支气管肺泡灌洗术治疗难治性重度哮喘的临床分析

目的探讨应用纤维支气管镜行支气管肺泡灌洗术治疗难治性重症哮喘的作用。方法选取常规治疗无效的支气管哮喘患者30例行支气管肺泡灌洗术治疗。治疗前1d及治疗后1～3d观察患者的临床表现,检测肺功能用力肺活量、第1秒用力肺活量、呼气峰流速等。结果经纤支镜行支气管肺泡灌洗术治疗后,哮喘症状、体征改善明显,肺功能指标得到改善。结论经支气管镜行灌洗不仅可清除黏液栓,而且经纤支镜气管内给药作用起效迅速、直接。从而改善气道的炎症反应,缓解了气道的痉挛和狭窄,是治疗哮喘急性发作合并黏液栓阻塞的最有效手段,见效快。     

外伤性支气管断裂的诊治体会

目的　探讨外伤性支气管断裂的早期诊断与外科治疗。方法　对 1997年 1月至2 0 0 3年 1月诊治的 7例外伤性支气管断裂患者的临床表现及外科治疗情况进行回顾性分析。结果　 7例患者均为胸部钝性伤 ,支气管断裂症状典型的 5例患者得到了早期诊断 ,无典型临床表现的2例患者诊断延误。全组均行支气管端端吻合术。 6例患者痊愈出院 ,1例术前呼吸心跳骤停 ,术后第 7天因脑未复苏死亡。结论　伤后出现典型临床表现 ,尤其是充分闭式引流后不能控制的气胸 ,支气管断裂的诊断可基本确定。一部分支气管断裂患者早期无明显临床表现 ,胸部CT和纤维支气管镜检查可确诊。诊断一经确立 ,应尽快行支气管吻合术。     

胸部钝性伤支气管断裂的外科治疗

目的探讨胸部钝性伤致支气管断裂的及时诊断和治疗方法。方法回顾性分析18例气管支气管损伤的临床特点、损伤部位及诊疗方法。结果18例患者均为胸部钝性伤（车祸或高处坠落伤）,临床症状典型的15例患者得到了早期诊断,无典型l临床表现的3例患者诊断延误。患者均行支气管端端吻合,其中同时行肺叶切除术6例,破裂处修补11例。17例患者痊愈,1例术前呼吸心跳骤停,紧急开胸后在术中死亡。结论严重胸部钝性伤的患者通常伴有气管或支气管损伤。如不能及时明确诊断,极易导致管腔狭窄,严重可致患者死亡,纤维支气管镜检查可确诊。积极的外科治疗是治疗支气管断裂的重要方法,可以降低死亡率,减少误、漏诊率且并发症少。     

外科治疗气管及主支气管肿瘤30例

目的探讨气管及主支气管肿瘤的外科治疗方法。方法回顾性分析2000年1月至2015年12月中国医科大学附属盛京医院30例气管、主支气管肿瘤患者的临床资料,其中男12例、女18例,年龄22~80岁。结果 10例行气管肿瘤核除术,12例行气管肿瘤切除+端端吻合术,1例行气管肿瘤窗形切除术,1例行气管肿瘤楔形切除术,5例行气管肿瘤切除+利用肺组织瓣行气管重建术,1例行左全肺切除术。1例患者于术后26 d突发大咯血死亡,2例患者出现围术期并发症,其余患者均恢复良好。随访11个月至14年,8例患者术后随访未满5年,1例术后14个月突发大咯血死亡,其余健在;21例患者随访超过5年,其中失访5例。结论气管、主支气管肿瘤首选外科治疗,良性病变且长度较小,可考虑行气管肿瘤局部切除,气管节段切除+端端吻合术是经常采用的手术方式,气管病变超过全长的1/2或存在吻合口缺血坏死风险的病例可选择气管重建。     

