2016年 · 第39卷第03期

The focus of this issue is bronchial thermoplasty (BT) in the treatment of severe bronchial asthma (asthma).

Bronchial asthma (asthma) is a common respiratory disease characterized by reversible airflow restriction. There are more than 300 million asthma patients in the world, and there are more than 30 million asthma patients in China. About 5% of them are severe asthma. Despite the application of sufficient inhaled glucocorticoids and bronchodilators, it is still difficult to effectively control asthma symptoms. The frequency of emergency medical treatment and hospitalization are 15 times and 20 times that of mild to moderate asthma, respectively, which are the main reasons for the increase of asthma treatment cost and asthma disability and death^[1]。

The "Expert Consensus on Differential Diagnosis of Fever with Lung Shadow" published in this issue was finalized by 19 domestic experts after one year, three discussions and many revisions. Its main contents include three parts: how to distinguish infectious and non-infectious lung lesions in fever patients, the diagnostic idea of infectious lung lesions and the diagnostic idea of non-infectious lung lesions. It is expected that the publication of this consensus will be helpful to clinicians in practice.

bronchial thermoplasty (BT) has attracted widespread international attention as a new non-drug treatment for bronchial asthma (asthma) after it was approved by the US Food and Drug Administration (FDA) for clinical application in 2010. It has been progressively carried out in many countries in recent years, although there are some different views^[1]However, its efficacy and safety have been generally recognized^[2,3,4]Global Asthma Prevention Initiative 2014 (global initiative for asthma, GINA)^[5]Take BT as one of the recommended treatments for asthma level 5.

Fever with pulmonary shadow is very common in clinic and can be caused by a variety of etiologies in infectious and non-infectious diseases. Therefore, for patients with fever with pulmonary shadow, the etiology should first be identified before correct countermeasures can be taken. At present, the clinical misunderstanding is that the etiology of these patients is not distinguished, and the diagnostic treatment of anti-infectious drugs is improperly used, resulting in increased selective pressure of drug resistance and delayed diagnosis and treatment of non-infectious diseases. On the other hand, appropriate early empirical anti-infective therapy can significantly improve the prognosis of patients with pneumonia and also verify the diagnosis of pneumonia. Therefore, in clinical practice, the interests and risks of patients should be balanced before deciding whether to use experimental anti-infective treatment for patients with fever and lung shadow. The treatment of the above problems and the mastery of related skills are one of the indispensable important skills of clinicians. Therefore, the consensus expert group on differential diagnosis of fever with pulmonary shadow has specially formulated this consensus for clinicians' reference.

The Global Asthma Initiative (GINA) has been guiding the standardized diagnosis and treatment of bronchial asthma (asthma) for nearly 20 years, and the incidence of asthma is still increasing in many countries, which has become a serious public health problem^[1]。 Recent studies have shown that vitamin D receptor (VDR) plays an important role in the immune mechanism of asthma pathogenesis. It is expressed in most immune cells and is an important upregulator of lung inflammation^[2]。 Inactivated Mycobacterium phlei by aerosol inhalation can alleviate airway inflammation and reduce airway reactivity in asthmatic mouse models, which is associated with toll-like receptor action^[3]It has a unique mucosal immunological basis, and can clinically improve airway hyperresponsiveness and reduce asthma attacks in patients with moderate persistent asthma in the short term^[4]。 The purpose of this study was to investigate the preventive effect of aerosol inhalation of Mycobacterium vaccae vaccine on asthmatic mice and its relationship with VDR, so as to provide evidence for finding alternative drugs for inactivated Mycobacterium phlei (drug deficiency).

