König P
Department of Child Health, University of Missouri, School of Medicine, Health Sciences Centre, Columbia 65212, USA.
Pediatr Pulmonol Suppl. 1997 Sep;15:34-9.
Earlier guidelines recommended the use of bronchodilators, such as beta 2-agonists, in patients with mild asthma (defined as having symptoms present on < or = 3 days per week), the use of sodium cromoglycate in moderately severe asthma patients (symptoms present on > 3 days per week), and inhaled corticosteroids in those not satisfactorily controlled by sodium cromoglycate (severe asthma). A retrospective study was performed to evaluate the effect of such a stepwise approach on the long-term outcome of the disease. A group of 175 children were followed for a mean of 8.4 years (range, 2-16 years) and divided into mild (treated with "as-needed" bronchodilators, usually beta 2-agonists), moderate (treated with sodium cromoglycate), and severe asthmatics (treated with inhaled corticosteroids). Treatment was altered if patients deteriorated or improved. The clinical improvement (as determined by days with symptoms present, emergency room visits, and hospitalizations) of patients being treated with anti-inflammatory agents (sodium cromoglycate or inhaled corticosteroids) was significantly greater than for those receiving bronchodilators. Delay in starting sodium cromoglycate, but not inhaled corticosteroids, had a negative effect on both clinical outcome and pulmonary function. Spirometry showed a significant worsening in the mild group but improvements in the moderate and severe groups. Thus, treatment with anti-inflammatory drugs improves the long-term prognosis and at least partially reverses the natural history of the disease; however, sodium cromoglycate should be started in milder patients than those recommended by the earlier guidelines. The new Global Initiative guidelines have recommended moving the indication for the start of non-steroidal anti-inflammatory drugs from having symptoms on > 3 days per week to having symptoms on > 1 day per week. Considering the fact that inhaled corticosteroids have some side effect even at standard doses, especially in patients with milder asthma, it would appear that a stepwise approach, starting with non-steroidal anti-inflammatory drugs is the most appropriate therapy for patients with mild-to-moderate asthma.
早期指南建议，对于轻度哮喘患者（定义为每周症状出现天数≤3天）使用支气管扩张剂，如β2激动剂；对于中度严重哮喘患者（每周症状出现天数>3天）使用色甘酸钠；对于使用色甘酸钠控制不佳的患者（重度哮喘）使用吸入性糖皮质激素。进行了一项回顾性研究以评估这种逐步治疗方法对该疾病长期预后的影响。一组175名儿童平均随访8.4年（范围为2至16年），并分为轻度（使用“按需”支气管扩张剂治疗，通常为β2激动剂）、中度（使用色甘酸钠治疗）和重度哮喘患者（使用吸入性糖皮质激素治疗）。如果患者病情恶化或改善，则调整治疗方案。接受抗炎药物（色甘酸钠或吸入性糖皮质激素）治疗的患者的临床改善情况（根据症状出现天数、急诊就诊次数和住院情况确定）明显优于接受支气管扩张剂治疗的患者。开始使用色甘酸钠延迟，但不包括吸入性糖皮质激素延迟，对临床结局和肺功能均有负面影响。肺功能测定显示轻度组显著恶化，但中度和重度组有所改善。因此，使用抗炎药物治疗可改善长期预后，并至少部分逆转疾病的自然病程；然而，应在比早期指南推荐的病情较轻的患者中开始使用色甘酸钠。新的全球倡议指南建议将开始使用非甾体抗炎药物的指征从每周症状出现>3天改为每周症状出现>1天。考虑到吸入性糖皮质激素即使在标准剂量下也有一些副作用，尤其是在轻度哮喘患者中，似乎对于轻度至中度哮喘患者，从非甾体抗炎药物开始的逐步治疗方法是最合适的治疗方法。
