Characteristics of lung function indexes in smokers with FEV1/FVC≥0.7 and its clinical significance
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摘要:背景 慢性阻塞性肺疾病(chronic obstructive pulmonary disease，COPD)患者在达到流速指标第1秒用力呼气容积(forced expiratory volume in one second，FEV1)/用力肺活量(forced vital capacity，FVC)＜0.7之前已经存在肺功能指标的受损，但具体受损特点尚不明确，目前相关研究较少。目的 本研究通过比较FEV1/FVC≥0.7的吸烟者和不吸烟者肺功能指标的差异，探讨FEV1/FVC≥0.7的吸烟者肺功能受损特点及其影响因素，以期为早期识别COPD提供依据。方法 回顾性研究2017年3月- 2020年4月在我中心接受肺功能检查的FEV1/FVC≥0.7且无慢性气道疾病的吸烟者(吸烟指数＞50)和不吸烟者共388例，其中男性223例，女性165例。依据年龄分为＜50岁组(86例)、50 ~ 70岁组(197例)和＞70岁组(105例)，对各组吸烟者与不吸烟者肺功能指标进行比较。对这一人群各肺功能指标影响因素进行统计分析。结果 ＜50岁组中吸烟者肺功能容量指标FVCpred%、ICpred%较不吸烟者明显降低(P均＜0.05)。50 ~ 70岁组中吸烟者流速指标FEV1pred%、FEV1/FVC和容量指标FVC、FVCpred%、ICpred%均较不吸烟者降低(P均＜0.05)。＞70岁组吸烟者FVCpred%、FEV1pred%、ICpred%低于不吸烟者(P均＜0.05)。以各肺功能指标为因变量，以性别、年龄、吸烟指数为自变量，分别对纳入的人群进行九次线性回归分析，结果发现FVC与性别(B=-0.756，95% CI：-1.079 ~ -0.432)、年龄(B=-0.032，95% CI：-0.040 ~ -0.025)、吸烟指数(B=-0.001，95% CI：-0.001 ~ 0.000)独立关联；FEV1与性别(B=-0.586，95% CI：-0.840 ~ -0.333)、年龄(B=-0.028，95% CI：-0.034 ~ -0.022)、吸烟指数(B=-0.001，95% CI：-0.001 ~ 0.000)独立关联；IC与性别(B=-0.530，95% CI：-0.814 ~ -0.247)、年龄(B=-0.018，95% CI：-0.025 ~ -0.011)、吸烟指数(B=-0.001，95% CI：-0.001 ~ 0.000)独立关联。在肺功能指标中，仅与吸烟指数独立关联的指标包括FVCpred%(B=-0.027，95% CI：-0.034 ~ -0.020)、FEV1pred%(B=-0.028，95% CI：-0.034 ~ -0.022)、ICpred%(B=-0.033，95% CI：-0.041 ~ -0.025)，RV仅与年龄独立关联(B=0.013，95% CI：0.003 ~ 0.024)，而FEV1/FVC、RVpred%几乎不受性别、年龄和吸烟指数的影响。结论 在FEV1/FVC≥0.7吸烟人群中，吸烟对肺功能的损伤在各年龄组均可发现。但在＜50岁组的年轻人群中，肺功能容量指标FVCpred%、ICpred%下降更明显。肺功能容量指标下降在吸烟导致的肺功能早期损害中需引起重视。Abstract:Background Patients with chronic obstructive pulmonary disease (COPD) may have impaired pulmonary function before reaching FEV1/FVC<0.7, and the characteristics of impaired pulmonary function are still unclear. There are few relevant studies at present.Objective To compare the differences of lung function indexes between smokers and non-smokers with FEV1/FVC≥0.7, and explore the characteristics and influencing factors of lung function impairment in smokers with FEV1/FVC≥0.7, so as to provide evidence for early identification of COPD.Methods Totally 388 smokers (smoking index: more than 50) and non-smokers who underwent pulmonary function examination in our hospital from March 2017 to April 2020 were studied retrospectively (including 223 males and 165 females). These included patients did not have chronic airway disease and their lung function showed FEV1/FVC ≥ 0.7. According to age, they were divided into younger than 50 years old group (n=86), 50-70 years old group (n=197) and more than 70 years old group (n=105). The pulmonary function indexes of smokers and non-smokers in each group were compared and analyzed. Statistical analysis was carried out on the influencing factors of each pulmonary function index in this population.Results In the younger than 50 years old group, the lung function volume indexes FVCpred% and ICpred% of smokers were significantly lower than those of non-smokers (P=0.041, P=0.043). In the 50-70 years old group, the flow rate indexes FEV1pred%, FEV1 / FVC, the volume indexes FVC, FVCpred% and ICpred% of smokers were lower than those of non-smokers (P<0.05). In the older than 70 years old group, the FVCpred%, FEV1pred% and IC pred% of smokers were lower than those of non-smokers (P<0.05). Nine linear regression analyses were performed on the smokers population with lung function indexes as dependent variables and gender, age and smoking index as independent variables. The results showed that the influencing factors of FVC included gender (B=-0.756, 95% CI:-1.079 to -0.432), age (B=-0.032, 95% CI: -0.040 to -0.025) and smoking index (B=-0.001, 95% CI: -0.001 to 0.000); the influencing factors of FEV1 included gender (B=-0.586, 95% CI: -0.840 to -0.333), age (B=-0.028, 95% CI: -0.034 to -0.022) and smoking index (B=-0.001, 95% CI: -0.001 to 0.000); The influencing factors of IC included gender (B=-0.530, 95% CI: -0.814 to -0.247), age (B=-0.018, 95% CI: -0.025 to -0.011) and smoking index (B=-0.001, 95% CI: -0.001 to 0.000). Among the lung function indexes, FVC pred% (B=-0.027, 95% CI:-0.034 to -0.020), FEV1 pred% (B=-0.028, 95% CI: -0.034 to -0.022) and IC pred% (B=-0.033, 95%CI: -0.041 to -0.025) were affected only by smoking index. RV was only affected by age (B=0.013, 95%CI: 0.003 to 0.024), while FEV1/FVC and RV pred% was almost not affected by gender, age or smoking index.Conclusion Among smokers with FEV1/FVC ≥ 0.7, the impairment of smoking to lung function can be found in all age groups. However, in the young population of < 50 years old group, the decline of FVC pred% and IC pred% were more obvious. The decline of volume indexes in the early impairment of lung function induced by smoking need to be paid more attention.
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军事飞行员在飞行中无法避免飞行器噪声，而噪声性听力损失是噪声对飞行员产生的最直接影响。有报道显示飞行员因听力损失导致的停飞率约为2.32%，位于耳鼻喉科停飞疾病谱第2位[1]。随着飞行器的更新换代，各种型号的降噪耳机、新型隔音材料等逐渐成为噪声防护的有力措施，但飞行员仍有较高的听力损失发生率[2-3]。本文旨在通过分析直升机飞行员和歼击机飞行员听力损失的特点，指导预防听力损失的航卫保障工作。
对象和方法
1 对象
收集南部战区空军医院空勤科2014年7月- 2019年9月检查的无耳鸣、听力下降症状、飞行合格的男性飞行员纯音测听资料316份。其中直升机飞行员186例，年龄21 ~ 51岁，飞行时间110 ~ 6 000 h；歼击机飞行员130例，年龄23 ~ 47岁，飞行时间300 ~ 3 600 h。直升机飞行员与歼击机飞行员年龄及飞行时间差异无统计学意义(P＞0.05)。见表 1。
