支气管内超声的应用进展

支气管镜检查是呼吸系统疾病重要的检查手段,但由于气道表面以及管壁的限制,对于管壁内以及纵隔病变,医生只能通过观察支气管黏膜改变、管腔狭窄、管壁压迹等间接征象作出判断。近年来,随着超声技术的发展,使得微型超声探头可以经支气管镜的操作通道进入气道,使得腔内超声的应用     

支气管镜在中央型气道狭窄病变介入治疗中的应用

中央型气道狭窄病变是指引起气管、主支气管和右中间段支气管狭窄的病变.根据病变部位和性质,可分为功能性和结构性病变.功能性病变包括气管软化、复发性多发性软骨炎,结构性病变包括管内型、管壁型、管外型和混合型病变.根据病因,又可分为良性和恶性.     

支气管镜球囊扩张治疗良性气道狭窄12例临床观察

气道狭窄为支气管结核常见的并发症,临床上患者可出现活动受限、气促、呼吸困难,导致劳动力的丧失,亦可引起狭窄远端反复肺部感染.支气管腔内介入治疗气道狭窄是近年开展的一项新技术,使得许多以往需要手术治疗或者无法治疗的一些气道腔内病变,可以借助支气管镜下介入治疗而获得满意疗效.经支气管镜介导球囊扩张术治疗良性气道腔内疾病引起的气道狭窄可改善患者通气功能障碍.[第一段]     

良性气道狭窄的处理方法

良性气道狭窄种类繁多,当病变累及范围过大或患者心肺功能差时,不能通过外科手术方式解除梗阻.内镜技术的进展为气道阻塞性疾病患者提供了大量的姑息性甚至治愈的方法,包括球囊扩张、电灼烧、激光消融、氩等离子体凝固技术、冷冻、腔内放疗、光动力治疗、支架植入等.但是没有随机试验比较不同治疗方法的效果,本文主要介绍几种良性气道狭窄性疾病及其处理方法.     

多发性大动脉炎颈动脉病变的超声诊断价值

目的评估彩色多普勒超声对多发性大动脉炎(Takayasu's arteritis,TA)颈动脉病变的诊断价值。方法回顾性分析30例多发性大动脉炎颈动脉病变患者的超声表现,按照疾病活动状态分为活动期组及非活动期组各15例,比较两组颈总动脉管壁厚度、管腔内径;再按照管腔狭窄程度分为三组,比较各组间管腔内径大小及血流动力学。结果 (1)TA颈总动脉病变多为双侧、弥漫性(46/53),增厚的管壁具有特征性超声表现。(2)活动期组管壁厚度大于非活动期组(P0.05),管腔内径两组无统计学差异(P0.05)。(3)颈总动脉血流速度随狭窄程度增高而增高(P0.05)。结论 TA颈动脉病变具有特征性超声表现,管壁厚度可用于评估疾病活动性,可作为TA颈动脉受累的首选筛查方法及随访手段。     

高分辨CT扫描对气管、支气管结核的诊断价值及临床意义

目的　探讨HRCT对气管、支气管结核的诊断价值及临床意义。方法 对32例诊断明确的气管、支气管结核住院患者行胸部HRCT扫描,结合纤维支气管镜检查,观察病变气道内壁及管腔的形态变化以及其病变远侧肺实质的病变情况。结果 气管、支气管壁病变检出率为73.9%,其中管壁轻度增厚54.3%,明显增厚19.6%;气道管腔形态改变检出率为67.4%,其中管腔狭窄<50%的41.3%,>50%的19.6%,管腔闭塞6.5%。同时观察到气管、支气管周围及纵隔淋巴结肿大7例,病变支气管远侧管腔内粘液栓12例,管腔局限性扩张5例,小叶性肺气肿18例,肺不张2例,肺内结核病灶39例。结论 HRCT检查观察气道病变部位和范围、气道病变与肺内病变的关系、危重患者纤维支气管镜检查前的定位准备及估计预后均有重要的临床意义。     

