呼出气CO2容积曲线对肺部疾病换气功能障碍的诊断与评价

目的 评价无创肺换气功能诊断技术即呼出气CO2容积曲线(VCap)对肺部疾病慢性阻塞性肺疾病(chronic obstructive pulmonary disease.COPD)、支气管哮喘(简称哮喘)和间质性肺疾病(ILD)患者换气功能障碍的诊断价值及临床意义.方法 对照组(医院对照)94人,平均年龄(61.59±8.73)岁.COPD组287例.平均年龄(64.31±11.71)岁.根据COPD肺功能分级标准分4级:COPD Ⅰ级(9例)、COPD Ⅱ级(141例)、COPD Ⅲ级(75例)、COPDⅣ级(62例).哮喘组251例,平均年龄(57.86±13.54)岁.根据气道阻塞程度分4级(分级标准同COPD):轻度阻塞(6例)、中度阻塞(113例)、重度阻塞(100例)、极重度阻塞(32例).ILD组45例,平均年龄(56.42±13.97)岁.主要分析变量:最大呼出气二氧化碳浓度、Ⅲ相斜率(dC/dV3)、呼出气最高CO2浓度的25%～50%时的容积与潮气容积的比值(Vm25-50/VT)、呼出气最高CO2浓度的50%～75%时的容积与潮气容积的比值(Vm50-75/VT).结果 ①ILD、哮喘和COPD分别与对照组比较:Vm25-50/VT、Vm50-75/VT、FeCO2max、dC/dV3,差异有统计学意义(P<0.01);②轻度哮喘和轻度COPD组比较:Vm50-75/VT,dC/dV3差异无统计学意义;中、重度组比较:Vms50-75/VT,dC/dV3差异有统计学意义(P<0.01);哮喘合并肺气肿和COPD(肺气肿)组比较差异无统计学意义;③Vm50-75/VT和dC/dV3用于COPD(肺气肿)的评价敏感度分别为98.3%和96.5%.特异度分别为91.4%和86.1%.结论 ①COPD、哮喘和ILD患者VCap形态异常.dC/dV3增高并且与疾病的严重程度有关,示肺内气体分布不均,系气道阻力增高和(或)肺顺应性改变导致吸入气体分布不均和呼出气体非同步排空所致,ILD相对于COPD和哮喘则气体分布不均更为突出;②变量Vm50-75/VT间接反映肺泡死腔量,相对受生理因素及通气量的影响小,与常规肺功能指标均有较好的相关性,可作为评价肺部疾病换气功能障碍即肺泡死腔增大,通气血流/灌注失调间接指标.③Vm50-75/VT%≥10%和dC/dV3≥1.3%/L用于评价肺气肿有较高敏感度和特异度.     

Pulmonary complications in patients with chronic obstructive pulmonary disease following transthoracic esophagectomy

AIM: To investigate the incidence of various types of postoperative pulmonary complications (POPCs) and to evaluate the significance of perioperative arterial blood gases in patients with esophageal cancer accompanied with chronic obstructive pulmonary disease (COPD) after esophagectomy. MEHTODS: Three hundred and fifty-eight patients were divided into POPC group and COPD group. We performed a retrospective review of the 358 consecutive patients after esophagectomy for esophageal cancer with or without COPD to assess the possible influence of COPD on postoperative pulmonary complications. We classified COPD into four grades according to percent-predicted forced expiratory volume in 1 s (FEV1) and analyzed the incidence rate of complications among the four grades. Perioperative arterial blood gases were tested in patients with or without pulmonary complications in COPD group and compared with POPC group. RESULTS: Patients with COPD (29/86, 33.7%) had more pulmonary complications than those without COPD (36/272, 13.2%) (P<0.001). Pneumonia (15/29, 51.7%), atelectasis (13/29, 44.8%), prolonged 02 supplement (10/29, 34.5%), and prolonged mechanical ventilation (8/29, 27.6%) were the major complications in COPD group. Moreover, patients with severe COPD (grade n B, FEV1 < 50% of predicted) had more POPCs than those with moderate(gradeⅡA,50%-80% of predicted) and mild (gradeⅠ≥80% of predicted) COPD (P<0.05). PaO2 was decreased and PaCO2 was increased in patients with pulmonary complications in COPD group in the first postoperative week. CONCLUSION: The criteria of COPD are the critical predictor for pulmonary complications in esophageal cancer patients undergoing esophagectomy. Severity of COPD affects the incidence rate of the pulmonary complication, and percent-predicted FEV1 is a good predictive variable for pulmonary complication in patients with COPD. Arterial blood gases are helpful in directing perioperative management.     

