纤维支气管镜下冷冻治疗气道阻塞性疾病的护理

晚期支气管肺癌、结核性肉芽肿、气管内支架放置后肿瘤物的再生成以及气管腔内放疗后肿瘤的坏死物所导致的气道阻塞 ,常规治疗均不能直接解决气道阻塞症状 ,手术治疗创伤大且不能反复进行。我科近年采用纤维支气管镜 (纤支镜 )下冷冻治疗 12例气道阻塞性疾病近期疗效较好。现将术前、术中及术后护理配合报告如下。材料与方法1.一般资料本组男性 8例 ,女性 4例 ;年龄 18～ 72岁。 12例中支气管肺癌 2例 ,其中腺癌 1例 ,鳞癌 1例 ;支气管内膜结核性肉芽肿2例 ,气管内支架放置后肿瘤物的再生成 4例 ,气管腔内放疗后肿瘤的坏死物 4例。临床上气…     

电子支气管镜下高频电刀治疗良恶性气道肿瘤

目的 观察支气管镜下高频电刀治疗良恶性肿瘤的临床疗效及安全性。方法 对20例支气管良恶性肿瘤致气道阻塞行支气管镜下高频电刀烧灼切割术。结果 1例主支气管软骨瘤、4例炎性肉芽肿及14例支气管肺癌患者经电灼后将阻塞气道完全打通，1例气管肿瘤患者经电灼后将气道打通1／2，并安装气管支架。结论 支气管镜下高频电刀治疗良恶性气道肿瘤疗效显著，良性肿瘤避免了开胸手术，达到临床根治；恶性肿瘤疗效直接，可延长生存时间。     

经支气管镜高频电凝治疗气管与支气管腔内新生物

目的探讨经支气管镜高频电凝治疗气管与支气管腔内新生物的有效性和安全性。方法经支气管镜插入高频电凝棒或钢丝分层对气管与支气管腔内病变组织电凝。结果气管与支气管腔内新生物病人16例,经高频电凝治疗后气管或支气管腔内新生物均明显减小,管腔阻塞明显减轻,呼吸困难症状立即改善,仅1例术后有少量咯血外,无严重并发症出现。结论高频电凝是治疗气管与支气管腔内新生物有效的方法,可迅速解除气道阻塞症状,对良性病变病人也可免除开胸手术的创伤。     

支气管镜下介入治疗支气管结核气道阻塞82例临床疗效分析

目的 探讨经支气管镜下介入治疗支气管结核气道阻塞的临床疗效。方法 对82例支气管结核气道阻塞的患者在全身常规抗结核治疗的同时,联用支气管镜下介入治疗,根据气道阻塞狭窄程度选择冲洗、钳夹清除、高频电凝治疗及球囊扩张术治疗,后再局部管腔内注入抗结核药物INH。结果 82例患者管腔完全通畅54例、管腔轻度狭窄26例,气道阻塞未改变2例。结论 经支气管镜下介入治疗支气管结核气道阻塞的疗效确切,能有效解除气道阻塞。     

镜下高频电刀及局部注药联合治疗气管支气管结核

目的探讨经纤维支气管镜高频电刀及局部注药联合治疗气管支气管结核的疗效及安全性。方法对161例气管支气管肉芽增殖型结核,经纤支镜高频电切、电灼肉芽组织,扩大管腔,并于病灶基底部注入异烟肼0.3 g及地塞米松5 mg。观察疗效及并发症。结果 151例患者解除了气道阻塞,症状消失,不张的肺复张,反复感染消除。治疗有效率93.8%。高频电刀治疗中发生严重心律失常（频发室性早搏、室上速、心动过缓）6例、大出血1例、休克1例。并发症发生率2.3%。结论经纤支镜高频电刀及局部注药联合治疗气管支气管肉芽增殖型结核疗效好,并发症少。治疗气道严重阻塞的重症病例有一定的技术难度和医疗风险。     

