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.     

Therapeutic bronchoscopy in lung cancer. Laser therapy, electrocautery, brachytherapy, stents, and photodynamic therapy

Therapeutic bronchoscopic techniques such as LPR, EC, brachytherapy, stents, and PDT are effective tools in the palliation and local control of lung cancer. Palliation of malignant tracheobronchial obstruction by LPR, stents, brachytherapy, PDT, or a combination thereof results in relief of dyspnea, hemoptysis, and postobstructive pneumonia. Importantly, it avoids intubation in patients with respiratory distress and facilitates the weaning of patients from MV. In the exciting field of lung cancer screening and treatment of early lung cancer, PDT, brachytherapy, EC, and LPR may represent treatment alternatives to surgical resection, especially in a select group of patients with high surgical risk or favorable endobronchial lesions. Clinicians await the results of future studies, which will (1) better define the impact of each treatment modality on patient care in terms of cost, survival, and improvement in quality of life, and (2) determine the optimal combination therapy relative to bronchoscopic and conventional treatment for effective palliation and cure of lung cancer.     

The role of interventional pulmonary procedures in the management of post-obstructive pneumonia

Post-obstructive pneumonia is the result of airway obstruction, commonly due to lung cancer. The majority of patients with lung cancer are non-operable and incurable at initial presentation. The clinical course of these patients is steadily downhill with complicating events such as post-obstructive pneumonia, respiratory failure, pleural effusion, and severe debilitation. Non-invasive conventional options for post-obstructive pneumonia include broad-spectrum antibiotics, combined with attempts at relieving the obstruction using radiation therapy. There is scant literature on the natural course of post-obstructive pneumonia, disease resolution, and optimal treatment. With the recent surge in technologic advances in interventional pulmonology, multiple airway recanalizaton options are now available. In this paper, we describe the causes of post-obstructive pneumonia, and the role of interventional pulmonary procedures in establishing an open airway.     

CO2冷冻联合钳夹治疗婴幼儿淋巴结瘘型气管支气管结核的疗效和安全性研究

目的: 评估CO₂冷冻联合钳夹介入治疗对婴幼儿淋巴结瘘型气管支气管结核(tracheobronchial tuberculosis,TBTB)的疗效和安全性。方法: 回顾性分析2012年7月至2020年7月天津市儿童医院呼吸科接受纤维支气管镜介入治疗的7例淋巴结瘘型TBTB患儿的临床资料(包括年龄、性别、临床症状、诊断结果、CT特点、支气管镜下病灶特征),通过描述性总结分析介入治疗前后的咳嗽等级、CT及支气管镜下病灶改变。结果: 7例患儿中,男6例,女1例,年龄8个月至3岁,病程5~70d。所有患儿主要采用支气管镜下CO₂冷冻联合钳夹治疗,介入次数为1~3次。介入治疗3个月后,5例患儿咳嗽评分从2分降为0分,治疗显效,2例患儿咳嗽评分从3分降为1分,治疗有效;5例患儿复查CT显示:肺门、纵隔肿大钙化的淋巴结、支气管阻塞、肺气肿、肺不张等表现与介入治疗前比较明显改善和好转。5例患儿中,4例患儿肺部病灶吸收≥1/2,治疗显效,1例患儿肺部病灶吸收<1/2,治疗有效。7例患儿复查纤维支气管镜可见镜下瘘口基本闭合,支气管病变明显吸收好转,管腔狭窄或阻塞情况较前减轻,支气管黏膜相对光滑。7例患儿中,5例患儿支气管病变吸收≥2/3,治疗显效,2例患儿支气管病变吸收好转但<2/3,治疗有效。所有患儿术中均无呼吸困难及血氧饱和度的下降。所有患儿术后均未出现气胸、纵隔气肿、气道痉挛、管腔水肿、大出血等严重并发症。应用纤维支气管镜介入随访3~6个月,除1例患儿失访,6例患儿均未见病灶复发。结论: CO₂冷冻联合钳夹介入治疗婴幼儿淋巴结瘘型TBTB取得良好的治疗效果,未见气管支气管狭窄、软化、阻塞性肺炎、肺不张等合并症的发生,该治疗方式安全有效。     

