纤维支气管镜和支气管肺泡灌洗在小儿难治性肺炎治疗中的临床研究
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摘要
背景
小儿肺炎为临床常见病,具有非常高的发病率,主要由细菌、病毒或支原体感染引起,临床表现为发热、咳嗽、咳痰等,需要密切的观察和治疗。一旦治疗不彻底,易反复发作,或演变成为小儿难治性肺炎,严重影响小儿的生长发育。
小儿难治性肺炎具有病情重、病程长、常规治疗效果差的特点,容易引发一系列肺外并发症,导致神经系统、循环系统功能紊乱或破坏。是临床治疗的一大难题。
纤维支气管镜于30余年前首次被用于儿童呼吸系统疾病。自此儿童纤维支气管镜技术逐步丰富、发展,已经由单纯的形态学检查发展至呼吸系统疾病的治疗,尤其是近些年发展的纤维支气管镜支气管肺泡灌洗,对于临床治疗小儿难治性肺炎开辟了新的、疗效好的治疗方法。但是目前关于纤维支气管镜支气管肺泡灌洗治疗小儿难治性肺炎缺乏对比性的研究。
目的
探讨纤维支气管镜支气管肺泡灌洗治疗儿童难治性肺炎的治疗效果。
方法
选择难治性肺炎患儿48例,随机分为实验组和对照组,实验组患者采用纤维支气管镜灌洗治疗+常规治疗,对照组患者单纯采用常规治疗。其中实验组26例,男童16例,女童10例,年龄最大为12岁,最小为2岁,平均年龄为(6.2±1.9)岁;对照组22例,男童14例,女童8例,年龄最大为13岁,最小为2.5岁,平均年龄为(6.8±2.1)岁。,对比两组治疗方案的疗效差异。
根据患儿的病情和实际情况、个体发育差异后再决定选择纤维支气管镜的粗细及型号,原则上是插入部外径适合患儿气道大小。8岁以下的患儿行全麻下气管插管呼吸机辅助下行气管灌洗;8岁以上的患儿行局部麻醉下气管灌洗,术前禁食8h,可由静脉补充一·定量葡萄糖。术前30min肌肉注射阿托品0.01～0.02mg/kg,以减少呼吸道分泌物。根据2002年中华医学会呼吸学分会制定的支气管肺泡灌洗液细胞学检测技术规范(草案)操作,自气管插管送入纤维支气管镜,对分泌物多、炎症重的病灶肺段进行重点进行反复加压灌洗,重复进行直至各级支气管腔内分泌物吸净至灌洗液清亮;再选用37℃溶解敏感抗生素的生理盐水冲洗病变肺叶3-5次并清理干净;最后检查双肺情况,彻底吸出灌洗液后完场操作。
结果
实验组累计支气管肺泡灌洗治疗29例次,其中3例灌洗2次,其余每例1次,治疗22例(84.62%)有效,对照组12例(54.55%)有效,两者之间比较有统计学意义(p<0.05)),说明实验组治疗效果较对照组治疗效果好;实验组肺炎治疗有效时间为(9±2.1)d,对照组肺炎治疗有效时间为(15.6±3.8)d,两者之间比较有统计学意义(p<0.05)。
结论
经纤维支气管镜灌洗治疗,能够充分清除呼吸道内分泌物,解除支气管阻塞,改善患者肺通气、换气功能,升高病灶内药物浓度,最终提高临床治疗效果,缩短临床治疗时间,是治疗小儿难治性肺炎及肺不张的有效治疗方法。
Background
Infantile pneumonia is a common disease in hospital, with a very high incidence rate, which was mainly caused by bacteria, virus or myoplasma infection. The main clinical manifestations of this patient is fever, cought, sputum, etc. These patients need close observation and treatment, because infantile pneumonia is easy to recurrent, or change into infantile refractory pneumonia, which is bad to children,s growth and development.
