国产支架支气管肺减容术在绵羊肺气肿模型中的初步应用

目的评价经气道国产单向活瓣支架肺减容术治疗肺气肿动物模型的放送技术和稳定性。方法应用局部气管内滴注木瓜蛋白酶方法复制6个月龄绵羊不均一肺气肿模型,经纤维支气管镜通过导丝和放送装置在肺气肿亚段放入1、2个单向活瓣支架,术后8周处死动物取出完整肺组织,在萎陷区、非萎陷区和对侧正常肺组织分别取材,观察大体及光镜下病理学改变。结果7只绵羊气肿模型,共放置支架10支,9支均成功植入。病理观察1只出现肺部炎症细胞浸润,2只植入支架处支气管壁有少量纤维母细胞、平滑肌细胞及支气管粘膜上皮细胞增生,4只未见明显异常。CT检查支架远端、肺组织大体标本和光镜下均证实存在肺不张。结论经纤维支气管镜植入单向活瓣支架行肺减容术治疗肺气肿创伤小,支架对气管壁的刺激小,可以达到外科肺减容术的效果。     

纤维支气管镜肺减容术在绵羊肺气肿模型中的应用

目的 评价使用纤维支气管镜单向活瓣支架肺减容术治疗肺气肿动物模型的疗效和安全性。方法 6月龄绵羊6只，全麻下经纤维支气管镜在肺段局部给予木瓜蛋白酶（75U／kg）后，机械通气15～20min形成肺气肿模型。通过CT确定靶区后，在X线造影定位并确定靶支气管后，经纤维支气管镜通过导丝和放送装置在肺气肿亚段放入1～2个单向活瓣支架，术后给予3d抗炎治疗。在术前和术后8周测量肺功能残气量；术后8周处死动物取出完整肺组织，在萎陷区、非萎陷区和对侧正常肺组织分别取材，观察大体及光镜下病理学改变。结果 应用纤维支气管镜肺减容术后，动物耐受性较好，术后无明显咳嗽、呼吸困难症状，术后1h动物即可进食、行走。病理观察无肺部炎症、肺脓肿和肉芽肿形成，2只动物支架处支气管壁少量纤维母细胞和平滑肌及支气管黏膜上皮细胞增生，4只动物未见明显异常。支架远端肺组织大体标本和光镜下均证实存在肺不张，术后肺功能残气量较术前明显降低（降低49．5％），手术过程安全、操作简单易行。结论 经纤维支气管镜单向活瓣支架肺减容术治疗肺气肿创伤小，支架对于气管壁的刺激小，可以达到外科肺减容术的效果；所做的动物模型为不均一肺气肿，与人类发病类型很相似，故对进一步行临床研究有一定的参考价值；因术后观察时间仅为8周，支架远期对气道的损伤及其疗效需要进一步研究。     

经纤维支气管镜介入肺减容术治疗重度COPD(附1例报道)

纤维支气管镜肺减容术（bronchoscopic lung volume reduction，BLVR）是使用纤维支气管镜在支气管内放置活瓣支架以形成医源性肺不张，从而达到内科肺减容的目的。其方法简单、微创，近年来发展迅速。目前，国外报道处于多中心试验阶段。我们应用纤维支气管镜介入肺减容术，在动物实验中治疗肺气肿的安全性和有效性的基础上，获得医学伦理委员会批准后应用国产单向活瓣支架于2006—05进行了1例临床试验，现报道如下。     

一例介入肺减容术治疗的护理

慢性阻塞性气肿(COPD)是一种常见的慢性肺部疾病,病程迁延,反复性发作。临床中多以保守治疗或外科手术治疗为主。我院于2006年5月首次应用经纤维支气管镜单向活瓣支架介入肺减容术(BILVR)治疗肺气肿,取得成功,现将手术配合体会报告如下。     

高龄慢性阻塞性肺病患者经气管镜肺减容术的疗效与安全性探讨

目的报告1例高龄慢性阻塞性肺病(COPD)患者成功经气管镜活瓣置入施行肺减容术治疗肺气肿,并就该技术的适应证和安全性进行探讨。方法对1例80岁患者按COPD诊疗指南进行病情评估,予以高分辨CT、肺功能和6 min步行试验检查,确定其病情分级为D级,肺功能重度损害,有不均质肺气肿,符合肺减容手术适应证。予常规气管镜检查准备后,经鼻腔插入气管镜,使用Chartis导管插入侧枝通气各肺叶段检测后,选择左下叶内前基底段予以支气管单向活瓣置入。结果患者良好耐受手术。单向活瓣置入位于左下叶内前基底段开口处,活瓣固定良好,随患者呼吸运动开闭正常。术后患者胸闷症状有所减轻,6 min步行距离增加。手术一周后胸片检查,活瓣无移位,活瓣远端肺透亮度较前降低。结论高龄重度肺功能损坏慢性阻塞性肺病患者可使用单向活瓣置入术经气管镜肺减容术治疗,该技术需要更多病例应用并长期观察以进一步确定其有效性和安全性。     

