29例肺弥漫性病变的临床诊断和鉴别诊断

目的：探讨肺弥漫性病变的临床诊断、鉴别诊断及对预后判断的意义．方法：对29例以弥漫性肺间质性病变为主要表现患者的临床症状、体征、x线胸片和高分辨率CT表现及其他辅助检查等结果进行回顾性分析。结果：29例中，男女比例为1：1．9．分别确诊为特发性肺间质纤维化9例(31％)，特发性非特异性间质性肺炎9例(31％)及特发性脱屑性间质性肺炎1例；结缔组织病肺部表现4例(14％)；过敏性肺泡炎2例(7％)；细支气管肺泡癌、转移性肺腺癌、嗜酸性粒细胞浸润性肺炎、非霍奇金淋巴瘤肺间质病变各1例(共占14％)，特发性肺间质纤维化组的病程长于特发性非特异性间质性肺炎组[3～25(中位数14)个月比1～5(中位数2)个月，P=0．036]，前者更易出现呼吸困难、紫绀、杵状指；X线及高分辨率CT检查特发性肺间质纤维化主要为网格状和蜂窝状表现，特发性非特异性间质性肺炎则以片状磨砂玻璃样影为主；特发性肺间质纤维化组ESR明显增快，且有明显肺通气和弥散功能障碍。结论：弥漫性肺疾病的诊断是一综合过程，除了与结缔组织疾病及肿瘤鉴别外，区分特发性肺间质纤维化与特发性间质肺炎，对指导治疗和判断预后具有重要意义。     

肺功能测定对几种间质性肺疾病的诊断价值

本文分析了22例特发性肺间质纤维化(IPF)、40例肺结节病(Sarc)和9例胶原病性肺炎(IP—CVD)的肺功能变化。IPF、IP—CVD肺功能改变较为明显,主要表现为严重的弥散功能障碍和限制性通气功能障碍。Sarc组近半数肺功能正常,其余主要为阻塞性通气功能障碍,限制性和弥散性肺功能障碍的程度较IPF和IP—CVD组明显为轻。Sarc三期间肺功能无明显差异。三组肺功能下降最为显著的是DLco,其次是FEV_1,FVC和FRC等,提出这些指标对间质性肺疾病可能有辅助诊断价值,但需结合其它检查才能确诊。     

2型糖尿病肺功能改变分析

目的：观察糖尿病患者肺通气功能以及换气功能的改变情况，分析患者不同病程、不同并发症以及不同糖化血红蛋白（HbA1C）水平对肺弥散功能的影响。方法：对81例2型糖尿病患者和71例健康志愿者进行肺通气功能和弥散功能的测定．并分析不同病程、并发症以及HbA1C水平对肺弥散功能的影响。结果：除用力肺活量外．糖尿病患者的肺通气功能指标均在正常预测值范围内，而肺弥散功能指标则显著低于健康志愿者；随着病程的增长、并发症的增加以及HbA1C水平的升高，2型糖尿病人肺弥散功能明显下降。结论：肺也是糖尿病损伤的重要靶器官之一，在临床工作中，对糖尿病患者应注意检测其肺功能尤其是弥散功能水平。     

特发性肺间质纤维化的全球发病率和病死率

<正>间质性肺疾病(ILD)是一组异质性疾病的总和,主要病理特征为弥漫性肺泡炎和(或)间质纤维化,也称弥漫性实质性肺疾病。特发性肺间质纤维化(IPF)是ILD的一种,病因不明,以成年人尤其是50岁以上人群多见,进行性呼吸困难伴刺激性干咳是其主要的临床特征,组织病理学和影像学类型为寻常型间质性肺炎(UIP),肺功能表现为限制性通气功能障碍伴不同程度的弥散功能障碍。随着病情持续发展,纤     

结缔组织病患者的肺功能表现

目的探讨结缔组织病患者肺功能受损的情况及其病理生理原因。方法测定80例患者的肺功能,并与正常对照组进行比较。结果弥散功能显著减低,且有显著性差异(P＜0.05);异常百分率经综合分析自高至低依次为弥散功能为68.7%,小气道阻塞为46.0%,肺气肿为42.0%,通气功能减退为28.7%,阻塞性通气障碍为26.2%,限制性通气障碍为21.2%;相关分析显示一氧化碳弥散量与肺总量呈正相关(r=0.68,P＜0.01)。结论结缔组织病患者的肺功能损害以弥散功能减退为主,其次可见小气道阻塞、肺气肿、通气功能减退,其肺功能损害的病理生理基础是肺间质受累致肺毛细血管床减少、间质纤维化、小气道阻塞及肺容积的改变。     