Infantile refractory pneumonia is characterized by sereve condition, long pathogenesis and bad result to conventional treatment, and leads to complications easily, damaging the nervous system and circulatory system. So Infantile refractory pneumonia also is a major clinical problem.
30 years ago, Bronchofibroscope was used in childhood respiratory disease first time. Since then, child bronchofibroscope developed gradually, from a tool of morphological examination developed to a tool of respiratory disease treatment, especially bronchoalveolar lavage by bronchofibroscope, which is a new and efficient therapeutic method to infantile refractory pneumonia. But there no comparative research on bronchoalveolar lavage by bronchofibroscope.
Objective
To study the therapeutic effect of lavage by bronchofibroscope in treatment of children refractory pneumonia.
Methods
All 48 children patients were randomly divided into two subgroups: experimental group (n=26,males:16,females:10,age:6.2±1.9y) and control group (n=22,males:14,females:8,age:6.8±2.1y). The experimental group was treated with lavage by bronchofibroscope and routine medical treatment, but the control group treated with routine medical treatment only. Compared the effective rate between the two groups.
According to the actual illness and the individual development differences of the patients,we dicided to choose the most optimal bronchofibroscope which completely fited the trachea. Children above 8 years were treated with BAL in the local anesthesia;others under 8 years were treated with BAL in ETGA .All of the patients were applied to abrosia but infused some glucose solution during the eight hours before the operation .All of the patients were injected atropine 0.01～ 0.02mg/kg,which could clean up the respiratory secretions.
According to the drift of the cytology for detection technical specifications about BAL-F which was formulate by the CMA,we focused on the refractory pneumonia focuses with more secretions and serious inflammation.BAL had not been done more times in the target points until the secretion be sucked clean and the BALF be clear.Then lesions lobectomy were flushed 3-5 times with the NS that were dissolved the sensitive antibiotics and in 37℃.After the lesions lobectomy had been clean the bilateral pulmonary were checked and the BALF. thoroughly epispaticed .
Results
The experimental group was consisted of 29 cases of BAL, amongst those 3 patients were treated with BAL 2 times,the others were treated only once.22 cases (84.62%) were effective in the experiment group, while only 12 cases (54.55%) were effective in the control group. There was a significant diference between the two groups(P <0.05). The average therapeutic time of the experimental group was (9±2.1) d, while the average therapeutic time of the control group was (15.6±3.8)d. The time for controlling the pneumonia in the experimental group was significantly shorter than that in the control group(P <0.05).
Conclusion
The BAL therapy can sufficientlly elimimate the respiratory secretions, release bronchinal obstrucion, improve pulmonary ventilation and raise drug concentration of refractory pneumonia focus. All these methods will improve clinical therapeutic effects, reduce clinical treatment time. So, BAL is a safe and useful therapy for children refractory pneumonia.
