(039)一种新的,用乙酰甲胆碱和过敏源进行支气管激发试验的潮汐式呼吸法

(039)一种新的,用乙酰甲胆碱和过敏源进行支气管激发试验的潮汐式呼吸法 一种新的，用乙酰甲胆碱和过敏源进行支气管激发试验的潮汐式呼吸法 引言 支气管激发试验是一种有价值的和被广泛应用的技术，不仅被用于诊断支气管哮喘，也被用来确认哮喘病人的特定过敏源。在哮喘病诊断结果可疑，或在病人无症状时，阳性的组胺 1和/或乙酰甲胆碱激发试验可证实哮喘病的存在。Orehek等人用建立累计吸入剂量--支气管响应关系曲线的，估计支气管高反应。根据这一剂量响应曲线，他们定义引起支气管收缩的药物剂量为支气管敏感度，而这一曲线的斜率为支气管反应度。这样，多次吸入浓度逐渐增加的支气管收缩剂，就可以得到支气管对支气管收缩剂的响应曲线。在用过敏源进行的支气管激发试验中，试验对象吸入的过敏源的浓度也是逐渐增加的，以防止诱发严重的哮喘， 23，4并获得剂量响应关系。吸入以后，用呼吸运动记录测量法或最大呼气流量-体积曲线来检查支气管对化学药剂和过敏源的反应。许多常用的激发试验法中，试验对象在多次吸入剂量不断增加的支气管收缩剂或过敏源后，要用最大力量呼气。这一过程需要耗费病人和医生许多时间，这是限制它们在哮喘门诊例行检查中的应用的最大原因。 评估支气管响应的用力通气法缺乏客观性，因为它依赖于病人的努力。另外，重复地用力呼气也可能增加哮喘病人支气管的收缩。即使现在应用体积描记法来测量气道阻力，从而评 5估支气管响应性，但它还是费时较多。 为了克服这些限制，我们创立了用我们的新装置测量支气管对化学药剂和过敏源的响应的6新方法。该装置包括两部分:一个是改进了的3Hz震荡装置和显示系统，他们被用来来计算总呼吸阻力(Rrs)，另一个是雾化系统。使用这种装置，病人可以在潮汐式呼吸中接受乙酰甲胆碱或过敏源的支气管激发试验。这种新装置的特点是能够在试验的整个过程中(特别是吸入雾化药剂或过敏源时)连续地测量Rrs。 6 如以前所报道的，我们已创建了使用这种装置评估支气管对乙酰甲胆碱的响应的新技术。在现在的研究中，我们检查了支气管对过敏源的敏感度和反应度的特点。除此之外，我们检查了酮替芬(抗过敏药)对过敏源支气管激发试验的效果，并展示了钙拮抗剂的支气管扩张作用。 试验对象和方法 对象 在乙酰甲胆碱支气管激发试验中我们研究了10个无心肺疾病、无个人或家族过敏史的正常人(全为男性，9个不吸烟，一个吸烟，平均年龄30岁)、14个急性支气管炎患者(8个男性，6个女性，平均年龄44岁)、16个慢性支气管炎患者(8个男性，8个女性，平均年龄48岁)和60个extrinsic哮喘病患者(36个男性，24个女性，平均年龄42岁)。慢性支气管炎患者的是在至少两年内，每年至少有3个月的咳嗽和多痰病史。慢性支气管炎患者没有过敏性鼻炎或支气管哮喘。支气管哮喘病的判断基础是病史和证据(用支气管扩张药 8物后明显可逆)。所有被试的支气管哮喘病人在检查时都没有可听到的哮喘声。急性支气管炎患者只有短期的咳嗽和多痰症状，在急性发作前没有慢性支气管炎、过敏性鼻炎或支气管哮喘。 在用室内灰尘过敏源进行的支气管激发试验中，我们研究了32个哮喘病人。有过敏性鼻炎者是在Tohoko 学医院鼻科确诊的。根据嗜曙红细胞减少，以及鼻科和临床症状，确定他们对室内灰尘过敏原的鼻响应 支气管激发试验仪器 application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical 研究中所用仪器绘在图1中。浓度渐增的乙酰甲胆碱系列溶液喂给系统包括12个相同的雾化器(Vaponephinrin; USV Pharmaceuticao Corp.)，它们由恒流速(5升/分)的空压机(Nissho)驱动。所有雾化器都接在纸嘴和流量计之间的主管上。空压机可以按一定的时间间隔从一个雾化器切换到下一个雾化器。这样就可以顺次给出12种不同的气雾剂。每个雾 9化器每分钟给出约0.15毫升溶液，溶液颗粒尺寸用激光雷达技术测量。根据制造厂的说明，微粒的平均直径为2.5微米，但用现在的系统观察的结果是中径为9微米，平均直径为11?6微米。 7 支气管响应以震荡法测得的Rrs表示。一个恒幅压力发生器连接到纸嘴上，通过喇叭盒系统，在嘴边产生3Hz恒幅正弦压力波。在雾化器和流量计之间引入一个0.4升/秒的偏流，使死区减至最小。嘴边的的气流(V)用呼吸速度计(Fleisch)和压差转换器(Validyne, MP45-1)测量。相对于大气压的嘴压(Pao)用压差转换器(Validyne, MP45-1)测量。为了直接描绘 10剂量-响应曲线，Rrs的计算由模拟计算机根据Hyatt等人的方法测量。为了只提取流速和压力波中的3Hz波分量，V和Pao要通过一个3Hz波段滤波器，它的宽度是0.4Hz，时间常数是0.3秒。流速被求导，由零比较电路识别出导数为零的点，与之相应的最大和最小流速被取样和保持。再用减法电路求出ΔV。另外，相应于最大和最小流速的压力的样本相减，得到ΔPao。Rrs由除法电路求出:ΔPao/ V。为了防止连续测量中Rrs的激烈波动，Rrs要通过0.2Hz滤波器(时间常数为4.0秒)过滤。使用该装置，对于90%的变化的响应时间为10秒。Rrs按时间顺序在X-Y记录器(惠普，7045A)上连续显示出来，从而可以直接观察乙酰甲胆碱的剂量-响应曲线。 图1. 装置方框图。用震荡法测量呼吸阻力。12个雾化器连接到主管上靠近嘴边处。 乙酰甲胆碱支气管激发试验 我们使用氢氧化乙酰甲胆碱的等渗盐水溶液作为支气管收缩剂。10个递增的浓度分别为49μg/ml、98μg/ml、195μg/ml、390μg/ml、781μg/ml、1563μg/ml、3125μg/ml、6250μg/ml、12500μg/ml、25000μg/ml。这些乙酰甲胆碱的浓度近似于Chai及其同事所建议的数量序列。2第1个雾化器中是2ml食盐溶液。第2到第11个雾化器各含2ml乙酰甲胆碱溶液，每种浓度各一个。每种浓度的吸入时间为1分钟。第12雾化器含异丙喘宁，用作支气管扩张剂。当Rrs增加到初始值的两倍时，或吸到最大浓度的乙酰甲胆碱时，或当试验对象有呼吸困难征兆时，就吸服异丙喘宁2分钟。所有试验对象都采取坐姿，在平静呼吸中接受检查。他们 e methession bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offlinan function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube opprre orgs (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and moritical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirementtion cnship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operawash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardiation salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery opera lear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit likeor nucmmatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumc heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic infladiation: rheumatidisease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image ra-ss of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in diseaseprogreion and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and g. