2016年 · 第39卷第04期

The Respiratory Branch of Chinese Medical Association promulgated China's first "Community Acquired Pneumonia (CAP) Diagnosis and Treatment Guidelines" in 2006, which has played an important leading role in guiding clinicians to correctly diagnose CAP, select appropriate etiological diagnosis methods, comprehensively assess the disease condition, optimize anti-infective drug treatment, effectively prevent, improve prognosis and promote the continuous progress of CAP scientific research in China. In the past ten years, the drug resistance spectrum of important CAP pathogens in China has changed, new pneumonia pathogens have been discovered one after another, and new evidence has been accumulated for anti-infective drug treatment and vaccine prevention. However, at this stage, there are still many problems in the diagnosis and treatment of CAP in China, such as the choice of treatment place for CAP patients does not refer to the severity of the disease; There is a tendency to be hospitalized for mild CAP; For CAP patients who are hospitalized or even in ICU, they are only satisfied with empirical treatment and neglect the search for etiological evidence and anti-infective treatment under the guidance of etiology; Empirical treatment of CAP is highly random, and it is customary to choose broad-spectrum antibacterial drugs or even broad-spectrum antibacterial drug combination therapy; Due to the lack of etiological evidence, descending ladder treatment is impossible to talk about; The incidence of viral pneumonia is underestimated and the use of antiviral drugs is low; Health education for CAP patients is neglected, and the vaccination rate of influenza virus vaccine and Streptococcus pneumoniae vaccine is low. Against this background, the Respiratory Disease Branch of Chinese Medical Association revised and updated the 2006 edition of the guidelines, and gave guiding opinions on the above problems. The new guidelines are mainly updated in the following aspects: (1) a 6-step method for adult CAP diagnosis and treatment is clearly proposed; (2) Adult CAP score criteria and severe CAP criteria are more simplified; (3) Clearly propose the identification points of bacterial, mycoplasma, chlamydia and viral pneumonia; (4) Empirical treatment refers to the pathogen spectrum and drug resistance characteristics of adult CAP in China; (5) Attach importance to etiological examination and target anti-infective treatment; (6) Attach importance to adult viral pneumonia and antiviral treatment. "Guidelines for the Diagnosis and Treatment of Community-Acquired Pneumonia in Chinese Adults (2016 Edition)" is published in the "Diagnosis and Treatment Plan" column of this issue. Please read and learn.

The Respiratory Branch of Chinese Medical Association issued the first "Community Acquired Pneumonia (CAP) Diagnosis and Treatment Guidelines" in China in 2006^[1]It has played an important leading role in guiding clinicians to correctly diagnose CAP, select appropriate etiological diagnosis methods, comprehensively assess the condition, optimize anti-infective drug treatment, effectively prevent, improve prognosis and promote the continuous progress of CAP scientific research in my country.

community acquired pneumonia (CAP) is a common and frequently occurring disease in respiratory department, ranking 5th to 6th in total human mortality. In particular, Severe CAP (SCAP) is a progressive disease, from local lung inflammation to systemic inflammation, leading to a series of infection-related complications, such as sepsis, sepsis, septic shock and multiple organ dysfunction, etc. If not treated in time and incorrectly, the course of the disease will develop progressively, with respiratory failure, circulatory failure, deterioration of underlying diseases and failure of initial anti-infective treatment, etc. At the end stage, it can also lead to hypercoagulation and fibrinolysis impairment, and the mortality rate can reach 21% ~54%^[1]。 This paper summarizes and analyzes the common misunderstandings in the diagnosis and treatment of SCAP at present, in order to form a correct clinical treatment path, reduce misdiagnosis and mistreatment, and improve the success rate of rescue.

For the treatment of general community-acquired pneumonia (CAP), satisfactory clinical efficacy can be achieved only by empirically selecting antimicrobial drugs covering possible pathogens according to clinical characteristics and referring to guidelines, which is not a difficult problem in the clinical treatment of CAP. However, for patients with severe pneumonia, especially those in ICU, there are often multiple organ dysfunctions, which may change the pharmacokinetic (PK) characteristics of antimicrobial drugs, thus affecting the efficacy of drugs. Because most antibacterial drugs are mainly cleared through the kidney, the influence of abnormal renal function in critically ill patients on antibacterial drugs is particularly prominent, especially for water-soluble antibacterial drugs. Understanding the influence of renal function changes on drugs during severe infection and adjusting according to PK can improve the efficacy of antibacterial drugs and reduce toxic and side effects, which is of great significance for improving the success rate of severe CAP patients. This article will discuss several problems that are easily overlooked in the treatment of severe infection.

At present, community-acquired pneumonia (CAP) remains one of the leading causes of death worldwide^[1]。 The most common pathogens of CAP were Streptococcus pneumoniae, Haemophilus influenzae and atypical pathogens (Legionella, Chlamydia and Mycoplasma), accounting for 30%, 12% and 22% respectively^[2,3,4]。 The abuse of antimicrobial drugs leads to the global spread of bacterial resistance, such as Streptococcus pneumoniae resistance to penicillin and cephalosporin although relatively stable, but the resistance to macrolides is on the rise^[5]； Among atypical pathogens, the resistance rate of Mycoplasma pneumoniae to macrolide antibacterial drugs is 10% ~90%, and the resistance rate in China is as high as 92%^[6]。 The incidence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) pneumonia has also increased year by year in recent 10 years^[7,8]； Vancomycin-mediated (VISA), vancomycin-resistant (VRSA), and even linezolid-resistant (LRSA) S. aureus is emerging^[9,10,11]It also brings challenges to the treatment of CA-MRSA.

Scope of application of this guideline: non-immunodeficient patients with community-acquired pneumonia (CAP) aged 18 years and older.