三通喉罩通气全麻下儿童支气管肺灌洗术的护理配合

目的总结三通喉罩气道通气全麻下儿童纤支镜支气管肺灌洗术的护理方法。方法对24例肺部疾病患儿在三通喉罩通气全麻下实施纤支镜支气管肺灌洗术,术前作好心理护理和术前准备,熟悉麻醉和手术要点;术中做到熟练、紧密配合;术后注意观察病情、及时处理。结果全部患儿术后复查X线摄片示肺部感染情况好转,无明显并发症,肺不张均痊愈出院。结论在三通喉罩通气全麻下纤支镜支气管肺灌洗术中,周密、及时、细致的护理措施可以使患儿平稳渡过麻醉期,提高手术成功率,减少并发症的发生。     

气管及支气管重建手术

虽然外科治疗在本世纪有很大发展,但气管及支气管的重建手术却发展缓慢。近年来肺移植术及对恶性肿瘤施行的广泛性气管切除术,为气管及支气管重建手术提供了有益的资料。本文将复习治疗气管及支气管外伤和疾病的各种外科手术。支气管破裂1945年Sanger报告了第一例支气管穿透性损伤修复成功的病例。1947年Kinsell等收集了文献中38例及自己2例的支气管外伤病例。由于很少采用手术治疗,40例中仅19例生存。1949年Griffith报告了第一个支气管外伤性断裂8个月后手术修复成功的病例。此例曾行外伤性支气管狭窄的切除及气管端-端吻合术。Hood等收集了至1959年为止的98例气管及支气管外伤病例,其中80例有支气管损伤。小的支气管裂伤可采用胸腔闭式引流     

喉罩在先天性心脏病伴气管狭窄患儿麻醉中的应用

先天性心脏病(先心病)伴气管狭窄,以往在先心病矫治术时气管狭窄不做处理,有些患儿会为此发生术后脱机困难;如果气管狭窄行一期矫治手术(去除狭窄段断端吻合术或补片扩大管径术等),手术创伤大,死亡率高[1],本文采用喉罩全麻下先心病矫治术联合纤支镜介入技术,检查评估先心病矫治术后气管狭窄改善情况,对中、重度气管狭窄患儿行纤支镜下球囊扩张、气管支架置入术等治疗,取得了很好     

经纤支镜气管内置管供氧救治慢性呼吸衰竭15例的护理配合

目的:探讨经纤支镜气管内置管供氧配合(FOB)救治慢性呼吸衰竭的护理方法.方法:对15例慢性呼衰的患者通过纤支镜行气管内置管供氧、吸痰和支气管肺灌洗,并应用经纤支镜气管内置管供氧技术,检测术前、术中、术后24小时动脉血氧指标[1],同时护理人员加强术前宣,术中配合和术后严密观察.结果:治疗组患者中有3例进行了两次气管内供氧和支气管肺灌洗,其余行1次治疗.术后呼吸困难明显缓解,咳嗽、咳疾、发热等症状明显减轻,肺部感染得到控制,所有患者均得到成功救活,未发生严重并发症.结论:周密的术前准备,心理护理,术中熟练的操作配合,严密观察病情及术后健康指导等护理配合是经纤支镜气管内置管供氧救治慢性呼衰成功的重要保证.     

闭合性颈段气管断裂伤的诊断及治疗

目的总结1例闭合性颈段气管断裂伤的诊治经验,进一步提高对该病的认识和诊疗水平。方法患者,男性,41岁。颈部被钢板撞击伤后出现高度皮下气肿、呼吸困难,皮下排气后症状改善不明显,紧急行颈胸部CT检查发现高度皮下和纵隔气肿、颈部气管不连续,考虑气管断裂伤,在急诊手术中发现气管1～2环间全断离,伴软骨骨折、周围软组织损伤,行气管断端吻合、低位气管切开术。结果术后恢复顺利,2周后拔除气管套管,病人呼吸、进食正常,但出现声音嘶哑,喉镜检查发现声带固定,半年后复查胸部CT气管断端吻合口无狭窄,因声音嘶哑未改善行双侧声带切除和气管切开术,带气管套管至今2年余。结论闭合性颈段气管断裂伤可能引起气道梗阻而窒息死亡,救治成功的关键是确保气道通畅、早期做出正确诊断和及时重建断裂气管,气管吻合术能取得满意的疗效。     

