CT对弥漫性泛细支气管炎诊断及疗效评价的临床研究

发布时间：2018-03-09 20:48

  本文选题：弥漫性泛细支气管炎　切入点：CT　出处：《第二军医大学》2012年博士论文　论文类型：学位论文

【摘要】：第一部分弥漫性泛细支气管炎的CT诊断 目的:提高弥漫性泛细支气管炎的CT诊断及鉴别诊断能力。 材料与方法:回顾性分析我院2001年～2011年收治的92例弥漫性泛细支气管炎的CT表现。 结果:1、病灶分布：84例表现为双肺弥漫性分布，其中82例以双下肺野及肺外围显著，仅2例双肺中上野病灶较下肺野明显，6例表现为双肺野内散在斑片状分布，2例局限于双肺下叶。2、CT征象：①92例均可见小圆形小叶中心结节，结节位于支气管血管分支顶端，被胸膜、肺静脉、小叶外肺静脉或支气管（即次级肺小叶边界）所包绕，并与这些结构相距约2～3mm；结节呈颗粒状，直径约1mm，边缘较模糊，无融合；部分可见结节与其近端细支气管分出的线状影相连，有些呈树芽征；②细支气管扩张68例，呈管状或静脉曲张样扩张，10例伴有大囊状支气管扩张，伴有管壁不规则增厚，次级肺小叶范围外的支气管扩张及支气管壁增厚也较常见，周围气道扩张较近端明显，在肺野中外带突出，35例扩张的支气管内可见粘液栓塞，CT上表现为管状或分枝状致密影；③58例可见周围性空气潴留，表现为周围肺野透亮度不同程度增高，肺外围区域和中心区域的透亮度有明显差异，即外围区密度较低，在窄窗上显示更明显。尽管两者间无明确的分界线可见，但胸膜下区域在HRCT上几乎表现为透亮影；④42例见斑片状影，在肺内呈散在分布，形态不规则，边缘模糊，内部密度不均匀，部分内可见细支气管充气影，3例合并右肺中叶不张，1例见左上叶舌段不张；⑤空洞3例，，均为薄壁空洞；⑥其它：肺间质纤维化9例，主要出现在双肺下叶底部,表现为条索影和不规则网格状影，肺动脉高压（主肺动脉直径27mm）8例，纵隔、肺门部分淋巴结肿大18例，6例伴有钙化，胸膜增厚粘连17例，其中1例伴左侧胸腔积液，合并胸腺瘤和肺癌各1例。3、CT分型与临床分期的关系：CT分型Ⅰ型见于临床分期1期病人，Ⅱ型见于2期病人，Ⅲ型或Ⅳ型见于2期或3期病人。 结论: CT是诊断弥漫性泛细支气管炎的重要依据，结合临床有助于鉴别诊断。 第二部分弥漫性泛细支气管炎与支气管播散性结核的临床CT比较 目的：提高对DPB和支气管播散性结核的鉴别诊断能力，以降低DPB的误诊误治率，改善患者预后。 材料与方法：比较分析我院收治的92例DPB病人和122例以树芽征为主要表现的支气管播散性结核的临床CT特点。 结果：DPB与TB患者的年龄(47.51±16.17岁vs50.58±16.76，P=0.820)、性别(47.83%vs45.90%，P=0.780)差异无统计学意义。而DPB患者合并副鼻窦炎的比率要显著高于TB(78.26%vs5.73%，P0.001)。两组病例主要的症状均为咳嗽、咳痰。咯血也比较多见于DPB和TB，两者比较差异无统计学意义(29.35%vs25.41%，P=0.521)。而劳力性呼吸困难(96.74%vs19.67%，P0.001)和粗湿罗音(100%vs36.89%, P0.001)更多见于DPB患者。DPB病人外周血WBC计数和免疫球蛋白IgA水平显著高于肺结核患者。肺功能检查FEV1/FVC 70%，或动脉血氧分压80mmHg的患者所占比率在DPB更高。胸部CT上所有的DPB患者病变均为双侧分布，而肺结核84.43%为双侧分布，两者差异有统计学意义（P＜0.001）。肺结核和DPB患者最常见的CT征象是细支气管炎和细支气管扩张。然而，在病变范围上，DPB患者分布更广泛。