2015年 · 第38卷第12期

Another year of snowflakes! On the occasion of the publication of the last issue in 2015, Beijing ushered in the first snow this year, which promised a good year. The fluttering snowflakes not only brought this year's harvest, but also indicated a fruitful next year?

percutaneous transthoracic lung biopsy (PTLB) is one of the important methods to determine the nature of intrapulmonary lesions^[1]CT has replaced ultrasound and chest X-ray as the preferred guidance technique for PTLB. The guidance of fluorescence CT further improves the diagnostic efficiency of PTLB for intrapulmonary lesions (especially minor lesions)^[2]While low-dose CT did not reduce the diagnostic efficiency of PTLB while reducing irradiation damage^[3]。 Our team performed a retrospective analysis of 1 014 patients who underwent PTLB over a 10-year undergraduate period as early as 2011^[4]It was found that percutaneous lung puncture biopsy had a high diagnostic efficiency (94.8% of patients obtained the final diagnosis by percutaneous lung puncture) and a relatively low complication rate (the overall complication rate was 18.5%), but there are still medical staff and patients who have doubts about the possible complications such as pneumothorax and hemoptysis caused by lung puncture. The continuous development of endobronchial ultrasound (EBUS) technology makes it possible to biopsy peripheral lung lesions under EBUS guidance, but we believe that PTLB still has an irreplaceable position in the diagnosis of the nature of intrapulmonary lesions.

Bronchial asthma (asthma) is a heterogeneous disease, which is characterized by varying degrees of tracheal spasm, airway hyperreactivity, mucus secretion and chronic inflammation, as well as hyperplasia and hypertrophy of airway smooth muscle. It is one of the common chronic diseases that seriously affects people's health. With the increasing incidence of asthma, severe or refractory asthma is also increasing. About 5% of asthma patients are severe or refractory asthma, and their emergency department rate and hospitalization rate are significantly higher than those of mild to moderate asthma, and their disability rate, fatality rate and medical expenses are also significantly increased. At present, the commonly used clinical asthma treatment drugs cannot alleviate the hyperplasia and hypertrophy of airway smooth muscle caused by repeated asthma attacks and disease progression, so they cannot fundamentally prevent the prolongation and recurrence of severe or refractory asthma patients.

Tuberculosis is a chronic infectious disease. Among the fatal diseases caused by a single infectious disease, tuberculosis currently ranks second, and has become a global public health problem that threatens human health. The World Health Organization lists tuberculosis as the most important killer of human beings together with AIDS and malaria. China's tuberculosis is not only one of the 27 countries with severe multidrug-resistant tuberculosis in the world, but also one of the 22 countries with severe endemic tuberculosis in the world due to its many sources of infection, high infection rate, high prevalence rate, high mortality rate and high drug resistance rate. The number of tuberculosis patients in China ranks second in the world, and the situation of tuberculosis prevention and treatment is very severe.

Tuberculosis is an ancient global infectious disease that seriously threatens human health. According to the World Health Organization, there are 2 billion people infected with MTB in the world. In 2013, 5.7 million new cases were confirmed worldwide, and 1.1 million people died of tuberculosis. In China, 850,000 new cases were confirmed, and 40,000 people died of tuberculosis^[1]The epidemic remains severe. The World Health Organization classifies anti-tuberculosis drugs into first-line oral anti-tuberculosis drugs, injectable anti-tuberculosis drugs, fluoroquinolones, second-line oral antibacterial anti-tuberculosis drugs and anti-tuberculosis drugs with uncertain efficacy^[2]All of the above drugs can cause different degrees of liver damage during use. acute liver failure (ALF) is a rare but most serious drug-induced liver injury in anti-tuberculosis therapy. The disease is dangerous, rapidly progressing, and the mortality rate is extremely high. It is reported that the mortality rate of anti-tuberculosis drug-associated ALF patients without liver transplantation is 67.1%^[3]。 In this paper, the research progress in diagnosis, pathogenesis, gene polymorphism, therapeutic prognosis and prevention of anti-tuberculosis drug-related ALF in recent 5 years was analyzed, aiming at providing reference for clinical and scientific research.

