纤维支气管镜引导下气管插管扩张术治疗良性气管狭窄
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摘要
目的：探讨纤维支气管镜(简称纤支镜)引导下气管插管扩张术治疗良性气管狭窄的疗效及安全性。
方法：研究分析广西医科大学第一附属医院2007年10月至2011年8月不同原因所致良性气管狭窄20例患者的临床资料,其中男9例,女11例,年龄25-65岁,平均(38±10)岁。根据采用不同扩张方法把患者分为2组：A组采用经纤支镜引导下气管插管扩张术治疗；B组采用高压气管球囊扩张术治疗。视情况需要,对于严重气道狭窄或不同程度气管软化患者临时置入气管金属支架治疗,或联合气管球囊扩张狭窄左或右主支气管。对2组患者均分别于术前和最后一次扩张术后的当天,对其狭窄段的气道直径、气促评分和第1秒用力呼吸量(FEV1)、血气分析进行测定,对其近期疗效及并发症的发生情况进行评价；门诊随访12-18个月,观察这两组扩张方法远期疗效及并发症情况。术后20例患者均以布地奈德雾化吸入(3-6个月),视情况加以阿米卡星雾化吸入以减轻黏膜充血水肿。
结果：1、A组与B组治疗情况的比较：A组中12例患者接受气管插管扩张术1-2次后,呼吸困难迅速缓解,酸中毒,C02潴留,气促指数明显改善,即刻疗效达到了100%；狭窄气管的直径由治疗前的(5.9±1.2)mm增加到(12.2±2.1)mm,FEV,由术前的(0.67±0.13)L,升高至(1.73±0.37)L,差异均有统计学意义(P＜0.01)。B组治疗有效的6例患者经高压气管球囊扩张1-3次后,气促指数由术前的(3.6±0.5)下降为(0.4±0.5),气道直径也由(5.8±1.6)mm升高为术后的(10.1±2.8)mm,FEV1亦由术前的(0.62±0.17)L增加到术后的(1.36±0.41)L,差异有统计学意义(尺0.01)。同时,对以上A、B两组结果数据进行两样本t检验分析,差异没有统计学意义(P＞0.05)。
2、A组与B组近远期疗效及并发症情况的比较：A组近期有效率为100%,远期有效率为81.8%,B组有效率为60%,远期有效率为66.7%。对其进行四格表卡方检验,差异有统计学意义(P＜0.05)。A组中12例患者术后均有不同程度口鼻粘膜损伤所致的疼痛；2例极度衰竭患者术中出现抽搐；3例患者因多次行介入治疗而合并真菌感染。B组中10例患者术中2例气道撕裂,其中1例纵膈气肿,1例大出血(>150m1),予止血对症处理；2例患者扩张无效,转入A组治疗。门诊随访12-18个月,A组中12例患者中10例气道无明显再狭窄；1例患者因左主支气管多次扩张无效,左肺并呈支气管扩张改变,反复感染,以予外科左肺切除；1例患者气管中段狭窄,多次扩张无明显增宽,以予切除及气管端端吻合术；4例患者行扩张术后须置入气管金属支架,其中3例患者1～2个月后其两端及腔内有较多肉芽组织形成,分别于术后3,6及8个月后局麻下用回收器将支架取出,气管管径稳定；第4例失去随访。B组中有2例患者气道管径不稳定,再狭窄,予外科切除；1例置入气管金属支架后肉芽组织形成以予取出,气管管径稳定。
结论：气管插管扩张术是治疗良性中心性气管狭窄的一种创伤小、安全、有效和价廉的方法。
Objective:To evaluate the efficacy and safety of the intubation dilatation under flexible bronchoscopic guidance in management of benign tracheal stenosis.
Methods:The clinical data about20patients with benign tracheal stenosis was analyzed,who were admitted to our department from October2007to August2011. There were9males and11females with a mean age of38±10years old (range:25～65). According to different interventional treatment,the patients were divided into two groups:group A with12patients were treated by intubation dilatation with different size under bronchoscopic guidance, and group B with10patients were treated by balloon dilatation. And metal stens were implantated when the severe airway stenosis or tracheomalocia would be occurred.Meanwhile, balloon dilatation were also performed for left or right main stem bronchial stenosis. Airway diameters, dyspnea index, blood gas analysis were evaluated in all patients and the forced expiratory volume in one second (FEV1) was tested in20cases before and after the treatment of intubation dilation, balloon dilation and others interventional therapy. Then postoperative20patients were all treated with budesonide atomization inhalation (3-6months), and amikacin were used if necessary, which can improve the bronchial inflammation.
