01:33,9,Oct,2006 | (724/0/0) | Original

pathology of bronchiectasis


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pathology of bronchiectasis

【Overview】 【epidemiology etiology】     【pathological changes in the pathogenesis of clinical manifestations】     【complications of diagnostic laboratory examinations】     【differential diagnosis of treatment】   【Outcomes Prevention
【Overview】 Back
Bronchiectasis are dealing with thoracic surgery is the most common chronic suppurative respiratory disease, pathological bronchial wall damage was sustained irreversible expansion of the deformation, accompanied by chronic inflammation of the surrounding lung tissue. The disease more common in children and young people, caused by a variety of causes, there is a small part of the genetic factors, some associated with other congenital anomalies. Before antibiotics are widely used in the important respiratory disease caused by respiratory death and disability reasons. In recent decades a significant effect of drug treatment, risk factors significantly reduced the incidence dropped significantly.
Diagnosis】 【Back
(A) of the symptoms, signs
The height of the following cases suspected support expansion.
1. The symptoms of chronic bronchial infection, lasting a purulent sputum, with or without hemoptysis history.
2. Simply repeated hemoptysis.
3. Often with fever, general malaise, chest pain, sputum or no sputum.
4. Limited or extensive lung auscultation, especially the persistence of the limitations of auscultation, sometimes accompanied by wheezing.
5. There clubbing.
6. Accompanied by puru
lent sinusitis.
(B) chest X-ray examination
1. This is the most basic plain film chest X-ray examination, a small part of the branch expansion of patients (less than 10%) plain film completely normal, but a careful reading of films, most of the plain film there are some changes, but these changes often without specific can not make reliable judgments, the final diagnosis to be bronchial angiography.
Support extended from light to heavy, pathological changes are very complex, involving bronchi, lung parenchyma and pleura, chest radiograph is generally a reflection of pathological anatomy, it is also seen in a variety of on-chip.
(1) The chronic infection bronchial wall, wall thickening and hyperplasia of connective tissue around the lesion area increased lung markings, thickening, disorganized, until the outer lung still obvious, such as thickening of the wall of the gas, on-chip double-thick lines can be seen in parallel, referred to as "double-track sign", if pus retention, the bar was rough and even clubbing. Expansion of the bronchial cross section was a circle in the film, such as multiple small circle shadow together to present honeycomb. Cystic dilation of large round or oval more visible translucent areas, size can be from several millimeters to 2 ~ 3cm, the lower edge of wall thickening and enhancement, like hair, also known as "hair sign", cysts in the sometimes fluid level.
(2) support expansion are accompanied by substantial inflammation of the lung, acute onset of a sheet when the local impact of acute infection often left behind after the disappearance of small pieces, small block, disease and fibrosis, thus often reducing the lung volume, and accompanied by the corresponding change: markings gather, density increased fissure displacement, hilar shadows shrink, translocation and displacement, no lesion compensatory emphysema, atelectasis eventually. Bilateral lower lobe atelectasis, such as small size, can be attached to the mediastinal surface, not easy to find in the plain film. Right upper lobe atelectasis may appear on the widened mediastinum. Right middle lobe atelectasis may be just the right dry Xinyuan's a blur, sometimes in oblique lateral crack chip thickening not identify.
Left lower lobe is to support expansion of the predilection sites, the present volume leaves narrow, flat piece with the heart shadow overlap completely, easily missed, but in case of lateral view and note the markings of the left lung and left the door to change, not hard to find.
(3) pleural changes, expand support patients often repeated lung infections, and sometimes inflammatory adhesions involving the pleura, the pleural-chip saw a lot of changes. Support for wide range of serious expansion, atelectasis, fibrosis, thickening of the pleura will appear dense shadow of the side of the lung, the diaphragm up, mediastinal shift, can be seen in the dense shadow of the branch expansion of the translucent zone, a so-called " damaged lungs. "
(4) late branch expansion may affect the heart, pulmonary hypertension, pulmonary hilar expansion at the thin outer weeks markings, the heart shadow may also be increased.
Support expansion of the site of predilection is a two-under the leaves, the middle tongue segment plus left lower lobe, right middle and lower leaves, so often confined to the chest change these parts, there is lateral view would be a clear scope, even if bilateral extensive Support is also often part of the expansion of the normal bronchus.
Pulmonary TB due to branch expansion in general predilection sites of the right upper lobe or left posterior tip of TB to be serious enough to support a considerable expansion of the extent to appear, see the TB-chip fiber cheese lesions. In determining the diagnosis, try to find the best all previous chest radiographs, such as repeated inflammation occurs in a particular area may have supported expansion of the department.
2. Radiographs generally do not support expansion of diagnostic radiographs alone, or after normal after anterior oblique film to see on the various changes in the lungs, but the expansion of the bronchial smooth, but not a clearly defined scope of the present thin CT support expansion of the display point more clearly, but still not a substitute for bronchography.
