2011年 · 第34卷第09期

Upper airway obstruction and bronchial asthma are two kinds of diseases that are completely unrelated, but sometimes they are confused clinically. Three cases are specially cited for reference by readers.

Respiratory tract, urinary tract and digestive tract are three relatively open channels in human body, which are easily invaded by external pathogens and infected. Among them, respiratory tract infection is the most common and harmful^[1]Nosocomial infections, not only seen in respiratory departments, but also in other departments, are often the direct cause of death in patients with non-infectious diseases such as chronic cardiorenal insufficiency, stroke and malignant tumors. The determination of targeted treatment regimens for respiratory tract infections depends on microbiological results. It should be noted that even the so-called empirical treatment is not blind treatment, but drugs are selected with reference to the relevant guidelines formulated according to evidence-based medicine and the epidemiological data and drug resistance characteristics of pathogens in the region. The pathogenic composition and drug resistance characteristics of the same disease will be quite different in different countries and regions. Therefore, the diagnosis and treatment of infectious diseases cannot copy foreign guidelines, and must be appropriately adjusted according to the pathogenic characteristics of the region. For example, the resistance rate and resistance degree of Streptococcus pneumoniae and Mycoplasma pneumoniae to macrolides in China are much higher than those in European and American countries^[2,3]Therefore, macrolides should not be used as the first-line treatment for community-acquired pneumonia (CAP) in my country^[4]。 In addition, Enterobacter gram-negative bacteria such as Klebsiella pneumoniae and Escherichia coli are common pathogens in elderly patients with CAP. Both bacteria produce extended-spectrum β-lactamase (ESBL) and are resistant to quinolones at high rates in China^[5]If the drug is used according to the current foreign guidelines, it may occasionally lead to treatment failure.

Patients with pulmonary fungal infection have diverse clinical manifestations and atypical imaging features. Laboratory etiology examination has become an important basis for diagnosis. Among them, microscopic examination of clinical body fluid smear and fungal culture are the most widely used. Although this method is difficult to distinguish whether it is colonization or infection in the diagnosis of some fungal infections, its results as "microbiological evidence" undoubtedly have important reference value for the diagnosis and treatment of invasive fungal diseases. At present, the value of judging the results of microscopic examination and culture of different body fluid specimens is still controversial in clinic. Now, this issue is discussed based on the author's experience, in order to provide reference for clinical diagnosis and treatment.

According to the definition of the American Society of Infectious Diseases (IDSA) and ATS, atypical pathogens refer to a class of microorganisms that can cause human respiratory infections but can neither be detected by Gram staining nor cultured using conventional bacterial media, including Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella, and respiratory viruses^[1]。 In recent years, with the widespread use of antibiotics, the change of living environment and the continuous update of diagnostic methods, it has been found that atypical pathogens occupy an important position in respiratory tract infections, Cao et al^[2]The pathogenic spectrum of 197 adult patients with community-acquired pneumonia (CAP) in Beijing was studied, and the results showed that nearly 40% of the cases were caused by atypical pathogens.

A large number of aerobic bacteria and anaerobic bacteria are colonized in human oropharynx, and the total number of bacteria in oral cavity can reach 10¹³～10¹⁵CFU/ml. Patients have different types of colonized flora due to different basic conditions, such as immunosuppression, alcoholism or chronic lung disease, and broad-spectrum antimicrobial therapy.

