2017年 · 第40卷第08期

Among the many older generation of respiratory scholars who founded and developed the respiratory specialty in China, Professor Mu Kuijin is one of the early founders and founders. 2017 marks the 100th anniversary of Mu Lao's birth and the 20th anniversary of his death. For this reason, Professor Liu Youning and Professor He Quanying, editors-in-chief of this journal, wrote articles in memory of Mu Lao, "The memory left by Mu Lao to me" and "The mountains stand up, and the style lasts forever", remembering Mu Lao, thanking and admiring his spirit of being a ladder for the development of respiratory diseases and his noble character of silent dedication. Let our colleagues in the breathing world commemorate his old man together!

2017 marks the 100th anniversary of Mu Lao's birth and the 20th anniversary of his old man's death. Don't forget the well digger when drawing water. Let our colleagues in the breathing industry commemorate his old man together.

Professor Mu Kuijin is the pioneer of respiratory disease in China, and at the same time, he is one of the early founders and founders of respiratory disease in China.

Since penicillin was applied in clinic in the 1940s, human beings have achieved remarkable results in fighting lung infections. However, in recent years, with the emergence of drug-resistant bacteria, intravenous and other systemic drug administration methods are difficult to achieve satisfactory efficacy for acute infections such as ventilator associated pneumonia (VAP). At the same time, the pathogens of structural lung diseases such as bronchiectasis and cystic pulmonary fibrosis are often difficult to remove, resulting in repeated and chronic infections, and the bacterial resistance caused by long-term use of antibacterial drugs makes it more difficult to treat. Topical administration methods such as aerosol inhalation antibacterial drugs can increase the drug concentration at the infected site and help to improve the curative effect. Therefore, it has been paid more and more attention, but its clinical application is not standardized. This paper introduces the application process and research progress of topical antibacterial drugs in lower respiratory tract, and puts forward the indications and precautions for use on this basis.

Gram-negative bacteria can cause a variety of infections, but they are more common in hospital-acquired infections, with the following respiratory infections being the most common. Resistant gram-negative bacteria mainly include Escherichia coli, Klebsiella pneumoniae and Enterobacter bacteria in Enterobacteriaceae and Pseudomonas aeruginosa, Acinetobacter baumannii and Stenotrophomonas maltophilia in non-fermenting bacteria^[1]。 Due to the severe drug resistance of Gram-negative bacteria, the available antimicrobial drugs are limited, and infected patients often have multiple basic diseases, so the treatment is difficult and the mortality rate is high. The World Health Organization also recently listed carbapenem-resistant Enterobacteriaceae (CRE), carbapenem-resistant Acinetobacter baumannii (CRAB) and carbapenem-resistant Pseudomonas aeruginosa (CRPA) as the most severe drug-resistant bacteria. Therefore, how to reasonably apply antibacterial drugs to treat drug-resistant Gram-negative bacteria infection is increasingly important.

"Chinese Adult Community-Acquired Pneumonia Diagnosis and Treatment Guidelines (2016 Edition)" was published in Chinese Journal of Tuberculosis and Respiration, Volume 39, Issue 4, 2016^[1]According to the guidelines, community-acquired methicillin-resistant Staphylococcus aureusStaphylococcus aureus,CA-MRSA) pneumonia has only been reported in a small number of children and adolescents, and no CA-MRSA was found in the pathogen testing of community-acquired respiratory infections in Chinese adults conducted from 2009 to 2010^[1]。 However, CA-MRSA can cause severe pneumonia, and many cases have been reported abroad, so it is of great clinical significance to correctly identify this disease. This paper discusses the epidemiological definition and limitation of CA-MRSA, gene definition and typing methods, comprehensive diagnosis and molecular epidemiological characteristics of CA-MRSA at home and abroad, so that clinicians can better understand the significance of genotyping in the diagnosis and clinical research of CA-MRSA pneumonia.

The problem of bacterial drug resistance is a common challenge faced by the world, and the problem of drug resistance of Gram-negative bacteria is particularly prominent. There are few types of new antibacterial drugs aimed at drug-resistant Gram-negative bacteria, and the problem of resistance to new antibacterial drugs is continuously reported. extensive drug resistance (XDR) bacteria and pandrug resistance (PDR) bacteria continue to appear, and even appear local epidemics in a few hospitals and a few areas, which need to be paid attention by clinicians.