3. Bronchography can be confirmed the presence of bronchiectasis, disease type and distribution. Because angiography has some pain and risk, without surgical indications, only for medical treatment, and do not contrast, for support with the general expansion of lung maturation in the treatment of disease, not the non-accurate understanding of their bronchial not change the situation. Only consider surgery, or in the future it may need surgery to confirm the diagnosis and extent of disease in order to decide whether the surgery and surgery.
Mentioned before, do not consider surgery without bronchial angiography, but in actual clinical work, do not do angiography, is sometimes difficult to determine whether the required surgery. The following situations, although a high degree of suspicion supported expansion of other tests, but do not do work temporarily Bronchography: ① chest plain film obviously extensive lesions on both sides, certainly not surgery. ② old, who has more than 50 to 60 years old, are generally not considered surgery. ③ heart and lung function is poor, non-surgical conditions. ④ mild symptoms, fewer attacks, inflammatory easy to control, temporarily consider the surgery, may suspend check (but in the long run, these patients in order to check the appropriate due to disease may progress, massive hemoptysis often no obvious incentive, angiography branch expansion as part of a clear, after surgery have also been under). ⑤ patients or their families refuse the inspection.
Line for the surgery and imaging scale, even if there is one side of the chest completely normal plain films should have done both sides, bilateral support for a high incidence of expansion. Bilateral angiography done at one time or separately, the second, according to the patient's tolerance, imaging physician experience. Lateral do technically simple point, patients are more susceptible to endure, made generally of good quality video, no overlap, easier to read. Bilateral same time to do, you can check to avoid the pain again, camera films gracefully position, both sides are able to clear, but if anesthesia is imperfect, or the patient can not tolerate, both sides made the original plan, after the side often done have aborted.
Zuijin a lung infection, preferably in the pneumonia 3 months before making a dissipated, dissipated due to the expansion of the bronchial inflammation may return to normal (ie, in the past so-called "branches which can be re-expanded"). Cough, sputum induced sputum before drug treatment as before making less. Bronchial inflammation, the easy tolerance of the contrast agent stimulation, severe cough, cough is easy to contrast agents, the results are not satisfied, patients were also observed between the cough frequently unclear. In sputum, and can block individual bronchus, filling the poor can not determine its nature. Avoided during hemoptysis contrast, in order to avoid massive hemoptysis, a small amount of hemoptysis patients (such as daily several mouth bloody sputum) if not completely disappeared long rule, you can imaging, but hemoptysis must check the blood after only 2 weeks.
Bronchography specific methods and precautions:
Imaging Radiology generally responsible, but thoracic surgeons in check the best in sound, prior to the radiology department that need to be considered from a clinical focus on all aspects of the area (from the plain film we begin with a heavy side), the imaging process personally observed in the bronchi near the dynamic changes. Some do not understand the bronchi due to contrast agent filling enough; posture inappropriate; bronchial distal lesions, negative pressure suction does not disappear into the contrast agent; the bronchial inflammation, sensitive, and then spit into the contrast agent; or the branch does has been completely blocked, these findings help to explain the contrast images. Imaging has some complications, such as local anesthetic allergy, also help surgeons to participate in observation of patients and treatment.
Contrast agent to use a 40% long-term iodized oil, because oil is thinner, and soon into the bronchioles and difficult to master, need to add sulfa powder (20ml plus 5 ~ 10g), the amount of bilateral 20 ~ 30ml. Iodine Acetone is water-based suspension, easy to spit up after angiography, it also diatrizoate plus sulfa powder. Agents need to do first with iodine iodine allergy test, but angiography experience, some so-called allergies may be caused by impurities in formulations, with the high quality of the contrast agent should be able to. Useful in the past, such as barium glue iodine allergy, it is best to avoid, after the barium paste difficult to discharge into the lungs, produce a large number of small granulomas in the lungs, a great impact on lung function.
Specific methods: 4 hours fasting before angiography to contrast room before the injection of sedative Ji cough agent. Patients taking the first seat, nose and throat after anesthesia catheter from the nose into the thick rubber, until slightly above the carina, and then injected anesthetic, so that the full bilateral bronchial linolenic acid, and supine in the imaging platform, to take the first low limbs high left lateral, oblique and other different positions, so that contrast agent injected into each bronchus, the bronchus in fluoroscopy must have been filling to the 5 to 6 after the photo film to take a different position. Anteroposterior and right unilateral right digital camera chip, left anteroposterior and oblique film camera, the camera bilateral anteroposterior and bilateral oblique film, avoid duplication, the best positioning according to the first point perspective piece.
Note contrast medium can also be used to bend the top of the special Metrass tube, under the perspective point to a specific bronchial injection. Contrast injection through the bronchoscope better bronchial secretions to exhaustion can be observed in each branch nozzle begging, and to evenly injected anesthetics, contrast agents of surgery can be sucked out. Note that the bronchoscopy biopsy hole is very small, only 2.0 ~ 2.2mm, more thick, a rapid injection of contrast agent is not easy, injection volume could cover the fiberoptic lens is too cool not see, can only be identified under fluoroscopy bronchial injection, angiography completed immediately wash bronchoscopy, in order to avoid damage.
