呼吸危重症临床决策中的若干问题

在临床实践中,呼吸危重症的诊断和治疗存在着一些不同的观点.就其中某些热点问题,如慢性阻塞性肺疾病合并哮喘的诊断和机械通气的指征、肺栓塞的诊断、急性呼吸窘迫综合征的治疗、呼吸重症监护病房的建设和呼吸危重症的伦理学问题进行阐述,以期提高对呼吸危重症的认识.     

睡眠呼吸暂停相关性高血压

睡眠呼吸暂停综合征是以睡眠过程中反复呼吸暂停进而引起慢性间歇性低氧、二氧化碳潴留为特征的常见睡眠呼吸障碍性疾病。阻塞性睡眠呼吸暂停与高血压密切相关,睡眠呼吸暂停相关性高血压为一常见的特殊患病人群,多导睡眠图是诊断睡眠呼吸暂停相关性高血压的“金标准”,其治疗在一般生活方式改变基础上,持续气道正压通气治疗是其重要治疗方法。     

睡眠呼吸暂停相关性高血压

睡眠呼吸暂停综合征是以睡眠过程中反复呼吸暂停进而引起慢性间歇性低氧、二氧化碳潴留为特征的常见睡眠呼吸障碍性疾病.阻塞性睡眠呼吸暂停与高血压密切相关,睡眠呼吸暂停相关性高血压为一常见的特殊患病人群,多导睡眠图是诊断睡眠呼吸暂停相关性高血压的"金标准",其治疗在一般生活方式改变基础上,持续气道正压通气治疗是其重要治疗方法.     

急性肺损伤/急性呼吸窘迫综合征诊断和治疗指南（2006）

急性肺损伤(ALI)/急性呼吸窘迫综合征(ARDS)是一种常见危重症,病死率极高,严重威胁重症患者的生命并影响其生存质量。尽管我国重症医学已有了长足发展,但对ALI/ARDS的认识和治疗状况尚不容乐观。中华医学会重症医学分会以循证医学证据为基础,采用国际通用的方法,经广泛征求意见     

ARDS诊断——“柏林标准”的价值与意义

急性呼吸窘迫综合征(ARDS)病死率高,其早期准确的诊断是有效治疗的前提.然而,当前ARDS诊断标准的准确性备受质疑,临床迫切需要便捷可靠严谨的诊断标准.“柏林标准”从起病时间、氧合指数、肺水肿的来源及胸部影像学表现四个方面对ARDS进行诊断,是既往诊断标准的总结与延伸,其有效性及准确性已被证实,对于临床诊疗和科学研究有重大意义.     

急性肺损伤/急性呼吸窘迫综合征诊断和治疗指南(2006)

急性肺损伤(ALI)/急性呼吸窘迫综合征(ARDS)是一种常见危重症,病死率极高,严重威胁重症患者的生命并影响其生存质量.尽管我国重症医学已有了长足发展,但对ALI/ARDS的认识和治疗状况尚不容乐观.中华医学会重症医学分会以循证医学证据为基础,采用国际通用的方法,经广泛征求意见和建议,反复认真讨论,达成关于成人ALI/ARDS诊断和治疗方面的共识,以期对成人ALI/ARDS诊断和治疗进行规范.中华医学会重症医学分会以后还将根据循证医学证据的发展及新的共识对ALI/ARDS诊断和治疗指南进行更新.     

整合临床医学的必要性、可行性及途径——以睡眠呼吸暂停防控为例

长期以来以专科划分为主的医疗发展方式确实促进了现代医学的进步.然而,人是一个整体不应该被割裂对待.所以,这种医学发展趋势应该加以控制,否则必然会阻碍医学事业的健康发展.另外,如果只关注局部治疗想要取得突破已经越来越难.因此,整合临床医学势在必行.本文分别从阻塞性睡眠呼吸暂停的病因、临床表现(包括合并症)及诊断和治疗三个方面阐述了只有全面进行医学整合才能提高阻塞性睡眠呼吸暂停的整体防控水平.     

