2011年 · 第34卷第11期

Drugs are an indispensable means for doctors to treat diseases. The quantity and quality of drugs that a country can have are directly related to the quality of medical care in that country, and it is more prominent for infectious diseases. With the increasingly serious bacterial drug resistance, we often encounter fatal infections caused by "superbugs" in clinic and can't get effective drug treatment. The author believes that the anti-infective drugs that are urgently needed but difficult to obtain in clinical practice in China can be mentioned as follows.

BACKGROUND AND OBJECTIVE: In survivors of ARDS, there are currently few interviews and examinations to obtain detailed follow-up data on 5-year outcomes. Methods: 109 ARDS survivors were evaluated at 3, 6 and 12 months and at 2, 3, 4 and 5 years after discharge from the intensive care unit. At each follow-up visit, patients underwent interviews and various tests such as pulmonary function test, 6-minute walk test, rest and exercise oximetry, chest imaging, and quality of life assessment; And report on their use of health care services. Results: At 5 years, the median distance walked in 6 minutes was 436 m (76% of the projected value) and the Quality of Life Assessment Short Form 36 (SF – 36) score was 41 points (normal mean 50 points, after matching by age and sex). For this score, younger patients recovered at a higher rate than elderly patients, but neither group recovered to the normal expected level. Lung function is near normal and normal. Patients and family caregivers have a range of physical and psychological problems for up to 5 years. If the patient has more co-existing diseases, the more medical expenses for 5 years will be. Conclusions: Restricted exercise, physical and psychological sequelae, decreased quality of life, and increased treatment costs and use of health care services are important legacies for survivors of severe lung injury.

Background: Epidemiological studies have shown that nutrient deficiencies such as selenium, zinc, vitamin A, vitamin C, vitamin D and vitamin E, as well as low fruit and vegetable intake are associated with the occurrence of bronchial asthma (asthma for short) and allergic diseases. Objective: To investigate the research evidence that nutrients and food intake influence the risk of asthma and allergic diseases in children. Methods: Eleven database systems were systematically searched and meta-analyses were performed after critical evaluation of the research literature. Results: 62 eligible articles were included in the study, including 21 in cohort study design, 15 in case-control study design, 26 in cross-sectional study design, and no randomized controlled studies. All studies were judged to have moderate to severe bias. The results of the meta-analysis showed that the serum vitamin A levels of children with asthma were lower than those of the controls (OR＝0.25，95%CI0.10-0.40); Mother's diet during pregnancy Vitamin D (OR＝0.56，95%CI0.42 to 0.73) and vitamin E (OR＝0.68，95%CI0.52-0.88) intake had an inhibitory effect on wheezing symptoms in children. Adhere to a Mediterranean diet for persistent wheezing symptoms (OR＝0.22，95%CI0.08-0.58) and atopic (OR＝0.55，95%CI0.31-0.97) has an inhibitory effect. Seventeen of the 22 studies on fruit and vegetable intake showed benefits for patients with asthma and allergic diseases. The findings do not support the association of these vitamins and nutrients with other allergic diseases. Conclusion: The epidemiological evidence obtained at present, although weak, indicates that vitamin A, vitamin D, vitamin E, zinc, fruits, vegetables and the Mediterranean diet have an inhibitory effect on asthma, and it is necessary to conduct an experimental study on these exposure factors.

Since 1950s, mechanical ventilation has gradually become the most important treatment for respiratory failure. While mechanical ventilation technology continues to advance, human-machine synchronization has been a significant challenge for clinicians. Even in assisted ventilation mode, 25% of patients with invasive ventilation still have severe human-machine asynchrony^[1]。 However, in non-invasive ventilation, the proportion of serious human-machine asynchronization is as high as 43% due to air leakage and other reasons^[2]。 In addition to affecting oxygenation, increasing respiratory work and causing patient discomfort, human-machine asynchrony is more likely to lead to increased transpulmonary pressure and increased ventilation-related lung injury (VALI). Faced with such a severe situation, we have to re-examine the problem of man-machine synchronization in mechanical ventilation, and explore the countermeasures for improving man-machine synchronization.

