2016年 · 第39卷第05期

This issue invites readers to focus on "Guidelines for the Diagnosis and Treatment of Cough (2015)".

Since 2009, China's "Guidelines for Diagnosis and Treatment of Cough" was promulgated^[1]Since the past six years, the Chinese cough guidelines have played an important role in improving the diagnosis and treatment level of cough in China. In recent years, many new advances have been made in the research on the pathogenesis, etiology distribution, diagnosis and treatment of cough at home and abroad, and many clinicians have been looking forward to the publication of the new cough guidelines. Therefore, the Asthma Group of the Respiratory Branch of the Chinese Medical Association started the revision of the new version of the "Guidelines for the Diagnosis and Treatment of Cough" in 2014, inviting experts in respiration, digestion, otolaryngology, pediatrics, traditional Chinese medicine and evidence-based medicine. After many face-to-face discussions or video conferences with experts, from literature retrieval, evidence extraction to the first draft of the guidelines, the new version of the Chinese Cough Guidelines was finally published^[2]。

Cough is the most common symptom of patients in respiratory specialty clinics and community outpatient clinics. In domestic specialty outpatient clinics, chronic cough patients account for more than one third. The etiology of cough is complex and involves a wide range, especially chronic cough with no obvious abnormalities in chest imaging examination. Because of unclear diagnosis, many patients often undergo various examinations repeatedly, or use antibacterial drugs and antitussive drugs for a long time, with little effect and many adverse reactions, which seriously affect the work, study and quality of life of patients, and also bring a serious economic burden^[1,2,3,4,5]。

The scabbard trachea was discovered by Simmods during autopsy in 1905. It was named after the morphological changes of the patient's trachea such as a scabbard. The pathological structure showed that the coronal diameter of the trachea was reduced and the sagittal diameter was normal. The ratio of the two was the trachea index, and the trachea index<2/3 is the scabbard trachea^[1]。 Chronic obstructive pulmonary disease (COPD) is a common disease characterized by persistent airflow restriction^[2]The literature reported that the scabbard trachea was visible in some COPD patients^[3,4,5,6,7]However, the relationship between scabbard trachea and disease grade, pulmonary function parameters and clinical prognosis of COPD patients is still lacking in further exploration. This study retrospectively analyzed the relationship between tracheal morphology and clinical data in patients with COPD, and explored the clinical significance of scabbard trachea in COPD, which is reported below.

Lung cancer is the most prevalent malignant tumor in the world^[1]CT-guided percutaneous lung tissue biopsy is one of the main methods to confirm the diagnosis of lung lesions, with an accuracy of about 74% ~99%^[2]。¹⁸F-fluorodeoxyglucose positron emission computed tomography (¹⁸F-FDG PET/CT) has the advantage of combining morphology and metabolic functional state images and complementing each other. Taking metabolically active lesions in PET/CT images as biopsy target areas can improve the puncture accuracy^[3]。 In this paper, the clinical data of 170 patients with suspected lung tumor were retrospectively analyzed by CT-guided percutaneous lung tissue biopsy, and the necessity of PET/CT routine examination before puncture and its influence on puncture accuracy were analyzed.

The patient was a 62-year-old male. He was admitted to hospital on March 23, 2015 due to "chest tightness, holding his breath with dry cough and expectoration for more than 2 months". He had a history of smoking for 40 years and had no obesity (BMI index: 19.6). Six months ago, he had irritating dry cough and yellow sputum with left chest pain without obvious trigger. He was treated with pneumonia in many hospitals, but his condition did not improve significantly, so he came to our hospital for treatment. Physical examination: The left lung breathing sounds were weakened, and wet rales could be heard. Laboratory tests: blood glucose 4.6 mmol/L, white blood cells 9.72×10⁹/L, lymphocytes 0.17, monocytes 0.13, neutrophils 6.69×10⁹/L. Bronchoscopy showed that a spherical mass grew at the distal end of the left main bronchus and the bronchial opening of the left upper lobe, with a smooth surface and tough texture, completely obstructing the lumen, the mirror could not pass, and the left bronchus at all levels could not be examined. Surgical treatment was recommended (Figure 1)。 CT examination showed that on plain scan, a type of round low-density shadow was found in the lumen of the bronchial opening of the upper lobe of the left lung with clear boundary, and the CT value was-107 HU. The upper lobe of the lung showed a patchy high-density shadow with blurred boundary (Figure 2), the lesion protrudes into the left main bronchus and blocks the bronchial opening of the lower lobe; After enhancement, the lesion was not enhanced, and the CT value was-98 HU (Figure 3)； Coronal CPR reconstruction revealed a broad base with thickened adjacent bronchial walls. The lesion was 3.6 cm away from the tracheal carina and about 2.1 cm ×1.9 cm ×2.2 cm in size. The upper lobe was filled with mucus with the distal bronchial lumen (Figure 4)； Energy spectrum curve: The lesion was consistent with the anterior mediastinal adipose tissue curve, showing a slow increasing type (Figure 5)。 Diagnosis: Left bronchial space-occupying lesion, considering lipoma and left upper lobe obstructive pneumonia and atelectasis; Iodine content measured by dual-energy CT iodine diagram (I =0.0 g/L) (Figure 6)。