硬质气管镜结合纤维支气管镜治疗气管支气管病变

目的探讨硬质气管镜(硬质镜)结合纤维支气管镜(纤支镜)治疗气管支气管疾病的价值。方法2002年9月至2005年10月,应用硬质镜结合纤支镜为23例气管支气管病变者进行了25次手术。男17例,女6例;年龄24~79岁,平均(53·9±14·5)岁;良性肿瘤9例次,恶性肿瘤14例/16次。采用静脉全身麻醉,经硬质镜腔内置入纤支镜对气管进行全面的检查和评估,再利用硬质镜器械进行冷冻、肿瘤切除及放置支架等操作,最后以纤支镜止血并处理管壁残余病变。结果全组病例手术均顺利,无死亡病例和严重并发症发生。除2例恶性肿瘤根治及1例肿瘤基底浸润广而中转开胸外,无1例因内镜操作原因而中转开胸的病例。术后随访3~32个月,良性病人均生存;恶性者中3例于术后2周至3个月死于其他疾病,其余11例目前生存,最长已达8个月。结论硬质气管镜结合纤维支气管镜治疗气管支气管病变安全、可靠,效果确实。     

Atrial rupture due to blunt chest trauma

Atrial rupture by blunt trauma is lethal and one of controversial problems for cardiovascular surgeons, because of complexed conditions due to multiple organ injuries. Some papers recommend strategy of early diagnosis and treatment at an acute phase for better clinical course, but high mortality rate has not been improved yet, especially that of left atrial rupture. Three patients were reffered to our hospital by blunt chest trauma, one of whom died due to hemorrhagic shock before receiving surgical or interventional treatment. The remaining 2 patients had surgical operations at an early phase and were discharged without severe complications. We review our strategy of atrial rupture of blunt chest trauma. At an acute phase, atrial rupture alone should be repaired urgently unless use of cardiopulmonary bypass is contraindicated by severe hemorrhage of the other organs.     

Right atrial rupture following a hoof kick to the chest wall

Several myocardial lesions can be induced by thoracic blunt trauma. It varies from myocardial lesions to heart rupture. We report a case of right atrial rupture due to unusual blunt trauma: a hoof kick. We describe a successful management of this case. We suggest that a diagnosis of cardiac chamber rupture should be considered in all cases of blunt thoracic trauma.     

食管破裂与穿孔15例的临床诊治分析

目的探讨食管破裂与穿孔的诊断与治疗,提高对该疾病的诊治水平。方法总结分析我科15例食管破裂与穿孔的临床病例资料。颈段食管穿孔3例,2例为异物所致,1例为外伤所致,均手术治疗,胸段食管破裂穿孔12例,其中自发性食管破裂穿孔4例,食管异物损伤5例,外伤性食管穿孔2例,医源性损伤1例,根据食管的损伤程度及感染累及范围分别采取食管切开异物取出食管修补,食管部分切除,纵隔引流,瘘口修补等手术治疗12例。结果15例食管破裂与穿孔治愈13例;1例死于合并糖尿病因胸腔和纵隔感染严重,中毒性休克,呼吸衰竭,肾功能衰竭;1例死于食管癌引发食管破裂穿孔致感染性休克,多器官衰竭。结论根据食管破裂与穿孔的大小、时间、部位、纵膈和胸腔污染程度,早期明确诊断,及时采取合适的手术方式是治疗的关键。     

Tracheal rupture following blunt chest trauma presenting as endotracheal tube obstruction

In this report, we describe a patient in whom a tracheal tear followed blunt thoracic trauma. The diagnosis was made late resulting in problems with ventilation, endotracheal tube obstruction and cardiac arrest. Difficulties with early recognition of tracheobronchial injuries may be caused by non-specific findings as well as the lack of exposure of physicians to patients with these injuries. The signs and symptoms of tracheobronchial injuries are described, as well as their differential diagnoses. A review of airway management has been made as it requires combined anaesthetic and surgical expertise. Injuries of the trachea may have severe, life-threatening consequences and early diagnosis and management reduce morbidity and mortality.     