肌抑制素与慢性阻塞性肺疾病患者的营养不良

Objective To investigate the prevalence and severity of malnutrition in patients with stable chronic obstructive pulmonary disease (COPD) , analyze serum levels of myostatin, tumor necrosis factor alpha (TNFα) and C reactive protein (CRP) , and investigate the relationship between serum myostatin and malnutrition in COPD. Methods Seventy-one patients with stable COPD and 60 age-matched healthy volunteers were recruited in this study. Pulmonary function was tested in all of the subjects and the severity of malnutrition was evaluated by a multiple-parameter malnutritional index (MNI). Based on the MNI scores, patients with COPD were divided into group Ⅰ (MNI≥5 score) and group Ⅱ (MNI ＜ 5 score) , the former represents the patients with severe or very severe malnutrition while the latter represents the patients with mild or without malnutrition. Serum concentration of myostatin, TNFα and CRP were measured by enzyme-linked immunosorbent assay. Results The MNI score was significantly elevated in patients with COPD [(7. 75 ±3. 86)score] compared with the controls [(1. 13 ±0. 96)score; P＜0.001],and 55 patients (77%) in COPD group Ⅰ showed MNI ≥ 5 (9. 30 ± 3. 01) score. Serum myostatin concentration was significantly elevated in COPD group Ⅰ [(12. 18 ±4. 76)μg/L] than in COPD group Ⅱ [(9. 73 ±2.85) μgL] and controls [(7.93 ±2.35) μg/L], with each P ＜ 0.001. Serum TNFα concentration was also significantly elevated in patients with COPD compared with the controls (P ＜ 0. 001).Pearson correlation analysis showed that serum myostatin levels were significantly correlated with MNI scores (r = 0. 438, P - 0. 000) and TNFa levels (r = 0. 234, P = 0. 041) in COPD group (combined group I and Ⅱ) while MNI scores were correlated inversely with BMI in COPD group (r = - 0. 530, P = 0. 000) . After stratified with subgroups, the correlation between myostatin levels and MNI scores was more significant and the correlation coefficient was higher (r =0.464, P =0.000) in COPD group I patients. Moreover,myostatin levels were inversely correlated with BMI (r = - 0. 287, P = 0. 034) and forced expiratory volume in one second of the predicted value (r = - 0. 264, P = 0. 049) in COPD group I patients. Conclusions Malnutrition commonly and substantially exists in patients with COPD; serum myostatin concentration is significantly elevated and is correlated with the severity of malnutrition in the patients. The elevation of serum myostatin may contribute to malnutrition in COPD patients.     

人重组胰岛素样生长因子1对慢性阻塞性肺疾病大鼠膈肌细胞凋亡的保护作用及机制探讨

Objective To investigate the prevetive effect and mechanism of rhIGF-1 on apoptosis of diaphgramatic muscle cell in rats with chronic obstructive pulmonary disease(COPD).Methods Forty-five male Wistar rats were randomly divided into control group(group A),COPD model group(group B),COPD model+rhIGF-1 intervention group(group C),15 in each group.Five rats in each group were killed respectively at a time on the first day,14th,28th day.Take complete diaphragms to detect rate of apoptosis with TUNEL method,detect Fas protein expression with immunohistochemistry and detect Fas gene expression with RT-PCR after weighing.Results Twenty-eight days later,the mass of diaphragms of group B and C was lighter than that of group A(P＜0.05),group C heavier than group B(P＜0.05).At the same time point,rate of apoptosis,Fas protein expression and Fas gene expression of group B and C were higher than those of group A,group C was lower than group B(P＜0.05).Conclusions Fas/FasL mediated apoptosis way involves in the diaphragm apoptosis,rhIGF-1 may interfere with Fas/FasL way to reduce the apoptosis of the diaphragm and may have a protective effect of diaphragm apoptosis.     