小儿肺炎为临床常见病,具有非常高的发病率,主要由细菌、病毒或支原体感染引起,临床表现为发热、咳嗽、咳痰等,需要密切的观察和治疗。一旦治疗不彻底,易反复发作,或演变成为小儿难治性肺炎,严重影响小儿的生长发育。
小儿难治性肺炎具有病情重、病程长、常规治疗效果差的特点,容易引发一系列肺外并发症,导致神经系统、循环系统功能紊乱或破坏。是临床治疗的一大难题。
纤维支气管镜于30余年前首次被用于儿童呼吸系统疾病。自此儿童纤维支气管镜技术逐步丰富、发展,已经由单纯的形态学检查发展至呼吸系统疾病的治疗,尤其是近些年发展的纤维支气管镜支气管肺泡灌洗,对于临床治疗小儿难治性肺炎开辟了新的、疗效好的治疗方法。但是目前关于纤维支气管镜支气管肺泡灌洗治疗小儿难治性肺炎缺乏对比性的研究。
目的
探讨纤维支气管镜支气管肺泡灌洗治疗儿童难治性肺炎的治疗效果。
方法
选择难治性肺炎患儿48例,随机分为实验组和对照组,实验组患者采用纤维支气管镜灌洗治疗+常规治疗,对照组患者单纯采用常规治疗。其中实验组26例,男童16例,女童10例,年龄最大为12岁,最小为2岁,平均年龄为(6.2±1.9)岁;对照组22例,男童14例,女童8例,年龄最大为13岁,最小为2.5岁,平均年龄为(6.8±2.1)岁。,对比两组治疗方案的疗效差异。
根据患儿的病情和实际情况、个体发育差异后再决定选择纤维支气管镜的粗细及型号,原则上是插入部外径适合患儿气道大小。8岁以下的患儿行全麻下气管插管呼吸机辅助下行气管灌洗;8岁以上的患儿行局部麻醉下气管灌洗,术前禁食8h,可由静脉补充一·定量葡萄糖。术前30min肌肉注射阿托品0.01～0.02mg/kg,以减少呼吸道分泌物。根据2002年中华医学会呼吸学分会制定的支气管肺泡灌洗液细胞学检测技术规范(草案)操作,自气管插管送入纤维支气管镜,对分泌物多、炎症重的病灶肺段进行重点进行反复加压灌洗,重复进行直至各级支气管腔内分泌物吸净至灌洗液清亮;再选用37℃溶解敏感抗生素的生理盐水冲洗病变肺叶3-5次并清理干净;最后检查双肺情况,彻底吸出灌洗液后完场操作。
结果
实验组累计支气管肺泡灌洗治疗29例次,其中3例灌洗2次,其余每例1次,治疗22例(84.62%)有效,对照组12例(54.55%)有效,两者之间比较有统计学意义(p<0.05)),说明实验组治疗效果较对照组治疗效果好;实验组肺炎治疗有效时间为(9±2.1)d,对照组肺炎治疗有效时间为(15.6±3.8)d,两者之间比较有统计学意义(p<0.05)。
结论
经纤维支气管镜灌洗治疗,能够充分清除呼吸道内分泌物,解除支气管阻塞,改善患者肺通气、换气功能,升高病灶内药物浓度,最终提高临床治疗效果,缩短临床治疗时间,是治疗小儿难治性肺炎及肺不张的有效治疗方法。
Background
Infantile pneumonia is a common disease in hospital, with a very high incidence rate, which was mainly caused by bacteria, virus or myoplasma infection. The main clinical manifestations of this patient is fever, cought, sputum, etc. These patients need close observation and treatment, because infantile pneumonia is easy to recurrent, or change into infantile refractory pneumonia, which is bad to children,s growth and development.
Infantile refractory pneumonia is characterized by sereve condition, long pathogenesis and bad result to conventional treatment, and leads to complications easily, damaging the nervous system and circulatory system. So Infantile refractory pneumonia also is a major clinical problem.
30 years ago, Bronchofibroscope was used in childhood respiratory disease first time. Since then, child bronchofibroscope developed gradually, from a tool of morphological examination developed to a tool of respiratory disease treatment, especially bronchoalveolar lavage by bronchofibroscope, which is a new and efficient therapeutic method to infantile refractory pneumonia. But there no comparative research on bronchoalveolar lavage by bronchofibroscope.
Objective
To study the therapeutic effect of lavage by bronchofibroscope in treatment of children refractory pneumonia.
Methods
All 48 children patients were randomly divided into two subgroups: experimental group (n=26,males:16,females:10,age:6.2±1.9y) and control group (n=22,males:14,females:8,age:6.8±2.1y). The experimental group was treated with lavage by bronchofibroscope and routine medical treatment, but the control group treated with routine medical treatment only. Compared the effective rate between the two groups.
According to the actual illness and the individual development differences of the patients,we dicided to choose the most optimal bronchofibroscope which completely fited the trachea. Children above 8 years were treated with BAL in the local anesthesia;others under 8 years were treated with BAL in ETGA .All of the patients were applied to abrosia but infused some glucose solution during the eight hours before the operation .All of the patients were injected atropine 0.01～ 0.02mg/kg,which could clean up the respiratory secretions.
