童年時持續的氣喘與後來比較早發生COPD有關


  【24drs.com】根據發表於5月12日新英格蘭醫學期刊的「Childhood Asthma Management Program (CAMP)」研究結果,童年時持續氣喘和後來比較早發生慢性阻塞性肺部疾病(COPD)有關。
  
  雖然在40歲前很少發生COPD,且受影響的一般是目前或以前有抽菸者,研究的孩童中,有11%在30歲前即符合全球慢性阻塞性肺病倡議組織(GOLD)的COPD準則。這些孩童在納入研究時,肺成長模式下降或肺功能降低,男童的風險增加。
  
  麻塞諸塞州波士頓哈佛醫學院、布萊根婦女醫院Michael J McGeachie博士等人寫道,我們的資料支持下述假設:成長下降和早期的衰退都會導致氣喘-慢性阻塞性肺部疾病重疊症候群,補充了最近的觀察發現,在老年患者,肺功能的快速下降會導致慢性阻塞性肺部疾病。
  
  以前的研究認為,肺功能的早期衰退和肺部成長下降的模式,與發生COPD有關,最近一篇研究發現,青年時期肺功能不佳與後來發生COPD有關。不過,此議題有關氣喘孩童的長期資料有限,而這些孩童的呼吸氣流阻塞風險已經上升。
  
  此次分析是隨機安慰劑控制CAMP研究的一部分,納入輕微到中度氣喘的5-12歲孩童,追蹤他們到30-40歲左右。這篇大型的CAMP研究發現,就肺功能發展而言,吸入型抗發炎製劑並未優於安慰劑。在這研究中,患者每年進行一次肺量計肺功能評估。
  
  研究者檢視了684名CAMP研究對象,這些人患有輕微到中度的持續氣喘,已有使用藥物。研究者依據孩童的肺成長和肺功能衰退曲線將這些孩童分成四組,測量方法是1秒用力呼氣(FEV1)。FEV1是一種肺功能測量方法,通常在青春期後期或青年時期達到顛峰,然後維持穩定數年,之後逐漸衰退。這四組包括:正常成長且有正常尖峰值、正常成長與早期衰退、成長下降但有正常尖峰值、成長下降與早期衰退。
  
  結果顯示,75% (n=514)的孩童在他們20歲初就出現肺部成長異常模式:26% (n=176)顯示肺部成長下降且有早期衰退,23% (n=160)只有肺部成長下降, 26% (n=178)有正常的肺部成長但有早期衰退。
  
  開始時的肺功能降低和男性這兩個因素是後來發生肺功能不佳的最強預測因子。為何男性的風險增加則尚屬未知, 不過他們發生肺部成長下降模式的機率是正常成長者的8倍以上(勝算比8.18;P < .001)。
  
  和肺部成長下降有關的其他因素,包括支氣管擴張劑反應較小、呼吸道過度反應、納入研究時比較年輕、母親在懷孕時抽菸、家長的教育程度較低、維他命D不足、prednisone的療程次數、皮膚測試更陽性。
  
  在大約26歲時,11% (n = 73)的研究對象有肺功能不佳,根據GOLD準則定義,認為是COPD。36%的研究對象有肺部成長下降模式,正常成長模式者有8%符合GOLD準則的COPD (P < .001)。
  
  這篇研究不能決定性地評估抽菸曝露情況,抽菸是COPD的已知風險因素。它也沒有探討遺傳風險因素、早產兒、童年呼吸道感染、以及其他環境風險。
  
  土桑市亞利桑那大學醫學副教授Stefano Guerra博士表示,追蹤期間太短,而無法評估氣喘患者的早期肺部功能衰退造成發生COPD的影響程度。
  
  儘管如此,他表示,就三級預防方面,這些研究結果具有重要意義,因為它們指出,減少孩童時期氣喘的長期後遺症的介入方式,必須在這些患者邁入青年時期之前及早開始。
  
  作者們指出,需要更多研究,以確認可以改善輕微到中度持續性氣喘孩童之結果的介入方式。
  
  資料來源:http://www.24drs.com/
  
  Native link:Persistent Childhood Asthma Linked to Early COPD

Persistent Childhood Asthma Linked to Early COPD

By Veronica Hackethal, MD
Medscape Medical News

Persistent childhood asthma may be linked to earlier development of chronic obstructive pulmonary disease (COPD), according to results from the Childhood Asthma Management Program (CAMP) study published in the May 12 issue of the New England Journal of Medicine.

