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噻托溴铵联合肺康复治疗轻中度支气管扩张症的疗效

目的探讨噻托溴铵联合肺康复治疗轻中度稳定期支气管扩张症的有效性。方法纳入 2017 年 9 月至 12 月就诊于山东第一医科大学附属莱钢医院呼吸科支气管扩张严重程度指数（BSI）评分为轻中度的稳定期支气管扩张症患者 90 例，随机分为常规治疗组、噻托溴铵组和联合治疗组，各 30 例。规律治疗 1 年后，比较三组患者改良呼吸困难指数（mMRC）评分、BSI 评分和肺通气功能检查的变化。结果治疗后常规治疗组 mMRC 为（2.00±1.08）分，BSI 评分为（4.40±0.89）分，明显高于联合治疗组［（1.37±0.49）分、（2.37±1.13）分］和噻托溴铵组［（1.47±0.57）分、（3.40±1.16）分］，差异均有统计学意义（均 P<0.05）。常规治疗组第 1 秒用力呼气容积占预计值百分比（FEV1%pred）为（71.70±6.46）%，用力肺活量占预计值百分比（FVC%pred）为（63.80±6.67）%，FEV1/FVC 为（74.00±5.47）%，明显低于噻托溴铵组［（74.97±5.33）%、（70.83±8.41）%、（79.47±4.90）%］和联合治疗组［（78.53±4.75）%、（74.23±5.19）%、（81.70±5.80）%］，差异均有统计学意义（均 P<0.05）。联合治疗组 FEV1%pred 明显高于噻托溴铵组，而 BSI 评分明显低于噻托溴铵组，差异有统计学意义（P<0.05）。结论噻托溴铵粉吸入剂联合肺康复治疗能减轻支气管扩张症患者的呼吸困难，提高肺通气功能，改善预后。

吸入激素在支气管扩张症中的应用

支气管扩张症(简称支扩)是以进行性和不可逆性气道破坏和扩张为特征的慢性气道炎症性疾病[1]，大多表现为长期咳嗽、咳脓性痰，反复急性发作，肺功能受损，后者主要表现为阻塞性通气功能障碍，气道反应性增高，晚期患者常常出现劳力性呼吸困难，严重影响患者生活质量[2,3] 。大部分支扩患者第1秒用力呼气容积(FEV )每年下降大约50mL [4] 。在我国支扩的发病率为0.3‰～0.5‰。2005年美国成人支扩发病率约为52．3／100 000。发病率随年龄而增加，在所有年龄阶段女性发病率均较男性高，预计在美国有18岁以上的支扩患者110 000例，每年医疗费用约6．3亿美元[5]。

Efficacy of Long-term Inhaled Salmeterol/Fluticasone Combined with Low-dose Oral Erythromycin in Patients with Bronchiectasis

Objective To evaluate the efficacy of long-term inhaled salmeterol / fluticasone combined with low-dose oral erythromycin in patients with bronchiectasis. Methods Sixty-two patients with bronchiectasis after exacerbation and maintained stable were randomly divided into three groups. Group A was treated with low-dose oral erythromycin, group B inhaled salmeterol/fluticasone, and group C inhaled salmeterol/fluticasone plus low-dose oral erythromycin. The study duration lasted for 6 months. The clinical symptoms, dyspnea scale, exacerbation frequency, and pulmonary function parameters were measured and compared. Results Fifty-four patients completed the whole study and 8 cases withdrew. The results showed that 6 months of low-dose erythromycin therapy can improve the clinical symptoms, whille exacerbation frequency was also decreased. Inhaled salmeterol/fluticasone improved lung function, however, had no effect on cough, expectoration and exacerbation frequency. Inhaled salmeterol/fluticasone combined with erythromycin was more significantly effective in improving lung functions as well as symptoms. Conclusions Long-terminhaled salmeterol/fluticasone combined with low-dose oral erythromycin can improve the clinical symptoms and lung function, decrease the frequency of exacerbation in patients with bronchiectasis. It may be as an alternative to the maintenance treatment of bronchiectasis.

