2012年 · 第35卷第05期

In the essay of the editor-in-chief in the first issue of 2012, the author talked about the problem of air pollution, which attracted the attention of many colleagues^[1]。 In view of the limitation of "overall situation" at that time, the author did not focus on the fine particulate matter, that is, PM2.5, which is not fully monitored and not disclosed to the public in China^[1]。 In recent months, the author is happy to learn from various media that the relevant departments have changed the previous state of "still holding a pipa and half covering their faces", and openly and positively responded to the public's worries about this problem. The environmental protection departments have also promulgated new ambient air quality standards, and Beijing and other cities have announced specific monitoring plans and countermeasures, which has brought a glimmer of dawn for fundamentally solving China's air pollution problem one day in several centuries.

In many articles, "chronic obstructive pulmonary disease (COPD)" is translated as "chronic obstructive pulmonary disease" and "Global initiative for chronic obstructive lung disease (GOLD)" Translated as "COPD Global Initiative", the report released by GOLD "Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease" Translated as "Global strategies for the diagnosis, management and prevention of chronic obstructive pulmonary disease". In 2011, GOLD released a new version of the report. After studying it, the author feels that the above translation is inappropriate at present, so I put forward the following opinions, and ask experts to criticize and correct it.

Due to various reasons such as dysphagia or ineffective cough, foreign bodies remain in the mouth or upper gastrointestinal tract, and enter the larynx and lower respiratory tract through the glottis, which is called aspiration. Aspiration events are a common and serious phenomenon in the elderly and premature infants, which are easily ignored or misdiagnosed, especially latent aspiration (aspiration without clear clinical manifestations), which causes lung injury and develops into aspiration syndrome (AS) in a high proportion. Chemical aspiration pneumonia, bacterial aspiration pneumonia, airway obstruction, lung abscess, exogenous lipid pneumonia, chronic interstitial pneumonia and incidental mycobacterial pneumonia are classified according to the amount, nature, frequency of inhalation and the body's response to the inhalation. Different types of AS determine different treatment principles, and it is also different from general pneumonia, in which the prevention and treatment of aspiration is the key factor to avoid its recurrence. Therefore, early determination of the presence and etiology of aspiration and its intervention can effectively prevent AS and reduce recurrence, such AS early bronchoscopic lavage, drug-enhanced cough and swallowing reflex, gastric tube nasogastric feeding, oral care, etc. At present, the clinical identification of aspiration depends on its clinical evidence, including aspiration history, laboratory data, oxygenation index, respiratory secretion culture, chest X-ray, pH monitoring, visual development, radioactive tracer labeling, microbiological tests, cytological tests of respiratory secretion, visual X-ray fluoroscopy and endoscopy techniques, etc. However, these tests as the "gold standard" still lack sufficient credibility and repeatability. Biomarkers are a kind of markers related to cell growth and proliferation which have been proposed in recent years with the development of immunology and molecular biology technology. The results show that biomarkers can not only explore the pathogenesis of many infectious diseases at the molecular level, but also have unique advantages in evaluating early and low-level damage, and guide the diagnosis and treatment of the above diseases. However, the role of these biomarkers in identifying AS is still inconclusive. Several biomarkers related to inhalation studied in recent years and their potential applications in the identification and guidance of inhalation events are presented^[1]The review is as follows.

central sleep apnea (CSA) is a type of sleep breathing disorder, which refers to the absence of oral and nasal airflow and the cessation of thoracic and abdominal respiratory movements for more than 10 s during sleep. CSA is classified into 3 categories: (1) periodic breathing; (2) idiopathic central sleep apnea; (3) Cheyne – Stokes respiration (CSR). Described by John Cheyne in 1818 and William Stokes in 1854, tidal breathing is a form of rhythmic breathing found in patients with severe heart failure, which is characterized by a process of gradually increasing, increasing, and gradually weakening and slowing breathing alternately with apnea^[1,2]。 CSR and CSA often coexist in patients with chronic heart failure, and the severity of CSA is linearly correlated with the degree of cardiac function impairment, which may increase the mortality of patients with heart failure, and is closely related to its prognosis, which has important clinical significance. This paper reviews the pathogenesis, diagnosis and treatment of heart failure and CSR-CsA, and introduces the new progress in pathogenesis research proposed in recent years, namely the loop gain theory.

