【作者】 王文雅；

【导师】 林江涛；

【作者基本信息】 北京协和医学院 ， 内科学， 2013， 博士

【摘要】 研究背景支气管哮喘(Bronchial asthma,简称哮喘)是由多种细胞(如嗜酸粒细胞、肥大细胞、T淋巴细胞、中性粒细胞、树突状细胞、气道上皮细胞等)和细胞组分参与的一种以气道高反应(airway hyper responsiveness, AHR)、气道炎症和气道重塑为特征的常见慢性呼吸系统疾病之一。随着全球工业化和城市化进程不断加快、环境污染以及气候和生态环境的变化等因素的影响,哮喘发病率和死亡率呈逐年增高的趋势,目前中国约有2000万人罹患哮喘,死亡率位居全球之首。哮喘不仅对患者生活质量造成巨大影响,同时所产生的直接医疗费用和间接成本均造成了巨大个人和社会经济负担。因此积极防治哮喘是目前医学界所面临的共同课题。并且随着人们环境和生活方式的改变,哮喘的危险因素也在不断变化,所以对不同人群进行哮喘患病率及其相关危险因素的研究是非常具有现实意义的。至今北京地区尚缺乏大样本高质量成人哮喘患病率及其相关危险因素的流行病学研究,且未形成有效的哮喘防治体系。北京哮喘流行病学的不足,已成为北京地区哮喘防控的瓶颈,影响了相关卫生政策和干预措施的制定。因此为全面了解北京地区哮喘患病率和相关危险因素的流行病学分布特点以及哮喘患者的临床特征、控制水平以及疾病的认知和管理的情况,我们利用北京市卫生局和中国哮喘联盟开展的“北京地区哮喘患病率及相关危险因素的调查研究”(首都医学发展科研基金项目)为平台,于2010年2月至2011年8月,通过多阶整群随机抽样的方法对北京地区年龄14岁以上人群展开了哮喘横断面调查,以了解北京地区哮喘的流行病学特点,为北京地区哮喘的预防和控制提供科学依据。研究结果来源于该研究的基线数据。本人是该研究的主要成员,主要负责该调查的组织实施、资料的整理归档和数据的统计分析工作。目的1.调查2010-2011年北京地区年龄14岁以上人群的哮喘患病率情况,明确北京地区哮喘的流行趋势。2.初步探讨北京地区哮喘发病相关的危险因素,明确诱发或加重哮喘的常见诱发因素。获得北京地区哮喘相关危险因素的分布特点。3.了解北京地区哮喘患者的常见临床症状、合并疾病等临床特征。4.获得目前北京地区哮喘患者的控制水平、疾病的认知和管理程度以及哮喘对患者生活质量的影响。方法1.对象：以北京地区年龄14岁以上的全部常住居民为研究目标人群,以其中多阶整群随机抽样确定并符合入选标准的居民为研究对象。研究对象入选标准为：(1)年龄14岁以上,性别不限；(2)具有北京市户籍且于北京连续居住2年以上或非北京市户籍于北京连续居住3年以上的北京市常住居民。2.方法：2010年2月至2011年8月,采用多阶整群随机抽样：北京市行政区划共有16个区、2个县,按照城区、近郊区及远郊区县分为3类。城区4个：东城、西城、宣武、崇文；近郊区4个：海淀、朝阳、石景山、丰台；远郊区县10个：通州、门头沟、大兴、房山、昌平、顺义、怀柔、平谷、密云区和延庆县。首先从3类区域内各抽取2个城区或县,然后按同样方法分别于所抽2个城区或县内随机抽取1-2个乡镇或下属街道办事处,最后分别于所抽1-2个乡镇或下属街道办事处内分别各抽取1-2个社区或村。当抽样落实到社区或村时,对其辖区内的所有符合入选标准条件的居民全部纳入。于城区、近郊区和远郊区内各抽取样本数20000人,抽样共计约60000人。根据病史、体征和肺功能检查确诊哮喘患者,研究北京地区哮喘患病率和相关危险因素的流行病学分布特点。然后对所确诊的哮喘患者进一步行哮喘控制水平、疾病的认知和管理程度、哮喘对患者生活质量的影响等方面详细问卷的填写,以了解北京地区哮喘患者的控制、认知和管理水平。调查完毕后将所有调查问卷汇总并进行审核,对每份试卷进行编码和整理归档。最后将调查问卷及相应的入档号由专人双份录入、双向核对,以确保数据准确。3.统计分析：所有数据资料采用计算机Epidata3.1软件录入和存储,以SAS9.2软件包进行统计学处理。计量资料采用最大值、最小值、均数±标准差(x±s)描述；计数资料以率、构成比、相对比及频数分布等表示。率的比较采用χ2检验或趋势χ2检验。样本均数间的比较采用单因素方差分析或非参数检验。以P<0.05为差异有统计学意义。结果1.入户调查共计61107人,回收有效调查问卷57647份；确诊哮喘患者687例,其中男296例,女391例；北京地区哮喘总体患病率为1.19%(687/57647),其中郊区人群患病率为1.40%(269/19179),显著高于市区的1.09%(418/38468)(χ2=10.850,P=0.001)；女性患病率为1.32%(391/29700),显著高于男性的1.06%(296/27947)(χ2=8.098,P=0.004)。不同年龄段人群哮喘患病率差异也有统计学意义(χ2=404.874,P<0.005)。市区与郊区人群患病率分别较2002年增高了1.12倍和2.26倍。2.女性、主动吸烟史、肥胖、合并过敏性疾病、14岁之前曾患有肺炎、气管／支气管炎、结核、过敏性鼻炎或湿疹、直系亲属患有哮喘和居住地为郊区可能是哮喘患病的危险因素。37.1%(255/687)哮喘患者存在诱发或加重哮喘的危险因素,常见的诱发因素依次为接触冷空气(154/687)、气候变化(141/687)、刺激性气体(120/687)、感冒(111/687)、劳累(75/687)、运动(67/687)和情绪紧张或激动(56/687)和吸烟(55/687)。3.本次调查共检出687名哮喘患者,年龄平均(60.7±16.5)岁,哮喘病程平均(20.8±17.3)年。哮喘患者中以高中以下文化程度者居多,职业分布以工人和农民为主。本次调查研究首次确诊哮喘患者198例,占全部哮喘患者的28.8%(198/687)。北京地区哮喘患者自诉其哮喘发作或加重时最严重的三种症状依次为：喘息(383/687)、气急(167/687)和胸闷(154/687)；常见症状依次为：喘息(557/687)、胸闷(497/687)、咳嗽(484/687)。哮喘患者有主动吸烟史者占31.9%(219/687)。哮喘患者合并过敏性鼻炎者占32.9%,合并湿疹者占9.3%,合并过敏性眼结膜炎者占5.5%,合并胃食管反流性疾病者占4.4%。4.本调查的哮喘控制测试评分显示,北京地区34.9%(240/687)哮喘患者达到哮喘控制,39.2%(269/687)处于部分控制,25.9%(178/687)处于未控制。在过去1年中21.3%(146/687)患者因哮喘加重而看急诊,14.0%(96/687)因哮喘加重住院。患者对哮喘的炎症本质和哮喘治疗目标的正确认识率分别为13.5%(93/687)和15.1%(104/687)。哮喘患者规律使用吸入激素的比例仅12.1%(83/687)。71.2%(489/687)患者在最近1年中未做过肺功能检查,12.3%(84/687)患者拥有峰流速仪,每日规律使用峰流速仪者仅占1.5%(10/687)。46.6%(320/687)患者因哮喘在娱乐、教育、生育和就业中受限,甚至3.6%(25/687)想过自杀。结论1.北京地区哮喘流行病学形势非常严峻,市区和郊区患病率较十年前均有大幅增高,其中女性高于男性,郊区高于市区。