呼吸机的撤离

呼吸机的脱机和撤离过程是一个重要的临床问题。呼吸机撤离是呼吸机由全部同期支持转为自主呼吸过程。在脱机过程中不必要的延迟会增加机械通气的复杂性,如肺炎或气道损伤,同时增加治疗的费用。撤机分为脱机和撤离人工气道,撤机参数对撤机后果预测的准确率不高,本文论述了对自主呼吸试验失败原因及实施自主呼吸方法以及完整呼吸机撤离过程。     

乌司他丁在ICU中的临床应用进展

乌司他丁具有抑制胰蛋白酶等胰酶的活性、稳定溶酶体膜以抑制溶酶体酶的释放及抑制心肌抑制因子的产生而常应用于重症急性胰腺炎及其他危重症的抢救治疗.     

呼吸机的撤离

呼吸机的脱机和撤离过程是一个重要的临床问题.呼吸机撤离是呼吸机由全部同期支持转为自主呼吸过程.在脱机过程中不必要的延迟会增加机械通气的复杂性,如肺炎或气道损伤,同时增加治疗的费用.撤机分为脱机和撤离人工气道,撤机参数对撤机后果预测的准确率不高,本文论述了对自主呼吸试验失败原因及实施自主呼吸方法以及完整呼吸机撤离过程.     

瘦素与慢性阻塞性肺疾病患者营养不良和呼吸肌疲劳的关系探讨

目前大量研究表明血清瘦素在慢性阻塞性肺疾病（COPD）患者营养不良病理生理机制中发挥重要作用,COPD患者多伴有呼吸肌疲劳,严重呼吸肌疲劳最终导致呼吸衰竭而危及生命,本文旨在综述瘦素、营养不良及呼吸肌疲劳之间的联系,以期从新的角度和细胞因子水平来探讨呼吸肌疲劳,为临床治疗呼吸肌疲劳,最终治疗呼吸衰竭提供新的方向。     

慢性阻塞性肺疾病诊治常见问题辨析

近年来,由于对COPD的临床和基础研究的不断深化,对COPD的认识也日益深入。本文结合目前COPD临床研究及防治的情况,对目前临床上COPD诊治的常见问题进行较深入辨析,进一步探讨了COPD诊治的一些见解及认识。     

Depressed and Anxious COPD Patients: Predictors of Psychotherapy Engagement from a Clinical Trial

This study examined patient-level factors associated with engagement in mental health treatment in a sample of medically ill patients with clinically significant symptoms of depression and/or anxiety. A total of 248 patients was enlisted from a randomized controlled trial of cognitive-behavioral therapy for depression and anxiety in patients with chronic obstructive pulmonary disease (COPD). Logistic regression analysis was used to predict mental health engagement, defined as attending at least one intervention session. Results indicated that patient-perceived mastery over COPD was negatively related to mental health engagement. Further, mastery was the only significant predictor of mental health engagement after controlling for patient demographic characteristics, severity of COPD, depression, and anxiety. To improve engagement for medically ill patients with comorbid mental health difficulties, clinicians should explore patients’ attitudes about their mental health within the context of their perceived ability to cope with their medical disease.     

临床整合医学的必要性及实施中存在的问题——以慢性阻塞性肺疾病及其合并症的诊治为例

近年来人们逐渐认识到慢性阻塞性肺疾病(COPD)是一种全身性疾病,即COPD不仅会影响到气道和肺,还会引起一系列合并症,包括心血管疾病、骨质疏松、焦虑和抑郁、癌症、感染、代谢综合征和糖尿病等。这些合并症会显著地影响COPD疾病严重程度和预后,因而必须对COPD进行整体防控,然而COPD的上述合并症的诊治分属不同学科,所以要做好COPD的整体防控就需要相关学科进行医学整合。     

吸烟与慢性阻塞性肺疾病基因易感性的辩证思考

慢性阻塞性肺疾病（COPD）是严重危害人们身体健康的疾病。吸烟是慢性阻塞性肺疾病主要的发病因素,然而。不是所有吸烟者都患有COPD,只有约加％发生。目前,许多研究表明,吸烟者发展为COPD患者与其基因易感性相关,综述了COPD的多种基因易感性,以期深入了解吸烟与COPD的关系,为COPD的预防和治疗提供依据。     

关于慢性阻塞性肺疾病的诊断和治疗

慢性阻塞性肺疾病(COPD)是呼吸系统最常见的疾病之一,综述了近年来,在COPD诊断和治疗上的最新进展,包括COPD的药物应用,手术治疗及基因治疗等。     

必须高度重视农村慢性呼吸病防控工作

在简要回顾性分析了国内农村常见呼吸病的患病率、死亡率显著高于城市,成为人口死亡的主要原因基础上,分析产生这种差别的根源,并对今后如何解决这个问题提出若干有益的建议。     

