【作者】 冯晓凯；

【导师】 林江涛；

【作者基本信息】 北京协和医学院 ， 内科学呼吸， 2014， 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、平滑肌细胞、气道上皮细胞等)和细胞组分参与的气道慢性炎症性疾病。主要特征包括气道慢性炎症,气道对各种刺激因素呈现的高反应性,广泛多变的可逆性气流受限以及随病程延长而导致的一系列气道结构的改变,即气道重构。随着全球工业化的进展,哮喘患病率呈逐年增高的趋势,目前中国约有2000万人罹患哮喘,不仅严重影响了患者生活质量,而且因其所产生的直接和间接成本均造成了巨大的个人和社会经济负担。因此如何防治哮喘已成为我国医学界目前所面临的重要课题。众所周知,导致哮喘发病和加重的危险因素多种多样,且某些危险因素对不同个体及其不同的生长发育阶段的有着不同的作用,因此探究哮喘患病相关危险因素将对未来的哮喘防治及管理具有里程碑式的意义。但目前我国尚缺乏关于哮喘患病率及危险因素的大规模流行病学调查,这种现状已经成为我国哮喘防治和管理水平进一步提高的桎梏,同时不利于国家制定相关的卫生政策以及合理的利用卫生资源。为全面了解我国支气管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、控制现状、对疾病的认知和管理的情况,我们以“全国哮喘患病情况及相关危险因素流行病学调查”(中华医学会临床医学科研专项资金和首都医学发展科研基金)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、上海、广东、辽宁、河南、陕西、江苏、四川八个省(市)年龄14岁以上人群展开了调查,以了解全国哮喘的流行病学特点,为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。本人作为该研究的主要成员,主要负责调查的组织实施、资料的整理归档和数据的统计分析工作。目的1.调查我国14岁以上人群支气管哮喘患病情况,以明确我国目前哮喘的流行趋势。2.初步探讨我国与支气管哮喘发病相关的危险因素,获得哮喘相关危险因素的分布特点。3.了解我国支气管哮喘患者的常见诱发或加重因素、临床症状等特征。4.获得目前我国支气管哮喘患者的控制现状、疾病的认知和管理程度以及哮喘对患者生命质量的影响。方法1.对象：(1)目标人群：首先按行政区域划分将我国分为华北、东北、华东、华南、中南、西南、西北7个区域,在各个区域分别选取1-2个具有代表性的省(市)进行支气管哮喘流行病学调查,最终确定北京、上海、广东、辽宁、河南、陕西、江苏、四川8个省(市)年龄>14的全部常住居民为研究目标人群,以其中多级整群抽样确定并符合入选标准的居民为研究对象；(2)入选标准为：①年龄>14岁,男女均可；②具有当地户籍且于当地连续居住2年以上或非当地户籍于当地连续居住3年以上。同时符合以上两条者即纳为研究对象。2.方法：按照分层整群不等比随机抽样方法对八个省(市)采用统一的流调表格,按照分层整群不等比随机抽样方法每省分别抽取3个县(县级市)和2个市辖区(县),每个县(县级市)和市辖区(县)分别抽2个乡镇和2个街道,每个乡镇分别抽2个行政村和2个居委会,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。以患病率1.5%计算决定每省抽样样本数至少为12000人。根据病史、体征和肺功能检查确诊哮喘患者,研究哮喘的患病率以及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,以了解我国哮喘患者的控制现状、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SPSS12.0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。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180099人,回收有效调查问卷164215份,男性79692名、女性84523名,哮喘患者2034人,全国哮喘总体患病率为1.24%,不同地区、年龄层哮喘患病率均存在明显差异。2.相关危险因素分析显示,吸烟[比值比(OR)=1.70,95%可信区间(CI)：1.55-1.86]、母乳喂养(OR=0.80,95%CI：0.67-0.96)、遗传因素[OR值及相应95%CI亦均大于1,以支气管哮喘最为显著(OR=10.44,95%CI:8.99-12.11)]、合并症(OR值及相应95%CI亦均大于1)、体重指数(与正常体重比较超重与肥胖发生支气管哮喘的OR值分别为：OR=1.36,95%CI：1.21-1.53和OR=10.63,95%CI：9.57-11.80)、宠物饲养(OR值及相应95%CI均大于1)。3.常见的诱发因素依次为感冒、气候变化、接触冷空气、劳累、油烟、情绪紧张或激动、接触或吸入灰尘、吸烟、跑步、屋尘；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、咳嗽和气急。4.本次调查共检出2034名哮喘患者,年龄平均(56±18)岁。哮喘人群中完全控制者占40.51%,部分控制者占42.58%,未控制者占16.91%。在过去1年中因哮喘加重平均住院率为22.62%,因哮喘平均急诊率为27.00%。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22.42%和14.85%。哮喘患者规律使用吸入激素的比例仅14.75%。22.71%患者在最近1年中做过肺功能检查,12.83%患者仅在疾病加重时使用过峰流速仪,每日规律使用峰流速仪者仅占1.62%。59.64%患者因哮喘在娱乐、教育、生育和就业中受限,甚至3.98%想过自杀。结论1.我国支气管哮喘总体患病率为1.24%,通过将部分省(市)哮喘患病率与其既往患病率比较,提示我国支气管哮喘患病率呈明显上升趋势。2.影响我国支气管哮喘发病的危险因素众多,其中既包括宿主因素如遗传因素、肥胖,也包括吸烟、母乳喂养、合并症、宠物饲养等环境因素。3.本次调查发现我国哮喘患者：(1)发作或加重时的常见诱发因素依次为：刺激性气体、感冒、气候变化、接触冷空气、劳累、油烟、情绪紧张或激动、接触或吸入灰尘、吸烟、跑步、屋尘；(2)发作或加重时的常见症状依次为：喘息、胸闷、咳嗽和气急；最严重症状为：喘息、气急和胸闷；(3)吸烟率高于普通人群；(4)最常见的合并症为过敏性鼻炎、GERD、COPD等。4.本次调查发现我国哮喘患者：(1)哮喘控制率较低,与GINA所提出的目标尚存很大差距；(2)对疾病的本质及治疗目标的认知程度较低；(3)哮喘管理程度较低,表现在：规范化药物的使用率、定期随访及病情监测等方面；(4)生命质量较低,表现在：近一半患者因哮喘在日常生活中明显受限；很多患者情感受到影响,甚至想过自杀。更多还原

【Abstract】 BackgroundBronchial asthma (asthma) is a chronic inflammatory airway disease in which many cells (such as eosinophils, mast cells, T lymphocytes, neutrophils, smooth muscle cells, airway epithelial cells) and cellular elements was involved. The disorder of the airway is characterized by chronic airway inflammation, airway hyperresponsiveness to various stimuli presented, reversible airflow limitation and a series changes of airway structure with the duration of disease caused which was called airway remodeling. The treatment not only consumes a large number of countries health resources, but also results in serious social and economic burden due to labor loss. With the development of global industrialization, the morbidity of asthma is increasing year by year, with an estimated20million affected individuals in China. There are about5-10%of patients who is still not well controlled after they were treated with the standard therapy. All these