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infectt usiny (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrumencation; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technologapplication; infection and antibacterial drug of clinical appli2epilepsy drug) of refers to levy, and side effects and clinical-rhythm disorders drug, and solutions spasm flat breath drug, and anti-ncy drug (heart lung recovery and the vascular activity drug, and buck drug, and antiemergey syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common od. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heav 的呼吸方式不受控制，因为当呼吸方式受控时，大概由于舌隙(glottic aperture)不稳定，Rrs的波动增加。两颊被用气球顶着，防止它们震动。 我们使用直接描绘式剂量-反应记录器检查了10个正常人、60个哮喘病人和30个支气管炎病人对乙酰甲胆碱的支气管高反应，研究了乙酰甲胆碱的剂量-响应曲线在他们身上的重演性。我们在第一次激发后7天内两个不同的日子里，检查了6个哮喘病人和2个急性支气管炎病人的剂量-响应曲线。另外，我们还在一个月内两到三个不同的日子里，检查了2个哮喘病人和1个急性支气管炎病人的剂量-响应曲线。 室内灰尘过敏源支气管激发试验 在进行支气管激发试验时，试验对象在至少两周内没有发生过哮喘症状。激发前24小时不服用任何药物。室内灰尘过敏源是Torri制药公司制造的，一只小瓶中含有39.4毫克/毫升浓度的冻干的室内灰尘过敏源。过敏源溶在10ml的等渗盐水中，含量为16900PNU/ml，或1:5w/v。 所有试验对象，在他们的Rrs达到稳定状态以后都要吸服等渗盐水一分钟，确认在吸服过程中Rrs没有变化后，再让他们吸雾化的室内灰尘过敏源一分钟。在暴露于过敏源以后，他们要被观察15分钟。Rrs达到初始值的两倍以后，立刻打开异丙喘宁雾化器的旋塞。当Rrs降到初始值以后，撤除试验装置。试验结束时，所有试验对象吸服orciprenaline 3分钟，并被观察，直到Rrs与本底值差不多时为止。 支气管激发试验——剂量计方法 使用 Chai及其同事所开发的这种方法，我们进行了乙酰甲胆碱支气管激发试验。我们也进行了室内灰尘支气管激发试验。在室内灰尘试验中，试验对象分5次吸服雾化盐水和雾化过敏源，间隔时间为15分钟，直到观察到FEV1下降了20%或以上时为止。在使用肺量计 PD进行评估前，先估算Rrs。我们获得了使FEV1下降20%(FEV1)、Grs(总呼吸气导)20 下降35%(PDGrs)和下降50%(PDGrs)的室内灰尘过敏源数量。数量单位为一次呼吸3550 所吸入的1:5000 w/v 室内灰尘过敏源。 皮下试验 所有接受室内灰尘支气管激发试验的人都要接受30种过敏源的皮下试验。试验方法是在 -32病人背部皮下注射0.02ml 10 w/v 稀释的过敏源。如果产生大于100 mm的风疹，就是阳性反应。在吸入激发以前，还要进行临试前的小臂内侧皮试，使用的是室内灰尘过敏源系列 5-1 稀释液(6.25 x 10到10w/v)。在每次进行支气管激发试验前，都要记录室内灰尘过敏源诱发阳性皮肤反应的阈值。 一种抗过敏药和一种钙拮抗剂的应用 为了进行这项试验，要按前述方法管理试验对象。在进行室内灰尘支气管激发试验前，让每人口服2 mg 酮替芬(一种抗过敏药)一周。在进行乙酰甲胆碱支气管激发试验前一小时，口服10mg硝苯地平一次。 结果 用乙酰甲胆碱进行的支气管激发试验 图2显示了在一个健康的试验对象(试例1)、一个慢性支气管炎病人(试例2)和几个支气管哮喘病人(试例3-6)身上的典型Rrs响应型式。在健康人的试验中，直至施用最大浓度的乙酰甲胆碱时，Rrs也没有变化。在慢性支气管炎病人的试验中，在乙酰甲胆碱浓度从 e review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagncs of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literatureristiements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different charactegrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirou intents life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patin opercture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubatiorious image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar punand vake testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understhin infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit lial wite duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease craniease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bildisease myocardial infarction ... 3. high requirements (1) learning disease species: disease species dis-evere pneumonia in diseaseent such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: svironmry response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid enn; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatoicatioication; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of appld antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical applapplication; infection an3lepilepsy drug) of refers to levy, and side effects and clinica-rhythm disorders drug, and solutions spasm flat breath drug, and anti-nd emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and antiosis a 3125µg/ml变到25000µg/ml的过程中Rrs逐步增加。在哮喘病人的试验中，短时间内Rrs几乎保持恒定，然后就迅速上升;吸入异丙喘宁以后，又迅速下降。其曲线类似于等腰三角形。这样，我们就能辨别正常对象、慢性支气管炎病人和支气管哮喘病人的Rrs型式之间的区别。 为了评估剂量-响应曲线，我们计算了三个参数(图3)。由于从Rrs计算得到的气导(Grs)显示出近乎线性的斜率，最佳拟合直线可以目测绘制。对于某些曲线，人们推导出一个线性回归方程来描述其Grs的斜率。但用回归方程画出的直线和用目测方法画出的直线差别不大。 Rrs (cmH2O/升/秒) 图2. 各类人员对支气管乙酰甲胆碱激发试验所产生的响应型式 Rrs (cmH2O/升/秒) 图3. 