BACKGROUND AND OBJECTIVES: In patients undergoing mechanical ventilation for ARDS, neuromuscular blockers have the potential to improve oxygenation and reduce ventilator-related lung injury, but they may also cause muscle weakness. We evaluated the clinical outcome of patients after 2 days of treatment with neuromuscular blockers in the early stages of severe ARDS. Methods: In this multicenter, double-blind, randomized controlled trial, 340 patients who had been admitted to the ICU for severe ARDS within the previous 48 h were randomly assigned to either cisatracuride besylate (178) or placebo (162) for 48 h. Severe ARDS is defined as PaO₂/FiO₂<150, with positive end-expiratory pressure ≥5 cm H₂O (1 cm H₂O =0.098 kPa) and a tidal volume of 6-8 ml/kg. The primary outcome was the proportion of patients who died before discharge or within 90 days of study entry (i.e., in-hospital mortality at 90 days), with the Cox model adjusted for covariates and baseline differences between groups. Results: Adjusted Baseline PaO₂/FiO₂and plateau pressure and APACHE II score, the 90-day hazard ratio of death was 0.68 (95%) in the cisatracuride group compared with the placebo groupCI0.48 to 0.98,P＝0.04)。 The crude 90-day mortality rate was 31.6% (95%) in the cisatracuride groupCI25.2 to 38.8) and 40.7% (95%) in the placebo groupCI33.5 to 48.4),P＝0.08。 The 28-day mortality was 23.7% (95%) in the cisatracuride groupCI18.1 to 30.5) and 33.3% (95%) in the placebo groupCI26.5 to 40.9),P＝0.05。 There was no statistically significant difference in the incidence of ICU-acquired paresis between the two groups. CONCLUSIONS: In patients with severe ARDS, early use of neuromuscular blockers reduces adjusted 90-d in-hospital mortality without increasing muscle weakness.

Background: Mild persistent bronchial asthma (abbreviated as asthma) accounts for about 70% of asthma patients, and it is very important to choose the best first-line treatment for mild asthma. We compared the effects of a combination of ciclesonide and fluticasone propionate/salmeterol as a first-line treatment for mild asthma. Methods: A randomized, double-blind, placebo-controlled study of 1432 patients aged 12 to 75 years with mild persistent asthma was performed. All patients were randomly assigned to ciclesonide (160 μ g/d), fluticasone propionate/salmeterol (100/50 μ g, twice/d), and placebo for 52 weeks. The primary study measures were the time to acute exacerbation of first severe asthma, and the secondary study measures were asthma symptoms recorded in electronic diaries, salbutamol use and quality of life questionnaire scores. Results: Compared with the placebo group, patients in the fluticasone propionate/salmeterol group showed prolonged first acute asthma attack and improved lung function (P=0.0002), whereas there was no statistically significant difference between the ciclesonide and placebo groups. The number of days of poor asthma control was significantly fewer in the ciclesonide group and fluticasone propionate/salmeterol group than in the placebo group (comparison between the two treatment groups,P≤0.0016)。 In addition, compared with the placebo group, the number of days of asymptomatic asthma in both treatment groups (P≤0.0001), days without modifying medication (P=0.0005, one-sided test) and days of asthma control (P≤0.0033) longer. The overall quality of life questionnaire scores in the two treatment groups were significantly higher than those in the placebo group (P≤0.0017)。 CONCLUSIONS: For mild asthma, patients treated with fluticasone propionate/salmeterol (100/50 μ g, twice/d) had a prolonged duration of the first severe acute asthma attack, and clinical efficacy was comparable for most asthma control indicators treated with ciclesonide (160 μ g/d) and fluticasone propionate/salmeterol (100/50 μ g, twice/d).

BACKGROUND AND OBJECTIVE: Recurrent occurrence of acute exacerbation of COPD (AECOPD) is one of the important reasons for the progression of COPD, and reducing the frequency of AECOPD is also one of the main objectives of COPD intervention. However, so far, there is no effective and standardized surveillance tool to assess the frequency, severity and duration of AECOPD. This study is a prospective study of the specific performance of a new assessment tool, the AECOPD Condition Self-Report Journal (EXACT). Methods: 222 cases in the acute exacerbation group were all patients who visited the doctor due to AECOPD; In the stable group, 188 COPD patients were contacted by telephone or routine follow-up visits, and no AECOPD occurred 60 days before enrollment. Patients in the acute plus recombination group completed the disease monitoring report log on days 1 to 29 and 60 to 67 after enrollment, and patients in the stable group completed the disease monitoring report log for any 7 days during the study period. Patients in both groups completed pulmonary function and St. George's Respiratory Questionnaire (SGRQ) tests in the stable phase, and patients in the acute exacerbation group also needed to complete the comprehensive assessment and grading of AECOPD severity and recovery by clinicians and patients themselves. Results: The mean age of the patients in both groups was (65 ± 10) years, 48% were males, and the stable FEV₁% of the estimated value is (51±20) %. The internal consistency (Pearson's separation index) of the EXACT score was 0.92 and the 1-week repeatability was 0.77. EXACT was significantly correlated with SGRQ (r＝0.64，P<0.0001), and can distinguish between patients with AECOPD and stable phase. The EXACT score of the acute plus exacerbation group improved significantly over time and could distinguish physician-rated severity of AECOPD. A change in the EXACT score on day 10 of enrollment can distinguish whether a patient is effective for treatment. CONCLUSION: EXACT score is a reliable, valid and sensitive tool for assessing the changes of AECOPD during recovery.