Radiography complete pull out catheters, contrast agents Zhu Huanzhe Qingke to discharge, and then taken back to the ward postural drainage. Water-based contrast agents, such as iodized oil can rapidly excreted into the "lung" may be long-lived, generally clean and can be discharged within a few days.
Individual patients may be a fever a few days, symptomatic treatment
4. Bronchus of making videos to read notes
(1) combined with the plain film to see, try to find all the past according to chest (usually due to disease from childhood "pneumonia" started), repeated lung infections often occurred at the branch expansion, increased lung markings on the plain film thick, gather and circular translucent area, the general performance is the branch expansion. As in the past have made films, even if a few years ago, and also try to avoid duplication of inspection, because of imaging support expansion of certain pain usually begins to form at an early age, branch expansion area will be repeated infection, pneumonia, but the original is normal bronchus, and later expand the recurrence of the few new sticks.
(2) evaluate the imaging quality, the general requirements of filling to the 5 to 6 bronchial, or a little remote that contrast agents do not enter the bronchioles or "alveolar", bilateral imaging of the various branches of the same time not to have too much overlap, the normal Far from the proximal to the bronchial carbonyl should be gradually filling fine, smooth edge.
(3) to read both sides made videos, you must find all the branches, such as the lack of a branch, to explore its causes; combination of imaging perspective see, judged as anatomical abnormalities, imaging technology has the problem is not filling, or lesions caused. Bronchial angiography, contrast agent mainly by inhalation of intrathoracic negative pressure to the bronchial tip, if given sufficient contrast dose, not filling the support and suspected lesions, and to raise the selective angiography via bronchoscopy.
(4) Note whether the narrow opening, such as the distal and proximal bronchus as thick or thicker, can be considered to support expansion, if any cystic changes more apparent. Change is associated with bronchial gather, lung volume is reduced, the normal compensatory pulmonary emphysema, the bronchial more dispersed.
(C) bronchoscopy
Diagnosis of bronchiectasis generally do not need line of fiberoptic bronchoscopy, but the following types of cases to check:
1. For the carriage other than blockage caused by expansion, the elderly, the infirm, children, mental patients, anesthesia, and the person sleeping with sleeping pills and other foreign bodies may be swallowed without even realizing it, plug the bronchial foreign body can cause long-lived branch expansion, after removing or can be restored.
2. To understand whether there is endobronchial tumor: lung cancer faster, occurred without prolonged obstructive pneumonia or atelectasis, benign tumors, polyps good because of slow growth, may cause long-term block expansion.
3. Purulent many, postural drainage and bad effects of drug treatment, purulent bronchoscopy can understand the source of clear lesions, postural drainage to determine the appropriate location, and through the suction and injection drugs (antibiotics, bronchodilators such as ephedrine, etc.), in which patients improved as soon as possible, easy operation.
4. Hemoptysis bronchial artery embolization for bleeding to be part of the blood vessels, hemoptysis is too big check before the risk of embolization, complete occlusion immediately check in at this time still left bronchial blood, verifiable embolism Locust area is appropriate.
5. If you are not satisfied with bronchography, such as the filling of a branch or a good filling, bronchoscopy can be found for the contrast of technical problems or other reasons, such as sputum, tumor, granulation openings are blocked or scar formation, if necessary, accompanied by Selective angiography of the support (from the bronchoscopy biopsy of contrast agent injection hole).
6. Branch expansion have more postoperative hemoptysis or purulent sputum, bronchial stump check whether the granulation, threads, ulcers, etc., and understand the source of bleeding, to provide material for further treatment.
7. Suspect there is some specific infections such as fungi, can be obtained by fiberoptic bronchial secretions distal respiratory secretions without checking the pollution.
(D) and radionuclide lung function check
Pulmonary function test: including ventilation ventilation function and blood gas, medical treatment of patients, repeated inspection and many have suggested comparable efficacy, prognosis. Consider surgical treatment, we can understand can tolerate surgery, surgery to facilitate better design of the program, and observe the surgery as the standard.
Radionuclide scan: Understanding bilateral lung perfusion, the way of removal decisions and help predict postoperative conditions. When the lung lesions, pulmonary artery thrombosis often unilateral pulmonary artery damage may be blocked in the total drying of the barrier, no longer perfusion lung resection, postoperative recovery is expected to be better.
Return】 【treatment
Support expansion of the complex disease, the symptoms vary, many related to the severity of the treatment program to determine a number of factors to consider:
1. Are asymptomatic, the severity of symptoms, with or without history of recurrent pulmonary infection, the number of episodes and the effects of treatment such as mild symptoms, infection is easy to control, to medical treatment, or to consider surgery.
2. To consider whether to focus on the history of hemoptysis, and some so-called "dry bronchiectasis", not the number of common symptoms of lung infection, but may be sudden hemoptysis. Branch expansion is a benign disease, in a variety of antibiotics today, most of the infection can be controlled, the illness can survive for years, but life-threatening hemoptysis, although now you can Jiqiu bronchial artery embolization, in the long run, a large hemoptysis or recurrent hemoptysis best surgery.
