2013年 · 第36卷第01期

Time flies, 2012 has passed in the blink of an eye, and 2013 is coming to us with pride! On the occasion of the New Year, all members of the editorial department of the Chinese Journal of Tuberculosis and Respiration would like to express their sincere gratitude to the colleagues who have supported the journal over the years. I wish you all a happy New Year and good health!

In 2013, the Chinese Journal of Tuberculosis and Respiratory Medicine celebrated its 60th anniversary. Sixty years, in the long river of history is only a flash of a finger, but for this magazine, it is a long history of development, in this heavy history condenses the hardships and efforts of our predecessors. Looking back at the past, I am filled with emotion.

Tigecycline belongs to the tetracycline class, which is a derivative of minocycline and the first glycinecycline to be marketed. Tigecycline is the antibiotic with the widest antibacterial spectrum and the smallest recommended daily dose so far. Its appearance undoubtedly brings new hope to anti-infective treatment, especially for some multidrug-resistant bacteria, which will play an irreplaceable role in other anti-infective drugs, but at the same time, there are also some practical problems to be solved, which cause confusion for clinicians. The following author, combined with my limited clinical experience, puts forward my personal opinions on the application prospects and existing problems of tigecycline in China, which are only for readers' reference.

endobronchial ultrasound (EBUS) technology is a major progress in respiratory endoscopy technology, which makes respiratory endoscopy technology move from the level of naked eye observation to the level of detection of fine structures, greatly enriches the content of endoscopy technology, and also changes the diagnostic thinking of respiratory physicians, so that the diagnostic range of endoscopy technology extends from the airway cavity to the whole chest cavity.

We refer to the pulmonary lesions that occur below the tertiary bronchi and above the respiratory bronchioles as peripulmonary lesions. Modern imaging techniques can show peripheral lung lesions, and the diagnosis requires ordinary bronchoscopy or percutaneous lung puncture guided by CT to obtain pathological specimens. However, the visual field of conventional bronchoscopy is limited to the bronchial lumen of grade 4~5, and it is difficult to find peripheral lesions under direct vision of bronchoscopy. The lowest diagnosis rate of these patients by blind examination and/or blind brushing is 16.7%, and the highest is only 65.6%. However, CT-guided percutaneous pulmonary biopsy has a higher risk and lower success rate for lesions paravascular, paraphragmatic and distant from the body surface of the heart, especially for peripheral diameter<2 cm Of lesions. It can be seen that the diagnosis of peripheral pulmonary lesions needs more effective diagnostic methods.

electromagnetic navigation bronchoscopy (ENB) is a new technique based on electromagnetic localization technology, combining the characteristics of computer virtual bronchoscopy and high-resolution spiral CT to diagnose through bronchoscopy^[1]It has the advantage that it can not only accurately reach the peripheral lung lesions that cannot be reached by conventional bronchoscopy or perform mediastinal lymph node localization, but also obtain the diseased tissue for pathological examination. This technology is a new progress in interventional respiratory diseases in recent years. It is mainly used in the diagnosis of peripheral pulmonary diseases, mediastinal and hilar lymph nodes and the localization of respiratory interventional therapy abroad.

In 1978, Professor Wang Guoben used a vascular puncture needle to biopsy a group of swollen lymph nodes next to the right trachea through the bronchial wall. The pathological results showed "small cell undifferentiated carcinoma", which pioneered the clinical application of transbronchial needle aspiration biopsy (TBNA)^[1]。 Over the past 30 years, this technique has gradually been widely accepted and continuously developed. It plays an important role in the diagnosis and staging of lung cancer, the diagnosis of primary and metastatic mediastinal tumors, sarcoidosis, mediastinal lymphatic tuberculosis and peripheral lung diseases, etc. It can increase the daily bronchoscopic diagnosis rate from 24% to 67%^[2]For extracavitary lesions, submucosal lesions and peripheral lung lesions, the diagnostic rate of TBNA increased from 65% to 91%, including peripheral lesions increased from 52% to 87%, extracavitary lesions increased from 85% to 100%, and submucosal lesions increased from 84% to 97%^[3]。 However, due to various factors, this technology has not been widely used. In 2002, convex ultrasound bronchoscopy (CP-EBUS) was applied in clinic, which can perform biopsy of lesions under direct vision, which makes the technique of TBNA fully interpreted. All lymph nodes displayed by CT scan can be detected by CP-EBUS. The sensitivity, specificity and accuracy of guided puncture to distinguish benign and malignant lesions were 95.7%, 100% and 97.1% respectively^[4]。 The characteristics of intratracheal ultrasound (EBUS) -TBNA, such as visibility and ease of operation, make this technology rapidly spread. The previous TBNA is called conventional TBNA (c-TBNA). The positive rate of EBUS-TBNA (69%) was much higher than that of C-TBNA (36%) in biopsy of the same lesion using both c-TBNA and EBUS-TBNA^[5]。 The development of Ebus-TBNA makes c-TBNA face greater challenges. In this case, how should doctors choose?

