2014年 · 第37卷第07期

Pneumometry is the most commonly used method in pulmonary function testing. Pneumometry is used to measure respiratory volume and flow, which can be converted to each other by differentiation or integration of respiratory time. There are two types of pneumometry^{[1,2,3,4,5,6]}: Volumetric pneumometer directly measures the volume of respiratory gas through a closed system, which is intuitive and easy to understand, but the instrument is large in volume, easy to cross-infect, high in respiratory resistance and few in measurement parameters; The flow-type pneumometer measures gas flow, has low respiratory resistance, is simple to operate, small in size, easy to clean and maintain, and has gradually replaced the volume-type pneumometer^[4,5,6,7]。

The incidence and mortality of lung cancer are increasing year by year, and the age of onset is getting younger, which seriously threatens human health. According to the statistics of my country's 2012 Cancer Registry Annual Report, the incidence and mortality of lung cancer rank first in malignant tumors in China^[1]。 In recent years, although the research of lung cancer has made great progress, the early diagnosis and treatment of lung cancer are still unsatisfactory, and a new and efficient detection technology is urgently needed to promote the research of lung cancer.

Chronic obstructive pulmonary disease (COPD) is a disease characterized by persistent airflow restriction, which develops progressively and is associated with an enhanced chronic inflammatory response of the airways and lungs to toxic particles or gases^[1]。 COPD has a high incidence, disability and mortality rate, and causes a serious social and economic burden^[2]。 Globally, the incidence of COPD in people over 40 years old is 9% to 10%. The World Health Organization projects that COPD will be the fourth leading cause of death worldwide by 2030^[3]。 The pathogenesis of COPD is still unclear, but it is currently believed to be related to chronic inflammation of airways and lungs, oxidative stress and protease-antiprotease imbalance. Oxidative stress can not only directly damage airways and lung tissues, but also lead to protease-antiprotease imbalance, promote inflammatory response, and play an important role in the occurrence and development of COPD. In this paper, the role of oxidative stress in the pathogenesis of COPD was reviewed, and the application prospect of oxidative stress indexes in evaluating the severity, treatment response and prognosis of COPD was described.

Under normal circumstances, the body's oxidation and antioxidant reactions are in dynamic equilibrium. When the balance between the two is broken, oxidative stress occurs. Oxidative stress can occur in a variety of pathophysiological processes, and there are oxidative stress links in the occurrence and development of pulmonary thromboembolism (PTE) and pulmonary hypertension. Understanding the specific role of oxidative stress will help to deeply understand the pathogenesis of PTE and pulmonary hypertension, find new biomarkers that can be used for its diagnosis, risk stratification, therapeutic effect monitoring and prognosis, and open up new ideas for the treatment of PTE and pulmonary hypertension. The role of oxidative stress in PTE and pulmonary hypertension and related research progress are summarized as follows.

Pulmonary arterial hypertension (PAH) is a kind of pulmonary vascular disease characterized by progressive increase of pulmonary vascular resistance^[1]。 Because the anatomical relationship between the pulmonary vessels and the peripheral airway is adjacent, the pathophysiological changes of PAH will affect the structure and function of the peripheral airway, and then there will be corresponding changes in the pulmonary function examination^[2]。 At present, it is believed that patients with PAH have ventilation and ventilation dysfunction, and pulmonary function test as an auxiliary examination can assist in the diagnosis and evaluation of PAH disease severity. Pulmonary function tests include: lung volume, lung ventilation, physiological dead space, alveolar gas distribution, airway resistance, lung compliance, diffusion function, blood gas analysis and cardiopulmonary exercise test (CPET). The characteristics of routine pulmonary function and CPET in PAH patients are summarized as follows.

Mechanical ventilation can lead to ventilation induced diaphragm dysfunction (VIDD), in which diaphragm atrophy is the main cause of VIDD^[1]。 The results showed that muscle fibrin was mainly degraded by the ATP-dependent ubiquitin-proteasome pathway (UPP) in atrophic atrophy^[1,2,3]。 However, the UPP system only breaks down the monomeric contractile proteins, but cannot degrade the skeletal proteins of intact muscle fibers. calpain is a family of calcium ion-dependent proteases that hydrolyze cysteine. The concentration of calpain is the highest in the Z-line of muscle cells, and its main function is to degrade cytoskeletal proteins and protein kinases^[3]。 Therefore, in this study, the effects of calpain inhibitor (calpeptin) on the structure of muscle fibers and muscle atrophy of rat diaphragm under controlled ventilation were observed, and the effects of calpain on muscle atrophy and its mechanism were discussed.

