胸腔内注入尿激酶及胸腔镜在结核性胸膜炎治疗中的应用研究
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摘要
目的：
(1)探讨胸腔内注入尿激酶对早期结核性胸膜炎(病程≤6周)引起胸膜增厚、粘连的预防和治疗作用；(2)探讨胸腔内注入尿激酶治疗对结核性胸膜炎作用机制；(3)探讨胸腔内注入尿激酶的不良反应及副作用；(4)探讨局麻下胸腔镜治疗结核性包裹性胸膜炎的疗效、及并发症；(5)探讨胸腔内注入尿激酶治疗结核性包裹性胸膜炎的疗效。
方法：
(1)选取60例病程≤6周且无胸膜包裹、广泛肥厚、粘连的结核性胸膜炎患者,随机分为尿激酶组及对照组。2组均行中心静脉导管胸腔置入术,首次抽液600ml后,尿激酶组经导管向胸腔内注入用生理盐水50ml溶解的尿激酶25万IU；对照组经导管向胸腔内注入生理盐水50 ml,2组其它治疗方法均相同。观察2组治疗72小时后临床症状(胸痛、气促、发热等)的改善情况；2组胸腔积液的纤维蛋白原、凝血酶时间、凝血酶原时间、D-二聚体的变化；2组胸水完全引流的时间及引流胸水总量；治疗前后2组间胸膜厚度和胸膜粘连程度的差异；治疗前后2组间肺功能的差异；尿激酶组胸腔内注入尿激酶的不良反应。(2)选取61例病程>6周且有明显胸膜包裹、肥厚、粘连的结核性包裹性胸膜炎患者,随机分为胸腔镜组及对照组。胸腔镜组给予局麻下胸腔镜治疗,对照组给予反复胸腔穿刺并胸腔内注入用生理盐水20ml溶解的尿激酶10万IU治疗,一般1-3次,2组其它治疗方法均相同。观察2组治疗后2个月临床症状的好转情况；胸液消失及胸腔分隔包裹、粘连情况；壁层胸膜厚度变化；肺功能的变化；胸腔镜组患者出现的并发症或不良反应。
结果：
(1)胸腔内注入尿激酶后72小时尿激酶组的气促改善优于对照组(P<0.05),而胸痛与发热等的改善差异无统计学意义(均P>0.05)；胸腔内注入尿激酶后72小时尿激酶组胸腔积液中纤维蛋白原的含量较治疗前和对照组明显降低(均P<0.01)；胸腔积液的凝血酶时间和凝血酶原时间均比治疗前和对照组延长(均P<0.01)；胸腔积液中D-二聚体的含量比对照组、治疗前显著升高(P<0.01)；胸腔积液完全引流时间2组间差异无统计学意义(P>0.05),与对照组比较,尿激酶组抽出胸腔积液总量显著增多(P<0.01)；尿激酶组经过2个月治疗后壁层胸膜明显变薄(P<0.01),而对照组壁层胸膜显著增厚(P<0.01),治疗后尿激酶组的胸膜粘连程度较轻(P<0.05)；经过抽排胸腔积液后肺通气功能有不同程度的改善,特别向胸腔内注射尿激酶后,FVC%和ERV%升高,FEV1/FVC%降低,与对照组比较有显著性差异(P<0.01)；胸腔内注入尿激酶后,血液系统的血小板、纤维蛋白原、凝血酶原时间、凝血酶时间与对照组相比差异无统计学意义(均P>0.05)；所有尿激酶组病人对尿激酶胸腔内注射耐受良好,治疗过程中及治疗后均未见发热、搔痒、皮疹及其它过敏反应,亦无皮下出血、牙龈出血或血尿出现。(2)治疗后2周,胸腔镜组发热、气促、胸痛等临床症状好转情况优于对照组(P<0.01或P<0.05)；治疗后2个月胸腔镜组胸液消失率高于对照组,而胸膜粘连、包裹率低于对照组(均P<0.01)；胸腔镜组治疗后2个月壁层胸膜厚度较治疗前及对照组明显变薄(均P<0.01),对照组治疗后2个月壁层胸膜厚度较治疗前明显增厚(P<0.01)；治疗后2个月胸腔镜组FVC%、ERV%高于对照组,而FEV1/FVC%低于对照组(均P<0.01)；胸腔镜组无大出血、空气栓塞、复张性肺水肿、肺不张、胸腔感染等较严重并发症发生。
结论：
(1)胸腔内注入尿激酶治疗早期无包裹性结核性胸腔积液(病程≤6周),可增加胸腔积液抽出量,使胸膜变薄,胸膜粘连发生率降低,改善肺的限制性通气功能障碍；(2)胸腔内注入尿激酶后通过增强胸腔积液的纤溶活性,致胸腔积液的纤维蛋白原和纤维蛋白降解,减轻胸腔粘连程度；(3)胸腔内注入尿激酶没有影响血液系统的凝血和纤溶活性,也没有增加胸痛、发热等不良反应,患者的耐受性好；(4)胸腔内注入尿激酶治疗早期无包裹性结核性胸腔积液(病程≤6周)是一种安全、疗效高的方法,值得临床推广。(5)局麻下胸腔镜治疗结核性包裹性胸膜炎,可使临床症状明显好转,提高胸液消失率,降低胸膜粘连包裹率,使壁层胸膜变薄,改善肺的限制性通气功能障碍；(6)局麻下胸腔镜治疗结核性包裹性胸膜炎安全、简便、损伤小、疗效好,并发症发生率低,且可同时获取病理诊断,值得临床推广；(7)胸腔内注入尿激酶治疗结核性包裹性胸膜炎疗效欠佳。
Objective:(1) Discuss the prevention and treatment role of intrapleural urokinase in early tuberculous pleurisy (duration≤6 weeks) caused pleural thickening and adhesion; (2) Discuss the mechanism of intrapleural urokinase therapy in tuberculous pleurisy; (3) Discuss the adverse reactions and side effects of intrapleural urokinase. (4)Discuss the efficacy and complications under local anesthesia-assisted thoracoscopic treatment of tuberculous encapsulated pleurisy; (5) to investigate the efficacy of the treatment of intrapleural urokinase for tuberculous encapsulated pleurisy
Method:(1) Select 60 patients whose course of tuberculous pleurisy≤6 weeks and without pleural package, extensive hypertrophy, adhesion, randomly divided into urokinase group and control group. All underwent chest central venous catheter implantation, after extracting 600ml at the first time, the UK group were injected urokinase 250000 IU which was soluted with 50ml sodium chloride through intrapleural catheter; the control group were injected 50ml sodium chloride through catheter, other treatments were same. Observing the improvement of the clinical symptoms after 72 hours (chest pain, shortness of breath, fever, etc.); and fibrinogen, thrombin time, prothrombin time, D-dimer of the pleural effusion; the time of complete drainage of pleural effusion and the total amount drainage of pleural effusion; the difference of pleural adhesion level and pleural thickness before and after the treatment; the difference of