BACKGROUND AND OBJECTIVE: In a research project of severe bronchial asthma (asthma for short), bronchoscopy was performed on some patients to observe the pathological manifestations of airways in severe patients, and the safety of bronchoscopy was evaluated in such patients, and the changes of lung function before and after bronchoscopy and the adverse events related to bronchoscopy were prospectively evaluated. Methods: Bronchoscopy followed a uniform operating procedure. Patients with severe airflow restriction, oral glucocorticoids, and recent acute asthma attacks were judged to be critically asthmatic. After the examination, the subjects were monitored for changes in lung function and followed up by telephone for 3 days. Results: Bronchoscopy was performed in 436 subjects, 97 healthy controls, 196 non-severe asthmatic patients, 102 severe asthmatic patients and 41 critical asthmatic patients. Nine subjects were monitored in the hospital after the examination, and seven of them had respiratory-related events. Asthmatic patients with recent emergency department visits, long-term oral glucocorticoids, and a history of pneumonia are more likely to develop acute exacerbations of asthma after bronchoscopy. FEV after bronchoscopy in patients with severe and mild asthma₁The degree of decline was similar. FEV after bronchoscopy in asthmatic patients with better lung function₁Significant reduction in baseline FEV₁The level of is the strongest predictor for assessing changes in lung function in such patients. Conclusions: Bronchoscopy is well tolerated in patients with severe asthma. Acute exacerbations of asthma occur less frequently after bronchoscopy, and the degree of lung function decline after examination is approximate in patients with severe and critical asthma. With sufficient vigilance, bronchoscopy can be safely performed in patients with severe asthma.

BACKGROUND AND OBJECTIVE: Recent findings suggest that bone morphogenetic protein 4 (BMP4) plays an important role in pulmonary vascular remodeling, but its mechanism of action is still unclear. In our earlier study, it has been found that the influx of calcium ions through calcium pool-manipulated calcium ion channels (SOCC) may be one of the causal factors leading to chronic hypoxic pulmonary hypertension, and it is currently believed that in pulmonary artery smooth muscle cells (PASMC), SOCC is mainly composed of classical transient receptor ion channel expression (TRPC) 1 – 6. In this study, the effects of BMP4 on TRPC protein expression, calcium pool manipulative calcium influx (SOCE) and intracellular basal calcium concentration in PASMC were investigated by increasing BMP4 concentration or inhibiting BMP4 expression. Methods: In the experimental group, the distal PASMC of rats was treated with 50 μ g/L BMP4 for 60 h, and the expression levels of TRPC RNA and protein were detected by real-time quantitative PCR and Western blot. Calcium ions traced by Fura-2/AM fluorescent probe were observed by fluorescence microscopy, and the cellular SOCE and basal calcium ion concentrations were monitored. Calcium-free Krebs-Ringer bicarbonate solution (KRBS), or SOCC blocker SKF-96365/NiCl₂The SOCE and basal calcium ion concentrations were monitored again after KRBS perfusion of cells. Small molecule interfering RNA was used to specifically reduce the expression of BMP4 in PASMC, and the expression of TRPC, SOCE and intracellular basal calcium ion concentration were observed. Results: The mRNA and protein levels of TRPC1, TRPC4 and TRPC6 were all increased in the cells treated with BMP4. At the same time, SOCE increased and the concentration of basal calcium ion increased in the cells, while SOCC blockers could reduce the increase of basal calcium caused by BMP4. After treating the cells with BMP4-specific small molecule interfering RNA, the expression of TRPC1, TRPC4, TRPC6 mRNA and protein in PASMC were significantly decreased, SOCE was decreased, and the intracellular basal calcium ion concentration was decreased. Conclusion: The promoting mechanism of BMP4 on pulmonary vascular remodeling and pulmonary hypertension may be related to the upregulation of TRPC protein expression in PASMC, resulting in the increase of SOCE and intracellular basal calcium ion concentration.

allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disease caused by allergic reaction to Aspergillus antigen parasitizing in the bronchi. In the past 20 years, the number of reported ABPA cases has increased year by year, but due to the lack of knowledge of ABPA by clinicians, it is often misdiagnosed. The progress of ABPA diagnosis and treatment is summarized as follows.

portopulmonary hypertension (PoPH) is a disease characterized by increased pulmonary artery pressure, increased pulmonary vascular resistance and normal pulmonary wedge pressure, which occurs on the basis of various causes of portal hypertension. It is reported in the literature that a considerable number of patients with decompensated liver disease are complicated with PoPH. PoPH is seriously affecting the quality of life of patients, disease progression and the effect of liver transplantation. Effective treatment of PoPH has important clinical significance. Sildenafil is a highly selective phosphodiesterase-5 inhibitor that can dilate pulmonary vascular smooth muscle, reduce pulmonary vascular resistance, and increase cardiac output. It is currently recommended as an effective drug for the treatment of idiopathic pulmonary hypertension. More and more research results show that sildenafil also has a good therapeutic effect on PoPH. The clinical application of sildenafil in PoPH is summarized as follows.

invasive airway aspergillosis (invasive airway aspergillosis) is a subtype of invasive pulmonary aspergillosis (IPA). At present, there is no clear definition. Most literatures describe that Aspergillus infection is localized to the trachea and bronchi, or mainly trachea and bronchi infection. Aspergillus invades the airway wall, and even spreads through the airway wall to the surrounding pulmonary parenchyma and pulmonary artery. There is little literature on airway invasive aspergillosis compared to pulmonary parenchymal and systemic disseminated aspergillosis. With the increase of people undergoing bronchoscopy, airway invasive aspergillosis is gradually recognized and attracts the attention of clinicians. The epidemiology, risk factors, clinical manifestations, imaging and endoscopic findings, pathological types and classification, diagnosis and treatment, and prognosis of the disease are summarized as follows.

Obstructive emphysema is the main pathological manifestation of COPD, and the oxidative stress caused by emphysema lesions can aggravate the apoptosis of alveolar wall cells. The transplantation of bone marrow mesenchymal stem cells (MSCs) can alleviate the apoptosis of alveolar wall cells and repair lung tissue in emphysema rats^[1]。 The purpose of this study was to investigate the repair mechanism of MSCs transplantation on lung injury in emphysema rats.

Although glucocorticoids (hormones for short) have been used for decades to treat sepsis and acute lung injury/acute respiratory distress syndrome (ALI/ARDS), their effects are still controversial. High-dose hormone therapy is currently not considered beneficial for sepsis and ALI/ARDS^[1,2]While low-dose hormones may improve the prognosis of patients with ALI/ARDS and partial septic shock^[3]。 However, it is not clear why different doses of hormones have different effects on the prognosis of sepsis and ALI/ARDS. We speculate that different doses of hormones may have different effects on the expression and activity of glucocorticoid receptor (GR), which may have some implications for explaining the different effects of different doses of hormones on the prognosis of sepsis and ARDS. In this study, the effect of low-dose hydrocortisone (HC) on GR expression was observed, and the results are reported below.

plemorphic adenoma (PA), also known as mixed tumor, is the most common salivary gland tumor. It can occur at any age, and it is more common in middle age. It is more common in parotid gland, palate gland and submandibular gland. Other parts such as lip, tongue, palate mucosa and other oral mucous salivary glands are less common, and sublingual glands and upper respiratory tract mucous glands are rare. The serous mucinous glands of the upper respiratory tract can be regarded as homologous tissues of the salivary glands, so tumors of the salivary gland type can also occur in the upper respiratory tract. The morphology and clinical characteristics of tracheal PA are similar to those of salivary gland PA, and its biological behavior ranges from benign to low malignant. The prognosis is good, but it is easy to relapse, and a few may become malignant^[1,2]。 A case of tracheal PA treated with argon gas knife was reported. The clinical pathological characteristics were summarized and related literatures were reviewed to explore the clinical significance of tracheal PA.

