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| 上海地区部分二、三级甲等医院稳定期慢性阻塞性肺疾病患者合并症特征调查及其临床意义 |
| 冯秀敏1,2,葛海燕3,顾文超4,杭晶卿5,周敏6,韩锋锋7,钱叶长8,金晓燕9,李圣青10,高蓓兰11,包红12,余莉13,揭志军14,王健15,张景熙1*,朱惠莉3* |
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(1. 海军军医大学(第二军医大学)长海医院呼吸与危重症医学科, 上海 200433;
2. 新疆医科大学第一附属医院昌吉分院呼吸与危重症医学科, 昌吉 831100;
3. 复旦大学附属华东医院呼吸与危重症医学科, 上海 200040;
4. 上海市浦东新区人民医院呼吸与危重症医学科, 上海 201200;
5. 上海市普陀区人民医院呼吸与危重症医学科, 上海 200060;
6. 上海交通大学医学院附属瑞金医院呼吸与危重症医学科, 上海 200020;
7. 上海交通大学医学院附属新华医院呼吸与危重症医学科, 上海 200092;
8. 上海中医药大学附属曙光医院宝山分院呼吸与危重症医学科, 上海 200940;
9. 上海交通大学医学院附属同仁医院呼吸与危重症医学科, 上海 200336;
10. 复旦大学附属华山医院呼吸与危重症医学科, 上海 200040;
11. 同济大学附属上海市肺科医院呼吸与危重症医学科, 上海 200433;
12. 复旦大学附属浦东医院呼吸与危重症医学科, 上海 201300;
13. 同济大学附属同济医院呼吸与危重症医学科, 上海 200065;
14. 复旦大学附属上海市第五人民医院呼吸与危重症医学科, 上海 200040;
15. 上海交通大学医学院附属第九人民医院呼吸与危重症医学科, 上海 200011
*通信作者) |
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| 摘要: |
| 目的 调查并分析上海地区二、三级甲等医院稳定期慢性阻塞性肺疾病（COPD）患者合并症的分布特征及其临床意义。方法 采用多中心、横断面调查设计，通过普查的方法，连续收集2018年10月至2019年8月上海地区14家二、三级甲等医院呼吸与危重症医学科门诊诊治的532例稳定期COPD患者的临床资料及8个类别33种合并症资料，并采用Charlson合并症指数（CCI）对合并症进行评分。根据COPD评估测试（CAT）评分和改良英国医学研究学会呼吸困难指数（mMRC）评分，将患者分为多症状（CAT评分≥ 10分或mMRC评分≥ 2分）与少症状（CAT评分<10分且mMRC评分为0~1分）组；根据过去1年内COPD急性加重次数，将患者分为频繁急性加重（FE，过去1年内急性加重≥ 2次或≥ 1次但导致住院）与非频繁急性加重（NFE，未出现急性加重或1次急性加重但未导致住院）组。比较不同组间的合并症分布特点，采用logistic回归分析探讨合并症与COPD患者多症状和FE的相关性。以CCI评分4分为界，将研究对象分为CCI高分（≥ 4分）与低分（<4分）组，比较两组患者的临床特征。结果 532例患者平均年龄为（70.44±8.98）岁，男472例（88.7%），吸烟指数为30（20，42）包年；有合并症的患者比例为73.9%（393例），发生率居前4位的合并症依次是肺动脉高压症（182例，34.2%）、高血压（144例，27.1%）、支气管哮喘（135例，25.4%）、代谢综合征（122例，22.9%）；按系统分类，居前4位的依次是慢性肺部疾病（221例，41.5%）、过敏性疾病（183例，34.4%）、心血管疾病（172例，32.3%）、代谢性疾病（141例，26.5%）。多症状组与少症状组有合并症的患者比例分别为72.4%（317/438）和80.9%（76/94），两组间比较差异无统计学意义（P>0.05）。FE组与NFE组有合并症的患者比例分别为71.5%（191/267）、76.2%（202/265），两组间比较差异无统计学意义（P>0.05）；FE组支气管扩张症发生率高于NFE组[11.6%（31/267） vs 6.0%（16/265），P=0.024]，且多因素logistic回归分析显示合并支气管扩张症是COPD患者FE的危险因素（OR=2.127，95%CI 1.114~4.060，P=0.022）。CCI高分组患者年龄、吸烟指数、COPD病程和呼出气一氧化氮（FeNO）水平均高于CCI低分组[分别为76（71，82）岁vs 66（61，69）岁、30（20，50）包年vs 30（20，40）包年、8（3，10）年vs 7（3，8）年、39×10-9（22×10-9，50×10-9） vs 28×10-9（19×10-9，45×10-9）]，吸入支气管舒张剂前第1秒用力呼气容积（FEV1）和用力肺活量（FVC）均低于CCI低分组[分别为（1.02±0.39） L vs （1.21±0.52） L、（1.97±0.60） L vs （2.33±0.77） L]，差异均有统计学意义（P均<0.05）。结论 上海地区稳定期COPD患者合并症发生率高且不受患者症状多少及是否FE影响，并以慢性肺部疾病、过敏性疾病、心血管疾病、代谢性疾病为主。CCI高分COPD患者的年龄更大、病程更长、肺功能更差。支气管扩张症可能是导致COPD患者FE的危险因素之一，及早发现并积极干预支气管扩张症将有助于提高COPD管理水平和改善预后。 |
| 关键词: 慢性阻塞性肺疾病 合并症 支气管扩张症 Charlson合并症指数 |
| DOI：10.16781/j.0258-879x.2021.02.0177 |
| 投稿时间：2020-06-09修订日期：2020-09-27 |
| 基金项目:国家自然科学基金（81670016，81600056），促进市级医院临床技能与临床创新三年行动计划项目（ChiCTR-INR-16009892）. |
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| Characteristics and clinical significance of comorbidities in patients with stable chronic obstructive pulmonary disease in secondary and tertiary first-class hospitals in Shanghai, China |
| FENG Xiu-min1,2,GE Hai-yan3,GU Wen-chao4,HANG Jing-qing5,ZHOU Min6,HAN Feng-feng7,QIAN Ye-chang8,JIN Xiao-yan9,LI Sheng-qing10,GAO Bei-lan11,BAO Hong12,YU Li13,JIE Zhi-jun14,WANG Jian15,ZHANG Jing-xi1*,ZHU Hui-li3* |