2型糖尿病患者的肺功能改变

目的：探讨2型糖尿病（T2DM）患者肺功能的变化。方法：采用意大利产QUARKPFT3型体积容积描记肺功能议检测65例T2DM患者（T2DM组）和40例健康对照组的肺通气和弥散功能，并进行比较分析。同时对T2DM组患者不同年限肺功能的变化进行了比较分析。结果：T2DM组总肺活量（TLC），用力肺活量（FVC），一秒用力呼气量（FEV1）一秒率（FEV2％）肺-氧化碳弥散量（DLCu）均明显低于正常组（P〈0．05或P〈0．01），T2DM患者肺功能损害与糖尿病病程有明显著相关（P〈0．01）．结论：T2DM患者存在以限制性为主的肺通气功能障碍和弥散功能障碍。     

临床非特异性间质性肺炎19例治疗体会

目的通过19例非特异性间质性肺炎诊疗体会,探讨其临床特征。方法对19例细胞型和混合型非特异性间质性肺炎临床病例从临床表现、诊疗经过及预后进行回顾性分析。结果19例非特异性间质性肺炎患者呼吸系统以咳嗽、咳痰、呼吸困难和爆裂音为主要表现,肺外以体重减轻和乏力为主要表现。胸部高分辨率CT都有毛玻璃影等表现,肺功能检查为限制性通气功能障碍及不同程度的弥散功能障碍,给予糖皮质激素治疗后均获得不同程度好转。结论通过临床症状、HRCT及肺活检,可明确非特异性间质性肺炎的诊断,运用糖皮质激素进行个体化治疗可明显改善患者症状,提高临床疗效。     

肾移植前后肺通气、弥散功能及肺部影像学变化

背景：慢性肾功能衰竭患者由于内环境的紊乱及免疫功能的低下，易受体内外致病因素的影响而发生心、肺病变。肾移植后传统非特异性免疫抑制剂的联合应用，成为肺损伤发生的高危因素。 目的：随访观察肾移植患者移植前后肺功能检测指标及肺部影像学的动态变化。设计、时间及地点：病例自身对照观察，于2003—02／2006—05在解放军北京空军总医院呼吸科及泌尿外科完成。 对象：纳入52例终末期肾病患者，均在解放军北京空军总医院接受肾移植手术。方法：分别于肾移植前、移植后3，6，12个月随访观察52例患者的自身肺功能变化，同期观察其肺部影像学变化。主要观察指标：肾移植患者肾移植前后肺通气功能、弥散功能及肺部影像学变化。 结果：①肾移植前，肺功能异常者占79％，其中多以阻塞性通气功能障碍和弥散功能下降为突出表现。②移植后3个月，患者的弥散功能和阻塞性通气功能障碍有部分好转，但肺限制性通气功能障碍比移植前突出。③移植后6，12个月，近一半的患者肺功能趋于稳定在正常范围之内。④移植前肺功能和弥散功能的损害较肺部影像学明显，前者发生率为79％，后者为54％。肾移植后，肺部影像学明显改善，且以肺部间质性改变为主要表现。 结论：肾移植能显著改善终末期肾病患者的肺功能，尤其是小气道功能和弥散功能。肾移植前后肺部影像学的异常主要表现为程度不同的肺间质性改变。     

CO弥散功能评价SLE肺间质病变

对２４例系统性红斑狼疮（ＳＬＥ）患者进行胸片、ＣＴ和肺功能（包括通气和换气功能）的检测，其中１２．５％的胸片示肺部间质病变，表现为肺纹理增粗、网格状改变、囊状透亮区；３７．５％的ＣＴ示肺间质性病变，表现为肺小叶间隔增厚、呈线网状；１２．５％示限制性通气功能障碍；４５．８％示肺换气（ＣＯ弥散）功能障碍，与对照组比较，差异有显著性［实验组平均ＣＯ弥散吸收率（８１．５±２３．９）％，对照组（１０１．４±５．６）％，Ｐ＜０．０１］。在胸片正常的患者中３５．３％有ＣＯ弥散功能下降。显示ＣＯ弥散功能测定是诊断ＳＬＥ肺部间质病变的一个有效手段。     

