2014年 · 第37卷第12期

The coexistence of chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) is an overlapping syndrome. Overlap syndrome is much more damaging to patients than COPD or OSA alone. For example, patients with overlap syndrome are more likely to develop cardiovascular disease. A recent exploratory study using MRI found that patients with overlap syndrome are more likely to develop cardiovascular disease than patients with COPD alone. Compared with patients with COPD, right ventricular hypertrophy and right ventricular remodeling are more severe^[1]。 Another study found that patients with overlap syndrome had higher β-brain natriuretic peptide and higher blood vessel tone than patients with COPD alone^[2]。 The results of large-scale epidemiological investigation showed that the mortality and hospitalization rate of patients with overlapping syndrome were higher than those of patients with COPD or OSA alone^[3,4]。 Patients with overlapping syndrome can further aggravate nocturnal hypoxemia on the basis of COPD due to repeated apnea, resulting in an increase in the incidence of cardiovascular and cerebrovascular diseases such as pulmonary hypertension and pulmonary heart disease, and a higher frequency of acute exacerbation of COPD and a higher mortality rate^[5]。

In 2014, the American Academy of sleep Medicine (AASM) published the international classification of sleep disorders, 3rd edition, ICSD-3^[1]。 sleep related breathing disorders (SRBD) are defined in this classification as "characterized by sleep breathing abnormalities, with or without waking breathing abnormalities". According to the existing clinical research data and the nomenclature of the 9th and 10th editions of the International Classification of Diseases (ICD-9 and ICD-10), ICSD-3 classifies SRBD into five categories, namely: obstructive sleep apnea disorders (OSA), central sleep apnea syndromes (CSA), sleep-related hypopnea, sleep-related hypoxemia, and individual syndromes and normal variants. The new classification is more logical and scientific, and more conducive to clinical practice. With the 2nd edition released in 2005^[2]In comparison, the main updates of this new classification are as follows.

Long-term mechanical assisted ventilation (LTMV) includes non-invasive ventilation (NIV) and invasive mechanical ventilation, including tracheotomy. Early experience with LTMV has shown that patients can maintain ventilatory function by continuous ventilatory support even if they do not have ventilatory function at all, while some patients who preserve some ventilatory function can be maintained by intermittent assisted ventilation, such as during sleep. Continuous positive airway pressure (CPAP) and intermittent positive pressure (IPPV) can be performed non-invasively and comfortably through a nasal mask^[1]。

The diagnosis of chronic obstructive pulmonary disease (COPD) depends on pulmonary function tests, but due to the examination cost and technical operation, pulmonary function is not popular in many hospitals (especially in primary hospitals), which leads to a considerable number of COPD patients being missed. The purpose of this study was to establish a simple and easy COPD screening questionnaire for COPD screening in primary hospitals and reduce COPD missed diagnosis. The study was completed in two phases: in the first phase, using the data of 19 800 residents aged ≥40 years in the epidemiological study database of COPD conducted in China in 2002, using statistical analysis of stepwise Logistic regression and other methods, a screening questionnaire for COPD was developed using seven entries closely related to COPD disease: age, smoking index, body mass index, cough, dyspnea, family history of respiratory disease and biofuel smoke exposure. In the second phase, we assessed the reliability and validity of this COPD screening questionnaire by conducting a cross-sectional COPD survey of 3 214 subjects aged ≥40 years. The results of the study showed that FEV₁/FVC<0.7 as the diagnostic criterion of COPD, the area under the curve of COPD screened by questionnaire was 0.812 (95% CI: 0.786-0.838); In FEV₁/FVC<0.7 and FEV₁% of estimated value<80% was used as the diagnostic criterion of COPD, and the area under the curve was 0.836 (95% confidence interval: 0.807-0.865); In FEV₁/FVC<0.7 and respiratory symptoms (one of four symptoms: cough, expectoration, shortness of breath and wheezing) were present, and the area under the curve was 0.907 (95% confidence interval: 0.879-0.934). The sensitivity, specificity and accuracy of the questionnaire were 60.6%, 85.2% and 82.7%, respectively. The results of this study indicate that this screening questionnaire can be used as a tool for primary screening of chronic obstructive pulmonary disease, and has great significance for reducing missed diagnosis of COPD.