Staphylococci, including Staphylococcus aureus (SA) and the coagulase-negative genus Staphylococcus (CoNS), are among the most common and important gram-positive cocci in clinic. Vancomycin and teicoplanin are the first-line antibacterial drugs against methicillin-resistant SA (MRSA) and methicillin-resistant CoNS (MRCoNS) infections. However, with the drift of MRSA MIC value, heterogeneous vancomycin-mediated SA (hVISA, which means that the MIC value of vancomycin is 1~2 mg/L, but less than 10^–6The MRSA strain can grow in medium with vancomycin concentration>2 mg/L, which is closely related to the poor response to vancomycin treatment, poor prognosis of patients with MRSA infection), vancomycin-mediated SA and even the emergence of vancomycin-resistant SA. The American Society of Infectious Diseases recommends linezolid, daptomycin and tigecycline for the antibacterial treatment of such infections^[1,2]。

According to the statistics of the World Health Organization, there were about 8.8 million new cases of tuberculosis worldwide in 2010, the total number of tuberculosis patients was about 12 million, and about 650,000 cases of multidrug-resistant tuberculosis^[1]。 The drug resistance of tuberculosis patients in China is very severe, the total drug resistance rate is 27.8%, and the multidrug resistance rate is 10.7%^[2]。 For a long time, the diagnosis of tuberculosis mainly depends on acid-resistant staining of sputum smear. However, due to the high requirement of bacterial content of sputum smear, its sensitivity in diagnosing tuberculosis is low, and the sensitivity is only 45% ~80% in the specimens with positive MTB culture^[3,4]。 The gold standard for diagnosing tuberculosis is MTB culture. This method requires high biosafety level in laboratories, and it can't be popularized in countries or regions with scarce resources. In addition, due to the slow growth habit of MTB, it takes a long time to cultivate MTB (2 to 6 weeks), and the diagnosis of tuberculosis with MTB culture alone may delay the treatment, thus leading to the worsening of the disease^[4]。 The traditional diagnostic method of MDR-TB is drug sensitivity test, which still has the disadvantages of high laboratory requirements and long time consumption. Therefore, seeking methods for rapid diagnosis of active tuberculosis and multidrug-resistant tuberculosis has become the focus of tuberculosis control. The Xpert MTB/RIF test, which has emerged in recent years, can rapidly diagnose tuberculosis. This method is based on fully automated semi-nested PCR technology, which can simultaneously detect MTB and its resistance to rifampicin, so it can be used to diagnose tuberculosis patients with suspected multidrug-resistant tuberculosis or human immunodeficiency virus (HIV) infection^[5]。

Due to the lack of clear etiological and pathological diagnostic basis, the patient to be diagnosed with pulmonary tuberculosis was defined as having typical clinical symptoms of pulmonary tuberculosis and chest CT findings, but sputum MTB was negative at least 3 times. We performed bronchoscopy in 70 patients with pulmonary tuberculosis, and analyzed the results of microscopic manifestations, pathological biopsy, brush smear, BALF smear and culture, so as to explore the diagnostic value of bronchoscopy in the etiology and pathology of patients with pulmonary tuberculosis.

chitin is the second most abundant polysaccharide in nature and can be degraded by chitase. The CHI3L1 gene is a chitase-like gene that encodes a protein called human cartilage glycoprotein 39 or chitase protein 40 (YKL-40). YKL-40 lacks enzymatic properties, but can bind to chitin and inactivate it. Abnormally expressed YKL-40 is related to inflammation, tissue remodeling and abnormal cell proliferation, such as rheumatoid arthritis, type 2 diabetes, inflammatory bowel disease, and some malignant tumors^[1]。

COPD is a progressive, incompletely reversible airflow restriction disease, and smoking is the most important risk factor^[1]。 Smoking cessation is one of the effective measures proven to delay the progressive decline of lung function in patients with COPD^[2]But its mechanism of action is unknown. The results of recent studies suggest that COPD may be an inflammatory response and autoimmune disease involved in T cells induced by smoking^[3]； CD that specifically secretes IL-17₄⁺Th cells (Th17 cells), expressing specific transcription factors retinoid-related orphan nuclear receptor (ROR γ t) and STAT3 transcription factor, mainly secrete inflammatory factors such as IL-17, IL-21 and tumor necrosis factor-α (TNF-α), and have powerful pro-inflammatory effects^[4,5]ROR γ t can reflect the level and functional activity of Th17 cells to a certain extent. The expression of IL-17A in bronchial mucosa increased in bronchial mucosa biopsy tissues of stable COPD patients, suggesting that Th17 cells may be involved in the pathogenesis of COPD and emphysema^[6]。 In order to study the changes of Th17 cells in COPD patients after smoking cessation, we established a mouse model of emphysema and smoking cessation, observed the changes of Th17 cells in lung of mice after tobacco smoke exposure and smoking cessation, and investigated the relationship between Th17 cells and lung inflammation and emphysema in mice after smoking cessation.

diffuse alveolar hemorrhage (DAH) is rare in clinical practice, and vascular inflammatory disease is the main cause of DAH^[1]IgA nephropathy is one of its rare causes. The clinical data and treatment of a patient with diffuse alveolar hemorrhage caused by IgA nephropathy are reported, so as to improve clinicians' understanding of this disease.

intratracheal ectopic thyroid tissue (intratracheal ectopic thyroid tissue) is relatively rare in clinical practice. A case of intratracheal ectopic thyroid tissue misdiagnosed as bronchial asthma for many years is reported to improve the understanding of this disease.