lung function before and after treatment; the adverse reactions of intrapleural urokinase. (2)Select 61 patients>6 weeks and showed pleural package, hypertrophy, adhesion of tuberculous encapsulated pleurisy and randomly divided into thoracoscopic group and control group. Thoracoscopic group received thoracoscope treatment under local anesthesia, the control group were given repeated thoracentesis and intrapleural 100000 IU urokinase dissolved with 20ml Sodium Chloride, usually 1 to 3 times, other treatments were same. To observe clinical symptoms improved after treatment; pleural effusion disappeared and separate parcels, adhesion; parietal pleural thickness; changes in lung function; complications or adverse reactions.
Results:(1)Intrapleural urokinase 72 hours later,there was significant difference in the improvement of shortness of the UK group and the control group (P<0.05), and there was no significant difference in the change of chest pain and fever and so on (all P>0.05); the fibrinogen concentration in pleural effusion was significantly decreased than in the control group and before treatment (P<0.01); thrombin time and prothrombin time of pleural effusion were significantly longer than which before the treatment and control group (all P<0.01); D-dimer levels in the pleural effusion was significantly increased than the control group and before treatment (P<0.01); there was no significant difference in the time of complete drainage of pleural effusion between 2 groups (P>0.05), compared with the control group, the total amount of pleural effusion of urokinase group were significantly increase (P<0.01); parietal pleura of the UK group after 2 months'treatment was significantly thinner (P<0.01), while the control group were significantly thicken (P<0.01), after treatment the pleural adhesion of urokinase group was lesser extent (P<0.05); after drainage pleural effusion, pulmonary function was improved, particularly after the injection of urokinase, compared with the control group FVC% and ERV% were significantly increased, FEV1/FVC% was significantly lower (P<0.01); after intrapleural urokinase, there were no significantly difference of platelets, fibrinogen, prothrombin time, thrombin time compared with the control group (P>0.05); All UK group Intrapleural injection of urokinase in patients tolerated the treatment, during and after the treatment showed no fever, itching, rash and other allergic reactions, no subcutaneous bleeding, gingival bleeding or hematuria occurs. (2)2 weeks after treatment, fever, shortness of breath, chest pain and other symptoms of thoracoscopic group were improved better than in the control group (P<0.01 or P<0.05); treatment 2 months later,the rate of disappearance of pleural effusion in thoracoscopy group was higher, while pleural adhesions, parcels were lower than control groups (P<0.01); 2 months after treatment, parietal pleural thickness of thoracoscopy group was significantly thinner than before treatment and the control group (all P<0.01),2 months after treatment the thickness of parietal pleural of control group thickening than before treatment (P<0.01); 2 months after treatment FVC%, ERV% of thoracoscopic group were higher, while the FEV1/FVC% lower than the control group (P<0.01); thoracoscopic group had no bleeding and air embolism, reexpansion pulmonary edema, pulmonary atelectasis, chest infections and other serious complications.