不同年龄、职业、受教育程度人群间哮喘患病率均存在差异。2.影响北京地区哮喘发病的相关危险因素众多,既包括宿主因素如遗传因素、特应质、性别和肥胖,也包括主动吸烟史、儿时罹患肺炎、气管／支气管炎、结核类呼吸道感染性疾病、居住在郊区等环境因素。37.1%患者存在哮喘发作或加重的诱发因素,常见的诱发因素依次为接触冷空气、气候变化、刺激性气体、感冒、劳累、运动和情绪紧张或激动和吸烟。3.本次调查共检出687名哮喘患者,其中首次确诊哮喘患者198例,占此次全部确诊哮喘患者的28.8%。哮喘患者中以高中以下文化程度者居多,职业分布以工人和农民为主。北京地区哮喘患者自诉其哮喘发作或加重时最严重的三种症状依次为：喘息、气急和胸闷；常见症状依次为：喘息、胸闷和咳嗽。31.9%的哮喘患者有吸烟史。哮喘患者合并过敏性鼻炎者占32.9%,合并湿疹者占9.3%,合并过敏性眼结膜炎者占5.5%,合并胃食管反流性疾病者占4.4%。4.本调查的哮喘控制测试评分显示,北京地区34.9%患者达到了哮喘控制,39.2%处于部分控制,25.9%处于未控制。哮喘患者的控制水平较前有所提高,但与GINA指南所推荐的治疗目标尚存差距,急诊率和住院率仍处于较高水平。患者对疾病的认知和病情的自我监测程度仍然较低。哮喘控制不佳对患者日常活动和心理社会功能均造成了很大影响。应进一步加强哮喘患者的教育和管理,避免哮喘的致病因素和诱发因素、减少急性加重。指导患者长期规范化治疗从而提高患者生活质量、降低疾病负担。更多还原

【Abstract】 BackgroundBronchial asthma (asthma) is a chronic pulmonary disease in which many cells (eosinophils, mast cells, T lymphocytes, neutrophils, dendritic cells, airway epithelial cells) and cellular elements play an important role. The disorder of the airway is characterized by airway hyper responsiveness (AHR), airway inflammation, and airway remodeling. With the effect of industrialized and urbanization, climate change and environmental or ecology pollution, the prevalence rate and mortality of asthma are increasing year by year. Asthma is also a problem in China, with an estimated20million affected individuals. It not only reduces the quality life of individual but also brings the serious burden to the social economic and the family because of the great cost. Therefore, asthma has been the universal subject of prevention. Moreover, the factors that influence the risk of asthma are gradually changing with the ecology and lifestyle. So the epidemiology survey on prevalence and risk factors of asthma in different regions will make great significance on asthma prevention.However, there is not much information on the epidemiological study of asthma in Beijing among the adults, especially lack of the effective prevention and treatment systems about it. The intervention measures and policy were not put into practice because of the deficiency of epidemiological survey data in Beijing. Then a comprehensive study was conducted to investigate the prevalence, risk factors, clinical feature, control level and reality of asthma. A collaboration of Beijing Health Bureau and China Asthma Alliance, provide an excellent platform to the epidemiological survey on prevalence rate and the associated risk factors of asthma in Beijing area (Projects in the Capital medical development scientific research). A cross-sectional study was carried out in this study (February2010to August2011) in Beijing residents among the people who aged more than14years. The multi-stage random cluster sampling methods was applied to obtain study subjects. In this report, the baseline data of the project was used. The author is one of the investigators of the project, responsible for coordination and inspection of the study field and data management and analysis.Objective1. To survey the prevalence rate and risk factors of bronchial asthma in Beijing area among the people who aged more