不同类型呼吸衰竭患儿行支气管镜检查灌洗术病例对照观察

目的 评价支气管镜检查灌洗术在不同类型呼吸衰竭(呼衰)患儿中的应用价值。方法 回顾性收集2011年3月至2012年6月于PICU住院并行支气管镜检查灌洗术的呼衰患儿的临床资料。分析患儿行支气管镜灌洗治疗前后血气变化、胸部X线（CT）改变及支气管镜检查镜下表现。结果 60例呼衰患儿进入分析。ARDS组11例和非ARDS组49例；非ARDS组中Ⅰ型呼衰亚组11例、Ⅱ型呼衰亚组17例和单纯高碳酸血症亚组21例。①60例患儿支气管镜下均可见黏膜粗糙、水肿。分泌物增多ARDS组8/11例（72.7%），非ARDS组19/49例（38.8%）；气管狭窄16例（均为非ARDS组）；通气不良ARDS组2/11例（18.2%），非ARDS组7/49例（14.3%）；黏膜糜烂ARDS组5/11例（45.4%），非ARDS组2/49例（4.1%）。②支气管镜检查明确病因诊断43.3%（26/60），ARDS组和非ARDS组分别为27.3%（3/11)和46.9%(23/49)。③51例行支气管肺泡灌洗治疗术前和术后胸部X线（CT）检查，ARDS组以实变影、磨玻璃影和支气管充气征为主；非ARDS组以实变影、支气管充气征和肺充气不良为主。非ARDS组和ARDS组胸部X线（CT）有效率分别为87.5％（33/40）和0。④58例支气管镜检查及灌洗术后较术前血气分析改善41例，其中ARDS组3/11例（27.3％），非ARDS组38/47例（80.8％）。⑤ARDS组和非ARDS组总有效率分别为27.3%（3/11）和93.9%(46/49)，差异有统计学意义(P=0.000)。Ⅰ型呼衰亚组、Ⅱ型呼衰亚组和单纯高碳酸血症亚组的有效率分别为90.9%（10/11）、94.1%(16/17)和95.2%（20/21）,与ARDS组有效率差异均有统计学意义（P均<0.05）。结论 ①ARDS患儿不宜行支气管镜检查灌洗治疗术。②非机械性梗阻的非ARDS呼衰患儿支气管镜灌洗治疗有效。③呼衰患儿病因不明时可行支气管镜检查协助病因诊断。

Bronchoscopic lavage in children with different types of respiratory failure: case-control analysis

Objective To evaluate the value of bronchoscopy in children with different types of respiratory failure. Methods The clinical data of cases with respiratory failure from March 2011 to June 2012 were collected retrospectively.Changes of arterial blood gas, lung imaging and fiberoptic bronchoscopic findings were analysed. Results Finally, the results of the 60 patients were analyzed. Based on the blood gas level children were divided into group A (ARDS Group, 11 cases)and group B (non-ARDS Group ,49 cases). Group B was divided into three subgroups: typeⅠrespiratory failure(11 cases), type Ⅱ respiratory failure(17 cases) and hypercapnia alone (21cases). ① Under bronchoscope rough mucosa and edema could be found in all 60 patients. In 8/11 cases (72.7%) more secretion could be found in ARDS group and in 19/49 cases (38.8%) in non-ARDS group. Tracheostenosis could be seen in 16 cases in non-ARDS group. Hypoventilation could be seen in 2/11 cases (182%) in ARDS group and in 7/49 cases (14.3%) in non-ARDS group. Mucosal erosion could be found in 5/11 cases (454%) in ARDS group and in 2/49 cases (4.1%) in non-ARDS gropup. ② Etilogical diagnosis was made with bronchoscopy in 26/60 (43.3%), 3/11 (27.3%) and 23/49 (46.9%) cases in ARDS and non-ARDS groups respectively. ③ Chest X-ray (CT) pre- and post-bronchoscopic lavage showed in ARDS group consolidation shadow, grind glass shadow and brochial aeration were the main findings, while in non-ARDS group consolidation shadow, fronchial aeration and insufficient aeration of lung were the main presentation. The efficacy rates of imaging were 87.5% (33/40) and 0% in non-ARDS and ARDS groups respectively. ④ Blood gas analysis showed that improvement was found in 3/11 (27.3%) and 38/47 (80.8%) cases pre- and post-bronchoscopy in ARDS and non-ARDS groups respectively. ⑤ Total efficacy rates were 27.3% (3/11) and 93.9% (46/49) in ARDS and non-ARDS groups, and there was significant difference between two groups (P=0.000). Total efficacy rates were 90.9% (10/11), 94.1% (16/17) and 95.2% (20/21) in type Ⅰ, type Ⅱ respiratory failure and hypercapnia groups respectively, and there all were significant differences compared to that of ARDS group (P all <0.05). Conclusions ①For children with ARDS, bronchoscopy should not be used.②Bronchial lavage treatment for non-mechanical obstruction respiratory failure in non-ARDS children was effective. ③When the etiology of respiratory failure in children is unknown, bronchoscopy may be helpful for etiological diagnosis.