2013年 · 第36卷第05期

Entering the first month after 2013, the unprecedented severe haze weather in and around Beijing has shocked the whole world again. Throughout January, Beijing citizens have not seen "blue sky" for a few days. At the worst, PM2.5 in Beijing once reached 900 μ g/m³Above, the air in Beijing and its surroundings of more than one million square kilometers (accounting for more than 1/10 of China's total land area) is seriously polluted. Such severe air pollution has raised concerns about whether Beijing is still livable. Being the capital of a large country has also caused unease among foreigners who have to live in Beijing, forcing them to choose between health or existing jobs. Our neighbors, South Korea and Japan, and even the United States on the other side of the ocean, are complaining about China's air pollution.

The main role of the small amount of fluid between the visceral and parietal pleural surfaces is to strengthen the mechanical connection between the chest wall and the lungs, allowing them to slide against each other under the action of shear forces, and to ensure the mutual conduction of vertical forces between these two pleural layers^[1]。 These physiological pleural fluids lubricate the mutual movement between the two pleural layers during breathing. The production and absorption of fluid in the pleural cavity of normal organisms maintain a dynamic balance, and pleural effusion will occur regardless of the reason of its excessive production and/or decreased absorption. Pathological pleural effusion is one of the common clinical manifestations of lung, pleura or many other systemic diseases. There are more than 100 causes of pleural effusion. Besides common lung and pleural diseases, it can also be caused by other tissue and organ diseases such as heart, liver and connective tissue^[2]。

malignant pleural effusion (MPE) accounts for about 22% of all types of pleural effusion. As the disease progresses, 50% of breast cancers, 25% of lung cancers, and>90% of mesotheliomas develop into symptomatic MPE^[1,2], which is a common clinical problem. The median survival time of MPE patients is 4 to 6 months, and the specific survival time is related to the type of tumor^[2]。

Thoracic infection is a common clinical disease, and it is still one of the important causes of death in infectious diseases, with a mortality rate of about 10% ~20%^[1]。 The evolution process after the occurrence of thoracic infection can be divided into three stages: (1) exudation stage: a small amount of sterile exudate is produced due to the increase of visceral pleural permeability; (2) Fibropurulent stage: caused by the infection of pathogenic bacteria in the sterile exudate, characterized by fibrin deposition in the visceral layer and parietal pleura, causing local wrapping and adhesion; (3) Organization stage: It is characterized by the growth of fibroblasts into the exudate, forming fibrous plates that lose elasticity, restricting the movement of the lungs and obviously affecting respiratory function. Pleural effusion during exudation often does not need drainage, and effective anti-infective treatment can be cured. During the stage of organization, the pleural cavity is obviously organized and the fluid is reduced, which often requires surgical intervention (such as thoracoscopic or thoracotomy for adhesiolysis ± pleural exfoliation). The treatment of fibropurulent stage (mainly including complicated parapneumonic pleural effusion and empyema) is very critical, and the treatment principles are mainly anti-infective treatment and adequate thoracic drainage. Because the pleural fluid is often viscous and has been separated by fibers at this stage, local administration of fibrolytic agent (referred to as fibrolytic agent for short) to improve thoracic drainage is one of the possible means to improve the success rate of medical treatment of thoracic infection. However, there are still controversies about its efficacy and application indications at present.

Idiopathic pleural interstitial elastic fibrosis is a newly recognized type of idiopathic interstitial pneumonia. First (2004) by Frankel et al.^[1]InCHESTFirst reported above, the article uses the name "idiopathic pleuroparenchymal fibroelastosis", and believes that this rare type of idiopathic interstitial pneumonia is characterized by the proliferation of elastic fibers in the upper lobe of the lung and its lower interstitial elastic fibers, which cannot be classified as the currently known type of idiopathic interstitial pneumonia, and may be a new and unique type. Subsequently, several literature reports^[2,3,4]。 To date, a total of 13 cases have been reported. Although the number of cases reported is small, these cases all exhibit common and unique clinical, imaging and pathological features, with rapid disease progression and poor prognosis. Therefore, although rare, this type of interstitial pneumonia is generally recognized in the industry. China has a vast territory and a large population base, but there have been no reports on idiopathic pleural interstitial elastic fibrosis, which is not excluded from interstitial lung diseases that are missed or classified as unclassifiable because of ignorance. Therefore, it is very necessary to improve the understanding of this disease in the industry. In this paper, the clinical, imaging and pathological characteristics of idiopathic pleural interstitial elastic fibrosis are briefly summarized in combination with several related literatures about this disease. We hope that the report on the incidence and case characteristics of this disease in China will be published as soon as possible.