According to domestic and foreign guidelines, the diagnosis of ventilator-associated pneumonia (VAP) is not difficult, but nothing more than the comprehensive judgment of clinical manifestations, imaging changes and respiratory secretion pathogens^[1,2]However, from the actual treatment effect and autopsy results, the accuracy of VAP diagnosis is not high. Obviously, there are many problems in its diagnosis methods, among which imaging changes are the core and the most common cause of misdiagnosis.

Community-acquired pneumonia (CAP) is the 7th leading cause of death in the United States^[1]The mortality rate of severe community-acquired pneumonia (SCAP) can be as high as 20% to 50%^[2]。 The most common causes of death in patients with SCAP are refractory hypoxemia, refractory shock, and other complications associated with pneumonia, particularly multiple organ dysfunction syndrome. The main reason for this outcome is not only the action of pathogenic bacteria, but also the excessive inflammatory response and dysfunction of the coagulation system and the resulting organ dysfunction. Therefore, in addition to anti-infection therapy, SCAP has more practical significance in controlling excessive inflammatory response and coagulation, and effectively and reasonably supporting organ function.

Lung is one of the most important organs of human life activities. It not only has the functions of ventilation and ventilation in the traditional sense, but also has the functions of circulation, metabolism and immunity. In addition to primary diseases of the lungs, diseases of other organs in the whole body can also involve the lungs and secondary respiratory failure, or even life-threatening. As early as 1,000 years ago, the motherland medicine realized the importance of the lung, and put forward the traditional Chinese medicine theory of "the lung faces a hundred veins", believing that the lung is a canopy, which runs through all the treasures, and is the important meeting of the hundred veins. Therefore, it is of great significance to deeply understand the pulmonary manifestations of critical diseases, correct diagnosis and effective treatment measures on this basis to save patients' lives in time and promote their recovery. Although there are many clinical diseases that can cause respiratory failure, if the disease affects the anatomical part of the lung, it can be divided into four parts: alveolar lesions, vascular lesions, airway lesions, and nervous/muscular system and chest wall lesions.

In 2010, the British Thoracic Society published guidelines for non-cystic fibrosis bronchiectasis^[1]As the first global professional guideline for bronchiectasis, it put forward standardized guidance for the diagnosis and treatment of bronchiectasis for the first time. The guideline committee searched a total of 1803 English-language articles on non-cystic fibrotic bronchiectasis, and finally assembled 549 articles in an attempt to provide guidance recommendations with evidence-based medical evidence (for grading of evidence, seeTable 1)。 Due to the lack of large-scale clinical studies, most of the recommendations of this guideline still stem from case reports and expert opinions, and some recommendations draw on the research of patients with cystic fibrosis. The adult content of this guideline is briefly introduced as follows.

Until the 19th century, it was believed that the onset of tuberculosis was caused by poor nutrition and unclean water and air. It was not until Koch's discovery of Mycobacterium tuberculosis in 1882 that clarified people's confusing ideas about the pathogen and pathogenesis of tuberculosis.

Acute lung injury/acute respiratory distress syndrome (ALI/ARDS) is a critical disease involving the respiratory system, with a mortality rate of 38.5%^[1]。 At present, the clinical diagnosis of ALI/ARDS mainly depends on oxygenation index and lung imaging changes, and the above changes often appear after severe lung lesions and serious impairment of respiratory function, with lag. Therefore, more sensitive indicators are needed to assist in predicting the occurrence of ALI/ARDS, judging the degree of lesions and evaluating the prognosis.

vibration response imaging (VRI) is a breathing imaging technology invented by Israeli scholars in 2005. Based on vibration response imaging technology and computer technology, it can output breathing sound image information in real time, reflect the information of breathing sounds in various parts of the lungs in the form of data tables, and at the same time provide the percentage of energy generated by airflow movement in various parts of the lungs. In addition, compared with other lung examination techniques, VRI technique has the advantages of non-invasive and radiation-free, so subjects can be examined repeatedly.