进行乙酰甲胆碱剂量-响应曲线分析所用的参数 第一个被计算出来的参数是气导控制值(Grs?cont)，也即在吸入盐水气雾剂时测到的Rrs的倒数。 第二个被计算出来的参数是乙酰甲胆碱最小剂量(Dmin)，它是对应于Grs(Rrs的倒数)线性下降转折点的累计剂量。如果Grs开始下降的转折点不清晰，就用控制值(Grs?cont)和Grs斜线的交点。我们将Dmin定义为支气管敏感度。在计算乙酰甲胆碱的剂量时所使用 emergey syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common od. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heave methession bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offlinan function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube opprre orgs (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and moritical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirementtion cnship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operawash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardiation salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery opera lear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit likeor nucmmatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumc heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic infladiation: rheumatidisease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image ra-ss of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in diseaseprogreion and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and g. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infectt usiny (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrumencation; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technologapplication; infection and antibacterial drug of clinical appli4epilepsy drug) of refers to levy, and side effects and clinical-rhythm disorders drug, and solutions spasm flat breath drug, and anti-ncy drug (heart lung recovery and the vascular activity drug, and buck drug, and anti 2的单位类似于吸入激发法标准化时所采用的单位，也即一单位等于平静潮汐式呼吸中，一分钟所吸入的浓度为1.0mg/ml的气雾剂溶液。因此，从吸入激发开始到结束，乙酰甲胆碱的总累计剂量为50单位。图3中乙酰甲胆碱的累计剂量也使用该单位。 第三个计算出来的参数是Grs下降的线性斜率(SGrs)，也即SGrs=ΔGrs / Δt(单位为升/秒/厘米水柱/分)，它被定义为气道反应度。 图4表示出10个正常人、60个哮喘病人和30个支气管炎病人的Grs?cont, Dmin和SGrs。所有数据来源都是第一天所获得的剂量-响应曲线。在哮喘病人中，Grs?cont(0.23?0.09)(平均值?标准偏差)显著低于正常人(0.35?0.09)和急性支气管炎病人(0.32?0.15;P<0.01)。但是正常人和急性及慢性气管炎病人(0.28?0.13)的Grs?cont并无显著差异。所有哮喘病人的Dmin都低于50单位(1.47?3.29 [平均值?标准偏差];中值0.45)。正常试验对象中，在所用乙酰甲胆碱浓度范围内， 我们看不出Rrs的增加。由于50单位是区分正常对象和哮喘病人的界线，Dmin大于50单位的人都被视作无响应者，Dmin小于50单位的人都被视作有响应者。在图4中，凡大于50单位的数值都被按50单位标示。因此，正常人、急性支气管炎病人(31.8?20.6)和慢性支气管炎病人(21.2?23.3)的平均Dmin被低估了。14个有急性支气管炎的试验对象中有响应者为50%(7人)，16个有慢性支气管炎的试验对象中有响应者为63%(10人)。哮喘病人的SGrs(0.053?0.28 [平均值?标准偏差];中值0.45)明显高于别的病人(P<0.001)，而急性(0.029?0.037)和慢性(0.023?0.023)支气管炎病人的SGrs却无显著差别。慢性支气管炎病人的SGrs/Grs最低，急性支气管炎病人居中，支气管哮喘病人最高。我们发现，支气管哮喘病人和慢性支气管炎病人的SGrs/Grs有显著差异，但急性和慢性支气管炎病人之间，以及急性支气管炎病人和支气管哮喘病人之间并无显著差异。 图5表示几个典型的剂量-响应曲线，它们是在不同的日子里进行吸入激发试验所获得的。图5A中，曲线(1)表示第一次激发中施用乙酰甲胆碱前的剂量-响应关系。Rrs上升的阈值对应于乙酰甲胆碱浓度390µg/ml;支气管敏感度为0.73单位(log Dmin = -0.14);支气管反应度为0.110升/秒/厘米水柱/分。曲线(2)表示事先吸异丙喘宁2分钟后的剂量-响应曲线。与第一次激发比较，阈值升高了2.45单位(log Dmin = 0.39)，支气管反应度降低了0.050升/秒/厘米水柱/分。图5B表示未吸阿托品气雾剂前和吸0.01%阿托品气雾剂0.5分钟后的剂量-响应曲线。未吸前反应阈值为0.34单位(log Dmin = - 0.47)，支气管反应度为0.120升/秒/厘米水柱/分。吸入以后，剂量-响应曲线向右移动，斜率也增大。阈值升高了5.16单位(log Dmin = 0.71)，支气管反应度降低了0.095升/秒/厘米水柱/分。 图6和7显示从本方法和剂量计方法所获得的结果。我们没有发现Dmin和PDFEV之201-间的关系(图6)。而图7显示，从两种方法获得的PDGrs是显著相关的(p<0.05)。 35 用室内灰尘过敏源进行的支气管激发试验 图8显示对室内灰尘过敏源的典型响应。我们将Rrs变化的型式分为三个类型。如图8上部所示，在暴露于室内灰尘过敏源后10分钟仍没有变化的，为阴性反应(类型1)。如下部所示，在头10分钟内Rrs增加到本底值两倍以上的，为阳性反应。在现在的研究中我们忽略去类型2(图8中部)，即在头10分钟内Rrs没有升到本底值两倍的情况。 为了评估图9所示的反应，我们定义下列4个指标: 1) Rrs.base – 吸入等渗压盐水时的 Rrs。 2) Ta(出现时间)- 从暴露于室内灰尘过敏源起到Rrs开始上升为止的一段时间。呼吸 阻力被转换成气导(Grs)，结果获得近似线性的曲线。 3) DTGrs(激发时间)- 从暴露于室内灰尘过敏源起到Grs降到本底值一半时的一段时50 间。 