than14years from2010to2011.2. To obtain the clinical feature of asthmatic patients in Beijing area such as clinical syndromes, combinations, triggers and so on.3. To evaluate the current level of asthma control and their insights and self-management from asthmatics and then assess the impaction on quality life of asthmatics.Methods1. Subjects:The people who aged more than14years in Beijing area were the target population of the study. And the objects were obtained by stratified cluster random sampling. The criterion of objects were as follow:(1) The age of the individual was more than14years, male or female;(2) People who had register of Beijing and lived here for no less than2years or those residents who had not registered of Beijing but lived here longer than3years.2. Methods:From February2010to August2011, a cross-sectional study was carried out in this study. The multi-stage random cluster sampling methods was applied to obtain study subjects. The16districts and2counties of Beijing were classified in to three categories as urban (Dongcheng, Xicheng, Xuanwu and Chongwen), suburb (Haidian, Chaoyang, Shijingshan and Fengtai) and outskirt (Tongzhou, Mentougou, Daxing, Fangshan, Changping, Shunyi, Huairou, Pinggu, Miyun and Yanqing). Steps1,2districts or counties were randomly selected in each category. Step2, in each of the2selected districts or counties,1-2towns or street offices were randomly sampled as the target towns or street offices. Step3, in each of the1-2selected towns or street offices,1-2communities or villages were randomly sampled as the target communities or villages in each of the grade from grade1to grade4. Steps4, all of the residents in the selected communities or villages were sampled. Every districts or counties were sampled20000, and the total sample size was about60000. Home visit completion of epidemiological questionnaires was conducted. And the asthmatics were diagnosed based upon case history, clinical signs and lung function test. Then the epidemiological status of Beijing area on prevalence and risk factors were investigated. Detailed epidemiology data on asthma control and reality was collected via face-to-face home visit interviews among the asthmatics so the control level and of asthma was investigated. All of the epidemiological questionnaires were collected and checked. Then they were coded and filed. At last, the questionnaires and their codes were input and checked by the professional person twice so that the data could correctly input.3. Statistical Analysis:The version3.1of Epidata system was used for data entry and the data were analyzed using SAS9.2software package. The General social characteristics of all the participants were described. Minium, Maximum, Means and standard errors were calculated for measurement data. And prevalence rate, relative rate and constituent ratio were calculated for numeration data. Analysis of variance or nonparametric statistics were used to compare statistical differences of variables. Chis-square test or trend chi-square was used to