COPD is a chronic airway inflammatory disease. Persistent airway inflammation leads to incompletely reversible airflow restriction and lung structure destruction. Therefore, controlling airway inflammation is the key to treat COPD. Among the drugs for the treatment of chronic airway inflammatory diseases, glucocorticoids (abbreviated as hormones) are the drugs with the strongest anti-inflammatory activity known at present. The value and status of hormones in the treatment of bronchial asthma (abbreviated as asthma) have been affirmed. A large number of studies have shown that hormones cannot effectively control the progressive airway inflammation in the treatment of COPD, nor can they reverse the decline of lung function caused by airway inflammation, resulting in the phenomenon of so-called insensitivity to hormonal therapy^[1]。 Therefore, understanding the mechanism of insensitivity to hormone therapy in COPD airway inflammation and exploring effective measures to control COPD airway inflammation will help to further understand the role of airway inflammation in COPD pathogenesis.

Those caused by abnormal non-acid reflux in gastroesophageal reflux induced cough (GERC) are called non-acid GERC. Traditional 24-h esophageal pH monitoring cannot detect non-acid reflux, and non-acid GERC is often misdiagnosed and missed. This study compared the clinical characteristics of acid and non-acid GERC with the aim of improving the diagnosis of non-acid GERC.

Emphysema is an important phenotype of COPD. The distribution and severity of lesions in emphysema patients are related to clinical manifestations, frequency of acute attacks, exercise endurance and therapeutic response^[1]This study aimed to observe the clinical, pathophysiological and systemic inflammatory characteristics of COPD emphysema phenotype.

A 25-year-old male was admitted to the hospital on March 5, 2009 due to "dry mouth, polydipsia for more than 1 month, loss of appetite, fatigue for 3 days, and dyspnea for 1 day". The patient developed symptoms of dry mouth and polydipsia 1 month ago, and developed loss of appetite, fatigue, nausea and vomiting of coffee residue in the past 3 days. The patient has lost about 10 kg of weight in the past 1 month. No previous history of hypertension, diabetes, chronic lung disease, etc. Admission physical examination: body temperature 36.4℃, pulse 120 beats/min, respiratory rate 40 beats/min, blood pressure 115/72 mm Hg (1 mm Hg =0.133 kPa), deep and rapid breathing, palpable snow gripping sensation in the skin of the neck, anterior chest wall and abdominal wall, low breathing sound in both lungs, no dry and wet rales, heart rate 120 beats/min, uniform rhythm, no pathological murmur. Blood routine showed: white blood cells 30.0×10⁹/L, neutrophils 0.89, red blood cells 7.04×10¹²/L, hemoglobin 196 g/L, platelets 270×10⁹/L. The urine routine showed pH 5.00, urine glucose 55 mmol/L and ketone body 14.4 mmol/L. Randomized blood glucose was 26.3 mmol/L, renal function tests showed urea nitrogen 21.1 mmol/L, creatinine 217 μ mol/L, blood electrolyte sodium 112 mmol/L, potassium 3.8 mmol/L, and chlorine 84 mmol/L. Arterial blood gas (oxygen inhalation 5 L/min) showed pH 7.10, PaCO₂is 10 mm Hg, PaO₂is 139 mm Hg, HCO₃^–was 3.1 mmol/L, BE^–was 23.8 mmol/L, SaO₂98%. Chest CT showed obvious esophageal dilation, partial thickening of the esophageal wall, obvious gas accumulation in the stomach, mediastinal gas accumulation, subcutaneous gas accumulation in bilateral anterior chest wall and abdominal wall, and no esophageal and tracheal tears (Figure 1)。 The initial diagnosis was diabetic ketoacidosis (DKA), mediastinal emphysema, and subcutaneous emphysema. Immediately give symptomatic treatment such as rehydration, correction of acidosis, intravenous infusion of ordinary insulin to hypoglycemic, and perform gastrointestinal decompression, drain out about 600 ml of gas and about 370 ml of coffee-colored liquid, perform upper mediastinal incision and place a drainage tube to drain mediastinal gas. Gastroscopy showed that coffee mud-like matter was found in the esophagus and fundus of the stomach, congestion and edema of the duodenal bulb, and no obvious perforation of the esophagus and stomach wall was found. Type 2 diabetes, DKA, spontaneous mediastinal emphysema and subcutaneous emphysema were finally diagnosed by serum C-peptide release test and diabetic autoantibody blot hybridization. Protamin biosynthetic human insulin injection, recombinant human insulin conventional refills and metformin enteric-coated tablets were given to control blood sugar. After the above treatment, the patient's condition improved significantly, and the symptoms of dyspnea disappeared. On March 11, 2009, chest X-ray examination showed subcutaneous emphysema and basic absorption of mediastinal gas (Figure 2)。 On March 17, 2009, blood routine, urine routine, renal function, arterial blood gas and blood electrolyte all returned to normal, blood glucose was well controlled, urine glucose and ketone bodies were all negative, and he was discharged from hospital on March 19, 2009. After 2 years of follow-up, the patients had no recurrence and good blood glucose control.

