2025 非结核分枝杆菌肺病与支气管扩张症复合病的诊断与治疗专家共识
编写组专家名单：
顾问：唐神结（首都医科大学附属北京胸科医院）；瞿介明（上海交通大学医学院附属瑞金医院）；李亮（首都医科大学附属北京胸科医院）；曹彬（中日友好医院）
总负责：沙巍、徐金富
执笔人：孙勤、王鹏、沙巍（同济大学附属上海市肺科医院）；徐金富（复旦大学附属华东医院）
咨询讨论专家（按单位拼音字母排序）：王华（安徽省胸科医院）；沈宁（北京大学第三医院）；彭丽（重庆医科大学附属第一医院）；裴异（长沙市中心医院）；邵凌云（复旦大学附属华山医院）；揭志军（复旦大学附属上海市第五人民医院）；宋元林（复旦大学附属中山医院）；刘旭晖（复旦大学医学院附属公共卫生临床中心）；陈品儒（广州市胸科医院）；白冲、黄怡（海军军医大学第一附属医院）；魏明（华中科技大学同济医学院附属武汉金银潭医院）；王琳（解放军第九〇五医院）；梁建琴（解放军总医院第八医学中心）；苏欣（南京大学医学院附属鼓楼医院）；张侠（南京市第二医院）；任涛（上海交通大学医学院附属第六人民医院）；秦慧（上海交通大学医学院附属仁济医院）；程齐俭（上海交通大学医学院附属瑞金医院北院）；陈雪融、张培泽（深圳市第三人民医院）；初乃惠、丁卫民、段鸿飞、聂文娟（首都医科大学附属北京胸科医院）；贺建清（四川大学华西医院）；吴妹英（苏州市第五人民医院）；高永华、顾瑾、李冰、刘一典、梁硕、陆海雯、毛贝、史祥、孙勤、王鹏、姚岚、郑旭彬（同济大学附属上海市肺科医院）；何贵清（温州市中心医院）；徐凯进、周华（浙江大学医学院附属第一医院）；蔡青山（浙江大学医学院附属杭州市胸科医院）；崔晓敬（中日友好医院）
证据评价组专家：张嵬（复旦大学）；蒋泓、徐飚、赵琦（复旦大学公 共卫生学院） 利益冲突 所有作者声明无利益冲突
参 考 文 献
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| 证据质量 | 具体描述 | 研究类型 | 表达字母 |
|---|---|---|---|
| 蕾 | 非常确信真实的效应值接近效应估计值 | 高质量的随机对照试验(RCT)；系统评价/Meta分析 | |
| 对效应估计值有中等程度的信心；真实值有可能接近估计有研究缺陷的RCT；低质量的系统评价/Meta分析；高质量 的观察性研究 | B | ||
| 天 | 对效应估计值的确信程度有限;真实值可能与估计值大不非随机对照病例研究;其他观察性研究 同 | ||
| 极 | 对效应估计值没有信心；真实值很可能与估计值大不相同病例报道；专家意见 |
| 推荐强度 | 具体描述 | 表达数字 |
|---|---|---|
| 支持使用某项干预措施的强推荐 | 评价者确信干预措施利大于弊 | |
| 支持使用某项干预措施的弱推荐 | 利不确定或无论高低质量的证据均显示利相当 | |
| 反对使用某项干预措施的弱推荐 | 利不确定或无论高低质量的证据均显示利相当 | |
| 反对使用某项干预措施的强推荐 | 评价者确信干预措施大于利 |
| 病因 | 临床表现 | 检查及评估方法 |
|---|---|---|
| 既往下呼吸道感染 | ||
| 婴幼儿和儿童时期下呼吸道感染是支气管扩张症 最常见的病因,如麻疹、百日咳、肺结核、肺炎 (细菌、病毒、支原体)。其中铜绿假单胞菌的感 染或定植与支扩病情发生发展的关系尤为密切 | 下呼吸道感染症状 | 需详细询问患者的病史和合并症,尤其是幼年下呼 吸道感染病史 |
| 原发性：低免疫球蛋白血症 | ||
| 继发性：长期服用免疫抑制药物、HIV感染 | ||
| 气道阻塞或误吸 | 病史询问、HIV抗体和病毒载量、全血细胞计数、外 周血淋巴细胞亚群计数 | |