Carinal injury: diagnosis and treatment--case report

Injury to the thoracic trachea is a potentially lethal condition in a patient with multiple injuries. Several clinical signs are commonly associated with this process: subcutaneous emphysema, aphonia, stridor, pneumothorax refractory to thoracostomy tube drainage, pneumomediastinum, and hemoptysis. The clinical appearance of tracheobronchial rupture may be delayed for hours or even weeks following injury. Standard treatment for disruption of the thoracic trachea is primary repair via a right thoracotomy. We describe a patient with a complex carinal injury following blunt thoracoabdominal trauma who was successfully managed with prompt surgical intervention.     

Surgical treatment for traumatic tracheobronchial injuries

Tracheobronchial injury is a relatively rare but often fatal condition due to the injury from the neck to the chest. Different clinical features depend on the site of injury. We experienced 5 cases of tracheobronchial injury; cervical trachea in 2, thoracic trachea in 1, tracheal carina in 1, left main bronchus in 1. Three cases were caused by blunt trauma by traffic accident and 2 cases were due to penetrating injury (stab wound and gunshot wound). Thoracotomy with primary repair for 3 (simple repair, bronchoplasty, pneumonectomy) and cervicotomy for 2 (end-to-end anastomosis) were performed. One patient with severe associated injury died of multiple organ failure after surgery. Accurate diagnosis and the appropriate treatment in the early stage is essential in the treatment of tracheobronchial injury.     

陈旧性创伤性主支气管断裂的临床特征和手术技巧

目的探讨陈旧性创伤性主支气管断裂的临床特征和吻合方法,提高诊断及治疗效果。方法17例陈旧性创伤性主支气管断裂患者,14例行支气管端端吻合术,2例行右肺上叶袖状切除术,1例左全肺切除术。5例用丝线或涤纶线间断全层缝合,6例用微桥线间断全层缝合,6例用prolene线行环部连续加膜部间断缝合。5例用带血管蒂的肋间肌包埋吻合口。结果围术期有3例出现胸腔积液;1例出现乳糜胸;随访2例出现刺激性咳嗽,镜下见肉芽组织增生。结论支气管纤维镜是明确陈旧性创伤性主支气管断裂诊断的重要手段;术中须彻底切除狭窄段支气管瘢痕,用prolene线行环部连续加膜部间断缝合既简化操作且临床效果满意。     

Tracheobronchial injuries in children.

Five patients with tracheobronchial injuries secondary to blunt thoracic trauma were reviewed over a 9-year period. Bronchial disruption occurred in four cases and tracheal disruption in one. Of the four patients with bronchial disruption, a major airway injury was suspected early because of a large air leak or persistent pulmonary atelectasis. However, definitive diagnosis by bronchoscopy was delayed from 4 to 16 days due to initial response to conservative management. Bronchial repair was achieved in every case: additional lobectomy was required in only one instance. Postoperative bronchial stenosis occurred in one patient and responded well to dilatation. The child with a blowout perforation of the trachea was diagnosed early by bronchoscopy and was successfully managed without surgery. Tracheobronchial injury is one of the most severe injuries caused by blunt trauma and requires a high index of suspicion for early diagnosis and surgery. Bronchial repair is successful in most instances.     

Isolated coronary artery rupture following blunt chest trauma. A case report

In connection with blunt chest trauma, a 44-year-old man sustained isolated rupture of the right coronary artery. The lesion, which is extremely rare, was overlooked as there was no haemopericardium. The patient died. Since early surgical repair is essential, the possibility of coronary artery lesion must be kept in mind in all cases of severe thoracic trauma.     

Traumatic rupture of diaphragm: surgical reconstruction with special reference to delayed closure.

Thirteen cases of diaphragmatic rupture following blunt trauma or gunshot wounds are presented. In 10 cases the diagnosis of diaphragmatic rupture was made immediately following the injury, and the defect was closed by primary diaphragmatic suture. In three cases, the diagnosis was delayed for 3 to 16 years after the initial trauma. In all of them, abdominal organs such as the colon or liver had migrated into the thoracic cavity. One of them had acute intestinal obstruction and died following several unsuccessful operations. The remaining two patients required plastic repair of the diaphragmatic hernia by a Dacron patch, and both recovered. The clinical and pathological aspects of diaphragmatic rupture, the importance of early diagnosis and surgical correction, and the surgical approach to this entity are considered. The use of Dacron fabric in delayed closure of diaphragmatic defects is described.