2018年 · 第41卷第03期

The Asthma Group of Respiratory Disease Branch of Chinese Medical Association compiled the first edition of the guidelines for the prevention and treatment of bronchial asthma (asthma) in 1993, which was revised in 1997, 2003 and 2008 respectively. In 2016, based on the research results of evidence-based medicine at home and abroad and combined with China's national conditions, a new edition of the guidelines was formulated, which provided guiding documents for asthma prevention and treatment for clinicians and medical institutions in China. After more than 20 years of clinical promotion and practice, the guidelines for asthma prevention and treatment have been well popularized and applied in first-and second-tier cities in China. However, at present, the majority of primary hospitals in China still lack the objective conditions for standardized diagnosis and treatment of asthma, and the vast majority of primary general practitioners do not understand the contents of the new guidelines. Therefore, Professor Zhou Xin, member of the editorial board of this journal and head of the asthma group of the Respiratory Branch of Chinese Medical Association, called for strengthening the training of grass-roots doctors on new asthma knowledge, providing first-line drugs for asthma treatment in grass-roots hospitals, promoting lung function tests in grass-roots hospitals, and making full use of mobile networks to carry out various forms of continuing education activities. Professor Lin Jiangtao, deputy editor-in-chief of this journal, reviewed "the progress made in bronchial asthma management in China" in recent years. He believed that the level of asthma control and disease cognition in China had been significantly improved, and the decrease in asthma hospitalization rate indirectly verified the effectiveness of promoting standardized treatment, and the mortality rate of hospitalized patients with asthma attacks was significantly reduced. It was suggested to further promote the asthma action plan and improve the self-management level of patients. Professor Shen Huahao, a member of the editorial board of this journal, compared the similarities and differences between the new Chinese bronchial asthma prevention and treatment guidelines and the global bronchial asthma prevention and treatment initiatives from several aspects, such as epidemiology, atypical asthma diagnosis, lung function examination, asthma assessment and standardized treatment. He emphasized that the new guidelines reflected more Chinese elements and the progress of asthma research in China, and hoped that there would be more and more high-quality clinical research in the field of asthma prevention and treatment in China in the future to continuously improve China's asthma guidelines. Professor Liu Chuntao from Chengdu elaborated on "Bottlenecks and Countermeasures of Prevention and Treatment of Bronchial Asthma in Western China" in combination with the local actual situation. He believes that primary medical and health institutions are the main battlefield of asthma prevention and treatment. However, due to backward concepts and constraints of economic ability, primary doctors don't know enough about asthma guidelines and progress of diagnosis and treatment, and are not familiar enough with standardized diagnosis and treatment technology, so there are various misunderstandings in medical behavior. I hope that respiratory workers in the west can't engage in academics behind closed doors, and should strengthen publicity and guidance.

China's new "Guidelines for the Prevention and Treatment of Bronchial Asthma" (referred to as the "New Guidelines" for short) was published in the 9th issue of Chinese Journal of Tuberculosis and Respiration in 2016, which played a positive role in promoting the prevention and treatment of bronchial asthma (asthma) in China. The new edition of the guidelines refers to the Global Asthma Prevention and Treatment Initiative (GINA), combines the results of evidence-based medicine research at home and abroad in recent years, and considers the national conditions in China, and elaborates the standardized diagnosis, treatment and prevention measures of asthma^[1]。 Since its establishment, the Asthma Group of Respiratory Disease Branch of Chinese Medical Association compiled the first edition of asthma prevention and treatment guidelines in 1993, and then revised them in 1997, 2003 and 2008. The new edition of the guidelines was collectively discussed and compiled by dozens of experts from the Asthma Group of Respiratory Disease Branch of China, and provided guiding documents on asthma prevention and treatment for clinicians and medical institutions in China. After more than 20 years of clinical promotion and practice, the guidelines for asthma prevention and treatment have been well popularized and applied in first-and second-tier cities in China, so that most asthma patients in these cities have been diagnosed and treated in a relatively standardized way, and the number of patients seeing and hospitalizing for acute asthma attacks has been significantly reduced, and the clinical control rate of asthma patients has also been improved^[2]。 However, at present, the majority of primary hospitals in China still lack the objective conditions for standardized diagnosis and treatment of asthma, such as lack of testing equipment, incomplete asthma treatment drugs, and imperfect physician education system. The vast majority of primary general practitioners do not understand the contents of the new guidelines. Many asthma patients in marginal areas of China still have frequent acute attacks, which seriously affect their life, study and work. To this end, the Asthma Group of Respiratory Disease Branch of Chinese Medical Association, together with dozens of experts from General Medicine Branch of Chinese Medical Association, compiled the Guidelines for Asthma Prevention and Treatment in China (Grassroots Edition) in 2013 according to the actual situation of grass-roots in China^[3]It is used to guide grass-roots doctors to carry out standardized asthma diagnosis and treatment, and has achieved good results. The promotion and popularization of asthma prevention and treatment guidelines to the grassroots level has always been one of the key tasks of asthma groups.