The characteristic change of chronic obstructive pulmonary disease (COPD) is chronic airway inflammation. histone deacetylase-2 (HDAC-2) is one of the important ribozymes involved in the regulation of gene transcription activity. It is mostly expressed in alveolar macrophages, and together with glucocorticoid receptors, it affects the transcription and expression of inflammatory genes, thus regulating the airway inflammation caused by smoking. The decrease of HDAC-2 activity can affect the action of hormones, so increasing HDAC-2 activity is one of the ways to improve the efficacy of hormones. Low-dose theophylline has the effects of inhibiting oxidative stress, immunomodulation and anti-inflammation, and may increase hormone sensitivity through HDAC-2 pathway. However, there is still a lack of in vivo studies using low-dose theophylline.

In the history of civilization in human history, the popularity of tobacco is one of the most absurd examples. On the one hand, governments keep warning people that smoking is harmful to health, on the other hand, they allow people to grow, process and sell tobacco products-cigarettes-on a large scale.

As early as November 2004, the Ministry of Health, the State Administration of Traditional Chinese Medicine and the Ministry of Health of the General Logistics Department of the People's Liberation Army issued the "Guiding Principles for Clinical Application of Antibacterial Drugs" (referred to as the Guiding Principles for short), which includes the basic principles of therapeutic application of antibacterial drugs, the basic principles of preventive application of antibacterial drugs, the basic principles of application of antibacterial drugs in patients with special pathophysiological conditions, the management of clinical application of antibacterial drugs, the indications and precautions of various antibacterial drugs, the treatment principles and etiological treatment of various bacterial infections. At the same time as the official release of this guiding principle, a notice was also issued, requiring all kinds of medical institutions and medical staff at all levels to study and implement it seriously. Since then, it has been more than 7 years, but the phenomenon of irregular application of antimicrobial drugs in China has continued unabated, and the work of correcting the abuse of antimicrobial drugs has had little effect. The reasons are many: (1) Although the guiding principles are comprehensive in content and clear in requirements, there are no corresponding legal provisions to restrict and correct the abuse of antimicrobial drugs, so those who abuse antimicrobial drugs still go their own way; (2) Despite the explicit regulations of the Ministry of Health, the problem of using medicine to support doctors in hospitals at all levels has long existed. Therefore, hospitals at all levels and types have insufficient understanding of the harm of abusing antibacterial drugs and turn a deaf ear. On the contrary, they can still profit from the overdose of antibacterial drugs without being punished, so they are indifferent to this problem; (3) Medical staff at all levels are not serious about studying the guiding principles, let alone truly restricting their medical practice with these guiding principles. On the one hand, everyone has insufficient understanding of the laws and characteristics of the harm of abusing antibacterial drugs. Secondly, in medical practice, they often accommodate the unreasonable requirements of patients in order to protect themselves. In addition, even if they abuse antibacterial drugs, they will not be punished, so they are in peace; (4) The masses, including patients, have insufficient understanding of the harm of antibacterial drugs. They simply think that antibacterial drugs are sterilizing, and even fever and cough require doctors to prescribe antibacterial drugs indiscriminately. If they do not meet their requirements, they will ask teachers for crimes or even insult doctors; (5) Almost all enterprises that produce and sell antibacterial drugs have the purpose of producing and selling antibacterial drugs to maximize their profits. In order to achieve this goal, they will do everything possible to promote antimicrobial drugs through various channels and various means, and the sales targets (including economic benefits) are rising year by year.