(1. Department of Respiratory and Critical Care Medicine, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai 200433, China;
2. Department of Respiratory and Critical Care Medicine, Changji Branch of the First Affiliated Hospital of Xinjiang Medical University, Changji 831100, Xinjiang Uygur Autonomous Region, China;
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3. Department of Respiratory and Critical Care Medicine, Huadong Hospital Affiliated to Fudan University, Shanghai 200040, China;
4. Department of Respiratory and Critical Care Medicine, People's Hospital of Shanghai Pudong New Area, Shanghai 201200, China;
5. Department of Respiratory and Critical Care Medicine, People's Hospital of Putuo District, Shanghai 200060, China;
6. Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200020, China;
7. Department of Respiratory and Critical Care Medicine, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China;
8. Department of Respiratory and Critical Care Medicine, Baoshan Branch of Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200940, China;
9. Department of Respiratory and Critical Care Medicine, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200336, China;
10. Department of Respiratory and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China;
11. Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University, Shanghai 200433, China;
12. Department of Respiratory and Critical Care Medicine, Shanghai Pudong Hospital, Fudan University, Shanghai 201300, China;
13. Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji University, Shanghai 200065, China;
14. Department of Respiratory and Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200040, China;
15. Department of Respiratory and Critical Care Medicine, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
*Corresponding authors) |
| Abstract: |
| Objective To investigate and analyze the constitutive characteristics and clinical significance of comorbidities in patients with stable chronic obstructive pulmonary disease (COPD) in secondary and tertiary first-class hospitals in Shanghai, China. Methods A multi-center, cross-sectional survey study was conducted on the clinical data and 33 kinds of comorbidities (8 major categories) collected from 532 stable COPD patients in the respiratory and critical care medicine departments of 14 secondary and tertiary first-class hospitals in Shanghai from Oct. 2018 to Aug. 2019. The comorbidities were scored by Charlson comorbidity index (CCI). According to the COPD assessment test (CAT) score and modified British Medical Research Council (mMRC) score, or the exacerbation times of COPD over the past year, the patients were divided into multi-symptom (CAT score ≥ 10 or mMRC score ≥ 2) and few-symptom (CAT score<10 and mMRC score 0-1) groups, or frequent exacerbation (FE, times of exacerbation ≥ 2 over the past year or ≥ 1 but resulting in hospitalization) and non-frequent