2013年 · 第36卷第02期

"Against drug resistance-no action today, no drugs will be available tomorrow", was the warning issued by the World Health Organization in 2010. Since 2011, the Ministry of Health in China has carried out special rectification activities for the clinical application of antimicrobial drugs. In 2012, the Ministry of Health officially promulgated the "Administrative Measures for the Clinical Application of Antimicrobial Drugs". Professor Liu Youning, the editor-in-chief of this journal, also talked about the issue of "rational use and management of antibacterial drugs under the New Deal" in his essay, which is worth thinking deeply.

The advent of antimicrobial drugs in the 1940s ushered in a new era of anti-infective treatment. At that time, some people thought that the time had come to completely solve the problem of infectious disease treatment. But now, half a century later, anti-infective treatments are not becoming simpler and simpler. On the contrary, we are facing more serious challenges. In 2010, the World Health Organization pointed out that bacterial resistance has become an increasingly serious global public health problem. In the same year, it raised the warning of "fighting resistance-if you don't take action today, there will be no drugs available tomorrow". It is urgent to strengthen the management of antimicrobial drugs.

weaning from mechanical ventilation (abbreviation) has always been a hot spot in clinical research. spontaneous breathing trial (SBT), as a routine examination before weaning, is the main diagnostic test to evaluate the successful extubation of patients with invasive ventilation. Many factors affect the success or failure of withdrawal. Cardiac insufficiency caused by withdrawal is the common cause of withdrawal failure. Early detection of cardiac insufficiency is of great significance to guide the withdrawal process. As cardiac markers, B-type natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) have received more and more attention in recent years. Recent findings suggest that BNP can predict the withdrawal outcome of mechanically ventilated patients and help improve the extubation success rate; NT-proBNP helps to identify whether the cause of withdrawal failure is cardiogenic. The dynamic change of BNP level in the process of withdrawal, and its application value in guiding the process of withdrawal, identifying the reasons of withdrawal failure and improving the success rate of withdrawal are worthy of deep research.

chronic thrombembolic pulmonary hypertension (CTEPH) is a disease caused by the inability to completely dissolve pulmonary thrombus or repeated reembolization. Clinically, a series of symptoms such as dyspnea, fatigue and decreased exercise tolerance are the main manifestations, which eventually lead to increased pulmonary artery pressure and progressive right heart failure. The incidence of CTEPH after acute pulmonary embolism is 0.57% ~9.1%^[1,2,3,4]。 The incidence of CTEPH in the United States was 1.02 cases/1 million per year in 2001 and increased to 1.75 cases/1 million per year in 2005. This data only includes patients who have been clearly diagnosed and registered, so the actual incidence rate may be higher^[5]。 Kirson et al.^[6]The incidence of CTEPH in the United States from 1999 to 2007 was calculated,<In the 65-year-old population, the incidence of CTEPH was 63/1 million; The incidence of CTEPH in people ≥65 years of age was 1007/1 million. In a large registry study in Spain, the results showed that the incidence of CTEPH was 3.2 cases per 1 million per year^[7]。

1,25-Dihydroxyvitamin D₃[1,25-Dihydroxyvitamin D3,1,25- (OH)₂D₃] is the most important active metabolite of vitamin D in the body. Previous studies have focused on 1,25- (OH)₂D₃Regulation of immune response and chronic airway inflammation in bronchial asthma^[1,2]In this study, an airway remodeling model of chronic asthma mice was established, and 1,25- (OH) was directly observed₂D₃Modulatory effects on airway remodeling in asthma and to examine its effect on nuclear transcription factor-κ B (NF-κ B) signaling pathway in lung tissue to explore 1,25- (OH)₂D₃Possible mechanisms of action for modulating airway remodeling in asthma.

Obstructive sleep apnea (OSAS) is a common sleep breathing disorder. Sanders et al.^[1]Sawtooth waves were found in the flow velocity-volume curve of OSAS patients, which can be used to diagnose upper airway obstruction. The purpose of this study was to investigate the incidence of sawtooth waves of velocity-volume curves in OSAS patients and the clinical characteristics of OSAS patients with sawtooth waves.

