2014年 · 第37卷第09期

Bacterial drug resistance is growing rapidly worldwide, but it is an indisputable fact that there are serious shortages of new effective anti-infective drugs. In response to this serious situation, some developed countries have adopted incentive policies for new drug research and development, and have taken action on appropriate changes in registration rules, among others, ahead of us. In addition, it is necessary to better realize the potential of existing anti-infective drugs and block the spread of drug-resistant bacteria, especially the latter^[1]。 The drug resistance characteristics of bacteria are different in different countries and regions. The author believes that the nosocomial transmission of multidrug resistant Acinetobacter baumannii is the most urgent and threatening problem in China at present.

Idiopathic pulmonary fibrosis (IPF) is a special form of chronic progressive fibrotic interstitial pneumonia of unknown origin, which occurs in the elderly. The lesions are confined to the lungs, and the histopathological and/or imaging findings are characteristic of interstitial pneumonia vulgaris (UIP), and the prognosis is poor^[1]。 The research on its drug therapy has always been one of the hotspots of clinical research. Because the etiology and pathogenesis of IPF are unknown, the research on drug therapy of IPF has been in a slow state, but there have been some new advances in recent years.

Gross and microscopic pathology of chronic interstitial lung disease was already well described at the beginning of the 20th century, when research on interstitial lung disease focused on possible occupational and environmental factors. Hamman and Rich in 1935^[1]Fulminant interstitial pneumonia of unknown etiology is described for the first time. 1944 The two reported four similar patients, all characterized by an acute onset with fever, cough and progressive dyspnea, diffuse infiltrating shadows of the lungs, rapid progression, and death in a short period of time, with an average survival of only 1.7 months. The pathological manifestation of lung tissue was diffuse hyperplasia of interstitial connective tissue^[2]。 Diffuse interstitial fibrosis with monocyte infiltration thus becomes a morphological feature of diffuse idiopathic fibrotic pulmonary disease. However, since then, there has been a lack of more in-depth research on interstitial pneumonia with unknown etiology. After 1950, the research of interstitial lung disease mainly focused on the description and study of imaging, pathology and pathophysiological characteristics. By the 1960s, the classification of interstitial lung disease had made obvious progress, including connective tissue diseases, drugs, interstitial lung disease caused by occupational and environmental factors, sarcoidosis, etc. were all identified as independent diseases.

The research on the diagnosis and treatment of idiopathic pulmonary fibrosis (IPF) has been paid more and more attention by academic circles. IFP is the most representative of interstitial pulmonary disease (ILD), and has been a hot spot at home and abroad. In recent years, there has been some research progress in the diagnosis and treatment of IPF in international academic circles, which is briefly introduced as follows.

The new classification of idiopathic interstitial pneumonia (IIP) in 2013 updates the relevant contents in the 2002 American Thoracic Society/European Society of Respiratory Diseases (ATS/ERS) IIP classification guidelines, mainly including: updating the definitions of some previously existing IIP subtypes, and proposing some new clinical and pathological subtypes of IIP. This consensus is not a standalone guide, but an update and supplement to the 2002 IIP guidelines. A total of 208 IIP-related articles were published between 2004 and 2011, of which 75% followed the contents of the 2002 IIP consensus. This consensus was generated on the basis of integrating the results of the above studies.

Chronic obstructive pulmonary disease (COPD) has obvious heterogeneity in clinical manifestations, imaging features, development of disease course and treatment response. phenotyping not only helps to recognize this heterogeneity, but more importantly has potential diagnostic and therapeutic implications^[1]。 The clinical phenotype of COPD can be identified by clinical observation, such as chronic bronchitis phenotype, emphysema phenotype and acute exacerbation phenotype^[2,3,4,5]It can also be found by unbiased analysis such as cluster analysis^[6]。 In recent years, the significance of COPD phenotype in guiding treatment has gradually emerged, such as phosphodiesterase-4 inhibitor roflumilast in the treatment of chronic bronchitis, lung volume reduction surgery in the treatment of emphysema (upper lobe emphysema), inhaled glucocorticoids (ICS) in the treatment of frequent acute exacerbations of COPD, etc. Another clinical phenotype of interest is the coexistence of COPD and bronchial asthma (asthma for short)^[7,8]The 2014 update of the Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease (COPD Global Strategy) has defined it as asthma-COPD overlap syndrome (ACOS), which is described in a separate chapter^[9]But how to target treatment according to phenotype remains unmentioned. It is worth noting that academic groups in some countries have taken a more positive attitude towards this, taking the lead in developing phenotype-based diagnosis and treatment guidelines, among which the Spanish COPD guidelines (referred to as Spanish guidelines for short) are the most influential. Starting in 2011, initiated by the Spanish Society of Pulmonology and Thoracic Surgery, scientific communities from the National COPD Strategy are invited to participate in the development of new Spanish guidelines. The English version of the Guide (Summary) was published in 2013^[10]Its main contents include three parts, namely, the definition and identification of COPD phenotype, the assessment of disease severity and treatment recommendations. Its innovation lies in the treatment of patients with stable COPD based on clinical phenotype.