According to the drift of the cytology for detection technical specifications about BAL-F which was formulate by the CMA,we focused on the refractory pneumonia focuses with more secretions and serious inflammation.BAL had not been done more times in the target points until the secretion be sucked clean and the BALF be clear.Then lesions lobectomy were flushed 3-5 times with the NS that were dissolved the sensitive antibiotics and in 37℃.After the lesions lobectomy had been clean the bilateral pulmonary were checked and the BALF. thoroughly epispaticed .
Results
The experimental group was consisted of 29 cases of BAL, amongst those 3 patients were treated with BAL 2 times,the others were treated only once.22 cases (84.62%) were effective in the experiment group, while only 12 cases (54.55%) were effective in the control group. There was a significant diference between the two groups(P <0.05). The average therapeutic time of the experimental group was (9±2.1) d, while the average therapeutic time of the control group was (15.6±3.8)d. The time for controlling the pneumonia in the experimental group was significantly shorter than that in the control group(P <0.05).
Conclusion
The BAL therapy can sufficientlly elimimate the respiratory secretions, release bronchinal obstrucion, improve pulmonary ventilation and raise drug concentration of refractory pneumonia focus. All these methods will improve clinical therapeutic effects, reduce clinical treatment time. So, BAL is a safe and useful therapy for children refractory pneumonia.
引文
1胡成平.拓展临床思维,提高难治性肺炎的诊断水平[J].中国感染控制杂志,2007,6(6):365—367
2王孟昭,陈勇,钟巍,等.经支气管镜淋巴结针吸活检对肺癌的诊断意义[J].中华肿瘤杂志,2006,28(7):533—535.
3高红,刘玺诚,江沁波.支气管肺泡灌洗在小儿肺部疾病治疗中的作用[J].中华儿科杂志, 1995, 33:136-137.
4 Kreider ME.Lipson DA.Bronchoscopy for atelectasis in the ICU[J].Chest,2003,124(3):344—350.
5 Luna C.Vuiacich P,Niederman M.et a1.Impact of BAL data on the therapy and outcome of ventilator associated pneumonia[J].Chest,1997,111(4):676-685.
6崔喜英,武芳,安淑华,等.支气管肺泡灌洗在儿童难治性肺炎治疗中的应用[J].临床荟萃,2008,23(6):432—433.
7 Vasic N.The role of ECG monitoring during bronchoscopy in lung cancer patients[J].Support Care Cancer,1995,3:402～408
8陈正贤.介人性肺病学.北京:人民卫生出版社,2004
9张耀亭,吴妙芬.经纤维支气管镜高频电刀治疗气道阻塞性病变[J],中国内镜杂志,2005,10;1068—1069.
10 Valipour A.Kreuzer A,Koller H.et a1. Bronchoscopy.Guided Topical Hemostatic Tamponade Therapy for the Man agement of Life-Threatening Hemoptysis[J].Chest,2005,127(121:2113-2118.
11刘玺诚,我国儿科支气管镜术的发展及前景[J].中华儿科杂志,2009年lO月第47卷第1O期,724-725
12 Wood RE. Spelunking in the pediatric airways: explorations with theflexible fiberoptic bronchoscope[J].Pediatr Clin North Am, 1984, 31:785-799.
13 Perez CR, Wood RE. Update on pediatric flexible Bronchoscopy[J].Pediatr Clin North Am, 1994, 41:385-399.
14 Godfrey S, Avital A, Maayan C. Yield from flexible bronchoscopy in children[J].Pediatr Pulmonol, 1997, 23: 261.
15刘玺诚,江沁波,高红.局部表面麻醉法在儿科纤维支气管镜诊疗中的应用[J].中华儿科杂志, 1994, 32:38
16陈志敏,刘金玲,王财富.小儿纤维支气管镜检查与治疗的安全性探讨[J].临床儿科杂志,2006,24(1):31—33.