The relationship between illness perceptions and panic in chronic obstructive pulmonary disease

BackgroundElevated levels of anxiety and panic are common in respiratory disease. To date the cognitive-behavioural model of panic has been utilised to help explain and manage panic in respiratory disease. This cross-sectional study investigated the relationship between illness perceptions and panic in chronic obstructive pulmonary disease (COPD) within a self-regulatory framework of adaptation to physical illness.MethodsFifty-nine participants with COPD completed questionnaires measuring illness perceptions, anxiety and depression, frequency and severity of panic attacks and impact of disease on daily life and well-being. The percent forced expiratory volume in the first second (FEV₁%) was used as an objective measure of lung function.ResultsHigh levels of clinical anxiety and depression were reported (35% and 19% respectively). Sixty-three percent of participants reported experiencing a panic attack during the previous year and of these 51% during the previous month. Panic was unrelated to level of disease severity. Specific illness perceptions (beliefs relating to illness identity, timeline, consequences and emotional representations) were important in differentiating between panickers and non-panickers.ConclusionsThe results highlight the importance of assessing illness perceptions within the framework of the self-regulatory model to provide an additional theoretical perspective for investigating and managing panic in chronic respiratory disease.     

Negative beliefs about breathlessness increases panic for patients with chronic respiratory disease

Breathlessness is a multidimensional symptom of respiratory disease and is associated with the experience of panic. Patients with panic disorder have increased mortality, morbidity and healthcare utilisation that is unrelated to their disease severity. Our qualitative study aimed to appraise respiratory patients' experiences of breathlessness and whether their cognitions were associated with panic aetiology. The self-regulatory theory was utilised to develop the framework for the semi-structured interview schedule. Twelve individuals with respiratory disease at a U.K. cardiothoracic centre participated and their data were analysed using interpretative phenomenological analysis. Perceived control over the disease, symptoms and panic emerged as the core theme with three related belief systems; (1) Perceived consequences of panic and disease; (2) Illness and symptom coherence; and (3) Emotional adaptation. Panic symptoms were most prevalent in participants with low perceived control over symptoms and the disease, negative beliefs about the life-limiting consequences of unpredictable breathless attacks and by those using emotional coping strategies such as denial and avoidance. The experience of panic for respiratory patients can be explained through the cognitive-behavioural model of anxiety, which highlights the contributory role of catastrophic beliefs about the control and consequences of symptoms and disease as a significant contributory factor for the prevalence and maintenance of panic. The mortality and morbidity of respiratory patients is significantly affected by a co-morbid diagnosis of panic disorder and so it is critical to patients' long-term healthcare that their psychological experiences are assessed. Healthcare services must enhance patients' understanding about their disease to improve their confidence to control symptoms. Recent evidence suggests that cognitive-behavioural interventions that increase problem-solving coping will reduce catastrophic misinterpretations about the perceived consequences of breathlessness and improve emotional adaption to respiratory disease.     

Prediction of end-of-life fears in COPD – hoping for the best but preparing for the worst

Objective: The diagnosis of a life-threatening illness can trigger end-of-life fears. Early studies show that end-of-life fears play an important role in chronic obstructive pulmonary disease (COPD). However, predictors of these fears have not yet been identified. This study investigated the relevance of socio-demographic variables, illness severity, psychological distress and disease-specific anxieties as predictors of end-of-life fears in COPD.

Design: A total of 131 COPD patients participated at two time points. Regression and mediation analyses, as well as cross-lagged panel analyses were conducted.

Main outcome measures: The participants completed questionnaires assessing end-of-life fears (Multidimensional Orientation toward Dying and Death Inventory), psychological distress (Hospital Anxiety and Depression Scale), and disease-specific anxieties (COPD Anxiety Questionnaire). Pulmonary function and a 6-min walk test served as measures of illness severity.

Results: Illness severity was not predictive of end-of-life fears. However, gender and psychological distress explained incremental variance. When disease-specific anxieties were included as additional predictors, psychological distress was no longer significant. Cross-lagged panel analyses mostly supported these results. Moreover, disease-specific anxieties mediated the association between psychological distress and end-of-life fears.

Conclusion: Administration and intensity of end-of-life care (especially concerning end-of-life fears) in COPD patients should be based not only on illness severity, but rather on psychological distress and disease-specific anxieties.