The patient was a 56-year-old female, a farmer, who was in good health and had no tobacco and alcohol habits. He was admitted to hospital on August 27, 2013 due to "cough, asthma and intermittent hemoptysis for more than 2 months". Two months before admission, there was no obvious trigger to suffocate and cough, mostly irritating dry cough, occasional cough of a small amount of white phlegm, intermittent hemoptysis, mostly blood in phlegm, no fever, night sweats, fatigue, chest pain, palpitations, dizziness, abdominal pain, diarrhea and joint swelling and pain, etc. Chest CT examination in the local hospital showed space-occupying lesions in the left lung. The patient underwent bronchoscopy in our hospital on July 14, 2013, which revealed congestion of the mucosa of the left lingual tube wall and cord-like necrosis, and pathological examination revealed necrotic tissue. The result of BALF culture was Aspergillus fumigatus, and the local hospital gave "voriconazole" treatment for more than 2 weeks, but the drug was stopped due to liver damage. On August 27, 2013, I came to our outpatient clinic again for re-examination of chest CT, which showed that there was no obvious change in the lesions compared with before (Figure 1), admitted to hospital for further diagnosis and treatment. Physical examination on admission: superficial lymph nodes were not palpable and enlarged, auscultation of both lungs had coarse breathing sounds, no dry and wet rales, harmonious heart rhythm, no murmur, soft abdomen, no tenderness and rebound pain, and no edema in both lower limbs. After admission, levofloxacin, cefotiam, ambroxol hydrochloride and other symptomatic and supportive treatments were given. Laboratory tests: ESR was 25 mm/1 h, neuron-specific dilute alcoholase was 18 μ g/L, fungal (1,3) -β-D-glucan, soluble cytokeratin 19 fragment, carcinoembryonic antigen, squamous cell carcinoma antigen, blood routine, C-reactive protein and urine routine were not abnormal. No fungi and acid-fast bacilli were found in the sputum smear, but more Gram-negative and Gram-positive cocci were found. Aspergillus serological test was negative. Bronchoscopy on August 28 revealed fish-like obstruction in the lumen of the left lingual lobe (Figure 2，Figure 3), lavage, brushing and biopsy tissues were taken. No acid-fast bacilli and fungi were found in brushing, sputum and BALF smears. A large number of ciliated columnar epithelium and a small number of lymphocytes were found in the brush smear of the left lung. The pathological results of biopsy showed extensive necrosis of the examined tissues of the tongue lobe of the left lung, with a large number of Aspergillus filaments and no tumor cells (Figure 4)。 On September 1, caspofungin was given as antifungal treatment, and on September 4, bronchoscopy was performed again. Under the microscope, there was still a fish-like obstruction in the lumen of the lingual lobe of the left lung. The pathological results showed a small amount of abnormal cell mass in the necrotic tissue, which was considered as neuroendocrine tumor combined with the immunohistochemical staining results (Figure 5)。 On September 15th, I underwent radical resection of the left upper lobe under video-assisted thoracoscopy under general anesthesia. Under the microscope, the tumor was located in the lingual segment of the left upper lobe, which was tough in texture. Multiple swollen lymph nodes were seen in the main pulmonary window, next to the inferior pulmonary vein and hilar. Postoperative pathology showed neuroendocrine carcinoma cells with large necrosis in the lingual segment of the upper lobe of the left lung (Figure 6), the tumor was located in the lumen, no cancer cells were found at the bronchial margin, and no metastasis was found in the lymph nodes submitted for examination. The patient recovered well after operation, and reexamination of chest CT on September 19 showed normal changes after operation (Figure 7)。

Primary botryomycosis is a rare chronic pyogenic granulomatous disease caused by bacterial infection^[1,2]。 Botryloidosis cutaneous involvement is more common, visceral involvement is less common^[3]。 Primary pulmonary staphylocosis is more common in patients with immunosuppression or concomitant chronic respiratory disease. A case of pulmonary staphylocosis in a healthy person is reported.

A 19-year-old male was admitted to the hospital on March 12, 2013 due to "intermittent chest pain for 2 weeks, cough and hemoptysis for 5 days, chest tightness and holding breath for 1 day". The patient had right chest pain without obvious trigger 2 weeks before admission, and no obvious abnormalities were found on chest X-ray and chest color Doppler ultrasound. The chest pain was aggravated 5 days ago, accompanied by cough, expectoration and hemoptysis, and there was no fear of cold, fever, pharyngeal discomfort, palpitations, precordial discomfort, etc. Four days ago, a chest CT examination in an external hospital showed a wedge-shaped patch shadow near the pleura of the right lung. The patient took cough and anti-inflammatory drugs (details unknown) by himself, but the effect was not good. For further treatment, he was admitted to the hospital with "pneumonia" after emergency department. Since the onset of the disease, the patient has suffered from poor spirit, diet and sleep, normal urine and defecation, and no obvious weight loss. He was diagnosed with deep vein thrombosis of the left lower limb in a foreign hospital in August 2012, and was given "oral warfarin 1.5 mg/d, Mailuo Shutong Granules" and stopped taking the medicine six months later according to the doctor's advice. There were no related high risk factors such as arrhythmia, malignant tumor, trauma, surgery, rheumatic immune disease, etc. No vaccination has been performed recently. The patient denied a family genetic history.