cases are called difficult asthma, although the proportion is not high, but it is an important reason for increasing costs of asthma. As everyone knows, there are many risk factors which are related to asthma and exacerbate the symptoms of asthma, and some risk factors have different effect on different individuals and different growth stages of individuals. Therefore, to explore the related risk factors of asthma is a milestone for the prevention and management of asthma in the future. But there is lack of large-scale epidemiological investigation on asthma prevalence and risk factors in China. Epidemiology survey on prevalence and risk factors of asthma will make great significance on the treatment and prevention of asthma. This situation has become the shackles of improving the level of the prevention and management of asthma, which also is an obstacle to formulate relevant health policies in order to make rational use of health resources.A comprehensive study was conducted to investigate the prevalence, risk factors, clinical feature, control level and reality of asthma, difficult asthma and special type of asthma. With the excellent platform we perform the epidemiological survey on China Asthma and Risk factors Epidemiologic investigation (Chinese Medical Association funds research special clinical medicine Projects in the Capital medical development scientific research). A cross-sectional study was carried out in this study (February2010to August2011) in Beijing, Shanghai, Guangdong, Liaoning, Henan, Shanxi, Jiangsu, Sichuan residents among the people who aged more than14years. The multi-stage random cluster sampling methods was applied to understand the epidemiological characteristics of asthma and provide scientific basis for prevention and control. 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 of bronchial asthma in China among the people who aged more than14years in order to to understand the epidemic trend of asthma.2. To obtain the associated with asthma risk factors and the distribution characteristics of risk factors in China.3. To understand the aggravating factors and the features of clinical symptoms of asthma in China.4. To evaluate the current status of asthma control and their insights and self-management of asthmatics and then assess the effect on on quality life of asthmatics.Methods1. Subjects:(1)the target population:According to the division of administrative regions in China which include north, northeast, southern china, east, south, southwest and northwest in the7regions, we selected for one province (city) or two in order to carry on epidemiology survey on the prevalence and associated risk factors of asthma. The people who aged more than14years in eight areas (Beijing, Shanghai, Guangdong, Liaoning, Henan, Shanxi, Jiangsu, Sichuan provinces (cities)) were the target population of the study. And the objects were obtained by stratified cluster random sampling.(2)The criterion of objects were as follow:①The age of the individual was more than14years, male or female;②People who had register of local areas and lived here for no less than2years or those residents who had not registered of local areas but lived here longer than3years.2. Methods:The multi-stage random cluster sampling methods was applied to obtain study subjects in8provinces (cities). Steps1,2districts or3counties were randomly selected in each category. Step2, in each of the selected districts or counties,2towns or street offices were randomly sampled as the target towns or street offices. Step3, in each of the selected towns or street offices,2communities or villages were randomly sampled Steps4, all of the residents in the selected communities or villages were sampled. Every province or city was sampled12000according to the prevalence rate of1.5%calculated, and the total sample size was about180000.