关键词： 哮喘；痰；一氧化氮；嗜酸细胞阳离子蛋白

【摘要】目的探讨痰液中一氧化氮（NO）代谢终产物——亚硝酸盐/硝酸盐（）测定在哮喘临床中的应用价值。方法应用Griess重氮法测定45例不同时期、不同程度哮喘患者及15例慢性支气管炎(慢支)合并肺心病急性发作期患者痰液、血清含量,同步测定哮喘患者痰液中嗜酸细胞阳离子蛋白（ECP）水平及肺通气功能。结果哮喘轻、中、重度发作期患者痰液中位数浓度（分别为131 μmol/L、136 μmol/L）与缓解期组（85 μmol/L）及正常对照组（63 μmol/L）比较，差异有显著性（P＜0.05）；发作期组与缓解期组比较差异有显著性（P＜0.05）；慢支合并肺心病急性发作期患者痰液水平（33 μmol/L）与各哮喘组及正常对照组比较，差异有显著性（P＜0.05）。缓解期及发作期哮喘患者痰液与一秒钟用力呼气容积占预计值百分比（FEV₁占预计值％）间呈显著负相关（r分别=-0.587、-0.485,P均＜0.05）；而痰液与ECP间呈显著的正相关（r分别=0.563,P＜0.05；0.535,P＜0.01）。15例中、重度哮喘患者治疗后,痰液水平与治疗前比较差异有显著性（P＜0.01）。结论痰液可能成为监测哮喘气道炎症,评价药物疗效的指标。

The changes of level in sputum from patients with asthma and their clinical implications

WANG Yu, WANG Chen, TONG Zhaohui

Respiratory Disease Research Center, Beijing Red Cross Chaoyang Hospital Affiliate of Capital University of Medical Sciences,Beijing 100020

【Abstract】ObjectiveTo evaluate the clinical applications of the detection of the stable end products of NO, nitrite and nitrate () in sputum from patients with asthma. Methods45 patients with asthma at remission (groupⅠ,n=15) or exacerbation state with mild attack (groupⅡ,n=15) or moderate to severe attack (groupⅢ,n=15) , 15 cases of chronic cor pulmonale secondary to chronic bronchitis at exacerbation (groupⅣ), and 20, normal control subjects (groupⅤn=20) were included in this study. in sputum and serum were measured by Griess reaction , while the eosinophil cationic protein (ECP) in sputum and pulmonary function were also measured in tested patients with asthma. ResultsThe median concentrations of sputum in groupⅠ, Ⅱand Ⅲwere 85, 131 and 136 μmol/L respectively , all were significantly higher than that in controls (63 μmol/L); those of groupⅡ and Ⅲ were significantly higher than that of groupⅠ, while that of group Ⅳ (33 μmol/L) was significantly lower than those of the asthmatic groups and the control. The level of NO derivatives in sputum was closely correlated with the degree of airflow obstruction and sputum ECP levels in patients with asthma at remission (r=-0.587, P＜0.05; r=0.535, P＜0.01 respectively) and exacerbation (r=-0.485, P＜0.05; r=0.563, P＜0.05 respectively). There was no significant correlation between serum and sputum , and no significant correlation between serum and the degree of airflow obstruction. A significant decrease in the concentration of sputum was observed after therapeutic treatment of patients with moderate to severe attack (136 vs 93 μmol/L). ConclusionThe level of in sputum may be a useful marker for monitoring the state of airway inflammation and assessing the therapeutic efficacy.

【Key words】AsthmaSputumNitric oxideEosinophil cationic protein

支气管哮喘是一种慢性气道炎症疾病。一氧化氮（NO）作为一种与气道炎症相关的物质近年来受到普遍重视, 研究表明，气道内NO水平可作为反映哮喘气道炎症的指标之一。国外报道，痰液中NO代谢终产物可以间接反映气道内NO的变化^［1］。我们的研究观察了不同时期、不同程度的哮喘患者痰液中的含量变化,及其与嗜酸细胞活化、气流阻塞程度之间的关系,并观察了15例中、重度哮喘患者治疗前后痰液的含量变化，比较哮喘患者与慢性支气管炎合并肺心病急性发作期患者痰、血水平的差异。旨在探讨痰液测定在哮喘临床中的应用,并比较痰液及血清在反映哮喘气道炎症方面的差异。

对象与方法

一、对象

1.哮喘组：根据中华医学会呼吸病学分会1997年哮喘防治会议制定的标准^［2］，选择明确诊断为过敏性支气管哮喘的患者45例。排除其它心肺疾病，无寄生虫感染及其它过敏性疾病；受检前8小时内未用β₂受体激动剂。根据病情分为以下三组：Ⅰ组：支气管哮喘缓解期患者15例，其中男7例，女8例，平均年龄42岁。该组中5例患者长期吸入丙酸倍氯米松气雾剂治疗，每日剂量200～300 μg，其余10例患者未行糖皮质激素吸入治疗。Ⅱ组：支气管哮喘轻度发作期患者15例，其中男8例，女7例，平均年龄45岁。该组患者全部接受二丙酸倍氯米松（400～800 μg/d）及沙丁胺醇气雾剂（400～600 μg/d）吸入治疗。Ⅲ组：支气管哮喘急性中、重度发作期患者15例，其中男8例，女7例，平均年龄47岁。该组患者根据病情接受口服泼尼松（10～20 mg/d）或静脉滴注糖皮质激素（琥珀酸氢化考的松400～800 mg/d）治疗，同时给予解痉、平喘等对症治疗；其中3例患者接受机械通气治疗。治疗前及治疗7～10天后临床达显效标准时分别测定各项指标，比较治疗前、后的变化。上述三组受试者均无吸烟史，近4周内无上呼吸道感染史。

2.慢性支气管炎合并肺心病急性发作期组（Ⅳ组）：根据1977年全国肺心病会议所订立的诊断标准，选择慢性支气管炎所致慢性肺心病急性发作期患者15例，其中男9例，女6例，平均年龄74岁，均有吸烟史（每年平均314支）。

3.正常对照组（Ⅴ组）：选择正常无吸烟史的健康成人20名，其中男7名，女8名，平均年龄45岁。根据病史及有关检查排除任何过敏性疾病、寄生虫感染及自身免疫性疾病；无心、肺、肝、肾等疾患,无服用硝酸酯类及激素类药物史，近4周内无上呼吸道感染史。上述各组间性别构成相匹配。

二、标本收集及处理

1.痰诱导及痰液收集：参照文献［3］报道方法以3.5%高渗盐水50 ml雾化吸入行痰诱导，诱导前吸入沙丁胺醇200 μg。诱导前、后及诱导过程中监测肺通气功能［一秒钟用力呼气容积（FEV₁）及一秒钟用力呼气容积占预计值百分比（FEV₁占预计值%）］。其中部分重度哮喘发作期患者采用经气管插管取痰(3例)或自发咳痰(4例FEV₁占预计值%＜40%哮喘患者)的方法留取痰液标本。收集的痰液标本在1小时内处理，处理前保存于4℃冰箱。

2.痰液的处理：以4倍痰液体积的1%二硫苏糖醇(DTT)及Dubecco平衡盐溶液(DBS)对痰液进行处理