A 52-year-old female was seen on May 20, 2014 due to "exertion dyspnea and cough for half a year". Six months ago, the patient developed exertion dyspnea with progressive aggravation without obvious trigger, accompanied by cough, occasional cough of a small amount of blood, no fever, night sweats, no palpitations, chest pain, chest tightness, headache, dizziness and other discomfort. On May 7, 2014, a foreign hospital diagnosed him as "bronchial asthma (asthma)". After treatment with montelukast, tiotropium bromide and levofloxacin, the symptoms were not relieved. No previous history of asthma or chronic obstructive pulmonary disease. Physical examination: Inspiratory coherent rales can be heard in the suprasternal fossa and the 1st and 2nd thoracic vertebrae. Chest CT showed nodular soft tissue density at the right posterior margin of the upper trachea (about the level of the second thoracic vertebra), about 1.00 cm ×1.17 cm ×1.00 cm, protruding into the trachea (Figure 1,Figure 2), no obvious signs of stenosis and obstruction in the trachea and bronchi, no abnormality in the size and shape of the heart, no effusion in the pleural cavity, and no obvious enlarged lymph nodes in the mediastinum. Pulmonary function test showed: FEV₁% of estimates is 80.8%, FEV₁/FVC accounted for 96.6%, PEF accounted for 62.1%, IC accounted for 69.0%, ERV accounted for 49.9%, and MVV accounted for 30.9%. On May 23, 2014, electronic bronchoscopy was performed under intravenous anesthesia. Electronic bronchoscopy showed that a new biological obstruction lumen was seen in the right lateral wall and membrane of the middle and upper trachea 5 cm below the glottis (Figure 3), bleeding at touch, fluorescence positive (Figure 4)。 Then new organisms were trapped with a high-frequency trap of 40 W, about 2 cm ×1 cm ×1 cm (Figure 5), and sent for pathological examination. After trapping, a small amount of basal bleeding was observed, and the basal area was cauterized by local perfusion of hemagglutinase 200 U and argon plasma coagulation (APC) to stop the hemorrhage (Figure 6)。 Residual neonates were measured to be 5 cm from the glottis and approximately 1 cm in length. There is a cartilage ring at the lower end of the distal trachea, which is sharp and movable. The bronchial mucosa of the trachea and each lobe segment on the left and right sides is normal, and the lumen is unobstructed. No stenosis, bleeding and new organisms are seen.

refractory cough refers to chronic cough with unknown etiology and/or poor efficacy. The diagnosis and treatment process recommended by the existing cough guidelines requires that on the basis of careful medical history and physical examination, the necessary auxiliary examinations be selected to identify the possible cause of chronic cough, and the treatment response to the cause is combined to confirm or rule out the diagnosis. Cough variant asthma, upper airway cough syndrome, eosinophilic bronchitis, allergic cough and gastroesophageal reflux cough are common causes of chronic cough^[1,2]Rare causes include obstructive sleep apnea syndrome and external auditory canal cerumen^[3]。 Following the diagnosis and treatment process, 88% ~100% of the patients' cough cause can be identified, and follow-up treatment can improve 84% ~98% of the patients' cough symptoms^[4]。 However, even after comprehensive auxiliary examination, the cause of cough in a small number of patients cannot be clarified, or although the cause can be identified, there is no effective treatment or lack of good treatment response, resulting in stubborn or persistent cough symptoms, all of which are refractory cough.

venous thromboembolism (VTE) includes pulmonary thromboembolism (PTE) and deep venous thrombosis (DVT). Worldwide, pulmonary embolism (PE) is the third most fatal circulatory disease after myocardial infarction and stroke^[1]Most of them are caused by thrombus in the venous system or right heart blocking the pulmonary artery or its branches. PTE has become a global health concern. About 900,000 new VTE cases occur in the United States every year^[2]One-third of the patients eventually died of PTE, and the remaining nearly 600,000 patients had huge medical expenses, with related investment as high as $5.8-7.8 billion/year. With the improvement of diagnostic technology and attention, the total number of PTE cases in more than 50 large hospitals in China increased by nearly 30 times from 1995 to 2006, among which the number of PTE cases diagnosed and treated by the PTE-DVT prevention and treatment cooperative group increased by 3~10 times^[3]。

Interventional respiratory disease is a medical science and technique concerning the invasive diagnosis and treatment of respiratory diseases^[1]。 With the development of modern science and technology such as basic medicine and medical engineering, the scope of interventional diagnosis and treatment and the application value of related technologies in respiratory diseases are increasing day by day. At present, interventional respiratory disease has entered a stable, healthy and rapid development stage, and has made outstanding achievements in many fields. This article summarizes the important technological progress made in clinical diagnosis and treatment of interventional respiratory disease in 2015 as follows.

