经气管镜介入抗痨治疗溃疡坏死型支气管结核疗效评价

发布时间：2018-03-17 03:03

本文选题：纤维支气管镜　切入点：支气管结核　出处：《天津医科大学》2012年硕士论文　论文类型：学位论文

【摘要】：支气管结核(endobronchial tuberculosis, EBTB),是指发生在气管、支气管黏膜、黏膜下层和外膜(软骨和纤维组织)的结核病,既往亦曾称为“支气管内膜结核”。活动性肺结核中大约10%～40%伴有EBTB。一般认为女性发病是男性的2-3倍,中青年发病更常见,但老年EBTB有增加趋势。主支气管、两肺上叶、右肺中叶、左肺上叶舌段支气管为好发部位。成人EBTB最常见的感染途径是肺内病灶中结核分支杆菌直接植入支气管黏膜。近年来随着纤维支气管镜应用的普及以及医务人员对EBTB认知度的提高,EBTB患者的确诊率逐步提高。但在常规抗结核治疗过程中患者临床症状缓解及痰菌阴转慢,受累支气管易发生不同程度狭窄甚至导致严重肺不张,重者需要手术治疗,因此在常规治疗基础上需对EBTB患者进行积极干预。在本临床研究中选取溃疡坏死型EBTB(即纤维支气管镜下结核病变明显期)患者做为研究对象,探讨在全身化疗基础上进一步通过纤维支气管镜对病变气管进行介入治疗的疗效评估。目的：评价在全身化疗(肺外结核化疗方案)基础上经纤维支气管镜局部注药治疗溃疡坏死型支气管结核的疗效。方法：选取经纤维支气管镜检查确诊的初次抗结核治疗的溃疡坏死型支气管结核45例,分为介入治疗组及基础治疗组,观察期为6个月。两组患者入组时需完善血、尿常规、肝肾功能、胸片、胸部CT及痰抗酸染色检查,无肝肾功能异常,此后前2月每半月复查血生化、胸部影像学及痰抗酸染色,后4月每月复查一次上述检查。两组患者观察期内化疗方案为2HRZE/4HR (INH0.3QD, RFP0.45QD, EMB0.75QD, PZA0.5TID)及雾化吸入抗痨药物治疗(NS20ML+1NH0.1+Amikacin0.2QD),观察期结束后继续巩固抗结核治疗。介入治疗组采用Olympus BF-1T30型纤维支气管镜及配套毛刷、活检钳、注药管,术前准备、局麻、操作步骤按纤支镜临床操作指南进行。具体操作为在气管镜直视下将气管内分泌物充分吸引、并应用活检钳钳取干酪坏死物质后局部注入抗痨药物凝胶(含INH、RFP、SM,若SM过敏可单独配药),每2周1次,根据病情好转情况停止注药。具体停止注药时机掌握为气管内干酪坏死物消失、痰抗酸染色检查连续2次阴性,至观察结束治疗组患者共计行3-7次纤支镜治疗。结果：介入治疗组患者临床症状缓解(平均16.2天)、痰菌阴转(平均25.3天)及胸部影像学好转(平均15.4天)均优于基础治疗组。介入治疗组中有21例患者入组时存在不同程度支气管狭窄,至观察结束支气管内干酪坏死物已消失,19例气管狭窄减轻,2例病变气管形成肉芽肿、狭窄较前加重。基础治疗组患者16例患者入组时存在不同程度支气管狭窄,至观察结束气管内干酪坏死物亦消失,仅有8例气管狭窄减轻,5例病变气管形成肉芽肿、狭窄较前加重,2例变化不大。结论：经纤维支气管镜局部注药治疗溃疡坏死型支气管结核,使患者临床症状缓解加快,加速痰菌阴转,减轻支气管狭窄,促进肺不张的复张,改善预后。
[Abstract]:Bronchial tuberculosis (endobronchial tuberculosis, EBTB), refers to the place in the trachea, bronchial mucosa, submucosa and tunica adventitia (cartilage and fibrous tissue) of tuberculosis, also known as the "history of endobronchial tuberculosis. Active pulmonary tuberculosis in about 10% ~ 40% with EBTB. is generally considered that the female incidence is 2-3 times that of men, in young onset is more common, but the old EBTB has an increasing trend. The main bronchus, two upper lobe, right middle lobe, left lung lingual lobe bronchus is the predilection sites of infection. The most common way of adult EBTB tuberculosis pulmonary lesions in branch coli directly into the bronchial mucosa. In recent years, with the popularity of the application of fiberoptic bronchoscopy. The medical personnel and improve awareness of EBTB, EBTB patients'diagnosis rate is gradually increased. But in the conventional process of anti tuberculosis treatment in patients with clinical symptoms and the sputum conversion is slow, not prone to bronchial involvement With the degree of stenosis and even cause severe atelectasis, or need surgery, therefore, on the basis of routine treatment for active intervention in patients with EBTB. Select the ulcer necrosis type EBTB in this clinical study (i.e. bronchoscopic tuberculosis lesions period) patients as the research object, discussed further on the basis of systemic chemotherapy through fiberoptic bronchoscopy to evaluate the effect of interventional therapy on lesions of the trachea.
