2015年 · 第38卷第01期

As a respiratory doctor, most of the patients faced are chronic or subacute diseases that cannot be completely cured in a short time, such as chronic obstructive pulmonary disease (COPD), bronchial asthma (asthma), pulmonary fibrosis and bronchopulmonary cancer. It can be said that the only exception is respiratory infection. As long as the diagnosis is correct and the treatment is timely and appropriate, the vast majority of them can be completely cured. Therefore, I often joke, "A respiratory doctor who doesn't understand infection is a doctor who can't cure diseases."

In recent years, with the increasing understanding of pulmonary aspergillosis and the accumulation of clinical data, its classification is also constantly evolving. In-depth understanding of the characteristics of pulmonary aspergillosis spectrum and its pathophysiological basis is particularly important for the diagnosis and treatment of the disease^[1]。 On the one hand, different types of pulmonary aspergillosis have distinct features that contribute to early diagnosis; On the other hand, the complexity and variability of pulmonary aspergillosis hinder accurate diagnosis, just like patients with low immune function. However, due to the different types and degrees of immune function suppression, the clinical manifestations after Aspergillus infection often vary greatly, and most of them lack typical characteristics; Another example is that the clinical manifestations of concomitant diseases often mask the clues that appear in the evolution of pulmonary aspergillosis. This paper introduces the common classification and characteristics of pulmonary aspergillosis at present, and on this basis talks about the problems needing attention in diagnosis.

Globally, there are often certain regional differences in the pathogenic characteristics and drug resistance of community-acquired pneumonia (CAP), which will directly affect the initial empirical treatment plan of CAP. The choice is also reflected in the CAP diagnosis and treatment guidelines of various countries. There are many reasons for this difference, including the uneven level of social and economic development, the differences in the production capacity and application management level of antimicrobial drugs, and the different use habits of antimicrobial drugs. In recent years, with the gradual development and deepening of adult CAP etiology research in China, some important differences in adult CAP etiology between China and European and American countries have gradually emerged, which are briefly summarized below for clinicians' reference.

Non-cystic fibrotic bronchiectasis (bronchiectasis) is an airway disease caused by a variety of causes. Chronic bacterial infections are associated with disease progression and repeated acute exacerbations, resulting in aggravation of symptoms, decreased lung function and quality of life, and are also one of the reasons for increased mortality^[1,2,3]。

Previous courses of antimicrobial therapy have been derived from expert advice. With the research of pharmacoeconomics, the monitoring of adverse drug reactions, the rapid growth of bacterial resistance and the development of evidence-based medicine, people began to pay attention to the course of antimicrobial therapy. The results of existing studies suggest that short-course therapy is as effective as long-course therapy. Although it is preliminary, it has or is shaking some old concepts that have been inherited for a long time in the field of antimicrobial therapy. If short-course treatment is achieved, in addition to rational use of medical resources and saving medical expenses, it can also reduce drug resistance and secondary infection. The results of a study of antimicrobial therapy in ICU patients showed that the incidence of secondary infection and/or colonization by drug-resistant bacteria was 38% in the traditional long-course treatment group, and decreased to 14% in the short-course treatment group (P＝0.017）^[1]。 Therefore, studying the course of treatment of antimicrobial drugs has important reference significance for how to change the management of antimicrobial drugs from the usual administrative means to the use of scientific means.

With the wide application of antimicrobial drugs in clinical practice, bacterial drug resistance has become increasingly serious, especially multi-drug resistance (MDR) bacteria have become an important reason for treatment failure of patients with severe infection, especially in recent years, the isolation rate of extensive drug resistance (XDR) bacteria and pan-drug resistance (PDR) bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA), extensive drug resistance non-fermenting bacteria (Pseudomonas aeruginosa and Acinetobacter baumannii), extended-spectrum β-lactamase (ESBL) -producing Enterobacteriaceae bacteria (Klebsiella pneumoniae and Escherichia coli) and carbapenemase-producing Enterobacteriaceae bacteria [CRE, mainly carbapenemase-producing Klebsiella pneumoniae (KPC)], make clinical treatment more difficult, among which insufficient antimicrobial drug exposure is an important reason for the production of drug-resistant bacteria. Therefore, it is very important to fully apply pharmacokinetics (PK) and pharmacodynamics (PD) theories to guide the rational application of antimicrobial drugs when XDR and PDR bacteria are infected, including maximizing the antimicrobial effect, reducing the production of drug-resistant bacteria as much as possible and avoiding drug toxicity. In addition to choosing the right antimicrobial, implementing the appropriate dosing strategy (dosage and method of implementation) will greatly affect clinical efficacy. The progress of applying PK/PD principle to guide the treatment of unconventional antimicrobial drugs in severe drug-resistant bacteria infection is introduced as follows, in order to provide reference for the treatment of drug-resistant bacteria in clinic^[1]。

renal replacement therapy (RRT) has been widely used in critically ill patients with or without acute renal injury (AKI) or chronic renal failure (CRF)^[1,2]。 Besides effectively removing metabolites and toxins from the body, RRT can also lead to insufficient drug dose, especially the insufficient concentration of anti-infective drugs, which can lead to the recurrence of infection and the production of drug-resistant strains^[3]And complicates the pharmacokinetics of anti-infective drugs. How to adjust the dosage of anti-infective drugs in patients receiving RRT is worth paying attention. Therefore, optimizing the antibiotic treatment regimen of RRT patients can play a key role in improving prognosis and reducing adverse drug reactions.

