支气管镜肺减容术治疗重度肺气肿的的临床护理

正重度肺气肿是慢性阻塞性肺疾病病(chronic obstructive pulmonary diseases,COPD)最常见、最严重的并发症之一。常见内科治疗为吸氧和解痉药物并辅以康复训练等措施,但仍不能阻止疾病的进展[1]。对于终末期的COPD患者,目前多采用肺移植及肺减容治疗,均取得了一定效果,但手术风险较大,病死率较高。最新多中心临床研究证实,支气管镜下植入活瓣(EBV)肺减容术能有效改善非均质性肺气肿患     

单向阀活瓣肺减容术治疗重度慢性阻塞性肺疾病研究进展

<正>慢性阻塞性肺疾病(chronic obstructive pulmonary disease, COPD)是世界上发病率高,病死率位居第三位的不可治愈的疾病[1]。尽管已有许多新药上市和肺康复治疗,其致残率仍非常高,仍需要其他医学方法来改善预后。肺气肿是疾病的主要特征,是肺实质的破坏,导致进行性不可逆的气流受限、日益加重的呼吸困难。国际肺气肿治疗研究组(NETT)发现合理选择重度COPD患者行外科肺减     

经支气管镜肺减容术的历史沿革与研究进展

肺气肿是慢性阻塞性肺疾病( 简称慢阻肺) 的特征之一,可引起肺过度充气,膈肌活动度减低,肺顺应性 下降,气体交换障碍。药物治疗对伴有重度肺气肿的慢阻肺患者临床疗效有限。近年来,经支气管镜肺减容术 (bronchoscopic lung volume reduction, BLVR) 的出现为慢阻肺合并重度肺气肿的治疗带来了希望。文章对目前 BLVR 的发展过程及常见的BLVR 的实施方法和疗效做一归纳总结。     

肺减容术治疗重度肺气肿疗效观察

对于重度肺气肿，目前尚无有效的内科治疗方法。近年来肺减容术(LVRS)开始用于晚期弥漫性肺气肿的治疗。2001年4月至2003年8月，我们对12例重度慢性阻塞性肺气肿(COPD)患者施行了LVRS，并对其疗效进行了观察。现报告如下。     

终末期COPD的治疗

肺气肿是一种严重威胁人类健康的慢性阻塞性肺疾病（COPD），临床表现为进行性呼吸困难，终末期肺气肿病人的5年生存率仅为25％左右。目前尚缺少治疗这一常见病和多发病的有效的内科手段，为探索治疗终末期肺气肿的有效手术方法，人们在过去的一个世纪中付出了艰苦的努力并取得了一些成绩，其中以肺移植术和肺减容术最为有效，本文就肺移植术和肺减容术对终末期肺气肿的治疗作一综述。     

慢性阻塞性肺疾病患者长期使用家庭氧疗和无创正压通气的作用

慢性阻塞性肺疾病（COPD）是以不完全可逆气流受限为特征的慢性气道疾病，严重的COPD是导致呼吸困难和呼吸衰竭的最常见的病因。对于极重度COPD（GOLD分级Ⅳ级），在常规的支气管舒张剂、吸人激素等药物治疗的基础上，非药物治疗是重要的综合治疗措施。常规推荐的非药物治疗包括康复锻炼和长期家庭氧疗。肺减容术和长期家庭无创通气治疗也是目前备受关注的治疗方法。下面重点讨论长期家庭氧疗和无创正压通气的问题。     

外科干预治疗COPD

COPD（尤其是重度阻塞性肺气肿）的治疗是临床一大难题，对内科治疗不能奏效的终末期肺气肿患者施行肺移植术（LT）和肺减容术（LVRS）等外科干预治疗，是目前公认的能够缓解症状、延长患者生命的有效措施。     

经纤维支气管镜治疗慢性阻塞性肺疾病研究进展

目前治疗慢性阻塞性肺疾病（COPD）的方法以药物治疗为核心,包括戒烟、肺康复训练、使用支气管扩张剂,必要时使用激素和氧疗。在近10年随着外科治疗的不断进展。美国肺气肿治疗试验研究结果显示外科肺减容术（LVRS）可以达到缓解COPD患者呼吸困难症状,提高患者生活质量。因此而出现各种研究试图替代LVRS,以减少LVRS的并发症。其中经纤维支气管镜LRVS目前研究较多,这种方法将来可能会占重要地位。特别是经纤维支气管镜单向活瓣支架LVRS和气道旁路已经进入临床研究阶段。     