non-invasive positive pressure ventilation (NPPV) has been widely used in patients with acute and chronic respiratory failure, which can effectively reduce the tracheal intubation rate, hospital stay and mortality rate of these patients^[1]。 Most patients with respiratory failure who need NPPV treatment often have varying degrees of airflow restriction, which not only affects the efficacy of NPPV, but also causes adverse consequences such as barotrauma^[2,3]。 Therefore, this group of patients [such as chronic obstructive pulmonary disease (COPD) and bronchial asthma (asthma)] may require both NPPV and aerosol inhalation therapy. Clinically, there are two ways of aerosol inhalation during noninvasive positive pressure ventilation, namely NPPV gap (equivalent to traditional aerosol inhalation) and NPPV simultaneously, the latter without interruption of NPPV treatment. The results of several studies show that noninvasive positive pressure ventilation simultaneous aerosol inhalation therapy is better than NPPV interstitial aerosol inhalation^[4,5]。 The study on the influencing factors of aerosol inhalation in invasive mechanical ventilation has been comprehensive^[6,7]However, noninvasive positive pressure ventilation is mechanical ventilation under non-closed circuit and air leakage, which has its own characteristics such as higher inspiratory flow rate and stronger inertial collision. Therefore, the influencing factors of simultaneous atomization inhalation of NPPV are more complex, so we review these influencing factors.

idiopathic pulmonary fibrosis (IPF) is a special type of chronic, progressive, fibrotic interstitial pneumonia. The histological and/or thoracic high-resolution CT characteristics are usual interstitial pneumonia (UIP). The etiology is unknown, and it occurs in middle-aged and elderly people. The lesions are confined to the lungs. The main manifestations are progressive aggravation of dyspnea and continuous deterioration of lung function.^[1]。

Chronic obstructive pulmonary disease (COPD) is a complex respiratory diseases characterized by progressive decline in lung function, chronic airway inflammation, and reduced quality of life^[1]。 It is estimated that COPD will rank fifth in the economic burden of disease in the world and third in the world for causes of death in 2020^[2]。 Respiratory specialists have long relied on pulmonary function tests and clinical symptoms to diagnose and treat COPD. Clinical use of pulmonary function FEV₁/FVC<0.7 Diagnosis of COPD and severity grading can lead to over-diagnosis of COPD in the elderly^[2]Moreover, the inherent limitations such as low correlation between lung function and airway inflammation, and the inability of lung function to reflect the activity of the disease have prompted the gradual development of some innovative sample collection techniques (such as exhaled air condensate and induced sputum, etc.) and their application in the determination of biomarkers. Oxidative stress can directly lead to lipid, protein and DNA damage, which is one of the important pathogenesis of COPD. Levels of oxidation products in blood, urine, induced sputum, and exhaled breath condensate (EBC) can assess the oxidative load of COPD patients and may reflect disease activity to some extent. The research progress of COPD oxidative stress biomarkers in recent years is summarized as follows.

The main characteristic of acute lung injury/acute respiratory distress syndrome (ALI/ARDS) is diffuse pulmonary interstitial and alveolar edema induced by multiple etiologies, but the pathogenesis is not completely clear^[1]。 angiopoietin (Ang) is a group of secreted endothelial cell-specific growth factors. Some recent studies have shown that ANG-2 plays an important role in the pathophysiological processes such as inflammatory response and vascular leakage in sepsis, and also shows a broad prospect in diagnosis and treatment^[2]。 In this study, the ALI model of SD rats was prepared by lipopolysaccharide-lipopolysaccharide "secondary blow" to induce sepsis, and the changes of Ang-2 in the lung tissue of SD rats in ALI were studied, and the Ang-2 specific antagonist (L1-10) was given to intervene. The so-called second blow is that the first blow (severe trauma or infection, etc.) causes systemic inflammatory response syndrome (SIRS) in the body, and on this basis, the second blow (post-traumatic infection, improper resuscitation, etc.) causes SIRS to lose control and lead to acute lung injury^[3]。

Nocardia is widely distributed in soil and other natural environments, and is susceptible to infection with patients with multiple chronic underlying diseases and low immune function. It is relatively rare in clinic, and the infection symptoms are severe and easy to be misdiagnosed. A case of chronic myelomonocytic leukemia combined with Nocardia infection diagnosed in our hospital is reported as follows.