经纤维支气管镜介入治疗肺癌的临床病例研究

目的 探讨经纤维支气管镜下高频电凝术、氩等离子凝固术(argon plasma coagulation,APC)方法治疗肺癌伴气道阻塞的疗效、并发症及不良反应.方法 17例经细胞学或病理确诊的肺癌患者,支气管镜下明确有气道阻塞和(或)阻塞性肺炎、肺不张,经支气管镜下行高频电凝术和(或)氩等离子凝固术,术后追踪观察气道狭窄再通程度及患者临床症状并予以评价.结果 17例患者经高频电凝术或氩等离子凝固术治疗共计24次后,临床评价完全有效1例,部分有效13例,轻度有效2例,无效1例,无严重并发症发生.结论 经支气管镜下行高频电凝术、氩等离子凝固术等介入治疗方法能完全或部分消除瘤体,减轻肿瘤负荷,缓解患者症状,且创伤小、并发症及不良反应少,是临床治疗晚期肺癌伴气道阻塞的有效方法,值得进一步推广.     

喉罩通气全麻下经支气管镜高频电刀治疗主支气管肿瘤的临床观察

目的探讨喉罩通气全麻下经支气管镜应用高频电刀治疗主支气管肿瘤导致的气道阻塞的疗效、方法、安全性。方法选择主支气管腔内恶性肿瘤阻塞大气道导致呼吸困难的患者12例,在用异丙酚、芬太尼和维库溴铵行静脉全身麻醉后,再在喉罩通气下经支气管镜应用高频电刀对病变进行治疗。结果 12例患者经支气管镜下高频电治疗后呼吸困难得到明显改善。12例患者肺功能FEV1,气促评分在术前、后均有明显改变,差异有统计学意义（P〈0.01）。结论喉罩通气全麻下经支气管镜高频电刀治疗主支气管肿瘤导致的气道阻塞,可以明显解除患者的气道阻塞,从而改善呼吸困难,提高生活质量,喉罩通气下经支气管镜高频电刀治疗大气道肿瘤安全、可行、治疗效果明显。     

纤支镜高频电刀治疗气管支气管结核

目的探讨经纤维支气管镜高频电刀治疗支气管结核的疗效。方法对在我科住院治疗的45例肉芽增殖型和瘢痕狭窄型的气管支气管结核患者,经纤支镜高频电切、电灼肉芽组织和瘢痕,扩大管腔,术后在病灶内注入异烟肼0.2、丁胺卡那0.4和地塞米松5 mg,并观察其疗效。结果 43例患者解除和缓解气道阻塞,症状消失,肺部病灶明显好转,治疗有效率95.6%。结论经纤支镜高频电刀治疗肉芽增殖型和瘢痕狭窄型的气管支气管结核会取得满意的疗效,但要掌握适应症和一定的操作技巧。     

气管支气管骨化症2例并文献复习

目的 提高对气管支气管骨化症的认识,提高疾病诊断率.方法 收集经郑州大学第一附属医院呼吸与危重症医学科确诊的气管支气管骨化症2例,对患者的临床症状,胸部CT、纤维支气管镜下表现、组织病理、治疗及效果进行回顾性研究,并复习相关文献对气管支气管骨化症进行分析.结果 2例患者均为女性,分别为55岁和33岁,均表现为咳嗽、咳痰,纤维支气管镜下可见结节样隆起突出气管、支气管管腔,质硬.1例患者经气道内结节高频电、氩气刀及冷冻治疗,另1例患者给予糖皮质激素口服治疗.2例患者治疗后患者临床症状较前均有所改善.结论 气管支气管骨化症临床症状各异,临床医师、影像学医师对气管支气管骨化症认识不足,导致该病诊断率低,易被误诊、漏诊,对原因不明的慢性咳嗽患者应行支气管镜检查排除气管支气管骨化症.     