As early as 1810, Bayh reported cases of lung cancer combined with pulmonary tuberculosis, and after the 1960s, China reported one after another^[1]。 Recently, we encountered a case of small cell lung cancer complicated with lung and bronchial tuberculosis with complete data in our clinical work, which is reported below.

Sleep apnea syndrome is a common chronic disease in clinic, which is prone to cardiovascular and other multi-system complications. In severe cases, sudden sleep death can occur. Its etiology is complex, and endocrine diseases such as acromegaly and hypothyroidism are the common causes of this disease. Acromegaly is a chronic disease caused by excessive growth hormone secreted by pituitary tumors, which is easy to cause serious cardiovascular complications. Part of goiter is also a clinical manifestation of acromegaly. A case of acromegaly complicated with sleep apnea syndrome and retrosternal goiter admitted to Henan Provincial People's Hospital was analyzed and discussed in the literature to attract clinical attention.

A 54-year-old female was admitted to the hospital on 3 November 2010 due to "dry cough for 2 months and a huge mass found in the right lower lobe for 10 days". Two months before admission, the patient developed dry cough without trigger, which was obvious at night, without fever, hemoptysis, chest pain and night sweats. 10 days before admission, chest X-ray showed a huge space-occupying lesion of the right lower lung (Figure 1), 10.3 cm ×7.5 cm ×13 cm round soft tissue mass with smooth edge and envelope was seen in the right lower lung on plain chest CT scan and enhanced scan, and the lesions on enhanced scan showed obvious uneven enhancement; A nodular shadow with a diameter of about 1.0 cm was seen in the bronchi of the middle trunk of the right lung, and no enlarged lymph nodes were seen in the mediastinum. First consider malignant neoplastic lesions (Figure 2，Figure 3，Figure 4), for further diagnosis and treatment income from Tianjin Medical University General Hospital. The patient was in prior health and denied a history of smoking, alcohol consumption and asbestos exposure.

The incidence of tooth aspiration is lower and is rarer in trauma patients. Although tooth aspiration is often described in patients' complaints, it is easy to miss or delay the diagnosis of polytrauma, especially patients with coma and mechanical ventilation, which may lead to serious complications^[1,2]。 The experience of diagnosis and treatment of 3 patients with multiple injuries undergoing mechanical ventilation is presented.

