2022年ERS成人哮喘诊断指南

前言：

最近各种任务，打乱了原有的节律。今日终于有时间学习了

尽管哮喘影响5%-10%的人群，但在真实世界的诊断仍是一个挑战，导致了过度诊断与诊断不足。

工作组定义了8个PICO（人群、指数、比较与结局）。

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PICO 1: Can airway obstruction measured by spirometry help diagnose asthma in adults with episodic/chronic suggestive symptoms? 

Recommendation 

 The TF recommends performing spirometry to detect airway obstruction as part of the diagnostic work-up of adults aged 18 years with suspected asthma (strong recommendation for the test, low quality of evidence) 

PICO 1：肺功能检测气道阻塞有助于发作性/慢性可疑哮喘的诊断吗？

推荐：18岁以上成人推荐使用肺功能检测气道阻塞作为哮喘诊断部分之一。（强推荐，低质量证据）

PICO 2: Can PEF variability testing help diagnose asthma in adults with episodic/chronic suggestive symptoms? 

PICO 2：PEF变异率有助于发作性/慢性可疑哮喘的诊断吗？

Recommendation 

 The TF suggests not recording PEF variability as the primary test to make a diagnosis of asthma diagnosis (conditional recommendation against the test, low quality of evidence) 

推荐：不建议使用PEF变异率作为哮喘的主要诊断检查（有条件反对，低质量证据）

Remarks 

 PEF may be considered if no other lung function test is available including spirometry at rest and bronchial challenge testing 

 PEF should be monitored over a two--week period and a variation of >20% considered as supportive of asthma diagnosis 

 PEF variability <20% does not rule out asthma 

 PEF may be especially useful to support a diagnosis of occupational asthma 

标注：

• 其它肺功能检查不可用时可考虑PEF变异率
• 应监测2周，变异率＞20%支持哮喘诊断；
• ＜20%不能排除哮喘诊断；
• PEF变异率对于诊断职业暴露获得性哮喘特别有用。

PICO 3: Can measuring fractional exhaled nitric oxide (FeNO) help diagnose asthma in adults with episodic/chronic suggestive symptoms? 

Recommendation 

 In patients suspected of asthma, in whom the diagnosis is not established based on the initial spirometry combined with bronchodilator reversibility testing, the TF suggests measuring the fraction of exhaled nitric oxide (FeNO) as part of the diagnostic work-up of adults aged >18 years with suspected asthma (conditional recommendation for the intervention, moderate quality of evidence) 

PICO 3：FeNO有助于诊断哮喘吗？

疑似哮喘患者，未行初始肺功能结合舒张试验，建议FeNO检查作为诊断手段的一部分（有条件推荐，中等质量证据）

Remarks 

 A cut-off value of 40 ppb offers the best compromise between sensitivity and specificity while a cut-off of 50 ppb has a high specificity >90% and is supportive of a diagnosis of asthma 

 A FeNO value <40 ppb does not rule out asthma and similarly high FeNO levels themselves do not define asthma 

 FeNO values are markedly reduced by smoking, impaired airway calibre, treatment with ICS or anti-IL4/IL13-receptor alpha antibody 

标注：

cut-off值 40 ppb的敏感性特异性最佳，而50 ppb的更高敏感性＞90%，支持诊断哮喘；

FeNO＜40 ppb不能排除哮喘，类似于高FeNO不能确诊哮喘；

吸烟者、气道直径异常，ICS、抗IL-4/IL-13受体阿尔发抗体治疗者FeNO明显降低。

PICO 4: Can measuring blood eosinophil count help diagnose asthma in adults with episodic/chronic suggestive symptoms? 

Recommendation 

 The TF suggests not measuring blood eosinophil count to make a diagnosis of asthma (conditional recommendation against the test, low quality of evidence) 

PICO 5: Can measuring total serum IgE help diagnose asthma in adults with episodic/chronic suggestive symptoms? 

Recommendation 

 The TF suggests not measuring total serum IgE to make to make a diagnosis of asthma (conditional recommendation against the test, low quality of evidence) 

Remarks 

 Total serum IgE does not define asthma but rather contributes to phenotyping 

PICO 6: Can combining FeNO, blood eosinophils and IgE help diagnose asthma in adults with episodic/chronic suggestive symptoms? 

Recommendation 

 The TF suggests not combining FeNO, blood eosinophils and serum IgE to make a diagnosis of asthma (conditional recommendation against the combination of tests, moderate quality of evidence) 

PICO 7: Can bronchial challenge testing help diagnose asthma in adults with episodic/chronic suggestive symptoms? 

Recommendation 

 The TF suggests bronchial challenge testing should be performed in secondary care to confirm a diagnosis of asthma in adults when the diagnosis was not previously established in primary care (conditional recommendation for the test, low quality of evidence) 

Remarks 

 A provocative concentration of methacholine (PC20-M) or histamine (PC20-H) <8 mg/ml in steroid-naïve patients and <16 mg/ml in patient receiving regular inhaled corticosteroids supports a diagnosis of asthma 

 Indirect challenges such as mannitol or exercise may be considered in patients who remain negative with direct constricting agents 

PICO 7：支气管激发试验有助于诊断哮喘吗？

推荐

初级医疗机构未诊断的哮喘在二级医疗机构建议行激发试验以明确诊断（有条件推荐，低质量证据）

标注：

• 未使用激素者乙酰胆碱或组胺浓度小于8mg/ml，常规ICS治疗者＜16mg/ml，结果阳性支持诊断哮喘
• 间接激发，如甘露醇或运动激发可考虑用于以上阴性者。

PICO 8: Can measuring of sGaw and RV/TLC help in the diagnosis of asthma with episodic/chronic suggestive symptoms? 

Recommendation 

 The TF suggests not measuring sGaw and RV/TLC by whole body plethysmography to make to make a diagnosis of asthma (conditional recommendation against the tests, low quality of evidence) 

Remarks 

 sGaw does not perform better than FEV1/FVC ratio to predict positive methacholine challenge in patients with normal baseline FEV1 

 RV/TLC >130% predicted has a high specificity (>90%) but poor sensitivity (25%) to predict a positive methacholine challenge in patient with normal FEV1/FVC 

Background 

Temporal fluctuation in airway caliber is linked to variation in airways resistance. Specific airway conductance