Chronic obstructive pulmonary disease (COPD) is a common chronic respiratory disease, mainly manifested by irreversible chronic airway obstruction and emphysema. Most patients have improved their asthma symptoms after quitting smoking and standardized drug treatment, but due to the irreversibility of emphysema, the quality of life of end-stage patients is severely reduced. lung volume reduction surgery (LVRS) can improve the respiratory mechanics of respiratory muscles by removing the severely reduced emphysema tissue, so that the adjacent lung tissue can function better. However, due to the poor pulmonary function of patients, it is difficult to tolerate surgical trauma. The mortality rate of surgery-related cases within 90 days after operation is 3% ~19%, and the incidence of serious complications is 59%, which is difficult for most patients to accept^[1,2]。 bronchoscopic lung volume reduction (BLVR) can reduce the volume of severe lung lobes and segments by a variety of minimally invasive non-resection techniques under direct bronchoscopy^[3]。 One-way endobronchial valve implantation has been gradually applied to the treatment of severe pulmonary emphysema. It has little surgical injury and can be removed without affecting future LVRS and lung transplantation. It has certain clinical prospects^[4]。 In September 2011, the First Hospital of Peking University performed trans-bronchoscopic one-way valve placement in a patient with extremely severe COPD, and achieved good results, which are reported as follows.

The patient was a 46-year-old female. Three years ago, due to coughing and expectoration for one month after catching a cold, a foreign hospital was diagnosed as "acute upper respiratory tract infection". Later, multiple nodules in the lungs were found to come to Taizhou Central Hospital for further examination and admitted to the respiratory department. The patient presented with paroxysmal dry cough, without fever, hemoptysis, shortness of breath, chest pain, night sweats and weight loss. Eight years ago, he underwent hysterectomy due to the discovery of "uterine fibroids", which was confirmed by pathology after operation. Physical examination at admission: the patient was conscious and cooperative, with a temperature of 37.1 ℃, 20 breaths/min, 76 pulses/min, and a blood pressure of 120/78 mm Hg (1 mm Hg =0.133 kPa). There is no cyanosis and anemia, and there is no swelling of superficial lymph nodes throughout the body. The thorax was symmetrical, the respiratory movement was normal, the percussion of both lungs was unvoiced, no wet and dry rales and pleural friction were heard, no abnormalities in the heart were seen, no tenderness, rebound pain and muscle tension in the abdomen, no mass was palpable, the liver and spleen were not reached under the costs, and the mobile voiced sound was negative. Auxiliary examination: white blood cells were 4.3×10⁹/L, 0.67 for neutrophils, 0.30 for lymphocytes and 115 g/L for hemoglobin. There were no abnormalities in blood biochemistry, tumor markers, antinuclear antibody series, complete set of rheumatism and anti-neutrophil cytoplasmic antibody. Multiple examinations of sputum exfoliated cells and acid-fast bacilli showed no abnormalities. Chest CT showed multiple nodules and massive shadows in both lungs, which were rounded, with clear and smooth boundaries, with more subpleural distribution, uneven density in the massive shadows, and no enlargement of hilar and mediastinal lymph nodes (Figure 1，Figure 2，Figure 3，Figure 4)。 After admission, bronchoscopy did not find any abnormality. Lung tissue samples were taken by percutaneous lung biopsy. Pathological examination was of smooth muscle origin. Immunohistochemical staining showed that desmin, vimentin, smooth muscle myosin (SMA) and progesterone receptor (PR) were all positive, anti-melanoma specific monoclonal antibody (HMB45), endothelial cell marker (CD₃₄), S-100 protein, tyrosine kinase growth factor receptor (CD117) and estrogen receptor (ER) were all negative (Figure 5，Figure 6，Figure 7，Figure 8)。 The clinical diagnosis was benign metastatic leiomyoma of the lung (PBML). During hospitalization, no surgical resection and drug treatment of pulmonary lesions were performed, and no obvious respiratory symptoms appeared after 3 years of follow-up. The lesions were stable with no obvious progression after chest CT review.

