2010年 · 第33卷第03期

Modern positive pressure mechanical ventilation technology began to develop in 1950s, and it has been more than half a century since now. The technology is becoming more and more mature, and new theories and new views are emerging one after another, which are constantly tested by clinical practice. Modern positive pressure mechanical ventilation was once praised as one of the important advances in clinical medicine in the second half of the 20th century. However, in recent years, the introduction of new technologies has obviously slowed down. Although new ideas have been put forward continuously, it has not further reduced the mortality of patients with severe respiratory failure. This indicates that the technical development of mechanical ventilation has entered a relatively stagnant plateau^[1,2]。

Fluoroquinolones are currently important second-line drugs for the treatment of tuberculosis, but they are proposed to be used as first-line drugs against tuberculosis due to their significant bactericidal activity against Mycobacterium tuberculosis. Since fluoroquinolones have been in clinical use for nearly 20 years and are widely used in the treatment of other bacterial infections, there is concern that high levels of fluoroquinolone resistance already exist in Mycobacterium tuberculosis and cannot be used as first-line drugs. In this paper, a retrospective study of fluoroquinolone resistance and its risk factors in tuberculosis patients in Shanghai was conducted.

With the development of unilateral lung transplantation and unilateral pulmonary endarterectomy, the number of cases that may lead to unilateral acute lung injury is increasing. Managing acute respiratory failure caused by unilateral lung injury currently includes postural ventilation and independent lung ventilation. In this study, we investigated the effects of different mechanical ventilation modes on cytokine markers in unilateral lung injury by animal model.

Keshan disease is an endemic dilated cardiomyopathy unique to selenium-deficient areas in China, and its etiology is still unknown. Selenium deficiency is the main conditional pathogenic factor, but it is not the only one. There are great differences in the risk of Keshan disease among individuals in the same low selenium environment, which suggests that there may be differences in genetic background among individuals in the disease area. The purpose of this study is to screen the single nucleotide polymorphism loci of GPx-1 gene related to Keshan disease, and conduct in-depth functional research on the related gene loci, so as to finally clarify the role of GPx-1 gene polymorphism loci in the pathogenesis of Keshan disease.

Cardiac insufficiency is a common clinical critical disease, which can be quickly relieved by drug therapy and oxygen therapy. If the drug cannot well coordinate the relationship between blood pressure, myocardial contractility and renal blood flow, the curative effect is poor and the mortality rate is high. The traditional concept is that mechanical ventilation can reduce the volume of blood returning to the heart and inhibit cardiac function, which limits its application in cardiac insufficiency, especially in severe patients. It is often applied "passively" when severe hypoxemia occurs, but at this time, severe circulatory dysfunction and multiple organ damage have occurred, and even if the transient oxygenation state improves, it can't improve the prognosis.

spontaneous breathing trial (SBT) refers to a technique in which patients use T-tube oxygen inhalation or a spontaneous breathing pattern with low pressure support level during invasive ventilation evacuation, and through close observation for a short time (30~120 min), judge whether their spontaneous breathing ability has recovered, so as to help doctors decide whether to go offline^[1,2,3]。 This technology has been used in clinical practice abroad for more than ten years, and has been widely used in patients with respiratory failure caused by acute exacerbation of COPD (AECOPD), ARDS, heart failure, pneumonia, trauma and coma. At present, some ICUs in China are also gradually developing this technology^[4,5]。 Correct operation of this technique and reasonable use of test results to guide off-line and extubation are of great significance to improve the evacuation level of invasive ventilation.

