【作者】 高海祥；

【导师】 金普乐；

【作者基本信息】 河北医科大学 ， 内科学， 2007， 硕士

【摘要】 目的:与纤维支气管镜专用双腔球囊导管气道内置入的方法相对照,探讨经纤维支气管镜引导下气管内置入双腔球囊漂浮导管治疗咯血方法的效果及其安全性。方法1临床资料:30例咯血患者,其中男性19例,女性11例,年龄24~76岁,平均54.87±14.34岁。病因分类:支气管扩张8例,肺癌13例,肺结核6例,其他如曲菌病等3例。所有患者均符合下列条件:(1)24h咯血量在300ml以上或一次咯血量达100ml;(2)经内科常规治疗一周无效,自愿接受双腔球囊漂浮导管或纤维支气管镜专用导管治疗;(3)无严重心、肺、脑功能疾病;(4)无明显纤维支气管镜检查的禁忌症。将该30例患者随机分为两组,观察组:15例大咯血患者,采用丝线固定、双腔球囊漂浮导管和纤维支气管镜并行气道内置入的方法治疗大咯血;对照组:15例大咯血患者应用纤维支气管镜专用双腔球囊导管治疗大咯血。两组患者在年龄、性别、咯血病因、咯血量、血红蛋白量等方面对比,差异无统计学意义(P>0.05)。2双腔球囊漂浮导管的置入:用丝线将纤维支气管镜头和球囊导管前端固定到一起,然后经鼻插入气道,在吸引气道内积血同时,循气道内血迹仔细寻找出血部位,在纤维支气管镜引导下将球囊导管推向出血的段或亚段支气管,球囊内注入生理盐水,使球囊膨胀至完全封闭其段或亚段支气管。然后,关闭阀门,放松丝线,用纤维支气管镜吸尽气道残血,证实无再出血后退出纤维支气管镜,记录球囊生理盐水的用量和导管在鼻部的长度,并用T型胶布固定于患者鼻翼旁。3纤维支气管镜专用双腔球囊导管的置入:患者局麻后经鼻插入纤维支气管镜,循气道内血迹仔细寻找出血部位,确定出血部位后,固定纤维支气管镜,将拆除了阀门系统的球囊导管涂抹利多卡因凝胶和消毒石蜡油,然后将球囊导管插入纤维支气管镜工作通道并准确地送至出血部位,固定球囊导管,缓缓退出纤维支气管镜,在球囊导管尾端装上阀门系统。再次经口腔插入纤维支气管镜达出血部位,在纤维支气管镜直视下,确认球囊位置,注入生理盐水使球囊膨胀至出血停止,记录生理盐水的用量和导管在鼻部的长度,并用T型胶布固定于患者鼻翼旁。结果1治疗效果:球囊导管置入后绝大部分患者出血立即停止,观察两组病人术后出血量、出血持续时间和住院总天数,两组之间无明显差异(P>0.05)。观察组咯血治疗有效人数为15例,有效率为100%;对照组咯血治疗有效人数为13人,有效率为86.7%,两组球囊导管置入治疗咯血总有效率为93.3%.2两组操作时间比较:观察组平均置管操作时间为8.3±1.0分钟;对照组平均置管操作时间为14.5±2.7分钟,观察组的置管操作时间明显较对照组的置管时间短,统计学有差异(P<0.05)。观察组球囊导管留置时间与对照组球囊导管留置时间无统计学差异(P>0.05)。3两组置管并发症:观察组术中诱发出血或出血加重观察组1例,对照组3例,两组无统计学差异(P>0.05);观察组球囊脱位及阻塞数2例,对照组4例,两组无统计学差异(P>0.05);两组术后均有1例发生阻塞性肺炎,拔管后,经抗生素治疗3~5天治愈。4球囊导管置入术的安全性4.1生命体征变化:置管前患者心率、呼吸频率高于术后2小时及拔管后,有统计学差异(P<0.05);置管前及置管术后2小时患者体温高于拔管后,它们之间有统计学差异,(P<0.05)。观察组和对照组两组之间比较,于置管前、置管后2小时、拔管后均无明显变化,统计学无差异(P>0.05) 4.2血气分析变化:患者的氧分压、二氧化碳分压及血氧饱和度于置管前、置管后2小时、拔管后测量的结果均位于正常值范围内,均无明显变化,无统计学差异(P>0.05)。同时观察组和对照组两组之间于置管前、置管后2小时、拔管后的血气分析也无明显变化,统计学无差异。结论:本研究显示丝线固定,纤维支气管镜与双腔球囊漂浮导管并行气道内置入,球囊充气,封堵和压迫出血支气管疗效确实。丝线固定双腔球囊导管置入的方法较支气管专用导管方法操作时间短、气道刺激性小、导管不易脱位,对患者的生命体征,血气无明显影响,是一种更加简单、安全、价廉和有效的新方法(P>0.05)。更多还原

