目的评估支气管扩张症(支扩症)患者咯血与疾病严重程度和急性加重的关系。
方法于2012年9月至2014年1月纳入148例稳定期支扩症患者，男56例，例女92例，平均年龄44.6岁。咯血组106例，男36例，女70例，平均年龄45.6岁；未咯血组42例，男20，女22例，平均年龄41.8岁。采集既往病史，评价胸部影像学、肺功能、辣椒素激发试验相关的咳嗽敏感性及气道炎症特征。对患者进行1年随访以判断咯血能否预测支扩症急性加重的风险。
结果咯血组24 h痰量中位数为20 ml，支扩症严重程度指数中位数为7.0，受累肺叶中位数为4.0个，胸部CT评分中位数为7.0分，胸部CT提示存在囊状支扩病变67例(63%)，肺部空洞形成52例(49%)，铜绿假单胞菌定植35例(33%)，辣椒素激发试验测定的咳嗽敏感度(引起≥5次咳嗽的辣椒素浓度)的几何均数为77 μmol/L。未咯血组24 h痰量中位数为5.0 ml，支扩严重程度指数中位数为4.0，受累肺叶中位数为3.0个，胸部CT评分中位数为5.0分，囊状支扩15例(36%)，肺部空洞形成10例(24%)，铜绿假单胞菌定植4例(10%)，辣椒素激发试验测定的咳嗽敏感度的几何均数为212 μmol/L。以上指标两组比较差异均有统计学意义(均 P<0.05)。咯血组在入组前2年内因治疗急性加重而静脉滴注抗生素者29例(27%)，住院治疗44例(42%)；未咯血组在入组前2年内因治疗急性加重而静脉滴注抗生素8例(19%)，住院治疗8例(19%)。经性别、年龄、吸烟状况、支扩严重程度指数校正后，咯血组在1年随访期内急性加重的风险更高(咯血组62例、未咯血组18例出现过急性加重，χ 2＝16.06， P＝0.03)。胸部CT提示存在囊状支扩的患者其咯血风险更高，咯血组67例(63%)，未咯血组15例(36%)，比值比为2.84(95%可信区间为1.00～8.14， P＝0.05)。
结论72%(106例)的支扩症患者出现过咯血，且咯血与疾病严重程度呈正相关；咯血患者较未咯血患者在随访期的急性加重风险更高。
ObjectiveTo investigate the association between hemoptysis and disease severity and risks of acute exacerbations in patients with bronchiectasis.
MethodsBetween September 2012 and January 2014, we recruited 148 patients (56 males, 92 females, mean age: 44.6 years) with clinically stable bronchiectasis, who were classified into hemoptysis group (36 males, 70 females, mean age: 45.6 years) and non-hemoptysis group (20 males, 22 females, mean age: 41.8 years). We inquired the past history, and evaluated chest imaging characteristics, lung function, cough sensitivity assessed using capsaicin cough challenge tests, and airway inflammation. We also performed a 1-year follow-up to evaluate whether patients with hemoptysis would have greater risk of having acute exacerbations.
ResultsIn the hemoptysis group, median 24-hour sputum volume was 20.0 ml, median Bronchiectasis Severity Index (BSI) was 7.0, median bronchiectatic lobes was 4.0, median chest CT score was 7.0, the geometric mean for eliciting 5 coughs following capsaicin cough sensitivity (C5) was 77 μmol/L, 67 cases (63%) had cystic bronchiectasis and 52 cases (49%) had pulmonary cavity shown on chest CT, and 35 cases (33%) had Pseudomonas aeruginosa colonization. In the non-hemoptysis group, median 24-hour sputum volume was 5.0 ml, median BSI was 4.0, median bronchiectatic lobes was 3.0, median chest CT score was 5.0, 15 cases (36%) had cystic bronchiectasis and 10 cases (24%) had pulmonary cavity, the geometric mean for C5 was 212 μmol/L, and 4 cases (10%) had Pseudomonas aeruginosa colonization. All the above parameters differed significantly between the hemoptysis and the non-hemoptysis group ( P<0.05). In the hemoptysis group, 29 patients with pulmonary cavity (27%) had reported the use of intravenous antibiotics, and 44 cases (42%) had at least one hospitalization within the previous 2 years. In the non-hemoptysis group, 8 cases (19.0%) had reported the use of intravenous antibiotics, and 8 cases (19.0%) reported hospitalization within 2 years. A prior history of hemoptysis was associated with a greater risk of experiencing bronchiectasis exacerbations during follow-up, after adjusting for age, sex, smoking status and BSI (62 cases in the hemoptysis group, 18 cases in the non-hemoptysis group, χ 2=16.06, P=0.03). In a multivariate model, cystic bronchiectasis was the sole risk factor for hemoptysis; 67 cases which accounted for 63% of patients in the hemoptysis group and 15 cases which accounted for 36% of patients in the non-hemoptysis group, odds ratio: 2.84, 95% confidence interval: 1.00-8.14, P=0.05 .
ConclusionsIn this study, 72% of bronchiectasis patients had experienced hemoptysis, which was associated with the severity of bronchiectasis. Patients with a prior history of hemoptysis had a greater risk of acute exacerbations during follow-up than those without.
关伟杰,袁婧婧,高永华,等. 支气管扩张症患者咯血与疾病严重程度和急性加重的关系[J]. 中华结核和呼吸杂志,2017,40(1)：16-23.
DOI:10.3760/cma.j.issn.1001-0939.2017.01.005
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