Tuberculosis is one of the leading causes of death from curable infectious diseases. Tuberculous pleural effusion (TPE) is caused by the invasion of the pleura by Mycobacterium tuberculosis (MTB) and is accompanied by the infiltration of a large number of inflammatory cells. CD₄⁺T cells dominate the immune response to TPE. After stimulation with MTB-specific antigen, CD₄⁺CD₆₉⁺T cells express high levels of IFN-γ, IL-2, and TNF-α, indicating that this population of T cells is a specific helper T cell subset (Th1) for MTB. Subsequently, another study found that regulatory T cells (Treg), Th17 cells, Th9 cells, and Th22 cells participated in the immune response of TPE.

Chronic obstructive pulmonary disease (COPD) is a common respiratory disease. The patient's respiratory muscles have different degrees of atrophy and function decline, which are manifested as insufficient respiratory power and decreased endurance, aggravated dyspnea, and even respiratory failure. Similar conditions can occur in other diseases such as bronchial asthma and interstitial lung disease. Therefore, it is very important to improve the respiratory muscle function of these patients, which is an important means of rehabilitation treatment of COPD patients. The patented product "respiratory muscle trainer" invented by Shanghai Qianshan Medical Technology Co., Ltd. [Class I medical device manufacturer registration number: 20142056, product registration certificate number: Shanghai Food and Drug Administration Equipment (Zhun) Zi 2014 No.1260579, registered product standard number: YZB/Shanghai 6876-26A-2014] can solve this kind of problem.

obstructive sleep apnea syndrome (OSAS) is a common syndrome of upper airway obstruction during sleep caused by many reasons, characterized by repeated shallow or paused breathing during sleep, daytime drowsiness and fatigue, etc. OSAS patients can cause damage to various systems, including sexual dysfunction, due to recurrent transient obstructive apnea, hypopnea, decreased blood oxygen saturation, fluctuations in intrathoracic pressure, sleep structure disorders, neuroendocrine changes, and micro-arousal. erectile dysfunction (ED) is the most common sexual dysfunction, which refers to the continuous (at least 6 months) inability of the penis to achieve and maintain sufficient erectile hardness to achieve a satisfactory sexual life^[1]。 Epidemiological findings indicate a higher incidence of ED in OSAS patients^[2]Can reach 30% to 50%^[3,4]This further suggests that there is a close relationship between the two. Even after removing age, obesity, drugs, mental illness, and other confounding factors, up to 28.6% of men with OSAS had ED^[5]。 There are many pathogenic factors in the formation of ED caused by OSAS, such as the enhancement of oxidative stress, the change of nerve pathway excitability and neurotransmitter concentration, hemorheological abnormalities, vascular endothelial cell dysfunction, and the change of sex hormone level (decrease of testosterone and increase of serum leptin level, etc.)^[6]。 These factors can directly cause the occurrence of ED, or become the cause of ED by acting on the cardiovascular system; It may be dominated by one of these factors, or it may be a combination of factors. The relationship between enhanced oxidative stress in OSAS and ED is reviewed as follows.

In recent years, more and more research results show that bronchial asthma (asthma for short) is a heterogeneous disease, and its clinical phenotype, pathogenesis and pathophysiological changes are complex and diverse. With the deepening understanding of the heterogeneity of asthma, people have observed and summarized various clinical and inflammatory phenotypes from different angles of asthma. There are many categories of asthma phenotypes, and this article reviews Th2 and non-Th2-related asthma phenotypes.

gastroesophageal reflux-induced chronic cough (GERC) is a special type of gastroesophageal reflux disease (GERD) with chronic cough as the only or prominent symptom^[1], is a common cause of chronic cough^[2]。 GERC accounts for about 10% ~40% of chronic cough abroad^[2]4.6% ~20.3% of chronic cough in China^[3,4,5,6]。 With the popularization of GERC knowledge and the change of people's lifestyle, there is an increasing trend of GERC in China^[7]。 The diagnosis and treatment of GERC is difficult, but it has progressed rapidly in recent years. The new understanding of its diagnosis and treatment is summarized as follows.