肌抑制素与慢性阻塞性肺疾病患者的营养不良

Objective To investigate the prevalence and severity of malnutrition in patients with stable chronic obstructive pulmonary disease (COPD) , analyze serum levels of myostatin, tumor necrosis factor alpha (TNFα) and C reactive protein (CRP) , and investigate the relationship between serum myostatin and malnutrition in COPD. Methods Seventy-one patients with stable COPD and 60 age-matched healthy volunteers were recruited in this study. Pulmonary function was tested in all of the subjects and the severity of malnutrition was evaluated by a multiple-parameter malnutritional index (MNI). Based on the MNI scores, patients with COPD were divided into group Ⅰ (MNI≥5 score) and group Ⅱ (MNI ＜ 5 score) , the former represents the patients with severe or very severe malnutrition while the latter represents the patients with mild or without malnutrition. Serum concentration of myostatin, TNFα and CRP were measured by enzyme-linked immunosorbent assay. Results The MNI score was significantly elevated in patients with COPD [(7. 75 ±3. 86)score] compared with the controls [(1. 13 ±0. 96)score; P＜0.001],and 55 patients (77%) in COPD group Ⅰ showed MNI ≥ 5 (9. 30 ± 3. 01) score. Serum myostatin concentration was significantly elevated in COPD group Ⅰ [(12. 18 ±4. 76)μg/L] than in COPD group Ⅱ [(9. 73 ±2.85) μgL] and controls [(7.93 ±2.35) μg/L], with each P ＜ 0.001. Serum TNFα concentration was also significantly elevated in patients with COPD compared with the controls (P ＜ 0. 001).Pearson correlation analysis showed that serum myostatin levels were significantly correlated with MNI scores (r = 0. 438, P - 0. 000) and TNFa levels (r = 0. 234, P = 0. 041) in COPD group (combined group I and Ⅱ) while MNI scores were correlated inversely with BMI in COPD group (r = - 0. 530, P = 0. 000) . After stratified with subgroups, the correlation between myostatin levels and MNI scores was more significant and the correlation coefficient was higher (r =0.464, P =0.000) in COPD group I patients. Moreover,myostatin levels were inversely correlated with BMI (r = - 0. 287, P = 0. 034) and forced expiratory volume in one second of the predicted value (r = - 0. 264, P = 0. 049) in COPD group I patients. Conclusions Malnutrition commonly and substantially exists in patients with COPD; serum myostatin concentration is significantly elevated and is correlated with the severity of malnutrition in the patients. The elevation of serum myostatin may contribute to malnutrition in COPD patients.     

肌抑制素与慢性阻塞性肺疾病患者的营养不良

Objective To investigate the prevalence and severity of malnutrition in patients with stable chronic obstructive pulmonary disease (COPD) , analyze serum levels of myostatin, tumor necrosis factor alpha (TNFα) and C reactive protein (CRP) , and investigate the relationship between serum myostatin and malnutrition in COPD. Methods Seventy-one patients with stable COPD and 60 age-matched healthy volunteers were recruited in this study. Pulmonary function was tested in all of the subjects and the severity of malnutrition was evaluated by a multiple-parameter malnutritional index (MNI). Based on the MNI scores, patients with COPD were divided into group Ⅰ (MNI≥5 score) and group Ⅱ (MNI ＜ 5 score) , the former represents the patients with severe or very severe malnutrition while the latter represents the patients with mild or without malnutrition. Serum concentration of myostatin, TNFα and CRP were measured by enzyme-linked immunosorbent assay. Results The MNI score was significantly elevated in patients with COPD [(7. 75 ±3. 86)score] compared with the controls [(1. 13 ±0. 96)score; P＜0.001],and 55 patients (77%) in COPD group Ⅰ showed MNI ≥ 5 (9. 30 ± 3. 01) score. Serum myostatin concentration was significantly elevated in COPD group Ⅰ [(12. 18 ±4. 76)μg/L] than in COPD group Ⅱ [(9. 73 ±2.85) μgL] and controls [(7.93 ±2.35) μg/L], with each P ＜ 0.001. Serum TNFα concentration was also significantly elevated in patients with COPD compared with the controls (P ＜ 0. 001).Pearson correlation analysis showed that serum myostatin levels were significantly correlated with MNI scores (r = 0. 438, P - 0. 000) and TNFa levels (r = 0. 234, P = 0. 041) in COPD group (combined group I and Ⅱ) while MNI scores were correlated inversely with BMI in COPD group (r = - 0. 530, P = 0. 000) . After stratified with subgroups, the correlation between myostatin levels and MNI scores was more significant and the correlation coefficient was higher (r =0.464, P =0.000) in COPD group I patients. Moreover,myostatin levels were inversely correlated with BMI (r = - 0. 287, P = 0. 034) and forced expiratory volume in one second of the predicted value (r = - 0. 264, P = 0. 049) in COPD group I patients. Conclusions Malnutrition commonly and substantially exists in patients with COPD; serum myostatin concentration is significantly elevated and is correlated with the severity of malnutrition in the patients. The elevation of serum myostatin may contribute to malnutrition in COPD patients.     