Effect of leukotriene receptor antagonist on airway mucus hypersecretion in patients with acute exacerbation of bronchiectasis

Objective To explore the effect of leukotriene receptor antagonist montelukast on physicochemical property of sputum and airway mucus hypersecretion in patients with acute exacerbation of bronchiectasis. Methods Eighty-four inpatients with acute exacerbation of bronchiectasis were randomly divided into a control group and an experiment group, with 42 cases in each group. The control group received conventional therapy and the experiment group took orally montelukast 10 mg before sleep every day based on conventional therapy for two weeks. At admission and 15 days after admission, the amount in 24 hours, dry/wet weight ratio and viscosity of sputum were observed while the levels of neutrophil elastase (NE) and mucin MUC5ac in sputum were determined by ELISA. The pulmonary ventilation function, airway resistance and blood gas analysis were also measured. Results The sputum amount in 24 hours, dry/wet weight ratio and viscosity of sputum, NE and MUC5ac of sputum, pulmonary ventilation function, blood gas analysis and airway resistance were declined or improved remarkably after treatment compared with before treatment in two groups (P<0.05). Meanwhile, the sputum amount in 24 hours [(5.62±1.83) g vs. (7.53±2.32) g], NE [(3.85±0.97) μg/ml vs. (4.54±1.03) μg/ml], MUC5ac [(0.65±0.21) μg/ml vs. (0.82± 0.29) μg/ml] and the airway resistance [(119.16±11.76)% vs. (128.37±12.08)%] were declined remarkably in the experiment group compare with the control group after treatment (all P<0.05). The viscosity of sputum between the two groups after treatment showed no significant difference. Conclusion In patients with acute exacerbation of bronchiectasis, montelukast can reduce amount of sputum and airway resistance, reduce expression of mucin MUC5ac through down-regulation of NE, thus inhibit airway mucus hypersecretion.

胸部物理疗法联合口咽通气管吸痰在支气管扩张症无创通气中的应用

目的 探讨胸部物理疗法联合口咽通气管吸痰对行无创正压通气的支气管扩张症患者的治疗效果及安全性。 方法 选取 2013 年 1 月—2015 年 8 月存在不同程度急性呼吸衰竭的急性加重期支气管扩张症患者 27 例，在给予抗菌药物治疗、对症治疗、营养支持的基础上行无创正压通气，护理上给予手法叩背、应用体外震动排痰机、体位引流等胸部物理疗法联合经口咽通气管吸痰。 结果 经综合治疗和护理后，患者最终显效 16 例，有效 9 例，无效 2 例，治疗有效率达 92.6%。 结论 对伴有呼吸衰竭的支气管扩张症急性加重期患者，在实施无创正压通气时，用胸部物理疗法配合口咽通气管吸痰能解决无创正压通气中患者无力咳痰的问题，保持呼吸道通畅，保障无创正压通气的顺利实施，改善患者预后。

Methodological study on N-of-1 trials of traditional Chinese medicine based on bronchiectasis

Objective A series of N-of-1 trials were conducted to evaluate the effects of traditional Chinese medicine (TCM) individualized syndrome differentiation on stable bronchiectasis, and to explore a clinical trial method that is consistent with the characteristics of TCM. Methods The original plan consisted of 3 cycles, with each cycle consisting of two observation periods: experimental and control. Take the medication for 3 weeks each period and then stop for 1 week. Because the results were not as expected, another cycle of trials was added (a total of 4 cycles). The trial period was treated with individualized syndrome differentiation prescription and the control period was treated with placebo. The outcome measures were Likert scale score of general symptoms (primary outcome), Likert scale score of respiratory symptoms, CAT score, 24h sputum volume and TCM symptom score. Data analysis (including residual effects and stage effects analysis) used group-designed independent sample t tests, paired t tests or non-parametric tests, mixed effects models, and Bayesian analysis. Results A total of 31 participants were formally enrolled, with 24 completing all four cycles. Independent sample t-tests and mixed-effects models showed no significant period or carryover effects. Bayesian analysis showed that there were residual effects on some outcome measures of some individuals. Six participants showed statistically significant differences in overall symptom Likert scale scores (P<0.05). Bayesian analysis found that TCM was more effective than placebo in more individuals. No significant differences were found between individualized TCM and placebo at the group level for any of the outcome measures. Conclusion This study method highly simulates the clinical practice of TCM, with good operability and patient compliance, and has no obvious residual effect of TCM on the whole, which can provide the best individualized evidence-based medicine evidence of short-term efficacy of TCM. Bayesian analysis can improve the sensitivity of individual statistics.

