2015年 · 第38卷第09期

sleep related breathing disorders (SRBD) are a group of diseases with abnormal breathing during sleep as the main manifestation, with or without daytime respiratory dysfunction. Patients with daytime respiratory dysfunction often get worse at night. SRDB mainly includes simple snoring, sleep apnea, sleep hypopnea, alveolar hypopnea, sleep-related hypoxemia and other rare types. The same patient can suffer from multiple SRBDs at the same time. For example, more than 90% of obesity hypopnea syndrome have obstructive sleep apnea (OSA), and COPD sleep hypoxia combined with OSA is called overlap syndrome. Such patients have a higher incidence of complications, worse prognosis and higher mortality.

Obstructive sleep apnea (OSA) is a common and frequently occurring disease, which is characterized by repeated apnea, frequent awakening, sleep fragmentation, intermittent hypoxia and hypercapnia during sleep, resulting in multiple organ systems, especially cardiovascular and cerebrovascular damage and cognitive dysfunction. At present, OSA has become a global health problem. However, with the increase of obese population, the incidence of OSA is increasing year by year. Although the pathogenesis of OSA is not completely understood, and there are still many problems in its diagnosis and treatment, with the deepening of research, people have a further understanding of this disease.

central sleep apnea syndrome (CSAS) is a type of sleep breathing disorder characterized by apnea and hypopnea caused by weakened or disappeared breathing effort during sleep. Respiratory events may occur intermittently or periodically, and patients may have obstructive respiratory events. The third edition of the International Classification of Sleep Disorders (ICSD – 3), published in 2014, provides a new classification of this group of disorders^[1,2]whose diagnostic criteria include symptoms such as apnea during sleep, sleep fragmentation, daytime drowsiness, or a history of characteristic underlying diseases; Central apnea/hypopnea index ≥5 times/h found during polysomnography (PSG) diagnosis or continuous positive airway pressure (CPAP) titration, with central respiratory events accounting for more than 50% of all respiratory events^[1]。 The specific classification is as follows.

Arterial blood CO₂Partial pressure (PaCO₂) is a reliable indicator reflecting alveolar ventilation, PaCO₂>45 mmHg (1 mmHg =0.133 kPa) That is, the presence of alveolar hypoventilation. When PaCO₂When it reaches 50-70 mmHg, the accompanying hypoxemia can lead to a series of pathophysiological changes and clinical symptoms such as erythrocytosis, pulmonary hypertension, pulmonary heart disease and respiratory failure, which is called alveolar hypoventilation syndrome. A variety of diseases can cause alveolar hypoventilation, and idiopathic hypoventilation is rare. The epidemiological characteristics of hypopnea are currently unknown, but almost all diseases that can cause significant hypercapnia are accompanied by sleep hypopnea manifestations. Recent studies have shown that at BMI>35 kg/m²Obesity Hypoventilation Syndrome was found in 31% of adult hospitalized patients, and the incidence of complications and mortality increased significantly, but the vast majority failed to attract the attention of medical staff^[1]。

In recent years, the research between neuromuscular diseases and sleep disorders of breathing has gradually attracted the attention of many scholars. Neuromuscular diseases can involve the respiratory muscles, resulting in a slow decline in respiratory function, usually manifested early as sleep breathing disorders during sleep, gradually progressing to nocturnal hypopnea, and eventually progressing to daytime hypopnea, pulmonary heart disease, and respiratory failure. Due to the low incidence of neuromuscular diseases, problems related to sleep breathing in such patients receive little attention, and even in specialized neuromuscular clinics, less than 2% of patients are concerned about sleep^[1]。

The ventilation of healthy people during sleep decreased in the non-rapid eye movement sleep period, but it was relatively more obvious in the rapid eye movement sleep period, but the decrease of ventilation volume was relatively small, which had little effect on blood oxygen, and had no clinical significance. Sleep-related hypoxemia specifically refers to sleep hypoxia caused by systemic or neurological diseases. This hypoxia cannot be explained by other sleep-related respiratory diseases. It is mostly secondary to airway diseases, pulmonary parenchymal diseases, chest wall diseases, pulmonary vascular diseases and neuromuscular diseases. Clinically, it is manifested as a persistent and significant decrease in blood oxygen saturation during sleep without sleep-related hypoventilation, usually due to ventilation/blood flow ratio imbalance, decreased oxygen partial pressure, arteriovenous shunt or a combination of the above factors. Patients may be asymptomatic, or they may suffer from sleep choking, chest tightness, sleep quality impairment and fatigue. If there is daytime hypoxia, the degree of hypoxia during sleep will be further aggravated.