GENERAL TREATMENT

objeetive:To assess the resPonse of the symPathetie ner-vous system(SNS)to handgriP test in Patients with essentialhypertension(EH)and evaluate the effeets of verapamil SR andbisoprolol on redueing the SNS aetivity.Methods:Totally,78patients with EH(verapamil group SR 50,bisoprolol group 28)performed handgrip test and the SBP,DBP and HR were mea-sured before and after the test.Before and after the Patients re-eeived the treatment of verapamil SR or bisoprolol,the plasmaeoneentratio…     

The effect of fine particles on the phagocytosis of alveolar macrophages potentially by Arp2/3 complex in a mouse model of chronic obstructive pulmonary disease

正Objective To investigate the mechanism of fine particulate matter (PM2.5) on the phagocytosis of alveolar macrophages (AM) in mice with chronic obstructive pulmonary disease (COPD) through actin-related protein(Arp) 2/3 complex.Methods Forty mice were divided into healthy control (A) group,healthy PM2.5 (B)group,COPD (C) group,and COPD PM2.5 (D) group     

Sequential blood purification therapy for critical patients with hyperlipidemic severe acute pancreatitis

AIM: To evaluate the efficacy of sequential blood purification therapy in the treatment of critical patients with hyperlipidemic severe acute pancreatitis.METHODS: Thirty-one intensive care unit(ICU) patients with hyperlipidemic severe acute pancreatitis treated at the Second Affiliated Hospital of Harbin Medical University were divided into either a study group(n = 15; July 1, 2012 to June 30, 2014) or a control group(n = 16; July 1, 2010 to June 30, 2012) based on the implementation of sequential blood purification therapy. The control group received continuous venous-venous hemofiltration(CVVH) on the basis of conventional treatments, and the therapeutic dose of CVVH was 30 m L/kg per hour. The study group received sequential plasma exchange and CVVH on the basis of conventional treatments. The anticoagulation regimen of CVVH is the regional citrate anticoagulation. Mortality rate on day 28, rates of systemic and local complications, duration of ICU, and time to target serum lipid level, as well as physiologic and laboratory indices were compared between the two groups.RESULTS: The mortality rate on day 28 was significantly lower in the study group than in the control group(13.33% vs 37.50%; P 0.05). The duration of ICU stay was significantly shorter in the study group than in the control group(7.4 ± 1.35 d vs 9.19 ± 2.99 d, P 0.05). The time to target serum lipid level was significantly shorter in the study group than in the control group(3.47 ± 0.52 d vs 7.90 ± 1.14 d, P 0.01). There were no significant differences in the rates of systemic complications and local complications between the two groups(60% vs 50% and 80% vs 81%, respectively). In the comparisons of physiologic and laboratory indices, serum albumin and C-reactive protein were significantly better in the study group than in the control group after treatment(37.8 ± 4.6 g/L vs 38.9 ± 5.7 g/L, and 20.5 ± 6.4 mg/L vs 28.5 ± 7.1 mg/L, respectively, both P 0.05). With the exception of plateletcrit, no other indices showed significant differences between the two groups.CONCLUSION: Sequential blood purification therapy is effective in the treatment of ICU patients with hyperlipidemic severe acute pancreatitis and can improve patient prognosis.     

肌抑制素与慢性阻塞性肺疾病患者的营养不良

目的 调查慢性阻塞性肺疾病(COPD)稳定期患者的营养状况,通过检测外周血清中肌抑制素的水平,探讨肌抑制素与COPD患者营养不良的关系.方法 选71例COPD稳定期患者和60例老年健康对照者,参照营养不良多参数评分(MNI)对所有受试者的营养状况进行总体评价;采用酶联免疫吸附法检测受试者血清中肌抑制素、TNFα、C反应蛋白(CRP)水平.结果 COPD患者MNI显著升高,其中MNI≥5分者55例(77%),MNI＜5分者16例.MNI≥5分者血清中肌抑制素水平为(12.18±4.76)μg/L,较MNI＜5分者[(9.73±2.85)μg/L]和健康对照者[(7.93±2.35)μg/L]显著升高(P＜0.001).COPD患者TNFα显著升高,与健康对照者比差异有统计学意义(P＜0.05).COPD患者血清肌抑制素水平与MNI、TNFα水平呈正相关(r=0.438,P=0.000;r=0.234,P=0.041).结论 COPD患者普遍存在较严重的营养不良,血清肌抑制素水平明显升高,营养不良与血清肌抑制素升高密切相关.

