【作者】 马莉；

【导师】 何巧洁；

【作者基本信息】 大连医科大学 ， 内科学， 2012， 硕士

【摘要】 目的：支气管哮喘（以下简称哮喘）是一种常见的慢性疾病，据资料显示全球哮喘患者已近3亿，由于大多数患者没有能够接受规范化的教育管理等原因造成了哮喘的反复发作，导致疾病进行性加重，给社会和家庭带来了沉重的的负担。本课题通过开展我院特色的哮喘专科门诊、哮喘知识讲座、哮喘之家的规范化教育管理模式并评估其对哮喘患者病情控制情况和生命质量的影响，为进一步推广这一管理模式提供依据。方法：2011年7月至2012年3月选取大连医科大学附属第二医院哮喘门诊就诊的哮喘患者157例，其中接受过我院规范化教育管理的患者为管理组（78例），每位患者均接受哮喘专科门诊、哮喘知识讲座、哮喘之家的教育管理模式，参加过一次初级班教育和至少两次强化班教育。未接受过我院规范化教育管理模式的患者为对照组（79例）。两组患者均符合2008年中华医学会呼吸病分会哮喘学组制定的支气管哮喘防治指南的诊断标准。由本课题研究生和医师采用面对面调查问卷的方式，应用通俗易懂的语言进行描述，分别调查两组患者的病情控制情况和生命质量评分。患者病情控制情况问卷参照国内外文献设计，问卷内容包括以下方面：1.基本资料：包括姓名、性别、年龄、文化程度、病程、病情严重程度等；2.哮喘控制情况：包括按2009年全球哮喘防治创议（GlobalInitiative for Asthma，GINA）制定的哮喘控制水平和按哮喘控制测试（ACT）评分两个标准进行评估；3.未来风险的评估：包括过去一年中因哮喘急性发作而急诊就医和住院的情况、FEV1低、高剂量糖皮质激素（简称激素）使用情况、有无烟草的暴露。高剂量激素的标准是参照2009年GINA指南定义的吸入激素（ICS）的剂量标准判定。在烟草暴露方面，调查问卷分为主动吸烟和被动吸烟两个方面，其中被动吸烟频率分为经常、有时和偶尔三种，本研究将主动吸烟和经常被动吸烟视为患者处于烟草暴露。患者生命质量的问卷采用李凡的成人哮喘生命质量5分制评分表，将测评期限调整为测评前8周。内容包括活动受限、哮喘症状、心理状况、对刺激原的反应和对自身健康关心5个维度，35个项目逐项计分，1分为最差，5分为最好，总分35～175分，分值越高，表明哮喘患者的生命质量越高。进行问卷调查时，问卷内容不得空缺，共完成问卷157份。采用SPSS13.0软件进行统计分析，P<0.05为差异有统计学意义。结果：1.临床控制水平：（1）按照2009年GINA指南制定的哮喘控制水平分级标准达到控制的患者，管理组为62.8％，对照组为20.3％（χ2=29.314，P＜0.01），管理组明显优于对照组，也高于1999年欧洲哮喘控制状况调查(AsthmaInsights and Reality in Europe, AIRE)的5.1％；与国内研究结果比较，管理组的控制率高于2006年全国10个省市三级医院（28.7％）和2007年陕西省6个地区级城市中8所三级医院（26.4％）的结果；也高于2007年北京城区3家教学医院（30.6％）和2007年沈阳市（13.68％）的结果。（2）按照ACT评分达到良好控制以上（ACT评分≥20分），管理为74.4％，对照组为44.3％（χ2=14.682，P＜0.01），管理组优于对照组。也高于2007年陕西省6个地区级城市中8所三级医院（36.7％）、2006年北京6大城区6家医院（46.3％）和2007年沈阳（59.43％）的结果，仅稍低于2006年北京大学人民医院接受过哮喘“三位一体”教育管理模式的教育组患者结果（85％）。2.未来风险的评估：（1）过去一年中因为哮喘急性加重而急诊就医和住院率的情况，管理组分别为15.4％和5.1％，不仅低于对照组（35.4％，21.5％）的结果（χ2分别为8.317和9.100，P均小于0.01），同时低于2000年亚太地区哮喘控制现状（Asthma Insights and Reality In Asia Pacific,AIRIAP）调查中中国的结果（33.3％，16.0％），也低于2006年全国10省市三级医院（33.9％，20.0％）的结果，但高于2005年北京大学人民医院接受过“三位一体”哮喘教育管理模式的教育组患者（7.1％，3.6％）的结果。（2）在肺功能方面，管理组FEV1％pred≥80％的患者占66.7％，对照组为25.3％，管理组明显优于对照组（χ2=27.029，P＜0.01）。（3）在应用高剂量激素治疗方面，管理组的比例为2.6％，对照组为15.2％，对照组高于管理组（χ2=7.703，P＜0.01）。（4）在烟草暴露方面，管理组为6.4％，对照组为27.8％，对照组烟草暴露的比率高于管理组（χ2=12.667，P＜0.01）。与国外比较，管理组烟草暴露的比率低于2000年AIRIAP（19.1％）、1999年AIRE（17.5％）和2000年美国（30.5％）的结果；与国内比较，低于2007年沈阳（29.41％）的结果。3.生命质量的评估：按照李凡的成人哮喘生命质量5分制评分表评估生命质量，将测评期限调整为测评前8周。结果显示：在活动受限方面，管理组为49.95±5.61分，高于对照组(39.99±7.64分)（t=9.3，P＜0.01）；在哮喘症状方面，管理组为36.54±3.61分，高于对照组(26.38±5.50分)（t=13.7，P＜0.01）；在心理状况方面，管理组为27.03±3.15分，高于对照组(21.16±5.66分)（t=8.0，P＜0.01）；对刺激原的反应方面，管理组为23.35±2.36分，高于对照组(18.32±4.13分)（t=9.4，P＜0.01）；对自身健康的关心方面，管理组为15.00±3.79分，高于对照组(11.42±4.90分)（t=5.1，P＜0.01）；管理组的生命质量总分为151.82±12.83分，明显优于对照组（116.87±20.66分）（t=12.7，P＜0.01）。结论：哮喘专科门诊、哮喘知识讲座、哮喘之家的规范化教育管理模式提高了哮喘患者的临床控制水平和生命质量，降低了未来的风险，值得进一步推广。更多还原