ou intents life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patin opercture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubatiorious image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar punand vake testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understhin infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit lial wite duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease craniease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bildisease myocardial infarction ... 3. high requirements (1) learning disease species: disease species dis-evere pneumonia in diseaseent such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: svironmry response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid enn; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatoicatioication; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of appld antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical applapplication; infection an5lepilepsy drug) of refers to levy, and side effects and clinica-rhythm disorders drug, and solutions spasm flat breath drug, and anti-nd emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and antiosis ae review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagncs of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literatureristiements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different charactegrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requir 4) SGrs(反应度)- 每分钟的Rrs下降率。 正常人 正常人 正常人 急支病人 急支病人 急支病人 图4. 各类人支气管激发试验结果 慢支病人 慢支病人 慢支病人 哮喘病人 哮喘病人哮喘病人 正常人 急支病人 慢支病人 哮喘病人 图5. 吸乙酰甲胆碱前后(A)和吸阿托品前后(B)进行激发试验所得的剂量-响应曲线。 an function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube opprre orgs (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and moritical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirementtion cnship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operawash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardiation salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery opera lear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit likeor nucmmatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumc heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic infladiation: rheumatidisease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image ra-ss of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in diseaseprogreion and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and g. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infectt usiny (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrumencation; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technologapplication; infection and antibacterial drug of clinical appli6epilepsy drug) of refers to levy, and side effects and clinical-rhythm disorders drug, and solutions spasm flat breath drug, and anti-ncy drug (heart lung recovery and the vascular activity drug, and buck drug, and antiemergey syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common od. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heave methession bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offlin 图6. 支气管乙酰甲胆碱激发试验中Dmin和-Grs 乙酰甲图7. 我们的方法和剂量法所获得的PD35PDFEV的比较 胆碱)的比较( 201.0 图8. 支气管室内灰尘激发的三种响应形式 图10. 用室内灰尘重复进行的支气管激发 图10表示用室内灰尘过敏源重复进行激发试验的结果。图10的上图和中图是两个病人接受支气管激发试验(过敏源为室内灰尘，间隔时间分别为1周和3周)的结果。下图所示是一个哮喘病人的支气管反应度，他没有接受过脱敏治疗，约有一年时间病情无变化。 -3 图11显示室内灰尘过敏源激发试验的结果与阳性皮试阈值的关系。在23个皮试(用10稀释的室内灰尘)呈阴性的哮喘病人中没有发现阳性激发试验。引起阳性皮试反应的稀释度阈值越低，病人越容易在其后的室内灰尘激发试验中显阳性。我们也注意到，引起阳性皮试反应的稀释度阈值越低，病人的Ta也越短。 图12显示阳性室内灰尘激发试验的出现率与RAST(室内灰尘过敏源的特定IgE 抗体)和皮试的关系。支气管激发试验阳性率升高对应于RAST分值的增加。