pulmonary alveolar proteinosis (PAP) is a diffuse pulmonary disease characterized by the deposition of insoluble phospholipid protein-like substances in the alveoli. The cause is still unknown. Whole lung lavage is an effective treatment for PAP. Traditional whole lung lavage usually washes one lung first, and then washes the other side at an interval of 7~10 days. There are few reports of sequential lavage of both lungs on the same day. Its lavage effect and safety deserve clinical attention. The treatment experience of 3 patients who successfully underwent double lung lavage in Beijing Tiantan Hospital is reported as follows.

Although the incidence of tuberculosis is declining worldwide, drug-resistant tuberculosis is spreading. Drug susceptibility test based on Roche medium is a common method to judge whether Mycobacterium tuberculosis is resistant to drugs. However, there are often inconsistencies between laboratory diagnosis and clinical treatment. Some patients with clinical diagnosis of multidrug-resistant tuberculosis (MDR-TB) can be cured by first-line anti-tuberculosis drug chemotherapy regimen. As the most commonly used and effective drug for anti-tuberculosis treatment, the accuracy of drug sensitivity test results of rifampicin is very important to guide clinical medication use.

Aspergillus tracheobronchitis (ATB) and invasive pulmonary aspergillosis (IPA) are two manifestations of invasive aspergillosis (IA), and immunosuppressed patients are at high risk for IA. The results of multiple studies suggest that ATB may progress to IPA, or both exist simultaneously, and ATB and IPA may be two different stages of one disease. Therefore, in this study we referred to the combination of ATB and IPA as invasive bronchopulmonary aspergillosis (IBPA). chronic obstructive respiratory diseases (CORD) are chronic obstructive diseases of the airways and lung tissues, mainly including COPD, bronchial asthma and bronchiectasis. Patients with CORD often experience acute exacerbations of underlying lung disease, combined with respiratory failure, and require ICU admission. Recent reports suggest that the incidence of IA in CORD and ICU patients is gradually increasing. The mortality rate of COPD combined with IPA can be as high as 67% ~100%, and the mortality rate of ATB can be as high as 80%. We believe that the reason for the high mortality rate is related to the unclear clinical characteristics of CORD combined with ATB or IPA, which leads to the delay of diagnosis and treatment. The purpose of this study is to describe the clinical manifestations of patients with severe CORD complicated with IBPA and to evaluate the value of current diagnostic methods, so as to identify patients with severe CORD complicated with IBPA in time, diagnose and treat them early.

pulmonary carcinosarcoma is a rare complex tumor composed of malignant epithelial components and mesenchymal components, accounting for 0.1% ~0.3% of lung cancer^[1]。 Lung carcinosarcoma can be divided into peripheral type and intraductal type. In order to improve clinicians' understanding of intraductal lung carcinosarcoma and evaluate the value of bronchoscopic interventional therapy combined with surgery in the diagnosis and treatment of this disease, 3 cases of intraductal lung carcinosarcoma patients recently admitted to Sir Run Run Shaw Hospital affiliated to Zhejiang University are retrospectively analyzed and reported in the literature as follows.

The second working meeting of the seventh editorial board (hereinafter referred to as the editorial board) of Chinese Journal of Tuberculosis and Respiratory Medicine (hereinafter referred to as the journal) was held in Fuzhou, Rongcheng on May 27th, 2011. Professor Xiao Heping, deputy editor-in-chief of the journal and chairman of the Tuberculosis Branch of Chinese Medical Association, presided over the meeting. 74 editorial board members from all over the country and leaders in charge of Chinese Medical Association and magazines attended the meeting (Figure 1)。

