2012年 · 第35卷第03期

About community acquired pneumonia (CAP), relatively complete guidelines have been formulated both at home and abroad^[1]Through years of various academic activities and post-graduation education, respiratory doctors are almost unknown, and they have basically formed a good habit of consciously choosing empirical drugs according to the guidelines. But even so, even if the initial treatment chooses a standardized combination regimen according to the guidelines, occasionally there will be cases of treatment failure. Although it is uncommon, it will also be related to the safety of the patient. The following are three "special" cases of CAP that the author has encountered in the past two years. I would like to share them with readers and learn from their experience together.

Specific immunotherapy for allergic diseases has a history of hundreds of years, and in China, it has a history of more than 50 years. Specific immunotherapy can change the natural course of diseases. As long as the correct vaccine is selected and the patient's indications are strictly mastered, specific immunotherapy can significantly improve allergic symptoms, reduce drug use and improve the quality of life of patients^[1,2,3,4]。 With the increase of the incidence of allergic diseases in China, the demand for specific immunotherapy among medical workers and patients increases. All regions and hospitals have carried out this project by themselves. However, due to the lack of unified standards that can be referred to and insufficient standardization, to a large extent, it is only based on clinical experience, so there are many potential medical safety hazards. Based on the specificity and safety considerations of specific immunotherapy, it is urgent to establish a set of common clinical practice standards for allergen-specific immunotherapy in China. This consensus was co-written by many experts working in the field of allergy in China. It is based on the relevant contents of "Medical Quality Management and Control Indicators of General Hospitals (2011 Edition)" and "Interim Provisions on Medical Quality and Safety Incident Reporting" of the Ministry of Health and refers to the local special conditions of medical service institutions and patients. The authors believe that this clinical consensus should be popularized so that all medical personnel engaged in allergen-specific immunotherapy can know and master it.

Clinically and in journals, it is often found that some people confuse vagus nerve, parasympathetic nerve and cholinergic nerve, and they are mixed with each other. It is difficult to distinguish the relationship between the three, so it is necessary to clarify.

Bronchial asthma (abbreviated as asthma) is a chronic airway allergic disease with genetic susceptibility involving multiple genes. Its pathogenesis involves a variety of inflammatory cells, inflammatory mediators and complex cytokine networks, and its clinical features are increased serum IgE, eosinophil infiltration of lung tissue and airway hyperresponsiveness^[1]。 The increase of serum IgE and specific IgE levels is the main clinical feature of asthma, and it is also one of the key links in the occurrence and development of asthma^[2]。 Omalizumab, an anti-IgE monoclonal antibody, can bind highly specifically to IgE in the blood circulation, block the interaction between IgE and effector cell membrane surface receptors, prevent effector cell degranulation, and thus block the occurrence and development of asthma. Refractory asthma accounts for about 5% of asthma patients. Although the proportion is not high, the emergency treatment rate and hospitalization rate are 15 times and 20 times that of mild and moderate asthma patients, respectively, which is one of the important reasons for the increase of asthma treatment cost^[3]。 More and more clinical studies of asthma have confirmed that omalizumab is expected to bring new prospects for the treatment of asthma, especially refractory asthma.

COPD is a complex and specific disease, and autonomic dysfunction plays an important role in the pathophysiological changes of COPD. Heart rate variability is currently recognized as an accurate and sensitive index to judge autonomic nerve function impairment. The application of heart rate variability in evaluating the severity, rehabilitation, prognosis, predicting mortality and guiding treatment of COPD patients has important clinical significance in the field of medical research. The author's research on the application of heart rate variability in COPD is summarized as follows.

OSAHS is one of the sleep respiratory diseases that seriously endanger human health. It is an independent risk factor for cardiovascular and cerebrovascular complications such as hypertension, coronary heart disease, arrhythmia and stroke due to repeated apnea and micro-awakening during night sleep caused by complete or incomplete obstruction of upper airway, resulting in hypoxemia, hypercapnia and destruction of sleep structure.

Tuberculosis is an important public health problem. According to the World Health Organization, 2 billion people worldwide are infected with MTB, including 20 million cases of active tuberculosis^[1]。 About 550 million people in China are infected with MTB, and it is estimated that there are about 4.5 million active tuberculosis patients, which suggests that only 5% ~10% of people infected with MTB suffer from tuberculosis. Recent studies have shown that autophagy can directly eliminate intracellular MTB and play a prominent role in the congenital and acquired immune response of tuberculosis^[2,3,4]Thus potentially becoming a target for therapeutic vaccines. Our research progress on autophagy is reviewed below.