The 82-year-old female was admitted to the hospital on January 18, 2012 with "pleural effusion to be examined" due to "chest tightness and asthma for more than 2 years, aggravated with cough for 14 days". Two years ago, the patient was hospitalized with right pleural effusion due to chest tightness and cough. Physical examination found that the speech tremor of the right lower lung was weakened, the percussion showed turbidity, and the auscultation breathing sound was weakened. After symptomatic treatment such as pleural effusion, anti-infection and phlegm resolution, the cough symptoms were relieved, but pleural effusion always existed. Because of the patient's advanced age, the patient and his family repeatedly refused thoracoscopy. The disease was repeated in 2 years, with multiple chest CT and one PET/CT (Figure 1，Figure 2) No obvious increase of SUV value in pleura and lung was found in examination. Multiple pleural effusion tests in the past two years revealed exudate, but the diagnosis was never confirmed. The patient's condition worsened again 14 days ago and he was hospitalized. Previous history of hypertension for 15 years and thyroid adenoma for 3 years. Physical examination: body temperature: 36.5 ℃, respiratory rate: 22 beats/min, pulse: 80 beats/min, blood pressure: 130/80 mm Hg (1 mm Hg =0.133 kPa), clear consciousness, no rash and bleeding spots all over the body, no palpable swelling of superficial lymph nodes, weakened breathing amplitude and dilatation of right lower lung, weakened speech tremor, voiced sound at percussion, no breathing sound, heart rate 80 beats/min, harmonic heart rhythm, no murmur, flat and soft abdomen, no liver and spleen under the costs, no moving voiced sound, no abnormalities in the rest of the examination results. Auxiliary examination: hematuria, fecal routine, biochemistry, C-reactive protein, etc. were all within the normal range. Blood tumor indexes: neuronal specific enolase (NSE) 30 U/ml, cancer antigen 724 (CA724) 14 U/ml, CA125 111 U/ml. There were no abnormalities in electrocardiogram and echocardiogram, and the tuberculin test was 1:2000 negative. After admission, pleural effusion was pumped multiple times, a total of about 2000 ml, which was pale yellow and slightly muddy. Check pleural effusion showed: cell number (380~1300) ×10⁶/L, monocytes 70%, Levanta test negative; Tumor markers: CA125 was 386 U/ml, carcinoembryonic antigen, NSE, CA724, etc. were all in the normal range; LDH was 154 U/L (blood LDH 219 U/L) and TP 49.5 g/L (blood TP 68.9 g/L); No abnormalities were found in the examination of remaining pleural effusion.

At present, going out by plane is an important and common mode of transportation. People are most concerned about its safety, including sitting there. Many people have the experience that sitting in the back of the cabin is easy to bump, so they think it is unsafe to sit in the back. What is the actual situation?

In 1974, Remy first applied bronchial artery embolization (BAE) to treat massive hemoptysis and achieved satisfactory clinical results. After more than 30 years of continuous development and improvement, it has become the most effective treatment for controlling massive hemoptysis in clinic^[1]。 There are many causes of massive hemoptysis. Pulmonary tuberculosis is a common cause of massive hemoptysis in clinic. It has a long general history and extensive pulmonary lesions, often accompanied by extrapulmonary systemic circulation blood vessels participating in blood supply, and the medical treatment effect is not good. The experience of treating patients with massive hemoptysis due to pulmonary tuberculosis in the past ten years is summarized as follows.

Bronchial tuberculosis (EBTB) refers to tuberculosis that occurs in the trachea, bronchial mucosa, submucosa and adventitia (cartilage and fibrous tissue). Even after active systemic anti-tuberculosis treatment, some EBTB are prone to tissue structure destruction, permanent stenosis or occlusion of airway, resulting in serious complications such as atelectasis or lung damage. In recent years, the therapeutic value of bronchoscopic interventional therapy in active EBTB has been fully affirmed. However, due to the various types of EBTB lesions and different treatment options, the clinical efficacy is also different. The treatment experience of 2 cases of active EBTB is reported as follows.

In recent years, critical care medicine in China has developed rapidly. Because of the inseparable relationship between critical care medicine and respiratory medicine, it will bring great impact to respiratory medicine. How should respiratory doctors face this impact? Judging from the situation in the United States, respiratory medicine is a specialty with a long tradition, and its business scope and knowledge content have long been stable. Although critical medicine started in the United States and made great progress here, its whole development process is only nearly 30 years. The respiratory profession in the United States has experienced the shock of the same nature and scale, and has basically completed the professional restructuring under the shock. This article briefly describes this period of history to provide reference for domestic counterparts.

The application of rigid bronchoscope (abbreviated as rigid bronchoscope) has been more than 120 years old. In 1897, German scientist Killian first reported that a rigid esophagoscope was used to remove bone foreign bodies from the trachea, which started the history of endoscopic operation by inserting a rigid esophagoscope into the trachea and bronchi. In 1968, American doctor Jackson improved the hard lens and formulated standardized operating procedures. By the 1960s, all countries mainly used hard lens to diagnose and treat lower respiratory diseases^[1]。

Hypoxemia is a lack of oxygen content in arterial blood due to various reasons, PaO₂Below the lower limit of normal in peers, mainly manifested as PaO₂and SaO₂/SpO₂Decline, at sea level height under inhaled air if PaO₂<60 mm Hg (1 mm Hg =0.133 kPa), It is defined as hypoxic respiratory failure. Its main pathophysiological basis is reduced oxygen uptake (e.g., asphyxia), effective alveolar hypoventilation (e.g., OSAHS), ventilation/blood flow imbalance (e.g., pulmonary embolism), right-to-left shunt (e.g., hepatopulmonary syndrome), and diffusion dysfunction (e.g., idiopathic pulmonary fibrosis). Clinically, hypoxemia of a disease is often caused by multiple of the above factors at the same time, such as acute lung injury caused by drowning, which is caused by reduced oxygen uptake, insufficient effective alveolar ventilation, imbalance of ventilation/blood flow ratio and diffusion dysfunction. Severe patients also have pathophysiological changes of right-to-left shunt in the lung. Positive pressure mechanical ventilation [including non-invasive positive pressure ventilation (NPPV) and invasive positive pressure ventilation (IMV)] is an effective treatment to improve pulmonary oxygenation and correct hypoxemia, which can solve the ventilation and partial ventilation disorders of patients with immediate effect^[1]The specific methods and related pathophysiological mechanisms are introduced below.