Conclusion:(1)intrapleural urokinase treatment of early non-encapsulated tuberculous pleural effusion (duration≤6 weeks), could increase the volume of pleural effusion, pleura thinning, lower the incidence of pleural adhesions, improve the restrictive pulmonary function disorder; (2) after intrapleural urokinase, because of the enhancement of fibrinolytic activity of pleural effusion, fibrinogen and fibrin degradatiohn, reduce the degree of pleural adhesions; (3) no effect of blood coagulation and fibrinolysis system, and no increase in chest pain,fever and other adverse reactions of intrapleural urokinase, patients were well tolerated; (4) Intrapleural urokinase in the treatment of early non-encapsulated tuberculous pleural effusion (duration≤6 weeks) is a safe, highly effective method, is worthy of promotion; (5) under local anesthesia-assisted thoracoscopic treatment of tuberculous encapsulated pleurisy, the clinical symptoms obviously improved, increased disappearance rate of pleural fluid, reduction package rates of pleural adhesion and to make thinner parietal pleura, improve the restrictive pulmonary function disorder; (6) thoracoscopy under local anesthesia to treat tuberculous encapsulated pleurisy is safe, simple, little damage, good efficacy, low complication rate, and can also obtain pathological diagnosis, is worthy of promotion; (7) intrapleural urokinase in the treatment of tuberculous encapsulated pleurisy had poor efficacy.
(1)探讨胸腔内注入尿激酶对早期结核性胸膜炎(病程≤6周)引起胸膜增厚、粘连的预防和治疗作用；(2)探讨胸腔内注入尿激酶治疗对结核性胸膜炎作用机制；(3)探讨胸腔内注入尿激酶的不良反应及副作用；(4)探讨局麻下胸腔镜治疗结核性包裹性胸膜炎的疗效、及并发症；(5)探讨胸腔内注入尿激酶治疗结核性包裹性胸膜炎的疗效。
方法：
(1)选取60例病程≤6周且无胸膜包裹、广泛肥厚、粘连的结核性胸膜炎患者,随机分为尿激酶组及对照组。2组均行中心静脉导管胸腔置入术,首次抽液600ml后,尿激酶组经导管向胸腔内注入用生理盐水50ml溶解的尿激酶25万IU；对照组经导管向胸腔内注入生理盐水50 ml,2组其它治疗方法均相同。观察2组治疗72小时后临床症状(胸痛、气促、发热等)的改善情况；2组胸腔积液的纤维蛋白原、凝血酶时间、凝血酶原时间、D-二聚体的变化；2组胸水完全引流的时间及引流胸水总量；治疗前后2组间胸膜厚度和胸膜粘连程度的差异；治疗前后2组间肺功能的差异；尿激酶组胸腔内注入尿激酶的不良反应。(2)选取61例病程>6周且有明显胸膜包裹、肥厚、粘连的结核性包裹性胸膜炎患者,随机分为胸腔镜组及对照组。胸腔镜组给予局麻下胸腔镜治疗,对照组给予反复胸腔穿刺并胸腔内注入用生理盐水20ml溶解的尿激酶10万IU治疗,一般1-3次,2组其它治疗方法均相同。观察2组治疗后2个月临床症状的好转情况；胸液消失及胸腔分隔包裹、粘连情况；壁层胸膜厚度变化；肺功能的变化；胸腔镜组患者出现的并发症或不良反应。
结果：
(1)胸腔内注入尿激酶后72小时尿激酶组的气促改善优于对照组(P<0.05),而胸痛与发热等的改善差异无统计学意义(均P>0.05)；胸腔内注入尿激酶后72小时尿激酶组胸腔积液中纤维蛋白原的含量较治疗前和对照组明显降低(均P<0.01)；胸腔积液的凝血酶时间和凝血酶原时间均比治疗前和对照组延长(均P<0.01)；胸腔积液中D-二聚体的含量比对照组、治疗前显著升高(P<0.01)；胸腔积液完全引流时间2组间差异无统计学意义(P>0.05),与对照组比较,尿激酶组抽出胸腔积液总量显著增多(P<0.01)；尿激酶组经过2个月治疗后壁层胸膜明显变薄(P<0.01),而对照组壁层胸膜显著增厚(P<0.01),治疗后尿激酶组的胸膜粘连程度较轻(P<0.05)；经过抽排胸腔积液后肺通气功能有不同程度的改善,特别向胸腔内注射尿激酶后,FVC%和ERV%升高,FEV1/FVC%降低,与对照组比较有显著性差异(P<0.01)；胸腔内注入尿激酶后,血液系统的血小板、纤维蛋白原、凝血酶原时间、凝血酶时间与对照组相比差异无统计学意义(均P>0.05)；所有尿激酶组病人对尿激酶胸腔内注射耐受良好,治疗过程中及治疗后均未见发热、搔痒、皮疹及其它过敏反应,亦无皮下出血、牙龈出血或血尿出现。(2)治疗后2周,胸腔镜组发热、气促、胸痛等临床症状好转情况优于对照组(P<0.01或P<0.05)；治疗后2个月胸腔镜组胸液消失率高于对照组,而胸膜粘连、包裹率低于对照组(均P<0.01)；胸腔镜组治疗后2个月壁层胸膜厚度较治疗前及对照组明显变薄(均P<0.01),对照组治疗后2个月壁层胸膜厚度较治疗前明显增厚(P<0.01)；治疗后2个月胸腔镜组FVC%、ERV%高于对照组,而FEV1/FVC%低于对照组(均P<0.01)；胸腔镜组无大出血、空气栓塞、复张性肺水肿、肺不张、胸腔感染等较严重并发症发生。