与TB相比，DPB患者细支气管炎和细支气管扩张累及更多的肺叶(分别为5.11±1.13vs3.83±1.62，P＜0.001；4.72±1.44vs1.76±0.45，P＜0.001)。DPB患者细支气管炎及细支气管扩张更多累及双肺下叶、右肺中叶及左上叶舌段，而TB更多见于双肺上叶及右肺下叶。肺内斑片影及空洞更多见于TB患者(分别为87.70%vs45.65%，P＜0.001；80.33%vs3.26%，P＜0.001)。 结论：DPB和支气管播散性结核的某些临床及影像学特点对两者具有一定的鉴别价值，但仍存在相当大的交叉，因此当鉴别困难时，有时为明确诊断，有必要采取有创性组组织学活检。 第三部分CT对弥漫性泛细支气管炎疗效评价的价值 目的：探讨CT对DPB患者病情评估及治疗后疗效评价的价值。 材料与方法：评价43例DPB病人阿奇霉素治疗前和治疗后6个月7项CT评分和肺功能参数之间的关系。 结果：1、43例均可见小叶中心结节及支气管扩张。37例（86.05%）小叶中心结节分布范围广泛，评分为3分，6例（13.95%）评分为2分。19例（44.19%）支气管扩张范围广泛，评分为3分，另外7例（16.28%）为2分，17例（39.53%）为1分。5例（11.63%）为重度支气管扩张（评分为3分），7例（16.28%）为中度支气管扩张（评分为2分），其余31例（72.09%）为轻度支气管扩张（评分为1分）。38例（88.37%）伴支气管壁增厚。35例（81.39%）见粘液栓塞。31例（72.09%）可见空气潴留。肺不张或实变见于20例（46.51%）。阿奇霉素治疗前CT评分总分由7项累计计算得出，总分为10.53±4.56分。2、阿奇霉素治疗后，CT评分与治疗前相比可见显著下降（p0.01）。在各项CT征象评分中，治疗后小叶中心结节、支气管扩张和粘液栓塞的范围，以及支气管壁增厚程度显著降低（小叶中心结节，p0.01；支气管扩张，p0.01；粘液栓塞，p=0.016；支气管壁增厚，p0.01）。然而，支气管扩张程度在治疗前后无显著差异，另外，肺气肿和空气潴留、不张和实变治疗后也无显著改善。3、治疗后FVC%、FEV1%、PaO2均可见显著提高（FVC%,71.05±18.64～87±21.01，p0.01；FEV1%,58.72±18.19～73.58±19.85，p0.01；PaO2，70.00±5.88～84.42±10.81mmHg, p0.01）。4、治疗前CT评分与FVC%（r=-0.743,p0.01）、 FEV1%（r=-0.723,p0.01）、 PaO2（r=-0.469,p0.01）均有显著的相关性。治疗后小叶中心结节△CT评分与△FVC%（r=-0.683,p0.01）、△FEV1%（r=-0.579,p0.01）具有显著相关性。 结论：CT评分可有效评价DPB病人气道病变的严重程度，阿奇霉素治疗后小叶中心结节、支气管壁增厚及粘液栓塞为可逆性病变，肺野中心区支气管扩张为不可逆病变，小叶中心结节的变化是DPB患者治疗后肺功能改善的主要因素，可利用CT对DPB进行分期、指导治疗、评估疗效及随访。
[Abstract]:CT diagnosis of diffuse bronchiolitis in the first part
Objective: to improve the CT diagnosis and differential diagnosis of diffuse bronchiolitis.
Materials and methods: a retrospective analysis of the CT manifestations of 92 cases of diffuse bronchiolitis in our hospital from 2001 to 2011.