Tuberculosis is a disease that can be treated, controlled and prevented, but at this stage remains the most serious public health problem in most parts of the world. According to the World Health Organization (WHO), the number of tuberculosis patients worldwide reached an estimated 9.4 million in 2009, with a prevalence rate of 137 per 100,000 and about 1.3 million deaths per year. After years of prevention and control, the incidence of tuberculosis has gradually decreased, but the total number of tuberculosis patients is still on the rise^[1]。 With the increase of multidrug-resistant strains and extensively drug-resistant strains, the epidemic situation tends to deteriorate further.

The incidence of tuberculosis increased with age, increased obviously after 55 years old, and reached the peak at 75 years old^[1]And the peak shifts back by 5 years every 10 years^[2]。 Our response to the PLA third ○ The elderly patients with pulmonary tuberculosis admitted to the Third Department of Tuberculosis of Nine Hospitals during 10 years were retrospectively analyzed to observe their clinical manifestations.

respiratory syncytial virus (RSV) is one of the important pathogens of lower respiratory tract infection in infants and young children. Epidemiological investigations have found that 50% ~70% of children with RSV bronchiolitis in infants and young children can develop repeated wheezing or even bronchial asthma (asthma for short)^[1]。 Th1/Th2 imbalance is the key to the development and development of airway inflammation and airway hyperresponsiveness in asthmatic children^[2]suppressor of cytokine signaling (SOCS) is closely related to Th1/Th2 differentiation^[3]。 In this study, we constructed a model of persistent infection of human bronchial epithelial cells (HBEC) by RSV in vitro, and co-cultured with lymphocytes to observe the expression of interferon-γ (IFN-γ) and IL-4, as well as SOCS3 and SOCS5, which provided evidence for the mechanism of Th immune imbalance caused by RSV infection and the relationship between SOCS and Th differentiation.

Bronchial asthma (asthma for short) is a chronic inflammatory disease of the airways. Oxidative stress plays a key role in inducing airway inflammation and its development. NF-E2-related factor 2 (Nrf2) is a redox-sensitive transcription factor, which regulates almost all related antioxidant genes in the lungs, such as γ-glutamylcysteine synthetase catalytic subunit (γ-GCSc), and exerts important antioxidant effects^[1]。 activating transcription factor 4 (ATF4) belongs to the family of CAMP-responsive element binding proteins (CREB) having a basic leucine zipper (bZIP). Under oxidative stress, ATF4 can bind to Nrf2 to form heterodimer, which regulates the expression of Nrf2 and its target gene γ-GCSc^[2]。 In this study, the expression changes of ATF4, Nrf2 and γ-GCSc in the lung tissues of guinea pigs during acute asthma attack were observed to explore their role in the pathogenesis and prevention of asthma.

A 54-year-old female with no smoking history developed severe irritating dry cough without obvious trigger since December 2004. She was diagnosed with adenocarcinoma of the left lower lobe of the lung by chest CT and bronchoscopic biopsy. She was given vinorelbine combined with cisplatin chemotherapy for 2 cycles. Left lower lobectomy was performed under general anesthesia on April 12, 2005. Postoperative pathological examination showed papillary adenocarcinoma in the basal segment of the left lower lobe, which was moderately poorly differentiated and invaded the visceral pleura. Postoperative diagnosis: lung adenocarcinoma (stage IIIA); The physical condition score was 0. After 4 cycles of chemotherapy with gemcitabine combined with carboplatin, the patients were followed up regularly. By July 2008, chest CT examination showed left lung tumor with dissemination in both lungs. They were given docetaxel and vinorelbine monotherapy for 17 cycles, and bone marrow suppression was obvious. On August 25, 2010, the reexamination of chest CT showed multiple metastases, inflammation and pleural effusion in both lungs after left lung tumor operation, suggesting that the disease still progressed. Considering that the patient had poor physical strength, could not tolerate chemotherapy, and was positive for epidermal growth factor receptor (EGFR) gene mutation, he was treated with the targeted drug gefitinib (250 mg/d) on September 1st. After 18 days of taking the drug, reexamination of chest CT showed that the lesions of both lungs were reduced and reduced compared with before, indicating that gefitinib was effective. One month after taking the drug, the patient had sudden limbs twitching, accompanied by unconsciousness, which lasted for several minutes and then improved on its own. No abnormalities were found in the emergency MRI of Zhongshan Hospital, and there was no recurrence after the suspension of gefitinib. After returning home, he continued to take gefitinib orally, and 20 days later, he had another limb twitching, lasting for 2 to 3 hours. He was treated again in the emergency department of Zhongshan Hospital for symptomatic treatment, and he was discharged after stopping gefitinib. After returning home, I took gefitinib again and had another limb twitching once, but it did not recur after stopping the drug. In early May 2011, there was a decline in self-awareness and a slow response to the outside world. EEG examination on 7 Jun 2011 showed moderate abnormality; MRI of the brain showed no abnormalities. He stopped taking gefitinib on June 10 and has not had another attack so far.