Bronchial asthma (asthma for short) is a common chronic respiratory diseases, and its prevalence is increasing year by year in recent years. The results of clinical research and practice show that standardized diagnosis and treatment, especially effective management, play an important role in improving the control level of asthma and improving the quality of life of patients. The Asthma Group of Respiratory Disease Branch of Chinese Medical Association revised China's "Guidelines for the Prevention and Treatment of Bronchial Asthma" (hereinafter referred to as "Guidelines") twice in 2003 and 2008, which played a positive role in promoting the prevention and treatment of asthma in China as a guiding document. However, primary medical institutions, as the main force of asthma prevention and treatment, are affected by various subjective and objective factors, such as lack of testing equipment, incomplete asthma treatment drugs, and imperfect physician education system, so the "Guidelines" have not been well popularized and implemented in primary medical institutions. Therefore, it is particularly important to develop a "basic version of the Guide" that is realistic and adapted to the use of primary health care institutions.

Bronchial asthma (asthma for short) is a chronic airway allergic disease with genetic predisposition involving multiple genes. Its pathogenesis involves a variety of inflammatory cells, inflammatory mediators and complex cytokine networks^[1], mainly manifested by airway hyperresponsiveness and reversible airflow obstruction with large variability^[2]。 Increased serum immunoglobulin E (IgE) and specific IgE levels are the main clinical characteristics of asthma, and also one of the key links in the development of asthma^[3]。 Airway remodeling is an important pathophysiological feature of asthma, including epithelial cell fibrosis, airway smooth muscle cell proliferation, mucous gland and goblet cell proliferation, and neovascular proliferation. Airway remodeling is closely associated with airway inflammation and decreased lung function, and is involved in the formation of refractory asthma. The existing evidence indicates that IgE plays an important role in asthma airway remodeling. Anti-IgE therapy can inhibit the early-onset asthma response and help to prevent and reverse airway remodeling. It is an effective way to treat asthma, especially refractory asthma.

The pathological features of OSAHS are intermittent hypoxia and fragmented sleep. hypoxia inducible factor-1 (HIF-1) is one of the key transcription factors for cell adaptive regulation of hypoxia. It consists of α and β subunits. In hypoxia, the signal transmission via HIF-L α is mainly through cAMP and protein phosphorylation pathway, which causes α and β to form dimers in the nucleus. Under the cooperation of other transcriptional coactivators, it regulates the expression of nearly 100 target genes related to hypoxia adaptation, inflammation and cell proliferation^[1]。 At present, it is believed that the main pathophysiological basis of OSAHS is the repeated intermittent hypoxia during sleep, which causes oxidative stress and inflammatory response, induces the expression of related susceptible genes and the synthesis of bioactive substances such as inflammatory proteins, and then leads to multiple organ systemic damage. HIF-1 is one of the key regulatory factors.

pulmonary thromboembolism (PTE) and deep venous thrombosis (DVT), collectively known as venous thromboembolism (VTE), have become a major global medical care problem, which has attracted widespread attention from society and academia. With the in-depth research on the pathogenesis and pathophysiology of VTE, there have been progress in the imaging diagnosis strategy, treatment plan and prevention strategy of VTE in recent years. This article will summarize from the above aspects.

Molecular epidemiology of tuberculosis mainly uses genotyping technology, which uses the characteristics of MTB genome to type it. Common methods include restriction fragment length polymorphism (IS6110-RFLP), spacer oligonucleotide typing (spoligotyping), variable number tandem repeats (VNTR), single nucleotide polymorphism (SNP) analysis and long fragment polymorphism (LSP) analysis.

