2012年 · 第35卷第09期

Infectious diseases are multiple clinical diseases, and severe cases often threaten patients' lives; It is also one of a limited number of diseases that can be completely cured. Infectious diseases can also be found in other clinical departments besides respiratory departments, especially critical care and emergency departments, such as bloodstream infections, urinary tract infections, reproductive tract infections, intestinal infections, abdominal infections and skin and soft tissue infections. Even respiratory tract infections, especially hospital-acquired pneumonia (HAP), not only occur in respiratory departments and respiratory care units (RICUs), but are also common in postoperative surgery, neurology, oncology, circulatory, digestive, kidney, endocrine, rheumatism and other hospitalized patients, and sometimes become the direct cause of final death. In developed countries, with the prolongation of average life expectancy, more and more cases of infectious diseases directly lead to death. In Japan, infectious diseases have replaced stroke as the third important cause of death after malignant tumors and heart diseases. On the other hand, the use rate and amount of clinical anti-infective drugs in my country account for an astonishing proportion of total drug costs.

Idiopathic pulmonary fibrosis (IPF) is a common type of idiopathic interstitial pneumonia (IIP). At present, there is no effective treatment. The prognosis is poor, and the median survival time is about 3 to 5 years^[1,2]。 Pulmonary hypertension (PH) in patients with IPF has a significant negative impact on their pulmonary function and quality of life, which often suggests a worse prognosis^[3]In recent years, it has attracted more and more attention of scholars at home and abroad.

idiopathic pulmonary fibrosis (IPF) is prone to embolic disease^[1]However, IPF complicated with pulmonary embolism has not been reported much. In the past 30 years, there are only 12 related reports^{[2,3,4,5,6,7,8,9,10,11,12,13]}9 articles abroad^{[2,3,4,5,6,7,8,9,10]}9 cases were reported; Domestic 3 articles^[11,12,13]All of them were case reports, of which 2 cases were actually pulmonary embolism and misdiagnosed as IPF, instead of IPF combined with pulmonary embolism. Therefore, only one case of IPF combined with pulmonary embolism in the true sense was reported in China^[11]。 Although there are few cases reported, the high risk of pulmonary embolism in IPF should be paid attention to by clinicians^[10]。

Idiopathic pulmonary fibrosis (IPF) is the most common type of idiopathic interstitial pneumonia. The disease progresses progressively, has a poor prognosis, and can have many comorbidities in its course, such as lung cancer. In fact, the relationship between lung cancer and fibrotic lung disease was first explained by Friedrich in 1939. Since then, research has shown that patients with IPF are more likely to have lung cancer than the general population. Due to the lack of effective treatment for both IPF and lung cancer after diagnosis, the coexistence of both is more adverse to the prognosis of patients, which has attracted great attention.