表 1 直升机飞行员与歼击机飞行员年龄和飞行时间比较Table 1. Comparison in age and flight time between the helicopter pilots and the fighter pilotsVariable Helicopter pilots (n=186) Fighter pilots (n=130) t P Age (yrs) 29.7±6.9 30.1±5.6 0.567 0.571 Fight time (h) 1 451.9±1 451.9 1 531.5±802.9 0.624 0.533 2 方法
按常规方法进行耳镜检查、声导抗测试，在声导抗排除中耳病变后，采用德国麦科MA51型听力测试仪进行纯音听阈测定，分别比较纯音测听在0.25 kHz、0.5 kHz、1 kHz、2 kHz、3 kHz、4 kHz、6 kHz及语频(≤2 kHz)和高频(≥3 kHz)气导听阈差异。
3 听力损失的界定
听力损失指纯音测听任何一个频率听阈下降＞25 dB，噪声性听力损失指高频(3 kHz、4 kHz、6 kHz)纯音测听至少一个频率听阈下降＞25 dB[4]。
4 统计学方法
采用SPSS26.0统计软件，计量资料符合正态分布者组间t检验，不符合正态分布者组间比较采用Wilcoxon秩和检验；计数资料以例数(百分比或构成比)表示，组间比较采用χ2检验。P＜0.05为差异有统计学意义。
结果
1 直升机和歼击机飞行员听力损失发生率
所有飞行员耳镜检查外耳道无异常，声导抗均为A型曲线。直升机飞行员和歼击机飞行员听力损失总发生率分别为16.4%和12.3%；噪声性听力损失的发生率分别为11.3%和10.8%，差异无统计学意义(P＞0.05)；单纯语频听力损失发生率分别为5.1%和1.5%，差异有统计学意义(P＜0.05)。见表 2、表 3。
表 2 直升机飞行员与歼击机飞行员听力损失的发生率比较Table 2. Incidence of hearing loss in the helicopter pilots and the fighter pilots (n, %)Frequency of pure tone (Hz) Helicopter pilots (n=372) Fighter pilots (n=260) χ2 P All frequencya 61(16.4) 32(12.3) 2.040 0.153 ≥3 ka 42(11.3) 28(10.8) 0.042 0.837 ≤2 ka 19(5.1) 4(1.5) 5.559 0.011 a>8 kHz was excluded in this analysis 表 3 直升机飞行员与歼击机飞行员纯音听阈＞25 dB发生频次比较Table 3. Incidence of pure tone > 25 dB at each frequency in the helicopter pilots and the fighter pilots (n, R/L)Frequency of pure tone (Hz) Helicopter pilots (n=372) Fighter pilots (n=260) χ2 P 0.25 k 12(5/7) 5(1/4) 0.992 0.319 0.5 k 18(8/10) 3(1/2) 6.469 0.011 1 k 5(1/4) 2(1/1) 0.462 0.497 2 k 1(0/1) 7(3/4) 7.192 0.007 3 k 6(2/4) 7(4/3) 0.885 0.347 4 k 33(14/19) 26(12/14) 0.230 0.631 6 k 12(7/5) 5(2/3) 0.992 0.319 All frequencya 61(27/34) 32(13/19) 2.040 0.153 ≥3 ka 42(20/22) 28(13/15) 0.042 0.837 ≤2 k 19(7/12) 4(0/4) 5.559 0.011 a>8 kHz was excluded in this analysis 2 直升机与歼击机飞行员语频听阈比较
0.5 ~3 kHz平均听力：直升机飞行员右耳(12.13±4.73) dB，左耳(12.81±5.39)d B；歼击机飞行员右耳(12.15± 5.09) dB，左耳(12.60±5.32) dB，均符合目前实行的飞行员体格检查标准。噪声性听力损失方面直升机飞行员和歼击机飞行员均表现为4 kHz损失发生率最高，单纯语频听力损失直升机飞行员以0.5 kHz损失发生率最高，歼击机飞行员以2 kHz损失发生率最高，见表 3。比较直升机与歼击机飞行员语频各频率听阈差异，发现右耳0.25 kHz、右耳0.5 kHz、左耳1 kHz听阈差异有统计学意义(P＜0.05)。见表 4。
表 4 直升机与歼击机飞行员语频听阈比较Table 4. Comparison of speech recognition threshold between the helicopter pilots and the fighter pilots (dB)Frequency of pure tone (Hz) R L Helicopter pilots Fighter pilots P Helicopter pilots Fighter pilots P 0.25 k 14.22±5.18 12.08±4.57 0.000 11.19±5.56 13.54±5.82 0.115 0.5 k 13.12±6.30 11.54±4.22 0.028 13.49±6.46 12.15±4.94 0.551 1 k 11.96±4.60 11.73±4.52 0.366 12.77±4.93 11.88±4.63 0.027 2 k 11.40±3.28 12.19±5.50 0.238 12.05±4.22 12.92±5.66 0.060 3 随访情况