Abstract：

Objective To investigate the prevalence and severity of malnutrition in patients with stable chronic obstructive pulmonary disease (COPD) , analyze serum levels of myostatin, tumor necrosis factor alpha (TNFα) and C reactive protein (CRP) , and investigate the relationship between serum myostatin and malnutrition in COPD. Methods Seventy-one patients with stable COPD and 60 age-matched healthy volunteers were recruited in this study. Pulmonary function was tested in all of the subjects and the severity of malnutrition was evaluated by a multiple-parameter malnutritional index (MNI). Based on the MNI scores, patients with COPD were divided into group Ⅰ (MNI≥5 score) and group Ⅱ (MNI ＜ 5 score) , the former represents the patients with severe or very severe malnutrition while the latter represents the patients with mild or without malnutrition. Serum concentration of myostatin, TNFα and CRP were measured by enzyme-linked immunosorbent assay. Results The MNI score was significantly elevated in patients with COPD [(7. 75 ±3. 86)score] compared with the controls [(1. 13 ±0. 96)score; P＜0.001],and 55 patients (77%) in COPD group Ⅰ showed MNI ≥ 5 (9. 30 ± 3. 01) score. Serum myostatin concentration was significantly elevated in COPD group Ⅰ [(12. 18 ±4. 76)μg/L] than in COPD group Ⅱ [(9. 73 ±2.85) μgL] and controls [(7.93 ±2.35) μg/L], with each P ＜ 0.001. Serum TNFα concentration was also significantly elevated in patients with COPD compared with the controls (P ＜ 0. 001).Pearson correlation analysis showed that serum myostatin levels were significantly correlated with MNI scores (r = 0. 438, P - 0. 000) and TNFa levels (r = 0. 234, P = 0. 041) in COPD group (combined group I and Ⅱ) while MNI scores were correlated inversely with BMI in COPD group (r = - 0. 530, P = 0. 000) . After stratified with subgroups, the correlation between myostatin levels and MNI scores was more significant and the correlation coefficient was higher (r =0.464, P =0.000) in COPD group I patients. Moreover,myostatin levels were inversely correlated with BMI (r = - 0. 287, P = 0. 034) and forced expiratory volume in one second of the predicted value (r = - 0. 264, P = 0. 049) in COPD group I patients. Conclusions Malnutrition commonly and substantially exists in patients with COPD; serum myostatin concentration is significantly elevated and is correlated with the severity of malnutrition in the patients. The elevation of serum myostatin may contribute to malnutrition in COPD patients.     

The Ability of Volumetric Capnography to Distinguish between Chronic Obstructive Pulmonary Disease Patients and Normal Subjects

Purpose

The aim of our study was to evaluate volumetric capnography (VCap) in the differentiation between chronic obstructive pulmonary disease (COPD) patients and normal subjects.

Patients and Methods

Thirty-nine healthy male volunteers and 60 male COPD patients were enrolled. Regression equations between VCap indices and age, weight, height, and tidal volume in healthy volunteers were established by stepwise regression analysis. Predicted normal values of VCap indices in COPD patients were calculated. A paired t test was used to compare the difference between observed and predicted values for VCap indices in COPD patients. Receiver operating characteristic (ROC) curve analysis was used to evaluate the power of each VCap index alone in differentiating COPD patients and normal subjects. The power of the combination of VCap indices was assessed by discriminant analysis.

Results

All regression equations were significant (P < 0.01) as were the differences between the observed and predicted normal VCap indices in COPD patients (P < 0.001). ROC curve analysis showed that the volume between 25 and 50 % of F CO2et (Vm25-50), slope of Phase II (dC2/dV), and slope of Phase III (dC3/dV) were valuable predictors. Nearly all (90.9 %) subjects were correctly classified by discriminant analysis.

Conclusion

Vm25-50, dC2/dV, or dC3/dV alone are valuable for differentiating COPD patients and normal subjects, but more powerful are the combinations of Vm25-50, dC2/dV, and dC3/dV, the ratio of dC2/dV to dC3/dV (SR23), dead space according to the Bohr method (VDB), and dead space according to the Wolff and Brunner methods (PIE).     