Although COPD rarely develops before the fourth decade of life and typically affects current or former smokers, 11% of the children in this study met Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria for COPD by age 30 years. Children with a decreased pattern of lung growth or decreased lung function at study entry and males were at increased risk.

"Our data support the hypothesis that both reduced growth and an early decline are trajectories leading to an asthma–COPD overlap syndrome and complement the recent observation that in older patients, a rapid decline in lung function can lead to COPD," write Michael J McGeachie, PhD, from Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, and colleagues.

Past studies have linked early decline in lung function and a pattern of decreased lung growth to the development of COPD. A recent study found that poorer lung function in early adulthood is associated with the development of COPD later in life. However, long-term data on the issue are limited in children with asthma, who are already at increased risk for airflow obstruction.

The current analysis was part of the randomized placebo-controlled CAMP study, which enrolled children aged 5 to 12 years with mild to moderate asthma and followed them into the third decade of life. The larger CAMP study found that inhaled anti-inflammatory agents were no better than placebo in terms of their long-term effects on lung function growth. During the study, participants underwent annual spirometry lung function assessments.

Researchers identified 684 CAMP participants who had mild to moderate persistent asthma despite medication use. They separated these children into four groups, based on their trajectories of lung growth and decline in lung function, as measured by forced expiratory volume in 1 second (FEV1). FEV1 is a measure of lung function that usually peaks in late adolescence or early adulthood, but then remains stable for many years before starting a gradual decline. The four categories included normal growth with normal peak, normal growth and early decline, reduced growth and normal peak, and reduced growth and early decline.

Results showed that 75% (n=514) of children showed abnormal patterns of lung growth before their early twenties: 26% (n=176) showed reduced lung growth along with early decline, 23% (n=160) had reduced lung growth alone, and 26% (n=178) had normal lung growth and early decline.

Decreased lung function at baseline and male sex were the strongest predictors of impaired lung function later in life. Reasons why males might be at increased are unknown, although they were a little more than eight times more likely to have a reduced pattern of lung growth compared with those with normal growth (odds ratio, 8.18; P < .001).

Other factors associated with decreased lung growth included less bronchodilator response, airway hyperresponsiveness, young age at study entry, maternal smoking during gestation, lower level of parental education, vitamin D insufficiency, number of courses of prednisone, and more positive skin tests.

By about age 26 years, 11% (n = 73) of participants had lung impairment suggestive of COPD, as defined by the GOLD criteria. Thirty-six percent of participants with a reduced lung growth pattern and 8% of those with a normal growth pattern met GOLD criteria for COPD (P < .001).

The study could not conclusively assess smoking exposure, a known risk factor for COPD. It also could not look at genetic risk factors, prematurity, childhood respiratory infections, and other environmental exposures.

The length of follow-up was also too short to assess the full extent to which early decline in lung function in patients with asthma contributes to COPD, Stefano Guerra, MD, PhD, associate professor of medicine at the University of Arizona in Tucson, told Medscape Medical News.

Nevertheless, he commented: "These findings have critical implications in terms of tertiary prevention because they indicate that interventions aimed at reducing the long-term sequelae of childhood asthma need to start early in life and to target patients years before they enter adulthood."

The authors note that more studies are needed to identify interventions that could improve outcomes in children with mild to moderate persistent asthma.

One or more authors reports receiving grants, fees, or other support from one or more of the following: National Institutes of Health, Alpha-1 Foundation, National Heart Lung Blood Institute, Roche, Merck, GlaxoSmithKline, AstraZeneca, Brigham and Women's Hospital, Agency for Healthcare Research and Quality, ICON Medical Imaging, Novartis, Dutch Lung Foundation, Teva, Ubbo Emmius Foundation, Stichting Astma Bestrijding, Parker B. Francis Foundation, Boehringer Ingelheim, Takeda, Chiesi, UpToDate, Genentech, Aerocrine, Mylan, Sunovion, Pfizer, Pulmonx, Spiration, Vertex, Verona, Bristol-Myers Squibb, Janssen, Theravance, and MedImmune. Dr Guerra has disclosed no relevant financial relationships.

N Engl J Med. 2016;374:1842-1852.

    
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