Airway stimulation by external factors can cause spastic contraction response, on the contrary, spastic contraction of the airway can be soothed naturally or after bronchodilator treatment, this phenomenon is called airway reversibility. Airway reactivity and airway reversibility are two important pathophysiological features of airway function changes. The same principle as bronchial challenge test, because it is difficult to measure the airway diameter directly, pulmonary function indexes are commonly used to reflect the changes of airway function in clinic. The method of observing the soothing response of obstructed airways through treatment with bronchodilating drugs is called bronchodilation test, also known as bronchodilation test.

familial pulmonary fibrosis (FPF) is a rare disease, which refers to the development of pulmonary interstitial fibrosis in two or more members of a family. The onset of FPF is insidious, its clinical symptoms and signs are similar to those of Idiopathic Pulmonary interstitial Fibrosis (IPF), and its histopathology and/or chest high-resolution CT (HRCT) manifestations are usual interstitial pneumonia (UIP), so some scholars call it familial Idiopathic Pulmonary Fibrosis (FIPF).

The precancerous lesions of the lung currently defined by the World Health Organization include squamous epithelial atypical hyperplasia (SD) and carcinoma in situ (CIS), atypical adenomatous hyperplasia (AAH) and diffuse hyperplasia of neuroendocrine cells of the lung (DIPNECH)^[1]。

In the past decade, the treatment of lung cancer has made great progress, but the main treatment modes have not changed much. At the same time, with the gradual deepening of genomics research, its research field has also expanded from limited genetic diseases to various common diseases. With the continuous development of related technologies, the application of whole genome sequencing in individualized diagnosis and treatment of tumors has received more and more attention. This technology not only helps to understand the causes of tumor occurrence and development, but also opens up new ideas for individualized diagnosis and treatment of tumors. The progress of whole genome sequence analysis in individualized tumor therapy, especially lung cancer therapy, is reviewed below.

Pulmonary function examination is one of the important examination methods in respiratory medicine, which plays a key role in the diagnosis, severity classification, treatment and prognosis evaluation of respiratory diseases. Pulmonary function tests mainly include ventilatory function and ventilatory function tests. Clinically, ventilatory dysfunction is the most common, divided into obstructive, restrictive and mixed ventilatory dysfunction. This standard has been used for many years and is widely accepted by everyone. However, the debate about determining the nature and severity of ventilatory dysfunction has not stopped. At present, the diagnosis of obstructive ventilatory dysfunction mainly relies on FEV₁/FVC, but it has problems such as poor early diagnosis sensitivity and difficulty in completing elderly or seriously ill patients; FEV₁% of the projected value is mainly used to judge the severity of obstructive ventilatory dysfunction, but for patients with mixed ventilatory dysfunction, due to FEV₁The reduction of FEV is affected by both obstruction and restriction, and FEV₁% of the estimated value It is difficult to accurately evaluate the degree of blockage. Therefore, in recent years, many scholars have studied FEV₃FEV₆and corrected FEV₁and other indicators have been studied, hoping to compensate for FEV₁/FVC and FEV₁Defects accounting for % of the estimated value. In addition, abnormal lung function with nonspecific ventilatory function indexes is often seen in clinic. In recent years, some scholars have put forward the concept of nonspecific pulmonary function (NSPF), and believe that this is an independent type of lung function, which has certain clinical significance. In this paper, some research reports on pulmonary ventilation function examination in recent years are reviewed.