Mechanical ventilation is the main means to treat all types of severe respiratory failure. Among the many mechanical ventilation-related complications, human-machine asynchronization or human-machine confrontation is one of the problems that occur frequently but are easily overlooked by clinicians. Human-machine coordination refers to the cooperation between the patient's respiratory pump (determined by the mechanical mechanical characteristics of the respiratory drive, neuromuscular system, lungs and thorax) and the ventilator (mechanical pump, determined by the setting of ventilator modes and parameters). If the two cooperate well, they will get appropriate respiratory support. If the cooperation is not good, man-machine confrontation will occur, resulting in patient discomfort and increased respiratory work, dynamic lung hyperinflation and difficulty in withdrawal, and even ventilator-induced lung injury and other organ failure (such as induced cardiac insufficiency, arrhythmia and barotrauma, etc.). Under normal circumstances, the phenomenon of man-machine asynchronization is not obvious when controlled ventilation is adopted, but once controlled ventilation is changed to partial controlled ventilation or spontaneous ventilation mode, or the patient's respiratory drive or mechanical condition has changed significantly but the ventilator mode and parameters are not adjusted in time, man-machine confrontation is most likely to occur. In clinical work, human-machine synchronization monitoring is one of the important contents of respiratory monitoring. Respiratory mechanics curve monitoring can provide more intuitive information and help clinicians to better judge the causes of human-machine asynchronization^[1,2]。

systematic evolution of ligands by exponential enrichment (SELEX) is a novel combinatorial chemistry technique developed in 1990s^[1]。 After more than ten years of development, SELEX technology has become an important research means and tool, and has been widely used in many research fields such as molecular biology, genomics and clinical medicine. In recent years, SELEX technology has also been applied to the research field of tuberculosis, providing new and effective methods for exploring the pathogenic mechanism, diagnosis and treatment technology of tuberculosis.

The recurrence of tuberculosis and the prevalence of drug-resistant tuberculosis are two major problems faced by tuberculosis control. Persistent MTB is resistant to drugs, which is an important reason for the prolonged course and recurrence of tuberculosis, and the prolonged course of tuberculosis increases the chance of drug-resistant MTB. The research progress of persisted MTB is reviewed.

C-type lectins are a class of non-enzymatic, non-antibody proteins whose activity depends on Ca^2＋In the form of transmembrane proteins and water-soluble proteins. The common structural feature of C-type lectins is that they have one or more sugar recognition domains that can selectively recognize and bind to the sugar domains of pathogenic microorganisms. Type C lectins can be divided into six families according to the different primary structure of glycorecognition domain: proteoglycan, type I transmembrane receptor, type II transmembrane receptor, collagen lectin, selectin and natural killer cell receptor. Among them, collagen lectin, type I transmembrane receptor and type II transmembrane receptor are closely related to the pathogenesis of tuberculosis.

In 1997, the American College of Chest Physicians (ACCP) and the American Association for Cardiovascular Pulmonary Rehabilitation (ACCVP) published evidence-based medicine guidelines for pulmonary rehabilitation (the Old Guidelines for short)^[1]The Guide was updated in 2007 (the New Guide)^[2]。 We can see from this that 10 years of research results further prove that pulmonary rehabilitation is effective for patients with chronic respiratory diseases^[3]。 The author reviews the changes before and after the revision of the guidelines here.

Troponin and myocardial enzymes are recognized blood biochemical markers of myocardial injury. The changes of these markers in acute coronary syndrome and their clinical significance have been elucidated. The results showed that the blood myocardial biochemical indexes of some patients with acute pulmonary embolism increased, which had a certain relationship with their prognosis. Some foreign scholars have regarded myocardial injury as one of the indicators of risk stratification of pulmonary embolism^[1]。 Although B-type natriuretic paptid (BNP) is a more studied marker to evaluate cardiac function in recent years, it is of great significance in the risk stratification of pulmonary embolism^[2]However, the application of this index has not been popularized in China, and troponin and myocardial enzymes are still routine detection items for unexplained chest tightness and dyspnea. The purpose of this study was to summarize the changes of troponin and myocardial enzyme profile in acute pulmonary embolism, and to explore the relationship between them and the severity of the disease.

Pulmonary embolism is a common serious complication of venous thrombosis, and hypercysteinemia is a risk factor for vascular endothelial injury and thrombosis^[1]。 Whether it can be speculated that hypercysteinemia can promote or increase the occurrence of pulmonary embolism is currently unclear. In this study, we established an animal model of hypercysteinemia after inducing pulmonary embolism to explore the possible correlation between the two.