The surgical treatment of tuberculosis has a history of 100 years, among which the surgical methods of pulmonary tuberculosis have undergone the evolution of compression surgery (such as thoracic reconstruction) and pulmonary resection, and the deep lesion removal such as spinal tuberculosis was also successful and widely carried out in 1947. In our long-term clinical work, we used focal fixed-point debridement to treat localized pulmonary tuberculosis and extrapulmonary tuberculosis, which achieved similar results as traditional tuberculosis surgery, with less trauma, less blood loss, and the maximum preservation of normal tissue, and the clinical effect was good^[1]Our experience is presented below.

The patient was a 68-year-old male. Intermittent cough for more than 10 years, often paroxysmal dry cough, sometimes cough yellow-white mucous sputum or light green sputum, no fever and night sweats, 9 years ago due to blood in sputum for 3 days, diagnosed with left upper lung tuberculosis in another hospital, intermittently taking anti-tuberculosis drugs and antibiotics for 10 years, the details are unknown. In the past 1 year, the cough was aggravated with chest tightness and shortness of breath after activity. In the past 2 months, the symptoms of cough and shortness of breath were aggravated. Anti-infective treatment in another hospital was ineffective, and he was admitted to hospital on September 27, 2011. He usually smokes occasionally. Admission physical examination: No obvious abnormalities were found in routine physical examination, body mass index 19.5 kg/m²Some wet rales could be heard in the left lung after auscultation, and no abnormalities were found in biochemical examinations such as blood glucose and blood lipids. Chest X-ray examination showed a dense shadow in the left hilar area, infectious lesions in the left lung and left atelectasis (Figure 1)。 Chest CT examination showed low-density shadows in the left main bronchus with a CT value of approximately – 96 HU, suspecting space-occupying lesions in the trachea (Figure 2，Figure 3)。 Then, 2 days after admission, bronchoscopy was performed and chest CT was re-examined (Figure 4，Figure 5，Figure 6，Figure 7), a pale yellow spherical superficially lobulated new organism at the end of the left main bronchus was found, almost completely obstructing the left main bronchus, and there was mucopurulent secretion overflow around the new organism. After biopsy under bronchoscope, the amount of bleeding was not large. Subsequently, the tumor tissue was removed by high-frequency electrosurgical snare, and it was found that the tumor originated from the anterior bronchus of the left upper lobe, which was diagnosed as bronchial lipoma. After operation, the symptoms of cough, chest tightness and shortness of breath disappeared. Postoperative chest CT examination showed that the bronchus at the site of tumor removal was slightly dilated, the left lung atelectasis was significantly improved, and the images of infectious lesions in the left lung disappeared. Histopathological examination of biopsy showed pseudo-stratified ciliated columnar epithelial cells, fibrous tissue, adipose tissue and a few glandular ducts, suggesting benign tracheal tumor with high possibility of lipoma (Figure 8，Figure 9), and there was no recurrence of symptoms after 5 months of follow-up.

A 20-year-old male was admitted to the hospital on 26 April 2007 mainly due to "high fever and cough for 21 days". The patient developed chills, fever, sore throat, body temperature 39.8℃, accompanied by profuse sweating, mild cough and expectoration after catching cold 21 days ago; No abdominal pain, diarrhea, urgency, painful urination, chills, headache and joint pain. On the third day of fever, blood white blood cells were 4.7×10 in outpatient clinic of other hospital⁹/L, neutrophils 0.45. Upper respiratory tract infection was diagnosed, and cefuroxime anti-infective treatment was given for 1 week without any relief of symptoms. No abnormalities were found on chest X-ray on the 9th day of fever (Figure 1)。 The ESR was 35 mm/1 h and the CRP was 40 mg/L. Switching to azithromycin and cefoperazone/sulbactam anti-infective therapy for 7 d was ineffective. Re-examination of chest X-ray showed increased texture in both lower lungs (Figure 2)。 A plain CT scan of the chest revealed diffuse ground glass shadows in both lungs. He was diagnosed as viral pneumonia in another hospital. He was treated with ribavirin and levofloxacin for 1 week, but his body temperature still did not relieve. He was admitted to our department for further diagnosis and treatment. Past physical fitness. Physical examination: body temperature 39.6 ℃, heart rate 110 beats/min, 26 breaths/min, blood pressure 110/80 mm Hg (1 mm Hg =0.133 kPa); There were no abnormalities in the ear and nose, no resistance in the neck, no distension in the jugular vein, centered trachea, coarse breathing sounds in both lower lungs, and no dry or wet rales. The heart rhythm is uniform and there is no murmur; The abdomen was flat and soft, without tenderness, the liver and spleen were not reached under the costs, the mobile voicing was negative, and there was no edema in both lower limbs.