In the late 1960s, flexible bronchoscopes were first used in clinic^[1]。 1974 Reynolds and Newball^[2]broncho alveolar lavage (BAL) with bronchoscope provides a new method for the diagnosis of respiratory diseases. With the improvement of clinical diagnosis, treatment and detection, it has been found that cytology, soluble proteins, enzymes, cytokines, bioactive mediators and other information can be obtained from bronchoalveolar lavage fluid (BALF). Therefore, BAL has become an important method for diagnosing some lung diseases such as bronchopulmonary cancer, interstitial lung disease and lung infectious diseases^[3,4,5,6,7]。 In order to standardize the operation technique of BAL, the Respiratory Branch of Chinese Medical Association formulated the "Technical Specification for Cytological Examination of Bronchoalveolar Lavage Fluid (Draft)" in 2002 according to the specific situation in China^[8]。 In 2012, the American College of Chest Physicians issued "Clinical Application of Cytological Analysis of Bronchoalveolar Lavage Fluid in Interstitial Lung Disease"^[9]。 In recent years, galactomannan (GM) test in BALF has become one of the diagnostic criteria recommended by the American Society of Infectious Diseases (IDSA), the European Collaborative Group for Cancer Research and Treatment of Invasive Fungal Infections and the American Association of Allergy and Infectious Diseases Mycosis Research Group (EORTC/MSG) because of its good sensitivity and specificity^[10,11]。 At present, the specific operations and processing procedures of using BALF to detect pathogens are different at home and abroad. In order to make full use of the detection value of BALF, increase the detection rate of BALF pathogens, and improve the success rate of diagnosis and treatment of pulmonary infectious diseases, it is necessary to further standardize the operation flow and specimen processing of BAL, so as to better guide clinical practice. Therefore, the Infectious Disease Group of Respiratory Disease Branch of Chinese Medical Association organized experts to write the "Chinese Expert Consensus on Detection of Bronchoalveolar Lavage Pathogens in Pulmonary Infectious Diseases".

Since December 2016, the number of confirmed cases of human infection with H7N9 avian influenza in China has increased significantly, and the mortality rate is high. In order to standardize the treatment of human infection with H7N9 avian influenza in China, improve the success rate of treatment and reduce the mortality rate, the Medical Administration and Hospital Administration Bureau of the National Health and Family Planning Commission organized relevant clinical and infection control experts to revise the 2014 version of the H7N9 diagnosis and treatment plan. Now, the main contents of the "Human Infection with H7N9 avian influenza diagnosis and treatment plan (2017 first edition)" are interpreted.

Pulmonary embolism is a common acute and critical disease in clinic, with high morbidity and mortality. It is estimated that the overall annual incidence of pulmonary embolism is 100~200/100,000 people. Among the deaths caused by venous thrombotic diseases, only about 7% are diagnosed before death, about 34% of patients have sudden death, and up to 59% of patients have never been diagnosed with pulmonary embolism^[1]The rate of early misdiagnosis and missed diagnosis is as high as 30%^[2]。 A patient with atypical pulmonary embolism with cough as the main manifestation was admitted to the respiratory department of the affiliated hospital of Ningbo University School of Medicine. The D-dimer test was negative multiple times, and the diagnosis was finally confirmed by CT pulmonary angiography. The diagnosis and treatment process of this patient is reviewed and reported as follows.

anti-synthetase syndrome (ASS) is a special type of idiopathic inflammatory myopathy (IIM), which has characteristic positive serum anti-synthetase antibodies. According to different anti-synthetase antibodies, it is divided into different clinical subtypes of ASS, and different clinical subtypes will have different clinical characteristics and prognosis. anti-histidyl-tRNA synthetase (anti-Jo-1) syndrome is the most common ASS subtype^[1]。 A patient with recurrent anti-Jo-1 syndrome is reported in order to improve the understanding of this type of disease.

Although the incidence of pulmonary actinomycosis has increased in recent years^[1,2]However, due to its relatively low incidence rate and atypical clinical symptoms and signs, it is easy to be misdiagnosed^[3,4]。 A case of pulmonary actinomycosis admitted to our hospital is reported as follows.