Modern respiratory disease is developing rapidly and is undergoing profound changes. In the past 30 years, the monitoring and treatment of respiratory failure has made great progress, and it has become increasingly important in the treatment of critical care. This situation has greatly promoted the combination of respiratory medicine and critical care medicine. It has become the inevitable trend and basic strategy of modern respiratory disease to firmly implement the bundling (blending) development mode of respiratory disease and critical care medicine. The treatment of respiratory failure is the inevitable responsibility of respiratory science. A respiratory department that can't treat respiratory failure in a standardized and high level is not a qualified respiratory department, and it is also difficult for a doctor who does not know and is not good at the treatment of respiratory failure to become a qualified respiratory professional. ICU is a place for the treatment of respiratory failure, and the respiratory department must include ICU, generally medical ICU (MICU) or at least respiratory ICU (RICU). Without ICU, it will be impossible to standardize the treatment of severe respiratory failure with modern medical technology. A respiratory department without an ICU will have difficulty performing the essential medical functions of its discipline. In order to reflect the basic pattern and establishment of the development of this modern Respiratory discipline and make the discipline conform to the name and reality, the Respiratory Department should be renamed as the Department of Respiratory and Critical Care Medicine, with MICU or RICU under it, which is responsible for the diagnosis and treatment of Respiratory diseases and the treatment of Critical illness in internal Medicine. The bundled development pattern of respiratory discipline and critical care discipline is not only beneficial to the development of respiratory discipline, but also beneficial to the development of critical care discipline, which is the strength and deepening of the two disciplines. It must be recognized that this pattern is a strengthening, not a weakening, of the critical care discipline. Therefore, a viable force that is most familiar with respiratory physiology and pathophysiology and is best at treating the most common respiratory failure in critical illness has joined the critical care discipline. In fact, in North America, the establishment of traditional respiratory departments has generally become the establishment of respiratory and critical care medicine departments for more than 20 years, and respiratory professionals have become the leading force of MICU. Since 1994, American Review of Respiratory Diseases, the most influential professional journal of respiratory diseases in the world (American Review of Respiratory Diseases) officially changed its name to American Journal of Respiratory and Critical Care Medicine (American Journal of Respiratory&Critical Care Medicine)。 Another famous journal in the field of respiratory disease, Thoracic (Chest) also explicitly positioned the journal to cover respiratory and critical care medicine content. In recent years, hospitals in European countries such as France and the United Kingdom have also begun to rename their traditional respiratory departments to respiratory and critical care departments.

The 4th activity of Beijing Young Respiratory Scholars Salon in 2011 was held in Chinese Medical Association on May 26th, 2011. The theme of this salon activity was "Clinical Case Discussion", which was presided over by Jin Jianmin, deputy chief physician of respiratory department of Beijing Tongren Hospital affiliated to Capital Medical University.

Professor Ho Quanying published the article "Is it necessary to change the name of Wegener's granulomatosis to necrotizing granulomatous vasculitis?" in the "Anecdotes" column of the fifth issue of this journal in 2011, arguing that it is not necessary to change the name of Wegener's granulomatosis to necrotizing granulomatous vasculitis, and at the end of the article emphasizing "Why do you bother?". Is it really "unnecessary"? Now there are three authoritative academic institutions or organizations in the international medical community that have implemented this initiative.

According to scientists' research, no matter how vital a tree (no matter what tree) is, no matter how carefully people care for it, it can only grow to 130 m high. It wasn't because the earth couldn't bear its tall body, or because it didn't want to grow taller, but because if it exceeded the limit of 130 m, if it grew taller, even a few centimeters might crush itself and fall to the ground. Therefore, the towering tree is just a kind of literary decoration, and there is no big tree in the world that towers into the sky. In fact, the same is true for people. Everyone's growth, study, work and achievements also have a limit. Even if you work hard, even if you work and study for 24 hours a day, day and night, you will not exceed the inherent energy limit, but on the contrary, it will be counterproductive. Therefore, people should be self-aware, don't blindly compare with others, and regard others' height as their own goal. That would probably suffer and destroy yourself.

As a doctor, in the process of practicing medicine, he will encounter various patients and various clinical phenomena, and he has experience and lessons. Professor Liu Youning of this journal described three consultation cases he encountered in the process of practicing medicine in the article "Essay of the Editor-in-Chief", from which we can see the importance of detailed medical history and physical examination.