【Abstract】 Objective: To evaluate the efficacy and the safety of endobronchial tamponade technique using Swan-Ganz catheter fixed by surgical thread to bronchofibroscope to treat massive hemoptysis, and compare with Fogarty catheter method.Method1. clinic data: 30 hemoptysis cases, 9 men and 11 women, their ages are between 24~76 years old, and average age is 54.87±14.34 years old. All patients including 8 bronchiectasis cases, 13 lung cancer cases 6 pulmonary tuberculosis and others such as aspergillomycosis 3 cases。They conform to the following conditions and were picked out for our research: (1) the total hemoptysis quantity was above 300ml in 24 hours or reached 100ml at one time; (2) all the patients were accepted hematostatic treatment for 1 week but had no effect, and accept the treatment with double-lumen balloon floatation catheter or Fogarty catheter voluntarily; (3 )has no serious heart, lung or brain function diseases or disturbance; (4) without obvious contraindications of bronchofibroscope. We divided the 30 patients into two groups randomly: observe group (15 examples) receive endobronchial tamponade technique of Swan-Ganz catheter fixed with bronchofibroscope by thread and control group (15 examples) were treated by endobronchial tamponade technique with Fogarty catheter. The comparison between two groups in some aspects such as age, sex, hemoptysis quantity, hemoglobin quantity and so on have no statistical significance(P>0.05).2. The method of placing Swan-Ganz catheter: Fix both tips of bronchofibroscope and the Swan-Ganz catheter with surgical thread, insert them tighter from nostril into trachea,suck the blood and find the bleeding site meanwhile. The catheter is pushed forward, place proximal to bleeding site and is inflated with Sodium Chloride until the bronchus is totally blocked up. Then shut the valve, relax the thread and pull out the bronchofibroscope after ensuring no continuous bleeding is observed. Write down the dosage of Sodium Chloride in the balloon and the length of the catheter from the nose, and then fix the catheter on nosewing with a“T”shape adhesive tape.3. The method of placing Fogarty catheter: Insert the bronchofibroscope from nostril into trachea under local anesthesia; follow the bloodstain in airway and find the bleeding site, then fix the bronchofibroscope. Deliver the balloon catheter daubed Lidocaine gelatin and disinfectant paraffin oil and removal the valve system to the bleeding site accurately through bronchofibroscope working channel, then withdraw the bronchofibroscope slowly, install the valve system. Insert the bronchofibroscope to the bleeding site once more through the oral cavity, after confirming the position of the balloon of catheter; inject Sodium Chloride until the bronchus is totally blocked up in order to stop the hemorrhage. Write down the dosage of Sodium Chloride in the balloon and the length of the catheter from the nose; fix the catheter on nosewing with a“T”shape adhesive tape at last.Results1 Curative effect: The majority of patients stop bleeding immediately after the balloon catheter was inserted. observe the bleeding quantity, the time of bleeding continues after tamponade of all the patients and the total days of patients in hospital of two groups, there is no obvious difference between two groups (P>0.05). 15 patients were effective in observe group, the effectiveness is 100% while 13 patients in control group,and the effectiveness is 86.7%,the total effectiveness of massive hemoptysis treated by double-balloon catheter tamponade technique in two groups is 93.3%.2 The comparison of two groups’operation time: The average operation time on observe group is 8.3±1.0 minutes while the control group is 14.5±2.7 minutes. The average operation time on observe group is obviously shorter than control group, there is statistics difference(P<0.05), but there is no statistics difference(P>0.05) of balloon catheter keeping time on observe group and control group.3 One patient of inducing or aggravating bleeding during the operation was observed in the observe group while three in control group, there is no statistics difference(P>0.05), the patients of catheter obstructed or dislodged was observed in the observe group were one and four in the control group, there is no statistics difference yet(P>0.05)Although one patient got obstructive pneumonia after the operation in each group, they all cured by antibiotic therapy for 3 to 5 days after the catheter was pulled out.4 Security of balloon catheter tamponade technique4.1 The change of vital signs: the patients’heart rate、respiratory frequency before catheter inserted is higher than the patients two hours after the operation, and higher than which after the catheter was pulled out too,there are statistics difference(P<0.05). Patients’temperature before catheter was inserted and two hours after the operation is higher than that after the catheter was pulled out, there is statistics difference(P<0.05). No obvious change of vital signs before catheter was inserted、two hours after the operation and after the catheter was pulled out was observed between two groups, and there is no statistics difference(P>0.05)4.2 The change of blood gas analysis: Before catheter was inserted、two hours after the operation and after the catheter was pulled out , all the patients’PO2、PCO2、SaO2 measurement results are all in normal range, there is no obvious change(P>0.05), The blood gas analysis comparison between two groups is no obvious before catheter was introduced, two hours after the operation and after the catheter was pulled out, there is no statistics difference(P>0.05)Conclusion: It is very good for the Massive hemoptysis therapy by the tamponade technique with Swan-Ganz catheter fixed with bronchofibroscope by surgical thread in airway. The operating time used by endobronchial tamponade technique with Swan-Ganz catheter fixed by surgical thread is shorter than the method Fogarty catheter inserted. Also there is no obvious affection to patients’vital signs, blood gas analysis. It is a kind of more convenient, operating easily, more safety and effective method.更多还原