置入支架行腔内放疗加体外照射治疗晚期肺癌

目的观察置入ＮＴ支架后行腔内１９２ＩＹ放疗加体外照射治疗大气道阻塞晚期肺癌患者的疗效。方法将４０例晚期肺癌患者，随机分为观察组（２０例）与对照组（２０例）。观察组采用ＮＴ支架及置入器，通过纤维支气管镜直视下无Ｘ线监视及钢丝引导，置入气道狭窄处，退出置入器，将施源器经纤维支气管镜活检管道插至肿瘤所致狭窄部位，然后遥控后装机，使１９２Ｉｒ进入该处行腔内放疗。腔内放疗结合体外照射，二者交叉进行。对照组只单纯行体外照射，１个月后，两组患者均行全身静脉化疗，化疗方案相同。结果观察组２０例，完全缓解７例（３５％），部分缓解１１例（５５％），无变化及恶化共２例（１０％），有效率９０％，明显高于对照组的６０％，Ｐ＜０．０５。结论置入ＮＴ支架后，能即刻解除患者的呼吸困难，行腔内加体外照射明显缓解因肺癌支气管内复发或其他部位肿瘤转移到气管、支气管树所引起的阻塞症状，其客观疗效及症状缓解均优于单纯体外照射。     

经纤维支气管镜高频电刀治疗气道内良恶性狭窄10例

目的探讨经支气管镜高频电刀治疗气道内良恶性狭窄的疗效及安全性。方法对10例气道内良恶性狭窄患者经支气管镜高频电灼扩大管腔．观察近期疗效、远期疗效及安全性。结果10例病人治疗后完全通畅率53．8％。总有效率92．3％。3例5次阻塞性肺不张得到缓解,4例6次阻塞性肺炎好转;治疗前气促指数为（3．21±0.51）,FVC（2．58±0.41）L,FEV1（1．63±0．25）L,治疗后气促指数为（1．51±0.60）．FVC（3．05±0．32）L,FEV1（1．71±0．27）L,治疗前后差异均有统计学意义（P〈0．005）。高频电刀治疗并配合放化疗可提高病人中位生存期．无出血、气胸、纵隔气肿、气管食管瘘及气管内烧伤、感染等并发症发生。结论经支气管镜高频电刀治疗气道内良恶性狭窄疗效好、并发症少,可替代部分外科手术,值得临床广泛应用。     

喉罩通气全麻下经支气管镜高频电刀治疗中央型肺癌12例的临床观察

目的：探讨喉罩通气全麻下经支气管镜应用高频电刀治疗晚期中央型肺癌导致的气道阻塞的疗效。方法：选择晚期中央型肺癌阻塞大气道导致呼吸困难的患者12例,在用异丙酚、芬太尼和维库溴铵行静脉全身麻醉后,再在喉罩通气下经支气管镜应用高频电刀对病变进行治疗。结果：12例患者经支气管镜下高频电力治疗后呼吸困难得到明显改善,气道直径由（3.20±1.56）mm扩大到（7.02±1.23）mm,差异有统计学意义（P〈0.01）;气促评分治疗前为（2.90±0.66）级,治疗后为（1.05±0.32）级,差异有统计学意义（P〈0.01）。结论：全麻下经喉罩通气高频电刀治疗中央型肺癌导致的气道阻塞,可以迅速缓解患者呼吸困难症状,改善生活质量,同时术中借助喉罩通气扩大了气管镜下介入治疗的适应证,手术安全、可行,为临床治疗重度气道梗阻提供了一种新的治疗手段。     

Approach for the interventional bronchoscopic treatment methods applied in tracheobronchial obstruction