Interventional pulmonology (IP) is a new field of respiratory disease focusing on advanced diagnostic and therapeutic techniques for airway and pleural diseases as well as lung cancer. Bronchoscopy, as the most important part of IP work, has become an indispensable technical means in daily diagnosis and treatment. Every day I studied in the bronchoscopy room of Cleveland Hospital, I gained a lot. I witnessed the breadth and depth of bronchoscopy work, and realized the standardization and meticulousness of the work of foreign colleagues. Here, I would like to share my experience and experience from the following aspects.

hypothyroidism (hypothyroidism) can cause OSAHS, but it is easily overlooked in clinical work. OSAHS combined with chronic obstructive pulmonary disease (COPD) is called overlap syndrome (OS)^[1]The impairment of cardiopulmonary function is more severe than that of OSAHS or COPD alone. Patients with co-existing hypothyroidism and OS can be life-threatening due to respiratory failure and/or heart failure, with extremely poor prognosis. The Respiratory Sleep Department of the First Affiliated Hospital of Zhengzhou University successfully treated a patient with OS complicated with hypothyroidism, which is reported as follows.

The patient, a 62-year-old male, was admitted to our department on March 4, 2013 in 2012 due to "cough and expectoration for 3 months". After admission, chest CT examination showed a mass-like soft tissue shadow in the right hilar, a mass-like soft tissue shadow in the lower lobe of the right lung, about 43 mm ×21 mm in size, with lobulated edges, multiple small nodules under the pleura of the right lower lung, and multiple enlarged lymph nodes in the mediastinum (Figure 1，Figure 2)。 The pathological report of the bronchoscopic biopsy specimen was adenocarcinoma. Abdominal CT showed multiple liver metastases, and whole body bone imaging showed multiple bone metastases. The diagnosis was confirmed as right lung adenocarcinoma (T4N2M1b, stage IV). The first treatment regimen was pemetrexed plus cisplatin, cisplatin 75 mg/m²and pemetrexed 500 mg/m²Intravenous drip on day 1. Folic acid 400 μ g/d and vitamin B were administered orally 1 week before administration₁₂1 000 μ g intramuscularly every 3 cycles; Dexamethasone 4 mg was administered orally twice a day 1 day before, on the same day, and on the first day after administration. The first chemotherapy patient experienced severe nausea, vomiting and other gastrointestinal reactions, and the patient experienced slight skin hypopigmentation on the face and abdomen, but no special treatment was performed. Follow-up blood routine after chemotherapy showed that the lowest white blood cell was 2.3×10⁹/L. Chest CT reexamination before the second chemotherapy showed partial reduction of the right lung lesion. The second chemotherapy regimen was changed to single-agent pemetrexed 500 mg/m due to large gastrointestinal reactions, poor tolerance and grade II myelosuppression in the first chemotherapy²Intravenous drip was performed on the first day, and no obvious abnormalities were found in blood routine monitoring within 1 week after chemotherapy. Three days after discharge, the patient showed skin hypopigmentation, vitiligo-like changes, and partial skin desquamation on the face, bilateral fingers, chest and abdomen, and anterior tibia (Figure 3,Figure 4,Figure 5), no obvious itching, pain, multiple ulcers in the oral mucosa, and fever, body temperature 39.1℃, cough, cough of yellow phlegm, blood test routine showed that white blood cells were 0.1×10⁹/L, platelets were 26×10⁹/L, the hemoglobin was 70 g/L, and he was admitted to the hospital in the emergency department. He was considered as grade IV myelosuppression after pemetrexed chemotherapy. Laminar flow chamber isolation, intravenous administration of leucovorin, subcutaneous injection of colony stimulating factor to promote bone marrow hematopoiesis, transfusion of red blood cells and platelets, administration of cefoperazone, sulbactam, moxifloxacin and fluconazole against infection, daily blood routine monitoring, blood routine on the 7th day showed that the white blood cells were 13.6×10⁹/L, platelets were 176×10⁹/L, the hemoglobin was 76 g/L, the patient's cough and sputum were relieved, and his body temperature was normal. He was discharged from the hospital and returned home. Follow-up, the patient's skin leukoplakia in many parts of his body has not recovered. Due to the severe reaction of the second chemotherapy, the third chemotherapy was not continued, and gefitinib was administered orally by himself, but the efficacy was not good, and he died six months later.

