慢性阻塞性肺疾病合并/不合并社区获得性肺炎的差异性研究
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摘要
目的探讨慢性阻塞性肺疾病(COPD)合并社区获得性肺炎(CAP)/不合并CAP的差异。方法收集符合入组标准的、曾有多次急性加重住院史的COPD患者共141例,其中既有不合并CAP又有合并CAP的急性加重住院史的COPD患者(A组)共40例,仅有合并CAP的急性加重住院史的COPD患者(B组)共38例、仅有不合并CAP的急性加重住院史的COPD患者(C组)共63例,比较三组患者年龄、性别、吸烟情况等人口学特征差异;分析比较A组患者在合并/不合并CAP的急性加重情况下的入院时临床症状及血液相关炎性指标,追踪此次起病前12个月急性住院次数及出院后12个月急性住院次数情况。结果 A组患者年龄、吸烟率、COPD-GOLD分级、呼吸困难指数、焦虑抑郁评分均高于B、C组,而第一秒用力呼气容积(FEV1)占预计值百分比低于B、C组,配合或需要长期家庭氧疗及药物治疗的患者比例多于B、C组,差异均有统计学意义(P <0. 05);而B、C组两组间各指标差异无统计学意义(P> 0. 05)。A组患者在合并CAP急性加重时,咳嗽、咳痰、发热等比例及血液相关炎性指标均不同程度较不合并CAP急性加重时高;不合并CAP的慢性阻塞性肺疾病急性加重(AECOPD)出院后12个月急性住院次数较合并CAP的COPD明显增多(P <0. 05);两种情况下的血气分析指标差异无统计学意义(P> 0. 05)。出院后12个月住院次数、中性粒细胞百分比(N)、IL-17水平是COPD合并CAP的独立临床预测因子。结论既有不合并CAP又有合并CAP的急性加重住院史的COPD(A组)患者的肺功能差,病情重,需要家庭氧疗及药物支持力度更大,生活质量差; COPD患者合并CAP时症状多、炎性指标水平高,但治愈后12个月内再次住院风险较不合并CAP的AECOPD时相对更小;出院后12个月住院次数、N、IL-17水平有助于从AECOPD患者中筛选出合并CAP患者。
Objective To explore the differences between patients with acute exacerbation of chronic obstructive pulmonary disease( AECOPD) accompanied with or without community-acquired pneumonia( CAP). Methods We collected 141 patients with COPD who met the admission criteria and had multiple acute exacerbation hospitalization history. Among them,40 patients with AECOPD accompanied with or without acute exacerbation of hospitalization of CAP( group A),38 patients with AECOPD accompanied with acute exacerbation of hospitalization of CAP( group B) and 63 patients with AECOPD but without acute exacerbation of hospitalization of CAP( group C). The demographic differences of age,sex and smoking status were analyzed and compared. The clinical symptoms and blood-related inflammatory indicators of patients in group A were analyzed and compared under the acute aggravation of CAP. The number of acute hospitalizations in 12 months before onset and 12 months after discharge were tracked. Results The age,smoking rate,COPD-GOLD classification,dyspnea index,anxiety and depression score in group A were higher than those in group B and C,while the percentage of forced expiratory volume in the first second( FEV1) in predicted value was lower than that in group B and C. The proportion of patients who cooperated or needed long-term home oxygen therapy and drug therapy was higher than that in group B and C,with statistical significance( P < 0. 05),but there was no statistical difference in each index between group B and C( P > 0. 05). The clinical symptoms of cough,expectoration,fever and other blood-related inflammatory indicators were aggravated in group A when accompanied with CAP. The number of acute hospitalizations in12 months after discharge of AECOPD without CAP was significantly higher than that of COPD with CAP( P < 0. 05),while there was no significant difference in blood gas analysis indicators between the two cases( P > 0. 05). The number of hospitalizations in 12 months after discharge,percentage of neutrophils( N)and the level of interleukin( IL)-17 were independent clinical predictors of COPD with CAP. Conclusions Patients with AECOPD accompanied with or without CAP( group A) had poor lung function,worse illness conditions,greater support of home oxygen therapy and drug therapy and poor quality of life. Patients with AECOPD accompanied with CAP had more symptoms and higher levels of inflammatory indicators,but less risk of re-hospitalization in 12 months after cure than AECOPD patients without CAP. The number of hospitalization in 12 month after discharge,the percentage of neutrophils( N),and IL-17 level were helpful in screening the patients with CAP from the AECOPD patients.