In 280 BC, King Min of Qi suffered from depression. He was gloomy all day, silent, and often sighed for no reason. After many doctors' treatment, he didn't get better. King Qi heard that there was a famous doctor named Wen Zhi in the neighboring Song Kingdom, who was skilled in medicine, so he sent someone to Song Kingdom to invite Doctor Wen Zhi.

Bacterial drug resistance has become a global problem that cannot be ignored. Antibiotic selectivity pressure is the main factor that leads to and accelerates the development of drug resistance, including inappropriate selection of antimicrobial drugs, insufficient dosage or course of treatment, and poor quality of antimicrobial drugs^[1]。 In order to strengthen the management of clinical application of antimicrobial drugs in medical institutions and effectively control bacterial resistance, in 2011, China formulated the "National Special Rectification Activity Plan for Clinical Application of Antimicrobial Drugs" and the "Administrative Measures for Clinical Application of Antimicrobial Drugs (Draft for Comment)"^[2,3]。 In 2012, in order to further consolidate the achievements of the special rectification in 2011, the "2012 National Special Rectification Activity Plan for Clinical Application of Antibacterial Drugs" was formulated^[4]。 The new plan not only proposes to strengthen the control of indicators related to clinical application of antimicrobial drugs, but also to investigate the application of antimicrobial drug use rate and intensity at the hospital and department levels in 2011. In short, limiting and slowing down bacterial resistance has become an urgent task, and reducing the use rate and intensity of antimicrobial drugs has become the core content of antibiotic management in China.

With the development of critical care medicine, mechanical ventilation is being widely used in hospitals at all levels. In order to achieve good ventilation effect and reduce mechanical ventilation complications, it is necessary to correctly select and adjust ventilation mode and ventilation parameters of ventilator. At present, there are at least 49 ventilators used in clinical practice, and 54 ventilation modes are independently named. The ventilation parameters derived from these ventilators are even more impossible to count^[1]。 Among them, there is a chaotic phenomenon of "one type with multiple names" or "different names with the same name", which confuses beginners, brings difficulties to operators, and is not conducive to training and communication. Therefore, this paper uses the classification system of mechanical ventilation modes which is relatively common in the world^[2,3,4,5]Based on the classification and interpretation of mechanical ventilation modes and parameters, it is hoped that it will help to better understand the substance of mechanical ventilation rather than simple name analysis.

The interpretation and evaluation of graphic report of pulmonary function test is the key to the application of pulmonary function test in clinical diagnosis and treatment. The graphic report contains a wealth of information, such as the basic condition of the subject, the quality control of the examination, the nature and severity of the respiratory physiological and pathological damage caused by the disease, and their response to interventions such as drugs, etc. It must be emphasized that the interpretation of the report must be combined with clinical data and knowledge accumulation, and cannot only look at the results without asking about the process. Due to space limitation, this article is only for the interpretation of the graphic report of ventilation function examination.

Towards the end of 2011, young physicians in Beijing gathered again to attend the last Beijing Young Respiratory Scholars Salon of the year. This event was hosted by Dr. Li Nan of Peking University First Hospital, and the theme of the conference was "Application of lung volume reduction surgery in COPD". The reason why this theme was chosen is that the one-way valve lung volume reduction technology has been approved in Europe and China, and has begun to be applied in clinical practice. However, the number of domestic cases is small, and the experience is insufficient, so it is necessary to enhance the exchange between them. In addition, there is also a tendency to abuse this technology in China. In order to improve the understanding level of this technology, exchange experience, and carry out clinical application in a standardized and orderly way, this salon activity was organized.

There are many reports on the harm of fine particulate matter in the atmosphere, especially PM2.5, to human body in various media, and people's attention is very high. Professor Liu Youning, the editor-in-chief of this magazine, talked about air pollution in the first editor-in-chief's essay in 2012. In this issue, Professor Liu further analyzed the harm of PM2.5 from a professional perspective, and at the same time talked about some "digressions" outside his profession, which reflected an expert's sense of social responsibility.