The patient was a 49-year-old female. He was admitted to the hospital on 23 August 2012 mainly for "dyspnea after activity for 2 months". The patient developed dyspnea without obvious trigger 2 months ago, which was obvious after activity, accompanied by fatigue. No fever, cough, chest pain, hemoptysis, no night sweats, loss of appetite and weight loss. Chest CT showed diffuse miliary nodules in both lungs, and small lymph nodes were seen in the mediastinum, with a maximum long diameter of about 8 mm (Figure 1，Figure 2，Figure 3，Figure 4，Figure 5)。 Past physical health, denial of exposure to special substances and history of allergies. Physical examination: There was no rash on the skin and mucous membranes, and the superficial lymph nodes were not palpable and swollen. Physical examination of heart, lung and abdomen showed no abnormalities. Preliminary diagnosis of admission: Diffuse nodule shadow nature of both lungs to be investigated-tuberculosis? Lung metastases?

Fungus is a conditional pathogen and is the main cause of death in immunosuppressed patients. Drugs for the treatment of fungal infections include pyrroles, polyenes, echinocanthins, fluorocytosines and propylene. New antifungal drugs echinocandins, including caspofungin, micafungin and anidulafungin, have a unique effect of interfering with fungal cell walls, and have become alternative drugs for traditional fungal treatment, with good clinical application prospects. How to optimize treatment is a very important issue in the application of echinocyanin. The research progress of pharmacokinetics/pharmacodynamics (PK/PD) of echinocyanin antifungal drugs and optimized treatment are introduced below.

Severe bronchial asthma (abbreviated as asthma) can be divided into two basic conditions: (1) sudden attack or aggravation, not timely treatment, rapid death in a short time, mainly rapid inflammatory reaction, and pathological changes into severe airway spasm; (2) Progressive aggravation of asthma, mainly with delayed inflammatory reaction, manifested as edema and hypertrophy of airway mucosa. In recent years, with the popularization of rational and standardized treatment of asthma, although the incidence of asthma is increasing year by year, the mortality rate has decreased significantly. Acute severe asthma attack is the main cause of death in asthmatic patients. Patients have the following characteristics at the time of attack: assistive respiratory muscle activity, obvious three-concave sign, extraordinary pulse (systolic blood pressure decreased by>25 mmHg during inspiration compared with expiration, 1 mmHg =0.133 kPa), heart rate>110 beats/min, respiratory rate>25 beats/min, intermittent or inability to speak, FEV₁% of estimated value<50%, arterial oxygen saturation<91%。 Approximately 4% of such patients will develop respiratory failure, requiring mechanical ventilation support. How to use mechanical ventilation reasonably and correctly to reduce complications and improve the prognosis of asthma patients has become an essential quality for respiratory and critical care doctors.

The third activity of Beijing Young Respiratory Scholars Salon in 2014 was held in Chinese Medical Association on April 24th, 2014, mainly to discuss tuberculosis and related diseases. This salon activity was hosted by Chen Xiaoyou, chief physician of Beijing Chest Hospital affiliated to Capital Medical University.

Pulmonary function test plays a vital role in the diagnosis and treatment of respiratory diseases such as bronchial asthma and chronic obstructive pulmonary disease. However, there has been a lack of corresponding diagnostic technical standards and quality control standards for pulmonary function test for a long time, which seriously limits the clinical application and development of pulmonary function technology. The "guidelines for pulmonary function examination" drafted by the pulmonary function professional group of the respiratory disease branch of Chinese medical association collectively discussed and solved this problem that has long plagued the respiratory disease community in China. Due to the complexity of pulmonary function testing technology and numerous testing indicators, the length of this guideline is large. Part 1 "Overview and General Requirements" of this guideline is published in the sixth issue of diagnosis and treatment plan column, and Part 2 "Pulmonometer Examination" is published in this issue. Pneumometry is the most commonly used method in pulmonary function examination. Pneumometry is divided into two types: volumetric type and flow type. Volumetric pneumometry directly measures the volume of respiratory gas through a closed system, which is intuitive and easy to understand, but the instrument is large in size, easy to cross-infect, and has high respiratory resistance and fewer measurement parameters. Because the flow-type pneumometer has low respiratory resistance for measuring gas flow, simple operation, small volume, easy cleaning and maintenance, it has gradually replaced the capacity meter. This chapter mainly introduces the indications and contraindications of pneumometer examination, instrument standards of pneumometer, subject preparation, procedures of pneumometer examination, test curves and indexes and quality control, evaluation of pneumometer examination results and safety of pneumometer examination. These contents have a good guiding role for clinicians. It is recommended that everyone read it carefully and promote its application.