The 11-year-old child was admitted to hospital for "coughing and expectoration for more than 3 months and wheezing for nearly 1 month". In June 2013, he developed high fever with no obvious trigger, up to 40 ℃, accompanied by cough and white sticky sputum, without chills, convulsions, wheezing, chest pain, vomiting, diarrhea and other discomfort, so he went to the local hospital for 15 days of anti-infective treatment with azithromycin, and his body temperature was normal, but he still had cough and sputum, so he was transferred to Wuhan Children's Hospital for 16 days of hospitalization. During his hospitalization, multiple chest CT examinations showed changes in lobar pneumonia. After anti-infective treatment, his condition improved and he was discharged.⁹/L, 0.26 for neutrophils and 1.13×10 for eosinophils⁹/L (14.7%). At the beginning of August 2013, the child developed wheezing, which was more severe at night, and still had cough in the morning, coughing yellow purulent sputum intermittently, accompanied by coughing bloodshot for 1 day. Blood routine in our outpatient clinic showed that the white blood cells were 14.4×10⁹/L, 0.32 for neutrophils and 3.74×10 for eosinophils⁹/L (26%). X-ray chest radiograph suggested the possibility of infectious lesions, so he was admitted to the pediatric ward of our hospital on September 17, 2013 with "pneumonia". The child had no previous history of drug or food allergy. Physical examination: temperature 36.0 ℃, pulse rate 104 beats/min, respiratory rate 21 beats/min, blood pressure 107/78 mmHg (1 mmHg =0.133 kPa), body weight 35.5 kg. Shortness of breathing, no obvious rash and bleeding spots all over the body, and no obvious swelling of superficial lymph nodes. The lips are red, the neck is soft, the pharynx is slightly congested, the right tonsil is I degree large, the breathing sounds of both lungs are coarse, and obvious expiratory phase wheezing sounds can be heard. Routine blood test at admission: white blood cells were 11.87×10⁹/L, 0.30 for neutrophils and 3.34×10 for eosinophils⁹/L (28.1%), CRP 0.2 mg/L (normal 0.1~3 mg/L), PCT 0.06 μ g/L (normal reference value<0.05 μ g/L). G test: 596.7 ng/L (normal reference value<20 ng/L), GM test: 0.27 (>0.5 is positive), full set of parasites: negative. After 1 week of anti-infection treatment (azithromycin 0.375 g once/d, stopped with 3 d for 4 d, paracillin and sulbactam sodium 1.5 g once/12 h), the patient's symptoms did not improve significantly. After reexamination of blood routine, the white blood cells were 8.95×10⁹/L, 0.28 for neutrophils and 2.97×10 for eosinophils⁹/L (33.2%), because the remission of the disease is not obvious, after consultation with our department, the total IgE>5 000 IU/ml (normal reference value<100 IU/ml), combined with chest CT (Figure 1，Figure 2), considered as "allergic bronchopulmonary aspergillosis (central bronchiectasis)".

Interventional embolization in the treatment of bronchiectasis and hemoptysis has been widely used in clinical practice and achieved good curative effect^[1]。 The involvement of unilateral inferior phrenic artery (IPA) in bronchiectasis hemoptysis has been reported in the literature^[2]While bilateral inferior phrenic arteries are involved simultaneously and both are accompanied by systemic-pulmonary circulatory shunt is relatively rare. Recently, our hospital successfully intervened in a patient with bilateral inferior phrenic artery with systemic-pulmonary shunt advantage involved in bronchiectasis and hemoptysis, which is reported below.

community-acquired pneumonia (CAP) is a common respiratory disease and a major cause of death and complications in humans^[1]。 The key to the cure of CAP lies in the early and accurate application of antibiotics, but at present, empirical treatment is still the main clinical treatment. In recent years, the pathogenic spectrum of CAP has been changing continuously, and the detection rate of rare pathogens has increased significantly. Therefore, empirical treatment of CAP cannot completely cover the pathogens, and clarifying the composition of CAP pathogenic spectrum will directly affect the prognosis of CAP patients. There are important advances in pathogenic detection methods, especially rapid detection methods, which play an important role in guiding the clinical use of CAP. The changes of the composition spectrum of CAP pathogens at home and abroad and the progress of laboratory detection methods are summarized as follows.

Obstructive sleep apnea syndrome (OSAS) refers to a sleep disorder of breathing in which partial or complete obstruction of the upper respiratory tract occurs repeatedly during sleep, resulting in interruption (apnea) or reduction (hypopnea) of airflow, resulting in decreased blood oxygen saturation and hypercapnia, followed by micro-arousal. Patients typically presented with fatigue and daytime drowsiness, loss of attention or memory, and a history of sleep snoring^[1]。 Apnea-hypopnea index (AHI) is the main index reflecting the severity of OSAS at home and abroad. According to AHI values, OSAS can be classified as mild (5 to 15 times/h), moderate (15 to 30 times/h) and severe (≥30 times/h). It has been found that whether patients with mild OSAS show daytime symptoms or not, it may be associated with a significant increase in the incidence of cardiovascular disease^[2]And the role of inflammatory response in the pathogenesis of OSAS and its complications has been paid more and more attention. The progress of genetic basic research for assessing inflammatory response in OSAS patients is reviewed below.

When you see the word "Hertz", the first thing that comes to mind is probably "This is the unit of frequency". Later, most people will think that this is because Heinrich Hertz confirmed the existence of electromagnetic waves, and the physics community named the unit of frequency after him in honor of him. However, only a few people know that Hertz confirmed the existence of electromagnetic waves in his own humble laboratory at the age of 30, and by the age of 36, this genius died young, which is a great loss for the physics community.