【Abstract】 Objective: Asthma is a common chronic disease. It is estimated that there arenearly30million asthmatic patients in the world. Because many patients didn’t takein standard asthma education and management, their asthma condition became worseprogressively which brought the family and whole society heavy burden. The purposeof the study was to evaluate the impact of standard asthma education and managementmodel on asthma control and quality of life in the asthmatic patients so that we couldget sufficient evidence for popularization of this model.Methods:157outpatients with asthma were selected in the second hospital ofDalian medical university during Jul,2011to Mar,2012. The managed group (78cases) took part in the standard asthma education and management model of ourhospital. The asthma education and management model developed by our hospitalwas composed of a clinic service for asthma, asthma lecture and the asthmatic patientassociation. They participated in one time primary education and at least two timesstrengthened education. The control group (79cases) didn’t take part in this asthmaeducation and management model. The two groups were in accord with the diagnosisstandard of Chinese guide for asthma in2008. The graduate student and doctorinterviewed157cases with asthma in the form of face-to-face. The level of asthmacontrol and the quality of life were evaluated. The questionnaire was designed withreferences, the contents of questionnaire were as follows:1. The basic data includedname, sex, age, education degree of the patients, the classification and course ofasthma.2. The current situation of asthma control included the level of controlledasthma according to the GINA criteria in2009and the level of well-controlled asthmaand complete controlled according to the asthma control test (ACT values≥20points).3. The assessment of future risk included ever admission to critical care or hospitalization in the past year, low FEV1, high dose of glucocorticoids medications,exposure to cigarette smoke. The standard of high dose glucocorticoids medicationsrefered to the standard which defined by GINA criteria in2009. We defined theexposure to cigarette smoke as initiative and often passive cigarette smoke. Thequestionnaire of life quality was the adult questionnaire designed by Li Fan, includedconfined activity, symptoms of asthma, the mentality of asthma, the reaction tostimulus, the personal health concerns. One point was the worst, five points was thebest. The total score was between35and175. The higher the score was, the better thequality of life was. The questionnaires of157cases were completed and analyzed bySPSS13.0statistical analysis software, P<0.05was considered statisticallysignificant.Results:1. In the current situation of asthma control, according to the GINAcriteria in2009, the rate of controlled asthma for the two groups was62.8%and20.3%，respectively (χ2=29.314, P<0.01). The result of the managed group was betterthan that of the control group, also better than the result of AIRE study in1999(5.1%).Compared with domestic research, the result of the managed group was better thanthose of Chinese ten provincial cities surveyed in2006(28.7%) and Shanxi provincein2007(26.4%), also better than those of three teaching hospitals in Beijing urbanarea surveyed in2006(30.6%) and Shenyang in2007(13.68%). While according tothe asthma control test, the rate of well-controlled and complete controlled for the twogroups was74.4%and44.3%, respectively (χ2=14.682, P<0.01). The result of themanaged group was better than those in the control group and in Shanxi province in2007(36.7%), also better than those in the six different urban districts of Beijing in2006(46.3%) and in Shenyang in2007(59.43%), but worse than that of the People’sHospital of Peking University in2006(85%).2. The assessment of future risk.