In recent years, many school tuberculosis outbreaks have occurred in some areas of China, which has aroused the attention of relevant departments. Therefore, it is urgent to establish scientific tuberculosis prevention and control strategies. PPD test has been used as a method to investigate MTB infection in China, because PPD test is affected by BCG vaccination and cross-immune reaction of some non-tuberculous mycobacteria^[1,2], poor specificity^[3]。 interferon gamma release assay (IGRA), which has emerged in recent years, is of great value in the evaluation of latent MTB infection. The application and research progress of IGRA in tuberculosis outbreak and group infection control are summarized as follows.

In recent years, the impact of air pollution on human health has become a global focus. Epidemiological findings show that atmospheric pollutants, especially particulate matter, are associated with increased population mortality^[1]Can cause acute exacerbation of cardiopulmonary disease and increase mortality^[2,3]。 In addition, air pollution has a significant impact on nervous and blood systems. Inflammation is one of the main mechanisms of negative health effects caused by air pollution. Particulate matter can cause a systemic inflammatory response^[4]。 The research on the mechanism of non-specific and specific lung immune response caused by particulate matter reported at home and abroad in recent years is summarized as follows.

In recent years, fine particulate matter (PM2.5) pollution has not only become the main culprit of frequent haze weather in large cities such as Beijing, Shanghai and Guangzhou, but also has gradually become an important factor affecting the health of Chinese residents^[1]。 In March 2012, the Environmental Protection Bureau of China issued the "Ambient Air Quality Standard (GB3095-2012)". The new standard includes PM2.5 as the monitoring index for the first time, and stipulates that the upper limit of PM2.5 will be controlled at the annual average value of 35 μ g/m³and daily mean 75 μ g/m³And is scheduled to be implemented nationwide from January 1, 2016^[2]。 The harm, pathogenic mechanism and preventive measures of PM2.5 to human respiratory system and cardiovascular system are summarized as follows, hoping to be beneficial to in-depth research in China.

receptor tyrosine kinases are a class of cell surface transmembrane proteins, which mediate the transduction of extracellular signals to intracellular cells, and play an important role in the regulation of cell proliferation, differentiation and death. epidermal growth factor receptor (EGFR) belongs to receptor tyrosine kinase, which can transfer a phosphorus atom from adenosine triphosphate (ATP) to itself or the tyrosine residue of the substrate, so that the cascade reaction after the activation of the substrate protein transmits information and causes biological effects. If the activity of the enzyme is too high, it can cause abnormal signal transduction, thus leading to abnormal cell proliferation and inducing a series of proliferative diseases^[1,2,3]。 This article reviews the relationship between EGFR and its receptor tyrosine kinase inhibitors and pulmonary fibrosis.

Brain metastasis of lung cancer is the most common intracranial metastatic tumor^[1,2,3]。 Myelin basic protein (MBP) is the main protein of central nervous system myelin sheath, which maintains the stability of central nervous system myelin sheath structure and function, and has nerve tissue specificity. When the central nervous system is damaged, the blood-brain barrier function is disrupted, its permeability is altered, and the serum MBP content is increased. Scholars at home and abroad have reported that MBP can be used as an index to judge the degree of central nervous barrier destruction^[4,5]。 Once brain metastasis of lung cancer occurs, it is clinically stage IV. Without any treatment, its natural median survival time is only about 1 month^[6]。 Therefore, early detection of brain metastases can be treated early, alleviate the pain of patients and improve the quality of life. In this study, the serum level of MBP in patients with brain metastasis of lung cancer was detected to explore its diagnostic value in brain metastasis of lung cancer.