系统性红斑狼疮患者的肺功能改变及其相关因素研究

目的：观察ＳＬＥ患者的肺功能受损情况并探讨其相关因素。方法：测定４２例ＳＬＥ患者肺通气功能、小气道功能、肺容量和肺弥散功能,并进行 相关分析。结果：统计学显著ＳＬＥ患者弥散功能明显受损,异常率计算表明ＳＬＥ患者肺功能损害以弥散功能障碍发生率最高,其次为小气道阻塞和肺气肿,相关分析表明,ＤＬＣＯ与ＴＬＣ及ＲＶ明显相关。结论：ＳＬＥ患者肺功能损害以弥散功能障碍为主,其次为小气道阻塞和肺气肿,此外,ＳＬ     

Evaluation of chronic dyspnea

Chronic dyspnea is defined as dyspnea lasting more than one month. In approximately two thirds of patients presenting with dyspnea, the underlying cause is cardiopulmonary disease. Establishing an accurate diagnosis is essential because treatment differs depending on the underlying condition. Asthma, congestive heart failure, chronic obstructive pulmonary disease, pneumonia, cardiac ischemia, interstitial lung disease, and psychogenic causes account for 85 percent of patients with this principal symptom. The history and physical examination should guide selection of initial diagnostic tests such as electrocardiogram, chest radiograph, pulse oximetry, spirometry, complete blood count, and metabolic panel. If these are inconclusive, additional testing is indicated. Formal pulmonary function testing may be needed to establish a diagnosis of asthma, chronic obstructive pulmonary disease, or interstitial lung disease. High-resolution computed tomography is particularly useful for diagnosing interstitial lung disease, idiopathic pulmonary fibrosis, bronchiectasis, or pulmonary embolism. Echocardiography and brain natriuretic peptide levels help establish a diagnosis of congestive heart failure. If the diagnosis remains unclear, additional tests may be required. These include ventilation perfusion scans, Holter monitoring, cardiac catheterization, esophageal pH monitoring, lung biopsy, and cardiopulmonary exercise testing.     

临床非特异性间质性肺炎3例报告及文献复习

目的:探讨非特异性间质性肺炎(NSIP)的临床特征。方法:对3例经支气管镜肺活检病理诊断的NSIP患者的发病诱因、临床表现、影像学、肺功能检查、病理资料及预后进行回顾分析。结果:3例中女性2例,男性1例,平均年龄45～47岁;发病至就诊时间15 d～4个月。发病前有吸烟史1例,慢性胃炎1例,3例均有咳嗽、进行性呼吸困难,2例有吸气相爆裂音,有发热和杵状指各1例。胸部高分辨CT(HRCT)均示有弥漫性斑片状磨玻璃样变,以两下肺及胸膜下为甚。肺功能检查示2例为限制性肺通气功能障碍,1例为混合性肺通气功能障碍,低氧血症1例。组织类型:细胞型2例,混合型1例。1例低氧血症给予无创机械通气治疗,3例均给予糖皮质激素治疗后病情明显好转。结论:对中年以上的患者,临床表现、胸部影像学等检查拟诊为间质性肺病变者要及时行支气管镜肺活检,以明确NSIP的病理诊断及组织学类型。确诊NSIP患者,加用糖皮质激素治疗可提高临床治疗效。     

Cigarette smoking in interstitial lung disease: concepts for the internist

Cigarette smoking is a common cause of lung disease. It is clearly implicated in the development of chronic obstructive pulmonary disease and lung cancer. Importantly, cigarette smoking has also been implicated in the development of interstitial lung diseases such as respiratory bronchiolitis interstitial lung disease, desquamative interstitial pneumonia, pulmonary Langerhans' cell histiocytosis,and idiopathic pulmonary fibrosis. The exact role of cigarette smoking in the development of interstitial lung diseases is still being defined; the relatively low prevalence of interstitial lung disease makes epidemiologic studies difficult.     