慢性阻塞性肺病诊治进展——外科干预治疗COPD

COPD(尤其是重度阻塞性肺气肿 )的治疗是临床一大难题 ,对内科治疗不能奏效的终末期肺气肿患者施行肺移植术(L T)和肺减容术 (L VRS)等外科干预治疗 ,是目前公认的能够缓解症状、延长患者生命的有效措施。1　 L VRS1.1　历史　早在 2 0世纪 2 0年代部分学者即开始探索外科疗法治疗重度肺气肿。 Voelcker采用胸廓成形术使肺气肿患者水平走行的肋骨恢复正常倾斜位置 ,Reich等提出采用人工气腹法提高膈肌的位置 ,限制肺气肿肺的过度膨胀 ,此阶段可视为广义上肺减容术的雏形阶段。由于当时的医学水平和对肺气肿病理改变认识的限制 ,外科…     

抗菌药物在慢性阻塞性肺疾病患者中的治疗作用

慢性阻塞性肺疾病（COPD）发病率、病死率高，社会经济负担重，已成为一个重要的公共卫生问题。COPD患者抗菌药物的应用尚有争议，大部分的研究结果表明在重度COPD急性加重期患者中应用抗菌药物治疗是有益的，关于COPD稳定期抗菌药物治疗的价值争议较大，一些研究表明大环内酯类抗苗药物对COPD稳定期治疗有效。本文拟对抗菌药物在COPD患者中的治疗作用作一综述。     

The epidemiology of vascular dysfunction relating to chronic obstructive pulmonary disease and emphysema

Cor pulmonale has long been described in very severe chronic obstructive pulmonary disease (COPD) and emphysema. Cross-sectional results from population-based studies show that left ventricular filling and a variety of vascular measures in the systemic circulation are abnormal in preclinical COPD and emphysema and that a predominant vascular change in COPD and emphysema is endothelial and microvascular dysfunction. These findings suggest that pulmonary vascular changes may occur early in COPD and emphysema and might contribute to pathogenesis. However, longitudinal epidemiologic studies with direct measures of the pulmonary vasculature are lacking; therefore, inferences are limited at present. New imaging-based approaches to the assessment of the pulmonary vasculature are applicable to epidemiologic studies and may help in defining the relationship of pulmonary vascular damage to progression of COPD and emphysema. These measures may also provide imaging-based surrogate markers, and novel therapeutics targeted to the pulmonary vasculature might reduce symptoms and improve function in these common diseases.     

Pulmonary hypertension and chronic obstructive pulmonary disease: a case for treatment

Current pharmacotherapy for chronic obstructive pulmonary disease (COPD) relieves symptoms and reduces exacerbation through improving airflow limitation. Such drugs do not effectively improve exercise tolerance due in part to pulmonary hypertension associated with severe COPD, nor impact on its increased morbidity and mortality. Exercise intolerance is often improved (temporarily) by lung volume reduction surgery and pulmonary rehabilitation. Ambulatory oxygen is the most effective treatment of exercise limitation. Chronic cigarette smoking is the principal cause of COPD. An early change in smokers' lungs is pulmonary artery intimal thickening and vessel narrowing, which, as COPD develops, is correlated with both the severity of emphysema and bronchiolitis. This may be the consequence of combined smoking-induced apoptosis, inflammation, and imperfect repair. End-stage bronchiolitis and emphysema are likely to limit the effectiveness of bronchodilators and corticosteroids. There are effective treatments for idiopathic and scleroderma pulmonary arterial hypertension, which increase exercise tolerance and improve survival. Because idiopathic and COPD pulmonary hypertension share a common vascular intimal thickening, excess endothelin receptor expression, and plasma endothelin-1, an important therapeutic question to address is whether an oral endothelin-1 antagonist can improve exercise tolerance in severe COPD.     