A 29-year-old woman was admitted to the hospital on 28 October 2011 due to "recurrent cough aggravated for 1 year and 1 month". The patient coughed intermittently for more than 1 year. He was diagnosed as "acute upper respiratory tract infection" or "acute bronchitis" in many hospitals and received treatment (details unknown). In mid-July, he developed asthma after activity with low fever in the afternoon and night sweats. He was diagnosed as "right lung infiltrating tuberculosis" by X-ray chest X-ray and CT examination in another hospital. The sputum test was positive for acid-fast bacilli. He received anti-tuberculosis treatment with HRZE (H: isoniazid, R: rifampicin, Z: pyrazinamide, E: ethambutol) regimen. His body temperature returned to normal, but the symptoms of cough and shortness of breath did not improve. One month ago, after cooling down, there was persistent wheezing, unable to lie down at night, and coughed a small amount of yellow-white sticky sputum. Physical examination: body temperature 36.5 ℃, 28 breaths/min, blood pressure 130/90 mm Hg (1 mm Hg =0.133 kPa), pulse oxygen saturation (SpO₂) 92%, conscious, emaciated, upright breathing with wheezing sound, positive three concave sign, intermittent language, sweating on the forehead and face, mild cyanosis of the lips, no distension of the jugular veins, loud dry rales and wheezing sounds in both lungs, no wet rales, heart rate 116 beats/min, homogeneous rhythm without murmur, untouched liver and spleen, and no edema of lower limbs. The admission diagnosis was considered as tracheal tuberculosis with stenosis, right lung infiltrating pulmonary tuberculosis, and severe attack of bronchial asthma. Laboratory test: white blood cell count 7.4×10⁹/L, neutrophils 0.72, hemoglobin 128 g/L, CRP 6 mg/L, ESR 8 mm/1 h. Blood glucose, liver and kidney function, electrolyte and coagulation function were all normal, and Mycoplasma pneumoniae antibody IgM and D-dimer were all negative. Arterial blood gas analysis showed pH 7.42, PaO₂71.5 mm Hg, PaCO₂35.8 mm Hg, PPD test (+ +), sputum smear for gram-positive cocci (+ +), 4 sputum acid-fast bacilli negative. Chest CT showed severe stenosis of the upper and middle trachea, about 1 cm in length, with a minimum diameter of 3~4 mm. The right main bronchial wall was extensively thickened, and the lumen was obviously narrowed. Diffuse small patches and nodular proliferative lesions were seen in the right lung distributed along the direction of bronchial walking, cord-like shadows mixed with a few punctate calcifications, no obvious exudative and cavitary lesions, and no obvious abnormalities were seen in the left lung (Figure 1，Figure 2，Figure 3)。 Pulmonary ventilation function test: FVC accounted for 58% of the predicted value, FEV₁% of projected value is 42%, FEV₁/FVC accounted for 62% of the predicted value, and the flow velocity-volume curve showed that the patient's inspiratory and expiratory flow were significantly limited, showing a plateau-like change, suggesting the possibility of upper airway obstruction. Bronchoscopy (model BF1T40, Olympus Company, Japan) showed that the tracheal wall was uneven after entering the glottis, with many hyperplasia of small nodules and scars, and the lumen was funnel-like stenosis. A stenosis was seen about 5 cm away from the glottis, with a diameter of about 4~5 mm, which could not be entered by bronchoscopy (Figure 4)。 Because the patient could not tolerate it, the examination was stopped after only 5 to 6 seconds of observation, and balloon dilatation was planned.