(1)During the past year, the rate of the emergency treatments and hospitalization due toexacerbation of asthma were significantly lower in the managed group than that in thecontrol group（15.4%,5.1%vs35.4%,21.5,respectively; χ2=8.317，9.100，and P＜0.01for both). The result of the managed group was lower than the Chinese data ofAIRIAP study in2000(33.6%,16.0%) and the result of Chinese ten provincial citiesin2006(33.9%,20.0%), but higher than the data of educated group took in theeducation and management model developed by People’s Hospital of PekingUniversity in2006(7.1%,3.6%).(2) In lung function, the rate of FEV1%pred≥80%forthe two groups was66.7%and25.3%, respectively (χ2=27.029，P＜0.01).(3) In the therapy of high dose glucocorticoids medications, the rate of the two groups was2.6%and15.2%, respectively（χ2=7.703，P＜0.01), the rate of the managed group waslower than that of the control group.(4) In the exposure to cigarette smoke, the rate ofthe two groups was6.4%and27.8%, respectively（χ2=12.677，P＜0.01). Comparedwith the overseas studies, the rate of the managed group was lower than that of theAIRIAP study in2000(19.1%) and that of AIRE study in1999(17.5%). Comparedwith the domestic studies, the rate of the managed group was lower than that ofShenyang in2007(29.41%).3. In the quality of life. for the limitation of activity, the score of the two groupswas49.95±5.61and39.99±7.64, respectively (t=9.3，P＜0.01). The sore of themanaged group was higher than that of the control group. In the symptoms of asthma,the score of the two groups was36.54±3.61and26.38±5.50, respectively (t=13.7，P＜0.01). The sore of managed group was higher than that of the control group. In thementality of asthma, the score of the two groups was27.03±3.15and21.16±5.66,respectively (t=8.0，P＜0.01). The sore of managed group was higher than that of thecontrol group. In the reaction of stimulus, the score of the two groups was23.35±2.36and18.32±4.13, respectively (t=9.4，P＜0.01). The sore of managed group was higherthan that of the control group. In the personal health concerns, the score of the twogroups was15.00±3.79and11.42±4.90, respectively (t=12.7，P＜0.01). The sore ofmanaged group was higher than that of the control group. the total score of the twogroups was151.82±12.83and116.87±20.66, respectively (t=12.7，P＜0.01). The soreof managed group was higher than that of the control group.Conclusions: The standard asthma education and management model cansignificantly improve asthma control and quality of life, reducing future risk. Thismodel is worth of being spread.更多还原