Ganglionoma is a benign tumor of nerve origin, and ganglionoma of the respiratory system is very rare. A case of giant ganglionoma of the posterior mediastinum without typical clinical manifestations is reported below to improve clinicians' understanding of the disease.

Once a patient with poor spontaneous cough function, unconsciousness or repeated aspiration develops a pulmonary infection, it is difficult to control the infection due to poor drainage of sputum. Tracheotomy is helpful for the drainage of airway secretions and the treatment of pulmonary infection. However, after tracheotomy, the loss of the warm and damp effect of the upper respiratory tract will easily lead to thick sputum, and the function of removing secretions in the airway will be reduced, which may not be conducive to the treatment of lung infection^[1]Therefore, it is necessary to strengthen the airway humidification of this part of patients. At present, the humidification methods reported in the literature mainly include continuous pumping of humidifying liquid with micro-pump and artificial nose^[2,3]The aforementioned method does not achieve the desired effect of airway humidification. MR850 humidifier is the most high-end humidifier at present. In the past, it was mainly used for mechanical ventilation patients, and can provide patients with the best humidity gas (37 ℃, relative humidity of 100%, absolute humidity of 44 mg/L). In this study, MR850 humidifier combined with RT305 oxygen therapy system was used to manage artificial airway in patients with tracheotomy after pulmonary infection, and good clinical results were achieved, which are reported below.

Cervical tracheal stenosis refers to the stenosis of the tracheal segment from the lower edge of cricoid cartilage to the upper edge of the sternojugular vein notch, which is caused by the obstruction of the lumen by the lesions of the airway itself or the compression of the lumen by the lesions outside the airway. The treatment of airway stenosis has always been a difficult and hot issue in clinic. After treatment, multiple follow-up examinations are needed to observe the improvement of tracheal stenosis. At present, bronchoscopy and chest CT are the main commonly used diagnostic techniques. Although the accuracy of both in the diagnosis of tracheal stenosis has been defined for a long time, bronchoscopy is a traumatic examination, chest CT is radioactive, and both are expensive, so they are not suitable for multiple reexaminations in a short time. Ultrasound has the advantages of non-invasive, radiation-free, high resolution and economical convenience. This study attempts to carry out a preliminary study on the application of ultrasound in detecting cervical airway stenosis by applying high-frequency ultrasound to detect the degree of cervical tracheal stenosis.

A 46-year-old male was seen on April 20, 2011 due to "fever and cough with blood in sputum for 1 year after repeated exertion". Since April 2010, the patient developed paroxysmal cough after exertion, coughing a small amount of bright red blood, mainly 4 to 5 mouthfuls of blood every day, accompanied by fever, with a maximum body temperature of 38.5℃, no chest pain and night sweats. After 3 days of penicillin antibacterial treatment (100 ml of normal saline plus 4.8 million units of penicillin sodium, intravenous drip, twice/d), the body temperature was normal, and the symptoms of cough and expectoration disappeared. The patient was not taken seriously and no special examination was performed. Skin bleeding and blood in urine are denied. He denied a history of tuberculosis, chronic liver disease and diabetes, and had no tobacco and alcohol habit. Personal history is not special. Familial genetic history denied. Physical examination: The superficial lymph nodes of the whole body were not palpable, the breathing sounds of both lungs were clear, no dry and wet rales were heard, the heart rate was 70 beats/min, the rhythm was uniform, no pathological murmur was heard in the auscultation area of each valve, the abdomen was flat and soft, the liver and spleen were not palpable under the costs, and there was no edema in both lower limbs. Laboratory test: white blood cells 7.64×10⁹/L, neutrophils 0.67, hemoglobin 160 g/L, liver and kidney function normal, ESR, C-reactive protein normal, carcinoembryonic antigen and neuroenolase normal. Rheumatic factors and vasculitis-related antigens were negative. Sputum look for tuberculosis bacilli and cancer cells negative. Auxiliary examination: normal pulmonary function. On April 20, 2011, chest CT showed an irregular air-containing cavity near the spine of the right lower lung, about 4 cm in diameter, with thin and smooth cavity wall, and no fluid accumulation in the cavity; The boundary between cavity and diaphragm is clear, and the surrounding lung field is clear; Stripe-shaped tortuous blood vessel shadows were seen around the cavity (Figure 1，Figure 2，Figure 3)。 CT three-dimensional angiography showed that the supply artery emanated from the abdominal aorta and entered the edge of the cavity; The drainage vessel is thick and enters the ipsilateral inferior pulmonary vein and left atrium (Figure 4)。 CT diagnosis was right lower pulmonary intra-lobar pulmonary sequestration (cavitation type). For financial reasons, the patient only received anti-inflammatory treatment in the outpatient clinic (100 ml of normal saline plus melocillin sodium 2.0, intravenous drip, 2 times/d) and the symptoms improved after 5 days. After 3 months of telephone follow-up, the symptoms did not onset, and the patient refused to be reviewed and operated.