Bronchial asthma (asthma) is a chronic respiratory diseases that seriously endangers human health, and its prevalence is increasing year by year worldwide in recent years. It is estimated that there are at least 300 million asthma patients in the world and 30 million asthma patients in China. How to ensure that so many patients can get scientific, reasonable and standardized treatment is a major event to protect patients from disease harm and improve their quality of life^[1]。

Guidelines for Prevention and Treatment of Bronchial Asthma (Asthma) (2016 Edition)^[1](hereinafter referred to as the "New Guidelines") summarizes the research development, diagnosis and treatment status of asthma in China in recent years. In the 2008 edition of the Asthma Guidelines^[2]Asthma epidemiology, assessment of asthma, severe asthma, special types of asthma and certain special problems of asthma^[3]。 The Global Asthma Prevention and Treatment Initiative (GINA) report is an important reference for the revision of asthma guidelines as a bellwether of global asthma prevention and treatment. By comparing the 2017 edition of the GINA Guide^[4](hereinafter referred to as "GINA2017") and the update of the new version of the guidelines will help to understand the global progress of asthma prevention and treatment, and further improve the formulation of asthma prevention and treatment strategies in China.

According to the asthma control level defined by the Global Bronchial Asthma (Asthma) Prevention and Treatment Initiative (GINA) standard, the latest epidemiological survey results of the control level of asthma patients in urban clinics in 30 provinces and cities in China reported in 2017 show that the symptom control rate of asthma patients in urban areas in China is only 28.5%, and the overall control level is not ideal^[1,2]。 The goal of asthma treatment is to achieve control of asthma symptoms, reduce the risk of acute attacks and reduce irreversible impairment of lung function^[3,4]。 To achieve the goal of asthma control, it is very important to improve the self-management level of asthma patients. In order to promote the self-management of asthma patients in China and explore the paths and methods of patient self-management, the asthma group of the respiratory branch of the Chinese medical association based on the "Guidelines for the Prevention and Treatment of Bronchial Asthma" formulated by the asthma group of the respiratory branch of the Chinese medical association in 2017 and 2016^[3,4]Combined with evidence-based medical evidence and clinical experience at home and abroad, the "Chinese Expert Consensus on Self-management of Patients with Bronchial Asthma", which is suitable for clinical practice application of respiratory specialists and grass-roots doctors, was formulated to provide reference for clinicians to guide asthma patients in self-management.

Bronchial asthma (asthma) is a chronic airway inflammatory disease with obvious heterogeneous and complex pathophysiological characteristics^[1]。 In recent years, the prevalence of asthma is on the rise, which has become a serious public health problem and has attracted global attention. The results of epidemiological surveys conducted in eight provinces and cities in China from 2010 to 2011 show that the prevalence of asthma among people over 14 years old in China is 1.2%^[2]About 2/3 of which are allergic asthma^[3]。 An epidemiological study in a southern Chinese city shows that the prevalence of asthma among adolescents aged 13 to 14 years has increased exponentially in the past 15 years, and dust mite allergy is the main risk factor for the increase in the prevalence^[4]。 The epidemiological survey results of asthma control level in 8 provinces and cities in China show that the uncontrolled rate of asthma is as high as 34.5%^[5]。 In addition, the proportion of allergic asthma among patients with severe asthma is as high as 50% to 90%^[6,7]。 Patients with moderate to severe asthma occupy much more medical and health resources than those with mild asthma^[6,8]And the risk of death from asthma is also significantly increased^[9]。