容积二氧化碳图在气道反应性测定中的应用

目的 探讨容积二氧化碳图(volumetric capnography,Vcap)参数在组胺激发试验中的反应性变化并与肺通气测定法做比较.方法 对60例门诊慢性咳嗽,疑诊咳嗽变异性哮喘患者进行组胺支气管激发实验,于基础状态、每次吸入组胺后,及吸入支气管扩张药后,先进行Vcap测定,再进行肺通气功能测定.使用Vcap来评价气道反应性.结果 60例患者气道高反应性的阳性率为50%.激发试验阳性组第1秒用力呼气容积(FEV1)、最大用力呼气峰流量(PEF)及Vcap参数Threshold死腔(VDT)、Fowler死腔(VDF)、Wolff死腔(VDW)、Ⅲ期斜率(dC3/DV)在基础值和激发后值之间差异均有统计学意义(P<0.01),激发后和舒张后值之间差异也有统计学意义(P<0.05).阴性组FEV1、PEF在基础值和激发后值之间、激发后和舒张后值之间差异无统计学意义(P>0.05),VDT、VDF、VDW激发后和舒张后值之间差异有统计学意义(P<0.05).所有患者的基础值、激发后、舒张后数据,FEV1均与PEF、Vcap各参数(除dC2/DV、dC3/DV、SR23外)呈显著直线相关(P<0.05).激发试验过程中各死腔参数的下降提前于FEV1和PEF的下降.激发试验终止时,ROC曲线提示VDT、VDF为最敏感指标,VDT较基础值增加28%、VDF较基础值增加20%,可作为Vcap气道高反应性阳性判断标准.结论 Vcap是一种定量评估支气管阻塞严重性的有效方法,可应用于气道反应性测定.     

容积二氧化碳图对支气管哮喘患者急性加重分级的意义

目的 探讨容积二氧化碳图(Vcap)参数对支气管哮喘(简称哮喘)诊断的临床价值.方法 2006年7月至2007年5月对64例哮喘急性发作期患者(哮喘组)及20名健康者(健康对照组)进行肺通气功能以及Vcap测定,并依据FEV,占预计值%将哮喘患者分为A组(＞80%,18例)、B组(40%～80%,26例)、c组(＜40%,20例),所有受试者先行Vcap测定,随后完成FEV1占预计值%、FEV1/FVC、FVC占预计值%、最大呼气中段流量(MMEF)占预计值%测定.统计学处理采用SPSS 13.0软件.计量资料采用-x±s表示,计数资料采用卡方检验,计量资料两组间比较采用t检验.肺通气参数与Vcap参数间的相关性采用一元线性回归检验;哮喘组与对照组间的差异采用独立样本t检验;健康对照组及哮喘各亚组间的比较采用单因素方差分析.结果 哮喘组患者FEV1占预计值%、FEV1/FVC、PEF占预计值%、MMEF占预计值%分别为(52±20)%、(50±10)%、(49±16)%、(28±16)%,与健康对照组[(98±9)%、(80±6)%、(91±15)%、(73±7)%]比较差异有统计学意义(t值分别为6.93～13.29,P均＜0.01);哮喘组患者Ⅱ期斜率(dC2/DV)、Ⅲ期斜率(dC3/DV)、Ⅲ期与Ⅱ期斜率之比(SR23)分别为(19±6)%/L、(2.9±1.2)%/L、(16.8±10.6)%,与健康对照组[(31±8)%/L、(1.0±0.4)%/L,(3.3±1.5)%]比较差异有统计学意义(t值分别为5.09、-6.14、-6.54,P均＜0.01);哮喘B、C组dC2/DV分别为(17±5)%/L、(13±4)%/L,与健康对照组[(31±8)%/L]比较差异有统计学意义(t=-11.82、-16.75,P均＜0.01);哮喘B、C组患者dC3/DV、SR23分别为(3.2±0.8)%/L、(17.2±3.5)%,(4.1±1.2)%/L、(28.3±6.9)%,与健康对照组[(1.0±0.4)%/L、(3.3±1.5)%]比较差异有统计学意义(t值分别为2.16～26.08,P均＜0.01);哮喘A、B、C组间dC3/DV、SR23比较差异有统计学意义(t值分别为0.91～22.18,P均＜0.05);相关分析结果表明dC2/DV与FEV1占预计值%、FEV1/FVC、PEF占预计值%、MMEF占预计值%呈正相关(r值分别为0.69、0.54、0.59、0.54,P均＜0.01);dC3/DV与FEV1占预计值%、FEV1/FVC、PEF占预计值%、MMEF占预计值%呈显著负相关(r值分别为-0.62、-0.45、-0.69、-0.58,P均＜0.01);SR23与FEV1占预计值%、FEV1/FVC、PEF占预计值%、MMEF占预计值%呈显著负相关(r值分别为-0.75、-0.52、-0.74、-0.62,P均＜0.01).结论 Vcap是一种简便易行、可定量评估哮喘患者支气管阻塞严重程度的有效方法.     