支气管镜球囊扩张治疗良性气道狭窄12例临床观察

气道狭窄为支气管结核常见的并发症,临床上患者可出现活动受限、气促、呼吸困难,导致劳动力的丧失,亦可引起狭窄远端反复肺部感染。支气管腔内介入治疗气道狭窄是近年开展的一项新技术,使得许多以往需要手术治疗或者无法治疗的一些气道腔内病变,可以借助支气管镜下介入治疗而获得满意疗效^[1]。经支气管镜介导球囊扩张术治疗良性气道腔内疾病引起的气道狭窄可改善患者通气功能障碍。     

高分辨CT扫描对气管、支气管结核的诊断价值及临床意义

目的：探讨HRCT对气管、支气管结核的诊断价值及临床意义。方法：对32例诊断明确的气管、支气管结核住院患者行胸部HRCT扫描，结合纤维支气管镜检查，观察病变气道内壁及管腔的形态变化以及其病变远侧肺实质的病变情况。结果：气管、支气管壁病变检出率为73．9％，其中管壁轻度增厚54．3％，明显增厚19．6％；气道管腔形态改变检出率为67．4％，其中管腔狭窄＜50％的41．3％，＞50％的19．6％，管腔闭塞6．5％，同时观察到气管、支气管周围及纵隔淋巴结肿大7例，病变支气管远侧管腔内粘液栓12例，管腔局限性扩张5例，小叶性肺气肿18例，肺不张2例，肺内结核病灶39例，结论：HRCT检查观察气道病变部位和范围，气道病变与肺内病变的关系，危重患者纤维支气管镜检查前的定位准备及估计预后均有重要的临床意义。     

高分辨率磁共振成像对缺血性卒中病因诊断价值的研究进展

正对于缺血性卒中,临床上主要采用CT血管成像(CTA)、MR血管成像(MRA)、DSA等方法评估管腔狭窄程度,并识别责任血管。该类技术均基于管腔成像,而对于引起管腔改变的管壁病变的病因诊断却存在不足~([1]),以上在管腔成像检查中可仅表现为轻-中度狭窄,甚至并无明显形态异常的血管却可引     

经纤维支气管镜行气道内超声检查的临床应用

目的　初步探讨气道内超声检查的临床应用价值。方法　对 15例X线胸片或CT发现肺部占位性病变或怀疑阻塞性肺炎、肺不张患者采用微探头通过纤支镜的工作通道做气道内超声检查。在气道轴的垂直平面得到一个 3 60°环形超声图象。结果　支气管壁回声增强并分层。肺实质呈致密斑点状强回声。血管影为搏动性的无回声影 ,内见漂浮点状回声。 10例患者超声扫描显示肿瘤破坏管壁 ,病理诊断均为恶性肿瘤 ;1例右肺尖段结节患者超声扫描见管壁完整 ,手术证实为结核。 1例右侧胸积液并肺不张患者纤支镜下见右下叶支气管通畅 ,用超声微探头探查远端支气管未见异常回声 ,提示肺不张为胸水压迫所致 ,排除阻塞性因素。 3例疑阻塞性肺炎患者 ,1例超声扫描见腔外肿大淋巴结压迫致管腔轻度狭窄 ,但管壁完整 ,余 2例未见肿瘤样回声 ,管壁完整 ,排除阻塞性因素。气道内超声检查仅少数患者有轻度不适 ,无明显并发症。结论　气道内超声能清晰显示气道壁和腔外的结构 ,是一项安全有效的纤支镜检查辅助手段     