In patients with OSAHS, due to repeated collapse or obstruction of the upper airway, repeated hypoxia-reoxygenation occurred, which caused damage to pulmonary circulation and respiratory function, and caused CO₂Retention, pulmonary hypertension, pulmonary function impairment, and aggravation of chronic obstructive pulmonary disease (COPD), respiratory failure and other respiratory diseases. In order to determine whether lung function is related to the mechanism of sleep apnea in patients with OSAHS, this study investigated the role of lung volume in sleep apnea by analyzing the correlation between lung function parameters and sleep respiration indexes.

Autoimmune response may be an important cause of disease progression in patients with chronic obstructive pulmonary disease^[1]But its specific mechanism of action needs to be studied in depth. In this experiment, xenogeneic endothelial cells were injected into the abdominal cavity of rats to establish an autoimmune emphysema model, and the apoptosis of alveolar septal cells and the changes of vascular endothelial growth factor (VEGF) and VEGF receptor-2 (VEGFR-2) expression levels in rat lung tissue were observed. The aim was to explore the pathogenesis of autoimmune emphysema and provide new ideas for the prevention and treatment of emphysema.

A 41-year-old female was admitted to the hospital on 5 March 2012 due to "repeated wheezing for more than 3 years". Three years ago, the patient had sudden chest pain, asthma, chest tightness without obvious triggers, could not go upstairs, could not walk more than 500 m on the flat ground, and had no cough, expectoration, hemoptysis, fever, night sweats and dizziness. On November 28, 2008, the chest CT showed a few patches in the left lung. After the anti-infective and anti-asthmatic treatment was ineffective, the local hospital planned to diagnose it as tuberculosis. After 12 months of treatment with "isoniazid 0.3 g/d, rifampicin 0.45 g/d and ethambutol 0.75 g/d", the chest pain gradually relieved, chest tightness and wheezing slightly improved, but there was still asthma and chest tightness after activity. After 3 years of intermittent anti-infective and anti-asthmatic treatment (details unknown), I still have exertion dyspnea, occasionally cough and expectoration, and no hemoptysis. One month ago, in order to rule out coronary heart disease, the color Doppler ultrasound and coronary angiography of the other hospital were normal. On February 14, 2012, the chest CT showed "patches and cords in the upper lobe of both lungs, the middle lobe of the right lung and the lower lobe of the left lung, thickening of the main pulmonary artery and thickening of the left lung pleura". The patient was previously in good health, and no obvious abnormalities were found in the admission physical examination. There were no abnormalities in blood, urine and stool routine. Liver and kidney function, blood lipid, electrolyte, D-dimer, tumor markers, rheumatic factor and vasculitis-related antigen, myocardial enzyme spectrum, myocardial troponin and blood gas analysis were all normal, and the ESR was 34 mm/1 h. Electrocardiogram and bilateral venous color Doppler ultrasound of upper and lower limbs were normal. Coagulation routine showed fibrinogen 5.02 g/L and activated partial thromboplastin time 44.2 s. Pulmonary function test showed "FEV₁1.93 L, FEV₁/FVC was 72%, FEV₁% of the projected value is 76%; Decrease in mid-end expiratory flow rate; Increased airway resistance; Decreased lung diffusion, D_LCO accounted for 66% of the predicted value, and the amount of carbon monoxide diffused per unit alveolar volume (D_LCO/VA) was 91% ". In order to identify the cause of abnormal pulmonary diffusion function, pulmonary ventilation/perfusion flow imaging showed that" the left lung ventilation function was impaired and there was no blood flow perfusion, while the right lung ventilation and blood flow perfusion function were generally normal "(Figure 1，Figure 2)； CT pulmonary artery imaging showed "scattered patch shadows on both lungs, abnormal bronchial shadows, and left pulmonary artery atresia" (Figure 3，Figure 4，Figure 5，Figure 6)。 In order to determine whether the patient's left pulmonary artery is congenital atresia, carefully reading the previous chest CT images of this case indicated that the patient's left pulmonary artery was basically normal 3 years ago, and the left pulmonary artery gradually narrowed in the past 3 years (Figure 7，Figure 8，Figure 9，Figure 10，Figure 11，Figure 12)。 Considering that the patient's left pulmonary artery is not congenital disease, it should be secondary atresia, and chronic pulmonary thromboembolism may be. The patient was recommended to undergo pulmonary angiography, pulmonary vascular endoscopy and further treatment, but the patient refused. At present, there is no significant progression of the disease in the follow-up.