3. Lesions within the scope of which is to determine the surgical treatment of the most important factor, limited to removal of lesions, more extensive lesions, but some parts of light, some heavy, and very obvious symptoms, pathological changes can be made removal of heavy palliative effect, but if both sides have the disease, the severity of related small, we can not consider the surgery.
4. The age of some cases, see 40-year-old patient after the disease can often be alleviated, not much progress, and patients aged over 50 have less physical and more, there are other diseases, tolerate surgery is poor, and therefore over the age of 40 to 50 Patients conservative.
5. Combined with other disease conditions such as blockage caused by benign support for the expansion, mainly for the treatment of tumor resection; tuberculosis due to branch expansion (mostly on the leaves), then TB has become more stable and do not have surgery.
6. General condition and whether any other disease, heart, liver, kidney and other systems a serious disease, or heart and lung function is poor, can not undergo surgery, only medical treatment.
7. Live, work and medical conditions such as living and medical conditions are good, work is not very tired, more conservative treatment to maintain stable disease. The case of field operations, manual labor, students in the study, medical conditions not too good, worsening disease treatment difficult, the best removal of lesions.
8. The patients themselves and family members agree to support expansion of general surgery in childhood disease, bronchial and lung parenchymal disease is not reversible, repeated lung disease worsened significantly affect the quality of life and labor, if the best conditions for removal of lesions. But in recent years emerging new antibiotics can effectively control the lung infection, a considerable part of the branch expansion of lesions can remain "steady state", the patients health, continue to work, need for surgery has decreased, but that no longer need to have surgery incorrect. Because thoracic surgery has been fairly safe operation, good results, so the treatment for each patient should be weighed against the individual consideration.
Support expansion of treatment consists of several parts: ① antibiotics to treat the infection. ② treatment of complications caused by branch expansion, such as sinusitis. ③ symptomatic treatment, such as hemoptysis, a large number of purulent sputum. ④ surgery or lung transplantation. ⑤ breathing exercises and physical therapy to improve the quality of life and ability to work, clinicians often easy to overlook this point. ⑥ special reasons, such as immune deficiency, congenital genetic disease caused by branch expansion, such as the original cause can not be corrected, and only show with a breast medical treatment.
Medical treatment is the basis, even if there is a clear indication for surgery is also medical treatment is to undergo a period of time, it was considered the treatment more than six months at least, for some support after the expansion in the lung infection control may return to normal, but after the disappearance of surgery in acute inflammation would also safer, better effect. Inoperable cases, you will need long-term medical treatment.
(A) support expansion of the medical treatment
1. Control the infection to relieve symptoms without surgery is life extension support the existence of disease, symptoms from time to time, when light weight, medical treatment to consider when to use, what drugs, how to use (dose, way and period). Absence of fever, cough is not increased, only the phlegm, the patient no discomfort, no need to use antibiotics. If sputum was purulent (often in the upper respiratory tract infection), with broad-spectrum antibiotics, the standard dose of at least 1 to 2 weeks to become mucoid sputum. A yellow-green purulent sputum, and shows the progress of inflammation, lung damage continues to be an active drug, but to make mucous sputum conversion is not easy. If the disease has been "stable", once the deterioration also need active treatment. Nong Tan of mucus often, the effectiveness of antibiotics is a problem. The choice of antibiotics based on experience and patient response to treatment, sputum culture and drug sensitivity test is not completely reliable. Acute infections such as pneumonia, congestive heart tissue, lung and blood in high concentrations of antibiotics, is effective. Chronic suppurative disease of drug reaction is not very good, perhaps because: â‘  antibiotics can not be through the bronchial wall to lumen, and bacterial two purulent secretions in the lumen. â‘¡ bacteria not sensitive to the drug itself, anaerobic bacteria (foul sputum cough) is also against the drug.
Treatment period of disagreement, some people believe that effective treatment can be about 2 weeks, there are claims 6 to 10 months of medication to reduce inflammation of the lung damage, prevent fibrosis, few studies in this area. As seen on the most current clinical is chronic, even if the long-term medication can not prevent lung damage, treatment to the symptoms disappear.
2. Postural drainage branch expansion occurred in the sagging parts of the lung, poor drainage. Normal expectoration by coughing, supporting expansion in patients with bronchial cartilage and mucus clearance mechanism has been damaged, can not cough, cough up phlegm all, X-ray examination, see the proximal bronchial cough completely collapse, not sputum row, so it is best postural drainage by gravity lines, so that flow around the sputum to be coughed up the hilar bronchus at large. According to the bronchial different direction gracefully after position, deep breathing, 10 ~ 15min cough up phlegm after, the implementation of several times a day, while additional treatment methods such as chest percussion. Phlegm day in 30ml or more, sooner or later drainage.
3. Hemoptysis hemoptysis is to support expansion of the treatment of common symptoms, and the main reason for the life-threatening hemoptysis often without clear incentives, not necessarily with other symptoms such as fever, cough purulent sputum and parallel. Small amount of hemoptysis by rest, sedatives, hemostatic, generally stopped. Possible massive hemoptysis of bronchial artery embolization. Bronchoscopy (preferably with a hard lens) check, local injection of ice water, with long and thin gauze or Fogarty tube blockage.
