免疫反应在慢性阻塞性肺疾病和肺气肿发生及发展过程中的作用

COPD是具有气流受限特征的疾病,气流受限不完全可逆,呈进行性发展,并与肺部对香烟烟雾等有害气体或有害颗粒的异常炎症有关,这种异常炎症累及各级气道、肺实质和肺血管.目前普遍认为,慢性的肺部炎症在COPD和肺气肿形成中起主要作用.近年来研究结果显示,T细胞介导的炎症反应参与COPD和肺气肿的发生与发展过程,并与疾病的严重程度相关,提示免疫反应可能在其中起重要作用.     

The diagnosis of acute pulmonary embolism in patients with chronic obstructive pulmonary disease.

The clinical features and noninvasive tests, including ventilation perfusion (V/Q) lung scans, were assessed in 108 patients with chronic obstructive pulmonary disease (COPD) suspected of having pulmonary embolism (PE). Twenty-one (19 percent) of 108 patients had PE. In the majority of patients, it was impossible to distinguish between patients with and without PE by clinical assessment alone. However, when a high clinical index of suspicion was present, PE was confirmed by angiography in three of three patients, but the V/Q scan was of intermediate probability. No roentgenographic abnormalities distinguished between PE and no PE. There was no difference between the alveolar-arterial oxygen gradients in either group, nor was there evidence of a reduction in the PaCO2 in patients with PE who had prior hypercapnia. Among the 108 patients with COPD, high, intermediate, low, and normal/near normal probability scans were present in 5 percent, 60 percent, 30 percent, and 5 percent, respectively. The frequency of PE in these V/Q scan categories was five (100 percent) of five, 14 (22 percent) of 65, two (6 percent) of 33, and zero (0 percent) of five, respectively. In conclusion, in the majority of patients, the V/Q scan diagnosis is usually intermediate and such patients require further investigational studies, including angiography. However, among the few patients who demonstrated a high probability lung scan, there was a high positive predictive value for PE effectively avoiding the need for further studies. In those patients with low probability or near normal/normal V/Q scans, the negative predictive value was not lower than the general hospital population.     

肺栓塞的早期诊断

目的通过分析肺栓塞患者临床资料,寻找早期诊断线索。方法确诊肺栓塞患者46例,年龄(70±10)岁,结合临床表现和实验室结果进行回顾性分析。结果98%患者存在高危因素,最常见为深静脉血栓形成(26%),最常见症状为呼吸困难(74%),其次为突然发生的胸痛(13%)和晕厥(13%),86%有血气分析异常,指标以肺泡-动脉血氧分压差>20mmHg(1mmHg=0.133kPa)最为敏感。D-二聚体阳性率为90%。78%有心电图变化,V1,2导联ST-T改变与不典型SⅠQⅢTⅢ较多见。93%有超声心动图异常,多见右心房、右心室肥大,肺动脉压力为(59±11)mmHg。结论突然发生的气促、胸痛等临床表现,结合心电图一过性变化、D-二聚体阳性或动脉血二氧化碳分压降低、肺泡-动脉血氧分压差超过20mmHg异常可为肺栓塞早期诊断提供线索,必要时行超声心动图,可早期确诊。     

Immunologic diagnosis]

The development of the immunologic basic research and a deeper insight into the pathogenesis of diseases with changed immune reactivity led to an intensivation of the clinic-immunologic in-vivo- and in-vitro-diagnostics. At the instance of the pulmonary diseases according to the classification of Gell and Coombs the immunologic-diagnostic possibilities and problems are shown. Here is referred to the importance of the use of standardized tests and of the wide replaceability of in-vivo-techniques by in-vitro-methods.     

痰液降钙素原对慢性阻塞性肺疾病急性加重期的诊断价值

目的探讨痰液降钙素原（PCT）在慢性阻塞性肺疾病急性加重期（AEcOPD）诊断中的价值。方法选择187例AECOPD患者分为感染组和非感染组,测定痰液及血清PCT、C反应蛋白、白细胞,并与20例对照组（COPD稳定期）进行比较。结果感染组痰液及血清PCT水平高于非感染组及对照组,差异有统计学意义（P〈0．05）,感染组痰液PCT检测阳性率90．12％（146／162）,血清PCT检测阳性率85．19％（138／162）,CRP检测阳性率83．95％（136／162）,WBC检测阳性率86．42％（140／162）,各指标阳性率间差异无统计学意义（P〉o．05）。结论痰液PCT检测亦可作为AEc0PD是否存在感染的辅助诊断指标。     

慢性阻塞性肺疾病急性加重的诊断与治疗新进展

慢性阻塞性肺疾病(COPD)是一种可预防和治疗的疾病,以气流限制不完全可逆为特征。如患者出现症状的加重和(或)需要增加药物的治疗,称为COPD的急性加重(acute exacerbationofCOPD,AECOPD)。早期COPD发生急性加重(AE)并不常见,中重度肺功能损害者发生频率明显增加,如第一秒用力呼气容积(FEV1)>1.5L,每年AE少于1次,如FEV1<1.25L,每年AE的次数将大于2.5次[1]。频繁发生AE对患者的自然病程将产生不利影响,如肺功能损害、气道炎症加重和气道定植菌的增加。严重AECOPD的住院病死率高达11%[2],入住ICU者病死率11%～24%[3]。而且,…     