但我们也发现有的 cs of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literatureristiements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different charactegrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirou intents life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patin opercture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubatiorious image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar punand vake testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understhin infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit lial wite duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease craniease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bildisease myocardial infarction ... 3. high requirements (1) learning disease species: disease species dis-evere pneumonia in diseaseent such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: svironmry response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid enn; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatoicatioication; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of appld antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical applapplication; infection an7lepilepsy drug) of refers to levy, and side effects and clinica-rhythm disorders drug, and solutions spasm flat breath drug, and anti-nd emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and antiosis ae review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagn 图9. 室内灰尘过敏源剂量-响应曲线分析所用的参数 图11. 阳性支气管激发试验和阳性皮试的关系 病人并没有RAST分值，他的激发试验也呈阳性。我们检查了室内灰尘支气管激发试验和乙酰甲胆碱激发试验之间的关系。根据他们对乙酰甲胆碱的敏感度，我们将哮喘病人分为高(Dmin<0.34)、中(0.343.08)响应者三类。图13显示，高响应者中支气管激发试验显阳性的较多。 图14 显示从我们的方法和剂量计方法所得的结果。根据两种方法的Rrs.base判断，所有试验对象都在同样条件下接受过这两种试验。可以看出，Ta和PDFEV之间，以及PT Grs20150和PDFEV之间有显著的相关性。表1显示阿托品对阳性支气管激发试验的影响。事先吸201 ritical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirementtion cnship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operawash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardiation salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery opera lear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit likeor nucmmatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumc heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic infladiation: rheumatidisease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image ra-ss of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in diseaseprogreion and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and g. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infectt usiny (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrumencation; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technologapplication; infection and antibacterial drug of clinical appli8epilepsy drug) of refers to levy, and side effects and clinical-rhythm disorders drug, and solutions spasm flat breath drug, and anti-ncy drug (heart lung recovery and the vascular activity drug, and buck drug, and antiemergey syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common od. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heave methession bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offlinan function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube opprre orgs (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and mo 入雾化的阿托品(0.05%)，可以不同程度地降低支气管对室内灰尘过敏源的响应，对阳性皮肤反应阈值较高的病人更是如此。 图12. 室内灰尘的皮试、RAST分值和支气管激发的相关关系 我们的方法(分) 剂量法(单位) 图14. 我们的方法和剂量法的比较 抗过敏药和钙拮抗剂对支气管激发试验的影响 图15显示抗过敏药酮替芬对室内灰尘支气管激发试验的影响。如上图所示，2 mg酮替芬降低了支气管对室内灰尘的敏感度。下图表明，3 mg酮替芬延长了Ta (上)，降低了SGrs(下)。 图16显示钙拮抗剂硝苯地平对乙酰甲胆碱支气管激发试验的影响。10个病人中有8个在施用一次硝苯地平后，改变了支气管对乙酰甲胆碱的响应。 