2011年 · 第34卷第02期

Methicillin-resistant Staphylococcus aureus (MRSA) has been widely prevalent, and vancomycin-resistant Staphylococcus aureus (VRSA), linezolid-resistant Enterococcus faecalis and Enterococcus faecium have also been reported. The authors of this paper report the first outbreak epidemic of linezolid-resistant Staphylococcus aureus (LRSA) in the ICU.

BACKGROUND AND OBJECTIVES: Endobronchial valves can allow gas to be expelled from the lung lobes without allowing it to enter, resulting in a reduction in lobar volume, improving the symptoms of hyperpulmonary inflation, and improving lung function and exercise tolerance in patients with advanced emphysema. Methods: To compare the safety and efficacy of endobronchial valve and standard therapy in the treatment of heterogeneous emphysema. Selection of FEV for efficacy determination₁and the change in % of the predicted value of the 6-min walk test. Results: 321 enrolled patients were randomized, 220 received endotracheal valve therapy (EBV group) and 101 received standard therapy (control group). At 6 months, FEV in the EBV group₁This increased by 4.3% (1.0% increase in % predicted value), while the control group decreased by 2.5% (0.9% decrease in % predicted value), with a mean between-group difference of 6.8%. There was no significant difference between the 6 min walking test groups. At 12 months, the incidence of complications was 10.3% in the EBV group and 4.6% in the control group. At 90 d, the incidence of hemoptysis was 6.1% in the EBV group and not in the control group; The incidence of acute exacerbation of COPD requiring hospitalization was 7.9%, all of which were significantly higher than those in the control group (1.1%). At 12 months, the incidence of target lobar pneumonia increased by 4.2% in the EBV group. The more obvious the heterogeneity of emphysema on imaging and the more complete the lung fissure, the better the response to treatment. Conclusion: Endobronchial valve can moderately improve lung function, exercise tolerance and symptoms in the treatment of advanced heterogeneous emphysema, but the incidence of acute exacerbation of COPD, pneumonia and hemoptysis is more frequent after valve implantation.

Nocardia can cause severe opportunistic infections, especially in patients with suppressed immune function. With the increase of tumor incidence and the extensive development of organ transplantation, the infection rate of Nocardia has also increased. Cases of sulfonamide resistance have been reported in Europe, Japan, Thailand and Kuwait.

Acinetobacter baumannii (ABA) is an important pathogen causing nosocomial infection, and ICU patients are more susceptible to infection due to impaired autoimmune function. In recent years, carbapenem-resistant ABA clinical strains have been continuously isolated around the world, and currently only a few antibiotics maintain high antibacterial activity against such bacteria, such as tegecycline, polymyxin and sulbactam. Clinicians are advised to use the above drugs in combination to treat infections caused by carbapenem-resistant ABA.

At present, most patients with COPD are receiving inhaled hormone (ICS) therapy, but unlike patients with bronchial asthma, the position of ICS in the treatment of COPD is unclear. Clinical studies have shown that ICS can reduce the number of acute exacerbations in COPD patients, but at the same time can increase the incidence of pneumonia in patients. The results of a study on the health survey of patients with COPD showed that the incidence of pneumonia was 18.3% in patients with COPD who inhaled fluticasone alone and 19.6% in patients who inhaled fluticasone/salmeterol, both of which were significantly higher than those in the placebo group (12.3%). The results of another study showed that patients with acute exacerbation of COPD inhaled fluticasone/salmeterol, salmeterol and tiotropium bromide, respectively, and the incidence of pneumonia in the inhaled hormone treatment group increased significantly. In order to further clarify the role of inhaled hormones in the treatment of COPD, it is necessary to understand the risk of ICS to patients with COPD in various stages, especially the incidence of severe pneumonia treated by ICS.

At present, pneumonia is still the main cause of death caused by various infections. According to statistics, the mortality rates of community acquired pneumonia (CAP) in general wards and ICU are 5.1% and 36.5%, respectively. The main reasons are that patients with severe pneumonia have low immune function, are prone to multidrug-resistant bacterial infection, severe hypoxemia, even septic shock and multiple organ failure. The main reason for this result is not only the role of pathogenic bacteria, but also the inflammatory waterfall effect caused by the immune process of the body. Current research results show that existing anti-infective treatments cannot further reduce the mortality rate of severe pneumonia. Therefore, how to actively explore other adjuvant treatments while anti-infection treatment to reduce the mortality of severe pneumonia has become a hot spot in clinical research in recent years. The current adjuvant anti-inflammatory treatment of severe pneumonia and its progress are summarized as follows.

