2014年 · 第94卷第38期

Modern noninvasive positive pressure ventilation was first used to treat obstructive sleep apnea. Its ventilation devices and techniques were produced in 1981^[1]The original device had only one mode of continuous positive airway pressure. In more than 30 years since the first generation of non-invasive positive pressure ventilator was introduced, many improvements have been made in ventilation mode and device technology, and the ventilation therapy function has been improved day by day. In recent years, the development speed and scope of non-invasive positive pressure ventilation technology in clinical application far exceed the original intention of the inventor, bringing new treatment concepts and benefits to clinicians and patients, and creating clinical and academic value that is difficult to estimate by numbers.

In the treatment of acute hypoxic respiratory failure, respiratory support is the most important measure besides the treatment of the primary disease. Ordinary oxygen therapy cannot provide positive pressure support and is only suitable for those with mild disease; However, invasive positive pressure ventilation (IPPV) requires high ventilation equipment and monitoring conditions, is expensive, complicated operation technology, many complications, and relatively lack of resources in China, so it is difficult to implement early intervention for respiratory failure. Non-invasive positive pressure ventilation (NPPV) has attracted more and more attention in recent 20 years because of its advantages of non-invasive, upper airway-preserving defense mechanism, simple operation, low cost and fewer associated complications. The application field of NPPV has also gradually expanded from acute exacerbation of chronic obstructive pulmonary disease to various acute hypoxic respiratory failure. Several studies have shown that for acute hypoxic respiratory failure caused by different causes, NPPV can improve oxygenation, reduce the occurrence of complications, and reduce tracheal intubation rate and mortality^[1]。 However, the success rate varies greatly between different causes. In addition to being related to the procedure, the grasp of the indication is the key to improving the success rate of NPPV in the treatment of acute hypoxic respiratory failure.

Non-invasive positive pressure ventilation (NPPV), as a respiratory support technique for the treatment of acute and chronic respiratory insufficiency, has been widely used in clinic in recent 20 years. It has been proved to have definite effect in the treatment of acute exacerbation of chronic obstructive pulmonary disease, acute cardiogenic pulmonary edema, respiratory failure secondary to immunosuppression and other diseases. In addition to conventional application fields, NPPV also has good application prospects in assisted bronchoscopy and assisted tracheal intubation. It is believed that through the continuous exploration of clinical medical staff, the clinical application fields of NPPV will continue to expand^[1,2]。

A 56-year-old female was admitted for "shortness of breath after activity for 10 years, with edema of both lower limbs for 9 years, aggravated for 7 days". The patient developed shortness of breath after "getting angry" 10 years ago. The symptoms were obvious when going up 3 floors or walking rapidly, accompanied by neck swelling and pain. No special treatment was given, and the symptoms persisted without improvement. 9 years ago, he developed edema of both lower limbs. He went to a local hospital 7 years ago and underwent cardiac ultrasound and other examinations. He was diagnosed as "pulmonary hypertension and right ventricular dysfunction". After diuresis and vasodilator treatment, the edema of both lower limbs improved. After long-term oral administration of "isosorbide nitrate and spironolactone", the patient's symptoms of shortness of breath gradually worsened. More than 1 year ago, multiple serous effusion occurred, and cardiac color ultrasound showed: obvious enlargement of right heart and left atrium, right ventricular hypertrophy, decreased right ventricular wall movement, mild aortic valve regurgitation, moderate-severe tricuspid valve regurgitation, obvious pulmonary artery widening, and pulmonary artery systolic pressure estimated by TI method of 150 mmHg (1 mmHg =0.133 kPa). "Xiaoxintong" was stopped, and "phosphodiesterase-5 inhibitor (sildenafil) 20 mg/time, once a day" was added orally, and diuresis and other treatments were given at the same time. The symptoms were significantly better than before. Hemoptysis occurred due to oral warfarin, and anticoagulation treatment was not given. One year later, cardiac ultrasound was repeated, and pulmonary systolic blood pressure decreased to 73 mmHg by TI method. For many years, patients have repeated "colds", which can be relieved by themselves. Every time symptoms such as low fever and burnout appear, the symptoms of chest tightness and shortness of breath are obviously aggravated. Seven days ago, the patient developed fever without obvious trigger, with the highest body temperature of 39.5℃, obvious wheezing, accompanied by nausea, vomiting, cough, expectoration, left back pain, transient loss of consciousness and blood pressure drop. He was sent to the local hospital for emergency treatment. After anti-infection, pressurization and symptomatic treatment, the patient gradually awoke, his body temperature dropped, and his symptoms of wheezing, cough and expectoration improved compared with before. However, he still needed to use pressurization prescriptions to maintain his blood pressure. For further treatment, he was transferred to Beijing Chaoyang Hospital on 21 August 2013. The patient began to develop muscular atrophy of the left upper limb 30 years ago and had no history of taking special drugs.