共随访飞行员88例，其中直升机飞行员48例，随访时间为3 ~ 47(27.15±11.34)个月，原有听力损失1例(1耳)，新出现听力损失7例(10耳)，无原有听力损失加重人员。歼击机飞行员40例，随访时间为1 ~ 72(25.30±17.60)个月，原有听力损失7例(10耳)，新出现听力损失6例(6耳)，原有听力损失加重2例(2耳)，直升机飞行员听力损失新发加重率为16.7%，歼击机飞行员听力损失新发加重率为20.0%，差异无统计学意义(P＞0.05)。
讨论
良好的听力是飞行员进行正常空中通信的基础，而空中噪声可引起听力下降和工作绩效下降，甚至会引起心肌梗死和脑卒中[5-7]。噪声性聋可导致部分飞行员言语识别障碍和脑功能的变化，严重威胁空中安全[8]。长时间噪声还可引起内分泌、心血管、神经系统等多系统改变，影响飞行员整体健康状况。
本研究发现，飞行员总体听力损失发生率为29.2%，噪声听力损失发生率为22.2%，发生率与外军报道基本接近[9]，直升机飞行员与歼击机飞行员的发生率无统计学差异。噪声聋主要观察3 kHz、4 kHz、6 kHz的听阈改变[4]，故本研究未统计8 kHz的阈值。本研究显示的4 kHz听力损失发生率最高，与熊巍等[10]的报道相同。有研究证明直升机空中机动时噪声可达110 dB以上[11]；而歼击机空中加油时舱内噪声可高达123 dB，舱外噪声可达140 dB[12]；目前这类噪声均超出军标范围[13]，但均可引起听力损失，应该及早做好对此类噪声的专项防护。本研究还发现有一定比例飞行员单纯语频听力损失，主要以直升机飞行员为主。这种现象考虑可能主要与直升机飞行员接触噪声的频谱特性有关[14]。其次直升机飞行员在飞行中无吸氧，而缺氧引起外毛细胞的损伤可能也是原因之一[15]。此外，直升机单架次飞行时间较长，噪声累积效应也能导致听力损失[16]。具体机制需进一步研究。
通过随访发现，飞行员听力损失新发率较高。徐先荣等[17]的报道显示飞行人员听力损失位于耳鼻喉科住院疾病谱第2位，并呈逐年上升趋势。本研究对象均工作于亚热带气候地区，夏季时间较长，温度较高，飞行员从开车到关车需经历较长时间的高温，而高温又可加重噪声引起的听力损失[18]。另外，高同型半胱氨酸、高血压、心血管疾病及吸烟饮酒也会引起听力损失[19-22]。这种高听力损失新发率除了与上述原因有关外，长期佩戴通话耳机的低强度噪声也是听力损失的不可忽略的重要原因[23]。通过以上的分析，航卫人员应重点对已发生听力损失并伴有高血压病、高同型半胱氨酸血症、心血管疾病的飞行员进行饮食管理，同时宣传戒烟戒酒，合理使用飞行员多种维生素，同时做好听力档案的建立，动态观察听力变化，并督促飞行员平时减少耳机佩戴或其他噪声的接触。
综上所述，飞行员听力损失发生率较高，除与飞行器自身产生的噪声相关外，更是多种因素相互作用的结果。合理饮食、健康生活方式、建立听力档案是航卫保障工作中听力损失防护的切入点。合理使用其他检查，做到早发现、早诊断、早治疗[18]。而针对直升机飞行员语频听力损失发生率明显高于歼击机飞行员的情况，应进一步深入研究，及早采取相应措施对不同机种飞行员进行有针对性的听力防护。
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表 1 年龄＜50岁组、50 ~ 70岁、＞70岁组吸烟与不吸烟者一般情况对比
Table 1 Comparison of general condition between smokers and non-smokers in younger than 50 years old group, 50-70 years old group and older than 70 years old group
Variable ＜50 years old group 50-70 years old group ＞70 years old group Smokers group Non-smokers group t/χ2 P Smokers group Non-smokers group t/χ2 P Smokers group Non-smokers group t/χ2 P Gender (male/
female)/n32/2 25/27 19.498 ＜0.001 83/8 32/74 75.032 ＜0.001 28/6 23/48 22.971 ＜0.001 Age/yrs 42.1±8.2 39.4±8.6 1.450 0.151 61.9±5.1 60.9±4.4 0.967 0.336 77.7±4.2 76.1±4.7 1.608 0.111 
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表 2 年龄＜50岁组、50 ~ 70岁、＞70岁组吸烟与不吸烟者肺功能对比
Table 2 Comparison of lung function between smokers and non-smokers in younger than 50 years old group, 50-70 years old group and older than 70 years old group
Indicator ＜50 years old group 50-70 years old group ＞70 years old group Smokers
group
(n=34)Non-smokers
group
(n=52)t P Smokers
group
(n=91)Non-smokers
group
(n=106)t P Smokers
group
(n=34)Non-smokers
group