From 2005 to 2009, in the Department of Thoracic Medicine of Tianjin Chest Hospital, 15 patients with stable general condition after disconnection, but unable to tolerate the test tube occlusion, which caused difficulty in removing tracheotomy cannula, were ventilated with non-invasive ventilator under complete tube occlusion. Results 14 patients were successfully removed tracheal cannula within 72 hours. The report is now as follows.

There has been controversy about whether noninvasive positive pressure ventilation can be used to treat infection-associated acute lung injury (ALI) /acute respiratory distress syndrome (ARDS). In recent years, with the improvement of clinicians' understanding of non-invasive positive pressure ventilation technology and the accumulation of practical experience, there are more and more successful cases of non-invasive positive pressure ventilation in the field of respiratory diseases. Especially in the treatment of H1N1 severe pneumonia in 2009, there are successful cases of non-invasive positive pressure ventilation at home and abroad. Eleven patients with ALI/ARDS treated in the respiratory department of Tianjin Medical University General Hospital had a rapid progression and the onset lasted for 2~3 days. The main manifestations were high fever with severe dyspnea. CT examination showed diffuse lesions in both lungs and PaO₂All were less than 60 mm Hg (1 mm Hg =0.133 kPa), and the oxygenation index was all<300 mm Hg, and the lowest case was only 100 mm Hg. Except for one case with severe underlying disease, the other 10 cases were successfully treated by non-invasive positive pressure ventilation. According to our experience of using noninvasive positive pressure ventilation technique to treat patients with infection-related ALI/ARDS and combined with the review of domestic and foreign literatures, we put forward the view that "noninvasive positive pressure ventilation can be used for the first-line treatment of infection-related ALI/ARDS". It is expected that seniors, experts and colleagues with rich experience in the treatment of non-invasive positive pressure ventilation will also express their opinions and jointly promote the application and development of non-invasive positive pressure ventilation in the treatment of infection-related ALI/ARDS.

coccidioidomycosis (coccidioidomycosis) is a localized or disseminated disease caused by coccidioidomycosis, which is an endemic disease. Primary pneumocystis was mainly distributed in the southwest of the United States, Mexico, Central America and South America. Cases were also reported in Europe, Asia and Africa. The primary pneumocystis reported in Japan were all returnees from endemic places^[1]。 Searching China National Knowledge Network showed that only cases of coccidioidomycosis infection with skin lesions were reported in China, but no relevant literature on pulmonary coccidioidomycosis was retrieved. We found a case of primary pneumocystis diagnosed by pathology after surgical resection. The clinical manifestations, imaging findings and treatment are reported below.

idiopathic hypereosinophilic syndrome (IHES) is a group of unexplained eosinophilic cells (>1.5×10⁹/L) Syndrome over 6 months with infiltration and functional impairment of one or more internal organs. The clinical manifestation of IHES is atypical, and it is rare for patients with multiple organ damage. A case of IHES with respiratory symptoms and multiple organ damage is reported to improve the understanding of this disease.

A 22-year-old female was a teacher. He was admitted to hospital on July 11, 2008 due to "left chest pain for 2 months and chest tightness for 1 month". Two months before admission, the patient developed left chest pain without obvious trigger, followed by chest tightness. X-ray chest radiograph showed that the right sixth posterior rib was thinner, and the left rib-diaphragmatic angle was blunt. After three thoracocentesis, light red and slightly turbid fluid was drawn out. Chyle test was positive twice, negative once, and PPD test was positive. On June 15, 2008, he was added with "isoniazid, rifampicin, butamicacin and levofloxacin" anti-tuberculosis treatment (dose unknown), but no obvious efficacy was transferred to our hospital. The patient had no fever, night sweats, cough, hemoptysis and weight loss since the onset of the disease. The patient suffered from right clavicle pain in 2000 and was not treated. In 2005, he suffered a sudden right clavicle fracture while playing badminton. He was treated with bone graft. During the operation, it was found that the original clavicle became black and thin. Postoperative pathology showed chronic inflammation and slightly active osteoclasts. Clinically, tuberculosis lesions were not excluded. Regular quadruple anti-tuberculosis treatment was performed for 7 months. Admission physical examination: normal development, absence of right clavicle, inability to lift right upper arm, tenderness in thoracic vertebra, solid sound in left lower lung percussion, no dry and wet rales in both lungs during auscultation, small liver and spleen, and no edema in both lower limbs.