catathrenia, also known as nocturnal groaning, was developed in 1983 by De Roek et al.^[1]First discovered and publicly published. Typical nocturnal moaning is characterized by prolonged expiratory phase after deep inhalation and accompanied by moaning-like monotonous sound. It mostly occurs in young adults. The main reason for seeing a doctor is social disorder, which is classified as parasomnia in the international classification of sleep disorder (ICSD-2) 2005^[2]。 Because moaning at night has typical breathing pattern changes, it has been controversial what kind of sleep disorder it belongs to. It was reported in 2006 that patients with nocturnal moaning combined with obstructive sleep apnea had improved nocturnal moaning after treatment with continuous positive airway pressure (CPAP)^[3], 2014 International Classification of Sleep Disorders 3rd Edition (ICSD – 3) formally included nocturnal moaning in sleep disorders of breathing, combined with simple snoring as a normal variant or simple symptom^[4]。 For this new sleep apnea, there are less than 100 cases reported at present, and the understanding at home and abroad is insufficient. Because it is mainly manifested by nocturnal vocalization, it is often mistaken for obstructive sleep apnea in outpatient clinics, and because the polysomnograph (PSG) performance of patients with nocturnal moaning is similar to that of central sleep apnea PSG, both of which have oral and nasal airflow apnea with disappearance of thoracic and abdominal movements, it is often misdiagnosed as central sleep apnea in clinic.

Pulmonary hypertension is a disease with high disability and mortality caused by primary diseases or some chronic lung diseases such as chronic obstructive pulmonary disease (COPD), which seriously affects human health. Chronic hypoxia causes pulmonary vasoconstriction and vascular remodeling, which leads to an increase in pulmonary artery pressure. The entry of calcium ions from extracellular to intracellular is a key step in the contraction of pulmonary vascular smooth muscle induced by chronic hypoxia. This process involves the classical transient receptor potential channel (TRPC) protein. Pulmonary blood vessels include three parts: arteries, veins and microvessels. The pathogenesis of pulmonary hypertension is focused on pulmonary arteries, while pulmonary veins are neglected to some extent. The results showed that the pulmonary vein plays an indispensable role in regulating blood flow and blood pressure in the pulmonary circulation. Under chronic hypoxic environment, the expression of TRPC1,6 in pulmonary artery smooth muscle increases, resulting in the increase of intracellular basal calcium concentration, which eventually leads to the contraction and remodeling of pulmonary artery. This paper mainly investigates whether chronic hypoxia affects the changes of TRPC protein and intracellular calcium level in distal pulmonary vein smooth muscle of rats.

sleep apnea hypopnea syndrome (SAHS) refers to a clinical syndrome that causes repeated apnea and/or hypopnea during sleep, fragmented sleep, and periodic decline of blood oxygen saturation, thus causing a series of pathophysiological changes in the body. sleep apnea (SA) is divided into three types: obstructive sleep apnea (OSA), central sleep apnea (CSA), and mixed sleep apnea (MA). The mechanism of SA is not fully understood, and recent studies suggest that humoral fluid transfer may be related to the development of SA^[1,2,3]。

Obstructive sleep apnea syndrome (OSAS) has become an important public health problem due to its prevalence and long-term health hazards^[1]At present, many evidences confirm its close relationship with cardiovascular diseases, stroke, metabolic disorders, motor vehicle traffic accidents and sudden death. Most of the evidence comes from large long-term cohort studies. With the continuous progress of research, the evidence of new epidemiological investigations has found the relationship between obstructive sleep apnea (OSA) and tumorigenesis and progression. Several large multicenter cohort studies have confirmed the correlation between OSA and the increase of tumor morbidity and mortality. The following is a systematic review of related studies.