氩等离子体凝固切除中心气道内阻塞性病变的疗效

目的了解氩等离子体凝固切除中心气道内阻塞性病变的疗效。方法2003年11月至2006年12月收治的53例伴有中心气道阻塞性病变患者，男37例，女16例，平均年龄55（14～82）岁，其中恶性肿瘤28例，良性肿瘤13例，其他疾病12例。使用局部麻醉或全身麻醉，支气管镜下应用德国ERBE公司氩等离子体凝固300型机切除病变。根据病变切除程度、狭窄再通和临床资料判断疗效。结果53例患者的病变分布于86处，有效切除病变的成功率分别为：气管内病变97％（35／36），主支气管79％（22／28），叶支气管和中间段支气管64％（14／22）；良性病变的成功率（92％，34／37）高于恶性病变（76％，37／49）。中心气道严重阻塞致呼吸衰竭的患者18例，全身麻醉下经氩等离子体凝固治疗即刻缓解。结论氩等离子体凝固适用于切除中心大气道的腔内增生性病变；治疗后即刻起效，可以用于抢救急诊重症病例。重症患者应该给予全身麻醉和机械通气，以提高介入治疗的成功率和安全性。     

滤网保护装置在颈动脉和椎动脉狭窄支架置入术中的应用

目的 探讨滤网保护装置在血管内支架治疗颈动脉和椎动脉狭窄中的应用。方法 配合应用滤网保护装置，对颈动脉和椎动脉狭窄患者进行经皮血管内支架成形术36例次(其中颈动脉33例次，椎动脉起始部3例次)，对手术过程、治疗效果和病理学检查结果进行分析。结果全部病例成功应用滤网保护装置进行了支架置入术，手术相关并发症的发生率为O。血管狭窄率由支架前的81．4％下降至支架后的14．1％；病理学检查显示，27例患者保护装置的滤网内有斑块成分，占75％；保护装置捕捉到的有形成分包括纤维蛋白、斑块碎片(坏死组织、胆同醇碎片、钙化成分等)。结论 滤网保护装置可以捕捉到颈动脉和椎动脉狭窄支架成形术中碎解的斑块成分，降低术中栓塞性并发症的发生概率；目前临床治疗中应用的滤网保护装置可以选择性地应用于椎动脉起始部狭窄的支架成形术中；滤网保护装置应进一步向微型化发展，以适应更多部位的血管内支架成形术。     

气道恶性肿瘤患者光动力治疗24例临床分析

目的回顾性分析经电子支气管镜腔内激光光动力疗法(photodynamic therapy, PDT)治疗的气道恶性肿瘤患者临床资料,探讨PDT治疗的规律性。 方法选择2019年2月至2021年3月由我院呼吸与危重症医学科进行PDT治疗的气道恶性肿瘤患者24例,分别对一般临床资料、PDT治疗情况和治疗后随访,以及治疗后存活患者和死亡患者的特征进行分析。 结果截止2021年8月7日,PDT治疗后获益最大的患者随访时长达13.2个月,远远大于PDT治疗后获益较小患者的随访时长总生存期(overall survival, OS)4.7个月(P＝0.02)。前者以管腔壁型为主(80%),而后者以管腔内型为主(50%)(P＝0.034)。前者腔内病变短于后者(中位数分别是3 cm和5 cm,P＝0.03)。前者年轻、病程短、以腺样囊性癌为主,而后者年龄大、病程长、以鳞癌为主(P>0.05)。 结论管腔壁型、气道腔内病变短,以及年轻、病程短和肺腺样囊性癌的气道恶性肿瘤患者可能在PDT治疗中获益较多;相反,管腔内型、气道腔内病变长,以及年老、病程长和非肺腺样囊性癌的气道恶性肿瘤患者可能在PDT治疗中获益较少。     

New technologies in interventional cardiology

This review confines itself to the new technologies that are widely used and that are being tested in formal trials. To date there have been few well-performed trials to compare the technologies, a fact that may have opened the way for the inappropriate use of some of these new technologies. This has allowed enthusiasts to perform procedures with as yet unproven tools no better and possibly worse than balloon angioplasty. New technologies can be broadly divided into three categories depending on their intended role: 1) mechanical removal, such as directional atherectomy, extractional atherectomy, and rotational atherectomy, that is designed to debulk lesions and remove atheromatous material, 2) high-energy removal by laser technologies designed to disobliterate lesions without producing the theoretically damaging lateral stretching of normal balloon angioplasty, 3) intraluminal scaffolding through the use of stents designed to give intravascular support, eg, balloon expandable, self-expanding, and temporary removable devices.     