Liposarcoma is a common soft tissue sarcoma, including three main pathological types: well-differentiated/dedifferentiated, myxoid/round cell and polymorphic. The proportion of primary mediastinal liposarcoma in malignant tumors<1%。 Giant abdominal liposarcoma is more common, but it is rare to occur in mediastinum. A rare fatal giant mediastinal liposarcoma with massive pleural effusion diagnosed by surgical pathology is reported and its possible pathogenesis is discussed.

Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by the persistence of restricted airflow^[1]Dyspnea is the most common clinical symptom and medical complaint of COPD, and about 94% of symptomatic patients can have dyspnea^[2]。 Dyspnea is a complex symptom involved in many factors, involving physiology, perception, respiratory function, psychology and social environment, etc. It not only limits the daily activity ability of patients, but also leads to psychological obstacles such as anxiety, depression and social separation, which significantly affects the health-related quality of life of patients^[2,3]。 In recent years, dyspnea has been paid attention to in the study of COPD. Evaluation and treatment of dyspnea has become an important part of the management of COPD. The author summarizes the clinical characteristics, significance, pathogenesis, evaluation and treatment of dyspnea in COPD.

Hospital-acquired pneumonia (HAP), especially ventilator-associated pneumonia (VAP), are common hospital-acquired infections, accounting for 25% of nosocomial-acquired infections in ICUs. Although the current treatment has made great progress, the mortality rate of HAP is still as high as 30% ~70%^[1]。 Early, timely and rational antibiotic treatment is the key factor to improve the prognosis of HAP. Therefore, early diagnosis of HAP is particularly important.

The 9th event of Beijing Young Respiratory Scholars Salon in 2012 was held on October 25th, 2012. This event was hosted by Dr. Huang Hui, Department of Respiratory Medicine, Peking Union Medical College Hospital. The main content of this issue is the discussion of new progress and difficult problems in the field of interstitial lung disease. First, Professor Xu Zuojun of the Department of Respiratory Medicine of Peking Union Medical College Hospital introduced the new classification of idiopathic interstitial pneumonia (IIP) just launched (not yet officially published) at the European Respiratory Diseases Annual Conference. Then, Dr. Huang Hui of Peking Union Medical College Hospital introduced the new disease in the new classification-pleuropulmonary parenchymal fibroelastosis (PPFE). Next, Professor Dai Huaping of Beijing Chaoyang Hospital introduced the treatment progress of idiopathic interstitial pulmonary fibrosis (IPF), a difficult point in the field of interstitial pulmonary diseases. Finally, Dr. Cui Ai of Beijing Chaoyang Hospital introduced granulomatous pulmonary disease to further deepen the understanding of diffuse pulmonary lesions.

After carefully reading the "Guidelines for Diagnosis and Treatment of Tracheobronchial Tuberculosis (Trial)" published in your journal, Issue 8, 2012^[1]"(hereinafter referred to as the guide), we are somewhat confused about some of the views in the chapter of trans-bronchoscopic interventional therapy. Tracheobronchial tuberculosis is a common disease in respiratory department, and with the popularity of high-resolution CT and bronchoscopy, its clinical diagnosis is no longer a problem. As stated in the guide," on the basis of systemic chemotherapy with anti-tuberculosis drugs, combined with endovascular interventional therapy under bronchoscopy, can not only improve the therapeutic effect of tracheobronchial tuberculosis, reduce various complications and sequelae caused by it, maximize the preservation of patients' lung function, but also effectively solve some problems that cannot be solved by traditional anti-tuberculosis drug chemotherapy ". The author believes that although the guidelines have comprehensively explained the indications, contraindications, precautions and adverse reactions of various interventional therapies, individual details and key points may need to be further improved.

The article "Guidelines for Diagnosis and Treatment of Tracheobronchial Tuberculosis (Trial)" (hereinafter referred to as the Guidelines) has been published in the Chinese Journal of Tuberculosis and Respiration, Issue 8, 2012. In order to enable everyone (especially non-tuberculosis professionals and non-respiratory professionals) to have a better comprehensive and correct understanding of this guide and avoid misunderstanding, the original intention, basic principles and some representative specific issues of the guide are further supplemented and explained below.