With the increasing application of broad-spectrum antibiotics, immunosuppressants and anti-tumor drugs, the progress of various interventional therapies, life support methods and the extensive development of organ transplantation, the incidence of pulmonary aspergillosis is increasing year by year. Among them, pulmonary aspergillococcus disease is mostly secondary to chronic cavity lesions of the lung. Generally, antifungal drugs are ineffective, and surgical resection is considered to be the only effective means to treat this disease. However, patients with aspergillococcus are often difficult to operate and manage after operation because of long-term lung disease, and the postoperative complications and mortality rate are higher^[1,2]Therefore, its treatment is a difficult problem in clinic. The development of interventional pulmonology has made possible the interventional treatment of pulmonary aspergillus globules. We treated 6 patients with pulmonary aspergillus bulbs admitted to Guangzhou Institute of Respiratory Diseases from February 2009 to February 2011 with trans-bronchoscopic debridement combined with local infusion of voriconazole, and achieved good results, which are reported below.

The patient was a 63-year-old male, Hui nationality, retired. He was admitted to hospital on January 21, 2011 due to "upper abdominal distension and pain with retrosternal discomfort for 1 month and blood in sputum for 1 week". In December 2010, the patient began to experience distension and pain in the upper abdomen without obvious trigger, mainly under the xiphoid process, with dull pain and discomfort like distension, sometimes accompanied by belching, which lasted for about 30 to 60 minutes, and could be relieved by itself, regardless of eating and posture. No precordial squeezing pain and liver pain, no radiation pain and involvement pain, and no lumbar fascicular pain; No fever, nausea, vomiting, acid reflux, hiccup and jaundice; No chest tightness, palpitation and shortness of breath. The sputum was bloodshot in the past week, and the shadow of the left tongue lobe was found on chest X-ray. The patient has lived in the city for a long time, has not been to a pastoral area, and had a pet dog 5 years ago. No smoking history. No obvious abnormalities were found on admission physical examination. Blood routine, urine routine and stool routine + occult blood were all normal. The ESR was 10 mm/1 h and tumor markers were normal. Blood gas analysis: pH 7.325, PaCO₂was 39.2 mm Hg (1 mm Hg =0.133 kPa), PaO₂For 69.9 mm Hg. All biochemistry is normal. Sputum look for tuberculosis negative. Electrocardiogram: Sinus rhythm, ST segment shift>0.05 mV in Ⅱ, Ⅲ and aVF leads. Pulmonary ventilation function was normal. Jan 26, 2011 CT showed a spherical shadow of the left lingual lobe with a cystic liquefied area (Figure 1，Figure 2)。 Feb 12, 2011 PET-CT showed mixed density shadows in the left lingual lobe, high uptake rate in the solid part, excluding tumors (Figure 3，Figure 4)。 Feb 15, 2011 X-ray chest radiograph showed spherical shadow of left lung lingual lobe (Figure 5)。 Cytological examination of sputum exfoliation revealed squamous epithelial cells and phagocytic cells, more neutrophils. Under bronchoscopy, the left and right bronchial mucosa was congested, the lumen was unobstructed, and no hemorrhage, edema and new organisms were seen. Columnar epithelial cells, phagocytic cells and neutrophils were seen in the left lingual brush. A few columnar epithelial cells and lymphocytes were observed in the left lingual lavage. Abdominal B-ultrasound showed cyst in the right kidney, no space-occupying lesions in the liver, pancreas and left kidney, no abnormalities in the gallbladder, and a small spleen. Cardiac Doppler ultrasonography showed uncoordinated overall movement of the left ventricular wall, mild regurgitation of the mitral valve orifice, aortic sclerosis with mild regurgitation of the valve orifice, mild regurgitation of the tricuspid valve orifice with mild pulmonary hypertension, and reduced active relaxation of the left ventricle. Preoperative diagnosis: The nature of left lingual space occupation is to be determined. Thoracoscopic wedge resection of left lingual lung was performed on 23 February 2011. During the operation, a lesion of about 7.5 cm ×6.5 cm ×1.7 cm was seen in the left tongue lobe, with a cyst wrapped in the middle, and a cyst cavity was seen in the rupture section of the pleural surface, with a diameter of about 2.5 cm, with a smooth inner wall and no content (Figure 6)。 Microscopic examination revealed intracystic protocephalic cysts and pulmonary echinococcal cysts (Figure 7，Figure 8)。 Postoperative diagnosis: hydatid in the lingual segment of the upper lobe of the left lung.