Objective To explore the differences between patients with acute exacerbation of chronic obstructive pulmonary disease( AECOPD) accompanied with or without community-acquired pneumonia( CAP). Methods We collected 141 patients with COPD who met the admission criteria and had multiple acute exacerbation hospitalization history. Among them,40 patients with AECOPD accompanied with or without acute exacerbation of hospitalization of CAP( group A),38 patients with AECOPD accompanied with acute exacerbation of hospitalization of CAP( group B) and 63 patients with AECOPD but without acute exacerbation of hospitalization of CAP( group C). The demographic differences of age,sex and smoking status were analyzed and compared. The clinical symptoms and blood-related inflammatory indicators of patients in group A were analyzed and compared under the acute aggravation of CAP. The number of acute hospitalizations in 12 months before onset and 12 months after discharge were tracked. Results The age,smoking rate,COPD-GOLD classification,dyspnea index,anxiety and depression score in group A were higher than those in group B and C,while the percentage of forced expiratory volume in the first second( FEV1) in predicted value was lower than that in group B and C. The proportion of patients who cooperated or needed long-term home oxygen therapy and drug therapy was higher than that in group B and C,with statistical significance( P < 0. 05),but there was no statistical difference in each index between group B and C( P > 0. 05). The clinical symptoms of cough,expectoration,fever and other blood-related inflammatory indicators were aggravated in group A when accompanied with CAP. The number of acute hospitalizations in12 months after discharge of AECOPD without CAP was significantly higher than that of COPD with CAP( P < 0. 05),while there was no significant difference in blood gas analysis indicators between the two cases( P > 0. 05). The number of hospitalizations in 12 months after discharge,percentage of neutrophils( N)and the level of interleukin( IL)-17 were independent clinical predictors of COPD with CAP. Conclusions Patients with AECOPD accompanied with or without CAP( group A) had poor lung function,worse illness conditions,greater support of home oxygen therapy and drug therapy and poor quality of life. Patients with AECOPD accompanied with CAP had more symptoms and higher levels of inflammatory indicators,but less risk of re-hospitalization in 12 months after cure than AECOPD patients without CAP. The number of hospitalization in 12 month after discharge,the percentage of neutrophils( N),and IL-17 level were helpful in screening the patients with CAP from the AECOPD patients.
引文
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[11]Atlantis E,Fahey P,Cochrane B,et al. Bidirectional associations between clinically relevant depression or anxiety and COPD:a systematic review and meta-analysis[J]. Chest,2013,144(3):766-777. DOI:10. 1378/chest. 12-1911.
[12]Rahman MS,Yang J,Shan LY,et al. IL-17R activation of human airway smooth muscle cells induces CXCL-8 production via a transcriptional-dependent mechanism[J]. Clin Immunol,2005,115(3):268-276. DOI:10. 1016/j. clim. 2005. 01. 014.
[13]Chiba Y,Tanoue G,Suto R,et al. Interleukin-17A directly acts on bronchial smooth muscle cells and augments the contractility[J]. Pharmacol Rep,2017,69(3):377-385. DOI:10. 1016/j.pharep. 2016. 12. 007.
[14]汪志方,徐金富,罗艳蓉,等. AECOPD与COPD合并CAP的差异队列研究[J].同济大学学报:医学版,2014,35(4):59-62,66. DOI:10. 3969/j. issn1008-0392. 2014. 04. 012.
[15]Perotin JM,Dury S,Renois F,et al. Detection of multiple viral and bacterial infections in acute exacerbation of chronic obstructive pulmonary disease:a pilot prospective study[J]. J Med Virol,2013,85(5):866-873. DOI:10. 1002/jmv. 23495.