干细胞疗法在肺气肿治疗中的研究进展

COPD是一种持续性不可逆气道受限的常见呼吸系统的疾病,肺气肿是 COPD晚期的病理改变,目前为止,尚没有有效的治疗方法。干细胞有分化为各种组织细胞的潜能,大量动物实验已经证实了干细胞移植治疗肺气肿起到了一定效果,所以干细胞疗法在肺气肿的治疗中的前景令人憧憬。本文将对近年来干细胞在肺气肿治疗中的研究进展进行综述。     

National Emphysema Treatment Trial state of the art: genetics of emphysema

Although a hereditary contribution to emphysema has been long suspected, severe alpha1-antitrypsin deficiency remains the only conclusively proven genetic risk factor for chronic obstructive pulmonary disease (COPD). Recently, genome-wide linkage analysis has led to the identification of two promising candidate genes for COPD: TGFB1 and SERPINE2. Like multiple other COPD candidate gene associations, even these positionally identified genes have not been universally replicated across all studies. Differences in phenotype definition may contribute to nonreplication in genetic studies of heterogeneous disorders such as COPD. The use of precisely measured phenotypes, including emphysema quantification on high-resolution chest computed tomography scans, has aided in the discovery of additional genes for clinically relevant COPD-related traits. The use of computed tomography scans to assess emphysema and airway disease as well as newer genetic technologies, including gene expression microarrays and genome-wide association studies, has great potential to detect novel genes affecting COPD susceptibility, severity, and response to treatment.     

Interventionelle bronchologische Therapie

Background

Chronic obstructive pulmonary disease (COPD) is an incurable progressive disease which is characterized by an irreversible occlusion of the small airways. Especially when pharmaceutical treatment attempts do not bring the desired success in patients with severe COPD, a new therapeutic concept for causal treatment of pulmonary emphysema is now available: endoscopic lung volume reduction. A differentiation is made between reversible occlusive treatment with endobronchial valves and irreversible nonocclusive procedures, such as thermoablation, bronchial glue, stents and spirals.

Methods

A systematic comparison of the most important procedures for lung volume reduction with respect to clinical outcome and complication profile was carried out based on a literature search and clinical experience.

Results

A complete occlusion in heterogeneously distributed lung emphysema and complete fissures are the most important predictive markers for successful valve therapy. The most important complication is the high rate of pneumothorax. The similarly effective irreversible procedure can be a possible therapy option for patients with collateral connections between the lung lobes but the current evidence from studies is insufficient for final conclusions to be drawn.

Conclusion

In summary interventional bronchological measures represent a new therapy option for COPD patients with severe emphysema and advanced disease stage. However, none of the procedures are currently suitable for broad application in the clinical routine.     

肺气肿动物模型研究进展

阻塞性肺气肿（肺气肿）是慢性阻塞性肺疾病（COPD）的主要病理表现,已成为研究中的焦点。多种实验性肺气肿动物模型的研究对揭示COPD的遗传背景、诱发因素、发病机制及新药的开发起了极大的促进作用。最近,有大量研究数据显示,细胞凋亡在COPD发病中起重要作用。本文就肺气肿动物模型的构建方法及其研究进展作一综述。     

Predominant emphysema phenotype in chronic obstructive pulmonary.

Patients with fixed airflow limitation are grouped under the heading of chronic obstructive pulmonary disease (COPD). The authors investigated whether COPD patients have distinct functional, radiological and sputum cells characteristics depending on the presence or absence of emphysema. Twenty-four COPD outpatients, 12 with and 12 without emphysema on high-resolution computed tomography scan of the chest, were examined. Patients underwent chest radiography, pulmonary function tests and sputum induction and analysis. Subjects with documented emphysema had lower forced expiratory volume in one second (FEV1), FEV1/forced vital capacity ratio, and lower carbon monoxide diffusion constant (K(CO)), compared with subjects without emphysema. Chest radiograph score of emphysema was higher, chest radiograph score of chronic bronchitis was lower, and the number of sputum lymphocytes was increased in patients with emphysema, who also showed a negative correlation between K(CO) and pack-yrs. Chronic obstructive pulmonary disease patients with emphysema, documented by high-resolution computed tomography scan, have a different disease phenotype compared with patients without emphysema. Identification of chronic obstructive pulmonary disease-related phenotypes may improve understanding of the natural history and treatment of the disease.     