17靳蓉,朱莉,苏守硕,等.纤维支气管镜在儿童肺不张病因诊断及治疗中的应用价值[J].临床儿科杂志,2008,26(8):721-723.
18陆敏,陆权,车大钿,等.纤维支气管镜在小儿难治性肺炎诊治中的价值[J].临床儿科杂志,2008,26(9):81l一8l5.
19 Berkenbosch JW,Graft GR,Stark JM,et a1.Use of aremifentanil—propofol mixture for pediatric flexible fiberoptic bronchoscopy sedation[J] .Paediatr Anaesth,2004,14(11):941-946.
20罗社声,王财富,祝国红,等.80例小儿气道异物支气管肺泡灌洗液细菌培养结果分析[J].中华儿科杂志,2006,44(6):469—470.
21焦安夏,刘玺诚,江沁波,等.慢性咳嗽和喘息性疾病支气管肺泡灌洗液成分分析[J].中华儿科杂志,2002,40(2):92—95.
22 Marchant JM,Masters IB,Taylor SM,et .Evaluation and outcome of young children with chronic cough [J].Chest,2006,129(5):1132一l141.
23张谦慎,常立文,容志惠.早产儿慢性肺疾病支气管肺泡灌洗液中细胞外基质的变化[J] .中国实用儿科杂志,2006,21(9):663—665。
24廖圣芳,陈汉民,张银清,等.支气管灌洗治疗重症高血压脑出血并肺部感染的临床研究[J].实用临床医学,2003,4(3):30一32。
25中华医学会呼吸病学分会.支气管肺泡灌洗液细胞学检测技术规范(草案)[J].中华结核和呼吸杂志,2002,25(7):390—391.
26刘长亭.现代纤维支气管镜诊断治疗学[M].北京:人民军医出版社.1997.3.
27张福瑞,刘霞,岳新召等.纤维支气管镜灌洗治疗顽固性肺部感染研究[J].医药论坛杂志,2010,31(9):43-44。
28张杰,张洪玉,翁心植.肺部感染的病原菌学诊断方法[J].中国内镜杂志,1998,4(6):60—63.
29宋满景,张永兴,刘卓拉,樊冬花,支气管肺泡灌洗在尘肺和肺炎研究中的应用[J].山西医药杂志,1991,20(5):265—266.
30 Klien, J. H., I. Y. Adamson. Fibroblast inhibition and prostaglandin secretion by alveolar epithelial cells exposed to silica. [J].Lab. Invest,1989.
60:808
31 Cott GR, Walker SR and Mason RJ. The effect of substratum and serum on the lipid synthesis and morphology of alveolar type II cells [J] .Am R ev Respir Dis,1987,135:A60
2王孟昭,陈勇,钟巍,等.经支气管镜淋巴结针吸活检对肺癌的诊断意义[J].中华肿瘤杂志,2006,28(7):533—535.
3高红,刘玺诚,江沁波.支气管肺泡灌洗在小儿肺部疾病治疗中的作用[J].中华儿科杂志, 1995, 33:136-137.
4 Kreider ME.Lipson DA.Bronchoscopy for atelectasis in the ICU[J].Chest,2003,124(3):344—350.
5 Luna C.Vuiacich P,Niederman M.et a1.Impact of BAL data on the therapy and outcome of ventilator associated pneumonia[J].Chest,1997,111(4):676-685.
6崔喜英,武芳,安淑华,等.支气管肺泡灌洗在儿童难治性肺炎治疗中的应用[J].临床荟萃,2008,23(6):432—433.
7 Vasic N.The role of ECG monitoring during bronchoscopy in lung cancer patients[J].Support Care Cancer,1995,3:402～408
8陈正贤.介人性肺病学.北京:人民卫生出版社,2004
9张耀亭,吴妙芬.经纤维支气管镜高频电刀治疗气道阻塞性病变[J],中国内镜杂志,2005,10;1068—1069.