The patient was a 34-year-old male who smoked 17 packs per year. Since December 2010, there was a recurrent cough without obvious trigger, and the chest CT examination in the local hospital showed a soft tissue block shadow in the right hilar area. For further diagnosis and treatment, he was transferred to the respiratory department of Fujian Provincial Hospital. After admission, chest CT examination showed space-occupying lesions near the right hilum and paracardial margin at the bronchial opening of the middle lobe of the right lung, about 4.6 cm ×5.2 cm in size, and the bronchi where the tumor was located were completely obstructed, which was significantly enhanced after enhanced scan, which was considered as lung cancer (Figure 1，Figure 2，Figure 3)。 Bronchoscopy showed a new organism at the bronchial opening in the middle lobe of the right lung, completely obstructing the lumen and easily bleeding at touch (Figure 4)。 Pathological biopsy of diseased tissue showed poorly differentiated squamous cell carcinoma; Immunohistochemical staining revealed CD₅₆, chromophin A, synaptophysin negative, broad-spectrum cytokeratin (+ + +), P63 (+ + +), seeFigure 5，Figure 6，Figure 7。 No metastasis was observed in target organs such as brain, liver and bone. Right middle and lower lobectomy was performed. Macroscopic view of the mass: A central mass can be seen 1.1 cm away from the bronchial incision, the size of the mass is 5 cm ×4 cm ×4 cm, without envelope, unclear boundary, the incision surface is gray-white and hard, has invaded the pleura, pleural scar formation, and no satellite foci are seen in the surrounding lung tissue. Postoperative pathology showed pulmonary lymphoepithelioma-like carcinoma, hyperplasia of interstitial fibrous tissue and lymphoid tissue, invasion of bronchus and lung capsule, no infiltration of cancer cells in bronchial resection, and metastasis of cancer cells in 1/23 hilar lymph nodes. The tumor stage was T2aN1M0 (stage IIA). Tumor immunohistochemical staining cytokeratin 56 (CD₅₆) (+ +), the positive rate of Epstein-Barr virus in situ hybridization staining was 70% (Figure 8，Figure 9，Figure 10)。 After operation, TP regimen (paclitaxel estoplasm 210 mg, day 1, cisplatin 40 mg, day 1 to day 3) was given for 4 cycles of chemotherapy. No obvious mass sign was found on the bronchial stump of chest CT, and a small number of patchy shadows were scattered in the upper lobe of right lung (Figure 11，Figure 12)。

Melanoma is a highly malignant tumor, usually occurring in the skin and mucous membranes near the skin. The nasal cavity, anorectal canal and oral cavity are the most common sites. It is rare to occur in mucous membranes, especially malignant melanoma occurring in pleura, which is very rare clinically. Because of the large histological variation of melanoma, it is difficult to confirm the diagnosis by ordinary examination methods. Several cases reported in the literature were diagnosed by pleural puncture biopsy, pleural effusion tumor cells, thoracotomy biopsy or based on previous medical history. This article reports a case of malignant melanoma diagnosed by medical electronic thoracoscopy and direct biopsy, showing the typical manifestations of melanoma under thoracoscopy, in order to improve clinicians' understanding of the disease.

A 59-year-old male was admitted to the hospital on 15 March 2010 due to "6 years after esophageal cancer surgery and 5 years of intractable cough". In February 2004, he underwent "radical esophageal cancer resection" in Jiangsu Cancer Hospital for "middle esophageal cancer". Postoperative pathological report: grade 2 squamous cell carcinoma, involving submucosa, negative upper and lower margins, negative adjacent lymph nodes and left gastric lymph nodes, and recovered well after operation, but had slight choking and cough after drinking water, which gradually decreased after changing eating habits. One year later, he developed a cough, coughed white sticky sputum with blood in the sputum, and hoarseness. Laryngoscopy showed bilateral vocal cord paralysis. Chest CT found swollen lymph nodes in the left tracheoesophageal sulcus of about 2.5 cm ×2.5 cm. Considering tumor recurrence, he started one course of three-dimensional conformal radiotherapy in August 2005, with a total dose of 6800 cGy, followed by five courses of chemotherapy with "oxaliplatin + calcium formyltetrahydrofolate +5-fluorouracil" regimen. The patient's hoarseness and choking cough after drinking water improved, and the mediastinal lymph nodes were significantly reduced, but the cough persisted. He has been transferred to many tertiary hospitals in the province, all of whom were diagnosed with "radiation bronchitis, radiation pneumonia, gastroesophageal reflux cough, etc.", and was given glucocorticoids, anti-infection and anti-reflux treatment, but there was no obvious effect. Cough symptoms have aggravated significantly in the past 1 year, accompanied by chest tightness, asthma, and occasionally blood in sputum. No history of exposure to irritating gases and dust, no smoking, no history of infectious diseases, no history of familial diseases and genetic diseases. After admission, there were no obvious positive signs on physical examination. Re-examination of chest CT showed thoracic and gastric shadows in the mediastinum, no abnormal soft tissue shadows and enlarged lymph nodes, tracheobronchial patency, slight deformation of the lower trachea, fibrous cord shadows and patchy lung consolidation shadows in both upper lungs, and bronchial inflation signs (Figure 1，Figure 2)。 Bronchoscopy showed bilateral vocal cord paralysis, closed glottis, and densely covered yellow nodules (2-5 mm in diameter) of different sizes on the surface of the middle and lower tracheal mucosa, especially the anterior and lateral walls. The nodules protruded into the lumen, partially fused, and hard as pebbles (Figure 3，Figure 4，Figure 5，Figure 6), using large crocodile bill clamp to take several pieces of diseased tissue for examination. The pathological results showed intact tracheal mucosa, mild epithelial hyperplasia with squamous metaplasia, submucosal cartilage tissue and focal calcification (Figure 7), pathological diagnosis: ossifying tracheobronchopathia osteochondroplastica (TO). After symptomatic treatment such as glucocorticoid, anti-infection, asthma and phlegm reduction, the symptoms improved and he was discharged from hospital. In June 2010, he died of respiratory failure caused by lung infection and failed to be resuscitated.

