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摘要: 过敏原鼻激发试验(nasal provocation test，NPT)是指在标准、有控制的条件下将过敏原直接作用于鼻腔黏膜，以观察其是否可激发出变应性鼻炎(allergic rhinitis，AR)的主要症状，再现上呼吸道对受控条件下自然暴露的过敏原的反应，且是目前唯一可用的确认鼻腔对过敏原反应性的测试。它在研究AR的机制和评估新型抗过敏治疗反应方面具有非常重要的价值。NPT在临床实践中的作用越来越大，尤其在局部AR的鉴别、职业性AR的诊断、明确过敏原组分、AR治疗效果评价和进行过敏原免疫治疗的患者选择等方面作用更大、更广。本文综述了NPT在变应性和非变应性鼻炎等诊断中的应用，并对临床实践中使用NPT评估鼻腔反应的适应证、禁忌证、优点和局限性等进行介绍。Abstract: The allergen nasal provocation testing(NPT), in which allergens are applied directly to the nasal mucosa under standard and controlled conditions to provoke the main symptoms of allergic rhinitis(AR), reproduces the response of the upper respiratory tract to natural exposure to allergens under controlled conditions and is the only test currently available to confirm nasal reactivity to allergens. It is invaluable in studying the mechanisms of AR and in assessing the response to novel anti-allergic treatments. The test may play an increasingly important role in clinical practice, especially in the identification of local AR, the diagnosis of occupational AR, the clarification of the composition of allergens, the assessment of the efficacy of AR treatment and the selection of candidates undergoing allergen immunotherapy. This article reviewed the application of NPT in the diagnosis of allergic and non-allergic rhinitis, and also introduces the indications, contraindications, advantages and limitations of NPT in evaluating nasal response.
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Key words:
- nasal provocation test /
- allergen /
- allergic rhinitis /
- local allergic rhinitis /
- non-allergic rhinitis
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表 1 关于NPT适应证与禁忌证的建议
适应证 过敏原的鉴定 科学目的 ①研究过敏反应的机制和各种制剂对过敏反应的影响；
②确定临床研究中重现鼻腔症状所需的过敏原最大剂量阈值。临床诊断 ①确定AIT的指征，确定直接导致患者症状的过敏原，因此确定疫苗的成分，监测脱敏和药物治疗的效果；
②AR、LAR和职业AR(可能伴有哮喘)；
③食物过敏的诊断；
④支气管哮喘的替代诊断；
⑤阿司匹林加重性呼吸系统疾病(aspirin-exacerbated respiratory disease，AERD)的辅助诊断；
⑥对难以接受疾病后果的患者进行确诊，如不养宠物或换工作。禁忌证 绝对禁忌证 ①怀孕或哺乳；
②患有不稳定和严重的全身性疾病患者，如不稳定缺血性心脏病、严重循环衰竭、恶性肿瘤和自身免疫性疾病(如韦格纳病，丘格-施特劳斯综合征)等活动期或加重期；
③正在接受全身抗肿瘤的免疫治疗；
④服用β-肾上腺素抑制药物或血管紧张素转换酶抑制剂、使用肾上腺素抢救有禁忌证的患者；
⑤无法控制的哮喘或慢性阻塞性肺疾病(FEV1 < 70%)；
⑥无应对过敏性休克所需的药物和设备。相对禁忌证 ①年龄 < 5岁；
②没有标准化的过敏原提取物；
③鼻腔解剖异常、慢性疾病：鼻畸形、后鼻孔闭锁、鼻中隔穿孔、严重鼻中隔偏曲、伴或不伴鼻息肉的慢性鼻窦炎、萎缩性鼻炎；
④身体其他部位的急性过敏反应、极高的致敏程度；
⑤多次暴露于化学刺激物或吸烟史。阶段性禁忌证 ①患者处于有症状期，如Lebel评分>3分；
②在NPT前1周接种疫苗、使用过抗组胺药或血管收缩药等，1个月内使用过鼻用糖皮质激素，3个月内使用过全身糖皮质激素；
③呼吸道严重的细菌或病毒感染(4周内)；
④鼻腔、鼻窦手术后2~3个月内；
⑤在检查前24~48 h内饮酒或吸烟、吃辛辣食物和(或)喝咖啡。
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表 2 NPT症状评分标准
症状 评分标准 打喷嚏 0分：0~2个 1分：3~5个 2分：>5个 鼻分泌物 0分：无 1分：少量(≤1 mL) 2分：多量(>1 mL) 鼻外症状 0分：无 1分：腭痒、眼痒、耳痒 2分：结膜炎、球结膜水肿、荨麻疹、咳嗽、呼吸困难
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表 3 2018年EAACI关于NPT阳性标准的建议
评估方法 强阳性(+++) 中等强度阳性(++) 主观评估 VAS评分 ≥5.5分 ≥2.3分 Lebel评分 增加≥5.0分 增加≥3.0分 Linder评分 增加≥5.0分 增加≥3.0分 TNSS 增加≥5.0分 增加≥3.0分 客观评估 PNIF 下降≥40% 下降≥20% 鼻声反射 距前鼻孔2 cm的横截面积下降≥40% 容积总和下降≥27% 主动经前鼻测压法 在150 Pa下鼻流量减少≥40% 在150 Pa下鼻流量减少≥20% 四相鼻阻力测试 对数曲线有效阻力增加≥40% 对数曲线有效阻力增加≥20%
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