Tuberculosis, an infectious disease caused by MTB, is the second most fatal infectious disease in the world after AIDS. Since 1940s, with the effective use of anti-tuberculosis drugs, the morbidity and mortality of tuberculosis once dropped sharply. However, in recent years, due to the emergence and widespread epidemic of drug-resistant MTB, tuberculosis has resurged, which brings severe challenges to the prevention and control of tuberculosis. The World Health Organization (WHO) estimates that about 300,000 cases of multidrug-resistant tuberculosis (MDR-TB) were reported worldwide in 2013, of which 9.0% were extensively drug-resistant tuberculosis (XDR-TB), while the global cure rate of MDR-TB was only 48%^[1]。 Therefore, drug-resistant tuberculosis, especially MDR-TB, has become the focus and difficulty of tuberculosis prevention and control.

A 55-year-old male was admitted to the hospital on 22 November 2014 due to "chest pain, hemoptysis, dyspnea for 1 d". The patient presented with intermittent chest pain, hemoptysis and dyspnea without obvious trigger 1 d before admission. The chest pain lasted from several minutes to several hours, and it was dull and painful, unrelated to breathing and without radiation. Fill your mouth with blood, about 60 ml; Dyspnea was aggravated after activity, without fever, palpitations, syncope, shock and other symptoms. History of tuberculosis and bronchiectasis was denied, and there was no history of hemoptysis. Physical examination: body temperature 36.5 ℃, pulse 76 beats/min, respiratory rate 20 beats/min, blood pressure 170/90 mmHg (1 mmHg =0.133 kPa), clear consciousness, rosy face, lips and limbs, no distension of jugular vein, centered trachea, no obvious abnormalities in respiratory mobility and percussion, coarse respiratory sounds in both lungs, heart sounds P2>A2, P2 hyperactivity, and no edema in both lower limbs. On November 22, 2014, the chest CT showed: (1) the left hilum was enlarged, the left lung bronchus was compressed and narrowed, and the left lung showed obstructive pneumonia changes; (2) Multiple enlarged lymph nodes in the mediastinum, partially fused, and unclear boundary with bronchoesophagus (Figure 1，Figure 2)。 Blood D-dimer was 3.28 mg/L; Blood routine showed: white blood cells 11.8×10⁹/L, neutrophils 0.90%, platelets 264×10⁹/L; Liver function and blood gas analysis were roughly normal; The male tumor series was negative. Levofloxacin hydrochloride sodium chloride injection (0.3 g, twice/d) was given for anti-inflammatory treatment, tranexamic acid sodium chloride injection 0.5 g for hemostasis, and pantoprazole sodium 80 mg for acid suppression and protection of gastric mucosa. The patient still had hemoptysis after application of hemostatic drugs. On November 22, 2014, plain chest CT scan + enhancement showed: (1) Considering right pulmonary bronchial artery malformation with left hilar area-mediastinal hematoma formation; (2) Left lung bronchial compression and left lung obstructive pneumonia changes (Figure 3,Figure 4,Figure 5,Figure 6)。 Bronchial arteriography was performed on November 24, 2014. It was found that the right bronchial artery was significantly thickened and tortuous, and the contrast agent spilled out at the same time. Coil embolization was given, and re-angiography showed successful embolization (Figure 7，Figure 8)。 After operation, the patient did not have hemoptysis again and continued anti-infective treatment. Definitive diagnosis: (1) Right pulmonary bronchial artery malformation; (2) Left obstructive pneumonia. The patient developed tearing pain in the anterior chest area on the evening of November 28, 2014. The next day, the enhanced chest CT examination showed: (1) dense shadow at the beginning of the bronchial artery, which was consistent with the postoperative changes; (2) The hematoma in the left hilar region-mediastinum was smaller than before, the compression narrowing of the left bronchus was alleviated compared with before, and the changes of left obstructive pneumonia progressed compared with before (Figure 9)。 After 1 d, the patient suffered from pain relief in the anterior chest area and no further hemoptysis. He was discharged from the hospital on 3 December 2014. On April 29, 2015, the patient came to the hospital for a follow-up visit and complained that there was no further hemoptysis after the operation. The reexamination of the chest CT scan showed that the hematoma in the left hilar area-mediastinum was absorbed compared with the previous one, the left lung bronchial compression narrowed, and the changes of left lung obstructive pneumonia were relieved compared with the previous one (Figure 10)。