Endoscopic management of benign tracheobronchial tumors

Even though benign tracheobronchial tumors are quite rare, they still can induce airway obstruction, result in suffocation, and need emergent management to remove the obstructing lesions and make the respiratory tracts unobstructed. Although the preferred therapy is surgery, it is still difficult to deal with the tumors in some cases, and the complications of surgery are common. Therefore, bronchoscopic managements, such as Nd: YAG laser, electrocautery, APC and Cryotherapy, are very important to treat benign tracheobronchial tumors and can cure most of them.The efficacy of therapeutic endoscopy for the treatment of patients with benign airways obstruction has been established. However, in order to maximally eradicate the benign tumors with minimal damage to patients, the success of bronchoscopic managements for the treatment strongly depends on the diligent identification of the various factors, including the location, size, shape of tumor, and the age, status, cardio respiratory function of patients, and full comprehension of the limits and potential of each particular technique.Because the advantages and disadvantages of above mentioned interventional methods, single method can not solve all clinical issues. Therefore, in order to remove benign tracheobronchial tumors completely, and reduce the incidence of recurrence as far as possible, many doctors combine several methods of them to treat complicated benign tracheobronchial tumors. This article reviews the core principles and techniques available to the bronchoscope managing benign tracheobronchial tumors.     

Emerging technologies for the thorax: Indications,management and complications

The field of interventional pulmonology has rapidly expanded to include the management and treatment of complex diseases of the chest. The management of central airway obstruction, pleural disease diagnosis, treatment and palliation, advanced bronchoscopic techniques to aid in the diagnosis of lung cancer and innovative therapies to treat asthma and COPD have all emerged over the past decade. As astute clinicians, we are all aware of the risks and benefits of using these therapies to treat our patients. In order to appropriately treat and manage these often complex medical situations, the physician should have an expert knowledge of all available modalities, the expertise to safely perform the procedure and the ability to minimize the risk of and manage the associated complications that may arise. In this chapter we review and update some of the bronchoscopic and pleural interventions offered by interventional pulmonologists as well as the associated complications and management.     

Endobronchial hamartoma removed by flexible fiberoptic bronchoscopy via electrocautery

Hamartomas are the most common benign tumors of the lung. It is most common peripherally in the parenchyma as solitary nodule or endobronchial lesion. Endobronchial form may cause obstruction of airway, atelectasis and recurrent pneumonia. Endobronchial hamartomas may be treated by surgical intervention or bronchoscopic excision (with rigid or flexible procedures). We are presenting a case of endobronchial hamartoma successfully treated with bronchoscopic electrocautery without a need for surgical removal.     

11例儿童气管支气管结核支气管镜诊断与介入治疗效果观察

为观察电子支气管镜诊断与介入治疗儿童气管支气管结核(TBTB)的效果,笔者收集2018年1月至2019年10月于昆明市儿童医院住院并进行支气管镜诊断和介入治疗的11例TBTB患儿作为研究对象。研究对象先通过影像学检查,结核菌素皮肤试验,γ-干扰素释放试验,痰液、胃液查结核分枝杆菌及培养;可疑者再经过支气管镜镜下观察其特异性改变并对活检组织进行病理检查,最终确诊。研究对象在非紧急情况下先行抗结核药物治疗2周后再行支气管镜介入治疗;其中,10例经电子支气管镜行钳夹术、冷冻治疗术治疗,1例经球囊扩张术及钬激光、冷冻治疗。研究对象经支气管镜检查发现肉芽增生性改变3例;干酪样坏死物破溃性改变8例,其中1例并发瘢痕性狭窄。11例患儿经支气管镜治疗2~6次/例,阻塞、狭窄的管腔恢复通畅。经追踪复查,全部患儿均介入治疗有效,均无发生气道痉挛、大出血、气胸、肺部继发感染、结核扩散等并发症。结果表明,TBTB在抗结核药物治疗的基础上,经支气管镜介入治疗可有效清除干酪样坏死物、减少肉芽增生,解除呼吸道梗阻,促进病灶吸收,从而有利于肺不张恢复,且安全可靠。     

经纤支镜冷基循环微波聚能刀治疗中心型肺癌的有效性和安全性评价

目的探讨经纤支镜冷基循环微波聚能刀治疗中心型肺癌的安全性和有效性。方法使用针式单极微波辐射天线、CT引导下经皮肺穿刺周围型肺癌、以2450MHz的微波,依据肿瘤大小以40～80w的微波辐射治疗5～20min,对45例患者的68个病灶进行治疗。选择中央型肺癌患者90例,均有肺不张和呼吸困难,分为微波联合化疗组（治疗组）和单纯化疗组（对照组）,观察患者症状的改善及胸部X线片和CT的变化,同时测定患者血液中自然杀伤细胞（NK细胞）的活性及淋巴细胞转化率,两组相比,疗效有极显著性差异（P〈0．01）。结果治疗组所有患者症状减轻,其中35例完全复张,8例部分复张,2例无效。同时血液中NK细胞活性增加（P〈O．01）。对照组仅8例部分复张,NK细胞活性降低,两组相比,疗效有极显著性差异（P〈0．01）。结论小于65W15s微波凝固治疗中央型肺癌是安全有效的,可显著减轻气道阻塞症状,并提高患者免疫力。     