Interventional Therapy of Supravalvular Pulmonary Stenosis via a Mechanical Valve in the Pulmonary Position

There is an increasing number of patients with congenital heart disease and pathology of the right ventricular outflow tract in whom a mechanical pulmonary valve replacement is chosen for permanent palliation. Despite corrective surgery, some of these patients may have residual or secondary supravalvular pulmonary stenosis or peripheral pulmonary stenosis, which necessitate interventional therapy after valve replacement. There is a general understanding that interventional therapy via a mechanical valve in pulmonary position may induce mechanical valve dysfunction and should therefore be avoided. We report our experience in three patients with a St. Jude Medical mechanical valve in pulmonary position and supravalvular pulmonary stenosis or a peripheral pulmonary stenosis where we have safely performed standard interventions (i.e., balloon angioplasty and stent implantation) across the mechanical valve without any complications. Our specific technique using a long sheath as safety guard, which holds the mechanical valve open during the procedure but allows the positioning of all mechanical devices and catheters necessary for the procedures, is described. In all patients, the long‐term follow‐up of the valve function is excellent.     

Mechanical properties of the upper airway

Abnormalities of upper airway mechanical properties are a well-recognized and important feature of the pathophysiology of the obstructive sleep apnea hypopnea syndrome (OSAHS). Recently, investigations enhanced our understanding of the factors that promote upper airway obstruction. In patients with OSAHS, anatomic narrowing of the pharyngeal airway, particularly in the lateral dimension with thickening of the lateral pharyngeal walls, is present. In addition, the passive upper airway (absent muscle activity) demonstrates increased collapsibility, which is modulated by caudal tracheal traction, mucosal surface forces, route of breathing, and the balance of intraluminal airway and extraluminal tissue pressures. In patients with OSAHS, pharyngeal dilator muscles (including the genioglossus and soft palate muscles) demonstrate a coordinated pattern of increased muscle activity while awake compared with normals. This is thought to represent a neuromuscular compensatory mechanism for the anatomically narrow, more collapsible upper airway. With the onset of sleep, the reflexes that drive this muscular compensation are diminished, leading to reduced muscle activity and predisposing the OSAHS patient to pharyngeal collapse. Better understanding of the mechanical properties of the upper airway in normals and patients with OSAHS should help in the development of new therapeutic strategies.     

重度气道狭窄置放国产镍钛记忆合金支架的方法学研究

目的 对重度气道狭窄患者置放国产镍钛记忆合金支架的方法学进行初步评价.方法 应用全身麻醉下分别采用经喉罩、气管插管或硬质气管镜的方法对2005年11月至2009年4月收入北京大坛医院呼吸科的40例难以在局部麻醉下操作的重症气道狭窄患者置入国产镍钛记忆合金气道支架.结果 40例患者根据病变部位及病变特点选择经喉罩23例,气管插管11例,硬质气管镜6例,并予全身麻醉及机械通气,共放置了42枚支架:气管支架27枚(其中覆膜支架9枚)、左主支气管支架8枚、右主支气管至右中间段支架2枚、气管至左主支气管楔形支架5枚.在全身麻醉、机械通气维持患者各项生命体征的条件下,所有病例都顺利置入,未出现并发症.支架释放后所有病例气道压力即降至正常,同时其他机械通气参数也恢复正常.大部分患者呼吸困难指数分级由Ⅳ～V级改善到0～Ⅱ级.结论 对于重度气道狭窄患者,在全身麻醉下经喉罩、气管插管及硬质气管镜的方法可以顺利放置局部麻醉下难以操作的各种高难度气道支架的置放,并且安全、有效、舒适,值得在临床进一步推广.     