1998 Gattinoni et al.^[1]Firstly, it was found that there were obvious differences in respiratory mechanics characteristics and efficacy of mechanical ventilation with different positive end-expiratory pressure (PEEP) in patients with ARDS caused by different triggers. Lung histopathological changes in ARDS caused by different triggers (especially in the early stage of disease)^[2]And chest CT features^[3]Each has its own characteristics, and the therapeutic effects of pulmonary retention, IL-6 and methylprednisolone are also different^[4,5,6]。 Propofol pretreatment can inhibit lung inflammation and reduce lung cell apoptosis in hydrochloric acid-induced ARDS rats, and has a good lung protection effect^[7]In this study, we intended to replicate the rat ARDS model with different triggers by intraairway hydrochloric acid instillation and intravenous oleic acid injection respectively, and compare the lung protective effect of propofol on the two.

In 2001, Japanese scholar Hamano et al.^[1]Significantly increased serum IgG4 levels were reported for the first time in a patient with sclerosing pancreatitis, suggesting that IgG4-related disease is a sclerosing disease involving multiple organs. Kamisawa, 2004^[2]Pulmonary involvement in a patient with IgG4-related disease is reported. In recent years, cases of IgG4-related lung disease (IgG4-RLD) have been reported and summarized in literature at home and abroad^{[3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18]}。 The coexistence of multiple organs in this disease is more common (>90%)^[19]Or pulmonary involvement alone. For IgG4-RLD with simple pulmonary involvement, its clinical and experimental examinations often suggest non-specific changes, the chest imaging findings are diverse, and the pathology suggests lymphoplasma cell infiltration, lack of specificity, and is easy to be misdiagnosed and missed. A case of IgG4-RLD with simple pulmonary involvement diagnosed in the First Affiliated Hospital of Guangzhou Medical University is reported below.

A 60-year-old male, farmer, was admitted to the hospital on 27 April 2012 due to "hemoptysis for 10 days". The patient had sudden hemoptysis without trigger 10 days before admission, 8 to 10 times/d. Chest CT examination in the local hospital showed space-occupying lesions in the right upper lung with mediastinal lymph node enlargement, infectious lesions in the right middle lung with pleural changes, and emphysema with pulmonary bulla formation. The symptoms of hemoptysis were not relieved after administration of pituitrin 6 U/d, and he was admitted to our hospital for further diagnosis and treatment. Past history: 80 years of smoking and 35 years of drinking (6 taels of liquor/d). Outpatient emergency blood routine: white blood cell count is 9.1×10⁹/L, the red blood cell count was 3.42×10¹²/L, and the hemoglobin was 108 g/L. Physical examination: Body temperature was 37.0 ℃, pulse 77 beats/min, breathing 18 beats/min, blood pressure 120/64 mmHg (1 mmHg =0.133 kPa). The superficial lymph nodes of the whole body were not swollen, the skin and mucous membranes were not yellowed or bleeding spots, the breathing sounds of both lungs were clear, no dry and wet rales were heard, the heart rhythm was uniform, no murmur was heard, the liver and spleen were not reached under the costs, and there was no edema in both lower limbs.

I carefully read the article "Application of carbon dioxide map monitoring in bronchoscopy under sedation" in Chinese Journal of Tuberculosis and Respiration, Volume 37, Issue 5, 2014^[1]I admire your editorial department for being good at promoting foreign advanced respiratory intervention concepts, and the author of this article for sharing the new knowledge he has learned from abroad with his domestic counterparts in time. Inspired by it, the author combined with the development of "painless bronchoscopy" in recent years^[2,3]To discuss whether the term "painless bronchoscopy" should be renamed.

One of the major updates of the 2014 revision of the Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease (COPD Global Strategy) is the addition of Chapter 7, namely: asthma COPD overlap syndrome (ACOS)^[1], but the Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) provides only a brief summary of ACOS. May 6, 2014 The Global Initiative on Bronchial Asthma (GINA) published for the first time in its 2014 revision the "ACOS" jointly drafted by GINA and the GOLD Scientific Committee^[2]。 This document provides a method to distinguish between asthma, COPD and ACOS, but at the same time points out that the definition and research of ACOS are not perfect, and there must be many subtypes. With the continuous deepening of research on clinical symptoms, pathophysiology and genetics of ACOS, more characteristics will be gradually clarified.