mediastinal fibrosis, also known as fibrosing mediastinitis and sclerosing mediastinitis, is a rare disease characterized by excessive proliferation of fibrous tissue in the mediastinum, mainly involving the middle mediastinum and around the hilum. Although mediastinal fibrosis is a benign disease, as the disease progresses, it can compress or block adjacent anatomical structures such as bronchi, pulmonary vessels and esophagus, causing corresponding clinical symptoms. The etiology is still unknown, but it is currently believed that it may be caused by excessive fibroproliferative reaction of the body caused by chronic infections such as histoplasma and mycobacterium tuberculosis^[1]。 Mediastinal fibrosis may also be associated with other fibrotic autoimmune diseases such as retroperitoneal fibrosis, sclerosing cholangitis, and fibrous thyroiditis^[2]。 Pulmonary hypertension can occur as fibrous tissue encapsulates and compresses the pulmonary arteries and/or pulmonary veins. According to the 2008 Dana Point classification, pulmonary hypertension caused by mediastinal fibrosis belongs to the fifth major category and is a rare disease causing pulmonary hypertension. A case of pulmonary hypertension caused by mediastinal fibrosis admitted to Peking University First Hospital is reported as follows.

ovarian hyperstimulation syndrome (OHSS) is a iatrogenic disease caused by the use of exogenous gonadotropin to control ovulation. It is a common complication in the process of assisted reproduction. The clinical manifestations include ovarian cystic enlargement, nausea, vomiting, pleural and abdominal effusion, electrolyte disorder, and even life-threatening thrombosis and multiple organ dysfunction^[1]。 Thromboembolic disease is one of the serious complications of OHSS. It is reported in the literature that the incidence of OHSS complicated by various deep venous thrombosis (DVT) is about 0.04%^[2]pulmonary thromboembolism (PTE) has been rarely reported. One case of OHSS combined with PTE admitted to us is reported below.

Histoplasmosis is a deep fungal infection caused by the biphasic fungus Histoplasma capsulatum infection^[1]China is not an endemic area, and only sporadic cases have been reported. A case of lung metastasis of nasopharyngeal carcinoma with pulmonary histoplasmosis was diagnosed in our department in April 2011, and the diagnosis was confirmed by bronchoscopic lung biopsy pathology, which is now reported as follows.

A 23-year-old male was admitted to the hospital on December 7, 2009 mainly due to "intermittent fever, expectoration and shortness of breath for 10 days". The patient began to have fever, cough, shortness of breath intermittently 10 days ago, with a maximum body temperature of 39.7 ℃, and no fear of cold and chills. The peripheral blood white blood cell count was 9.0×10 in our outpatient clinic⁹/L, neutrophils accounted for 81%, ESR was 35 mm/1 h, and CRP was 15 mg/L. X-ray chest radiograph showed a little exudation in both lower lungs (Figure 1)。 Then he was admitted to the Department of Infectious Diseases of our hospital with "lung infection". Past history: He suffered from tuberculosis 18 years ago and recovered; Three months ago, due to "fever, rash and hepatic impairment", the skin pathology diagnosed as recurrent non-suppurative nodular panniculitis (Weber-Christian disease), and was treated with prednisone at an initial dose of 60 mg/d. After one month of treatment, the above symptoms disappeared, and then the dose was gradually reduced to the current 40 mg/d. No history of smoking or drug allergy. Physical examination: body temperature 37.9 ℃, blood pressure 140/90 mmHg (1 mmHg =0.133 kPa). Full moon face, reddish complexion, multiple folliculitis-like red spots on the face and chest and back skin, no deformity in the thorax, clear breathing in both lungs, no dry and wet rales, uniform heart rhythm, no murmur, flat and soft abdomen without tenderness, not reaching the liver and spleen under the costs, asymmetric old rash and pigmentation on the inner thighs on both sides, no liver palms and spider nevus. Blood gas analysis: pH 7.463, PaO₂was 55.3 mmHg, PaCO₂was 30.4 mmHg and the inhaled oxygen concentration (FiO₂) was 21%.