经支气管镜介入诊断和治疗支气管肺癌

经支气管镜介入诊断主要包括肺泡灌洗、肺活检、针吸活检、超声支气管镜、自荧光支气管镜、窄谱高清晰支气管镜和电磁导航等;治疗方面主要包括激光、微波、氩等离子体凝固、高频电凝、冷冻、腔内后装放疗和支架置入等。对于肺癌患者,无论在哪一期,均需个体化的综合治疗,而介入治疗对于改善症状、乃至在早期根治方面均有其独到之处。     

Update on interventional bronchoscopy for the thoracic radiologist

Interventional bronchoscopy, together with other domains of interventional pulmonology, has experienced tremendous technological advances. Diagnostic applications include endobronchial ultrasound, which enables endoscopists to see through airway walls. White light videobronchoscopy, autofluorescence imaging, and narrow band imaging have enhanced the ability to detect early lung cancer at a preinvasive stage. Electromagnetic navigational bronchoscopy, ultrathin bronchoscopy, and virtual bronchoscopy increase the diagnostic yield of biopsy of small peripheral lung lesions. The options that are currently available for the relief of central airway obstruction are also numerous, with both flexible and rigid bronchoscopic applications. Stents, although dichotomized to silicone and metal, come in various sizes and shapes to suit the requirements of the pathology being treated. Ablative techniques are categorized into those with an immediate effect and those with a delayed effect. Laser, electrocautery, and argon plasma coagulation can immediately relieve obstruction and control hemoptysis, whereas cryosurgery, brachytherapy, and photodynamic therapy have established roles in subacute airway obstruction and in the treatment of early lung cancer. Microdebriders have recently been added to the armamentarium of modalities for mechanical debulking of tumor. Distal airway obstruction has also been targeted with bronchial thermoplasty treatment of refractory asthma and with bronchoscopic lung volume reduction for the management of severe emphysema. This array of new technology has fostered collaborative work with a wide range of other medical specialties to deliver safer, more effective, minimally invasive treatment.     

经纤维支气管镜治疗急性肺不张45例临床分析

目的探讨经纤维支气管镜治疗急性肺不张的临床价值。方法对45例急性肺不张患者行纤维支气管镜检查,并行吸引、局部灌洗治疗。结果 36例患者经1次纤维支气管镜吸引灌洗后肺复张,9例经2次吸引灌洗后肺复张,未发生意外情况。结论纤维支气管镜对急性肺不张的诊断与治疗有重要价值,可有效清除气道内血凝块、痰液及分泌物,缩短病程,是急性肺不张患者的一种操作简便、安全、有效、经济的治疗手段。     

气管支气管支架置入的临床应用(附5例报告)

目的观察经纤维支气管镜国产镍钛记忆合金大气道支架置入的近期疗效。方法5例气管支气管狭窄,在电视透视下行经纤支镜气管支气管支架置入术。结果一次性放置成功4例。5例均扩张良好,4例呼吸困难立即缓解,缺氧症状改善;1例左主支气管内膜结核致伴左肺阻塞性肺气肿患者,复查左肺阻塞性肺气肿消失。结论经纤支镜大气道支架置入治疗大气道重度狭窄安全、有效。     

Tracheobronchopathia osteochondroplastica

Tracheobronchopathia osteochondroplastica (TPO) is an uncommon benign disease of unknown etiology characterized by multiple cartilaginous or bony submucosal nodules, which project into the tracheobronchial lumen. The nodules originate in the airway cartilages and thus typically spare the posterior membranous wall of the airways. The disorder is more common in men and the diagnosis is usually made in the fourth through sixth decades of life. There is no relationship to smoking or other systemic disorders. The disease is manifested by chronic cough and wheezing, which frequently lead to the mistaken diagnosis of asthma. Other pulmonary symptoms include dyspnea and hemoptysis. One of the complications is the increased incidence of recurrent respiratory infections. The pulmonary symptoms and complications are the consequence of narrowing and thickening of the airway walls. Even though roentgenologic imaging studies may indicate the diagnosis, bronchoscopy is the most definitive diagnostic test. The bronchoscopic appearance alone is diagnostic of the disease, and biopsy of the airway lesions is seldom, if ever, required. Although there is no specific therapy for this disorder, management of tracheobronchopathia osteochondroplastica includes bronchodilators, prompt treatment of pulmonary infections, and bronchoscopic dilatation when indicated.     

