2010年 · 第33卷第10期

Although new antibacterial drugs are constantly being introduced and applied in clinic, pulmonary infections are still a serious problem for respiratory doctors. Especially in the past 20 years, the number of patients with low immune function caused by various reasons has increased year by year, and on this basis, the number of patients with complicated pulmonary infection has also increased. Moreover, the condition of such patients is complicated, the treatment is more difficult, and the prognosis is poor, which brings a heavy medical and health burden to society and families.

In recent years, breakthroughs have been made in hematopoietic stem cell and solid organ transplantation in China, and the number of transplantation operations has ranked among the top in the world; Thanks to the progress of radiotherapy, chemotherapy and comprehensive treatment, the survival of cancer patients has been greatly prolonged; The diagnosis and treatment level of rheumatism and other immune-related diseases has improved, and patients need to use glucocorticoids (hormones for short) and/or immunosuppressants for a long time or even lifetime in order to maintain symptom relief; As epidemiological trends change, the number of patients with acquired immunodeficiency syndrome in Asia is in a period of rapid growth. Due to the above factors, the number of immunocompromised patients in China is constantly growing, and with a large population base, the absolute number of immunocompromised patients ranks first in the world. The most common complication in immunocompromised patients is pulmonary infection, and non-infectious complications such as pulmonary edema, alveolar hemorrhage, drug-induced lung injury, radiation pneumonia, bronchiolitis obliterans, lymphoid pneumonia, post-transplant lymphoproliferative disease (PTLD), pulmonary thromboembolism, tumor and primary lung invasion may also occur^[1]。 Acute pulmonary complications, especially infection, are often the cause of death in immunocompromised patients, but there are many difficulties in clinical management. First of all, pulmonary complications are difficult to detect early, especially in patients with agranulocytosis, where the inflammatory response is severely inhibited, and even if infection occurs, there are few to no clinical symptoms and imaging changes; Secondly, pathogenic diagnosis is difficult. On the one hand, it is difficult to collect qualified pathogenic diagnosis specimens. On the other hand, due to the unsatisfactory sensitivity and/or specificity of detection technology, many detection technologies for special pathogens have not yet been established or popularized in China. Thirdly, the treatment and treatment are confusing. Due to the frequent use of extended-spectrum antibiotics or inappropriate combination therapy covering multiple microorganisms that lack comprehensive evaluation and careful consideration, the clinic has become the hardest hit area for irrational use of antibiotics. Therefore, not only basic scientific research and in-depth clinical research are needed, but also it is urgent to sort out, summarize and popularize the accumulated or mature clinical experience and technology in this field.

Pulmonary complications in patients with immunocompromised function have been paid attention by many clinical disciplines because of the characteristics of complex disease, many basic diseases, many complex and drug-resistant pathogens, poor responsiveness to treatment, rapid progress and poor prognosis. Patients often lead to misdiagnosis, misdiagnosis and mistreatment due to unclear diagnosis and unclear treatment direction. Therefore, the diagnostic thinking and empirical treatment direction of this kind of patients are the most important contents of clinical decision-making. The author combines his own clinical experience, focusing on the basic clinical thinking of diagnosis and differential diagnosis.

In bronchial asthma (asthma for short), Th2 cells and their cytokines contribute to the inflammatory infiltration of airway eosinophils and the production of airway hyperresponse, which is an important target of asthma treatment. More and more studies have shown that in addition to Th2 cells, other CD₄⁺T cells [including Th1, Th17, and regulatory T cells (Treg)] can also be recruited into the airway to participate in asthma pathogenesis. The immunological treatment of asthma is complex, and now each subgroup of CD₄⁺The research progress of T cells in asthma treatment is reviewed below.

At the end of March 2010, Beijing, which had just sent away the cold winter, was covered with yellow sand. The average visibility of the whole city was only about 1000 m, and the concentration of respirable particulate matter in the urban air exceeded 1000 μ g/m for 5 days³The air quality has reached the highest level of pollution-Grade 5 severe pollution, which is the dust weather raging all over China. Dust weather can be divided into three categories: floating dust, blowing sand and sandstorm, among which sandstorm refers to strong wind blowing up a large amount of dust and sand on the ground, and horizontal visibility<1 km Of weather phenomena. As early as the Northern Wei Dynasty, there are detailed records of dust storms. In the past 50 years, due to the overexploitation, the ecological environment has been damaged, the land has been seriously desertified, and the frequency and intensity of dust weather have become more and more severe. In addition to serious harm to urban traffic and agriculture, dust weather also has adverse effects on human health, and the respiratory system bears the brunt.