Nanotechnology is a multi-disciplinary new technology, which is closely related to basic research and application development. It includes many new disciplines such as nanomaterials science, nanochemistry, nanomechanics and nanomedicine. It can also be applied to vaccine development, immunoassay, gene diagnosis, immunohistochemistry and cell imaging, etc. Nanotechnology has become a research hotspot in the medical field.

With the widespread application of anti-tuberculosis drugs and antibiotics, the number of patients with multi-drug resistant tuberculosis (MDR-TB) and extensively drug resistant tuberculosis (XDR-TB) has increased significantly, and the global tuberculosis epidemic situation is very severe. According to the 2014 World Health Organization Global Tuberculosis Report, there were 480,000 new cases of MDR-TB in 2013. Among the global tuberculosis patients, new cases of MDR-TB accounted for 3.5%, and previously treated cases accounted for 20.5%^[1]。 The treatment of MDR-TB is very difficult due to the increased resistance rate of existing antituberculous drugs, and it is urgent to find effective therapeutic drugs.

chronic cough (CC) is a common clinical symptom, but up to 40% of patients suffer from cough because they cannot identify the cause or have not been effectively treated, which greatly affects the quality of life, and has become an urgent problem in clinical practice^[1]。 June 2015 online versionCHESTThis chronic cough of unknown etiology or failure of empirical treatment is collectively referred to as unexplained chronic cough (UCC) in the guidelines and expert panel reports^[2]。

On January 28, 2016, the first Beijing Young Respiratory Scholars Salon in 2016 was held in Chinese Medical Association. The theme of this discussion is "Precision Medicine of Respiratory Diseases", and the related issues of precision medicine of respiratory diseases are discussed in depth. Liu Guoliang, Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, presided over it.

At concerts, we can often hear a very beautiful chorus song-"Miss Hometown": "Miss Hometown, Miss Hometown, Hometown is really lovely, the sky is blue, the wind is cool, and nostalgia comes in waves...". This "Missing Hometown" is actually an adaptation of the second movement of the "New World Symphony" by Czech musician Dvořák. In 1892, Dvorak was invited by a wealthy American businessman to teach in New York. In the New World, I miss my hometown, and my homesickness is getting thicker, so I have this homesickness that has been sung until now.

Non-bronchial asthmatic (asthmatic) eosinophilic bronchitis (NAEB), a common cause of chronic cough, shares eosinophilic airway inflammation similar to asthma and is effective with glucocorticoid therapy without airflow obstruction and airway hyperresponsiveness. About 30% to 49% of patients with chronic obstructive pulmonary disease (COPD) have airway eosinophil inflammation and respond well to hormone therapy. There have been previous case reports of patients with NAEB who eventually develop irreversible airflow obstruction. Whether NAEB can progress to asthma or COPD is not conclusive.

Common causes of chronic cough include cough variant asthma (CVA), upper airway cough syndrome (UACS), eosinophilic bronchitis (EB), gestroesophageal reflux-related cough (GERC) and atopic cough (AC). Among them, CVA, EB and AC can be classified as corticosteroids responsive cough (CRC) because they are effective for hormone therapy, while UACS, GERC and other causes can be classified as non-corticosteroids responsive cough (NCRC). fractional exhaled nitric oxide (FeNO) is a novel marker that can reflect eosinophil inflammation of the lower airways. The previous value of FeNO in predicting the effectiveness of inhaled hormone therapy in patients with chronic cough remains unclear. Therefore, this study investigated the predictive value of the FeNO assay alone, or the combination of FeNO assay, percentage of induced sputum eosinophils (Eos%) and detection of allergic signs for hormone-sensitive cough.

There are many clinical and basic studies on bronchial asthma (asthma), and the expressions of "severe asthma" and "severe asthma" can often be seen in domestic literature. The author searched the Chinese Journal of Tuberculosis and Respiration in Wanfang Database with the titles of "severe" + "asthma" and "severe" + "asthma" respectively. The search time was from January 2000 to November 2015, and it was found that there were 8 articles of "severe" + "asthma"^{[1,2,3,4,5,6,7,8]}"Severe" + "Asthma" is 7 articles^{[9,10,11,12,13,14,15]}If it is a full-text search, the number is larger. For example, Professor Sun Yongchang has "severe asthma"^[4,5]Also have "severe asthma."^[9,10,12,15]Professor Liu Guoliang's statement is also the same^[6,7,13]。 Reading a large number of literatures related to "severe asthma" and "severe asthma" also found that at present, no scholars strictly distinguish between the two, and there seems to be little difference.

Dr. Ji Ningfei put forward the different expressions of "severe asthma" and "severe asthma" common in domestic literature, and proposed that medical vocabulary should be standardized, unified and avoid ambiguity as much as possible. Here, I will reply to this question.

In 2015, the main lung function parameters were interpreted in 6 phases, and the relevant parameters of mechanical ventilation were continued to be interpreted according to the established plan in this period^[1], the first is the pressure of mechanical ventilation.