compare statistical differences of prevalence rates. A2-tailed P value less than0.05was considered statistically significant.Results1. In total, sampling population was61107and57647questionnaires were valid actually. Of which687had asthma. Male asthmatics were296and female asthmatics were391. The overall prevalence rate was1.19%(687/57647). The asthma prevalence rates in urban and suburb of Beijing area were1.09%(418/38468) and1.40%(269/19179) respectively and the prevalence rate of asthma in suburb area was significantly higher than that of urban area (χ2=10.850, P=0.001). The asthma prevalence rates in male and female were1.06%(296/27947) and1.32%(391/29700) respectively and the prevalence rate of asthma in female was much higher than that of male (χ2=8.098, P=0.004). There was a significant difference among different age groups (χ2=404.874, P <0.005). The asthma prevalence rates in urban and suburb of Beijing area were highly increased by1.12and2.26times respectively than that of2002.2. The risk factors associated with asthma may be female, active smoking, obesity, combination of allergic rhinitis, diagnosis of pneumonia, bronchitis/bronchiolitis, tuberculosis, allergy rhinitis, eczema, and direct relatives diagnosed of asthma and living in the suburb.255asthmatics were attacked or aggravated by some triggers which accounted for37.1%in all asthma patients. Patients-reported asthma triggers were exposure to cold air (154/687), climate change (141/687), irritant gas (120/687), catching a cold (111/687), tired (75/687), exercise (67/687), stress or nervous (56/687) and smoking (55/687).3. A total of687asthmatic patients were detected in this survey with a mean age of (60.7±16.5) years and disease duration of (20.8±17.3) years.198asthmatics were first diagnosed in this survey which accounted for28.8%(198/687) in all asthma patients that were diagnosed in the survey.15.0%(103/687) asthmatics were diagnosed as asthma when they were in their childhood before14years. The severe symptoms that the asthmatics self-reported when they episodes were wheeze (383/687), shortness of breath (167/687) and dyspnea (154/687). The predominant symptoms that the asthmatics self-reported were wheeze (557/687) followed by dyspnea (497/687) and cough (484/687). The smoking rate of asthmatic patients was31.9%(219/687). The asthmatics who had a complication of allergic rhinitis, eczema, allergy conjunctivitis or GRED were accounted for32.9%,9.3%,5.5%and4.4%respectively.4. In this study, according to the ACT test,34.9%(240/687) of the asthmatics in Beijing area had complete control,39.2%(269/687) had partially control and25.9%(178/687) had poorly controlled asthma. In the past year,21.3%(146/687) of patients reported emergency room visit at least one time within the past year due to asthma exacerbation and14.0%(96/687) had been hospitalized because of sudden attacks.13.5%(93/687) of the asthmatics knew that the intrinsic feature of asthma was inflammation and5.1%(104/687) of the asthmatics understood the treatment goal of this