Using routine transbronchial needle aspiration (TBNA) technique to obtain mediastinal lymph node specimens to clarify the etiology of mediastinal lymph node enlargement, its safety and efficacy have been recognized^[1,2]。 The purpose of this study was to clarify the differences between Wang's TBNA needle 319 (abbreviated as needle 319) and Wang's TBNA needle 121 (abbreviated as needle 121) in the complications and diagnosis of obtaining specimens, in order to understand the effect and safety of needle 319 in patients with mediastinal lymphadenopathy.

After reading the case report "A case of diffuse disease of both lungs with pulmonary hypertension" published in your journal, Volume 37, Issue 12, 2014, I was confused, so I wrote an article to explain it^[1]。

The debate about pulmonary veno-occlusive disease (PVOD) and pulmonary capillary hemangiomatosis (PCH) is very challenging. The author believes that there are three main problems in the cognition and judgment of the two.

Hydrogen is the simplest and most abundant chemical element in nature, accounting for 75% of the mass of all elements. Hydrogen (H₂) is a colorless and odorless gas, which has been often used in the field of diving medicine in the past due to its relative physiological inertness. With 2007 Ohsawa et al.^[1]The selective antioxidant function of hydrogen has been reported for the first time, and its biological effects have been widely concerned. At the same time, the antioxidant, anti-apoptotic, anti-inflammatory and anti-allergic properties of hydrogen make it have a broad application prospect in the field of disease prevention and treatment.

Airway hyperresponsiveness is one of the important characteristics of bronchial asthma (asthma), which is an indirect response to airway inflammation. The measurement of airway reactivity has important reference value for confirming and excluding the diagnosis of asthma, and has reference significance for the assessment of asthma condition and curative effect^[1]。

A 26-year-old male was admitted to the hospital on 17 May 2014 mainly due to "dry cough with neck mass found for 6 d". Six days before admission, the patient developed a cough without obvious trigger, mainly dry cough, and a hard neck mass was found. At that time, there was no fear of cold and fever, no chest tightness, palpitations, no chest pain and hemoptysis. On May 15, 2014, he was seen in another hospital, and the blood routine showed that the white blood cells were 12.5×10⁹/L, C-reactive protein 93.2 mg/L, blood T-spot test (T-spot) positive. B-ultrasound of superficial lymph nodes showed that bilateral cervical, axillary and inguinal lymph nodes could be detected, and the left cervical lymph nodes were swollen. Thoracic CT showed enlargement of the left hilum, mass shadow, and multiple enlarged lymph nodes in the mediastinum. Consider "cervical lymph node tuberculosis, hilar and mediastinal lymph node tuberculosis". Admitted to our department for a clear diagnosis.

A 39-year-old male, a university teacher, was admitted to the hospital on October 17, 2014 due to "recurrent fever with cough for 5 days and right chest pain for 3 days". The patient developed fever without obvious trigger 5 days ago, with the highest body temperature of 39.0℃, accompanied by cough, cough of a small amount of bloody sputum, intermittent yellow sputum, no fear of cold, chills, no chest pain, night sweats, shortness of breath, self-oral "moxifloxacin hydrochloride tablets 400 mg, once/d", fever again 3 days ago, with the highest body temperature of 37.8℃, all of which were afternoon fever, cough worsened than before, and right chest pain, aggravated when deep breathing, and slight shortness of breath after activity. Chest CT showed infectious lesions in the upper, middle and lower lobes of the right lung with a small amount of effusion in the right pleural cavity and pleural thickening (Figure 1，Figure 2，Figure 3)。 He was in good health in the past, and his hemoglobin fluctuated between 160 and 180 g/L in physical examination and blood routine in the past 2 years. He had no history of smoking and alcohol abuse. Those without hereditary diseases in their families.

On June 3, 2015, I attended the 15th Annual Breathing Conference in Toronto, Canada (XXV Annual Research Day in Respirology). This conference mainly reports on the progress of respiratory physiology and treatment of patients with chronic obstructive pulmonary disease (COPD), OSAS, respiratory failure and mechanical ventilation, and the scope is very wide. I will summarize the main report content of the conference, combined with my experience of working in the ICU of a teaching hospital in Toronto for nearly 1 year, as follows, and share it with my domestic counterparts.