A 24-year-old male suffered from self-conscious fatigue 5 years ago, and his exercise tolerance was lower than that of his peers, but it had no obvious influence on daily work and study. In the past 2 years, chest tightness and shortness of breath have occurred repeatedly, intermittently accompanied by edema and fatigue of both lower limbs. He has been to other hospitals many times. Previous blood gas analysis indicated the existence of type II respiratory failure. Cardiac color Doppler ultrasound showed enlargement of right atrium and right ventricle, increased pulmonary artery pressure, and widened pulmonary artery diameter. Cardiac catheter examination showed increased pulmonary artery pressure and right ventricular pressure, and no abnormalities were found in the rest. X-ray chest radiograph showed no obvious abnormality, and the diagnosis was unexplained pulmonary hypertension, pulmonary heart disease and respiratory failure. After oxygen inhalation, symptomatic anti-inflammatory, antispasmodic and asthmatic treatment, the symptoms were relieved. One month ago, I saw the doctor again due to the aggravation of dyspnea. Physical examination: chronic disease, weight loss, cyanosis of lips and nails, respiratory rate of 24 times/min, weakened breathing movement amplitude of chest, damp rales in inspiratory phase can be heard in the upper lung, no bulge in the apical area, no pathological murmur, and mild edema in both lower limbs. Blood gas analysis showed PaO₂was 46.99 mm Hg (1 mm Hg =0.133 kPa), PaCO₂115.04 mm Hg. Pulmonary function tests showed severe restrictive ventilatory dysfunction and normal diffusion function. Chest CT showed obvious thickening of the main pulmonary artery and no pulmonary embolism; Inflammation of the posterior segment of both upper apices. It is proposed to be diagnosed as pulmonary hypertension, pulmonary heart disease, type II respiratory failure and suspected primary alveolar hypopnea. Anti-infection and oxygen inhalation were given, and the symptoms were improved. A comprehensive respiratory muscle function examination was performed using a diaphragmatic function test tube, and the maximum inspiratory oral pressure was found to be 21 cm H₂O (1 cm H₂O =0.098 kPa) and the highest inspiratory nasoesophageal pressure was 18 cm H₂O, esophageal pressure changed in the same direction as gastric pressure during inspiration and the diaphragmatic electrical response disappeared. Magnetic stimulation of phrenic nerve failed to induce diaphragmatic compound action potential, and twitching transdiaphragmatic pressure disappeared (normal value>18 cm H₂O). Severe respiratory insufficiency and diaphragmatic paralysis were diagnosed, and noninvasive ventilation was given.

Cytochrome P450 2E1 (CYP2E1) is an important member of the cytochrome P450 gene family, which is involved in the metabolic activation of procarcinogens such as nitrosamines in vivo. CYP2E1 gene has polymorphism, among which the relationship between RsaⅠ/Pst Ⅰ gene polymorphism and lung cancer risk is not clear at present, and the research results are inconsistent in various places. We retrieved the literature of relevant studies in Pub Med, Embase, Web of Science and CNKI databases, extracted relevant data, and analyzed CYP2E1 polymorphism and lung cancer risk using meta-analytical volumes. A total of 21 articles and 9380 samples were included. Compared with the wild-type genotype (c1/c1), the homozygous type of c2 mutation (c2/c2)ORThe c2 mutation carrier (c1/c2+ c2/c2) was 0.734 (95% confidence interval 0.628-0.847).ORThe value was 0.852 (95% CI, 0.777-0.933). In the population subgroup analysis, the Asian population results were statistically significant, whereas in the Caucasian population different genotypes were not statistically significant. Subgroup analysis of lung cancer histological types showed that the c2 mutation homozygous (c2/c2) and c2 mutation-carrying types of lung squamous cell carcinomaORThe values were 0.749 (95% CI 0.683-0.813) and 0.726 (95% CI 0.662-0.847), respectively, with statistically significant differences. In the subgroup analysis of smokers, there was no statistically significant difference in genotypes between smokers and non-smokers. The presence of the c2 allele of the CYP2E1 RsaⅠ/PstⅠ polymorphism can reduce the risk of lung cancer development, especially in Asian populations and lung squamous cell carcinoma. CYP2E1 polymorphism and lung cancer risk can be evaluated by meta-analysis system. Because of the large number of included literatures, we performed detailed subgroup analysis and sensitivity analysis, and their conclusions have high confidence. However, this result still needs to be verified by large-scale trials with homogeneous lung cancer patients and highly matched controls.

In 1991, Autofluorescence bronchoscopy (AFB) was first reported by Stephen et al. Under the irradiation of helium-cadmium laser with a wavelength of 442 nm, normal bronchial mucosa can produce green fluorescence after absorption, while precancerous lesions and carcinoma in situ tissues can produce red or brown fluorescence.