[16]Huerta A,Crisafulli E,Menéndez R,et al. Pneumonic and nonpneumonic exacerbations of COPD:inflammatory response and clinical characteristics[J]. Chest,2013,144(4):1134-1142.DOI:10. 1378/chest. 13-0488.
[2]S?gaard M,Madsen M,Lkke A,et al. Incidence and outcomes of patients hospitalized with COPD exacerbation with and without pneumonia[J]. Int J Chron Obstruct Pulmon Dis,2016,11:455-465. DOI:10. 2147/COPD. S96179.
[3]Liapikou A,Polverino E,Ewig S,et al. Severity and outcomes of hospitalised community-acquired pneumonia in COPD patients[J]. Eur Respir J,2012,39(4):855-861. DOI:10. 1183/09031936. 00067111.
[4]Snijders D,van der Eerden M,de Graaff C,et al. The influence of COPD on mortality and severity scoring in community-acquired pneumonia[J]. Respiration,2010,79(1):46-53. DOI:10.1159/000213757.
[5]中华医学会呼吸病学分会.中国成人社区获得性肺炎诊断与治疗指南(2016年版)[J].中华结核与呼吸杂志,2016,39(4):1-27. DOI:10. 3760/cma. j. issn. 1001-0939. 2016. 04.005.
[6]Liu DS,Han XD,Liu XD. Current Status of Community-Acquired Pneumonia in Patients with Chronic Obstructive Pulmonary Disease[J]. Chin Med J(Engl),2018,131(9):1086-1091. DOI:10.4103/0366-6999. 230727.
[7]Lin SH,Ji BC,Shih YM,et al. Comorbid pulmonary disease and risk of community-acquired pneumonia in COPD patients[J]. Int J Tuberc Lung Dis,2013,17(12):1638-1644. DOI:10. 5588/ijtld. 13. 0330.
[8]刘瑞平,王萍.慢性阻塞性肺疾病中焦虑抑郁情况的分析[J].中国医师杂志,2016,18增刊1:107-108. DOI:10. 3760/cma. j. issn. 1008-1372. 2016. z1. 044.
[9]Bridges CB,Coyne-Beasley T. Advisory committee on immunization practices recommended immunization schedule for adults aged19 years or older:United States,2014[J]. Ann Intern Med,2014,160(3):190. DOI:10. 7326/M13-2826.
[10]许银芳,韩淑华,林勇.慢性阻塞性肺疾病患者合并焦虑/抑郁障碍的相关因素[J].中国老年学杂志,2012,32(15):3180-3182. DOI:10. 3969/j. issn. 1005-9202. 2012. 15. 020.
[11]Atlantis E,Fahey P,Cochrane B,et al. Bidirectional associations between clinically relevant depression or anxiety and COPD:a systematic review and meta-analysis[J]. Chest,2013,144(3):766-777. DOI:10. 1378/chest. 12-1911.
[12]Rahman MS,Yang J,Shan LY,et al. IL-17R activation of human airway smooth muscle cells induces CXCL-8 production via a transcriptional-dependent mechanism[J]. Clin Immunol,2005,115(3):268-276. DOI:10. 1016/j. clim. 2005. 01. 014.
[13]Chiba Y,Tanoue G,Suto R,et al. Interleukin-17A directly acts on bronchial smooth muscle cells and augments the contractility[J]. Pharmacol Rep,2017,69(3):377-385. DOI:10. 1016/j.pharep. 2016. 12. 007.
[14]汪志方,徐金富,罗艳蓉,等. AECOPD与COPD合并CAP的差异队列研究[J].同济大学学报:医学版,2014,35(4):59-62,66. DOI:10. 3969/j. issn1008-0392. 2014. 04. 012.
[15]Perotin JM,Dury S,Renois F,et al. Detection of multiple viral and bacterial infections in acute exacerbation of chronic obstructive pulmonary disease:a pilot prospective study[J]. J Med Virol,2013,85(5):866-873. DOI:10. 1002/jmv. 23495.
[16]Huerta A,Crisafulli E,Menéndez R,et al. Pneumonic and nonpneumonic exacerbations of COPD:inflammatory response and clinical characteristics[J]. Chest,2013,144(4):1134-1142.DOI:10. 1378/chest. 13-0488.