Common interstitial pneumonia, also known as usual interstitial pneumonia (UIP), is the main pathological type of interstitial pneumonia, 1968 Liebow and Carrington^[1]For the first time, UIP is listed as a basic type in the classification of interstitial pneumonia. In the past 50 years, with the deepening of understanding of interstitial pneumonia, its classification has been revised and improved many times^[2,3]But UIP as the basic type of interstitial pneumonia has remained unchanged. Because UIP lesion specimens are not very common, and its specimen handling and pathological diagnosis thinking are different from other diseases, it is difficult to get due attention because it needs multi-disciplinary information such as clinical, imaging and pathology to confirm the diagnosis. So far, there is still a lack of consensus on standardized pathological diagnosis of UIP in domestic pathological circles. In view of this, the Respiratory Pathology Working Committee of Respiratory Physicians Branch of Chinese Medical Physicians Association organized experts to conduct serious discussions, and combined with clinical practice and research progress at home and abroad, formulated the Chinese Expert Consensus on UIP Pathological Diagnosis (Draft), aiming at providing pathologists with specific and feasible operating specifications, diagnosis and differential diagnosis suggestions for clinical work, so as to improve the accuracy, consistency and repeatability of UIP pathological diagnosis.

Brucellosis is a zoonotic infectious disease caused by the infection of Brucella bacteria. It is mainly infected by cattle, sheep and pigs. People are mainly infected by damaged skin and mucosa, digestive tract and respiratory tract^[1]。 The clinical manifestations of brucellosis are complex, the severity of the disease varies, and can invade many systems in the whole body. However, pulmonary involvement is rare, especially in cases with simple pulmonary involvement, the clinical manifestations and imaging specificity are poor, and it is easy to be misdiagnosed or missed^[2]。 A case of brucellosis with simple pulmonary involvement is reported in order to improve the understanding of this disease.

Bronchial asthma (asthma) is a heterogeneous disease characterized by chronic airway inflammation, and the prevalence of asthma in China is still increasing year by year^[1]。 Although the promotion of the Global Asthma Initiative (GINA) has brought most asthma patients under control, 5% to 10% of asthma patients still have poor efficacy for inhaled glucocorticoids (ICS), even in combination with long-acting beta₂-Receptor agonists (LABAs), leukotriene modulators (LTRAs), long-acting anticholinergic drugs (LAMAs) and even oral glucocorticoids, etc., are still difficult to achieve complete or good control of asthma^[2]。 Starting from the pathogenesis, exploring and developing highly effective and individualized new asthma treatment drugs has become a research hotspot. This article summarizes the research progress of new asthma treatment drugs as follows.

Atmospheric particulate matter refers to a mixture of solid or liquid particles suspended in the air, which can be divided into coarse particulate matter (PM₁₀) and fine particulate matter (PM_2.5) and ultrafine particulate matter (PM_0.1)。 Coarse particulate matter mainly stays in the mucus in the nasal cavity and respiratory tract, which can be easily eliminated by normal respiratory activity, while PM_2.5and PM_0.1Can reach the distal airway and deposit in the alveolar region, causing respiratory pulmonary disease^[1]。 Chronic obstructive pulmonary disease (COPD) is a common disease that can be prevented and treated, characterized by persistent respiratory symptoms and restricted airflow, caused by airway and/or alveolar abnormalities caused by exposure to harmful particles or gases. COPD has become the third leading cause of death worldwide, with short-term or long-term exposure to PM in normal people_2.5Can cause a series of respiratory symptoms, such as coughing, wheezing, and dyspnea^[2,3]。 At present, 83% of our population lives in PM_2.5Concentration over 35 μ g/m³In 2013, 1.37 million people were affected by PM_2.5Premature death due to exposure, of which about 12.4% were patients with COPD^[4]。 The results of the study showed that environmental PM_2.5There is a clear association between increased case mortality and PM_2.5Related health burden of COPD patients and susceptible populations is attracting increasing attention^[5]。 But PM_2.5The relationship with COPD is still unclear, and it now revolves around PM_2.5The research progress on the influence of COPD is summarized below.

Bronchial asthma (asthma) is a heterogeneous disease characterized by chronic airway inflammation^[1]。 Previous studies have shown that the pathogenesis of asthma is mainly involved in the adaptive immune response mediated by Th2 cells, and its secretion of type 2 cytokines plays an important role. The results of recent studies show that the occurrence of asthma is the result of the interaction between innate immunity and adaptive immunity, which complement each other and promote the occurrence of airway inflammation^[2]。 The role of innate immune receptors and innate immune cells in the pathogenesis of asthma is reviewed as follows.

idiopathic pulmonary fibrosis (IPF) is a pulmonary disease with unknown etiology, rapid progression, irreversibility and poor prognosis. The 5-year survival rate of patients is only 20%, even lower than that of some tumor diseases^[1]。 Recurrent alveolar injury caused by abnormal injury-repair response is generally believed to be the main cause of this disease. The results show that the interaction between environment and host plays a role in the occurrence and development of IPF^[2]In particular, microbial infectious factors have important significance in the pathogenesis and progression of IPF.