支气管镜肺减容术在极重度慢性阻塞性肺疾病中的应用

目的总结采用Zephyr单向活瓣进行支气管镜肺减容术治疗的极重度慢性阻塞性肺疾病(COPD)患者的临床资料,提高临床医师对该技术的理解和认识。方法患者男性,52岁,肺减容术前FEV1占预计值19.3%,诊断为慢性阻塞性肺疾病(极重度)。胸部CT显示双侧非均质性肺气肿。采用ChartisR系统测定肺旁路通气,结合同位素肺通气/灌注测定结果选择肺减容的靶肺叶。采用可弯曲支气管镜行单向活瓣肺减容术。结果于右上叶B1、B2、B3段支气管置入Zephyr活瓣共3枚。术后1和8个月复查肺功能显示FEV1、FVC、DLco增加,RV下降,6 min步行试验由术前的210 m增加到术后8个月的400 m。复查胸部CT示右肺上叶局限性肺膨胀不全,右上叶肺容积缩小。术后无不良事件发生。结论采用Zephyr单向活瓣的支气管肺减容术是治疗经过严格筛选的极重度COPD的一项安全有效的方法。     

支气管镜介入冷冻治疗支气管结核临床探究

支气管结核（bronchial tuberculosis,BTB）又称支气管内膜结核,是肺结核中的常见类型,是指发生在气管、支气管黏膜、黏膜下层和外膜（软骨和纤维组织）的结核病。由于病变部位隐匿,早期诊断困难,而病情迁延发展,会导致组织增生,瘢痕挛缩,支气管狭窄或阻塞,产生肺不张,毁损肺等严重后果。     

镜下射频置管肺减容术在肺气肿绵羊的应用

目的探讨经纤支镜射频置管建立气道旁路肺减容术治疗绵羊肺气肿模型的有效性及优越性。方法将16只6个月龄雌性绵羊随机分为A、B两组,木瓜蛋白酶方法建立肺气肿模型。A组经纤支镜射频建立气道旁路并放置支架,给予内科治疗,B组仅给予常规内科治疗。分别测两组绵羊术前和术后24 h、4周、8周的第1秒用力呼气容积(B超仅衔常规内科治疗,FEV1.0),且进行比较,A组定期行胸部CT检查,两组动物治疗8周均予以处死,行病理学检查。结果①成功复制绵羊肺气肿动物模型16只,A组术中、术后无明显异常;②A组胸部CT示术后4周及8周,在治疗区均出现肺容积缩小,出现肺不张表现;③两组不同时间点FEV1.0水平差异有显著性(F时间=1 352.409,P<0.001),两种治疗手段效果差异有显著性(F组间=5 004.278,P<0.001),治疗手段和时间之间有交互作用(F交互=1 325.058,P<0.001);④病理示A组治疗区见肺泡萎陷区,非治疗区域见肺气肿,肺泡萎陷区见粒细胞和淋巴细胞浸润;B组见肺气肿的肺泡组织。结论该技术治疗绵羊肺气肿模型具有有效性及优越性。     

右肺上叶前段内亚段实变的X线鉴别诊断

目的：准确鉴别两种性质不同的病变(炎症、肿瘤)防止误诊。材料与方法：收集右肺上叶前段内亚段(简称右肺S3b见下注)肺炎9例，右肺S3b肺癌6例，共右肺S3b实变15例，均摄正位及右侧位片和胸部CT扫描，根据其X线征象，结合解剖学特点，病理学基础等方面进行探讨。结果：两种性质不同的病变(炎症、肿瘤及肿瘤引起的阻塞肺炎)虽均侵犯右肺S3b在正位胸片上投影于右肺门上极平面呈现约核桃大致密团块影，但单纯细菌肺炎。1、支气管无活瓣较少合并肺不张并于肺炎实变区段可见“支气管气相”征。2、阻塞肺炎，由于活瓣作用常于支配区远端组成单发的或多发的泡性肺气肿，因此，肺炎、肺膨胀不全，泡性肺气肿(支气管活瓣三联征)同时存在并非少见，单纯细菌肺炎极少有此表现。3、胸部CT片证实，阻塞肺炎近端，支气管不全梗阻，单纯细菌肺炎，支管壁光整、畅通无阻。结论：X线、CT表现均具有诊断价值。     