| 支气管哮喘症状 | 病史询问,有无误吸史。影像学检查、局灶性疾病 的支气管镜检查 | |
| 变应性支气管肺曲霉病 | 曲霉特异性IgE,血清总IgE水平 肺功能检查 | |
| 慢阻肺病或支气管哮喘 遗传因素 | 咳、痰、喘 | |
| 囊性纤维化 | 发病早,鼻窦炎、胰腺炎或吸收 汗液氯化物检测,囊性纤维化跨膜传导调节蛋白 (CFTR)基因突变 | |
| 原发性纤毛运动障碍 | 发病早,鼻窦炎,慢性扁桃体炎，鼻呼出气一氧化碳(FeNO)浓度检测、基因检测、纤 毛功能评估 | |
| αl-抗胰蛋白酶缺乏症 | 肺气肿 | αl-抗胰蛋白酶水平与表型 |
| 先天支气管病变：巨大气管-支气管症、软骨塌陷等 | CT检查 | |
| 自身免疫性疾病 | ||
| 类风湿性关节炎 | 晨僵等 | 类风湿因子 |
| 干燥综合征 | 口干、鼻干、眼干等 | 抗环瓜氨酸肽 |
| 硬皮病 | 面具脸等 | 抗核抗体 |
| 炎症性肠病 | 腹泻、便血 | 肠镜黏膜活检 |
| 项目 | 大容 |
|---|---|
| 临床表现具有呼吸系统症状和(或)全身性症状 | |
| 影像学经胸部影像学检查发现空洞性阴影、多灶性支气管扩张以及多发性小结节病变 | |
| 并且排除其他肺部疾病 | |
| 微生物学在确保标本无外源性污染的前提下，符合以下条件之一者可诊断为NTM肺病 | |
| 1.2份分开送检的痰标本NTM培养阳性并鉴定为同一致病菌，和(或)NTM分子生物学检测均为同一致病菌； 2.支气管冲洗液或支气管肺泡灌洗液NTM培养和(或)分子生物学检测1次阳性； | |
| 3.经支气管镜或其他途径肺活组织检查发现分枝杆菌病组织病理学特征性改变(肉芽肿性炎症或抗酸染色阳性),并且NTM培 养和(或)分子生物学检测阳性； | |
| 4.经支气管镜或其他途径肺活组织检查发现分枝杆菌病组织病理学特征性改变(肉芽肿性炎症或抗酸染色阳性),并且1次及 以上的痰标本、支气管冲洗液或支气管肺泡灌洗液中NTM培养和(或)分子生物学检测阳性。 |
推荐意见与 GRADE 证据分级
| # | 推荐意见 | 证据等级 | 出处 |
|---|---|---|---|
| 1 | 不同病因的支扩治疗策略和预后有所不同。因此，发现NTM‑PD 患者合并支扩时，建议对支扩病因学进行排查，有助于NTM‑PD 与支扩复合病患者的诊治和预后判断（1B）。 | 1B | |
| 2 | 支扩病因学的检查及评估方法，包括：1）询问病史和临床症状；2） 痰细菌、真菌、分枝杆菌培养等；检测血细胞计数、血清免疫球蛋白 $(\mathrm{{logG}\,\mathrm{{logM}\,\mathrm{{lgA})}}}$ ）水平，曲霉特异性IgE、血清总IgE水平；检测肺功能；3）怀疑合并遗传或自身免疫性疾病时，进一步行相关的特殊检查。详见表3（1B）。 | 1B | |
| 3 | 具有以下4 种情况的支扩患者，建议重点排查是否合并NTM 感染：1）新诊断；2）临 | — | |
| 4 | 推荐的送检标本包括：（1）痰、诱导痰、支气管肺泡灌洗液等呼吸道标本；2）肺部穿刺及活检等病理标本。推荐的检测方法：抗酸染色涂片、分枝杆菌培养（固体或液体培养基）、菌种鉴定和药物敏感试验（1A）；质谱、高通量测序等具有诊断效率快、可鉴定至菌种水平的优势，但不作为常规检测，建议参照相关指南或共识中的临床应用指征酌情开展高通量测序或质谱分析等分子检测以协助NTM‑PD的诊断（2B）。 | 1A | |
| 5 | 拟对支扩患者长期使用大环内酯类药物前，需明确其有无NTM‑PD 或既往有无NTM‑PD 病史，尤其是鸟分枝杆菌肺病。若存在上述情况，不建议长期、小剂量、单独使用大环内酯类药物治疗支扩（2C）。 | 2C | |