10 Valipour A.Kreuzer A,Koller H.et a1. Bronchoscopy.Guided Topical Hemostatic Tamponade Therapy for the Man agement of Life-Threatening Hemoptysis[J].Chest,2005,127(121:2113-2118.
11刘玺诚,我国儿科支气管镜术的发展及前景[J].中华儿科杂志,2009年lO月第47卷第1O期,724-725
12 Wood RE. Spelunking in the pediatric airways: explorations with theflexible fiberoptic bronchoscope[J].Pediatr Clin North Am, 1984, 31:785-799.
13 Perez CR, Wood RE. Update on pediatric flexible Bronchoscopy[J].Pediatr Clin North Am, 1994, 41:385-399.
14 Godfrey S, Avital A, Maayan C. Yield from flexible bronchoscopy in children[J].Pediatr Pulmonol, 1997, 23: 261.
15刘玺诚,江沁波,高红.局部表面麻醉法在儿科纤维支气管镜诊疗中的应用[J].中华儿科杂志, 1994, 32:38
16陈志敏,刘金玲,王财富.小儿纤维支气管镜检查与治疗的安全性探讨[J].临床儿科杂志,2006,24(1):31—33.
17靳蓉,朱莉,苏守硕,等.纤维支气管镜在儿童肺不张病因诊断及治疗中的应用价值[J].临床儿科杂志,2008,26(8):721-723.
18陆敏,陆权,车大钿,等.纤维支气管镜在小儿难治性肺炎诊治中的价值[J].临床儿科杂志,2008,26(9):81l一8l5.
19 Berkenbosch JW,Graft GR,Stark JM,et a1.Use of aremifentanil—propofol mixture for pediatric flexible fiberoptic bronchoscopy sedation[J] .Paediatr Anaesth,2004,14(11):941-946.
20罗社声,王财富,祝国红,等.80例小儿气道异物支气管肺泡灌洗液细菌培养结果分析[J].中华儿科杂志,2006,44(6):469—470.
21焦安夏,刘玺诚,江沁波,等.慢性咳嗽和喘息性疾病支气管肺泡灌洗液成分分析[J].中华儿科杂志,2002,40(2):92—95.
22 Marchant JM,Masters IB,Taylor SM,et .Evaluation and outcome of young children with chronic cough [J].Chest,2006,129(5):1132一l141.
23张谦慎,常立文,容志惠.早产儿慢性肺疾病支气管肺泡灌洗液中细胞外基质的变化[J] .中国实用儿科杂志,2006,21(9):663—665。
24廖圣芳,陈汉民,张银清,等.支气管灌洗治疗重症高血压脑出血并肺部感染的临床研究[J].实用临床医学,2003,4(3):30一32。
25中华医学会呼吸病学分会.支气管肺泡灌洗液细胞学检测技术规范(草案)[J].中华结核和呼吸杂志,2002,25(7):390—391.
26刘长亭.现代纤维支气管镜诊断治疗学[M].北京:人民军医出版社.1997.3.
27张福瑞,刘霞,岳新召等.纤维支气管镜灌洗治疗顽固性肺部感染研究[J].医药论坛杂志,2010,31(9):43-44。
28张杰,张洪玉,翁心植.肺部感染的病原菌学诊断方法[J].中国内镜杂志,1998,4(6):60—63.
29宋满景,张永兴,刘卓拉,樊冬花,支气管肺泡灌洗在尘肺和肺炎研究中的应用[J].山西医药杂志,1991,20(5):265—266.
30 Klien, J. H., I. Y. Adamson. Fibroblast inhibition and prostaglandin secretion by alveolar epithelial cells exposed to silica. [J].Lab. Invest,1989.
60:808
31 Cott GR, Walker SR and Mason RJ. The effect of substratum and serum on the lipid synthesis and morphology of alveolar type II cells [J] .Am R ev Respir Dis,1987,135:A60