怎样读片 第5讲 呼吸系统异常影像及临床意义

1　肺部1 1　透光度增强 　即肺的含气量增多。由于支气管部分性阻塞形成活瓣样作用 ,使空气吸入容易而呼出困难 ,久而久之导致肺泡过度充气膨胀而形成阻塞性肺气肿 ;或由于长期慢性咳嗽 ,导致末梢细支气管远端的肺组织过度膨胀或肺泡壁破裂而体积大于正常 ,形成泡性肺气肿。常见于支气管内炎症、结核、肿瘤、异物或痉挛等。Ｘ线表现为肺透光度增强 ,肺体积增大 ,肋间隙增宽 ,膈肌下降等。1 2　透光度减低 　肺内密度增高时 ,其透光度减低。这是因为肺泡内的空气被炎性渗出物、血液或肉芽组织所代替的结果。Ｘ线表现为片状阴影 ,边缘模糊 …     

Effect of removal of bullae on airway conductance and conductance volume ratios

Airway conductance is known to increase with an increase in the lung volume at which it is measured, owing to a change in transpulmonary pressure and lung tissue tension. We investigated the effect of surgical resection of lung tissue on functional residual capacity and airway conductance in patients with localized lung disease (i.e., carcinoma or tuberculosis) and in patients with lung cysts or bullous emphysema. In four out of five of the patients who had resection of one or more lobes of the lung to remove localized disease there was a reduction both in the airway conductance and in the functional residual capacity with relatively little change in the conductance volume ratio.By contrast, in all patients who underwent bullectomy, there was a decrease in functional residual capacity but an increase in airway conductance, and an increase in the conductance/volume ratio. This change was sustained in patients who had had localized cysts removed. However, the measurements gradually reverted toward preoperative values in those patients who had generalized emphysema.The increase in airway conductance after resection of blebs and bullae presumably was due to improved lung elastic pressure causing the airways to increase in diameter and conductance. In addition, some patients may have experienced relief of compression of neighboring airways.     

Surgical lung volume reduction--an option for treating severe pulmonary emphysema

Lung volume reduction surgery is a novel operative concept, which may be applied in certain patients, who are severely handicapped by advanced pulmonary emphysema and suffer from dyspnea at minimal exercise despite optimal medical therapy. The most destroyed lung parts are resected by video-assisted thoracoscopy. This type of surgery has a surprisingly low morbidity and mortality at specialized centers. It improves symptoms by ameliorating lung function and exercise tolerance. Maximal functional improvement is observed and lung function starts to decline slowly within one to two years thereafter.     

手指扩张法在后腹腔镜手术中的应用

目的探讨手指扩张法在泌尿外科后腹腔镜手术中的应用。方法对2005年至今开展的共58例后腹腔镜泌尿外科手术分2组进行分析,第1组(A组)26例患者采用自制气(水)囊扩张法建立后腹膜腔,第2组(B组)32例患者采用手指扩张法建立后腹膜腔。结果A组中11例自制气囊破裂,1例中转开放手术,其余14例及B组手术均获成功。A组建立后腹膜腔时间为9～16min,B组为3～5min,差异有显著性;2组手术时间及出血量差异无显著性。结论手指扩张法建立后腹膜腔方便可行,可作为泌尿外科后腹腔镜手术的一种方法。     

不同胸腔灌洗液对肺癌脱落细胞的影响及意义

[目的]研究术中不同胸腔灌洗液对肺癌脱落细胞的影响及意义.[方法]选择无恶性胸腔积液和胸膜未受侵犯的80例肺癌患者,随机分为四组,开胸后用温热生理盐水灌洗胸腔及术毕胸膜腔分别用生理盐水、蒸馏水、顺铂 蒸馏水、顺铂 蒸馏水冲洗,通过透视电子显微镜观察胸腔灌洗液中肺癌脱落细胞的差异,术后患者随访.[结果]顺铂 蒸馏水组灌洗液中完整脱落癌细胞较其他组少,而细胞碎片、凋亡细胞较其他组多不同的胸腔灌洗对胸腔引流量、拔管时间、住院时间没有明显影响,顺铂和(或加)蒸馏水组一年局部复率较对照组明显偏低.[结论]顺铂或(和)蒸馏水对肺癌根治术后胸腔进行灌洗,可减少肺癌脱落细胞在胸腔再种植,提高手术效果.     

Surgical and bronchoscopic treatment for COPD

Lung volume reduction surgery (LVRS) has been proved as the safe, effective, and durable treatment which improves life-span, exercise tolerance, QOL, and dyspnea in patients with severe COPD selected appropriately by distribution of emphysema (upper lobe vs non-upper lobe) and exercise capacity(low vs high) through the National Emphysema Treatment Trial (NETT) as well as previous or concurrent reports of clinical studies. However, this procedure has not always been offered to those patients who might benefit from it these years because of significant morbidity and mortality during perioperative period and in part because of misleading in early results of the trial. On the other hand, nonsurgical procedures, such as endobronchial valve to intend collapse of the emphysematous lung, extra-anatomical airway bypass to eliminate excessive residual lung volume, and remodeling of emphysematous lung with biological adhesives or vapor ablation have been proposed as alternative treatments for emphysema recently. However, efficacy and duration of these bronchoscopic lung volume reduction procedures are less than those of LVRS, and issues to be clarified remain. LVRS should be re-considered as a promising and practical tool for patients with emphysema confronting severe dyspnea during daily activities.     