Early, convenient and exact risk stratification indicators are particularly important for guiding the further diagnosis and treatment of patients with community-acquired pneumonia (CAP). Pneumonia Severity Index (PSI) is a widely used evaluation method, but it is too cumbersome. The results of the study showed that three kinds of natriuretic peptides, including B-type natriuretic peptide (BNP), N-terminal natriuretic peptide precursor (NT-proBNP) and middle-anterior atrial natriuretic peptide (MR-proANP), were valuable in evaluating the prognosis of CAP patients. The authors explored the predictive value of three different types of natriuretic peptides and PSI in the prognosis of patients with CAP. A total of 341 CAP patients in the emergency department were enrolled in this study, and the mean follow-up time was 942 days. The patient's plasma BNP, NT-proBNP and MR-proANP levels at the time of visit were measured and paired compared with the patient's PSI and CURB-65 (disturbance of consciousness, increased blood urea nitrogen, rapid respiratory rate, hypotension, age>60 years). The results showed that the plasma levels of NT-proBNP, MR-proANP and BNP were significantly higher in patients who died within 30 days (recent) and more than 30 days (long-term) compared with survivors (4882, 1133 ng/ml, 426 and 178 pmol/L, 436 and 155 ng/L, respectively in patients who died and survivedP<0.001； Long-term deaths and survivors were 3515 and 548 ng/L, 283 and 136 pmol/L, 318 and 103 ng/L, respectively, allP<0.001)。 The accuracy of PSI, NT-proBNP, MR-proANP and BNP in predicting prognosis was similar. The area under the curve for predicting near-term mortality was 0.76, 0.73, 0.72 and 0.68, and the long-term mortality was 0.72, 0.75, 0.73 and 0.70, respectively. The results of multivariate regression analysis showed that NT-proBNP was an independent predictor of case mortality (the hazard ratio of recent death was 1.004,P＝0.02； The long-term hazard ratio of death was 1.004,P=0.001, an increase of 300 ng/L). The combination of PSI and NT-proBNP can divide newly diagnosed CAP patients into low-risk, medium-risk, high-risk, and long-term mortality risk groups. The results of this study suggest that multiple plasma natriuretic peptide levels, especially NT-proBNP and MR-proANP levels, have similar effects to PSI in predicting short-term and long-term mortality in CAP patients, while the former is more convenient and clinically operable, but the combination of the two has a better effect.

Correct procedures of bronchoalveolar lavage (BAL) and standardized treatment of bronchoalveolar lavage fluid (BALF) are the prerequisites for obtaining the exact cytological results of BALF, which play an important role in improving the diagnosis and differential diagnosis of interstitial lung disease (ILD). However, at present, respiratory experts and medical centers around the world have different procedures for BAL operation and BALF treatment. Experts from the American thoracic society (ATS) hope to further standardize the operation process of BAL, the treatment of BALF and the interpretation of BALF cytology results through the promulgation of this guideline, and further clarify the role of BALF cytology analysis in the diagnosis and evaluation of ILD.

You will be surprised when you see this topic. Why do you bring these two things together? When you read this essay, you will understand what the internal connection between these two words is.

mucin (MUC) is an important component of airway mucous layer, which is the first barrier of human respiratory tract. Proper secretion of the mucus layer can adsorb harmful substances and pathogens in the gas and expel them from the body by ciliary swing. Airway mucus contains about 2% mucin. The amount of mucin and the proportion of different types of mucin can affect the amount and viscoelasticity of sputum. At present, the research on airway mucin mainly focuses on diseases characterized by hypersecretion of airway mucus, such as COPD, bronchial asthma, cystic fibrosis, diffuse panbronchiolitis (DPB), while the research on interstitial lung disease (ILD) and mucin is few. On the one hand, it is because the goblet cells that synthesize and secrete mucin are mainly distributed in the proximal airway under normal circumstances, while the distal small airway is less, and the diameter<Almost no goblet cells in the 1 mm bronchiolar epithelium^[1]。 ILD is a large class of pulmonary interstitial lesions caused by immune system dysfunction due to known or unknown reasons. The pathological changes are mainly alveolitis and progressive pulmonary interstitial fibrosis^[2]。 In addition, hypersecretion of mucin is manifested by increased sputum, while ILD is often manifested by dry cough and dyspnea. Except for concurrent infection, there is mostly no excessive sputum. Therefore, previous studies have rarely paid attention to the relationship between ILD and mucin. However, recent studies have found that the pathological changes of ILD are not limited to the terminal alveoli and pulmonary interstitium, and the mucin secretion of ILD patients also has its own unique characteristics. The related research of ILD and mucin is summarized as follows.

Hemoptysis caused by bronchial artery rupture is more common in bronchiectasis, tuberculosis, lung cancer and lung abscess. In the past, it was often difficult to control the disease mainly through conservative medical treatment. Massive hemoptysis can cause complications such as asphyxia or hemorrhagic shock, and the mortality rate is extremely high. With the development of interventional radiology, the report of selective bronchial artery embolization (BAE) in the treatment of massive hemoptysis is increasing year by year^{[1,2,3,4,5,6,7,8,9,10],}Because of its exact curative effect and thorough hemostasis, it has been widely used in clinical practice. To further evaluate the efficacy, the clinical data of 110 patients with hemoptysis treated with BAE in Beijing Military Region General Hospital from January 1999 to December 2011 are summarized as follows.