Objective: To evaluate the systemic chemotherapy (pulmonary tuberculosis chemotherapy) on the basis of transbronchial treatment of local injection of necrotizing ulcerative endobronchial tuberculosis patients. Methods: 45 cases of ulcer necrosis endobronchial tuberculosis by fiberoptic bronchoscopy confirmed the initial anti tuberculosis treatment, divided into treatment group and treatment group. The observation period was 6 months. The two groups were enrolled to improve the blood, urine routine, liver and kidney function, chest X-ray, chest CT and sputum acid fast staining, no liver and kidney dysfunction, since before the February fortnightly review of blood biochemical, radiological and sputum acid fast staining, after a review of the April monthly check. Two groups of patients in the observation period of chemotherapy for 2HRZE/4HR (INH0.3QD, RFP0.45QD, EMB0.75QD, PZA0.5TID) and inhalation of anti tuberculosis drugs (NS20ML+1NH0.1+Amikacin0.2QD), after the end of the observation period to continue to consolidate the anti tuberculosis treatment. The dielectric In the treatment group were treated with Olympus BF-1T30 type of fiberoptic bronchoscopy and biopsy forceps, brush supporting, injection tube, preoperative preparation, anesthesia, operation step by bronchoscopy clinical practice guidelines. The specific operation is in the bronchoscope under direct vision tracheal secretions to attract, and the application of anti tuberculosis drugs injected gel biopsy forceps after taking the cheese necrotic material (including INH, RFP, SM, SM if allergies can separate dispensing), 1 times every 2 weeks, according to the condition improved. Stop injection stop injection timing specific disappeared endotracheal cheese necrosis, sputum acid fast staining examination of 2 consecutive negative, to the end of the observation group a total of 3-7 patients underwent bronchoscopy treatment. Results: the treatment group clinical symptoms (average 16.2 days), sputum conversion (average 25.3 days) and chest imaging improvement (mean 15.4 days) were better than the control group. Intervention group of 21 patients in When there are different degrees of bronchial stenosis, to observe the end of endobronchial cheese necrosis has disappeared, 19 cases of tracheal stenosis reduced, 2 cases of tracheal granuloma formation, stenosis were worse than before. The basic treatment of 16 cases of all patients have different degrees of bronchial stenosis group, to observe the end of endotracheal cheese necrosis also disappeared. Only 8 cases of tracheal stenosis reduced, 5 cases of tracheal granuloma formation, 2 cases of stenosis were worse than before, little change. Conclusion: fiberoptic bronchoscopy in treatment of local injection of necrotizing ulcerative type of bronchial tuberculosis in patients with clinical symptoms, accelerate, accelerate sputum conversion, relieve bronchial stenosis, promote atelectasis reexpansion and improve the prognosis.

【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R521.2

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