16层螺旋CT肺容积与肺密度指标与肺通气功能的相关性研究

目的通过分析16层螺旋CT（MSCT）肺容积和肺密度指标与肺通气功能指标的相关性,探讨MSCT与肺功能试验（PFT）指标的关系。方法选取64例受试者行胸部MSCT及PFT检查。MSCT观察不同呼吸时相下肺密度指标：深吸气末平均肺密度（MLDin）、深呼气末平均肺密度（MLDex）和肺密度差（MLDex-MLDin）,PFT观察肺功能指标包括肺总量（TLC）、残气量（RV）、残气量与肺总量比（RV/TLC）、用力肺活量（FVC）、第1秒用力呼气容积（FEV1）和第1秒用力呼气容积与用力肺活量比（FEV1/FVC）。结果 64名受试者依据CT肺气肿诊断标准,可分为MSCT肺气肿组40例和MSCT正常组24例,依据PFT肺气肿诊断标准,可分为PFT肺气肿组38例和PFT正常组26例。MSCT肺容积指标与肺功能指标均呈不同程度的正相关（P〈0.05）,绝对指标Vin、Vex与PFT静态肺容积指标TLC、RV的相关性高于肺通气功能指标FVC、FEV1。MSCT肺密度指标与PFT静态肺容积指标呈负相关（P〈0.05）,与肺通气功能指标呈正相关（P〈0.05）。结论 MSCT肺容积和肺密度指标与PFT肺通气功能指标有较好的相关性。MSCT检测能较好地判断患者肺功能状况,具有较好的临床应用的价值。     

降钙素原指导下的抗生素应用与标准抗生素应用对于胸外科术后肺部感染预后的比较

[目的]比较降钙素原指导下的抗生素应用与标准抗生素应用对于胸外科术后肺部感染预后的影响.[方法]观察与分析了60例使用了同类抗生素胸外科术后并发肺部感染的患者在降钙素原指导下的抗生素应用与标准抗生素应用对感染治疗的结果.其中28例患者在使用抗生素后每日抽血化验降钙素原水平,在降钙素原恢复正常（小于0.5 ng/mL）后停用抗生素.其余32例患者使用抗生素后依据传统标准停用抗生素.比较两组患者的肺部感染的治疗结果及预后情况及抗生素使用天数.[结果]降钙素原指导组与传统标准组对于肺部感染治疗效果比较不存在统计学意义（P＞0.05）,且降钙素原指导组抗生素使用天数短于传统标准组并存在统计学意义（P〈0.05）.[结论]对于胸外科术后肺部感染在降钙素原指导下的抗生素应用要优于标准抗生素应用.     

The presence of emphysema further impairs physiologic function in patients with idiopathic pulmonary fibrosis

BACKGROUND: Emphysema, especially in the upper lobes, is frequently observed in association with idiopathic pulmonary fibrosis (IPF). However, the combination of emphysema plus IPF has received little attention. OBJECTIVE: To investigate the additional functional impairment from emphysema in IPF patients. METHODS: Twenty-one patients (mean age 66 y, 20 men) (Group I) who had both IPF (mean 35% of total lung volume) and emphysema (mean 14% of total lung volume) were compared to a group of 21 subjects who had IPF but no emphysema (Group II). The groups were matched for (among other criteria) the total extent of disease. Pulmonary function tests, Medical Research Council dyspnea score, 6-min walk test, and radiographic extents of both IPF and emphysema were obtained for each patient. The Composite Physiologic Index was calculated. In the total population (n = 42), the independent contributions of IPF and emphysema to several physiologic variables were investigated by using stepwise multiple regression analysis. RESULTS: Despite the limited extent of emphysema, Groups I and II had similar physiologic impairment. Only residual volume and total lung capacity were significantly higher in Group I. According to stepwise multiple regression analysis, the extent of IPF and either the presence or the extent of emphysema in the total population were independent and significant predictors of dyspnea score, 6-min walk test, P(aO2), forced expiratory volume in the first second (FEV(1)), forced vital capacity (FVC), FEV1/FVC, the diffusing capacity of the lung for carbon monoxide, carbon monoxide diffusing capacity adjusted for alveolar volume (gas-transfer coefficient), and residual volume. The Composite Physiologic Index was closely related to the extent of IPF (r = 0.65, p < 0.0001) and to the dyspnea score (rho = 0.59, p < 0.0001). CONCLUSIONS: In former smokers with IPF, the presence and the extent of emphysema have a profound influence on physiologic function in terms of both further impairment and confounding effects.