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 eight areas 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 SPSS12.0software 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.2-tailed P value less than0.05was considered statistically significant.Results1. Sampling population was180099and164215questionnaires were effective actually, of which2034had asthma. Male were79692and female were84523. The overall prevalence rate was1.24%(2034/164215). In different region, age, nationality, occupation and level of education people there are difference in the prevalence of asthma.2. Correlation analysis of risk factors showed that smoking (OR=1.70,95%CI:1.55-1.86), breast feeding (OR=0.80,95%CI:0.67-0.96), genetic factors (OR and corresponding95%CI were greater than1, asthma is the most significant (OR=10.44,95%CI:8.99-12.11), complications (OR and95%CI were greater than1), body mass index(compared with normal weight, overweight(OR=1.36,95%CI:1.21-1.53), obesity (OR=10.63,95%CI:9.57-11.80)), pet (OR and the corresponding95%CI is more than1).3. Patients-reported asthma triggers were catching a cold, climate change,exposure to cold air, tired, irritant gas, stress or nervous, contact or inhalation of dust, smoking, exercise and house dust. The severe symptoms that the asthmatics reported when they episodes were wheezes, shortness of breath and dyspnea. The predominant symptoms that the asthmatics reported were wheeze, followed by dyspnea, cough and shortness of breath.4. A total of2034asthmatic patients were detected in this survey with a mean age of (56+18) years. In this study, according to the ACT test15.63%(318/2034) of the asthmatics had complete control,49.46%(1006/2034) had partially control and34.91%(710/2034) had poorly controlled asthma. In the past year,27.00%(549/2034) of patients reported emergency room visit at least one time within the past year due to asthma exacerbation and22.62%(460/2034) had been hospitalized because of sudden attacks.22.42%(456/2034) of the asthmatics knew that the intrinsic feature of asthma was inflammation and14.85%(302/2034) of the asthmatics understood the treatment goal of this disease. Only14.75%(300/2034) patients used inhaled corticosteroids regularly.22.71%(462/2034) asthmatics had undergone a lung functional test in the past year.12.83%(261/2034) had used peak flow meter of their own only in the exacerbation of the disease, but only1.62%(33/2034) monitored peak flow regularly.59.64%(1213/2034) asthmatics reported that their activities including entertainment, learning, fertility and employment were limited due to asthma, Even3.98%(81/2034) had mind of suicide.Conclusions1. The prevalence rate of asthma is1.24%in China.The prevalence rate of asthma in China increased significantly compared with before in some areas.2. There are many kinds of associated risk factors of asthma. Host factors such as genetic factors, obesity and environmental factors included history of smoking, breastfeeding, comorbidity, pets and other factors.3. The survery found:(1)Patients-reported asthma triggers were exposure to irritant gas, catching a cold, climate change, cold air, tired, stress or nervous, contact or inhalation of dust, smoking, exercise and house dust.(2)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, cough and shortness of breath.(3)Smoking rates of asthmatics are higher than in the general population.(4)The most common complications is allergic rhinitis, GERD, COPD and so on.4. In this study,(1)The rate of asthma control is relatively lower in China. It still falls down below the GINA goals (2)The patients who can understand correctly the nature and goals of treatment are lower.(3)The levels of management of asthma in China are lower which include the use of rate of standardized medicine, regular follow-up and monitoring and so on.(4)The levels of quality of life are lower which include have activity limition of nearly half of patients, emotion affected of many patients, even to commit suicide.更多还原