The infection caused by Yersinia pestis belongs to Class A infectious diseases, and its clinical types are mainly bubonic plague, septic plague and pneumonic plague. A few patients can also develop plague meningitis, etc. The clinical experience is dangerous and infectious, and even with appropriate intervention, its prognosis is not satisfactory. The plague among rats in China still exists in Qinghai, Inner Mongolia, Hebei and Yunnan, and cases of Yersinia pestis infection occur every year. However, due to the lack of knowledge and clinical experience of most clinicians, it is difficult to detect it in the early stage and the prognosis is poor. Therefore, early detection and early diagnosis are one of the main factors that determine the prognosis of patients. The following is a summary of the current status of diagnosis and treatment of plague in the world, so as to improve the awareness of Chinese clinicians about the disease and improve the treatment ability.

high altitude pulmonary edema (HAPE) is a kind of pulmonary edema that occurs in high altitude hypoxic environment, with acute onset, rapid progression and great harm^[1]。 The results showed that the incidence of HAPE was 0.4% ~2% in the population above 3700 m above sea level. It was more common in those who entered the plateau rapidly from the plain, but also in those who stayed in the plateau for a long time when they entered higher altitude or stayed in the plain for a period of time and returned to the plateau^[2]。 The results of animal experiments and epidemiological investigations showed that HAPE pathogenesis was ethnically specific and familial and individual predisposition. The incidence of HAPE among Tibetans living in the Tibetan plateau is much lower than that of Han immigrants. The General Hospital of the Tibet Military Region reported that in the past 10 years, only 1 case was treated by Tibetans. There are also reports in China that those who had suffered from HAPE have entered the plateau again, and there is an obvious tendency of HAPE recurrence^[3,4]。 Zhang Xuefeng^[5]Among the 1532 reported cases of HAPE, 27% of the patients with 2 or more episodes of HAPE were reported, and the incidence rate of those with HAPE when they entered the plateau again was 81.8%. Zhang Huayao^[6]It is reported that 12 cases of HAPE occurred in 6 cases of three generations of grandparents in a family during 40 years. The ethnic specificity of HAPE and the tendency of family and individual susceptibility suggest that both environmental and genetic factors can affect the occurrence of HAPE, and the susceptibility of the body to the environment is also affected by genetic factors.

Both bronchial asthma (asthma for short) and COPD are obstructive airway inflammatory diseases. The airflow restriction of the former is reversible, while the latter is incompletely reversible. However, irreversible airflow restriction often occurs in long course of disease, especially in adult asthma patients who smoke, and some COPD patients also have good response to inhaled glucocorticoid (abbreviated as hormone) therapy and partial reversible airflow restriction. These signs have troubled clinicians to diagnose and differentiate the disease, and therefore have aroused people's attention to asthma complicated with COPD^[1]。 Understanding the epidemiology, natural history, risk factors and mechanisms of asthma complicated with COPD, as well as the characteristics of airway inflammation and remodeling, will not only help to diagnose and treat the coexistence of both diseases, but also help to clarify the relationship between asthma and COPD, which has important clinical significance for better prevention and treatment of asthma and COPD.

Idiopathic pulmonary fibrosis (IPF) is a kind of chronic interstitial lung disease with unknown etiology and common interstitial pneumonia (UIP) as the characteristic pathological changes. The main manifestations are diffuse alveolitis, alveolar structural disorder and pulmonary fibrosis. IPF is the most common subtype of all idiopathic interstitial pneumonia, with rapid progression and poor prognosis, with a median survival of only 2.8 years^[1,2]。 Prognostic research on IPF is constantly being updated and developed. The author reviews the current research progress as follows.

Paraquat is a widely used non-selective contact killing herbicide, which has strong toxicity to humans and animals. After poisoning, it can involve many important organs, and the lung is the main target organ. After oral administration of large doses, acute lung injury (ALI) can occur rapidly within 24 hours, and ARDS can occur within 1~3 days^[1], followed by multiple organ failure, with a mortality rate of up to 80%. In the past 40 years, scholars at home and abroad have given glucocorticoids (hormones for short) and cyclophosphamide to intervene in the lung injury caused by oxygen free radicals and cellular inflammatory factors in the mechanism of paraquat poisoning, trying to prevent lung injury from forming pulmonary fibrosis, but the curative effect is not satisfactory. In this study, the dynamic expression changes of tumor necrosis factor-α (TNF-α), nuclear factor-κ B and interleukin (IL) -10 in lung of rats treated with ulinastatin before and after treatment were observed in the early stage of paraquat poisoning, so as to provide a basis for finding new therapeutic methods.

Mucosa-associated lymphoid tissue (MALT) lymphoma is a malignant non-Hodgkin's lymphoma (NHL) derived from B cells of mucosa-associated lymphoid tissue at the outer margins of lymph nodes. Multi-system complicated MALT lymphoma is rare, and cases of MALT lymphoma found in lung and stomach are rarely reported at home and abroad. An example of the present report is as follows.

