纤支镜下一次置入2根双腔微导管在治疗肺大咯血中的价值及安全性评价

目的探讨纤维支气管镜(纤支镜)下一次性置入2根新型双腔微导管在治疗肺大咯血中的价值及安全性。方法 10例患者均先行X线胸片、胸部HRCT检查,初步明确出血部位及病因,按纤支镜操作常规准备。术前30min无水吞服30mg可待因,尽可能在大咯血间歇期进行。操作过程中边插入纤支镜边止血,直至找到目标支气管,随即沿工作通道放入引导导丝,在纤支镜直视下沿导丝放入第1根双腔微导管。判定球囊所能寻求支撑的着力点后,依据管径大小向球囊导管工作通道分别注入不等量冰生理盐水固定球囊。随后观察另一段或亚段支气管是否仍在持续出血,再继续按上述方法置入第2根球囊导管。纤支镜下观察3～5min,确定封堵目标支气管已停止出血后退出纤支镜。每隔1～2h向球囊的工作通道注入凝血酶500U,并回抽以观察微球囊封堵支气管内出血情况,以确定球囊导管放置时间。每6～8h回抽固定球囊液体量的一半,避免完全放松固定球囊而导致导管在气管内随呼吸发生移位。如在此期间或之后再次出现大咯血,则立即进行支气管动脉栓塞或手术治疗。以术后患者咯血量等症状的减轻,并结合从工作通道回抽吸液体颜色深浅的改变情况,分为出血完全停止、明显减少、有所减少、失败无效等4个层次进行疗效的判断。并通过该项技术与支气管动脉栓塞术(BAE)治疗肺大咯血对作比观察。结果 10例患者纤支镜下一次置入2根新型微导管操作顺利,操作时间约20～30min。大咯血即刻控制率达80%。术后出血即刻完全停止4例、明显减少3例、有所减少1例、失败无效2例。出血有所减少的1例术后4h经BAE术疗出血完全停止。失败无效的2例中,1例后经外科手术切除右肺中叶,出血完全停止。另外1例随即行BAE,但术后24h再次出现大咯血窒息死亡。结论一次性置入2根新型微导管治疗肺大咯血为有条件的患者和可能需要进一步行BAE,及外科手术治疗的患者创造了诊断和气道准备条件的时间。具有一定临床应用价值及可靠的安全性,值得在临床进一步推广应用。

Values and safety evaluation of treatment of massive hemoptysis through merging two new double cavity micro-catheter in one time with the fiber bronchoscope

Objective To discuss the value and the safety of treatment of massive hemoptysis of through merging two new double cavity micro-catheter in one time with the fiber bronchoscope. Methods Ten patients were operated X-ray radiograph and HRCT firstly, to preliminarily identify the positions and etiology of haemoptysis. Then the operation was set out according to conventional operation of fiber bronchoscope. The patients were all taken 30 mg codeine without water half an hour before operation, and to operate during the intermission of the haemoptysis. In the process of the operation,the bronchoscopy was inserted as well as bleeding was stopped, until the target bronchial was found, then the lead wire was put in the channel, and put into the first double cavity micro catheter along the guide wire with the direct guide of fiber optic bronchoscopy. It was judged that the origin of point of balloon can be supported, and then according to the size of trachea diameter, to inject inequality of cooled physiological saline solution into channel to fix balloon catheter. It was observed whether another section or sub-section of bronchial was continued hemorrhage, and continued to put into the second balloon catheter based on the process mentioned above. It was observed that the condition for 3~5 min through bronchoscope, and dropped out the bronchoscope until the target has been plugginged and stopped to bleeding. 500 U of thrombin was injected into the channel of balloon every 1~2 h, and pumped back to observe the bronchial internal bleeding. The placed time of the balloon catheter was determined. Half of the liquid of fixed balloon catheter was pumped back every 6~8 h to avoid completely relaxing the fixed balloon catheter and leaded to the shifting of catheter along with breathe in the endotrachea. Bronchial arterial embolization or surgery was immediately performed when serious haemoptysis was happened in or after this period again. The patients were divided into four levels to judge the curative effect according to the ease of amount of haemoptysis and combined with the change of color of pumped liquid from channel, complete stopping, significantly reduced, reduced, and failure. To contrast the differences between using the new technology and bronchial artery embolization (BAE) to treat pulmonary serious hemoptysis. Results Ten patients with inserting two new micro catheter with the guide of fiberoptic bronchoscopy was successful, and the the operation lasted about 20~30 min. The immediate control rate of serious hemoptysis reached 80%, and the postoperative bleeding immediate stopping was four cases, obvious decreased was three cases, decreased was one case, and failure was two cases. The decreased case was performed BAE 4 h later, and the bleeding was stopped completely. One failed case was performed surgical resection of right middle lobe later, and the bleeding was stopped completely. Another failed case was performed BAE, but he was dead of suffocation due to serious haemoptysis 24 h later. Conclusion Placed 2 new micro-catheter disposably to treat serious haemoptysis create more time for diagnosis and airway preparation for more BAE of surgical treatment. It has certain clinical application value and reliable safety, and it is worth in clinical further popularized.