Spontaneous pneumothorax is a common clinical emergency in respiratory medicine, and closed thoracic drainage is a common treatment^[1,2,3]However, the choice of drainage tube size varies according to the basic conditions of the hospital and the personal habits of the doctor. In recent years, small-diameter thoracic drainage tube has been used more and more widely in clinic^[4,5,6]However, there is still a lack of reliable prospective study data to evaluate its efficacy. This study intends to conduct a prospective, randomized controlled and open clinical trial to compare the efficacy and patient tolerance of two different calibers of thoracic drainage tubes in the treatment of pneumothorax, so as to provide a reference for the clinical treatment choice of pneumothorax.

Acute appendicitis is a common disease. Patients often experience severe abdominal pain. If not diagnosed and treated in time, many adverse consequences may occur, including appendix perforation and suppurative peritonitis.

With the development of medical science, medical knowledge and medical technology are changing with each passing day. Modern clinical medicine has higher and higher requirements for doctors' qualification. The development of critical care medicine in the United States has lasted for decades. The introduction of critical care medicine has had an unprecedented impact on the traditional respiratory specialties, and even more than 90% of respiratory specialties have been expanded and renamed as respiratory and critical care medicine specialties. As a result, the qualification requirements of respiratory specialists have changed greatly. This article focuses on the qualification training of respiratory and critical care medicine specialists in the United States, and focuses on the new component of the discipline-critical care medicine. Obviously, the most fundamental step to successfully launch a medical specialty business is to establish a strong team of professional doctors. Specialist training in the United States is very strict and has fixed procedures. The two most basic steps include: (1) entering and completing a formal training program; (2) Take and pass the specialist certification examination.

esophagorespiratory fistula (ERF) is the most common airway fistula, followed by broncho-pleural fistula (BPF) and tracheo-mediastinal fistula (TMF). Because the ERF fistula is located in the trachea or bronchus and can lead to the esophagus, stomach, mediastinum or chest cavity, clinical treatment is extremely difficult. In recent years, due to the wide application of tracheal and esophageal stents, most of them have good curative effects^[1,2,3]。 Esophageal stents are often placed in ERF^[3]While BPF and TMF require tracheal stent placement. For ERF patients who cannot place an esophageal stent or who fail to place an esophageal stent, tracheal stent placement can also achieve better curative effect^[4,5,6,7]。 Our experience in the treatment of ERF with encapsulated metal stents in recent years is presented below.

The patient is a 52-year-old female, a farmer in Bachu County, Xinjiang, and is of Uygur nationality. He was admitted to hospital on 10 April 2012 due to "intermittent fever for 6 months, lung shadows and ocular masses found for 2 months". The patient developed intermittent fever 6 months ago, with a body temperature of 39~40.5 ℃, accompanied by chills and chills, which lasted for 30 min ~3 h and could drop to normal by itself. The fever time interval was 2~10 d. The X-ray chest X-ray examination in the local hospital "No obvious abnormalities were found", and the treatment with "cephalosporins" antibiotics was ineffective. Two months ago, the patient developed discomfort in both eyes and decreased vision in his right eye. Ophthalmological examination showed "right eye mass", and the pathology of resection of the mass showed "a little necrotic tissue". Preoperative chest X-ray examination revealed "circular density increased shadow in upper field of right lung" (Figure 1)； Chest CT showed "mass shadow in the upper lobe of the right lung, with lobulation sign around it and cavity inside; spherical space-occupying shadow in the lower lobe of the left lung, with scattered patchy exudation around it" (Figure 2，Figure 3)。 Then he was hospitalized in a local hospital for diagnosis and treatment. Bronchoscopy revealed that "the tumor in the right upper lobe grew, the lumen of each branch was narrow, the branches of the right middle and lower lobes were unobstructed, and the branches of the left bronchus were unobstructed". A brush examination of the left lower lobe bronchus was performed, and the pathological report was "large inflammatory exudation and necrotic tissue". Then percutaneous lung biopsy was performed on the left lower lobe lesions, and the pathological report was "partial alveolar epithelial hyperplasia, degenerative and necrotic tissue inflammatory cell infiltration". The diagnosis of fever and pulmonary mass is unknown.

