Diagnosis of asthma in symptomatic children based on measures of lung function: an analysis of data from a population-based birth cohort study.
Diagnosis of asthma in symptomatic children based on measures of lung function: an analysis of data from a population-based birth cohort study.
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DOI：
10.1016/s2352-4642(17)30008-1
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发表时间：
2017-10
期刊：
影响因子：
--
通讯作者：
Simpson A
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作者：
Murray C;Foden P;Lowe L;Durrington H;Custovic A;Simpson A
人们对哮喘过度诊断表示担忧。英国国家健康与护理卓越研究所（NICE）提出了一种新的诊断算法，依次应用四种肺功能指标（1秒用力呼气量[FEV 1]与用力肺活量[FVC]之比<70%，支气管扩张剂可逆性≥ 12%，呼出一氧化氮分数[FeNO] ≥35 ppb，呼气峰流速变异性>20%）。我们的目的是单独评估三个测试的诊断价值，然后在有症状的儿童中测试所提出的算法。我们使用了曼彻斯特哮喘和过敏研究中13-16岁的随访数据，这是一项前瞻性、基于人群的出生队列研究。我们首先介绍整个人群的结果，然后按疾病亚组进行。为了模拟初级保健的情况，我们纳入了在过去12个月内报告喘息、咳嗽或呼吸困难症状且未定期吸入皮质类固醇的参与者。我们使用流行病学定义的当前哮喘，定义为所有三个医生诊断的哮喘，当前喘息，目前使用的哮喘治疗，由父母在一份有效的问卷报告。我们将对所有三个问题都有否定回答的儿童指定为非哮喘对照组。我们还在随访时测量了肺功能测定、支气管扩张剂可逆性和FeNO;未获得呼气峰流速变异性的数据。我们在算法的每一步计算了当前肺功能测试阳性的参与者比例，并记录了符合我们哮喘定义的参与者数量。在该队列出生的1184名儿童中，有772名在2011年7月22日至2014年11月11日期间在13-16岁时参加了随访。在630名完成肺功能测定的儿童中，10名（2%）儿童的FEV 1：FVC低于70%，其中只有2名（20%）儿童目前患有哮喘。624名儿童中有54名（9%）支气管扩张剂可逆性阳性，其中只有12名（22%）目前患有哮喘。485名儿童中有115名（24%）的FeNO为十亿分之三十五或更多，其中29名（25%）目前患有哮喘。56例哮喘患儿中仅有4例的三项检查（肺量测定、支气管扩张剂可逆性和FeNO）结果均为阳性。相反，56名哮喘儿童中有24名（43%）在所有三项测试中均为阴性。在多变量logistic回归模型中，FEV 1：fvc（p= 0.0075）和FeNO（p<0.0001）与哮喘独立相关，而支气管扩张剂可逆性（p= 0.97）与哮喘无关。在报告近期症状的儿童中，该算法的诊断准确性较差。我们的研究结果挑战了肺量测定的建议截止值，肺功能检查的顺序，以及支气管扩张剂可逆性在算法序列中的位置。在获得更好的证据之前，建议的哮喘诊断NICE算法不应在儿童中实施。英国医学研究理事会。
Concerns have been expressed about asthma overdiagnosis. The UK National Institute of Health and Care Excellence (NICE) proposed a new diagnostic algorithm applying four lung function measures sequentially (ratio of forced expiratory volume in 1 s [FEV1] to forced vital capacity [FVC] <70%, bronchodilator reversibility ≥12%, fractional exhaled nitric oxide [FeNO] ≥35 parts per billion, and peak expiratory flow variability >20%). We aimed to assess the diagnostic value of three of the tests individually, and then test the proposed algorithm in symptomatic children. We used follow-up data at age 13–16 years from the Manchester Asthma and Allergy Study, a prospective, population-based, birth cohort study. We initially present results for the whole population, then by subgroup of disease. To simulate the situation in primary care, we included participants reporting symptoms of wheeze, cough, or breathlessness in the previous 12 months and who were not on regular inhaled corticosteroids. We used an epidemiological definition of current asthma, defined as all three of physician-diagnosed asthma, current wheeze, and current use of asthma treatment, reported by parents in a validated questionnaire. We assigned children with negative answers to all three questions as non-asthmatic controls. We also measured spirometry, bronchodilator reversibility, and FeNO at follow-up; data for peak expiratory flow variability were not available. We calculated the proportion of participants with a current positive lung function test at each step of the algorithm, and recorded the number of participants that met our definition of asthma. Of 1184 children born into the cohort, 772 attended follow-up at age 13–16 years between July 22, 2011, and Nov 11, 2014. Among 630 children who completed spirometry, FEV1:FVC was less than 70% in ten (2%) children, of whom only two (20%) had current asthma. Bronchodilator reversibility was positive in 54 (9%) of 624 children, of whom only 12 (22%) had current asthma. FeNO was 35 or more parts per billion in 115 (24%) of 485 children, of whom 29 (25%) had current asthma. Only four of 56 children with current asthma had positive results for all three tests (spirometry, bronchodilator reversibility, and FeNO). Conversely, 24 (43%) of the 56 children with current asthma were negative on all three tests. FEV1:fvc (p=0·0075) and FeNO (p<0·0001), but not bronchodilator reversibility (p=0·97), were independently associated with asthma in multivariable logistic regression models. Among children who reported recent symptoms, the diagnostic accuracy of the algorithm was poor. Our findings challenge the proposed cutoff values for spirometry, the order in which the lung function tests are done, and the position of bronchodilator reversibility within the algorithm sequence. Until better evidence is available, the proposed NICE algorithm on asthma diagnosis should not be implemented in children. UK Medical Research Council.