ents life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patin opercture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubatiorious image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar punand vake testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understhin infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit lial wite duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease craniease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bildisease myocardial infarction ... 3. high requirements (1) learning disease species: disease species dis-evere pneumonia in diseaseent such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: svironmry response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid enn; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatoicatioication; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of appld antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical applapplication; infection an9lepilepsy drug) of refers to levy, and side effects and clinica-rhythm disorders drug, and solutions spasm flat breath drug, and anti-nd emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and antiosis ae review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagncs of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literatureristiements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different charactegrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirou int 图15. 酮替芬对室内灰尘支气管激发的影响 表1 阿托品对阳性支气管激发试验的影响

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施用阿托品前 施用阿托品后 皮试 年龄 性别 Rrs.base Ta SGrs Rrs.base Ta SGrs -6男 51 3.2 1.13 0.065 3.0 1.33 0.095 10 -5男 27 3.7 2.43 0.065 3.4 2.53 0.030 10 -5女 23 5.0 1.80 0.050 5.0 2.00 0.065 10 -5女 21 6.0 1.27 0.052 5.7 1.34 0.055 10 -5男 42 3.0 1.00 0.097 3.2 1.40 0.080 10 -4女 17 4.2 3.20 0.040 4.3 5.23 0.043 10 -4女 34 4.8 1.33 0.035 4.7 3.00 0.025 10 -4男 37 3.1 2.80 0.035 2.7 >10 10 -4男 64 3.5 1.80 0.055 3.9 >10 10 -3女 54 4.33 4.33 0.045 3.2 >10 10 salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery opera lear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit likeor nucmmatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumc heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic infladiation: rheumatidisease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image ra-ss of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in diseaseprogreion and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and g. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infectt usiny (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrumencation; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technologapplication; infection and antibacterial drug of clinical appli10epilepsy drug) of refers to levy, and side effects and clinical-rhythm disorders drug, and solutions spasm flat breath drug, and anti-ncy drug (heart lung recovery and the vascular activity drug, and buck drug, and antiemergey syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common od. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heave methession bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offlinan function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube opprre orgs (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and moritical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirementtion cnship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operawash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardiation 图16. 硝苯地平对乙酰甲胆碱支气管激发试验的影响 讨论 使用本文方法，我们可以测量平静呼吸中Rrs的连续变化，因此只需要病人最低限度的配合。另外，试验可以在短时间内完成(每个对象10-15分钟)，并且非常安全，因为在测量时可以同时监视Rrs，所以不会诱发哮喘发作。除此之外，直接绘制的剂量-响应图重演性良好。因此这种方法对诊断和筛查支气管高反应病人有实用价值。因为Rrs不能很好地反映小 112气道的变化，不能区别于非哮喘病人的非特异性响应，所以标准化委员会建议在吸入试验中用FEV作为诊断参数。在许多一般的支气管激发试验中，试验对象必须重复地用力呼112,13气，这本身就可能诱发某些哮喘病人的非特异性支气管收缩。 