Population ageing has become a social problem facing the world. It is estimated that between 2011 and 2050, the number of older people over the age of 65 will increase from 546 million to 1.6 billion, accounting for 17 percent of the global population; The number of people suffering from respiratory diseases will grow at a similar rate, with an estimated 300 million people worldwide suffering from bronchial asthma (asthma), with 250,000 people losing their lives every year^[1]。 Asthma has long been thought to occur in children and adolescents, but in reality, the incidence of asthma in people over 65 is similar to that in other age groups^[2]And the prevalence is increasing year by year. Compared with other age groups, the clinical diagnosis and treatment of asthma in the elderly face more difficulties: clinical diagnosis is difficult, the majority of severe patients, poor response to drug treatment, high hospitalization rate and mortality rate^[3]。 However, at present, the principles followed in the process of asthma diagnosis and treatment are mainly for the research results of young patients, and the lack of clinical research for elderly patients, which is mainly closely related to the following factors^[4]: (1) the elderly population generally does not meet the age-admission criteria for randomized controlled studies; (2) Elderly asthma patients are often accompanied by a variety of diseases, which affect the interpretation of research results. With the gradual deepening of research on asthma, it has been increasingly confirmed that asthma is a very heterogeneous disease type^[5]And the pathogenesis of elderly patients is more unique, which is reviewed as follows.

transbronchial cryobiopsy (TBCB) is a technique in which a cryoprobe is extended into the distal bronchus through the bronchi, and the adhesion of the cryoprobe during freezing is used to violently tear the lung tissue around the probe to obtain histological specimens. Freezing technology was first applied in the diagnosis and treatment of airway diseases in 1976^[1]It is mainly used for freeze-thaw treatment of tumors in the airway. Hetzel et al.^[2]In 2008, the concept of cryobiopsy was formally proposed, and this technique was introduced into the field of respiratory intervention. In this study, endobronchial cryobiopsy (EBCB) was performed on 12 patients with endobronchial tumors, and good results were achieved. 2009 Babiak et al.^[3]This technology has been successfully used in lung biopsy, which is now TBCB. Because TBCB has the advantages of less trauma, high specimen quality, low cost and fewer complications, it was quickly developed in Germany, the United States, Italy, the United Kingdom, Spain, Israel, Portugal and China.

The differentiation between benign and malignant solitary pulmonary nodule (SPN) or mass has been an important issue in clinical and imaging diagnosis^[1,2]。 Traditional transbronchial lung biopsy (TBLB) is blind in the examination, and the diagnostic rate of peripheral pulmonary nodules is relatively low because it simply assists in judging the location of lesions based on chest CT reading. In addition, CT-guided percutaneous lung puncture leads to a higher risk of pneumothorax and sudden death^[3,4]。 virtual bronchoscopy navigation (VBN), including Directpath VBN, Lungpoint VBN and electromagnetic navigation bronchoscopy (ENB), is a novel virtual imaging technology based on CT^[5]Where electromagnetic navigation is real-time navigation on micromagnetic fields, not virtual navigation in the complete sense. Through image recognition technology, VBN can establish a virtual bronchial pathway, and at the same time, combined with C-arm X-ray fluoroscopy (X-Flu) or radial probe endobronchial ultrasound (RP-EBUS), the bronchoscope can be guided to the target lesion, which can greatly improve the accuracy of biopsy and puncture site and reduce trauma. In recent years, scholars at home and abroad have tried to perform lung biopsy through bronchoscopy with the assistance of VBN. This article summarizes the diagnostic application of VBN as follows, aiming to evaluate the diagnostic value of VBN combined with EBUS or X-Flu in peripheral pulmonary lesions (PPLs), and further promote the development of research related to rapid diagnosis of peripheral pulmonary lesions.

idiopathic inflammatory myopathy (IIM) includes polymyositis, dermatomyositis, inclusion body myositis, and immune-mediated necrotizing myopathy; In recent years, with the proposal and clinical application of myositis-specific antibodies (MSA) and the research progress on interstitial lung diseases, the anti-synthetase syndrome (ASS) and clinically amyopathic dermatomyositis (CADM) and other special subtypes have been further understood^[1,2]。 Interstitial lung disease was associated in 20% ~78% of patients with IIM. ASS, CADM and traditional polymyositis and dermatomyositis were more common, which seriously affected the prognosis of these patients^[3,4]。 In order to improve the diagnosis and treatment level of IIM associated interstitial lung disease (IIM-ILD), the progress of diagnosis and treatment of IIM-ILD in the past three years is summarized as follows.