Results:1、The interventional treatment of group A and B:One to two attempts of intubation dilation were required to achieve dilatation in group A.There was immediate postoperative relief of dyspnea for12patients.And PaO2and SaO2rose markedly, but PaCO2declined after intubation dilatation. The effective rate of intubation dilation was of100%. The average airway diameter was increased from (5.9±1.2) to (12.2±2.1) mm. FEV1was improved from (0.67±0.13) to (1.73±0.37) L (P＜0.01). After one to three trials by high-pressure balloon dilation in group B,6patients were treated successfully.Dyspnea index was decreased from (3.6±0.5) to (0.4±0.5).The average airway diameter was increased from (5.8±1.6) to (10.1±2.8) mm. FEV1was improved from (0.62±0.17) to (1.36±0.41) L (P＜0.01).The results of two groups were analyzed by t-test which indicated that there were no significant differences between them (P＞0.05).
2、The short and long term curative effects and complications of group A and B:In group A,the recent clinical total efficiency was of100%,but of60%in group B.And respectively,the long-term efficacy were of81.8%,66.7%(P<0.05).Group A with12patients were all fully successful:the clinical symptoms obviously improved,but they felt more or less painful on their noses.During the operation,the spasm happened to2extremely weak patients.And3cases were suffered from the fungal infection.They were all better by the corresponding symptomatic treatment. In group B,2cases were lacerated wound of bronchea:1case with mediastinal emphysema,another one bled excessively(＞150ml). Immediately the hemostatics were used.With12-18months follow-up: In group A,10patiens were no obvious airway restenosis,but one patient's left main bronchus dilation for many times were ineffectiveness,which demonstrated the focal area of dilated bronchi with bronchiectasis and recurrent infections,so pneumonectomy were treated.One other patient with the middle tracheal stenosis also dilated many times in vain, consequently trachea end to end anastomosis were treated.3of4cases who treated by metal stent after intubation formatted a great munber of granulation tissue around it in1-2months,then removed it by recoverer of stent, respectively, in3,6and8months under local anesthesia.One other lost follow-up,but no one was obvious narrow, collapse, softening. In group B,two patients airway pipe diameter were not stable, restenosis.One case was treated by metal stent after balloon dilatation, but a great munber of granulation tissue was formatted around the stent it, so stent was removed finally.
Conclusions:The management of benign tracheal stenosis with intubation dilatation is minimally invasive, safe, effective and low cost.
方法：研究分析广西医科大学第一附属医院2007年10月至2011年8月不同原因所致良性气管狭窄20例患者的临床资料,其中男9例,女11例,年龄25-65岁,平均(38±10)岁。根据采用不同扩张方法把患者分为2组：A组采用经纤支镜引导下气管插管扩张术治疗；B组采用高压气管球囊扩张术治疗。视情况需要,对于严重气道狭窄或不同程度气管软化患者临时置入气管金属支架治疗,或联合气管球囊扩张狭窄左或右主支气管。对2组患者均分别于术前和最后一次扩张术后的当天,对其狭窄段的气道直径、气促评分和第1秒用力呼吸量(FEV1)、血气分析进行测定,对其近期疗效及并发症的发生情况进行评价；门诊随访12-18个月,观察这两组扩张方法远期疗效及并发症情况。术后20例患者均以布地奈德雾化吸入(3-6个月),视情况加以阿米卡星雾化吸入以减轻黏膜充血水肿。
结果：1、A组与B组治疗情况的比较：A组中12例患者接受气管插管扩张术1-2次后,呼吸困难迅速缓解,酸中毒,C02潴留,气促指数明显改善,即刻疗效达到了100%；狭窄气管的直径由治疗前的(5.9±1.2)mm增加到(12.2±2.1)mm,FEV,由术前的(0.67±0.13)L,升高至(1.73±0.37)L,差异均有统计学意义(P＜0.01)。B组治疗有效的6例患者经高压气管球囊扩张1-3次后,气促指数由术前的(3.6±0.5)下降为(0.4±0.5),气道直径也由(5.8±1.6)mm升高为术后的(10.1±2.8)mm,FEV1亦由术前的(0.62±0.17)L增加到术后的(1.36±0.41)L,差异有统计学意义(尺0.01)。同时,对以上A、B两组结果数据进行两样本t检验分析,差异没有统计学意义(P＞0.05)。
2、A组与B组近远期疗效及并发症情况的比较：A组近期有效率为100%,远期有效率为81.8%,B组有效率为60%,远期有效率为66.7%。对其进行四格表卡方检验,差异有统计学意义(P＜0.05)。A组中12例患者术后均有不同程度口鼻粘膜损伤所致的疼痛；2例极度衰竭患者术中出现抽搐；3例患者因多次行介入治疗而合并真菌感染。B组中10例患者术中2例气道撕裂,其中1例纵膈气肿,1例大出血(>150m1),予止血对症处理；2例患者扩张无效,转入A组治疗。门诊随访12-18个月,A组中12例患者中10例气道无明显再狭窄；1例患者因左主支气管多次扩张无效,左肺并呈支气管扩张改变,反复感染,以予外科左肺切除；1例患者气管中段狭窄,多次扩张无明显增宽,以予切除及气管端端吻合术；4例患者行扩张术后须置入气管金属支架,其中3例患者1～2个月后其两端及腔内有较多肉芽组织形成,分别于术后3,6及8个月后局麻下用回收器将支架取出,气管管径稳定；第4例失去随访。B组中有2例患者气道管径不稳定,再狭窄,予外科切除；1例置入气管金属支架后肉芽组织形成以予取出,气管管径稳定。
结论：气管插管扩张术是治疗良性中心性气管狭窄的一种创伤小、安全、有效和价廉的方法。
Objective:To evaluate the efficacy and safety of the intubation dilatation under flexible bronchoscopic guidance in management of benign tracheal stenosis.