The global initiative for chronic obstructive lung disease (GOLD) was established in 1998 with the goal of developing management recommendations for COPD based on the latest and best published research results. In 2001 GOLD released the first edition of its global strategy for COPD, and in 2006 and 2011^[1]Comprehensively revised. The GOLD 2011 revision was released in 2013, 2014, 2015 and 2016 respectively, and basically follows the original framework and central content. GOLD 2017^[2]The fourth comprehensive revision was carried out, and the framework and content were updated. The revised contents involved the definition of COPD, disease assessment, drug and non-drug treatment, complication management and many other aspects. While GOLD 2018^[3]It is a revision based on GOLD 2017 according to the latest research results published between January 2016 and July 2017. The newly added content covers some research results of domestic scholars. This paper introduces and interprets its important updated content.

We conducted an exploratory study with a small sample, because the baseline level of exhaled nitric oxide (FeNO) has previously been used to predict the responsiveness of inhaled glucocorticoid (ICS) treatment, and there have been no reports of observing the change of FeNO after a single dose. The question raised in the article "Whether the change in exhaled nitric oxide after a single dose is meaningful" is very valuable, and this is the purpose of our study. As the author said, ICS should be used regularly and continuously for more than one week to be effective. The main reason is that glucocorticoids need to bind to receptors and translocate into the nucleus, and bind to glucocorticoid response elements to exert biological effects, that is, the so-called "classical pathway" of the mechanism of action of glucocorticoids. There is no doubt that ICS needs long-term regular use to exert anti-inflammatory effects. However, what we observed was not the clinical efficacy, nor the level of inflammation in the whole airway, but FeNO. As we all know, FeNO mainly comes from airway epithelial cell-induced nitric oxide synthase (iNOS), and iNOS is very sensitive to hormones. Whether a single ICS can affect iNOS activity is a question worth exploring, not to mention that in addition to the "classical pathway", the mechanism of action of hormones also includes the "non-classical pathway" without gene transcription, which can play a role in several hours. Although this phenomenon mainly occurs when hormones are used in large doses, it cannot be ruled out that a single ICS can affect some particularly sensitive inflammatory indicators through the "non-classical pathway". Our results showed that only one patient had a decrease in FeNO at 1 h after a single dose, five at 3 h and 24 h, and the remaining seven patients at 48 to 96 h, with a mean onset time of (55 ± 25) h after a single dose. The mean maximum action time was (96 ± 31) h based on the decrease of FeNO to the lowest value. Six patients had FeNO levels close to or even higher than baseline at the end of the trial (10 d), but seven patients still had significantly lower FeNO levels. Our results show that although there is a large heterogeneity in the alteration of FeNO after a single dose of ICS in asthmatic individuals, all patients have varying degrees of reduction in FeNO within 96 h, which is an objectively existing trial phenomenon. It is generally believed that ICS exhibits obvious anti-inflammatory effects at about 1 month, so the level of FeNO 1 month after administration and the decrease from baseline are more accurate for judging the responsiveness of ICS, but it is difficult to regularly review FeNO clinically. Therefore, we attempted to explore whether it is possible to predict long-term treatment responsiveness through the change of FeNO after a single dose, so as to provide a timely predictive index for clinicians. In fact, we have observed that some patients who responded well to a single dose had a more obvious reduction in FeNO in the first month, but there were few cases in this study, and most of them fell off, so statistical processing could not be performed. This study does not answer the question of whether a single dose can predict long-term responsiveness, and further investigation, combined with the results of a single dose and long-term follow-up, is pending to understand the exact significance of the change in FeNO at a single dose.

"Dynamic Changes and Significance of Exhaled Nitric Oxide in Patients with Bronchial Asthma after Single Dose" published in Chinese Journal of Tuberculosis and Respiratory Medicine, Issue 8, 2015^[1]A single-dose inhaled glucocorticoid (ICS) /long-acting beta₂-The pharmacodynamic test of receptor agonist, to observe the immediate change trend and regularity of exhaled nitric oxide (FeNO) after medication, to provide preliminary laboratory basis for exploring the short-term response of FeNO to predict the long-term response of bronchial asthma (asthma) treatment. So, is it possible to predict the responsiveness of asthma to long-term treatment of ICS by looking at the effect of a single dose on FeNO? Discussion is raised here.