Bronchoscopy used commonly in the diagnosis and staging of the lung cancer was applied successfully in the palliative treatment of the patients with lung cancer. The patients with tracheobronchial obstruction may develop many symptoms like dyspnea, cough and haemoptysis, and atelectasis and pneumonia but these symptoms were recovered with applying interventional bronchoscopic methods. These methods are laser therapy, electrocautery, argon plasma coagulation, cryotherapy, brachytherapy, photodynamic therapy and airway stents. The obstructed airway was reopened by these bronchoscopic methods and dyspnea, atelectasis and post-obstructive pneumonia were relieved. In addition, with establishment of the airway patency, chemotherapy and/or radiotherapy may be applied to the patients with lung cancer. The treatment of tracheobronchial obstruction was achieved a thorough evaluation of the etiology, physiology, diagnostic and treatment options of the disease and a multidisciplinary team approach including anesthesiology, medical oncology, thoracic surgery, radiology and interventional pulmonology. In this multidisciplinary team approach, all of the doctors dealing with the diagnosis and treatment of lung cancer should know interventional bronchoscopic methods, endobronchial treatment, and indications of these procedures. The aim of this review is to fresh our knowledge about the interventional bronchoscopic treatment methods in patients with lung cancer.     

Advanced malignant lung disease: what the specialist can offer

Lung cancer is not only the most commonly diagnosed cancer worldwide, but it is still the leading cause for cancer-related death. The 5-year survival for lung cancer in Europe and in the USA is totally 16%. Therefore, a palliative therapy regimen is required to control the disease and reduce symptoms with the objective of enhancing quality of life of lung cancer patients. In addition to chemotherapy that is still one of the most important pillars in the treatment of advanced lung cancer, further interventional strategies can be offered to improve a patient's quality of life. A locoregional tumour progression is frequently associated with malignant pleural effusion or pericardial effusion, central airway obstruction, tracheo-oesophageal fistula, severe haemoptysis or superior vena cava (SVC) syndrome threatening life and necessitating urgent palliation. Recurrent pleural effusion causing dyspnoea can be managed by pleurodesis, serial thoracocentesis or insertion of an indwelling catheter. Symptomatic malignant pericardial effusion often requires an urgent pericardiocentesis. Furthermore, surgical procedures, instillation of sclerosing agents or local chemotherapy should be considered in refractory pericardial effusion. The therapy regimen of central airway stenosis includes mechanical and thermic endoscopic procedures providing rapid relief of symptoms. To prevent recurrence of airway obstruction, the insertion of a stent or palliative brachytherapy provide re-establishment of the patency of obstructed airways. Haemoptysis can be managed by bronchoscopic interventions as well as by arterial embolization or palliative thoracic radiotherapy. The therapy of SVC syndrome is dependent of histology. In small-cell lung cancer, chemotherapy is recommended. In non-small-cell lung cancer, stent insertion and/or radiotherapy are the therapeutic pillars.     

Outcome of treated advanced non-small cell lung cancer with and without central airway obstruction

OBJECTIVE: In patients with advanced non-small cell lung cancer (NSCLC) treated with chemotherapy, we compared survival in patients with treated central airway obstruction to those who did not have central airway obstruction. METHODS: One hundred forty-four patients with advanced and inoperable NSCLC were included. These consisted of 52 consecutive patients treated with therapeutic bronchoscopy plus chemotherapy with or without radiotherapy (group A) and 92 consecutive patients who did not have central airway obstruction treated with chemotherapy alone (group B). Chemotherapy consisted of cisplatin or carboplatin, and one third-generation chemotherapy agent. RESULTS: There was no significant difference in the survival of patients with and without central airway obstruction (p = 0.395). There was no influence of the histologic subtype on survival in both groups combined and also in each group separately. Median survival in patients belonging to group A was 8.4 months and those in group B was 8.2 months; 3-, 6-, and 12-month survival rates in patients in group A were 90%, 71%, and 40%, respectively, and those in group B were 82%, 63%, and 34%. CONCLUSION: Patients having advanced NSCLC with locally treated malignant central airway obstruction in combination with chemotherapy do not have a worse survival compared to those with advanced NSCLC without central airway obstruction. Therapeutic bronchoscopy should be offered to patients with NSCLC and central airway obstruction.     