Tracheobronchial amyloidosis is clinically rare. In 1877 Lesser reported the first case of localized amyloidosis of the lower respiratory tract. This disease often leads to localized airway or diffuse stenosis, which endangers patients' life and has poor prognosis. At present, there is no standard and effective treatment in clinic^[1]。 argon plasma coagulation (APC) has been widely used in the treatment of gastrointestinal tumors and polyps, but it is rarely reported to be used in the treatment of tracheobronchial amyloidosis. Two cases of tracheobronchial amyloidosis treated with APC through bronchoscopy are reported below.

Artificial ventilation has become an indispensable life support technology in the treatment of critically ill patients. Rational selection of ventilation mode and parameter adjustment is one of the keys to reduce ventilator-related lung injury (VILI). Commonly used clinical modes include a volume control/volume limit/volume target (VCV) type targeting a preset air supply volume, and a pressure control/pressure limit (PCV) type targeting a pressure limit. The ventilation mode should be selected considering: (1) how much ventilatory support is provided; (2) the characteristics of respiratory mechanics and the changes of respiratory pathophysiology; (3) the characteristics of various ventilation modes; (4) Coordination between patient and ventilator. This paper compares the characteristics of volume and pressure controlled ventilation modes, and introduces the new ventilation modes and their rational clinical application.

The 8th event of Beijing Young Respiratory Scholars Salon in 2012 was held in Chinese Medical Association on September 27th, 2012. It was hosted by Dr. Li Nan of Peking University First Hospital. Respiratory and otolaryngologists from many hospitals in Beijing analyzed and discussed "Problems related to the treatment of sleep apnea-hypopnea syndrome".

I have read the "Expert Consensus on Diagnosis and Treatment of Adult Bronchiectasis" published in the 7th issue of your journal in 2012^[1]Bronchiectasis is a common disease in respiratory medicine, and its diagnosis is no longer a problem with the popularization of high-resolution CT technology. In clinical practice, patients with bronchiectasis mostly come to the doctor with massive hemoptysis and/or infection, so the treatment of massive hemoptysis is a topic that deserves clinicians' attention.

Bronchiectasis is a common disease in respiratory department. Many patients suffer from repeated infection and hemoptysis, which finally leads to incomplete reversible airflow restriction, which seriously affects their quality of life. However, for many years, the diagnosis and treatment of bronchiectasis still remains in the symptomatic treatment stage of antibacterial drugs when infected and hemostatic drugs when hemoptysis, and there is insufficient understanding of its etiology, disease course and prognosis. Therefore, based on the "Guidelines for Non-Cystic Fibrosis Bronchiectasis" developed by the British Thoracic Association in 2010, we organized 11 experts to develop the "Expert Consensus on Diagnosis and Treatment of Adult Bronchiectasis" (hereinafter referred to as the "Consensus"). Due to the extremely limited research related to bronchiectasis, most of the contents of this "consensus" lack sufficient evidence-based medical evidence. The purpose of formulating this "consensus" is to hope that the publication of "consensus" can improve doctors' understanding of bronchiectasis, standardize the diagnosis and treatment of bronchiectasis, especially attach importance to identifying the cause of bronchiectasis, standardize the use of sputum culture and antibacterial drugs, and explore the chronic management plan of bronchiectasis.