Results: 1 lesions: 84 cases showed diffuse distribution, including 82 cases with double lung and peripheral lung significantly, only 2 cases of lung lesions than in Ueno significantly lower lung field, 6 cases showed double lung field scattered and patchy in distribution, 2 cases were confined to the lower lung leaf.2, CT signs of the 92 cases showed small round centrilobular nodules, nodules in the bronchial vascular branches are top, pleura, pulmonary vein, pulmonary vein or bronchial extralobular (i.e. the secondary pulmonary lobule boundary) surrounded, and these structures are about 2 ~ 3mm; granular nodules, a diameter of about 1mm no, blurry edge, fusion; visible nodules with proximal bronchi into linear opacities connected, there was a tree in bud; the bronchiolar dilatation in 68 cases, tubular or varicose vein dilation, 10 patients with large cystic bronchiectasis, with irregular wall thickening, outside the scope of the secondary pulmonary lobule branch Bronchiectasis and bronchial wall thickening is common around airway dilation than proximal obviously in the lung in 35 cases with prominent dilated bronchial mucus visible embolism, CT showed tubular and branching density; the 58 cases showed peripheral air retention, performance for the surrounding lung touliangdu wild in different degrees increased brightness of peripheral lung region and the central region have obvious difference, namely the peripheral area of low density in the narrow window shows more obvious. Although no clear demarcation line between the two is visible, but the subpleural region in the HRCT is almost translucent shadow in 42 cases; the patchy shadow in the lung was. Scattered, irregular shape, edge, internal uneven density, some visible bronchial inflatable shadow, 3 cases with right middle lobe atelectasis, 1 cases of left lobe atelectasis; the cavity in 3 cases, all the other: thin-walled cavity; interstitial pulmonary fibrosis Of the 9 cases, mainly in the lung by the bottom, as the cable video and irregular grid shadow, pulmonary hypertension (pulmonary artery diameter 27mm) 8 cases, mediastinum, 18 cases of enlarged lymph nodes of lung door part, 6 cases with calcification, pleural thickening in 17 cases, including 1 cases with left pleural effusion, 1 cases of lung cancer complicated with thymoma and the relationship between.3, CT classification and clinical stages: CT type I type in clinical staging in 1 patients, type II in 2 patients, type III or type IV in 2 or 3 patients.
Conclusion: CT is an important basis for the diagnosis of diffuse bronchiolitis and it is helpful for differential diagnosis.
The clinical CT comparison of diffuse bronchiolitis and bronchoalveolar tuberculosis in the second part
Objective: to improve the differential diagnosis of DPB and bronchoalveolar tuberculosis, in order to reduce the misdiagnosis and mistreatment rate of DPB and improve the prognosis of the patients.
Materials and methods: the clinical CT characteristics of 92 cases of DPB patients and 122 cases of bronchial disseminated tuberculosis were compared and analyzed in our hospital.
Results: DPB and TB with age (47.51 + 16.17 vs50.58 + 16.76, P=0.820), gender (47.83%vs45.90%, P=0.780) showed no significant difference. The rate of DPB in patients with sinusitis was significantly higher than that of TB (78.26%vs5.73%, P0.001). The main symptoms of two cases were cough, sputum hemoptysis is also more. In DPB and TB, there was significant difference between the two groups (29.35%vs25.41%, P=0.521) and exertional dyspnea (96.74%vs19.67%, P0.001) and coarse rales (100%vs36.89%, P0.001) is more common in patients with DPB.DPB patients peripheral blood WBC count and immunoglobulin IgA levels were significantly higher in patients with pulmonary tuberculosis. Pulmonary function tests FEV1/FVC 70% or 80mmHg, PaO2 higher proportion of patients in DPB. Chest CT of all patients with DPB lesions were bilateral distribution, and bilateral distribution of pulmonary tuberculosis in 84.43%, the difference was statistically significant (P < 0. 001) CT. The most common symptoms in patients with pulmonary tuberculosis and DPB are bronchiolitis and bronchiolectasis. However, in the range of lesions, DPB were more widely distributed. Compared with TB, DPB patients with bronchiolitis and bronchiolectasis involving more lobes (5.11 + 1.13vs3.83 + 1.62, P < 0.001; 4.72 + 1.44vs1.76 + 0.45, P < 0.001) of.DPB patients with bronchiolitis and bronchiolectasis more involving both lower lobe, right middle lobe and left lobe, while TB is more common in upper lobe and lower lobe of right lung. Lung patchy shadow and cavity is more common in patients with TB (87.70%vs45.65%, P < 0.001; 80.33%vs3.26%, P < 0.001).
Conclusion: some clinical and imaging features of DPB and bronchogenic disseminated tuberculosis have certain differential value for both. However, there still exist considerable crossover. Therefore, when identifying difficulties, it is sometimes necessary to make a definite diagnosis. It is necessary to take invasive histologic biopsy.
The value of the third part CT for the evaluation of the curative effect of diffuse bronchiolitis
Objective: To explore the value of CT in evaluating the patient's condition of DPB and evaluating the curative effect after treatment.
Materials and methods: the relationship between 7 CT scores and pulmonary function parameters before and after treatment with azithromycin in 43 DPB patients and 6 months after treatment was evaluated.
缁撴灉锛

本文编号：1590194