(n=71)t P FVCpred% 89.67±17.40 96.89±14.60 2.077 0.041 88.19±20.12 96.19±14.32 3.166 0.002 76.78±23.07 91.99±19.64 3.401 0.001 FVC/L 3.93±0.91 3.70±0.65 -1.389 0.169 3.19±0.74 2.89±0.68 -2.917 0.040 2.32±0.86 2.05±0.60 1.834 0.070 FEV1pred% 88.17±16.90 93.54±14.45 1.575 0.119 87.16±17.03 93.12±13.71 2.642 0.009 78.47±22.84 94.04±19.23 3.540 0.001 FEV1/L 3.12±0.74 2.99±0.59 -0.851 0.397 3.07±5.73 2.28±0.511 -1.405 0.162 1.79±0.66 3.04±11.80 -0.604 0.547 FEV1/FVC/% 80.40±6.10 80.87±5.53 0.370 0.712 77.12±5.99 79.31±5.63 2.631 0.009 78.81±7.27 79.69±7.28 0.568 0.570 ICpred% 87.02±20.24 95.97±19.40 2.056 0.043 83.01±24.42 93.64±22.31 3.150 0.002 70.76±19.86 87.07±27.26 2.990 0.004 IC/L 2.76±0.71 2.53±0.45 -0.1674 0.100 2.22±0.65 2.08±0.58 -1.605 0.110 1.77±0.57 1.56±0.45 1.980 0.500 RVpred% 106.17±23.07 105.60±24.19 0.109 0.914 106.74±31.09 109.34±28.77 0.609 0.543 105.82±38.04 105.43±27.45 0.053 0.958 RV/L 2.0±0.50 1.85±0.54 -1.196 0.235 2.12±0.64 2.39±0.74 -2.607 0.100 2.45±1.00 2.20±0.60 1.179 0.246
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表 3 FEV1/FVC≥0.7吸烟人群性别、年龄、吸烟指数与各肺功能指标的线性回归分析
Table 3 Correlation of gender, age, smoking index with various pulmonary function indexes in smokers with FEV1/FVC≥0.7 by linear regression analysis
Index Factor B 95% CI t P R2 FVC Gender -0.756 -1.079 - -0.432 -4.617 <0.001 0.574 Age -0.032 -0.040 - -0.025 -8.195 <0.001 Smoking index -0.001 -0.001 - 0.000 -7.500 <0.001 FVCpred% Gender 6.785 -2.357 - 15.927 1.467 0.145 0.307 Age -0.013 -0.231 - 0.206 -0.113 0.910 Smoking index -0.027 -0.034 - -0.020 -7.693 <0.001 FEV1 Gender -0.586 -0.840 - -0.333 -4.566 <0.001 0.581 Age -0.028 -0.034 - -0.022 -8.897 <0.001 Smoking index -0.001 -0.001 - 0.000 -6.987 <0.001 FEV1pred% Gender 0.240 -7.609 - 8.090 0.060 0.952 0.362 Age 0.104 -0.084 - 0.292 1.090 0.277 Smoking index -0.028 -0.034 - -0.022 -9.038 <0.001 FEV1/FVC Gender -1.263 -4.559 - 2.032 -0.758 0.450 0.033 Age -0.072 -0.152 - 0.008 -1.788 0.076 Smoking index 0.002 -0.001 - 0.004 1.355 0.177 IC Gender -0.530 -0.814 - -0.247 -3.695 <0.001 0.486 Age -0.018 -0.025 - -0.011 -5.223 <0.001 Smoking index -0.001 -0.001 - 0.000 -7.683 <0.001 ICpred% Gender 4.614 -5.605 - 14.832 0.892 0.374 0.341 Age -0.014 -0.259 - 0.230 -0.116 0.908 Smoking index -0.033 -0.041 - -0.025 -8.348 <0.001 RV Gender -0.332 -0.764 - 0.099 -1.524 0.130 0.061 Age 0.013 0.003 - 0.024 2.467 0.015 Smoking index 0.000 -0.000 - 0.000 -1.646 0.102 RVpred% Gender 9.912 -7.838 - 27.662 1.104 0.271 0.022 Age -0.100 -0.531 - 0.331 -0.459 0.647 Smoking index 0.008 -0.022 - 0.006 -1.166 0.246
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