The prevalence of obstructive sleep apnea syndrome (OSAS) is high, which can promote the occurrence and development of cardiovascular and cerebrovascular diseases, metabolic abnormalities and other complications. It is well known that the gold standard for diagnosing OSAS is in-laboratory polysomnography (in-lab PSG). However, in 2014, the American academy of sleep medicine (AASM) published the international classification of sleep disorders 3rd edition (ICSD3) For the first time, out-of-center sleep testing (OCST) can be used as a means to confirm the diagnosis of adult OSAS. So far, OCST has been promoted to an important position.

polysomnography (PSG) sleep breathing monitoring is the gold standard for diagnosing sleep disorders including sleep apnea hypopnea syndrome (SAHS), and has been used in clinical practice for more than 40 years. In recent years, a simpler portable sleep breath monitoring device, namely out center sleep test (OCST), has been used in clinic. In 2014, the international classification of sleep diseases 3rd edition (ICSD-3) formulated by the American sleep Society (AASM) listed OCST as one of the diagnostic methods of adult SAHS, and suggested its popularization and application. As early as 2003, AASM published guidelines detailing the indications for the use of portable sleep monitors in the diagnosis of sleep apnea in adults. In the developed countries of Europe, the corresponding inspection methods have been widely used. The diagnosis and treatment of SAHS in China has a history of more than 30 years. At present, a large number of patients have not yet been diagnosed and treated. Besides insufficient understanding, the limited number of PSG sleep monitoring beds is also one of the important reasons why patients are difficult to get timely diagnosis and treatment and delay diagnosis and treatment. Can we solve this problem by widely applying OCST to replace PSG sleep respiration monitoring in China like developed countries in Europe and America? Combined with the development of domestic sleep medicine, we think it is too early.

A 44-year-old male was admitted to the hospital on 30 October 2013 due to "repeated cough, chest tightness, low fever for 10 months, aggravated with asthma after activity for 1 week". In January 2013, the patient began to have repeated cough, sometimes severe, occasionally with a little white sticky sputum or yellow sticky sputum, accompanied by chest tightness and asthma, aggravated after activity, intermittently accompanied by low fever, and the highest reached 38.2℃. Chest CT film was taken at the local hospital in February 2013 (Figure 1，Figure 2) suggested "right lung tuberculosis with double upper lobe bronchiectasis", and was transferred to a local designated medical institution for anti-tuberculosis treatment. Chest CT was re-examined in May 2013 (Figure 3，Figure 4) showed that the right lung lesion was basically absorbed, and new patches appeared in the left lung, and anti-tuberculosis treatment continued. Chest CT was re-examined in August 2013 (Figure 5) showed that the original patch shadow of the left lung dissipated, and new patch shadows appeared in different parts of the left side, and anti-tuberculosis treatment was still given. Later, the patient's symptoms could not be relieved and chest tightness and asthma aggravated, and he was admitted to our hospital. Past history: denial of tuberculosis, bronchiectasis, denial of allergic diseases such as bronchial asthma, allergic rhinitis and eczema, denial of exposure to dust, denial of family history of bronchial asthma. Physical examination after admission: body temperature 37.5 ℃, pulse 86 beats/min, respiratory rate 24 beats/min, blood pressure 120/70 mmHg (1 mmHg =0.133 kPa), consistent respiratory movement on both sides, coarse respiratory sounds on both lungs, and scattered wheezing sounds can be heard. Heart rhythm, no murmur. The abdomen was flat and soft, and the liver and spleen were not touched under the costs. Preliminary diagnosis of admission: fever to be examined: bilateral pulmonary tuberculosis? Bronchiectasis? Bronchial asthma?