Non-tuberculous mycobacteria (NTM) refer to other mycobacteria other than the M. tuberculosis complex and M. leprae, widely present in the living environment^[1]154 species and 13 subspecies have been reported so far^[2]It can invade the host lungs, lymph nodes, bones, joints, skin and soft tissues and cause systemic dissemination. Lung infection is the most common, and hand infection caused by contact with marine organisms in coastal areas and being stabbed by them has also attracted the attention of domestic scholars^[3]。 Since Williams et al.^[4]Mycobacterium marinum infection of the hand was reported, and the number of cases of NTM infection of the hand ranged from sporadic case reports to small sample studies^[5]The number of diseases causing hand infection has been 18 since its discovery^[1]The number of cases and disease species showed an upward trend^[5]。 The clinical symptoms of the disease are atypical, and NTM is mostly resistant to common antituberculosis drugs^[2]Its drug resistance patterns, clinical drug types and treatment courses are quite different, and it is easy to misdiagnose and miss diagnosis, delay treatment, and cause different degrees of hand function loss^[3]。 Therefore, it is particularly important to choose a method that can identify and diagnose non-tuberculous mycobacteria and their subspecies early, quickly, accurately and conveniently, and guide clinical treatment.

There are many pro-angiogenic and immunosuppressive regulatory factors in the tumor microenvironment, among which regulatory T cells (Treg) are the key mediators in the pathophysiological regulation of various tumors. In many kinds of malignant tumors such as breast cancer, gastric cancer and ovarian cancer, the increased number of Treg is related to its shorter survival period, suggesting that Treg plays an extremely important role in tumor evolution^[1,2,3]。

With the accumulation of experience and the deepening of research, the use of non-invasive positive pressure ventilation (NPPV) is more and more widely. Some patients who previously required invasive therapy can now be successfully treated with NPPV. In conjunction with this, the rate of NPPV treatment in critical unit patients is increasing, while the rate of tracheotomy and tracheal intubation is decreasing. Through early use of NPPV, the rescue success rate of critically ill patients is further improved. At present, the therapeutic scope of NPPV is constantly expanding, which can be used in both home and critical unit, and has become an important tool for the treatment of acute and chronic respiratory failure. Diseases that can be treated with NPPV include chronic obstructive pulmonary disease (COPD), chronic alveolar hypopnea, obstructive sleep apnea (OSA), pulmonary edema associated with cardiac insufficiency, and the like. In addition, NPPV is often used as an adjuvant treatment when invasive ventilation is discontinued. Although there are multiple modes of NPPV, the predominant modes remain bihorizontal positive airway pressure (BiPAP) and continuous positive airway pressure (CPAP) mainly for OSA and congestive heart failure. Nasal, nasal, or full face masks are the primary means of connecting a noninvasive ventilator to a patient. BiPAP can set positive airway pressure in inspiratory phase (IPAP) and positive airway pressure in expiratory phase (EPAP) respectively. By adjusting IPAP and EPAP, the purpose of maintaining upper respiratory tract opening and changing tidal volume and minute ventilation volume can be achieved. In addition to patients with sleep apnea, some patients who can maintain normal ventilation and blood gas during the day can also develop hypoxemia or even respiratory failure at night, especially during rapid eye movement sleep (REM). For example, we have recently found that the respiratory central drive decreases during sleep in patients with COPD, particularly during fast eye movement sleep^[1]。 If BiPAP is adjusted only according to the patient's daytime condition, sleep-related hypoventilation or even respiratory failure may occur after the patient falls asleep, thus affecting the patient's sleep quality and the progress of the disease. Although BiPAP may be set during the day, for example, for some patients with the purpose of reducing symptoms or who do not tolerate excessive IPAP/EPAP, treatment pressure may depend on CO over a period of time or even a week₂Partial pressure, blood oxygen saturation (SaO₂) and symptom relief, but for some people who need long-term NPPV treatment, parameter adjustment under polysomnography (PSG) monitoring should be performed. Pressure regulation in patients with chronic alveolar hypopnea and OSA is reviewed below.