The patient, a 74-year-old male, was admitted to our ward on October 2, 2016 mainly due to "intermittent cough with fever for 3 months". The patient developed fever after catching cold 3 months ago, with a maximum body temperature of 38.5 ℃, accompanied by cough and expectoration, and increased peripheral blood eosinophilia. X-ray chest radiograph showed consolidation of left lung and right upper lung (Figure 1)。 The hospital diagnosed "pulmonary infection". After antibiotics and glucocorticoid treatment (details unknown), the body temperature and blood image returned to normal, and the pulmonary lesions were obviously absorbed. This was followed by oral prednisone 30 mg/d with a weekly reduction of 5 mg, which had been reduced to 5 mg/d prior to admission. One day before admission, fever and cough appeared again after bathing and catching cold, and the peripheral blood white blood cell count was 12.9×10⁹/L, neutrophils 0.773, eosinophils 0.056%, C-reactive protein 100 mg/L, chest X-ray showed left lung exudation (Figure 2), after 5 days of anti-infective treatment with moxifloxacin, reexamination of chest X-ray showed obvious progression of left lung lesions (Figure 3)。 Previous chronic obstructive pulmonary disease for 10 years. History of allergies to drugs such as penicillin, sulfa, streptomycin, etc. There are many plants in the living environment for a long time, including asparagus, etc. Recently, the environment has not changed, and there is no contact with pets, poisons and dust. Smoking for 30 years, 2 packs/d, having quit smoking for 20 years, occasionally drinking alcohol. History of rhinitis and sinusitis denied. Physical examination: body temperature 39.2 ℃, 20 breaths/min, blood pressure 143/83 mmHg (1 mmHg =0.133 kPa), fingertip oxygen saturation 94% (no oxygen inhalation), no rash on the skin and mucosa of the whole body, small superficial lymph nodes, no conjunctiva congestion, no tenderness in the sinus area. There was no thoracic deformity, bilateral respiratory motility was symmetrical, damp rales in inspiratory phase could be heard in the left lung, but dry rales and pleural friction sounds were not heard. No obvious abnormalities were observed in the heart. Both lower limbs are not swollen.

The patient was a 55-year-old female. He went to the outpatient clinic of our hospital on April 22, 2016 because of "the discovery of lung shadow for 1 year". The patient found a shadow in the left lower lung during physical examination 1 year ago, and chest CT showed multiple nodules in both lungs, notably in the left lower lung, and multiple enlarged lymph nodes in the mediastinum (Figure 1,Figure 2,Figure 3,Figure 4), without fever, cough, shortness of breath and night sweats. Considering the possibility of tuberculosis, the local hospital gave experimental anti-tuberculosis treatment for 6 months. After reexamination of chest CT, the left lower lung nodule did not shrink compared with before. Later, a puncture biopsy of the left lower lung nodule was performed in the outside hospital, and the pathology was granulomatous inflammation, so he came to the outpatient clinic of our hospital. Past physical health, denial of exposure to special substances and history of allergies. Physical examination: There was no rash on the skin and mucous membranes, and the superficial lymph nodes were not palpable and swollen. No abnormalities were observed in the heart, lung and abdomen. Preliminary diagnosis: The nature of multiple nodules in both lungs is to be investigated.

Community-acquired pneumonia in adults is a common disease. "Guidelines for Diagnosis and Treatment of Community-acquired Pneumonia in Adults (2016 Edition)"^[1]It has been published in Chinese Journal of Tuberculosis and Respiration, Volume 39, Issue 4, 2016. The diagnostic criteria of severe pneumonia in this paper are: meeting one primary criteria or ≥3 secondary criteria. Main criteria: (1) Mechanical ventilation treatment required tracheal intubation; (2) Septic shock that still needs vasoactive drugs and vasopressor drugs after active fluid resuscitation. Secondary criteria: respiratory rate ≥30 beats/min, arterial oxygen partial pressure/oxygen concentration ≤250, multiple lobar infiltration, disorder of consciousness and/or disorientation, blood urea nitrogen ≥7.14 mmol/L, systolic blood pressure<90 mmHg (1 mmHg =0.133 kPa), Aggressive fluid resuscitation is required^[1]。 Compared with the guidelines jointly developed by ATS and IDSA in 2007, the secondary criteria developed by our guidelines have reduced leukopenia (<4×10⁹/L), thrombocytopenia (count<10×10⁹/L) and hypothermia (deep body temperature<36 °C), while no other criteria were mentioned, including hypoglycemia (non-diabetic patients), acute alcohol withdrawal syndrome, hyponatremia, unexplained metabolic acidosis or hyperlactatemia, cirrhosis, or absence of spleen^[2]。 Simplifying the diagnostic criteria of severe pneumonia is mainly based on Salih et al^[3]In 2013 atEur Respir JPublished meta-analyses.

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