Methods:The clinical data about20patients with benign tracheal stenosis was analyzed,who were admitted to our department from October2007to August2011. There were9males and11females with a mean age of38±10years old (range:25～65). According to different interventional treatment,the patients were divided into two groups:group A with12patients were treated by intubation dilatation with different size under bronchoscopic guidance, and group B with10patients were treated by balloon dilatation. And metal stens were implantated when the severe airway stenosis or tracheomalocia would be occurred.Meanwhile, balloon dilatation were also performed for left or right main stem bronchial stenosis. Airway diameters, dyspnea index, blood gas analysis were evaluated in all patients and the forced expiratory volume in one second (FEV1) was tested in20cases before and after the treatment of intubation dilation, balloon dilation and others interventional therapy. Then postoperative20patients were all treated with budesonide atomization inhalation (3-6months), and amikacin were used if necessary, which can improve the bronchial inflammation.
Results:1、The interventional treatment of group A and B:One to two attempts of intubation dilation were required to achieve dilatation in group A.There was immediate postoperative relief of dyspnea for12patients.And PaO2and SaO2rose markedly, but PaCO2declined after intubation dilatation. The effective rate of intubation dilation was of100%. The average airway diameter was increased from (5.9±1.2) to (12.2±2.1) mm. FEV1was improved from (0.67±0.13) to (1.73±0.37) L (P＜0.01). After one to three trials by high-pressure balloon dilation in group B,6patients were treated successfully.Dyspnea index was decreased from (3.6±0.5) to (0.4±0.5).The average airway diameter was increased from (5.8±1.6) to (10.1±2.8) mm. FEV1was improved from (0.62±0.17) to (1.36±0.41) L (P＜0.01).The results of two groups were analyzed by t-test which indicated that there were no significant differences between them (P＞0.05).
2、The short and long term curative effects and complications of group A and B:In group A,the recent clinical total efficiency was of100%,but of60%in group B.And respectively,the long-term efficacy were of81.8%,66.7%(P<0.05).Group A with12patients were all fully successful:the clinical symptoms obviously improved,but they felt more or less painful on their noses.During the operation,the spasm happened to2extremely weak patients.And3cases were suffered from the fungal infection.They were all better by the corresponding symptomatic treatment. In group B,2cases were lacerated wound of bronchea:1case with mediastinal emphysema,another one bled excessively(＞150ml). Immediately the hemostatics were used.With12-18months follow-up: In group A,10patiens were no obvious airway restenosis,but one patient's left main bronchus dilation for many times were ineffectiveness,which demonstrated the focal area of dilated bronchi with bronchiectasis and recurrent infections,so pneumonectomy were treated.One other patient with the middle tracheal stenosis also dilated many times in vain, consequently trachea end to end anastomosis were treated.3of4cases who treated by metal stent after intubation formatted a great munber of granulation tissue around it in1-2months,then removed it by recoverer of stent, respectively, in3,6and8months under local anesthesia.One other lost follow-up,but no one was obvious narrow, collapse, softening. In group B,two patients airway pipe diameter were not stable, restenosis.One case was treated by metal stent after balloon dilatation, but a great munber of granulation tissue was formatted around the stent it, so stent was removed finally.
Conclusions:The management of benign tracheal stenosis with intubation dilatation is minimally invasive, safe, effective and low cost.
引文
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