结论：
(1)胸腔内注入尿激酶治疗早期无包裹性结核性胸腔积液(病程≤6周),可增加胸腔积液抽出量,使胸膜变薄,胸膜粘连发生率降低,改善肺的限制性通气功能障碍；(2)胸腔内注入尿激酶后通过增强胸腔积液的纤溶活性,致胸腔积液的纤维蛋白原和纤维蛋白降解,减轻胸腔粘连程度；(3)胸腔内注入尿激酶没有影响血液系统的凝血和纤溶活性,也没有增加胸痛、发热等不良反应,患者的耐受性好；(4)胸腔内注入尿激酶治疗早期无包裹性结核性胸腔积液(病程≤6周)是一种安全、疗效高的方法,值得临床推广。(5)局麻下胸腔镜治疗结核性包裹性胸膜炎,可使临床症状明显好转,提高胸液消失率,降低胸膜粘连包裹率,使壁层胸膜变薄,改善肺的限制性通气功能障碍；(6)局麻下胸腔镜治疗结核性包裹性胸膜炎安全、简便、损伤小、疗效好,并发症发生率低,且可同时获取病理诊断,值得临床推广；(7)胸腔内注入尿激酶治疗结核性包裹性胸膜炎疗效欠佳。
Objective:(1) Discuss the prevention and treatment role of intrapleural urokinase in early tuberculous pleurisy (duration≤6 weeks) caused pleural thickening and adhesion; (2) Discuss the mechanism of intrapleural urokinase therapy in tuberculous pleurisy; (3) Discuss the adverse reactions and side effects of intrapleural urokinase. (4)Discuss the efficacy and complications under local anesthesia-assisted thoracoscopic treatment of tuberculous encapsulated pleurisy; (5) to investigate the efficacy of the treatment of intrapleural urokinase for tuberculous encapsulated pleurisy
Method:(1) Select 60 patients whose course of tuberculous pleurisy≤6 weeks and without pleural package, extensive hypertrophy, adhesion, randomly divided into urokinase group and control group. All underwent chest central venous catheter implantation, after extracting 600ml at the first time, the UK group were injected urokinase 250000 IU which was soluted with 50ml sodium chloride through intrapleural catheter; the control group were injected 50ml sodium chloride through catheter, other treatments were same. Observing the improvement of the clinical symptoms after 72 hours (chest pain, shortness of breath, fever, etc.); and fibrinogen, thrombin time, prothrombin time, D-dimer of the pleural effusion; the time of complete drainage of pleural effusion and the total amount drainage of pleural effusion; the difference of pleural adhesion level and pleural thickness before and after the treatment; the difference of lung function before and after treatment; the adverse reactions of intrapleural urokinase. (2)Select 61 patients>6 weeks and showed pleural package, hypertrophy, adhesion of tuberculous encapsulated pleurisy and randomly divided into thoracoscopic group and control group. Thoracoscopic group received thoracoscope treatment under local anesthesia, the control group were given repeated thoracentesis and intrapleural 100000 IU urokinase dissolved with 20ml Sodium Chloride, usually 1 to 3 times, other treatments were same. To observe clinical symptoms improved after treatment; pleural effusion disappeared and separate parcels, adhesion; parietal pleural thickness; changes in lung function; complications or adverse reactions.