Computed tomography phenotypes in severe, early-onset chronic obstructive pulmonary disease

Subjects with severe chronic obstructive pulmonary disease (COPD) may have marked differences in emphysema severity on chest computed tomography (CT) scans. Although many patients with severe COPD will have chest CTs performed during their clinical care, chest CTs have not been widely included in epidemiologic and genetic studies of COPD. We sought to determine whether chest CT scans performed for clinical indications can provide useful data in an epidemiologic study of COPD and to determine whether chest CT scans can be used to define subtypes of severe, early-onset COPD. Clinical chest CT scans on 91 probands in the Boston Early-Onset COPD Study were retrospectively reviewed by 2 pulmonologists and 1 to 2 chest radiologists, using a semi-quantitative emphysema severity score, ranging from 0-24. 88 of 91 chest CT scans were suitable for emphysema analysis. There was a wide range of emphysema severity, from mild to severe (1.3-23.7). Emphysema-predominant subjects (upper 3 quartiles of emphysema scores) had more severe airflow obstruction than airway-predominant subjects (lowest quartile of emphysema scores): FEV(1) 17.4% vs. 22.4% predicted, p=0.009. A higher percentage of airway-predominant subjects had a positive bronchodilator response (28.6% vs. 6.7%, p=0.009). Airway-predominant subjects also had a higher frequency of physician-diagnosed asthma (p=0.04) and a trend towards higher serum immunoglobulin E levels (p=0.09). Analysis of siblings of early-onset COPD probands suggested a genetic contribution to the subgroups. Using clinical chest CT scans, we were able to identify an airway-predominant subgroup with asthma-like features among subjects with severe, early-onset COPD.     

Successful lobectomy in 3 lung cancer cases with severe COPD after treatment with tiotropium bromide]

It is well known that lung cancer patients with severe chronic obstructive pulmonary disease (COPD) have a higher risk of postoperative complications than patients without COPD. However, the information regarding preoperative treatment to improve pulmonary function of the lung cancer patients with severe COPD is limited. Here, we report 3 lung cancer cases with severe COPD. Although all patients received medication without tiotropium bromide in combination with pulmonary rehabilitation for 1 or 2 months, their pulmonary function did not improve and the predicted postoperative FEV1/predicted FEV1 was below 40% in all cases. After the approval in Japan for use of tiotropium bromide in the treatment of COPD, all patients were treated with tiotropium bromide. The pulmonary function in all patients improved 2-4 weeks after the start of tiotropium bromide, and we performed lobectomy safely. Currently all patients maintain good pulmonary function without recurrence of lung cancer. We propose that treatment of tiotropium bromide might be one of the effective preoperative methods to improve pulmonary function of lung cancer patients with severe COPD.     

Management of COPD: surgical options.

Dyspnoea on exertion and exercise intolerance are the hallmarks of chronic obstructive pulmonary disease (COPD); the primary causes appear to be respectively, increased airway resistance with reduced maximal ventilatory capacity and peripheral skeletal muscle dysfunction with early onset of anaerobic metabolism. Patients with end-stage COPD usually show little or no benefit from conventional medical treatment. Physical training is capable of ameliorating exercise tolerance, but improvement is usually modest in the advanced disease state. Two surgical options are generally accepted for carefully selected patients with emphysema: resection of large bullae, when identified, and lung transplantation. Transplantation, the only effective cure for advanced COPD, is of limited use primarily because of age, comorbidity, limited availability of organs and cost. A different approach for severe emphysema, lung volume reduction surgery (LVRS), has been increasingly utilized during the past several years. In carefully selected emphysematous patients, LVRS improves lung volumes and mechanics, and reduces exertional dyspnoea. Unfortunately, surgical mortality still remains high and some patients show no measurable improvement after surgery. There is an urgent need for data on long-term effects of LVRS; the results of large, randomized trials will soon be forthcoming. The aim of this brief review is to summarize the available knowledge on the effects of LVRS, the criteria for patient selection, short- versus long-term effects and, finally, to propose future directions in this field.