Division of Pulmonary and Critical Care Medicine, Department of Medicine, National Jewish Health and the University of Colorado Denver, Denver, CO.
Division of Pathology, Department of Medicine, National Jewish Health and the University of Colorado Denver, Denver, CO.
Chest. 2012 Mar;141(3):599-606. doi: 10.1378/chest.11-0741. Epub 2011 Aug 11.
The pathophysiology of refractory asthma is not well understood; thus, treatment modalities are not targeted to specific phenotypes but rather to a broad-based treatment approach. The objective of this study was to develop refractory asthma phenotypes based on bronchoscopic evaluation and to develop from this information specific, directed, personalized therapy.
Fifty-eight patients with difficult-to-treat (refractory) asthma were characterized by the use of fiber-optic bronchoscopy with visual scoring systems of the upper and lower airways as well as with BAL, endobronchial biopsy, and brush. Response to changes in therapy was evaluated by changes in the Asthma Control Test and pulmonary function.
Five mutually exclusive phenotypes were formulated based on bronchoscopic evaluation: gastroesophageal reflux, subacute bacterial infection, tissue eosinophilia, combination, and nonspecific. Specific directed therapy yielded a significant improvement in the Asthma Control Test and pulmonary function for the entire group as well as for each defined subgroup except for the nonspecific group. Of interest, visual scoring of the supraglottic abnormalities identified 34 of 35 patients with gastroesophageal reflux and may give a better insight into asthmatic problems associated with chronic proximal reflux than standard testing.
Bronchoscopic evaluation of the upper and lower airways can provide important information toward characterizing refractory asthma so as to better individualize therapeutic options and improve asthma control and lung function in patients with difficult-to-treat asthma.
难治性哮喘的病理生理学尚未得到很好的理解；因此，治疗方法不是针对特定的表型，而是针对广泛的治疗方法。本研究的目的是基于支气管镜评估开发难治性哮喘表型，并从中获取信息，制定具体、有针对性、个性化的治疗方案。
采用纤维支气管镜检查，使用上、下呼吸道视觉评分系统以及支气管肺泡灌洗、支气管内膜活检和毛刷，对 58 例难治性哮喘患者进行特征描述。通过哮喘控制测试和肺功能的变化来评估治疗反应的变化。
根据支气管镜评估结果，制定了五个相互排斥的表型：胃食管反流、亚急性细菌感染、组织嗜酸性粒细胞增多、联合和非特异性。针对特定表型的定向治疗，对整个组和每个定义的亚组（除了非特异性组）的哮喘控制测试和肺功能均有显著改善。有趣的是，对声门上异常的视觉评分可以识别出 35 例胃食管反流患者中的 34 例，这可能比标准测试更能深入了解与慢性近端反流相关的哮喘问题。
上、下呼吸道的支气管镜评估可以为难治性哮喘的特征描述提供重要信息，从而更好地为治疗选择个体化，并改善治疗困难的哮喘患者的哮喘控制和肺功能。