Interferon gamma-1b therapy for advanced idiopathic pulmonary fibrosis

OBJECTIVE: To report on observations made in a group of patients with idiopathic pulmonary fibrosis/usual interstitial pneumonia (IPF/UIP) who were treated with interferon gamma-1b. PATIENTS AND METHODS: We reviewed the clinical records, radiological studies, and pulmonary function data of all patients treated with interferon gamma-1b between January 2000 and March 2002 at the Mayo Clinic in Rochester, Minn. RESULTS: Twenty-one patients (mean age, 68 years; range, 52-80 years) were treated with interferon gamma-1b for a mean duration of 82 months (range, 3-21 months). All patients had been diagnosed previously as having IPF/UIP based on clinical, pulmonary function, and chest high-resolution computed tomographic scan criteria; 12 patients had also undergone video-assisted thoracoscopic surgical lung biopsy. Baseline pulmonary function data (mean +/- SEM percent predicted) were as follows: total lung capacity, 57.3 +/- 2.5; vital capacity, 55.0 +/- 3.3; diffusing capacity of lung for carbon monoxide, 39.7 +/- 2.8; and forced expiratory volume in 1 second, 58.1 +/- 3.6. Only 1 patient showed symptomatic and functional improvement, and 7 discontinued treatment because of a perceived lack of benefit. Eleven patients (52%) died after a mean of 6.4 months of treatment, and follow-up pulmonary function data suggested continued worsening in all but 1 patient. CONCLUSION: These observations do not support the use of interferon gamma-lb therapy for patients with advanced IPF/UIP.     

内科胸腔镜肺活检对弥漫性间质性肺疾病诊断价值及安全性分析

目的探讨内科胸腔镜肺活检对弥漫性间质性肺疾病患者的诊断价值及安全性。方法回顾性分析35例内科胸腔镜肺活检的弥漫性间质性肺疾病患者临床及病理诊断资料。结果 31例患者获病理确诊,确诊率88.6%(31/35),其中普通型间质性肺炎(UIP)10例,肺结核6例,肺泡细胞癌4例,非特异性间质性肺炎(NSIP)、隐源性机化性肺炎(COP)各3例,肺泡蛋白沉着症(PAP)2例,韦格纳肉芽肿病(WG)、急性间质性肺炎(AIP)和淋巴管肌瘤病(LAM)各1例。术后并发症3例(8.6%),其中肺部感染合并呼吸衰竭2例,特发性肺间质纤维化急性加重1例,导致死亡2例(5.7%)。结论内科胸腔镜肺活检是诊断弥漫性间质性肺疾病安全有效的方法。     

Angiotensin-converting enzyme inhibition facilitates alveolar-capillary gas transfer and improves ventilation-perfusion coupling in patients with left ventricular dysfunction

OBJECTIVE: The backward effects of left ventricular dysfunction include alterations in alveolar-capillary gas transfer and ventilation-perfusion coupling. Because the angiotensin-converting enzyme (ACE) is highly concentrated in the vascular endothelium of the lungs, we examined whether ACE inhibitors may influence the pulmonary function in patients with congestive heart failure. METHODS: In 20 patients with idiopathic cardiomyopathy, pulmonary function and exercise capacity were evaluated at baseline and 6 and 12 months after treatment with enalapril (10 mg twice a day) was started. The study also included 19 age- and sex-matched control subjects with mild primary hypertension and normal left ventricular function who were given enalapril as a standard treatment of high blood pressure. RESULTS: In congestive heart failure, forced expiratory volume in 1 second, vital capacity, and total lung capacity did not vary significantly with enalapril; alveolar-capillary diffusion of carbon monoxide (DL(CO)) increased toward normal; exercise tolerance time, peak exercise oxygen uptake (peak VO2), minute ventilation and tidal volume (peak VT) also increased; and the ratio of volume of dead space (VD) to VT (peak VD/VT) at peak exercise reduced. Changes in peak VO2 showed a direct correlation with those in DL(CO) and an inverse correlation with those in peak VD/VT. Results at 6 and 12 months were comparable. Enalapril did not affect these variables in the control population. CONCLUSIONS: In patients with idiopathic cardiomyopathy heart failure, but not in control subjects, gas transfer and ventilation-perfusion improved with ACE inhibition. These pulmonary changes may contribute to the associated increase in exercise tolerance.     

Diagnosis and management of idiopathic pulmonary fibrosis: Implications for respiratory care

Although poorly understood, idiopathic pulmonary fibrosis is the most common of the idiopathic interstitial lung diseases. Its etiology is unknown, but how this fibrotic process develops in the lung has been studied over the last 60 years. It is a relatively rare disease, afflicting those 50-70 years of age, slightly more common among men than women, without racial predilection. The most common complaint is progressive shortness of breath. Pulmonary function testing reveals a restrictive ventilatory defect with a diminished diffusion capacity. The lungs demonstrate fibrotic and cystic areas interspersed with normal lung on radiographic and pathologic examination. No definitive medical treatment is available, although most patients are given trials of corticosteroids, alone or in combination with cytotoxic agents. On average, patients survive 2-4 years after diagnosis. Lung transplantation has been the only therapy shown to improve survival of those with idiopathic pulmonary fibrosis.     

