管扩张剂前的值。这不是一个微不足道的问题; Tilert及其同事表明，使用支气管扩张剂后固定比率小于0.70和使用支气管扩张剂前比率小于LLN提供了相似的气流阻塞人群估计值，而将支气管扩张剂前标准应用于支气管扩张剂后试验导致的患病率估计值是使用支气管扩张剂前试验获得的患病率估计值的三分之二（3）。因此，使用支气管扩张剂后LLN可能更具特异性，但这可能导致遗漏早期气流阻塞病例，而敏感性可能更重要。其次，计算机断层扫描可以在检测气流阻塞之前识别肺实质和气道的改变，但大多数吸烟者可能有一些结构性变化，
The Perspective article by Martinez and colleagues on differentiating early chronic obstructive pulmonary disease (COPD) from mild disease is an excellent and timely discourse on this important topic (1). Mild and early airflow obstruction are frequently conflated by both clinicians and researchers. Mild disease, when observed, is hard to differentiate from early disease, and the only differentiator is temporal information. The authors propose a number of criteria to attempt differentiation of early and mild disease. Although these suggestions are practical, there are some issues with adapting the “required” criteria for clinical or research purposes. The recommendation that persons younger than 50 years of age should be considered to have early disease does not have a temporal component and does not take into consideration that a majority of smokers start smoking in their teens and hence would have already accumulated a substantial number of pack-years of smoking burden by the time they are in their forties. We recently showed that the duration of smoking is more strongly associated with measures of COPD than the composite index of pack-years (2). It is easy to ascertain the onset of smoking, and so a temporal component can be easily included by terming those with airflow obstruction within a conservative 10 years of smoking onset as having early COPD. For non–smoking-related COPD, temporality is harder to establish, but a lower age threshold may help. Furthermore, a few other suggestions need clarification. First, the authors recommend using post-bronchodilator values for the lower limit of normal (LLN). Unfortunately, available LLN values are prebronchodilator. This is not a trivial issue; Tilert and colleagues showed that using post-bronchodilator fixed ratio less than 0.70 and prebronchodilator ratio less than LLN provide similar population estimates of airflow obstruction, whereas applying prebronchodilator criteria to post-bronchodilator tests results in prevalence estimates that are two-thirds of those obtained using prebronchodilator tests (3). Thus, post-bronchodilator LLN is likely to be more specific, but this may result in missing early cases of airflow obstruction for which sensitivity may be more important. Second, computed tomography can identify alteration in the lung parenchyma and airways before detection of airflow obstruction, but most smokers are likely to have some structural changes, and