Results:(1)Intrapleural urokinase 72 hours later,there was significant difference in the improvement of shortness of the UK group and the control group (P<0.05), and there was no significant difference in the change of chest pain and fever and so on (all P>0.05); the fibrinogen concentration in pleural effusion was significantly decreased than in the control group and before treatment (P<0.01); thrombin time and prothrombin time of pleural effusion were significantly longer than which before the treatment and control group (all P<0.01); D-dimer levels in the pleural effusion was significantly increased than the control group and before treatment (P<0.01); there was no significant difference in the time of complete drainage of pleural effusion between 2 groups (P>0.05), compared with the control group, the total amount of pleural effusion of urokinase group were significantly increase (P<0.01); parietal pleura of the UK group after 2 months'treatment was significantly thinner (P<0.01), while the control group were significantly thicken (P<0.01), after treatment the pleural adhesion of urokinase group was lesser extent (P<0.05); after drainage pleural effusion, pulmonary function was improved, particularly after the injection of urokinase, compared with the control group FVC% and ERV% were significantly increased, FEV1/FVC% was significantly lower (P<0.01); after intrapleural urokinase, there were no significantly difference of platelets, fibrinogen, prothrombin time, thrombin time compared with the control group (P>0.05); All UK group Intrapleural injection of urokinase in patients tolerated the treatment, during and after the treatment showed no fever, itching, rash and other allergic reactions, no subcutaneous bleeding, gingival bleeding or hematuria occurs. (2)2 weeks after treatment, fever, shortness of breath, chest pain and other symptoms of thoracoscopic group were improved better than in the control group (P<0.01 or P<0.05); treatment 2 months later,the rate of disappearance of pleural effusion in thoracoscopy group was higher, while pleural adhesions, parcels were lower than control groups (P<0.01); 2 months after treatment, parietal pleural thickness of thoracoscopy group was significantly thinner than before treatment and the control group (all P<0.01),2 months after treatment the thickness of parietal pleural of control group thickening than before treatment (P<0.01); 2 months after treatment FVC%, ERV% of thoracoscopic group were higher, while the FEV1/FVC% lower than the control group (P<0.01); thoracoscopic group had no bleeding and air embolism, reexpansion pulmonary edema, pulmonary atelectasis, chest infections and other serious complications.
Conclusion:(1)intrapleural urokinase treatment of early non-encapsulated tuberculous pleural effusion (duration≤6 weeks), could increase the volume of pleural effusion, pleura thinning, lower the incidence of pleural adhesions, improve the restrictive pulmonary function disorder; (2) after intrapleural urokinase, because of the enhancement of fibrinolytic activity of pleural effusion, fibrinogen and fibrin degradatiohn, reduce the degree of pleural adhesions; (3) no effect of blood coagulation and fibrinolysis system, and no increase in chest pain,fever and other adverse reactions of intrapleural urokinase, patients were well tolerated; (4) Intrapleural urokinase in the treatment of early non-encapsulated tuberculous pleural effusion (duration≤6 weeks) is a safe, highly effective method, is worthy of promotion; (5) under local anesthesia-assisted thoracoscopic treatment of tuberculous encapsulated pleurisy, the clinical symptoms obviously improved, increased disappearance rate of pleural fluid, reduction package rates of pleural adhesion and to make thinner parietal pleura, improve the restrictive pulmonary function disorder; (6) thoracoscopy under local anesthesia to treat tuberculous encapsulated pleurisy is safe, simple, little damage, good efficacy, low complication rate, and can also obtain pathological diagnosis, is worthy of promotion; (7) intrapleural urokinase in the treatment of tuberculous encapsulated pleurisy had poor efficacy.
引文
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