Bedside respiratory monitoring during mechanical ventilation is very important for understanding the changes of disease and guiding the use of ventilator. Modern and advanced monitoring equipment and ventilators all have bedside respiratory monitoring functions, including ventilation-related parameters, lung function, exhaled breath and respiratory mechanics, etc. Therefore, bedside respiratory monitoring has become a problem that modern intensive care medicine needs to face every day. However, it is necessary to comprehensively analyze the monitoring indicators in combination with patients' clinical status and respiratory physiology knowledge to rationally apply these monitoring indicators^[1,2]。

translational research refers to the process of rapidly and effectively transforming the latest achievements of biological basic research into clinical medical technology, that is, the continuous process from laboratory to clinic and then from clinic to laboratory. The main purpose is to break the barrier between basic research and clinical medicine, strive to shorten the time from basic research to clinical application, and quickly and effectively transform the scientific research results obtained from basic research into new clinical treatment technologies. Indeed, the emergence of translational research is the result of the transformation of biomedicine. In the early days of molecular biology research, most of the work was carried out in the laboratory. By the age of genetic engineering, basic research began to integrate with applied research and industrial development. In the post-genomic era, much of what used to be considered basic research was closely linked to applied research from the beginning. In the past, it took an average of 17 years from a new discovery in the laboratory to a successful translation to clinical medicine, but now this time has been greatly shortened.

The TORCH (towards a revolution in COPD health) study is an internationally collaborative multicenter, randomized, double-blind, placebo-controlled, parallel design clinical study, which initially enrolled 8554 COPD patients. Although long-acting beta₂-Receptor agonist (LABA) and inhaled cortisol hormone (ICS) combination therapy has been widely used in the treatment of COPD, but has failed to show the impact of this therapy on patient mortality. The core conclusion of the TORCH study is that after 3 years of combined treatment with LABA + ICS, the mortality rate of COPD patients due to all causes did not decrease significantly, but other indicators such as the number of acute exacerbations, health status and lung function could be significantly improved. These key findings were published in the New England Journal of Medicine in 2007^[1]。

After more than half a century of development, mechanical ventilation technology has brought good news to countless patients, but now it has entered a relatively stagnant plateau period. Where will the research of mechanical ventilation technology go? "Advocating individualized mechanical ventilation therapy" is a new view put forward by Professor Liu Youning, the editor-in-chief of this journal, in the "Review" column of this issue. "Treatment by syndrome differentiation, different from person to person", on the basis of absorbing the essence of motherland medicine and fully drawing on the research conclusions of evidence-based medicine, Editor-in-Chief Liu Youning expounded the basis and strategy of individualized mechanical ventilation from a high position, which will play a guiding role in the future research of mechanical ventilation. In addition, in the column of "Special Written Talk" in this issue, Professor Zhang Bo, a member of the editorial board of this journal, analyzed the reasons of man-machine asynchronization in the process of mechanical ventilation in detail, and put forward targeted solutions; Professor Zhu Lei, member of the editorial board of this journal, introduced in detail the pathophysiology of cardiogenic pulmonary edema and the clinical application, effect evaluation and adverse reactions of mechanical ventilation in patients with cardiac insufficiency in the article "Application of mechanical ventilation in patients with cardiac insufficiency"; Professor Tong Zhaohui, a member of the editorial board of this journal, gave a detailed analysis of the technical principle, operation procedure and clinical significance of spontaneous breathing test (SBT), which is very meaningful for how to skillfully apply SBT in the process of invasive ventilation evacuation.