In the 1940s, foreign scholars found that the fluorescence phenomenon of tumor tissue is different from that of normal tissue. Subsequently, a lot of research has been conducted around the fluorescence phenomenon of human tissues. One of the purposes is to enhance the visual contrast between malignant tissues and surrounding tissues through this technology, so as to help doctors better identify tumor tissues. At present, image diagnosis based on fluorescence has become a rapidly developing and widely used medical technology. Autofluorescence, as one of its main forms, has been widely used in bronchoscopy.

pulmonary alveolar proteinosis (PAP) is a rare pulmonary disease in which excessive lipoprotein deposition in the alveolar cavity causes gas exchange disorder and leads to progressive respiratory insufficiency. PAP can be divided into three types: congenital, primary (idiopathic) and secondary, of which more than 90% are primary. Studies on the pathogenesis of PAP show that lipoprotein deposition in alveolar cavity of patients is mainly caused by alveolar macrophages and alveolar type Ⅱ epithelial cells catabolizing alveolar surfactant dysfunction. Granular macrocolony stimulating factor (GM-CSF) is a key factor to maintain alveolar surfactant metabolism. Current research evidence shows that there are high levels of GM-CSF neutralizing antibodies in the serum and alveolar lavage fluid of patients with primary PAP, which leads to GM-CSF dysfunction and lipoprotein accumulation in the alveolar cavity, so it is also called autoimmune PAP. The pathogenesis of congenital PAP is mainly due to the dysfunction of GM-CSF receptor, which leads to the metabolism of alveolar surfactants. Secondary PAP is a group of pulmonary alveolar proteinosis caused by infection, blood disease, and inhalation of dust or smoke, whose true pathogenesis remains unclear. Recent studies have shown that patients with secondary PAP are negative for serum GM-CSF antibodies, but occupational inhalation-related secondary PAP is not included in these studies. Some studies have shown that 26% of patients with autoimmune PAP have a history of occupational inhalation exposure, and in another study, the proportion of occupational inhalation exposure among patients with PAP is as high as 54%. Therefore, whether PAP with occupational exposure is autoimmune or secondary PAP is currently unknown. The attribution of occupational exposure-related PAP to PAP classification needs further research and clarification, so we conducted a prospective observational study of the relationship between occupational inhalation exposure and serum GM-CSF antibodies in PAP patients.

Figure 1，Figure 2，Figure 3Is an ancient installation, produced in the early 20th century. The unit has a manometer and switch, and it is also equipped with 3 hollow metal tubes. What's this for? When I showed these pictures to medical students in class, the answers from medical students were varied. Some people think that this is an air pump, which is designed to make artificial pneumoperitoneum, or a device that extends into the esophagus and uterine cavity to compress and stop bleeding; Some people also think it is a negative pressure suction device to suck pleural effusion/ascites.

The 4th National Conference on Sleep Respiratory Diseases, sponsored by the Sleep Respiratory Disorder Group of the Respiratory Disease Branch of Chinese Medical Association, and co-organized by Chinese Journal of Tuberculosis and Respiratory Diseases and Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine, was held in Shanghai from June 19 to 21, 2015. Academician Wang Chen, chairman of the Respiratory Disease Branch of Chinese Medical Association, spoke at the opening ceremony, pointing out that the sleep breathing disorder group should adhere to the development strategy of "raising awareness, standardizing diagnosis and treatment, going deep into the grass-roots level, strengthening discipline construction, and advocating cross-integration". With the theme of "Comprehensive Understanding and Promoting the Diagnosis and Treatment of Sleep Respiratory Diseases", this conference aims to make people's understanding of sleep respiratory disorders go beyond the limitations of "sleep apnea (OSA)" as a single disease (i.e. beyond OSA concept); Correspondingly, we should improve the level of understanding and rational application of non-invasive ventilation. The academic sections are interlocked. The theme report of the conference guides the academic direction and introduces several guidelines and expert consensus to be released in advance. The special report is divided into clinical field and basic field, and has a heated discussion on the progress of clinical technology, basic research methods and existing problems in this field at home and abroad in recent years. Case discussions, continuing education classes, technical workshops and sleep laboratory demonstrations focused on improving the practical ability of grass-roots students. In addition, a total of 232 high-quality professional papers were received in this conference, and 16 outstanding papers were exchanged in the conference, covering the diagnosis and treatment technology of sleep apnea, the mechanisms related to respiratory physiology and the basic research on intermittent hypoxia.

After interpretation of lung volume parameters, ventilation function parameters, airway hyperresponsiveness, etc^[1,2,3,4,5]This issue continues to interpret the standard terminology of lung function diagnosis.