Bronchial artery embolization before interventional bronchoscopy to avoid uncontrollable bleeding: a case report of endobronchial metastasis of renal cell carcinoma

Extreme caution should be taken to avoid uncontrollable bleeding in treating hypervascular tumors via bronchoscope. We report two cases of endobronchial metastasis of renal cell carcinoma treated with bronchial artery embolization (BAE) before endoscopic treatments. The intraluminal lesions were removed swiftly and safely. Although arterial embolization is not always efficacious in cases of tracheal lesions, BAE is effective for tumors located in the carina, bilateral main bronchus or intermediate bronchus. The addition of BAE before endoscopic tumor removal should be considered a treatment option in patients suffering from airway obstructions due to hypervascular tumors such as renal cell carcinoma.     

Manual vs. mechanical ventilation in patients with advanced airway during CPR

Early chest compressions and rapid defibrillation are important components of cardiopulmonary resuscitation (CPR). American heart association (AHA) recommends two breaths to be delivered for every 30 compressions for an adult cardiac arrest victim. Patient with an advanced airway like endotracheal tube (ETT) should be given one breath every 6 s without interruptions in chest compression (10 breaths per minute). All of the modern mechanical ventilators have option to generate spontaneous breaths by the patient if the patient has spontaneous respiratory efforts. During CPR, the mechanical ventilator is fallaciously sensing the chest compressions as patient's spontaneous trigger and thereby it delivers higher respiratory rates. Avoiding excessive ventilation is one of the components of high quality CPR as excessive ventilation decreases venous return thereby decreasing the cardiac output and also it affects intra-thoracic pressure thereby adversely affects intra-arterial pressure. As modern ventilators have trigger for spontaneous breaths and they will be erroneously triggered by chest compressions, it would be prudent to use volume marked resuscitation bags or manual breathing devices (manual self-inflating resuscitation bag, Bain's circuit) for delivering breaths which can be synchronised with compression phase of CPR at RR of 10 breaths per min with advanced airway in place. If any patient who is on mechanical ventilation develops cardiac arrest, patient should be disconnected from the mechanical ventilator and should be ventilated manually. Manual ventilation with aforementioned breathing devices should be used in a patient without and with advanced airway devices during CPR.     

The management of life-threatening airflow obstruction

Summary Patients with status asthmaticus commonly develop progressive airflow obstruction over hours to days as a result of airway wall inflammation, bronchospasm and intraluminal mucus. In sudden asphyxic asthma, airflow obstruction results primarily from smooth muscle mediated bronchospasm. Airflow obstruction causes ventilation-perfusion inequality, lung hyperinflation, and increased work of breathing. Severe cases are characterized by an inability to speak, diaphoresis, altered mental status, poor air movement, widened pulsus paradoxus, accessory muscle use, and low peak expiratory flow rate. Lack of early response to bronchodilator therapy, a rising partial pressure of carbon dioxide, and need for assisted ventilation are additional markers of severe disease. First line treatment consists of oxygen, beta agonists, and corticosteroids. In mechanically ventilated patients, bronchodilators must be given in higher dosages to achieve a physiologic effect. Agents of debated efficacy include theophylline, anticholinergics, and magnesium sulfate. Heliox and noninvasive positive pressure ventilation are promising adjuncts to the treatment of nonintubated patients. In patients requiring intubation and mechanical ventilation, a ventilatory strategy should be used that avoids excessive lung hyperinflation by prolonging expiratory time. In many cases, this strategy requires acceptance of hypercapnea and high peak airway pressures. Patients should be aggressively sedated to decrease the need for muscle paralysis and the risk of post paralytic myopathy. Indirect evidence suggests that the current approach to mechanical ventilation in acute severe asthma decreases morbidity and mortality; however, the key to the management of this disease (which in many cases represents a failure of outpatient management) is patient education and disease prevention. Received: 25 October 1996 Accepted: 13 November 1996