慢性阻塞性肺疾病急性加重症的临床诊断复杂性。
Complexity in clinical diagnoses of acute exacerbation of chronic obstructive pulmonary disease.
机构信息
Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
Division of Infectious Diseases, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
出版信息
BMC Pulm Med. 2023 Aug 14;23(1):298. doi: 10.1186/s12890-023-02587-1.
BACKGROUND
Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a clinical syndrome with various causes. It is not uncommon that COPD patients presenting with dyspnea have multiple causes for their symptoms including AECOPD, pneumonia, or congestive heart failure occurring concurrently.
METHODS
To identify clinical, radiographic, and laboratory characteristics that might help distinguish AECOPD from another dominant disease in patients with a history of COPD, we conducted a retrospective cohort study of hospitalized patients with admitting diagnosis of AECOPD who were screened for a prospective randomized controlled trial from Sep 2016 to Mar 2018. Clinical characteristics, course in hospital, and final diagnosis at discharge were reviewed and adjudicated by two authors. The final diagnosis of each patient was determined based on the synthesis of all presenting signs and symptoms, imaging, and laboratory results. We adhered to AECOPD diagnosis definitions based on the GOLD guidelines. Univariate and multivariate analyses were performed to identify any associated features of AECOPD with and without other acute processes contributing to dyspnea.
RESULTS
Three hundred fifteen hospitalized patients with admitting diagnosis of AECOPD were included. Mean age was 72.5 (SD 10.6) years. Two thirds (65.4%) had spirometry defined COPD. The most common presenting symptom was dyspnea (96.5%), followed by cough (67.9%), and increased sputum (57.5%). One hundred and eighty (57.1%) had a final diagnosis of AECOPD alone whereas 87 (27.6%) had AECOPD with other conditions and 48 (15.2%) did not have AECOPD after adjudication. Increased sputum purulence (OR 3.35, 95%CI 1.68-6.69) and elevated venous pCO2 (OR 1.04, 95%CI 1.01 - 1.07) were associated with a diagnosis of AECOPD but these were not associated with AECOPD alone without concomitant conditions. Radiographic evidence of pleural effusion (OR 0.26, 95%CI 0.12 - 0.58) was negatively associated with AECOPD with or without other conditions while radiographic evidence of pulmonary edema (OR 0.31; 95%CI 0.11 - 0.91) and lobar pneumonia (OR 0.13, 95%CI 0.07 - 0.25) suggested against the diagnosis of AECOPD alone.
CONCLUSION
The study highlighted the complexity and difficulty of AECOPD diagnosis. A more specific clinical tool to diagnose AECOPD is needed.
背景
慢性阻塞性肺疾病（COPD）急性加重（AECOPD）是一种具有多种病因的临床综合征。对于以呼吸困难为表现的 COPD 患者，其症状的多种病因并不少见，包括同时发生的 AECOPD、肺炎或充血性心力衰竭。
方法
为了确定有助于区分 COPD 患者中 AECOPD 与另一种主要疾病的临床、影像学和实验室特征，我们对 2016 年 9 月至 2018 年 3 月期间因 AECOPD 入院并接受前瞻性随机对照试验筛选的住院患者进行了回顾性队列研究。由两位作者对临床特征、住院期间的病程和出院时的最终诊断进行了回顾和裁决。每位患者的最终诊断是根据所有现有症状、影像学和实验室结果综合确定的。我们根据 GOLD 指南中的 AECOPD 诊断定义进行了分析。对有和无其他导致呼吸困难的急性过程的 AECOPD 相关特征进行了单变量和多变量分析。
结果
共纳入 315 例因 AECOPD 入院的患者。平均年龄为 72.5（10.6）岁。三分之二（65.4%）的患者有肺功能检查明确的 COPD。最常见的首发症状是呼吸困难（96.5%），其次是咳嗽（67.9%）和痰液增加（57.5%）。180 例（57.1%）最终诊断为单纯 AECOPD，87 例（27.6%）为 AECOPD 合并其他疾病，48 例（15.2%）经裁决后未诊断为 AECOPD。痰液脓性增加（OR 3.35，95%CI 1.68-6.69）和静脉血 pCO2 升高（OR 1.04，95%CI 1.01-1.07）与 AECOPD 相关，但与无合并症的 AECOPD 无关。胸腔积液的影像学证据（OR 0.26，95%CI 0.12-0.58）与 AECOPD 或无其他疾病相关，而肺水肿的影像学证据（OR 0.31；95%CI 0.11-0.91）和大叶性肺炎（OR 0.13，95%CI 0.07-0.25）提示不应单独诊断为 AECOPD。
结论
该研究强调了 AECOPD 诊断的复杂性和难度。需要更具体的临床工具来诊断 AECOPD。
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