4. Other therapies in the acute infection, adequate rest, nutrition, supportive care can be lacking. Bronchodilators may be useful in pulmonary function tests found that airway blockage, FEV1 had improved after treatment, and may continue medication, the trial of prednisone may be invalid, such as subjective symptoms with no improvement after, do not give. In some rare cases, if any, immune suppression, you can use human globulin.
(B) surgery
1. Surgical indications
(1) In patients with limited, there are obvious symptoms, or recurrent pulmonary infection, which is the main indication, lung lesions can be completely removed, and achieved good results.
(2) had bilateral disease, a serious side, the opposite is very light, the main symptoms of seriously ill from the side of the square, you can remove this side, such as the contralateral lesions after drug therapy is still the symptoms can be.
(3) severe lesions double rule has limitations, if any, and other symptoms of hemoptysis, the first removal of heavy side, after contralateral lesions, such as stability, observation and medical treatment, such as the lesions progress, and then removed.
(4) removal of acute hemoptysis. Existing bronchial artery embolization, most can be changed to this method to stop bleeding after elective surgery. Had bronchial angiography, the lesions clear, the current technology level, acute hemoptysis can also be removed. If the original non-bronchial angiography, and extent of the lesion is unknown, then the operation is difficult. It was based on signs (such as auscultation with rales), chest radiograph, and no intention to see the decision support removal of fiber mode, but not very reliable. Bronchoscopy can see the bleeding source, but a large check dangerous hemoptysis, bronchoscopy may soon make up the lens into the stain, after what was invisible. Call within the bronchial tree is full of blood, or suction clean Which shortly after endobronchial emission and no blood, you can not locate. Sometimes seen in the total bronchial blood, but not the side of the lung have lesions. Small bronchial lumen, bronchial secretions lubricate the wall there, bleeding easily flow to the low post (such as the lower lying under the dorsal segment or the whole leaf), easy to make wrong judgments. In short, without special needs, it is best not acute lung resection, due to the high technical requirements of anesthesia, thoracotomy sometimes see most of the lungs with blood, was purple, can not determine the resection, and even more mistakenly cut lung tissue. After lung resection, lung due to inhalation of more than blood, or infection may be poor expansion, so emergency surgery complications and mortality are high.
(5) have extensive bilateral lesions, the patient general condition and worsening lung function, medical therapy, estimated survival time of less than 1 to 2 years age and under 55 years of age, consider bilateral lung transplant. Human lung transplantation was the same kind of success in 1983, and 1998 have applied to more than 8000 cases worldwide, indications are charged to a certain percentage of total expansion. 1 year survival rate of 79% to 90% of a dying patient, this effect is quite satisfactory.
2. Surgical program design
(1) If the limitations of disease, it is at the normal section to the whole of resectable lung, the most common is the left lower lobe resection plus lingual segment, left or right lower lobe and right middle lobe.
(2), the basal leaves of the lesion, while the back section of the normal situation many see the back section can be retained. But even without all the affected basal segment, generally do not make a single basal segment resection, because of unclear boundaries between segments, not the size of each basal segment large, forced separation, retained a limited lung function, complications were significantly increased.
(3) sometimes did not reach the tongue segment, segmental resection of the tongue can be a separate line.
(4) bilateral lesions, such as are more limited, the young patients, in general good, can be removed at once, with the chest with bilateral anterior incision or sequential bilateral incision surgery. If the general situation does not allow, do first side of the Ceguo 3 to 6 months before making an interval of the length of the case may be based on physical recovery, individual patients had complications due to surgery or the side of greater impairment of lung function may eventually be not contralateral surgery.
Many see the expansion of bilateral support: such as massive hemoptysis, and recurrent pulmonary infection, treatment difficulties. Often from the child support extended by the disease, as long as there is enough to leave normal lung tissue, can be divided into sub-cut, the literature has been reported in 3 surgeries, and finally left upper lobe and bilateral leaving only a total of 8 segments right upper lobe lung. Great potential for pulmonary respiration due, this can maintain the political life of the lung. Important is that each operation requires cautious. Can not be any complications.
Support expansion of lung tissue removed Duoshao solely on the basis of preoperative bronchography Suoxian may be, surgical thoracotomy Suojian reference, a considerable proportion of patients the appearance of normal lung, palpation and no exception, can not determine the extent of disease. Between the pathological changes seen in patients from heavy to light, can reduce lung volume, atelectasis or consolidation; small lesions in the lung parenchyma; sometimes pigment decreased pulmonary disease, emphysema was pink like, perhaps because of childhood illness, pregnant not participate in respiratory ventilation, dust the outside world did not inhale. Disease has spread to the pleura with adhesion. Almost all had hilar inflammation, enlarged lymph nodes, the organizations are closely adhesion. Ipsilateral normal lung more than a compensatory emphysema. Perioperative surgical plan are all these findings affect the decision. Lingual segment left upper lobe resection in Canada under the leaves, such as the large area of lung is not healthy, very little volume, leaving the residual cavity is too large, and sometimes had to change the whole lung resection in order to avoid serious complications.