Airway insufflation: physiologic effects on acute and chronic gas exchange in humans

Reduction in dead space through conventional tracheostomy has been used to treat patients with chronic CO2 retention. The insufflation of air directly into the trachea by transtracheal catheter (airway insufflation, AI) provides reductions in dead space as great or greater than those of tracheostomy. The physiologic effects of AI on gas exchange have not been adequately studied because instillation of gases into the trachea contaminates minute ventilation (VL), dead space volume (VD), tidal volume (VT), and other indices of gas exchange, as measured by usual technics. We overcame this problem by devising special methods of measuring inspired and expired ventilation, alveolar and dead space ventilation, and VT and VD by using pneumotachographic timing of inspiration and expiration so that true inspired and expired ventilation were calculated. We studied 5 patients with chronic CO2 retention from either COPD, scoliosis, or muscular dystrophy (annual average PaCO2 = 45 to 75 mm Hg) during 75 min of AI with serial gas exchange and arterial blood gas measurements. AI at about 5 L/min of room air through the trachea in 5 patients reduced VL by 18% (from 7.91 to 6.48 L/min), VT by 25% (from 450 to 338 ml), and VD by 37% (from 223 to 141 ml), while not affecting PaCO2 (from 51.8 to 48.2 mm Hg) or PaO2 (from 65.1 to 63.4 mm Hg). In 2 patients, AI administered continuously for 4 to 12 months (as 30 to 50% O2) maintained PaCO2 as well as or better than breathing enriched O2 from a tracheal collar via an open tracheostomy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Noninvasive measurement of mean alveolar carbon dioxide tension and Bohr's dead space during tidal breathing.

The lack of methodology for measuring the alveolar carbon dioxide tension (PA,CO2) has forced investigators to make several assumptions, such as that PA,CO2 is equal to end-tidal (PET,CO2) and arterial CO2 tension (Pa,CO2). The present study measured the mean PA,CO2 and Bohr's dead space ratio (Bohr's dead space/tidal volume (VD,Bohr/VT)) during tidal breathing. The method used is a new, simple and noninvasive technique, based on the analysis of the expired CO2 volume per breath (VCO2) versus the exhaled VT. This curve was analysed in 21 normal, healthy subjects and 35 chronic obstructive pulmonary disease (COPD) patients breathing tidally through a mouthpiece apparatus in the sitting position. It is shown that: 1) PA,CO2 is similar to Pa,CO2 in normal subjects, whilst it is significantly lower than Pa,CO2 in COPD patients; 2) PA,CO2 is significantly higher than PET,CO2 in all subjects, especially in COPD patients; 3) VD,Bohr/VT is increased in COPD patients as compared to normal subjects; and 4) VD,Bohr/VT is lower than the "physiological" dead space ratio (VD,phys/VT) in COPD patients. It is concluded that the expired carbon dioxide versus tidal volume curve is a useful tool for research and clinical work, because it permits the noninvasive and accurate measurement of Bohr's dead space and mean alveolar carbon dioxide tension accurately during spontaneous breathing.     

小潮气量通气对创伤性ARDS的疗效分析

目的：探讨小潮气量通气对创伤性ARDS的疗效。方法：回顾性分析48例创伤性ARDS患者的病历资料，分为两组，大潮气量组23例，VT10～12ml／kg理想体重，PEEP5～10cmH2O，平台压35-50cmH2O；小潮气量组25例，VT5～8ml／kg理想体重，PEEP10～15cmH20，平台压≤35cmH2O。观察两组通气治疗前、后3dPaO2／FiO2、PaCO2、pH值及气压伤的发生情况和ICU住院期间病死率。结果：通气治疗后两组PaO2／FiO2均较通气治疗前明显升高（P〈0．05，P〈0．01），但在第3天，小潮气量组PaO2／FiO2明显低于大潮气量组（P〈0．01）；小潮气量组出现明显高碳酸血症，但在机体可耐受范围。大潮气量组出现3例气压伤，小潮气量组无气压伤发生。小潮气量组病死率16％（4／25）低于大潮气量组26．08％（6／23）（P〉0．05）。结论：小潮气量通气可改善创伤性ARDS患者氧合状态和预后，减少呼吸机相关性肺损伤的发生。     

Effect of salmeterol on the ventilatory response to exercise in chronic obstructive pulmonary disease.