Treatment of Adult Tracheobronchomalacia and Excessive Dynamic Airway Collapse

Tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC) are both dynamic forms of central airway obstruction characterized by a decrease of >/=50% in the cross-sectional area of the tracheobronchial lumen. The differences between these two entities, however, are not uniformly accepted in the medical community. While TBM is characterized by a weakness of the tracheobronchial cartilaginous structures, EDAC is marked by excessive bulging of the posterior membrane into the airway lumen during exhalation. These disease entities are probably underdiagnosed because they present with a variety of nonspecific symptoms similar to patients with other obstructive ventilatory disorders such as asthma and COPD. Diagnosis is confirmed by dynamic radiologic imaging studies or bronchoscopy. Current therapeutic management depends on the extent, type, and severity of airway abnormalities noted and the clinical presentation. Proposed management alternatives include conservative medical therapy, and minimally invasive and open surgical interventions. Inhaled bronchodilators should be used only if symptoms and ventilatory function improve after use. Continuous positive airway pressure acts as a pneumatic stent and should be considered as an alternative or additional therapeutic modality. Endoluminal stent insertion can improve symptoms and pulmonary function in patients with central airway obstruction and should be considered for patients with symptoms refractory to conservative therapy. Several open surgical procedures have also been performed over the years, including tracheostomy, airway splinting, tracheal resection and, more recently, external tracheal stents. Endobronchial laser therapy, resorbable stents, application of grafting materials used to support the collapsed airway as well as the use of cartilage regeneration techniques are experimental, and their efficacy in humans remains to be determined. Future studies should compare therapeutic interventions and outcomes such as functional status, ventilatory function, and bronchoscopic and radiologic appearances in order to define the costs and benefits of individual and combined treatment modalities.     

Interventional bronchoscopy in the management of airway stenosis due to tracheobronchial tuberculosis

STUDY OBJECTIVES: To assess the efficacy and complications of interventional bronchoscopic techniques in treating airway stenosis due to tracheobronchial tuberculosis. DESIGN: Case series. SETTING: Respiratory care centers at two tertiary care referral teaching hospitals in Japan, Hiroshima City Hospital and Okayama Red Cross Hospital. PATIENTS AND INTERVENTIONS: A total of 30 patients were admitted to the hospital with a diagnosis of tracheobronchial tuberculosis between January 1991 and January 2002. Of those 11 patients received interventional bronchoscopy, including stent placement, laser photoresection, argon plasma coagulation (APC), balloon dilatation, cryotherapy, and endobronchial ultrasonography (EBUS). One patient with complete bronchial obstruction underwent a left pneumonectomy. RESULTS: Six patients underwent stent placement after balloon dilatation, while the remaining five patients underwent only balloon dilatation. In six patients, Dumon stents were successfully placed to reestablish the patency of the central airways. Two patients first had Ultraflex stents implanted but had problems with granulation tissue formation and stent deterioration caused by metal fatigue due to chronic coughing. Dumon stents then were placed within the Ultraflex stents after the patient had received treatment with APC and mechanical reaming using the bevel of a rigid bronchoscope. In four patients, EBUS images demonstrated the destruction of bronchial cartilage or the thickening of the bronchial wall. The main complications of Dumon stents are migration and granulation tissue formation, necessitating stent removal, or replacement, and the application of cryotherapy to the granuloma at the edge of the stent. CONCLUSION: Interventional bronchoscopy should be considered feasible for management of tuberculous tracheobronchial stenosis. Dumon stents seem to be appropriate, since removal or replacement is always possible. Ultraflex stents should not be used in these circumstances because removal is difficult and their long-term safety is uncertain. EBUS could provide useful information in evaluating the condition of the airway wall in cases of tracheobronchial tuberculosis with potential for bronchoscopic intervention.     