3. Preoperative preparation
(1) a variety of routine laboratory tests, special attention to sputum culture and drug allergy test.
(2) pulmonary function, blood gas, nuclear, pulmonary perfusion.
(3) to improve nutrition.
(4) sputum to the appropriate antibiotics, the best sputum volume reduced to 30ml / d below the sputum becomes purulent mucus from the time of reoperation, treatment time may grow to more than 2 weeks.
(5) sputum postural drainage.
(6) respiratory training and physical therapy to improve lung function.
(7) recently made bronchography using iodized oil iodized oil to be drained to do. General can be drained in a few days. However, individual lipiodol has entered the bronchioles or alveolar, possible long-term retention, can not wait, said from the lung, angiography 3 days after the surgery has little impact.
4. Support some expansion of the residual lung resection symptoms of reasons:
(1) plastic surgery of bilateral bronchography, and some poor filling branch was not found, surgical resection is not clean, support expansion of residual symptoms.
(2) The bilateral lesions, only the removal of heavy side, the lighter side of the branch is still extended.
(3) side of the partial lung resection, after more than over-expansion of lung bronchial distortion, poor drainage, infection, or even the formation of a new branch expansion.
(4) bronchial stump after lung resection to stay too long, there is secretion retention, or for cable head stump stimulation, granulation formation, induced cough hemoptysis.
(5) support expansion of the original cause relevant factors, such as the unprecedented nasal inflammation, chronic bronchitis or untreated with immune-related defect.
(6) may have occult bronchial fistula, bronchial stump fistula leading to a small abscess. Cough cough, yellow sputum and sometimes after a general respiratory infections, the support may not extend the original surgery related. Support expanding again after partial lung resection hemoptysis, or seen from time to time of hemoptysis, bronchoscopy bronchial stump often normal, I do not necessarily have residual pulmonary angiography branch expansion, we are treated with bronchial artery embolization, a very effective Well, before embolization of bronchial arteriography see a lot of local thickening of the hilar vessels, and even cluster into groups, and other reasons to explore. If embolization is not valid, and if other conditions permit, the resectability of the remaining lung tissue.
5. Surgical treatment results and indications of choice has a lot to strict precedent operative mortality <1% in experienced units, essentially no operative mortality, postoperative symptoms 80%, 15% improvement, still a bit Zhengzhuang , 5% no improvement or deterioration. Relationship between symptom improvement and the surgery is sometimes difficult to determine, resulting in more than symptoms of lung conditions, and some already clear before surgery, but not by surgery.
6. Anesthetic and surgical problems related to double-lumen endotracheal intubation, anesthesia is best, even if much of preoperative sputum of patients, surgery may be squeezed between the lung due to a large number of purulent emission, such as single-chamber suction tube may be too late frequently affect the respiratory suction and ventilation. If hemoptysis hemoptysis among patients, double lumen intubation to prevent blood flow to the opposite, in the positioning of hemoptysis is also helpful. When the branch expansion of the lung after bronchial clamping should no longer have blood sucked out, such as blood continued to consider other parts of the bleeding.
Children or young female patients than tracheal tube can not be inserted bilaterally, phlegm, consider taking the prone position, with the postural expectoration. Can also be inserted to the side of a single chamber, to be returned to operation after being caught between the bronchial airway, such as the disease spread to the pleura, tight adhesion, in which more than a body - pulmonary artery communicating branch, separation should pay attention to hemostasis ligation.
May not support extended by pleural adhesions due to recurrent lung infections, and even has shown a close almost all the hilar scar adhesions, a variety of anatomical structures and lymph nodes stick together, during which almost no loose connective tissue layer. Wild expansion tortuous bronchial arteries is a common degree of the most serious lung disease, normal hilar bronchial artery diameter at little more than 1 ~ 2mm, and made from our video to see a lot of bronchial artery, patients can be roughly up to support expansion 5 ~ 6mm, special attention when dealing with hilar, when necessary and possible first bronchial artery in the aorta (the equivalent of T5, T6 height) ligation or the beginning part of the soft tissue next to the first bronchial all suture. Hilar adhesions tight situation, sometimes surrounding the lung start to separate from the final disposition of all pathological lung tissue. Bronchial quality hardware and easy to identify, if necessary, cut off, you can see the suture lumen. Its next to the ligation of blood vessels can be divided into bundles to avoid damage caused by forced separation of the blood vessels do not intend to remove the lung.
Etiology】 【Back
Branch expansion is acquired in childhood diseases, it may be a number of congenital abnormal results or for genetic diseases caused by defects (the relevant factors see table). The main reason for the lesions of acquired infection and bronchial congestion, drugs can control most of the infected cases, congenital or genetic factors relative fold increase in the proportion, of course, in general, or very little.
Relevant factors have bronchiectasis
(A) congenital
Is divided into primary and secondary categories.