This study examined the effects of bronchodilator-induced reductions in lung hyperinflation on breathing pattern, ventilation and dyspnoea during exercise in chronic obstructive pulmonary disease (COPD). Quantitative tidal flow/volume loop analysis was used to evaluate abnormalities in dynamic ventilatory mechanics and their manipulation by a bronchodilator. In a randomised double-blind crossover study, 23 patients with COPD (mean +/- SEM forced expiratory volume in one second 42 +/- 3% of the predicted value) inhaled salmeterol 50 microg or placebo twice daily for 2 weeks each. After each treatment period, 2 h after dose, patients performed pulmonary function tests and symptom-limited cycle exercise at 75% of their maximal work-rate. After salmeterol versus placebo at rest, volume-corrected maximal expiratory flow rates increased by 175 +/- 52%, inspiratory capacity (IC) increased by 11 +/- 2% pred and functional residual capacity decreased by 11 +/- 3% pred. At a standardised time during exercise, salmeterol increased IC, tidal volume (VT), mean inspiratory and expiratory flows, ventilation, oxygen uptake (VO2) and carbon dioxide output. Salmeterol increased peak exercise endurance, VO2 and ventilation by 58 +/- 19, 8 +/- 3 and 12 +/- 3%, respectively. Improvements in peak VO2 correlated best with increases in peak VT; increases in peak VT and resting IC were interrelated. The reduction in dyspnoea ratings at a standardised time correlated with the increased VT. Mechanical factors play an important role in shaping the ventilatory response to exercise in chronic obstructive pulmonary disease. Bronchodilator-induced lung deflation reduced mechanical restriction, increased ventilatory capacity and decreased respiratory discomfort, thereby increasing exercise endurance.     

Increased oxygen pulse after lung volume reduction surgery is associated with reduced dynamic hyperinflation

Stroke volume augmentation during exercise is limited in chronic obstructive pulmonary disease patients because of decreased preload from dynamic hyperinflation (DH). We hypothesised that oxygen pulse and pulse pressure (PP) improve following lung volume reduction surgery (LVRS), and the magnitude of improvement correlates with reduction in DH. We compared 16 emphysema patients undergoing LVRS with six emphysema patients not undergoing LVRS. Oxygen pulse and PP were calculated from maximal cardiopulmonary exercise tests at baseline and 6 months. End-expiratory lung volume (EELV)/total lung capacity (TLC) represented DH. Comparisons were made between baseline and 6 months at metabolic isotimes (per cent maximal carbon dioxide production (V'(CO(2),max))). At baseline, the LVRS group was older with higher forced expiratory volume in 1 s, but had similar hyperinflation to the non-LVRS group. At 6 months, oxygen pulse (50%, 75%, and 100% V'(CO(2),max)) and PP (50% and 75% V'(CO(2),max)) increased in the LVRS, but not in the non-LVRS group. Baseline functional residual capacity/TLC inversely correlated with resting oxygen pulse (r= -0.449, p=0.04). Decreased EELV/TLC correlated with increased oxygen pulse at 75% (r= -0.487, p=0.02) and 100% V'(CO(2),max) (r= -0.548, p=0.008). LVRS led to increased oxygen pulse and PP during exercise at metabolic isotimes 6 months following surgery. Reductions in DH correlated with increases in oxygen pulse during exercise. Reducing lung volume may improve stroke volume response to exercise by decreasing DH.     

慢性阻塞性肺疾病患者炎症细胞因子与肺通气功能的相关研究

目的　探讨慢性阻塞性肺疾病 (COPD)患者肺通气功能改变与炎症因子变化之间的关系。方法　稳定期COPD和慢性支气管炎 (简称慢支 )患者各 8例 ,,另有 8名健康者作为对照 ,进行肺功能检查 ,并经支气管肺泡灌洗获取肺泡巨噬细胞进行培养 ,采用酶联免疫吸附 (ELISA)方法测定大肠杆菌内毒素 (LPS)刺激后上清液中白细胞介素 8(IL 8)、IL 1β、IL 6和肿瘤坏死因子α(TNF α)的浓度 ,细胞因子之间相关性采用Pearson相关阵分析 ,肺功能值与细胞因子相关性采用多元后退回归法分析。结果　 (1)肺泡巨噬细胞释放IL 8:加入LPS后COPD组为 [(43± 2 7) μg/L和 (5 7± 41) μg/L],与正常对照组 [(13± 10 ) μg/L和 (2 0± 13 ) μg/L) ]比较差异有显著性 (P <0 .0 5 ) ;与慢支组 [(2 9± 2 1)μg/L和 (3 2± 2 3 ) μg/L]比较差异有显著性 (P >0 .0 5 )。 (2 )加入LPS前、后 ,COPD组、慢支组和正常对照组肺泡巨噬细胞释放IL 1β分别为 [(5 0± 41)ng/L、(94± 5 9)ng/L、(3 7± 3 2 )ng/L、(2 2 5± 10 8)ng/L、(15 3± 175 )ng/L、(70± 3 7)ng/L],与IL 8的释放呈正相关 (P <0 .0 5 ) ;三组肺泡巨噬细胞在LPS刺激后释放TNF α分别为 [(12 3 8± 679)ng/L、(3 0 88± 2 879)ng/L、(13 3 2± 1846)ng/L],与IL 1β呈正相