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。     

Interventional bronchoscopy in the treatment of tracheal obstruction secondary to advanced thyroid cancer

BACKGROUND: Surgery is the choice treatment for symptomatic tracheal obstruction due to malignant thyroid disease. Few additional therapeutic alternatives are available: radiotherapy (RT), chemotherapy (CT) or radioiodine therapy (1311). Only few studies on interventional bronchoscopy (IB) as well as alternative or palliative procedures have been reported so far. This study is a retrospective report of results of IB performed in patients with severe tracheal obstruction due to advanced thyroid cancer. SETTING: Pulmonary and Endocrinology Units of a University Hospital. Patients and interventions: From January 2, 2000 to March 1, 2004 14 consecutive patients [5 males, mean age: 62.2+/-10.7 (SD) yr] underwent IB due to tracheal obstruction for anaplastic (ATC: 7 patients), differentiated (DTC: 5), medullary (MTC: 1) and non-epithelial malignant (NEMN: 1) thyroid cancer. Eight out of 14 patients had local advanced inoperable disease, 6 had local relapse after surgery, 1311 or RT. Ten out of 14 patients suffered from severe dyspnea. In 4 patients airway patency was maintained by insertion of a stent; in 3 the tracheal lesion was removed by Nd-YAG laser; in 7 both procedures were performed. RESULTS: All 10 patients with dyspnea showed an improvement in symptoms. Early and late complications were observed in 4 and in 3 patients, respectively. All but 4 DTC patients died 11.9+/-14.2 months after the diagnosis (4.20+/-5.1 after IB). In 4 DTC patients still alive 90.7+/-59.2 since diagnosis and 16.7+/-9.2 months since IB, the airway dilatations allowed further treatments like 131-I and/or RT. CONCLUSIONS: Interventional bronchoscopy, including Nd-YAG laser and airways stenting are alternatives to surgery in inoperable thyroid-induced tracheal obstruction. Moreover, airway dilatation improves dyspnea and may allow further treatment.     

A case of dimethyl sulfate intoxication manifested by persistent dyspnea]

A 35-year-old man had been exposed to the vapor of dimethyl sulfate which was split over the bed of a truck from an accidentally broken container. After receiving treatment at the critical care unit of our university hospital for respiratory failure, he was transferred to our ward with dyspnea persisting for one month. Chest X-ray showed diffuse nodular and infiltrative shadows and shadows suggestive of bronchial wall thickening. Bronchoscopy demonstrated tracheobronchial stenosis due to severe inflammation, and transbronchial lung biopsy revealed erosion and granulation in tissues of the bronchiolar walls. These findings suggested extensive inflammatory involvement of the respiratory tract extending from the trachea to the bronchioles. Treatment with antibiotics, especially agents with antipseudomonal activity, was effective against secondary pneumonia. Administration of corticosteroid for stenotic lesions of the airway was extremely beneficial. The clinical course of the respiratory lesion caused by dimethyl sulfate intoxication was following, including the bronchoscopic findings. The efficacy of treatment with corticosteroid and antibiotics was evaluated by successive bronchoscopic examinations of the lesions.     

累及气道的复发性多软骨炎的临床特征及其处理

目的提高对侵犯气管、支气管的复发性多软骨炎的临床特征及治疗方法的认识。方法回顾性分析2000年8月至2006年10月收治的13例侵犯气管、支气管的复发性多软骨炎患者的临床资料。结果13例累及气管、支气管的复发性多软骨炎患者中男9例，女4例，年龄30-61岁，平均年龄50岁。疾病早期临床表现以咳嗽、咽喉痛及声嘶多见，疾病后期常表现为胸闷、气促、呼吸困难，重者可表现为下呼吸道反复感染和（或）呼吸衰竭。支气管镜检查早期可见喉、声带水肿，气管、支气管黏膜充血、水肿，软骨环肿胀及管腔狭窄；疾病后期由于气管、支气管软骨破坏而出现气道软骨环消失，管壁软化，呼气时部分气道陷闭。胸部CT检查早期可见气管、支气管壁弥漫性增厚伴管腔狭窄；疾病后期出现管腔重度狭窄，部分患者可有气道壁的钙化。肺功能测定表现为不同程度的阻塞性通气功能障碍。13例患者中有12例患者接受了糖皮质激素和（或）免疫抑制剂治疗，其中6例疾病早期患者症状均有不同程度的改善，其余6例患者症状无改善，在给予气道金属支架置入后（共放置气管、支气管支架12枚）5例患者气道阻塞明显改善，1例无缓解，仍需呼吸机辅助通气。随访1—48个月后有12例存活，1例随访2年后死亡。结论侵犯气管、支气管的复发性多软骨炎患者疾病早期糖皮质激素治疗可显著改善症状，疾病后期出现明显气道阻塞时可行支架置入、气管切开及呼吸机辅助通气治疗，以延长生存期。