超声心动图诊断急性肺动脉栓塞的价值

目的 :分析评价床旁超声心动图 (ECHO)在急性肺动脉栓塞 (APE)诊断中的实用价值。方法 :采用经胸ECHO对临床怀疑APE的 5 8例患者在 4～ 6h内行床旁ECHO检查。结果 :超声直接检出主肺动脉及左右肺动脉主干近端血栓者 4例 ,均被外科手术或肺动脉造影证实。本组具有典型右心负荷过重超声征象者 15例 (其中包括具有超声直接征象的 4例 ) ,核素肺灌注 通气扫描提示为双肺多发性大面积栓塞。仅右房、右室轻度增大或肺动脉轻度增宽者 19例 ,ECHO无改变者 2 4例 ,但核素肺灌注 通气扫描均提示为肺段或亚段栓塞。结论 :ECHO能够发现主肺动脉、左右肺动脉干内附壁血栓直接提示肺动脉栓塞 ,或根据右室负荷过重表现间接提示肺栓塞的可能 ,但对肺段或亚段栓塞者超声不能作出或排除诊断。     

心电图在急性肺栓塞诊断中的应用

目的 探讨心电图在诊断急性肺栓塞中的作用。方法 回顾性分析25例（26例次）确诊的急性肺栓塞患住院首次,溶栓后及出前系列心电图变化。结果 （1）急性肺栓塞心电图改变：SI＞0.1mV22例次（84．6％）,SIQⅢTⅢ型16例次（61．5％）。QⅢTⅢ型16例次（61．5％）。TⅢ倒置23例次（88．5％）,TV1－V2倒置19例次（73．1％）,TV1－V3倒置13例次（50．0％）,TV1－V4倒置11例次（42．3％）,TV1－V5倒置3例次（11．5％）。T波倒均呈对称性,不完全性右束支传导阻滞3例次,SV1－V5R粗纯,挫折13例次（50．0％）。（2）溶栓后心电图变化：SⅠ变浅,QRS电轴左移,QⅢ减小或消失,TⅢ倒置变浅5例次,加深6例次,TV1－V2倒加中直立变倒置13例次（56．5％）,T波倒变浅或直立4例次,不完全性右束支传导阻滞消失2例次,SV1－V5R挫折,粗钝消失8例次（61．5％）。（3）出院前变化,RⅡ增加,RⅢ减小,QⅢ减小,TⅢ变直立10例次（38．5％）。TV2直立7例次（26．9％）。结论 急性肺栓塞心电图改变是非特异性的,但加能紧密结合临床,动态密切观察心电图典型,不典型或所谓“大致正常”的轻微改变是对筛选急性肺塞是有帮助的。有效溶栓治疗后,胸前导联T波倒置加深可能是右室荷减轻的一种表现。     

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慢性阻塞性肺疾病(COPD)是一种以不完全可逆性气流受限为特征的可以预防和治疗的气道慢性炎症性疾病。COPD病程中,患者常因感染等因素诱发出现COPD急性加重(AECOPD)。频繁发作的急性加重可使患者生存质量下降,肺功能进一步恶化,住院率和病死率上升。本文简述AECOPD诊治进展的相     

Physical diagnosis of chronic obstructive pulmonary disease

Among the various diagnostic strategies of chronic obstructive pulmonary disease (COPD), physical diagnosis is the quickest and requires no extra cost. Rapid physical diagnosis of COPD in primary care practice can lead to earlier actions of preventive measures and counseling for patients. Further, rapid physical diagnosis of COPD in an emergency department is also crucial for timely use of potentially lifesaving therapy specific for COPD patients. In this review, we will present a broad scope of physical findings for rapid physical diagnosis of COPD.     

Challenges in the diagnosis of acute pulmonary embolism

The state of the art of diagnostic evaluation of hemodynamically stable patients with suspected acute pulmonary embolism was reviewed. Diagnostic evaluation should begin with clinical assessment using a validated prediction rule in combination with measurement of D-dimer when appropriate. Imaging should follow only when necessary. Although with 4-slice computed tomography (CT) and 16-slice CT, the sensitivity for detection of pulmonary embolism was increased by combining CT angiography with CT venography, it is not known whether CT venography increases the sensitivity of 64-slice CT angiography. Methods to reduce the radiation exposure of CT venography include imaging only the proximal leg veins (excluding the pelvis) and obtaining discontinuous images. Compression ultrasound can be used instead. In young women, radiation of the breasts produces the greatest risk of radiation-induced cancer. It may be that scintigraphy is the imaging test of choice in such patients, but this pathway should be tested prospectively. A patient-specific approach to the diagnosis of pulmonary embolism can be taken safely in hemodynamically stable patients to increase efficiency and decrease cost and exposure to radiation.     

修正Geneva量表及D-二聚体对慢性阻塞性肺疾病急性加重合并肺血栓栓塞症的预测价值

目的评价修正Geneva量表结合D-二聚体在诊断慢性阻塞性肺疾病急性加重期（AECOPD）合并肺血栓栓塞症（PTE）中的诊断价值。方法收集2011年1月至2013年5月于我院急诊及住院的AECOPD疑似合并PTE的210例患者进行前瞻性研究,对患者临床资料,并分别以修正Geneva量表、D-二聚体测定以及两者结合评估合并肺栓塞的可能性,并与最终确诊的诊断结果进行分析比较。结果其中41例患者确诊PTE。AECOPD＋PTE组与单纯AECOPD组在症状、体征上仅不对称下肢水肿有统计学差异。D-二聚体〈500μg／L的阴性预测值为96．1％,而阳性预测值仅34．3％,特异度58．0％灵敏度90．2％。修正Geneva量表可能性高组阳性预测值为64．0％,可能性低组阴性预测值为94．7％;两者结合的阳性预测率为42．5％,阴性预测值96．9％。结论修正Geneva量表和血浆D-二聚体测对慢性阻塞性肺疾病急性加重期合并肺栓塞早期筛选具有价值,两种方法结合可以提高诊断的准确性,降低漏诊率。