A 51-year-old man went to a local hospital for "cough for 2 weeks and intermittent fever for 7 days". At the time of treatment, his body temperature was 39℃, accompanied by cough and expectoration. The sputum was gray and bloodshot in the sputum (twice), accompanied by chest tightness and choking, without chills, chills, rash, nausea, vomiting, abdominal pain and diarrhea. The self-measured blood glucose was 19.8 mmol/L. X-ray chest radiography revealed multiple patches on both lungs (Figure 1)。 Due to the serious condition, he was transferred to a superior hospital the next day. Chest CT showed multiple flaky shadows in both lungs and cavities formed (Figure 2，Figure 3)。 Blood routine: white blood cells were 29.8×10⁹/L, neutrophil ratio was 0.96, hemoglobin was 105 g/L, and platelet count was 211×10⁹/L, C-reactive protein was 3.1 g/L, and was treated with meropenem, vancomycin, voriconazole and ambroxol.

pulmonary venous stenosis (PVS) refers to a series of clinical diseases that occur due to various factors caused by pulmonary venous lumen stenosis, resulting in obstruction of pulmonary venous blood return. Some patients go to respiratory department with hemoptysis as the first symptom. Respiratory doctors may delay diagnosis and treatment due to specialty restrictions and insufficient understanding of these causes. Three cases of pulmonary vein stenosis with hemoptysis as the first symptom admitted to our hospital are reported, and discussed in combination with the literature as follows.

Congenital dyskeratosis Congenita (DC) is a rare genetic disease characterized by abnormal skin pigmentation, nail dystrophy and leukoplakia^[1]At the same time, pulmonary interstitial fibrosis is more rare. Foreign literature reports that about 20% of DC are complicated with pulmonary interstitial fibrosis^[2]At present, there is no report in China. The diagnosis and treatment experience of a patient with DC complicated with pulmonary interstitial fibrosis admitted to the First Affiliated Hospital of Zhengzhou University is reported as follows.

Tracheal sleeve resection is the preferred treatment for traumatic tracheal stenosis, but the operation is traumatic and complications such as anastomotic restenosis often occur after surgery^[1]。 For patients who are not suitable for surgery or who do not wish to do so, internal stent placement may be applied for treatment^[2]。 The stents are divided into metal and silicone. Because silicone stents are easy to remove and adjust their positions, they are the first choice for the treatment of benign tracheal stenosis^[3]。 In China, metal brackets are mostly selected. Metal tracheal stents have been placed in our hospital to treat many cases of traumatic tracheal stenosis, and good results have been achieved. In March 2014, the silicone stent was officially listed in China, and our department was the first to use this kind of stent in China. The preliminary experience of using tracheal silicone stent in the treatment of traumatic tracheal stenosis in our department since April 2014 is reported below.

Chinese Journal of Tuberculosis and Respiration, Issue 12, 2014, published a series of controversial articles on whether portable sleep respiratory monitoring (OCST) can be gradually promoted for the diagnosis of OSAHS in adults^[1,2]After reading it, it feels novel and enlightening. Because I am very interested in this issue, and at the same time, this issue is related to the development of sleep respiratory medicine in China and whether the majority of OSAHS patients can be diagnosed and treated in time, so regardless of closeness (because the author with the opposite view is a rising star in my respiratory department, and one of them was once my student), I don't want to be shallow, let me talk about my personal opinions, and please criticize and correct any inappropriate things.

Sponsored by Chinese Journal of Tuberculosis and Respiration, the 3rd Young Respiratory Scholars' Salon in 2015-Experience Exchange Forum on bronchial thermoplasty (BT) in the Treatment of bronchial Asthma (Asthma) was held in Hangzhou on May 24, 2015. Professor Shen Huahao, leader of Asthma Group of Respiratory Disease Branch of Chinese Medical Association, attended this salon. The participating doctors discussed and shared experiences on hot issues such as patient selection and perioperative management of BT, which deepened young doctors' understanding of thermoplasty in the treatment of severe asthma.

