Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Francisco, San Francisco, California.
The Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon.
Ann Am Thorac Soc. 2021 Nov;18(11):1822-1831. doi: 10.1513/AnnalsATS.202006-757OC.
Diagnosis of chronic obstructive pulmonary disease (COPD) relies on abnormal spirometry. However, spirometry may underestimate the effects of smoking, missing smokers with respiratory disease who have minimal or no airflow obstruction. To develop a multidimensional definition of a lung-related "resilient smoker" that is useful in research studies and then identify a resilient smoker subgroup in the SPIROMICS (SubPopulations and InteRmediate Outcome Measures In COPD Study) cohort using this definition. We performed a three-round modified Delphi survey among a panel of COPD experts to identify and reach a consensus on clinical and radiographic domains to be included in a lung-related resilient smoker definition. Consensus on domains of resilience was defined as ⩾80% of experts voting "agree" or "strongly agree" on a 5-point Likert scale. The Delphi-derived definition of resilience was applied to SPIROMICS to identify resilient smokers, whom we then characterized using known biomarkers of COPD. Consensus was achieved on 6 of 12 diagnostic items, which include cough and sputum production, dyspnea, radiographic measures of emphysema and small airways disease, exacerbations, and decline in forced expiratory volume in 1 second. Although 892 SPIROMICS participants were classified as smokers with preserved lung function by spirometry, only 149 participants (16.7%) qualified as resilient smokers by our definition. Blood biomarker expression of CRP (C-reactive protein) and sTNFRSF1A (soluble tumor necrosis receptor factor1A) was lower in resilient than nonresilient smokers ( = 0.02 and = 0.03). A Delphi-derived consensus definition of resilient smoker identified 83.3% of smokers with preserved spirometry as "nonresilient" based on the presence of adverse effects of smoking on the lung. Resilient smokers were biologically distinct from nonresilient smokers based on CRP measurements. Clinical trial registered with ClinicalTrials.gov (NCT01969344).
慢性阻塞性肺疾病（COPD）的诊断依赖于异常的肺量测定。然而，肺量测定可能低估了吸烟的影响，漏诊了那些有呼吸道疾病但气流阻塞最小或没有气流阻塞的吸烟者。为了制定一个有用的肺相关“有弹性的吸烟者”的多维定义，并在 SPIROMICS（COPD 研究中的亚群和中间结果测量）队列中使用该定义确定一个有弹性的吸烟者亚组。我们在一组 COPD 专家中进行了三轮改良 Delphi 调查，以确定并就纳入肺相关有弹性吸烟者定义的临床和影像学领域达成共识。对弹性的共识定义为在 5 分制的李克特量表上， ⩾80%的专家投票“同意”或“强烈同意”。德尔菲法得出的弹性定义应用于 SPIROMICS 以确定有弹性的吸烟者，然后我们使用 COPD 的已知生物标志物对这些吸烟者进行了特征描述。在 12 项诊断项目中的 6 项上达成了共识，这些项目包括咳嗽和咳痰、呼吸困难、肺气肿和小气道疾病的影像学测量、加重和 1 秒用力呼气量下降。尽管 SPIROMICS 有 892 名参与者被肺量测定法归类为保留肺功能的吸烟者，但根据我们的定义，只有 149 名参与者（16.7%）符合有弹性的吸烟者标准。有弹性的吸烟者的 CRP（C 反应蛋白）和 sTNFRSF1A（可溶性肿瘤坏死受体因子 1A）血液生物标志物表达低于非弹性吸烟者（ ⁇ 0.02 和 ⁇ 0.03）。基于吸烟对肺部的不良影响，德尔菲法得出的有弹性吸烟者的共识定义将保留肺量测定的 83.3%的吸烟者定义为“非弹性”。基于 CRP 测量，有弹性的吸烟者与非弹性吸烟者在生物学上是不同的。在 ClinicalTrials.gov（NCT01969344）上注册了临床试验。