1. Major structural defects trachea, bronchus huge disease, bronchial softening, sequestration, other.
2. Ultrastructural defects in cilia syndrome does not resign, Kartargener syndrome, Young syndrome.
3. Metabolic defects in cystic fibrosis, α1-antitrypsin deficiency.
(B) Acquired
1. Primary infection (usually when the child) measles, whooping cough, bronchiolitis, pneumonia, tuberculosis.
2. Blockage of secondary infection bronchial foreign body, tumor.
(C) disease associated with immune disorders
1.'s Own immune disease ulcerative colitis, rheumatoid arthritis, lupus erythematosus, idiopathic fibrosis, pneumonitis, thyroiditis, pernicious anemia.
2. Allergic bronchial sexually transmitted diseases, pulmonary aspergillosis.
(Iv) support expansion of its progress, repeated or persistent infections
Pathogenesis】 【Back
Infection is the main source of the disease, and many support expansion of early childhood respiratory damage from the patient to recall the characteristics of lung disease have, hours with pneumonia, whooping cough, measles or tuberculosis history.
Bronchial congestion is an important factor, but the ultimate cause may still be blocked because of poor drainage, after, secretion retention, infection. Lung bronchus in 6 to 7 remote, if not infection is a sterile, simply plug the bronchial atelectasis varies from time to time caused by infection, such as trauma following the split of bronchial atelectasis after a few year later in the lung may bronchial anastomosis still healthy open. Human lung congestion around the bronchioles of the common changes for children, chest X online pertussis often small pieces atelectasis. Support for children Xue tube soft, easy to be enlarged lymph nodes oppression. The most common is the right middle bronchus, due to relatively smaller, and the angle between the lower lobe was an acute angle, the up and down and around the front of the lymph nodes, when there is inflammation of the lungs, lymph nodes increase the oppression of the middle bronchus, caused wholly or partially sheets or blockage of pneumonia, bronchial wall damage, and ultimately the formation of branch expansion. In the inflammation disappeared, lymph nodes can be reduced further after the middle of the opening, but the support has been extended irreversible disease and pneumonia, the formation of a common "middle lobe syndrome."
Damage due to inflammation in the bronchial wall weakness, but also reduced lung volume, atelectasis, intrathoracic negative pressure increases, the role of the bronchial wall are involved, causing expansion, support expansion of the patient's chronic cough, the bronchial pressure increases, more emphasis the lumen of the expansion and retention of bronchial secretions pressure, and pulmonary fibrosis, traction bronchiectasis, etc. It is formed by several mechanisms.
Pathological changes】 【Back
Expansion of the total expenditure changes: invasion and medium-sized bronchi, from about 4 to 9, branch expansion area is covered by squamous or columnar epithelium, often without cilia, the surface may not see the epithelium. According to severity, bronchial wall have different degrees of atrophy, muscular layer and elastic layer damage, replaced by fibrous tissue, sometimes leaving only a small amount of muscle or cartilage. Neutrophils soak the wall, and some patients have dense infiltration of lymphocytes. According to the range of lesions, small bronchi and bronchioles side can be breaking from its mother, plugging and disappeared (the result of inflammation), this change of bronchiolitis obliterans in lung function than the expansion itself more damage. Expansion of the dendrites from the form of points, mixed cystic and three, and sometimes there are two changes, as leaves cystic, and the tongue-shaped section of the operation. Pathological changes in columnar light, cystic heavier, the naked eye can see the cavity and bronchial phase can, thin wall, constituted by the fiber or granulation, and some live coverage of the material keep mucus, cystic expansion of the branch pocket full of pus, these instructions have active infection. If there is no infection, only a small amount of mucus secretions, which is "dry branch expansion," because a large number of chronically infected mucus secretions continued to "wet branch expansion."
Peribronchial fibrosis often, there are different degrees of pulmonary fibrosis, atelectasis and pneumonia.
Support expansion of areas: the left lower lobe and more common, the Ye Shao, middle and middle section of the tongue, the tongue section of the lower left lobe plus the most common lesions.
Epidemiology】 【Back
Because the expansion is supported by the diagnosis of bronchial angiography and autopsy, not the census, the incidence of the total population of no reliable figures. 1953 Bedford reported incidence rate of 1.3% in the control of tuberculosis in 1956 campaign, 350 million chest X-ray inspection, see expanded incidence rate of 1.5% support and some of those reported in the general incidence rate of 0.3% to 0.5% General autopsy was 2% to 3%, chronic lung infections in 23.3%. Although these figures may not be accurate, but can be seen in the past is considerable. General experience in a wide range of antibiotics decreased the incidence after application, due to the treatment of respiratory tract infection in children is more effective as a predisposing factor supporting expansion of whooping cough, measles is close to disappearing, the prevalence of TB has decreased, so in the Western developed countries, support expansion have been rare, but in the third world is still a widespread problem.
Clinical manifestations】 【Back
Support expansion of more men than women.