The first Respiratory Critical Care Forum of Respiratory Disease Branch of Chinese Medical Association was held in Bengbu from March 27 to 29, 2015. The meeting was hosted by Respiratory Disease Branch of Chinese Medical Association and hosted by the First Affiliated Hospital of Bengbu Medical College. This was the first grand meeting since the establishment of Respiratory Critical Care Group. Academician Wang Chen, chairman of Respiratory Disease Branch of Chinese Medical Association and head of Respiratory Critical Care Group of Respiratory Disease Branch of Chinese Medical Association, made an important speech at the opening ceremony. The theme of this forum is to practice the bundled development strategy of respiratory medicine and critical care medicine, which aims to improve the diagnosis and treatment level of respiratory critical disease and promote the construction of the disciplinary system of respiratory and critical care medicine. The conference covered 13 topics such as respiratory physiology and respiratory therapy, ARDS diagnosis and treatment, severe respiratory infection, invasive and non-invasive mechanical ventilation, etc. Nearly 60 famous domestic experts gave 63 wonderful special reports. Nearly 1,000 doctors, nurses, respiratory therapists and researchers in respiratory and critical care medicine from across the country attended the forum.

The "2015 National Conference on Clinical Application and Standardization of Lung Function Training" jointly sponsored by the Lung Function Professional Group of Respiratory Disease Branch of Chinese Medical Association, China Lung Function Alliance, State Key Laboratory of Respiratory Diseases and National Clinical Medical Research Center of Respiratory Diseases of the First Affiliated Hospital of Guangzhou Medical University was held at the main venue in Guangzhou from March 28 to 29, 2015. Live video broadcast and interactive exchange were conducted at nine sub-venues in Beijing, Shanghai, Wuhan, Chengdu, Nanjing, Shenyang, Jinan, Tianjin and Hangzhou. A total of 1,522 respiratory experts and representatives from all over the country attended the meetings in 10 venues. At the same time, 1,029 live streaming points of the conference were opened online, covering 619 hospitals in 193 cities in 29 provinces across the country, and nearly 10,000 doctors watched the live streaming of the conference online.

Europe and America published the relevant standards of pneumometry examination in 2005^[1]And clinical evaluation criteria^[2]China also published guidelines for pulmonary function testing (Part II) in 2014 – pneumometer testing^[3]And put forward the evaluation criteria of pulmonary ventilation function. The author has the following questions about the latter.

Professor Liu Youning emphasized the importance and existing problems of pulmonary function examination and interpretation in the "Editor-in-Chief Essay" column of Chinese Journal of Tuberculosis and Respiratory Medicine, and pointed out that after the pulmonary function fever in the 1970s and 1980s, this part of the content was neglected for a long time, resulting in a series of problems in the training of respiratory doctors^[1]。 Both domestically and internationally, there is a lack of accepted standards for pulmonary function testing and evaluation. As described in the article "Questions on the Evaluation of Pulmonometric Results", ATS/ERS published the relevant examination and diagnostic criteria in 2005. The standard has not been approved by clinicians for a number of reasons and has not been revised for the past 10 years^[2]。 In 1988, the pulmonary function prediction formula was established in six regions in China, which was formally assembled and published in 1990^[3]But no one-second rate (commonly used FEV₁/FVC, FEV₁/FEV₆or FEV₁/VC), and there is no consistent evaluation criterion; It has not been subsequently revised. This is in sharp contrast to the frequent update or revision of relevant guidelines for other common diagnosis and treatment techniques and diseases. Therefore, it is very common to have controversies or even larger controversies on issues related to lung function. The pulmonary function professional group mainly took the ATS/ERS 2005 edition standard as a reference, and combined with the situation in China, published a series of guidelines in 2014, which is a great progress and will be further revised and improved in the future. In response to several questions raised by the author, the reply is as follows.

The flow-volume curve is closely related to Part II, "Common ventilation functional parameters"^[1]。