In recent years, with the extensive application of thermal therapy techniques such as laser and argon plasma coagulation (APC), the incidence of serious complications (7.39‰) and mortality (0.13‰) of interventional therapy increased significantly^[1]。 Now, 9 cases of sub-airway combustion occurred in the interventional treatment of bronchoscopy in recent years are reported as follows, and I hope my colleagues will take them as a warning.

Recently, a fire broke out in the operating room of the Third People's Hospital affiliated to Shanghai Jiaotong University School of Medicine (Baoshan District Baosteel Hospital), and a general anesthesia patient who was undergoing amputation died. Professor Wang Hongwu's article published in this issue introduces the experience of intra-airway combustion and its treatment in airway interventional therapy. Although different from the reasons reported in the news, combustion in the airways not only causes harm to patients, but can also cause fires and cause more serious disasters.

The results of epidemiological surveys show that the annual prevalence of community-acquired pneumonia (CAP) in the general population is about 0.1% to 1.16%, and in people>65 years of age is about 2.5% to 4.4%. The mortality rate of CAP was 1% to 5% in outpatients, 12% in inpatients, and about 40% in ICU patients^[1]。 The overdose of empirical anti-infective drugs leads to a gradual increase in the resistance rate of common pathogens in CAP. The latest survey results show that the insensitivity rate of Streptococcus pneumoniae to penicillin in China is as high as 24.9%, and the resistance rate to macrolides is as high as 87.5%^[2]。 Macrolides have always been considered the first choice drug for the treatment of Mycoplasma pneumoniae, but recent research results show that the resistance rate of Mycoplasma pneumoniae to macrolides in my country is as high as 90% of children^[3,4], up to 69% of adults^[5]。 Patients with pneumonia caused by drug-resistant mycoplasma in children and adults had long duration of fever and a high proportion of antibiotic replacement after failure of initial macrolide therapy, but there was no difference in case mortality^[6,7]。

(Continued from the previous period)

The 6th activity of Beijing Young Respiratory Scholars Salon in 2011 was held on July 28th, 2011. This activity was hosted by Dr. Bu Xiaoning of Beijing Chaoyang Hospital affiliated to Capital Medical University. The theme of the conference was "A respiratory professional problem that I am concerned about".

Medicine is a science and an empirical discipline. Without years of experience accumulation, it is difficult to become a qualified doctor. However, sometimes the price paid by the accumulation of experience is unbearable for individuals, especially in the current medical environment where the contradiction between doctors and patients is increasingly aggravated, there are many medical practitioners who do not seek merit, but seek no fault. How can we make great strides with minimal costs? Experience and lesson sharing can achieve this goal. However, at present, what we share is often successful experience, while the failure experience and lesson are rarely reported. In this issue of the article "Treatment of Intraairway Combustion in the Process of Bronchoscopic Argon Plasma Coagulation", the author shared his experience and lessons with the readers without reservation. Thank the author for his selflessness and frankness, and I believe that this will be of important reference significance for peers who are engaged or about to enter this field. Professor Wang Guangfa, editorial board member of this journal and head of interventional respiratory disease group of Chinese Medical Association Respiratory Disease Branch, put forward the development concept of "standardization, popularization and improvement" from the perspective of discipline development, and called on "the majority of colleagues in interventional respiratory disease circles to work together to promote the standardized application of interventional respiratory disease technology in China, promote technology popularization and discipline development, and improve the level of interventional respiratory disease in China" for the benefit of the majority of patients.