80% ~90% of acute exacerbations of COPD are caused by bronchopulmonary infection. Mechanical ventilation can buy time for patients with severe respiratory failure to treat the primary disease, but long-term use of mechanical ventilation is prone to ventilator-associated pneumonia (VAP) and ventilator dependence. Therefore, once the primary disease improves, the tube should be extubated in time on the premise of ensuring the ventilation effect, and non-invasive mechanical ventilation through nasal mask should be used to assist ventilation, so as to help patients solve the problems of respiratory muscle fatigue and poor ventilation function^[1,2]。 In this study, the previous study^[1,2,3,4,5]The pressure-supported ventilation (PSV) parameters of invasive-non-invasive sequential mechanical ventilation were discussed, aiming to further shorten the time of invasive mechanical ventilation, reduce the occurrence of VAP and ventilator dependence, and improve the therapeutic effect.

Pulmonary edema caused by increased pulmonary microvascular permeability is one of the main pathological features of acute lung injury/acute respiratory distress syndrome (ALI/ARDS)^[1]。 Pulmonary aquaporins (AQPs) play an important role in maintaining intracellular and extracellular water balance^[2,3],The changes of AQPs content and function are closely related to the formation of pulmonary edema in ALI/ARDS^[4]。 In this study, the expression characteristics of AQP1 and AQP5 in rat lung tissue and their relationship with pulmonary edema were observed, and the effects of different levels of positive end-expiratory pressure (PEEP) ventilation on pulmonary edema and AQP1 and 5 were investigated, and the influence pathways of mechanical ventilation on pulmonary edema induced by hydrochloric acid inhalation ALI/ARDS were investigated.

peroxisome proliferator activated receptor γ (PPAR γ) is a member of nuclear receptor superfamily, which is widely distributed in the airway, and may have an important influence on the occurrence and development of bronchial asthma. PPAR γ can attenuate airway inflammation by affecting the function of immune cells^[1,2]。 In this study, the effect of PPAR γ ligand rosiglitazone on the contraction of isolated tracheal ring in asthmatic rats was investigated.

A 28-year-old male was admitted to the respiratory department of our hospital on November 12, 2006 due to "fever, hemoptysis and chest pain for 7 days". The patient consciously caught a cold in an air-conditioned room 7 days ago, with a body temperature of 37.3~38.1 ℃, accompanied by cough, expectoration and blood in sputum; Occasional left lower chest pain, aggravated by deep inhalation, accompanied by mild holding. Peripheral blood leukocytes examined in other hospitals were 15.51×10⁹/L, neutrophil count 0.76, hemoglobin 134 g/L, platelets 245×10⁹/L. The symptoms were not relieved after 5 days of intravenous infusion of cefuroxime in other hospitals. Outpatient chest X-ray showed reduced left lung texture and left lower lung exudation (Figure 1)。 Admitted to our hospital for further diagnosis and treatment. Past physical fitness; Smoked for 5 years, 20 cigarettes/d. Physical examination: temperature 38.1 ℃, pulse 99 beats/min, breathing 27 beats/min, blood pressure 120/70 mm Hg (1 mm Hg =0.133 kPa). Superficial lymph nodes were unpalpable and enlarged. No abnormalities in the ear and nose; The neck is soft, no resistance, and the thyroid is not large. The breathing sounds of the left lower lung were reduced, and damp rales in the inspiratory phase could be heard. Heart rhythm uniform, no murmur, P₂>A₂。 The abdomen was flat and soft without tenderness, the liver and spleen were not reached under the costs, and there was no edema in both lower limbs. Admission diagnosis: community-acquired pneumonia, type I respiratory failure.