obstructive sleep apnea Syndrome (OSAS) is a common disease. The latest survey results show that 6% to 13% of men and 2% to 6% of women in adults suffer from moderate to severe OSAS^[1]Among school-aged children, the proportion is 2% to 4%^[2]。 Clinically, it is characterized by frequent apnea and micro-awakening caused by repeated upper airway collapse during sleep. The fragmented sleep of patients can lead to daytime drowsiness, reduce the quality of life, and increase the incidence of traffic accidents and work-related injuries. continue positive airway pressure (CPAP) is currently recognized as an effective treatment for OSAS, which can improve the symptoms of drowsiness and reduce the complications of cardiovascular diseases.

bronchial thermoplasty (BT) is a new bronchoscopic treatment technique with high safety, which significantly reduces airway smooth muscle (ASM) and ASM contractility^[1,2,3,4,5]Improve bronchial asthma (asthma) control, improve the quality of life of patients, reduce drug use, and the like^[6,7,8,9]。 China officially approved this technology for the treatment of severe asthma in 2014, and its efficacy and safety are gradually being confirmed by more and more studies^{[10,11,12,13]}。 This article summarizes the application of BT in asthma and its research progress as follows.

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease characterized by persistent airflow restriction, often associated with lung inflammation caused by harmful gases or particles such as tobacco smoke. Chronic bronchitis and emphysema caused by inflammation are the pathological basis of airflow restriction in patients with COPD, whose characteristic changes are. Acute exacerbation of COPD is an important factor that accelerates the deterioration of lung function and seriously affects the quality of life of patients^[1]。 COPD is expected to be the third-leading fatal disease and seventh-leading cause of disability in the world by 2030^[2,3]。 Bronchodilators are the core therapeutic drugs to control COPD symptoms. Existing inhaled long-acting bronchodilators include anticholinergic drugs and beta₂There are two main categories of receptor agonists. Tiotropium bromide is the first long-acting anticholinergic drug (LAMA). It was launched globally in 2002 and entered China in 2006. It has been ten years since it has played an important role in the treatment of COPD. The results of studies on the mechanism of action of tiotropium bromide and its efficacy and safety are briefly summarized below.

Acquired respiratory fistulas refer to acquired abnormal passages between any component of the respiratory tract or between the respiratory system and surrounding organs, including tracheal fistulas and bronchial fistulas. Tracheal fistula includes tracheoesophageal fistula, tracheomediastinal fistula, tracheal-mediastinal-gastric fistula, etc. Among them, the incidence of tracheoesophageal fistula is relatively high. Common causes of tracheoesophageal fistula include malignant tumor, tuberculosis and complications of tracheal intubation^[1]The main manifestations are choking and cough after eating and repeated aspiration pneumonia. Bronchial fistula includes bronchoesophageal fistula, bronchopleural fistula, bronchocutaneous fistula and bronchobiliary fistula, among which bronchopleural fistula is the most common. Common causes of bronchopleural fistula include stump fistula, trauma or spontaneous after lung cancer surgery^[2], mainly manifested as pneumothorax, refractory thoracic infection, etc.

Exhaled breath detection has long been used in daily life and clinical practice, such as determination of ethanol concentration during drunk driving and diagnosis of stomach Helicobacter pylori (HP) infection.¹³C/¹⁴C Exhaled breath detection and clinical end-respiratory CO₂Determination etc^[1]。 Human exhaled breath contains many substances, including small molecules of non-organic matter, such as O₂CO₂； Volatile organic compounds (VOCs), such as hydrocarbons, aldehydes, esters, etc. There are about 3,000 kinds of such substances, and generally 200 kinds can be detected; Non-volatile substances such as cytokines and leukotrienes, which can be detected in exhaled air condensate (EBC)^[2]。

Pulmonary hypertension is a series of diseases characterized by changes in pulmonary vascular function and structure, which are manifested by continuous contraction, abnormal proliferation and remodeling of distal pulmonary arterioles, which can eventually lead to right heart failure. At present, it is believed that the abnormal proliferation and migration of pulmonary vascular smooth muscle cells lead to the proliferation and remodeling of pulmonary arterioles during its pathogenesis.

Respiratory Interventional therapy originated in the mid-1990s, and "Interventional pulmonology" began to be used abroad. The correct translation should be "Interventional pulmonology".