| 6 | 对于痰抗酸染色涂片阳性和（或）影像学有空洞样病灶改变的支扩合并NTM‑PD 患者，建议启动抗NTM治疗（2B）。 | 2B | |
| 7 | NTM‑PD 与支扩复合病患者，抗NTM 治疗期间，支扩感染病情加重，推荐在加用抗菌药物治疗前，完善痰及呼吸道分泌物的病原学检测，包括细菌、真菌培养及药敏检测（1A）。病原学结果出来前，建议维持原NTM 治疗，经验性加用抗菌药物治疗；抗菌药物的选择参考既往药敏结果，对既往无病原学培养结果的中重度支扩患者，建议常规覆盖铜绿假单胞菌（1B）。除细菌之外，病毒、真菌等其他病原体也可能与病情急性加重有关，应注意鉴别诊断（2C）。 | 1A | |
| 8 | 抗NTM 治疗失败、或无法耐受正规抗NTM 治疗方案的患者，考虑治疗重点应集中在支扩的治疗和管理（2C）。 | 2C | |
| 9 | NTM‑PD 与支扩复合病的患者，不考虑常规使用激素控制症状。如患者存在阻塞性通气功能障碍，优先推荐吸入性支气管舒张剂。合并哮喘、系统性红斑狼疮、类风湿性关节炎等需要使用激素控制病情的疾病时，参照各相关疾病诊治指南或共识谨慎使用激素（2C）。 | 2C | |
| 10 | 手术治疗需慎重，内科抗分枝杆菌治疗有效的情况下不推荐外科手术（1A）。建议应在经验丰富的、多学科专家评估后开展手术治疗（1B）。 | 1A | |
| 11 | 对于肺内病灶集中且局限，患者心肺功能能够耐受手术，无手术禁忌证，并且符合下列3 种情况或之一的复合病患者，建议外科手术治疗：1）多次药敏结果显示NTM 菌株对大环内酯类耐药，正规抗分枝杆菌药物治疗失败；或者感染大环内酯类耐药的脓肿分枝杆菌，经内科治疗效果不佳的患者；2）经药物治疗后虽症状缓解，病情好转，但发生难治性咯血甚至可能危及生命者的患者；（3）反复NTM 感染影响日常生活和工作的患者（1B）。 | 1B | |
| 12 | NTM‑PD 与支扩复合病患者，术后建议继续抗NTM 治疗，直至患者痰分枝杆菌培养转阴至少1年后停药（1B）。 | 1B | |
| 13 | 疗效与转归判定建议同时兼顾“NTM‑PD 的预后判定标准”和“支扩症状指标”（1B）；判定可分为3 个等级：（1）治疗成功：符合NTM‑PD 判定标准 $\textcircled{\scriptsize{1}}$ \~ $\textcircled{4}$ 中任何1条，同时支扩病情稳定；2）好转：符合NTM‑PD 判定标准 $\textcircled{1}$ \~④中任何1 条，或支扩病情稳定；（3）治疗失败：符合NTM‑PD 判定标准 ${\widehat{\mathcal{S}}})\cdot$ \~ $\textcircled{2}$ 中任何1条，和（或）支扩反复急性加重（2D）。 | 1B | |
| 14 | 治疗成功的NTM‑PD 与支扩复合病患者，日常生活中，建议减少NTM 的环境暴露，评估生活方式和习惯（1B）；对于体重指数低和（或）有体重减轻史的患者，可考虑进行营养评估和干预（2D）；对于全身免疫功能低下或长期使用免疫抑制剂/激素的患者，应在专业医师指导下，在不影响原有疾病治疗的前提下，尽可能减少免疫抑制剂/激素的剂量或使用时间，同时建议定期复查胸部CT和痰分枝杆菌培养（2D）。 | 1B |
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引用 / 出处
中华医学会结核病学分会 中华医学会呼吸病学分会. 2025 非结核分枝杆菌肺病与支气管扩张症复合病的诊断与治疗专家共识[S/OL]. 2025.