A 22-year-old male was admitted to the hospital on August 11, 2011 due to "face and neck swelling for 1.5 months, cough and chest tightness for 1 month". 1.5 months ago, the patient developed facial and neck swelling with limb weakness without obvious trigger. One month ago, I started to have cough, shortness of breath, occasionally bloodshot sputum, no fever, chest pain and other symptoms, and self-administered traditional Chinese medicine treatment had no obvious effect. X-ray chest radiography in another hospital showed a huge occupation of the right upper mediastinum, and a moderate amount of pleural effusion on the right side (Figure 1，Figure 2), admitted to our hospital for further diagnosis and treatment. Since the onset of the disease, the appetite has decreased, the defecation is normal, and the body weight has lost 7.5 kg in the last 1.5 months. Past physical health, no history of exposure to radiation and toxic substances, smoking index 6-18 pack years. Physical examination after admission: temperature 36.6 ℃, pulse 80 beats/min, respiratory rate 18 beats/min, blood pressure 120/70 mm Hg (1 mm Hg =0.133 kPa). Mild edema of the face and neck, unpalpable swelling of superficial lymph nodes; The neck is soft without resistance, the trachea is centered, the thyroid is not large, the jugular vein is full, and varicose veins can be seen on the anterior chest wall (Figure 3), the blood flow direction is from top to bottom, the left lung breathing sound is enhanced, the right lung breathing sound is weakened, the right upper and right lower chest percussion shows turbid solid sound, the heart rhythm is uniform, there is no murmur, the abdomen is flat and soft without tenderness, and the lower limbs are not swollen. Admission diagnosis: right upper mediastinum occupying space to be examined, right pleural effusion.

Mechanical ventilation improves gas exchange but can also lead to ventilator-associated lung injury (VILI) and inhibition of circulatory function, so protective lung ventilation should be emphasized. Acute lung injury/acute respiratory distress syndrome (ALI/ARDS) is a respiratory failure disease with a very high mortality rate, and VILI is also prone to occurrence when treated with mechanical ventilation. For this reason, the American Heart, Lung and Blood Institute (NHLBI) organized a multicenter prospective study^[1]。 The study classified patients with ALI/ARDS into low tidal volume [6 ml/kg, limiting plateau pressure ≤30 cm H₂O (1 cm H₂O =0.098 kPa)] and conventional tidal volume (12 ml/kg, limiting plateau pressure ≤50 cm H₂O) In the two groups, the mortality rate was 31% in the small tidal volume group, which was significantly lower than 40% in the traditional tidal volume group. The results of this study have caused great repercussions and led to low tidal volume and permissive hypercapnia (PHC) becoming the basic concepts of pulmonary protective ventilation, which are widely used in the treatment of ARDS as well as many other respiratory failures. The ensuing question is, do small tidal volumes and PHC necessarily play a lung protective role? Does lung protection necessarily reduce the mortality rate? First of all, the above-mentioned experimental design has a big problem. Besides the different tidal volume, the plateau pressure also has obvious differences, that is, there are two variables. It is impossible to judge whether the decrease of mortality rate in the experimental group is caused by small tidal volume or low plateau pressure, especially the allowable plateau pressure in the control group is as high as 50 cm H₂O, it is easy to induce VILI in some severe patients, which does not meet the requirements of physiology and ethics. There is also a big problem in the selection of tidal volume itself. The two groups are 6 ml/kg and 12 ml/kg respectively, with a double difference, and no conventional value such as 10 ml/kg is selected. Therefore, even if the influence of plateau pressure is excluded, it can only show that traditional tidal volume is easy to lead to high mortality rate, but not that small tidal volume can reduce mortality rate. In fact, regardless of the form of pulmonary protective ventilation, it must first conform to the physiological characteristics of the patient's respiration, at the core of which is the pressure-volume (P-V) curve reflecting respiratory compliance. Airflow resistance characteristics and basic PaCO₂Level is also a factor that must be valued^[2]。

Beijing's air pollution was a hot topic in the world in 2012, and the severe smog weather in January 2013 brought this topic to its peak, "shocking the world again"! In this editor's essay column, Professor Liu Youning, the editor-in-chief, talked about the problem of air pollution for the third time. Facing the control of air pollution, where does "joy" come from? Where is the "worry"?