Chronic obstructive pulmonary disease (COPD) is a chronic pulmonary disease with increasing morbidity and mortality in the world. It is estimated that COPD will rank third among the world's causes of death in 2020^[1]。 Data from an epidemiological survey in China in 2007 showed that the prevalence of COPD in the population over 40 years old was 8.2%, of which 12.4% were males and 5.1% were females^[2]。 Environmental factors (such as smoking, exposure to harmful dust, etc.) and genetic factors are the main causes of COPD, among which smoking is the most important risk factor^[3]。

Mechanical ventilation is a very important symptomatic and supportive treatment for respiratory failure caused by various causes, which greatly improves the prognosis of patients. However, improper mechanical ventilation often leads to ventilator induced lung injury (VILI), so appropriate ventilation strategy is the key factor for the success of mechanical ventilation. Because the respiratory movement process itself is a mechanical process in which the respiratory muscles contract (or relax) under the regulation of central regulation, nerve reflex, etc., and then drive the inhalation (or exhalation) of gas. The significance of respiratory mechanics in mechanical ventilation has attracted more and more attention of scholars. Respiratory mechanics is a science that studies the three elements of pressure, volume and flow related to respiratory movement and their related mechanical parameters such as compliance, resistance and respiratory work. Various diseases of the respiratory system can cause changes in respiratory mechanics, which can lead to abnormal respiratory movements. Therefore, respiratory mechanics is an important part of respiratory physiology, and it is also the theoretical basis of mechanical ventilation. It is an important basis for proper ventilation strategy.

The 5th activity of Beijing Young Respiratory Scholars Salon in 2014 was held on August 28th, 2014. This conference took the form of a debate competition, with the theme of "Initial treatment of sub-massive pulmonary embolism: thrombolysis is better than anticoagulation alone". This event was hosted by Dr. Bu Xiaoning of Beijing Chaoyang Hospital affiliated to Capital Medical University.

Vasculitis refers to a group of systemic diseases characterized by vascular wall inflammation and fibrous necrosis. The discovery of such diseases has a history of nearly 260 years, but it is still one of the difficulties in current clinical work. On the one hand, such diseases are relatively rare and many clinicians are unfamiliar with them; On the other hand, the clinical manifestations of such diseases are diverse but lack of specificity, and are easily confused with other diseases, such as infectious diseases. The clinical manifestations of various vascular diseases also overlap, and the etiology and pathogenesis are unclear. In 1755, Michaelis and Martani reported a deceased patient with a pathological change of diffuse vasculitis, the first case of "primary" vasculitis reported in the world, but the disease was not named at that time. Over the past 200 years, there are more and more cases, diseases and research reports of vasculitis, but the classification and nomenclature have been confusing. Due to the needs of clinical communication and research work, this type of disease was named uniformly for the first time in 1993, and vasculitis was reclassified and named in 2012. The change of vasculitis classification and naming reflects the process of people's understanding of this type of disease.

The Scientific Committee of the Global Strategy to Prevent and Treat Chronic Obstructive Pulmonary Disease (COPD) (GOLD) and the Global Initiative to Prevent and Treat Bronchial Asthma (Asthma) (GINA) jointly developed guidelines on asthma-COPD syndrome (ACOS), which were published in full on their respective websites in May 2014^[1]。 However, we searched the PubMed database and found that there are many literatures that also refer to it as COPD-Asthma Overlap Syndrome (CAOS)^{[2,3,4,5,6,7]}。 So, is it COPD or asthma? Some people think that it doesn't matter, this is done at will; Some people also think that it is in order of the English initials of asthma and chronic obstructive pulmonary diseases (COPD). However, the author thinks that these two seemingly identical names should reflect different emphases of diseases.

Since the Global Initiative for Bronchial Asthma (ASTMA) (GINA) and the Global Initiative for Chronic Obstructive Pulmonary Disease (COPD) (GOLD) jointly proposed asthma-COPD overlap syndrome (ACOS)^[1], whose diagnostic and therapeutic problems have aroused our great interest^[2]It has also attracted a lot of controversy or discussion. The letters from Dr. Mou Xiangdong and Dr. Chen Yahong reflect everyone's concern from one aspect^[3]。 Here are some personal views on the issues mentioned in the letter for discussion.

The year is approaching, the snow is flying to welcome the new year, and another year is flying by in the blink of an eye. Thank you to the readers, authors and editors who have worked together with us to make progress together in the coming 2014.