2018年 · 第41卷第04期

The focus of this issue is lower respiratory tract infection. In the essay column of the editor-in-chief, Liu Youning, the editor-in-chief of this journal, introduced the contents of the 1999, 2006 and 2016 editions of the guidelines for the diagnosis and treatment of community-acquired pneumonia in China in the article "The evolution and progress of the guidelines for the diagnosis and treatment of community-acquired pneumonia in adults in China", analyzed the problems existing in the guidelines and expressed his personal opinions. The writing is fluent and recommended to read.

The first edition of "Community Acquired Pneumonia Diagnosis and Treatment Guidelines (Draft)" developed by the Respiratory Branch of Chinese Medical Association^[1]It was published in 1999 in Chinese Journal of Tuberculosis and Respiration, Volume 22, Issue 4. It is the first step from scratch. Looking back at the guide from the present point of view is indeed too simple, and it is suspected of sorry readers. The full text is only a little more than 2 pages, without personal signature. It is only stated in parentheses at the end of the text that the draft was adopted at the Third National Academic Conference on Pulmonary Infections and Interstitial Lung Diseases in 1988, and there is no reference after the text.

The Respiratory Branch of Chinese Medical Association promulgated the first "Guidelines for Diagnosis and Treatment of Hospital Acquired Pneumonia (Draft)" in China in 1999^[1]It has played an important leading role in guiding clinicians to correctly diagnose and treat hospital-acquired pneumonia (HAP). In recent 20 years, a series of guidelines on HAP/ventilator-associated pneumonia (VAP) have been published and updated at home and abroad^[2,3,4,5,6]Both diagnosis and treatment have made great progress, but there are still many controversies and difficulties. Similarly, China has accumulated a large amount of evidence-based medical evidence in the diagnosis and treatment of HAP/VAP, and many aspects, especially the etiology and drug resistance, are different from those in European and American countries. Therefore, how to guide our clinicians to correctly diagnose and treat HAP/VAP is a difficult problem faced by our country's respiratory and critical care medicine departments. It is urgent to update our country's guidelines to further standardize clinical diagnosis and treatment.

hospital acquired pneumonia (HAP) and ventilator associated pneumonia (VAP) are the first nosocomial infectious diseases in China, and the second to fourth in western developed countries; According to the prevalence, the results of the International ICU One-Day Prevalence Survey of Infection showed that the prevalence of overall infection was 51% (7 087/13 796), and the use of antimicrobial drugs was 71%; 56% of the patients underwent mechanical ventilation, and the infection rate was 67.6%; The prevalence of culture-positive respiratory infections was 63.6%, much higher than abdominal infections (19.6%), bloodstream infections (16.1%) and kidney or urinary tract infections (19.3%)^[1]。 According to literature reports, 30% ~60% of ICUs have unnecessary, inappropriate or undesirable use of antimicrobial drugs^[2]About 50% of ICU antimicrobial prescriptions are for the treatment of VAP. We often say that ICU is the hardest hit area with a large amount of antibacterial drugs, and it is also the key department for infection control and antibacterial drug treatment. VAP is the key disease.

Clinically, according to the resistance of microorganisms to antimicrobial drugs, they are divided into multidrug resistance (MDR), extensive drug resistance (XDR) and pan-drug resistance (PDR). These drug-resistant microorganisms can cause a variety of refractory infections, and it is often necessary to passively upgrade the level of antimicrobial drugs or combine multiple antimicrobial drugs to deal with them in clinic. At present, the situation of microbial resistance to antimicrobial drugs is becoming increasingly severe.

Whether in the empirical treatment of critical infections, refractory infections, or in the targeted treatment of drug-resistant bacterial infections, the combined application of antimicrobial drugs is one of the commonly adopted therapeutic strategies. Theoretically, compared with single-agent anti-infective therapy, combination drugs can obtain a wider antibacterial spectrum through the complementarity of antibacterial spectra between different drugs, and produce stronger antibacterial activity through the synergistic action between different drugs. In addition, combination drugs may also help to reduce the risk of rapid secondary resistance of pathogenic bacteria during anti-infective therapy. However, the adverse effects of combination of antimicrobial drugs cannot be ignored, including the risk of drug-related adverse reactions, the increase of treatment costs and the increase of total amount of antimicrobial drugs leading to the increase of antimicrobial drug selection pressure, etc^[1]。 It is worth noting that from the available data, most clinical research results have not confirmed the theoretical efficacy advantages of combination drugs, and some research results suggest that only a specific few patients can benefit from combination therapy with anti-infective drugs^[1,2,3]。 At present, bacterial drug resistance is constantly increasing, and various super-drug-resistant bacteria are spreading rapidly all over the world. Anti-infection treatment is facing unprecedented severe challenges. Controlling the use of antimicrobial drugs in total amount and reducing the pressure of antimicrobial drug selection are the overall strategies to control the development of bacterial drug resistance. Under this background, it is necessary to adopt a more cautious attitude towards the combined application of antimicrobial drugs. Otherwise, it is inevitable that it will fall into the vicious circle of "one foot high, one foot high". In practice, each patient with pneumonia should be carefully evaluated from the aspects of necessity, rationality and safety before determining whether to use combination drugs, so as to minimize unnecessary or unreasonable combination drugs.

hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are the most common hospital-acquired infections in China, which are difficult to diagnose and treat, and have a high mortality rate. In 1999, China published the "Guidelines for the Diagnosis and Treatment of Hospital Acquired Pneumonia (Draft)"^[1]It has been nearly 20 years, during which many HAP/VAP related guidelines have been published and updated at home and abroad^{[2,3,4,5,6,7,8,9,10]}。 With the deepening of related research, the definition of HAP/VAP is changing, and a large number of new research results have been accumulated in epidemiology, etiology, clinical diagnosis and treatment, especially the research evidence in China is increasing day by day. The results show that there are great differences between HAP/VAP in China and abroad in terms of etiological distribution and drug resistance rate. Therefore, the original guidelines need to be revised to better guide clinical practice.

Leeches, commonly known as leeches, mainly live in freshwater reservoirs, ditches, paddy fields, lakes and marshes, and are addicted to human and animal blood. The adult leech is flat spindle-shaped, with a body length of about 2~15 cm and a width of about 2~15 mm. The front end of the body is slightly pointed, and the back end is blunt and round. The whole body is composed of most links. The front suction cup is not significant and the rear suction cup is larger. The back is dark brown with 5 longitudinal lines formed by many black spots. When drinking water containing young leeches, leeches often stay at the top of the nasopharynx and nasal cavity where the airflow is small, and can also enter the trachea, but it is rare to stay in the trachea^[1]。 A case of intratracheal living leech was recently treated in the Respiratory Department of Xiamen Third Hospital affiliated to Fujian University of Traditional Chinese Medicine, which is reported as follows.

pulmonary fibroleiomyomatous hamartomas (PLH) is a rare benign pulmonary tumor with no specific clinical symptoms and imaging findings, which is easy to be misdiagnosed. A case of multiple PLH is reported in order to improve the understanding of the disease.

A 36-year-old female was admitted to the hospital on March 20, 2014 due to "fever, dry cough, sore throat for 8 days, hoarseness and dyspnea for 3 days". The patient developed fever after exertion 8 days before admission, with a body temperature of 38.5 ℃, accompanied by fatigue, dry cough, sore throat, and muscle soreness. After that, the body temperature gradually increased to 40 ℃, and there was no dizziness, headache, cough, expectoration, chest tightness, chest pain, palpitations, sweating and other discomfort. After the local hospital gives symptomatic fever reduction, the body temperature can drop to normal for a short time. He visited the local municipal hospital 4 days ago, and the white blood cell count was 6.17×10 in the blood routine⁹/L, neutrophils were 0.84, and chest CT showed patchy and patchy exudates distributed along the bronchi of both lungs (Figure 1，Figure 2), diagnosed as pulmonary infection and given intravenous infusion of azithromycin. Three days ago, the patient developed dyspnea and gradually worsened, accompanied by hoarseness, and body temperature fluctuated between 39 and 40 ℃. He went to the emergency department of our hospital. Arterial blood gas analysis showed (inhaled air): pH value was 7.47, PaO₂was 69 mmHg (1 mmHg =0.133 kPa), PaCO₂It was 26 mmHg. After 4 days of moxifloxacin 400 mg/d (intravenous drip for 1 d and then oral administration), the patient's body temperature still rose to 39 ℃ every afternoon, accompanied by mild chills and chills, and the remaining symptoms were the same as before, so he was admitted to the hospital. Past physical fitness. Denial of tobacco and alcohol addiction. Physical examination at admission: body temperature 39.1 ℃, pulse 122 beats/min, respiratory rate 35 beats/min, blood pressure 130/80 mmHg. Shortness of breath, acute fever face, clear consciousness. Dyspnea with three concave signs. Percussion of both lungs showed voiceless sounds, and both lungs were full of wheezing sounds, with the upper lungs as the focus. A small amount of wet rales could be heard in both lower lungs, but no pleural friction sounds could be heard. No abnormalities were observed.