复发性小细胞肺癌的治疗策略及进展

小细胞肺癌是一种对放、化疗敏感,但易复发的实体性肿瘤.对于身体状况许可的小细胞肺癌复发患者,应接受二线化疗;若一线治疗无效或无疾病进展时间小于3个月,应选择与一线化疗非交叉耐药的二线化疗;若一线治疗有效且无疾病进展时间大于3个月,拓扑替康是首选;若无疾病进展时间超过6个月,则可继续原方案治疗;若出现有症状的脑和骨转移、胸腔内复发和(或)出现大气道阻塞、上腔静脉阻塞综合征的患者,可考虑放疗或放、化疗结合.针对小细胞肺癌的生物靶向治疗有待进一步研究.     

化疗联合经气管镜氩等离子体凝固治疗中央型肺癌的临床研究

目的探讨给予含铂方案全身化疗联合经支气管镜氩等离子体凝固技术治疗中央型非小细胞肺癌的疗效及安全性。方法经支气管镜对21例中央型非小细胞肺癌患者进行1～3次氩等离子体凝固联合2～8次化疗,并从支气管狭窄再通疗效、气促好转、体力状况变化等方面进行评价。结果 21例患者经氩等离子体凝固及化疗后症状改善、病情好转,Karnofsky体力状况评分明显提高。结论化疗联合经支气管镜应用氩等离子体凝固技术治疗中央型肺癌安全有效。     

Lung hyperinflation and its reversibility in patients with airway obstruction of varying severity

The natural history of lung hyperinflation in patients with airway obstruction is unknown. In particular, little information exists about the extent of air trapping and its reversibility to bronchodilator therapy in those with mild airway obstruction. We completed a retrospective analysis of data from individuals with airway obstruction who attended our pulmonary function laboratory and had plethysmographic lung volume measurements pre- and post-bronchodilator (salbutamol). COPD was likely the predominant diagnosis but patients with asthma may have been included. We studied 2,265 subjects (61% male), age 65 ± 9 years (mean ± SD) with a post-bronchodilator FEV(1)/FVC <0.70. We examined relationships between indices of airway obstruction and lung hyperinflation, and measured responses to bronchodilation across subgroups stratified by GOLD criteria. In GOLD stage I, vital capacity (VC) and inspiratory capacity (IC) were in the normal range; pre-bronchodilator residual volume (RV), functional residual capacity (FRC) and specific airway resistance were increased to 135%, 119% and 250% of predicted, respectively. For the group as a whole, RV and FRC increased exponentially as FEV(1) decreased, while VC and IC decreased linearly. Regardless of baseline FEV(1), the most consistent improvement following bronchodilation was RV reduction, in terms of magnitude and responder rate. In conclusion, increases (above normal) in airway resistance and plethysmographic lung volumes were found in those with only minor airway obstruction. Indices of lung hyperinflation increased exponentially as airway obstruction worsened. Those with the greatest resting lung hyperinflation showed the largest bronchodilator-induced volume deflation effects. Reduced air trapping was the predominant response to acute bronchodilation across severity subgroups.     

暂时性金属裸支架治疗晚期肺癌中心气道狭窄的探讨

目的观察经可弯曲支气管镜置入呼吸道暂时性镍钛合金裸支架治疗肺癌中心气道狭窄的临床疗效和安全性。方法 38例伴有气管、主支气管外压性狭窄为主的晚期肺癌患者,确诊后先予置入暂时性国产镍钛合金裸支架。置入支架前生活质量Karnofsky评分为42±13(x珋±s),气促指数为2.9±0.7。支架通过支气管镜直视下定位释放置入,通过上拉线取出法或下拉线取出法取出支架。结果 38例每例均置入1枚支架,均一次成功置入。支架置入后狭窄管腔均迅速扩大,置入后第2天气促指数、Karnofsky评分与置入前比较均有显著性差异(P<0.01)。支架置入后均行放疗或/和化疗,支架于置入后1～3个月予取出。未见与支架置入及取出相关的严重并发症。结论暂时性金属裸支架治疗晚期肺癌中心气道狭窄疗效确切,为后续的放化疗创造了条件,同时避免了支架长期放置的并发症,且支架的置入及取出操作简单安全,值得临床推广应用。