Interstitial lung disease

The interstitial lung diseases are comprised of a group of pulmonary disorders characterized clinically by diffuse infiltrates on the chest radiograph and histologically by distortion of the gas exchanging portion of the lung. The physiologic correlates are restriction of lung volumes and impaired oxygenation. The term "interstitial" when applied to these diseases is actually a misnomer because it implies that the inflammatory process is limited specifically to the area between the alveolar epithelial and capillary endothelial basement membranes. The diseases currently grouped as "interstitial" also frequently involve the alveolar epithelium, alveolar space, pulmonary microvasculature, and less commonly, the respiratory bronchioles, larger airways, and even the pleura. The enormous differential diagnosis of interstitial lung disease can be made manageable by understanding that pneumoconiosis, drug-induced disease, and hypersensitivity pneumonitis account for over 80% of the responsible entities and can usually be identified from the patient's history. The nine remaining diseases/disease categories include: sarcoidosis, idiopathic pulmonary fibrosis, bronchiolitis obliterans-organizing pneumonia, histiocytosis X, chronic eosinophilic pneumonia, collagen vascular disease-associated interstitial lung disease, granulomatous vasculitis (Wegener's granulomatosis, Churg-Strauss syndrome, lymphomatoid granulomatosis), Goodpasture's syndrome, and pulmonary alveolar proteinosis. The diagnosis of a specific interstitial lung disease can be made via various means including the patient's history, specific serologies, bronchoalveolar lavage, transbronchial biopsy, and biopsy of extrathoracic tissues or open lung biopsy. A directed diagnostic approach can be formulated based on an understanding of these techniques and a thorough knowledge of the clinical presentations and specific diagnostic criteria for each of the major diseases. This monograph will serve as a guide for the clinician to use in evaluating and treating patients with interstitial lung disease. We begin by reviewing the clinical presentation, diagnostic criteria, and management of specific interstitial lung diseases excluding pulmonary infection, neoplasm, and sarcoidosis. Pneumoconiosis and drug-induced syndromes are not discussed in detail, but the agents responsible and pertinent exposures are presented in tabular form in the discussion of the general diagnostic approach.     

糖尿病对慢性阻塞性肺疾病患者肺功能及血气分析影响的研究

目的：探讨慢性阻塞性肺疾病（COPD）合并糖尿病患者的肺功能及血气分析特点并分析其临床意义。方法：选取2008年1月～2009年1月在我院门诊就诊的稳定期患者53例作为研究对象,并根据是否合并糖尿病分为COPD合并糖尿病组26例,单纯COPD组27例,并通过肺功能检测及血气分析,检测肺活量（VC）、用力肺活量（FVC）、第1秒钟用力呼气容积（FEV1）、FEV1/用力肺活量（FVC）、用力呼气中期流速PEF（25%～75%）、肺一氧化碳弥散（DLCO）及肺一氧化碳弥散量实测值占预计值的百分比（DLCO/PRED）等肺功能指标及PaO2、PaCO2等血气指标,并进行组间分析。结果：COPD合并糖尿病组肺通气功能指标VC、FVC、FEV1、PEF（25%～75%）和弥散功能指标DLCO、DLCO/PRED及PaO2显著低于单纯COPD组。结论：COPD合并糖尿病时肺通气功能和弥散功能都可受损。     

护理干预对老年呼吸机相关性肺炎发生的预防作用分析

目的探讨护理干预对老年呼吸机相关性肺炎发生的预防作用。方法选取本院接诊的80例接受机械通气患者作为研究对象。按照随机抽签法分为观察组和对照组各40例,2组患者进行常规对症治疗,包括气管插管、化痰止咳、纠正酸碱失衡及水电解质紊乱、解痉平喘、抗生素治疗等。对照组采用常规护理,观察组采用护理干预。观察2组患者机械通气时间和住院时间,动脉血气分析,生命体征,肺功能指标,呼吸机相关性肺炎发生率及病死率。结果观察组机械通气时间和住院时间低于对照组;pH值、p(O_2)值均高于对照组,p(CO_2)低于对照组(P0.05);Sa O2显著高于对照组(P0.05),心率、呼吸频率低于对照组(P0.05);2组患者肺功能指标PEF、PEEPi均改善,且观察组改善程度优于对照组(P0.05);呼吸机相关性肺炎发生率及病死率均低于对照组(P0.05)。结论加强护理干预在对老年呼吸机相关性肺炎发生具有显著的预防作用,能够促进患者恢复,缩短机械通气治疗时间,从而减少肺部感染。