大环内酯类抗生素在支气管扩张症中的应用

Role of aspergillus infection in bronchiectasis and its diagnosis and treatment

Bronchiectasis is a heterogeneous disease characterized by abnormal expansion of the bronchi, manifested by cough, sputum, and recurring lung infections. As one of the common fungi of lung infection, aspergillus can not only appear as the outcome of the disease in bronchiectasis, but also as an inducement to participate in the disease progression, and ultimately complicate the course of bronchiectasis. This article describes the susceptibility factors and pathogenic mechanisms of aspergillus in bronchiectasis, and further introduces the diagnosis and treatment status of bronchiectasis combined with aspergillus infection, aiming to clarify the effect of aspergillus infection on bronchiectasis and provide new thinking directions for its clinical diagnosis and treatment.

Correlation analysis of red blood cell distribution width and disease severity of acute exacerbation of bronchiectasis in the elderly patients

ObjectiveTo investigate the relationship between the red blood cell distribution width (RDW) and the severity of acute exacerbation of bronchiectasis in elderly patients.MethodsThe clinical data of 216 elderly patients with acute exacerbation of bronchiectasis admitted from January 2015 to October of 2018 were analyzed retrospectively. The severity of acute exacerbation of bronchiectasis in the elderly was evaluated by bronchiectasis severity index (BSI) score. Meanwhile, 50 elderly people receiving qualified medical examination were collected as a healthy control group in the same period. The distributions of BSI score, RDW, procalcitonin (PCT), neutrophil percentage (NEU%) and C-reactive protein (CRP) were described in the patients with different risk degree. The severity of acute exacerbation of bronchiectasis in the elderly was evaluated by BSI. The patients were divided into three groups by BSI score: a low risk group, a middle risk group, and a high risk group. The indexes were described including the distribution of stratified BSI score, RDW, PCT, NEU%, CRP at different risk levels. The correlation of each index was analyzed by Spearman correlation. The threshold value of RDW was calculated by general linear regression, and the influencing factors of BSI score were analyzed by multivariate linear regression analysis.ResultsThe higher the risk stratification, the higher the BSI score, RDW, PCT, NEU% and CRP were. RDW was positively correlated with PCT, NEU% and CRP (r values were 0.425, 0.311, 0.177, respectively, P<0.05). BSI score was positively correlated with RDW, PCT, NEU%, and CRP (r values were 0.425, 0.394, 0.650, 0.578, respectively, P<0.05). RDW was positively correlated with PSI score (r=0.425, P<0.05). The thresholds of RDW were 11.45% and 14.03%. Multiple linear regression showed that RDW, PCT, NEU% and CRP were all influential factors of BSI score and explained 52.3% of the total mutation rate.ConclusionRDW is related to the severity of acute exacerbation of bronchiectasis in the elderly, and can predict the severity of acute exacerbation of bronchiectasis in the elderly.

支气管扩张症的抗生素治疗

支气管扩张症(简称支扩)是指由多种原因引起支气管壁肌肉和弹力支撑组织的破坏而引起的中等大小支气管的不正常扩张，是一种肺组织结构破坏性疾病，表现为反复呼吸道感染，大量脓痰，可出现咯血。支扩有许多相关因素及病因，总体来说，其发生可归结于以下两个因素：① 感染的持续刺激；②气道阻塞、支气管引流功能损害和防御功能的缺陷。两种因素可以同时存在，互为因果。支扩的病程一般呈进行性发展，其机制可用Cole[1] 在1984年提出的恶性循环(vicious circle)假说来解释，该假说认为感染或定植的细菌触发气道上皮的炎症反应，释放炎症介质和酶，持续的慢性炎症反应引起支气管壁和肺组织的损伤，破坏气道纤毛上皮的清洁功能，进一步加重感染和细菌定植，形成一个周而复始的恶性循环。因此，抗生素几乎是现阶段治疗支扩的主要药物之一。