14，15另外，对于吸服了卡巴可的某些哮喘病人，深吸气会妨碍FEV1的变化。这些观察结 n opercture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubatiorious image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar punand vake testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understhin infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit lial wite duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease craniease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bildisease myocardial infarction ... 3. high requirements (1) learning disease species: disease species dis-evere pneumonia in diseaseent such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: svironmry response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid enn; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatoicatioication; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of appld antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical applapplication; infection an11lepilepsy drug) of refers to levy, and side effects and clinica-rhythm disorders drug, and solutions spasm flat breath drug, and anti-nd emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and antiosis ae review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagncs of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literatureristiements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different charactegrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirou intents life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma pati 果表明，深吸气可能短暂地以各种方式改变支气管状况，导致FEV1的变化。使用改进的3Hz震荡法，避免了强制通气法所产生的上述缺点，评估了激发后的支气管响应。 16药物引起的支气管收缩可能伴随着喉管收缩;但是没有发现在支气管激发试验中，喘气或用力呼气能防止喉管变细的现象。因此，为了了解在人类支气管激发试验中，喉部变细如何影响支气管收缩的间接测量，还需进行进一步地研究。在试验对象咳嗽、咽唾液和屏气时，Rrs会变化。这可能是由于声门(glottic aperture)暂时变细。否则，Rrs是相当正常的。 我们用只显示Rrs，不显示Grs的方法研究了乙酰甲胆碱剂量-响应曲线。该剂量-响应曲线是非直线型的，反应度大的哮喘病人的曲线较陡。这些病人常常害怕诱发过度的支气管收缩，除非在达到某一Rrs值时，让他们吸服异丙喘宁(图3)。但是从Grs图上，我们看不出吸服异丙喘宁前一刹那 Rrs的急剧上升。也就是在病人被诱发严重的支气管收缩时，Grs的变化不如Rrs大。作为支气管收缩的指标，Rrs似乎比Grs更为灵敏。不过，两种显示图(Rrs和Grs)和计算机计算的敏感度和反应度都是需要的。 2现在这种方法和Chai等人建议的标准化过程并无多大的差别。他们建议的方法是进行5次呼吸，每次都将给定稀释度的药物从FRC吸到TLC(全肺量)，而我们的方法是在平静潮汐式呼吸状态下吸服给定稀释度的药物一分钟。这样，如果吸气量是2.5升的话，标准过程中的累计吸入的给定浓度的药物体积是12.5升，而现在这种方法大约为8升。 实际上，我们比较了支气管激发试验和剂量计方法的结果，正如“结果”中所述，未能发现Dmin和PDFEV1之间的关系。一个可能的原因是，Dmin只反映支气管对乙酰甲胆20 碱的敏感度，而不是反应度。另一方面，我们观察到了从这两种方法获得的PDGrs之间的35显著关系，因为这些参数既依赖于支气管敏感度，又依赖于支气管反应度。因此可以说明，我们的方法和作为支气管激发试验标准的剂量计方法是可比的。 该项研究中，试验对象吸服高浓度(16900 PNU/ml)室内灰尘过敏源。但是，雾化的室内灰尘过敏源在纸嘴子这里被稀释了，因为纸嘴子和雾化器之间有相对较大的死区。此外，偏流的泄漏气也造成雾化过敏源的损失。为了估计雾化过敏源的稀释率，我们测量了纸嘴子处的氖气浓度。在我们的系统中，嘴这里的氖气浓度下降到雾化器处的1/6。从而我们推测，纸嘴子处的过敏源浓度大约为2800 DNU/ml。 在我们的室内灰尘支气管激发试验中，无论在皮试阴性的哮喘病人中，还是在室内灰尘皮试阳性的鼻腔过敏患者中，都没有发现阳性反应。我们也观察到，阳性皮试反应越多，其后的支气管激发试验呈阳性的病人也越多。这样，就可以用我们的方法检测对室内灰尘的特异支气管反应。 由于在整个激发试验中连续地监视Rrs，我们可以查出Rrs开始上升的准确时间。我们说明了，皮试反应越小，Ta就越短。我们也说明了，用我们的方法测出的Ta和用剂量计方法测出的PDFED是显著相关的。应用支气管吸入激发试验，我们也可以弄清从暴露于室内20 灰尘到开始发生支气管响应这段时间的重要意义。值得注意的还有:我们的PTGrs和剂量50计方法中的PDFEV1显著相关。在室内灰尘支气管激发试验中，我们的方法可以和剂量计20 方法相比。最近Rya和他的同事说明了，剂量计方法获得的和潮汐呼吸法获得的PCFEV120可以相比。我们现在的研究也肯定了，气雾计产生方法和吸入方法的不同，对室内灰尘支气管激发试验影响不严重。 我们发现，在对乙酰甲胆碱响应较重的病人中，室内灰尘支气管激发试验呈阳性者较多。这表明，支气管对过敏源的响应至少包括两个部分:一个部分类似于对乙酰甲胆碱的响应，另一部分是免疫行为。我们也说明了，使用阿托品可以减轻支气管对室内灰尘过敏源的响应。我们的数据也印证了这样的概念:过敏源的类胆碱功能导致阳性的过敏源支气管激发试验。 s (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and moritical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirementtion cnship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operawash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardiation salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery opera lear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit likeor nucmmatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumc heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic infladiation: rheumatidisease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image ra-ss of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in diseaseprogreion and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and g. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infectt usiny (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrumencation; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technologapplication; infection and antibacterial drug of clinical appli12epilepsy drug) of refers to levy, and side effects and clinical-rhythm disorders drug, and solutions spasm flat breath drug, and anti-ncy drug (heart lung recovery and the vascular activity drug, and buck drug, and antiemergey syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common od. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heave methession bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offlinan function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube opprre org 在阳性室内灰尘支气管激发试验后，试验对象讲述他们在试验中的感受说:“胸部发紧”、“憋气”、“耳鸣”、“有点呼吸困难”。没有人诉说在头四个小时后有任何其它不适。我们发现，在暴露于室内灰尘过敏源12个小时后，少数病人有轻度的呼吸困难。与其它一般的支气管激发试验比较，有一点值得注意，即在我们的吸入激发试验中，很少有病人发生后发 19响应。因为试验对象在他们的Rrs达到本底值的两倍时就立刻服用异丙喘宁，在过敏源诱发的支气管收缩的早期阶段就停止吸入激发试验。这是我们的支气管激发试验中很少发生后发响应的一个重要原因。 关于我们的激发试验中后发响应少的原因，我们考虑还有以下几个:试验对象接受了潮汐式呼吸激发试验的所有过程;他们的Rrs被连续地监视;他们在诱发性支气管收缩的早期阶段就吸服异丙喘宁。吸入的异丙喘宁不仅抵抗住了诱发性支气管收缩，还阻止了被激活的柱细胞释放组胺。前一个作用有下列证据:β-肾上腺素刺激剂强有力地抵抗了哮喘病人的 20过敏源诱发的支气管收缩。后一个作用可能是后发响应少的一个原因，因为细胞内循环 21AMP的增加阻止了柱细胞释放组胺。在一般的激发试验中，重复地用力呼吸可能促使过敏源再分配，加重了诱发性支气管收缩。这样我们就阐明了，在Rrs增加到本底值两倍时，吸服β-肾上腺素刺激剂可以完全消除诱发性支气管收缩。 22，23人们已经知道，酮替芬能阻止柱细胞释放组胺。在现在的研究中我们观察到，口服酮替芬可以不同程度地降低支气管对室内灰尘过敏源的响应。这样，酮替芬也表现出它有防支气管痉挛的效力。我们正在研究，长期服用酮替芬是否能够阻止支气管对过敏源(包括花粉)的响应。 24，25最近发现，作为心血管疾病治疗药的一种拮抗剂具有支气管扩张功能。我们研究了硝苯地平对乙酰甲胆碱引起的支气管响应的影响。这种拮抗剂减轻了一些病人对乙酰甲胆碱的敏感度，也减轻了另一些病人的支气管反应度。 我们相信，我们的方法在临床上是有用的。原因如下:首先，在整个试验过程中可以连续地监视病人的Rrs变化情况;我们不要求病人重复用力呼吸;我们可以迅速地改变支气管收缩药物、过敏源和支气管扩张药物的稀释度，不让病人知道;我们可以在15分钟内评估阳性支气管激发试验;试验后病人无不适现象，后发响应很少;最后，我们的结果和一种常用的方法是可比的。 我们再次强调，我们的方法对病人和医生都是既省时又省力的。 结论 我们已阐明，由于操作简单，以及由于可以定量地区分支气管敏感度和反应度，我们的方法可以用于临床评估支气管对吸入激发的反应。我们的结论是:在乙酰甲胆碱和室内灰尘过敏源支气管激发试验中，我们的方法和剂量计方法是可比的。我们也相信，我们的方法对病人和医生都是既省时又省力的。 e review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagncs of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literatureristiements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different charactegrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirou intents life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patin opercture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubatiorious image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar punand vake testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understhin infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit lial wite duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease craniease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bildisease myocardial infarction ... 3. high requirements (1) learning disease species: disease species dis-evere pneumonia in diseaseent such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: svironmry response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid enn; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatoicatioication; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of appld antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical applapplication; infection an13lepilepsy drug) of refers to levy, and side effects and clinica-rhythm disorders drug, and solutions spasm flat breath drug, and anti-nd emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and antiosis a