exacerbation (NFE, no exacerbation or one exacerbation but no need for hospitalization) groups. The constitutive characteristics of the comorbidities were compared among different groups. Logistic regression analysis was used to investigate the correlation between comorbidities and multiple symptoms and FE in the stable COPD patients. In addition, the patients were also divided into high-CCI (≥ 4) and low-CCI (<4) groups, and the clinical characteristics were compared between the two groups. Results The average age of 532 patients was (70.44±8.98) years, with 472 (88.7%) males; the smoking index was 30 (20, 42) pack-years; and the proportion of the patients with comorbidities was 73.9% (n=393). The top four comorbidities in order were pulmonary hypertension (n=182, 34.2%), hypertension (n=144, 27.1%), bronchial asthma (n=135, 25.4%) and metabolic syndrome (n=122, 22.9%). According to the systematic classification, the top four were chronic lung diseases (n=221, 41.5%), allergic diseases (n=183, 34.4%), cardiovascular diseases (n=172, 32.3%) and metabolic diseases (n=141, 26.5%). The proportions of patients with comorbidities were 72.4% (317/438) and 80.9% (76/94) in the multi-symptom and few-symptom groups, respectively, with no significant difference (P>0.05). The proportions of patients with comorbidities were 71.5% (191/267) and 76.2% (202/265) in the FE and NFE groups, respectively, with no significant difference (P>0.05). Compared with the NFE group, the proportion of patients with bronchiectasis was significantly higher in the FE group (11.6%[31/267]vs 6.0%[16/265], P=0.024); multivariate logistic regression analysis showed that bronchiectasis was a risk factor of FE in COPD patients (odds ratio[OR]=2.127, 95% confidence interval[CI]1.114-4.060, P=0.022). Compared with the low-CCI group, the age, smoking index, course of COPD and fractional exhaled nitric oxide (FeNO) were significantly higher in the high-CCI group (76[71, 82]years vs 66[61, 69]years, 30[20, 50]pack-years vs 30[20, 40]pack-years, 8[3, 10]years vs 7[3, 8]years, 39×10-9[22×10-9, 50×10-9]vs 28×10-9[19×10-9, 45×10-9]), and the forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC) before inhaling bronchodilator were significantly lower ([1.02±0.39]L vs[1.21±0.52] L,[1.97±0.60]L vs[2.33±0.77]L) (all P<0.05). Conclusion The incidence of comorbidities in stable COPD patients in Shanghai, China is high and is not affected by multior few-symptom or FE, and the main comorbidities are chronic lung diseases, allergic diseases, cardiovascular diseases and metabolic diseases. Patients with high-CCI are usually elder, with long course of COPD or poor lung function. Bronchiectasis may be one of the risk factors of FE in COPD patients, and early diagnosis and active intervention can improve the management and prognosis of COPD. |
| Key words: chronic obstructive pulmonary disease comorbidities bronchiectasis Charlson comorbidity index |
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