Benign tumors originating from trachea-bronchus are rare, among which neurilemmoma is rare, and occasional cases are reported at home and abroad. From March to May 2011, 3 patients with endotracheobronchial schwannoma were successfully treated in the Department of Respiratory Medicine, Changhai Hospital, Second Military Medical University. The report is summarized as follows, and the relevant literature is reviewed to improve the clinical understanding of benign endotracheobronchial schwannoma.

The patient was a 19-year-old male, farmer. He was admitted to the hospital on 16 November 2010 for "recurrent hemoptysis for 11 months". The patient had a sudden hemoptysis, about 50 ml, bright red, on 6 Dec 2009 while riding a flatbed. Accompanied by mild chest tightness, no cough, expectoration, fever, chest pain, fatigue, night sweats and other symptoms. On December 7, 2009, the blood routine and coagulation function of the local hospital were normal, and the chest CT examination showed infiltration of the right middle and lower lung (Figure 1)。 After administration of cephalosporin antibiotics for anti-infective treatment, there was still intermittent hemoptysis, about 50-100 ml per day, and continued to give hemostatic and anti-infective treatment for 1 week, and the amount of hemoptysis gradually decreased after discharge. No further medication was taken after discharge. On January 5, 2010, the patient had hemoptysis again without obvious inducement, about 20 ml, which was bright red, but the chest tightness symptom was significantly worse than the previous hemoptysis, so he was hospitalized to the local chest hospital. On January 6, 2010, the chest CT showed a flaky infiltrating shadow in the right middle and lower lung (Figure 2), the extent of the lesion was significantly larger than that in December 2009. In order to clarify the cause of hemoptysis, bronchoscopy was performed twice, and no active hemorrhagic focus was found after the blood clot in the trachea and main bronchus was removed. At the same time, hemostatic and anti-infective treatment were given, and hemoptysis stopped completely after 1 week. On 6 Oct 2010, the patient was given bright red blood again during labor, about 150 ml. On October 7, 2010, the chest CT showed diffuse exudation shadow in the right middle and lower lung, and a little exudation shadow in the left lower lung (Figure 3)。 Hemoptysis was not controlled and the amount gradually increased after hemostatic therapy such as phenolsulfamide, carbamate and thrombin was given in the outpatient department of local hospital. In order to further clarify the cause of hemoptysis, he was transferred to our department. Since the onset of the disease, the patient has clear consciousness, poor spirit, good appetite and sleep, normal urine and defecation, and no decrease in physical strength and weight. He is usually in good health and denies the history of chronic diseases and family genetic diseases. No tobacco and alcohol addiction.

The results of pulmonary function tests are a reflection of respiratory physiological functions, which cannot explain exactly the anatomical location and pathological nature of the dysfunction. It must be comprehensively analyzed in combination with the examination graphics, medical history and chest imaging results, and then conclusions and recommendations are drawn. This article only evaluates the results of pulmonary function tests.

The 8th event of Beijing Young Respirators Salon 2011 was held at the Chinese Medical Association on October 27th, 2011. The theme of this salon was "Diagnosis of Pleural Effusion: Are There Still Difficulties?", which was presided over by Professor Sun Yongchang, Department of Respiratory Medicine, Beijing Tongren Hospital affiliated to Capital Medical University.

The domestic "guidelines for the diagnosis and treatment of community-acquired pneumonia" have been formulated for more than five years. Respiratory doctors basically master and consciously choose empirical drugs according to the guidelines, but is this enough? Professor Liu Youning, the editor-in-chief of this journal, introduced three cases in which he participated in the diagnosis and treatment, and there were no problems in the initial medication in principle, but the treatment failed. Professor Liu believes that the conditions of patients in clinical practice vary widely, and it is far from enough to memorize books and keep guidelines in mind. It is necessary to conduct specific analysis for specific cases and adopt different individualized diagnosis and treatment plans.