Two cases of pulmonary mucormycosis were treated in the Second Affiliated Hospital of Jilin University from 2008 to 2010, all of which were complicated with community-acquired pneumonia and diabetes, which are reported below.

pulmonary thromboembolism (PTE) is one of the critical medical diseases that directly threatens the life of patients. The main clinical manifestations of large-area PTE are shock and hypotension, namely systemic arterial systolic pressure<90 mm Hg (1 mm Hg =0.133 kPa), partially manifested as cardiac arrest, shock, syncope, acute attack of severe dyspnea and difficult to correct hypoxemia, also known as fatal pulmonary embolism (FPE), is an extremely dangerous critical disease in clinic, with a mortality rate of 65% to 95%. Early diagnosis and treatment are the key to improve prognosis. At present, there is no consensus on the diagnosis and treatment of respiratory and cardiac arrest caused by suspected pulmonary embolism. A case of respiratory and cardiac arrest caused by massive pulmonary embolism successfully treated by the respiratory department of the Third Hospital of Hebei Medical University is reported, in order to improve the success rate of treatment.

COPD is the fourth cause of death worldwide and has become an important public health problem. COPD is characterized by incompletely reversible airflow restriction, i.e. FEV after inhalation of bronchodilators₁/FVC<70%^[1]。 The therapeutic goal of COPD is to reduce dyspnea and improve activity endurance, and bronchodilators are the main therapeutic drugs. Although the FEV₁It is an important index to evaluate the severity and efficacy of COPD, but it is only weakly correlated with dyspnea symptoms and limited activity in COPD. Therefore, bronchodilators are able to improve the symptoms of COPD, not only due to alleviation of airflow restriction, but also by other important mechanisms. From the perspective of pathophysiology and respiratory mechanics of COPD, the authors expounded the therapeutic effect of tiotropium bromide on COPD.

The 8th activity of Beijing Young Respiratory Scholars Salon in 2010 was held in Chinese Medical Association on October 28th, 2010. Young and middle-aged respiratory doctors from many hospitals in Beijing jointly discussed the "problems in the diagnosis and treatment of bronchial asthma". This salon activity was hosted by Jin Jianmin, deputy chief physician of respiratory department of Beijing Tongren Hospital affiliated to Capital Medical University.

With the increasing application of broad-spectrum antibiotics, immunosuppressants and anti-tumor drugs, the progress of various interventional therapies, life support means, and the extensive development of organ transplantation, various fungal infections have increased, which has become another thorny problem after drug-resistant bacterial infection in clinical practice. Compared to bacterial infections, the drug options for treating fungal infections are more limited, and the prognosis of patients is generally worse. It has been reported that severe invasive fungal infections, even with active treatment, have a mortality rate of as much as 50%. Therefore, it is a very important and urgent task to understand the epidemiology, etiology and clinical characteristics of pulmonary mycosis in China.

In recent years, invasive pulmonary fungal diseases (IPFD) have been gradually recognized by the majority of medical workers, especially various guidelines for the diagnosis and treatment of invasive fungal infections at home and abroad have been published continuously, such as the consensus developed by the European Cancer Research and Treatment Organization/invasive fungal Infection Collaboration Group (EORTC/IFICG) and the American Mycosis Research Group (MSG)^[1], Clinical practice guidelines for aspergillosis and candidiasis developed by the American Society of Infectious Diseases (IDSA)^[2,3]The principles of diagnosis and treatment of invasive fungal infection (IFI) formulated by the professional committees of blood, respiratory and ICU in China and the "Expert Consensus on Diagnosis and Treatment of Pulmonary Fungal Diseases" formulated by the Respiratory Disease Branch of Chinese Medical Association^[4]etc., which have greatly improved clinicians' understanding and diagnosis and treatment level of invasive fungal diseases. However, at the same time, we have also found in clinical work that even if we follow the requirements of consensus or guidelines, there are still many problems that cannot be solved, such as early diagnosis. reliability, clinical diagnostic value of biomarkers, timing and course of empirical treatment, etc. With the increasing evidence of evidence-based medicine in recent years, these problems have gradually gained new interpretations and understandings. Now I have my own humble opinions based on my own clinical diagnosis and treatment experience discussion points for your reference and correction.

To all medical staff:

With the increasing application of broad-spectrum antibiotics, immunosuppressants and anti-tumor drugs, the progress of various interventional therapies, life support means, and the extensive development of organ and blood transplantation, various fungal infections have increased, which has become another thorny problem after drug-resistant bacterial infections in clinical practice. Relative to bacterial infections, there are more limited drug options for treating fungal infections, and generally the prognosis of patients is worse. It has been reported that severe invasive fungal infections, even with active treatment, have a mortality rate of as much as 50%. Therefore, it is a very important and urgent task to understand the epidemiology, etiology and clinical characteristics of pulmonary mycosis in China.