Aspergillus is a saprophytic bacterium widely existing in nature. Its spores are 2~3 μ m in diameter and are easily inhaled into the lungs. Among more than 300 species of Aspergillus, the most common pathogenic bacteria are Aspergillus fumigatus and Aspergillus niger^[1]。 pulmonary aspergillosis is divided into three categories: aspergilloma, allergic bronchopulmonary aspergillosis (ABPA) and invasive pulmonary aspergillosis (IPA), among which IPA can be further divided into airway invasive and angioinvasive^[2]。 European countries advocate that aspergillosis, chronic cavitary pulmonary aspergillosis and chronic fibrogenic pulmonary aspergillosis, which occur in patients with structural destruction of the original lung, be classified as chronic pulmonary aspergillosis (CPA)^[3]。 Pulmonary Aspergillus infection is related to the immune status of patients and Aspergillus virulence^[2]。 Aspergillus bulbs often occur in patients with cavities in the lungs, such as tuberculosis cavities and bronchiectasis. ABPA mainly occurs in patients with bronchial asthma (1% to 2%) and cystic fibrosis (1% to 15%). IPA mainly occurs in immunocompromised patients, such as after organ transplantation or patients treated with immunosuppressants^[4]。 Different types of pulmonary aspergillosis mostly exist alone, but the same patient can also occur simultaneously, and when they occur concomitantly, they are called aspergillous overlap syndrome (aspergillus overlap syndrome, AOS)^[5], also known as mixed pulmonary aspergillosis^[6]。 The progress of diagnosis and treatment of AOS is summarized as follows.

idiopathic pulmonary fibrosis (IPF) is a common type of idiopathic interstitial pneumonia (IIP) characterized by dyspnea and progressive deterioration of lung function and associated with poor prognosis. At present, there is a lack of effective objective predictive indicators for early warning, differential diagnosis, treatment strategy selection and prognosis judgment of IPF. The precision medicine medical model emphasizes the fine classification of diseases based on clinical manifestations and auxiliary examinations, combined with genes or molecular mechanisms, and based on personal genomic information, combined with related information such as proteome and metabolome, to tailor the best treatment plan for patients. The exploration of implementing precision medicine initiatives was initially in the areas of malignancies, cystic fibrosis (CF) and diabetes^[1]For example, epidermal growth factor receptor (EGFR) mutations in lung adenocarcinoma preferentially respond to tyrosine kinase inhibitors, and ivacaptor is effective against specific types of CFTR gene mutations in CF. These undoubtedly open a new era of precision treatment of lung diseases.

The diagnosis of pulmonary function mainly involves the judgment of normal values of pulmonary function parameters and the evaluation of pulmonary ventilation function and ventilation function. At present, the standards of 2005 version of ATS/ERS are often referred to^[1]And a series of guidelines developed by the Chinese Respiratory Society with reference to this standard^[2,3]。 The criteria of the Global Initiative to Prevent and Treat Chronic Obstructive Pulmonary Disease (COPD) (GOLD) are also commonly used in the diagnosis and evaluation of ventilatory dysfunction^[4]However, these standards have certain limitations, which can easily lead to confusion in clinical evaluation. This paper mainly refers to the standard applied by Zhongshan Hospital affiliated to Fudan University^[5], taking clinical respiratory physiology as the core, combining clinical characteristics and operability to put forward diagnostic suggestions.

The 18th Academic Annual Meeting of Respiratory Disease Branch of Chinese Medical Association was held on September 21-24, 2017 at the Strait International Convention and Exhibition Center in Fuzhou, Fujian Province. The conference was novel and rich in content, with a total of 4,068 contributions and more than 8,500 participants. Academician Zhong Nanshan, Academician Wang Chen, Professor Liu Youning and Chairman Chen Rongchang of the Chinese Academy of Engineering attended the meeting. Deputy Secretary-General Guo Weihua of Chinese Medical Association, Party Secretary and Director Zhu Shufang of Fujian Provincial Health and Family Planning Commission, Secretary-General Ruan Mengyuan of Fujian Medical Association and Ms. Stepanie levine, President of American Chest Physicians Association, were also invited to attend the meeting.

Nemonoxacin malate (Nemonoxacin for short) is a novel 6-position fluorine-free C8-methoxy structure quinolone antibacterial drug developed by TaiGen Biotechnology Company in Taiwan in recent years^[1]In 2012, Zhejiang Pharmaceutical Co., Ltd. obtained the right to produce and sell this product. In May 2016, it was approved by the China Food and Drug Administration (CFDA) for the treatment of mild and moderate adult community-acquired pneumonia (CAP). This is the only Class 1.1 antibacterial drug approved for marketing in my country since the CFDA issued the "Announcement on Carrying out Self-examination and Verification of Drug Clinical Trial Data" in 2015. It has been listed as a national new drug creation project in the "12th Five-Year Plan" by the National Health and Family Planning Commission^[2]。