Support expansion of the severity of the symptoms of the disease, or worse still type and the different treatment of reactions are very different. Light may have no symptoms, only to find in the physical examination. Weight continued to cough, a large number of mucous purulent, foul sputum, the patient long-term difficulty in breathing, weakness. The extensive application of antibiotics, patients continued to have little severe symptoms, many patients can maintain a certain level of health and labor. However, when lung infection is (often repeated in the same area), often feel chest discomfort, cough, a small amount of purulent sputum, high quality of life of patients, poor tolerance of labor.
Chronic cough, sputum and hemoptysis as the main symptoms. The most common persistent cough, cough is caused by inflammation, mainly for expectoration, when the early morning when expectoration or postural drainage array cough, take the affected side of the lateral position in the low, cough that is reduced, increased cough, sputum disease aggravated degradation . Sputum and the disease severity, scope and delivery tube drainage is clear about, such as increased disease, fever, bronchial obstruction, sputum volume has decreased. Static lesions may not sputum, a "dry branch expansion." Lesions of patients every day, a small amount of light yellow sputum, severe sputum volume up to several hundred milliliters of the day, standing for the post-bubble see the upper, middle for the mucus, the lower block of yellow pus, in a growth of anaerobic bacteria, and sputum have evil self. At present, because there are several effective antibiotics, a large number of Nong Tan has been limited.
Due to repeated lung infections and worsening of chronic, often systemic symptoms such as fever, anorexia, weight loss, anemia. Growth and development in children and can cause malnutrition. Disease has spread to the pleura pleurisy and empyema, chest pain is often the main complaint of patients. Recurrent disease deterioration, and finally to the whole lung or part of the lung damage, can form heart disease, even right heart failure. In the era before antibiotics, blood infection spread, resulting in brain abscess, is now rare. The combined symptoms of upper respiratory tract infection and sinusitis, tonsillitis and so on.
Signs: Early and mild positive signs do not support expansion, generally in support of patients with locally persistent expansion of moist rales, coughing, after expectoration disappeared only temporarily, such as a wide range of bilateral dry rales, then expand the merged Forum bronchitis. Clubbing Field1994 report found that 44% of 20 years to 7%. There are other complications have corresponding signs.
Lung damage depends on the number of damaged tissue, mild support extended examination no abnormality was found more in the diagnosis of little importance, but in the surgical treatment to consider.
Prognosis】 【Back
For the prognosis of branch expansion, more reports, opinions are very inconsistent, owing to local conditions and treatment of patients is different. Significant changes in the natural history of bronchiectasis.
Difficult to estimate the prognosis of branch expansion, but also some of the observed CONCLUSION: ① The number of different pathogens branch expansion is the final pathological results, the different prognosis of different diseases such as tuberculosis and a good cause, but genetic cystic fibrosis, since mortality still high. ② poor prognosis extensive disease, disease deterioration, and sometimes with pulmonary heart disease and finally death. ③ broad-spectrum antibiotics Po Support Children's Hospital expansion decreased. Although the symptoms had improved gradually ④, chest disease may progress. ⑤ judge the results of surgical treatment is very subjective, due to surgery precedent different standards, different length of follow-up years, from 50% to 75% of patients improved completely asymptomatic or greatly improved range.
To further improve the prognosis of the disease depends on understanding of the mechanisms that support expansion of idiopathic causes, and improve special reasons (such as immune deficiency) due to branch expansion of processing and trying to prevent "dangerous" people charged to expand place.
Pathophysiology of bronchiectasis
Time: March 6, 2010 Source: www.yodak.net Font Size: [medium and small] online consultation online registration Abstract: Bronchiectasis can be unilateral or bilateral, mostly in the lower lobe, but also occurs in tongue right middle lobe and left upper lung lobe. Traditionally, according to pathology and X-ray will be divided into cylindrical, varicose or cystic-like. However, little clinical value of this distinction.
Bronchiectasis can be unilateral or bilateral, mostly in the lower lobe, but also occurs in the right middle lobe and left upper lobe lung tongue. Traditionally, pathology and X-ray according to its divided into cylindrical, varicose or cystic-like. However, little clinical value of this distinction. Recently, high-resolution and helical CT with pathological features related to this classi
fication tends to have been abandoned.
Pathology, the bronchial wall show a wide range of inflammatory damage, chronic inflammation, mucus plugs and cilia loss. Adjacent areas of interstitial and alveolar destruction, tissue regeneration and fibrosis, leading to reduced lung volume. Often accompanied by chronic bronchitis, bronchiectasis and / or emphysema and the degree of fibrosis.
Pathological changes in the extent and characteristics of the decision of this disease and hemodynamic abnormalities, usually including reduced lung volume and gas flow rate decreased, ventilation / perfusion imbalance and hypoxia. Bronchial artery and pulmonary artery are widely seen fit, with significant enlargement of bronchial arteries. Bronchial veins and pulmonary venous anastomosis also increased, the above results in increased blood flow, right to left shunt and hypoxemia, leading to advanced pulmonary hypertension and pulmonary heart disease.
(Editor: Michael)
Key words: bronchiectasis
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