Smoking is associated with the onset of a variety of respiratory diseases, known as lung cancer and emphysema. More and more data show that smoking is related to the pathogenesis of interstitial lung diseases, and scholars at home and abroad have proposed the concept of smoking-related interstitial lung diseases (SR-ILDs)^[1,2,3]。 SR-ILDs include respiratory bronchiolitis-associated interstitial lung disease (RB-ILD) and desquamative interstitial pneumonia (DIP)^[2]et al., while RB-ILD and DIP are two diseases classified as idiopathic interstitial pneumonia of interstitial lung disease^[4]。 The so-called idiopathic interstitial pneumonia refers to interstitial pneumonia with unknown etiology. Correct classification will help prevent, treat and improve the prognosis of the disease. Based on the results of the present study, we boldly call for the reclassification of idiopathic interstitial pneumonia and the elimination of RB-ILD and DIP from the idiopathic interstitial pneumonia classification. RB-ILD and DIP are smoking-related diseases, not idiopathic diseases of unknown etiology, for the following reasons.

Intermittent command ventilation (IMV) is relative to continuous command ventilation (CMV), which means that the ventilator performs mechanical ventilation intermittently according to preset requirements, and spontaneous breathing is allowed between every two mechanical ventilations, at which time the ventilator only provides an air source; A variety of "spontaneous ventilation modes" can be added during spontaneous breathing, the most commonly used is pressure support ventilation (PSV). If mechanical ventilation is synchronized with spontaneous inspiration trigger, it is called synchronous intermittent command ventilation (SIMV). The IMV of modern ventilators is synchronized, so unless otherwise specified, the IMV is common to the SIMV^[1,2]。 IMV is divided into volume-controlled intermittent command ventilation (VC-IMV) and pressure-controlled intermittent command ventilation (PC-IMV). The former means that each inspiration process is completed according to the preset tidal volume and inspiration time, while the latter is completed according to the preset ventilation pressure and inspiration time.

Chronic obstructive pulmonary disease (COPD) is an important disease that threatens human health. Oxidative stress and hypersecretion of mucus play an important role in its pathogenesis. N-acetylcysteine is a potent mucolytic agent that reduces sputum viscosity and elasticity, improves mucociliary clearance function and regulates inflammatory responses. In addition, N-acetylcysteine has direct and indirect antioxidant properties, which may have important implications for the long-term management of COPD patients. This study aimed to investigate whether high doses of N-acetylcysteine (600 mg, twice/d) could provide a better and effective treatment for patients with COPD.

In the golden autumn season, the fragrance of osmanthus is floating. The 9th issue of this magazine in 2014 met with you readers. The rapid growth of bacterial resistance on a global scale and the shortage of new effective anti-infective drugs are now serious problems facing the world. In the essay column of the editor-in-chief of this issue, Professor Liu Youning called on everyone to pay attention to the epidemic situation of multi-drug-resistant Acinetobacter baumannii in China, and pointed out that the characteristics of bacterial drug resistance in China are different from those in European and American countries. Since 2004, the resistance rate of Acinetobacter baumannii to hydrocarbone antibiotics in China has continued to rise, reaching 50% in recent years, and has remained high. This situation means that only a few drugs such as polymyxin, tigecycline and sulbactam are available for clinical use. However, polymyxin and sulbactam alone are difficult to obtain in my country, while tigecycline has not been approved for use in nosocomial acquired pneumonia. More seriously, in recent years, there have been reports of tigecycline-resistant Acinetobacter baumannii. In the past, Acinetobacter baumannii was not the most important pathogen of nosocomial pneumonia in European and American countries. Clinically, it was once considered a conditional pathogen, with weak virulence and pathogenicity. It was mainly colonized, and even thought that it was not necessary to treat it. However, recent research results show that severe pneumonia, sepsis and even meningitis caused by Acinetobacter baumannii are more and more common in China, and if the current situation is taken lightly, it may have catastrophic consequences. In the article, Professor Liu called on everyone to establish mandatory and binding nosocomial infection control measures against the spread of drug-resistant Acinetobacter as soon as possible, strengthen the control of nosocomial infections, and fundamentally delay bacterial drug resistance.