disease. Only12.1%(83/687) patients used inhaled corticosteroids regularly.71.2%(489/687) asthmatics had never undergone a lung functional test in the past year.12.3%(84/687) had a device for peak flow meter of their own but only1.5%(10/687) monitored peak flow regularly.46.6%(320/687) asthmatics reported that their activities including entertainment, learning, fertility and employment were limited due to asthma, Even3.6%(25/687) had mind of suicide.Conclusions1. The prevalence rate of asthma in urban and suburb are highly increased than ten years ago and it posed urgent situation to us. The prevalence rate of asthma in suburb area was significantly higher than that of urban area and the prevalence rate of asthma in female was much higher than that of male. There are significant different prevalence rates between different ages, occupations and education level but There is no differences between Han and Non-Han race.2. There are many kinds of associated risk factors of asthma. Host factors such as atopy, sex, obesity and environmental factors included history of smoking, respiratory tract infection disease in childhood included pneumonia, bronchitis/bronchiolitis, tuberculosis and living in the suburb.255asthmatics were attacked or aggravated by some triggers which accounted for37.1%in all asthma patients. Patients-reported asthma triggers were exposure to cold air, climate change irritant gas, catching a cold, tired, exercise, stress or nervous and smoking.3.687asthmatics were detected and198asthmatics were first diagnosed in this survey which accounted for28.8%in all asthma patients that were diagnosed in the survey. The severe symptoms that the asthmatics self-reported when they episodes were wheeze, shortness of breath and dyspnea The predominant symptoms that the asthmatics self-reported were wheeze followed by dyspnea and cough. The asthmatic patients who had history of smoking was accounted for31.9%. The asthmatics who had a complication of allergic rhinitis, eczema, allergy conjunctivitis or GRED were accounted for32.9%,9.3%,5.5%and4.4%respectively.4. In this study,34.9%of the asthmatics in Beijing area had complete control,39.2%had partially control and25.9%had poorly controlled asthma. The level of asthma control in Beijing area has been improved greatly but it still falls down far below the GINA goals and there were also many times of emergency room visits and hospitalizations of asthmatics in Beijing area in the last year. The level of self-monitoring and insight about the disease among the asthmatics were very low. Activity limited, psychological and social functions were largely impacted by the disease because of the uncontrolled asthma. Therefore it is necessary to educate the asthmatics, guide the patients to the long-term management and standardized therapy and avoid the cause and the triggers of asthma. And then the times of exacerbations of asthma would be reduced and thus the life quality of asthmatics would be improved and the burden of this disease on society would be reduced.更多还原