venous thromboembolism (VTE) includes pulmonary thromboembolism (PTE) and deep vein thromboembolism (DVT), where PTE is the leading cause of death in pregnant women^[1]Physiological changes in pregnancy include the typical thrombotic triad: hypercoagulability, venous stasis, and vascular endothelial injury. These risk factors lead to a significant increase in the incidence of venous thromboembolic disease in pregnancy. However, the normal physiological changes during pregnancy are similar to the clinical manifestations of PTE or DVT, and the commonly used diagnostic methods are closely related to infant teratogenicity and tumor, which brings great trouble to the clinical diagnosis of VTE during pregnancy. The advantages and disadvantages of common examination methods and diagnostic methods of VTE during pregnancy are analyzed, aiming at seeking an effective diagnostic process that is more suitable for clinical practice.

Severe central airway stenosis can directly endanger patients' lives due to airway obstruction and respiratory failure. Airway stent can quickly relieve airway stenosis and maintain it for a long time, which is one of the effective methods for treating malignant central airway stenosis. The Department of Respiratory Medicine of Zhejiang Provincial People's Hospital successfully treated a patient with severe tracheal stenosis caused by adenocarcinoma and severe type II respiratory failure by placing a nickel-titanium alloy stent under local anesthesia under direct bronchoscope. The report is as follows.

When pulmonary function is measured, it is necessary to prevent cross-infection between subjects or between subjects and medical personnel. During the pulmonary function measurement, the subject's respiratory tract must be connected with the test tube of the pulmonary function meter and need to breathe forcefully repeatedly. If the subject has upper respiratory tract infection, intestinal infection, blood infection, etc., it can cause direct contact contamination of the bite, proximal tube or valve of the instrument. During the operation, medical staff may also contaminate the bite, pipeline and other components of the instrument, leaving behind the source of pollution, and then cause contact infection. The results of the study demonstrated that the corresponding respiratory microorganisms could be detected at the bite and proximal end of the tube used by the subject's pulmonary function test. While hepatitis B virus and human immunodeficiency virus (HIV) are unlikely to be transmitted through saliva, transmission through direct contact is possible if there is an open wound in the oral mucosa or if bleeding in the gums is present. Recent studies have demonstrated that respiratory symptoms and abnormal lung function (diffuse dysfunction and/or ventilatory dysfunction) are still common in HIV-infected patients even after the application of combination antiretroviral therapy, and HIV-infected people are likely to develop other diseases, such as COPD and lung cancer, while underestimating COPD is common. Therefore, it is very important for HIV patients to perform timely pulmonary function measurement^[9]。 The flow of air that the subject breathes forcefully during the ventilatory function test may be sufficient to form aerosol droplets containing contaminating microorganisms that can be suspended in the air of the examination room for hours, through which tuberculosis, viruses, opportunistic infections and nosocomial infections can be transmitted indirectly^[1,5,6]。

The 4th event of Beijing Young Respiratory Scholars Salon in 2012 was held in Chinese Medical Association on May 31st, 2012, with the theme of "Discussion on Related Issues of Bronchial Asthma (Asthma for short)", which was presided over by Dr. Yang Hui, Department of Respiratory Affairs, Shougang Hospital, Peking University.

In late summer and early autumn, the cold night gradually began. The change of seasons is often the high incidence of infectious diseases. In the essay column of the editor-in-chief of this issue, Professor Liu Youning wrote an article on the most common infectious diseases in clinic, pointing out that respiratory tract infection is the most common and frequent infectious disease, and the mortality rate of hospital-acquired pneumonia and mechanical ventilation-related pneumonia is high. He called on respiratory doctors to be familiar with and proficient in the diagnosis and treatment of respiratory tract infections as much as possible, and then shoulder the heavy task of clinical anti-infectious treatment. He hoped that fellow respiratory doctors would master this technology and carry it forward. Its writing is simple and simple, and its content is in line with clinical practice, which is worth reading.