2016年 · 第96卷第06期

Tumors have a long history with us human beings. The British Guardian reported that there was cancer in the dinosaur period. Cancer occurred based on various genetic defects, not a single disease, but a loose combination of hundreds of disease factors. Cancer, like human beings, is constantly evolving for survival. The longer the life span, the greater the possibility of cancer, and no one can completely avoid the risk of cancer.

acute respiratory distress syndrome (ARDS) is a kind of acute and diffuse inflammatory lung injury. It is one of the common respiratory critical diseases that endanger human health. The mortality rate of severe ARDS patients in intensive care unit (ICU) is 40% ~50%^[1,2,3]。 Mechanical ventilation is the key medical measure in the treatment of ARDS patients. Rational mechanical ventilation treatment strategy can significantly reduce the mortality rate, otherwise it will further aggravate the deterioration of the disease^[4]。 In recent years, with the deepening of the understanding of the pathophysiology of ARDS and the continuous development of clinical respiratory support technology, the mechanical ventilation treatment strategy of ARDS has also undergone significant changes. In order to update the understanding of mechanical ventilation therapy for ARDS and standardize its clinical application, the Respiratory Critical Care Medicine Group of Respiratory Medicine Branch of Chinese Medical Association summarized and constructed 12 important problems in clinical practice according to the latest research progress at home and abroad, and adopted the evidence-based medicine method-GRADE (Grades of Recommendation, Assessment, Development, and Evaluation), which is widely used in the world^[5]The "Guidelines for Mechanical Ventilation in Patients with Acute Respiratory Distress Syndrome (Trial)" (hereinafter referred to as the "Guidelines") was developed.

Pulmonary function in patients with severe chronic obstructive pulmonary disease (COPD) is no longer suitable for lung resection, but lung volume reduction surgery in such high-risk patients can improve lung function, relieve symptoms and improve quality of life in a short time, and buy time for donors waiting for lung transplantation^[1,2,3]。 Our hospital has gained some experience in the anesthesia management of lung volume reduction surgery in patients with severe COPD, which is summarized as follows.

A 77-year-old male was admitted to the hospital on 7 February 2013 mainly due to "anorexia for 3 days". The patient had anorexia 3 days before admission, no abdominal pain, no nausea, vomiting, no yellowing staining of the skin and sclera, no defecation for 3 days, and exhaustion. He went to the emergency department of our hospital, and the routine blood test showed: hemoglobin 85 g/L; Fecal occult blood positive (+); Gastroscopy showed: multiple gastric ulcers; He was discontinued from aspirin, fasted water, acid suppression, fluid rehydration and other treatments, and was admitted to the hospital for further treatment. Past history: 50-year history of hypertension, highest blood pressure 180/110 mmHg (1 mmHg =0.133 kPa), long-term oral felodipine 2.5 mg/d, blood pressure control; He had a history of cerebral infarction for 10 years, and was treated with long-term oral aspirin 100 mg/d and Tongxinluo and ginkgo leaves; 10 years of chronic glomerulonephritis. Physical examination at admission: pulse 80 beats/min, blood pressure 110/60 mmHg, anemia appearance, no obvious positive signs on heart, lung and abdomen examination. Laboratory test after admission: blood routine: white blood cells 13.37×10⁹/L, hemoglobin 76 g/L, platelets 213×10⁹/L; Biochemistry: alanine aminotransferase 14 U/L, aspartate aminotransferase 30 U/L, total bilirubin 34.54 μ mol/L, direct bilirubin 12.57 μ mol/L, creatinine 131 μ mol/L, urea nitrogen 15.28 mmol/L; Coagulation function: prothrombin time (PT) 12.9 s, prothrombin activity 76.6%, activated partial prothrombin time 42 s, plasma fibrinogen 2.22 g/L, D-dimer 9.8 mg/L; After admission, the active gastrointestinal bleeding of the patient was controlled after treatment. Three days after admission, the patient complained of muscle pain in the right lower limb with fever, and the body temperature was 39.0 ℃. Blood test routine: white blood cells 5.7×10⁹/L, the percentage of midline granulocytes was 0.821, and the soft tissue ultrasound of the right leg showed that there was no echo and flocculate echo between the fat layer and the muscle layer in the inner and lower part of the right thigh, with a range of about 6.1 cm ×3.4 cm. Hematoma was considered first; CT of the right lower limb showed: swelling of the soft tissue on the medial and posterior side of the right thigh, mass-like slightly high-density shadow, peripheral exudation, and possible hematoma; According to the orthopedic consultation advice, the patient was treated with hot compress and intravenous drip of second-generation cephalosporin antibiotics for anti-infective treatment. The pain and swelling of the patient's right lower limb gradually decreased, and the extent of hematoma gradually decreased. 15 days after admission, the patient suddenly lost consciousness and lost consciousness after vomiting twice. The blood pressure was 130~150/80~90 mmHg, and the heart rate was 138 beats/min. Emergency head CT showed multiple cerebral hemorrhage and subarachnoid hemorrhage in the right temporal region, right temporofrontal parietal lobe, head of corpus callosum, part of the sulcus and cistern; Right subarachnoid hemorrhage was not excluded, the left lateral ventricle and the third ventricle were compressed and narrowed, the fourth ventricle was narrowed, and the midline shifted to the left; Please consult with neurology and surgery to explain the advantages and disadvantages of craniotomy and puncture and hematoma drainage to the family members. The family members gave up the operation and asked for conservative treatment. The treatment effect of dehydration and brain rejuvenation was not good, and the patient died nearly 10 hours later.

There are many risk factors for bronchial asthma, including host factors such as genetics and obesity, as well as environmental factors such as smoking and pet keeping^[1]Long-term repeated stimulation by various factors eventually leads to the occurrence of airway remodeling in asthma. Airway remodeling involves immune, inflammatory and structural changes of the airway, which are characterized by irreversible airflow restriction, increased airway resistance and increased airway hyperresponsiveness. It is the pathological basis of refractory asthma^[2]。 Early studies showed that serum angiotensin (Ang) converting enzyme (ACE) activity was significantly increased in asthma patients, and total IgE levels were significantly correlated with serum ACE activity, suggesting that asthma may be related to renin-Ang system (RAS)^[3,4]。 In recent years, in the studies of myocardial vascular remodeling and renal fibrosis, it has been found that local fibrosis and collagen deposition are accompanied by RAS expression^[5,6]。 The involvement of local RAS in the process of airway remodeling and related signaling pathways in asthma has gradually become a research hotspot.

At present, the clinical effect of anti-inflammatory therapy is mainly based on the symptomatic control and lung function changes of patients, but some studies have shown that there is no significant correlation between ventilatory function measurement and airway inflammation degree^[1]。 Although endobronchial biopsy, induced sputum detection and peripheral blood eosinophil (EOS) counting can be used to evaluate the degree of airway inflammation, these methods are high risk, time-consuming and labor-intensive, or lack high sensitivity and specificity, so it is difficult to be widely used in clinical practice.