本文追溯了过去25年来GINA指南中哮喘控制的概念。在1995年后的最初15年中,哮喘管理的主要目标是控制哮喘的所有临床和功能特征。一项具有里程碑意义的研究(GOAL)首次表明,良好的哮喘控制是一个合理的结果,可以在大部分哮喘患者中通过定期适当的治疗来实现。在接下来的几年里,更加强调急性发作作为哮喘控制不佳的关键表现的作用,其频率与FEV1过度下降和死亡风险增加有关。因此,2014年GINA报告明确区分了日常症状的控制和严重加重风险的降低,声明这两个条件都应该得到。2019年的更新包括轻度哮喘的管理发生了重大变化,将预防恶化优先于轻度症状。这个观点在2021年的更新中重复了,在预防恶化的地方,加上可接受的症状控制,最少使用救援药物,似乎是哮喘管理的真正主要目标。虽然在轻度哮喘中可能存在当前症状和恶化之间的差异,在中重度哮喘中观察到这两个特征之间的显著关系:持续的不良症状控制是加重的主要危险因素,而通过常规治疗实现症状控制与恶化率降低有关。因此,在没有急性加重的情况下,频繁症状并不重要的观点应该被劝阻,而对患者进行良好的症状感知教育并提高对常规治疗的依从性。此外,风险因素的持续存在,如增加气道炎症,即使是每天有轻微症状的患者,应考虑优化治疗。
The article traces the concept of asthma control within GINA
guidelines over the past 25 years. In the first 15 years after 1995, the main objective of asthma management was to obtain the control of all clinical and functional characteristics of asthma. A landmark study (GOAL) showed for the first time that a good control of asthma is a reasonable outcome that can be achieved in a large proportion of asthmatics with a regular appropriate treatment. In the following years, more emphasis was placed on the role of exacerbations as critical manifestations of poor asthma control, whose frequency is associated with excessive FEV1 decline and increased risk of death. Accordingly, the 2014 GINA report makes a clear distinction between the control of the day-by-day symptoms and the reduction in the risk of severe exacerbations, stating that both conditions should be obtained. The 2019 update included a significant change in the management of mild asthma, prioritizing the prevention of exacerbations to that of mild symptoms. This view was repeated in the 2021 update, where the prevention of exacerbations, together with an acceptable symptom control with a minimal use of rescue medication, appeared to be the real main goal of asthma management. While a discrepancy between current symptoms and exacerbations may be present in mild asthma, a significant relationship between these two features is observed in moderate-severe asthma: a persistent poor symptom control is a major risk factor for exacerbations, whereas achieving symptom control through regular treatment is associated with a reduction in exacerbation rate. Thus, the opinion that frequent symptoms are not important in the absence of acute exacerbations should be discouraged, whereas education of patients to a good symptom perception and to improve adherence to regular treatment should be implemented. Furthermore, the persistence of risk factors, such as increased airway inflammation, even in a patient with minor daily symptoms, should be considered for optimizing treatment.