The mechanism by which smoking causes glucocorticoid resistance is currently unknown, and the findings suggest that^[1]Glucocorticoids inhibit inflammatory genes mainly by recruiting histone deacetylase 2 (HDAC2) to reach the initiation site of inflammatory genes, so we speculate that smoking may affect the expression of HDAC2, thus leading to glucocorticoid resistance. P13K signal transduction pathway is closely related to HDAC2 expression^[2]。 In this study, we replicated the smoke-exposed asthma mouse model to observe the effect of tobacco smoke on HDAC2, and investigated the possible mechanism of action of PI3K δ/Akt signaling pathway on HDAC2 by studying the activity change of serine/threonine protein kinase (Akt), an important downstream signaling molecule of P13K.

Community-acquired pneumonia (CAP) is the most common respiratory infectious disease and has always been the top cause of death from infectious diseases. According to statistics, about 916,000 adults ≥65 years old in the United States suffer from CAP every year^[1]。 In Europe, the annual incidence of CAP ranges from 1.6/1 000 to 19/1 000^[2]。 At present, there is a lack of large-scale epidemiological data in China. It is estimated that the annual incidence of CAP in China is 2.5 million. 10% ~20% of hospitalized CAP patients need to be admitted to ICU, and up to 50% of them have complicated septic shock^[3]。 After the advent of antibiotics in the 1950s, the CAP mortality rate dropped sharply, but has remained relatively stable since then. It is well known that severe infections are associated with excessive inflammatory responses in the body. Therefore, the research of CAP treatment gradually turned to non-antibiotic adjuvant measures. Glucocorticoids (hormones) are by far the most effective anti-inflammatory drugs and are gaining increasing attention as an adjuvant treatment for lung infections. The adjuvant therapeutic value and mechanism of hormones in severe CAP are summarized as follows. Because the anti-infective treatment of atypical pathogens such as mycoplasma pneumonia has been relatively perfect, and the research on the systemic manifestation mechanism caused by special immune response and the understanding of the immunomodulatory role of hormones in the treatment process have been relatively mature, it is not within the scope of this article.

In recent years, the incidence of invasive fungal infection (IFI) remains high, and early diagnosis and treatment can significantly improve the survival rate. Traditional methods of mycosis diagnosis include fungal culture of sputum, blood or BALF, histopathology and characteristic imaging. However, the specificity and sensitivity of these diagnostic methods are low, and the cycle is long, so there is the possibility of diagnosis delay; Traumatic diagnostic methods are limited by the patient's condition and physical condition. Therefore, non-invasive rapid detection methods are attached importance.

community acquired pneumonia (CAP) is a common disease that seriously threatens human health and is one of the leading causes of death in children and the elderly worldwide. S. pneumoniae (Streptococcus pneumoniae) is the primary pathogen of CAP^[1,2,3]。 Long-term follow-up of recovered patients with Streptococcus pneumoniae pneumonia showed that the 10-year mortality rate was significantly higher than that of patients without previous Streptococcus pneumoniae pneumonia^[4]。 At present, the traditional pathogen detection method of Streptococcus pneumoniae has a low detection rate. Urinary antigen detection is an in vitro rapid immunochromatographic method for the detection of Streptococcus pneumoniae antigen in patients' urine, which can be used for the etiological diagnosis of patients with CAP. The research on urine antigen detection for Streptococcus pneumoniae infection in CAP patients is summarized as follows.

Bronchial asthma (asthma for short) is a recurrent chronic inflammatory disease of the respiratory tract^[1]。 With the development of social economy, the incidence of asthma in China has increased obviously^[2]Especially in some big cities^[3,4]。 Th2 cells and their related cytokines (IL-4, IL-5, and IL-13) dominate in the pathogenesis of asthma^[2,5]。

Chronic obstructive pulmonary disease (COPD) is a common disease that can be prevented and treated, and its basic pulmonary lesion is an incompletely reversible airflow restriction that progresses progressively and is associated with an abnormal inflammatory response of the lungs to harmful gases or harmful particles. COPD has a high prevalence and mortality rate worldwide, currently ranking fourth among the causes of death worldwide, and is predicted to rise to third among the causes of death by 2020^[1]。

Ajlan AM, Ahyad RA, Jamjoom LG, et al. Am J Roentgenol, 2014, 11: 1 – 6.

Best DH, Sumner KL, Austin ED, et al. Chest, 2014, 145: 231 – 236.

Chronic obstructive pulmonary disease (COPD) is a common disease of the respiratory system. 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 (Zhun) Zi 2014 No. 1260579, registered product standard number: YZB/Shanghai 6876 – 26A – 2014] can solve this kind of problem.