The 2010 International Conference of the American Thoracic Society (ATS) was held in New Orleans, USA from May 17 to 22. Like previous annual meetings, COPD remains one of the areas of great concern. There are 6 topics in the conference alone, of which 3 involve COPD comorbidities (especially cardiovascular diseases), and small seminars and posters involve COPD pathogenesis, diagnosis, treatment and management. Throughout the academic topics of this conference, several key words for COPD research can be seen: phenotype, comorbidities, systemic inflammation, and multicenter collaborative research. It is worth mentioning that the newly launched large-scale project "COPDgene Research" in the United States reported the analysis results of its baseline data in the form of seminars and posters at this annual meeting, which attracted attention. The COPDgene study is dedicated to discovering COPD susceptibility genes in non-Hispanic whites and African Americans. The first batch of enrollment included a total of 2,500 COPD patients who smoked more than 10 pack years or smokers without COPD. Due to space limitations, the author only briefly introduces the phenotype, comorbidities and drug treatment progress of COPD.

Among the large-scale evidence-based medicine studies of COPD, the research on understanding potential long-term impacts on function with tiotropium (UPLIFT) is rich in content and has far-reaching influence significance^[1,2]。 The results of the UPLIFT study showed that FEV before and after bronchodilator inhalation in the tiotropium group₁The mean value was significantly higher than that of the control group, and the FEV before and after bronchodilator inhalation in the two groups after 30 d of treatment₁There was no significant difference in the annual decline rate; The quality of life in the tiotropium group was higher than that in the control group, and the incidence of acute exacerbation, hospitalization and respiratory failure were lower than that in the control group. It suggests that tiotropium bromide has a tendency to reduce the mortality of patients with COPD and has a positive therapeutic effect on the clinical progress of COPD^[1]。 In recent years, the research results of UPLIFT have been paid more and more attention by scholars from various countries, and a number of UPLIFT subgroup analyses on different severity, smoking status and gender of COPD have emerged^[3,4]As well as the response of patients to bronchodilators at baseline levels, the effect of treatment on mortality, and the efficacy without concomitant basal medication^[5,6,7]。 The UPLIFT study has the following implications for us.

The third event of Beijing Young Respirators Salon in 2010 was held on May 27th, 2010. The theme of this event was "Lung Imaging and Lung Biopsy Method Choice". Young doctors from many hospitals in Beijing had a heated discussion on this topic with great interest. This salon activity was hosted by Dr. Guo Yanfei, Department of Respiratory Medicine, Beijing Hospital, Ministry of Health.

After a paper is written, we should examine whether the paper has reached the level of publication from the following aspects: (1) whether the experimental design of the paper is accurate; (2) Whether the clinical research papers meet the ethical requirements; (3) Whether the purpose and method of the article are consistent, and whether the title of the article is consistent with the content; (4) Whether the discussion part of the paper focuses on the results of this study; (5) whether the number and attributes of the specimens of each group are identical; (6) Whether the statistical treatment of the research results is correct and standardized; (7) Whether the structure of the article is rigorous, the language expression is concise and the grammar is correct. In addition to the above problems, we should pay attention to carefully reading the manuscript of the submitted magazine, because the manuscript includes the report content of the magazine and the requirements for writing the paper. At the same time, we should pay attention to whether the magazine has published articles with similar content to this article. If the content is duplicated, the possibility of re-publication will be reduced.

Although new antibacterial drugs are constantly coming out and being applied in clinic, pulmonary infection is still a serious problem faced by respiratory doctors, especially the pulmonary infection of patients with low immune function, whose condition is complicated and difficult to treat has become the difficulty of respiratory disease treatment. This issue focuses on immunocompromised lung infection, and organizes experts to discuss this issue. Professor He Quanying specially wrote a review for this issue, "We should attach great importance to pulmonary infection of patients with low immune function". The article pointed out that in the past 20 years, the number of patients with low immune function caused by various reasons has increased year by year, and the number of patients with concurrent pulmonary infection has also increased. Moreover, such patients have the characteristics of complicated diseases, many basic diseases, many complex and drug-resistant pathogens, poor response to treatment, rapid progress and poor prognosis, which brings difficulties to clinical treatment. It is pointed out that because the etiology of pulmonary infection in patients with low immune function is complex, once pulmonary infection occurs, doctors in related disciplines should contact respiratory doctors as soon as possible to discuss treatment strategies, correctly handle the relationship between immune function, pathogenic microorganisms and anti-infective drugs, and improve the prognosis of patients. In the special written talk column, Professor He Lixian wrote the article "Difficulties and Clinical Strategies of Diagnosis and Treatment of Pulmonary Complications in Immunocompromised Patients" based on his many years of clinical experience, and interpreted the heterogeneity and diversity of pulmonary complications in immunocompromised patients, the interpretation of imaging examination and abnormal signs, etiological diagnosis and empirical antimicrobial therapy. In the article "Diagnostic Ideas of Pulmonary Complications in Immunocompromised Patients", Professor Zhang Bo put forward his own views from the key issues that need attention in clinical data, the value of chest imaging examination, diagnostic ideas and the significance of active bronchoscopy.