bronchiectasis
Bronchiectasis is caused by inflammatory destruction of bronchial wall and its surrounding lung tissue. Mainly due to bronchial obstruction and infection at its distal end, the two are often mutually causal. The causes of bronchial obstruction are lymph node enlargement, foreign body, thick secretion pus, tumor and so on. Patients with congenital defect of cartilage supporting tissue in bronchial wall are more prone to infection and bronchiectasis. Anatomically, bronchiectasis can be divided into columnar and cystic dilatation. The former has mild lesions, while the latter has severe wall damage. Bronchiectasis mostly occurs in the peripheral third and fourth bronchial branches, and the lower lobe is more common than the upper lobe. Inflammation first damages the ciliated columnar epithelium of the tube wall, and then damages the elastic fibers, smooth muscles and cartilage of the tube wall. After the tissue is destroyed, it is gradually replaced by fibrous tissue, and the bronchi expand columnar or saccular, becoming tubular columns or sacs of infected secretions. Some bronchi can also be occluded due to inflammatory scars and fibrotic contraction, leading to atelectasis. General anti-infection therapy can improve bronchial and pulmonary inflammation, but it can't reverse the pathological changes of bronchiectasis. Therefore, resection of diseased lung tissue is an effective method to treat moderate bronchiectasis.
The main clinical manifestations are expectoration, hemoptysis and repeated respiratory and lung infections. The patient has a large amount of sputum, which is yellow-green purulent mucus and even stinks. Postural changes, especially when getting up in the morning, can induce severe cough and expectoration, which may be caused by pus accumulated in dilated bronchi draining to the proximal airway, causing irritation. Sometimes there is blood in the sputum or a lot of hemoptysis. The long course of disease may be anemia, malnutrition or clubbed fingers (toes).
The main diagnostic method of bronchiectasis is bronchography, and the location, scope and characteristics of bronchiectasis are clearly defined. Generally divided into three categories: columnar, cystic and mixed.
treat cordially
1. Surgical indications: If the whole body is in good condition and the functions of important organs such as heart, liver and kidney are normal, different surgical methods can be selected according to the following conditions.
(1) If the lesion is confined to one segment, one lobe or multiple segments, pneumonectomy or lobectomy can be used.
(2) If the lesion invades one lobe or even the whole lung, and the contralateral lung function is good, lobectomy or even Ye Quan pneumonectomy is feasible.
(3) Bilateral lesions. If the lesion of one lung segment or lobe is significant, but the lesion of the other side is slight, it is estimated that the sputum or blood mainly comes from the severely affected side, and unilateral lung segment or lobe resection is feasible.
(4) Bilateral lesions, if the total vital capacity of the lesion area does not exceed 50%, the respiratory function will not be seriously affected after resection, and bilateral surgery can be performed in one stage or by stages according to the situation. Generally, the seriously ill side is carried out first. The interval between stages is at least half a year.
(5) Bilateral lesions are extensive and generally not suitable for surgical treatment. However, if repeated massive hemoptysis does not stop, active medical treatment is ineffective, and the bleeding site can be determined, we can consider removing the bleeding diseased lung to save lives.
2. Contraindications for surgery
(1) Patients are generally in poor condition, with heart, lung, liver and renal insufficiency, and cannot tolerate surgery.
(2) The lesion is extensive, which may seriously affect the respiratory function after resection of the diseased lung.
(3) Patients with emphysema, asthma or pulmonary heart disease.
3. Preparation before operation
(1) Preoperative examination: In addition to routine examination of major surgery, sputum bacteria culture and drug sensitivity test are needed to guide clinical medication. Bronchography must be completed in the near future to determine the scope of operation and the main suppression and staging operations. However, the operation can only be performed after the contrast agent is basically exhausted. In order to observe the source of hemoptysis or find out whether there are tumors or foreign bodies, bronchoscopy can be considered when necessary. Cardiopulmonary function examination is an important examination item. Clinically, the cardiac function can be roughly estimated according to the activity ability after accelerated exercise, the height of climbing stairs and the recovery time of heartbeat, and then combined with ECG and echocardiography for comprehensive analysis. Respiratory function can be used as lung ventilation function, such as vital capacity, maximum ventilation capacity, time vital capacity, blood gas analysis, etc., to understand lung function and tissue oxygen supply.
(2) Control infection and reduce sputum volume: In order to prevent asphyxia or aspiration pneumonia during and after operation, effective antibiotics should be used before operation. The amount of sputum should be controlled below 50 ml/d as far as possible, and it is beneficial to improve the expectoration effect to guide patients to perform body position drainage and ultrasonic atomization inhalation of antibiotics. Postural drainage is not suitable for patients with hemoptysis.
(3) Support therapy: Because patients are very exhausted and often malnourished, they should be given a high-protein and high-vitamin diet. Correct anemia. For chronic infection lesions, it is best to remove them to prevent respiratory infection.
4. postoperative treatment: there should be special care before complete awakening and 6 ~ 12 hours after awakening. Blood pressure, pulse and breathing should be carefully observed within 24 ~ 48 hours. Record the drainage volume, urine volume and body temperature of pleural effusion in detail. Pay special attention to the patency of pleural cavity drainage tube, breathing sound after lung recruitment, and whether there is hypoxia. Routine oxygen inhalation. In the first 24 hours, the drainage volume of pleural cavity is generally about 500ml. If you see a large amount of bloody liquid flowing out, when it exceeds 10ml per hour, you should be alert to intrathoracic bleeding.
Help change posture and cough and expectoration. Early atomizing inhalation of antibiotics and fibrinolytic protease is helpful to liquefaction and expectoration. When respiratory secretions cannot be discharged, a nasal catheter can be inserted to suck sputum to prevent atelectasis. When all kinds of expectoration methods are ineffective, fiberoptic bronchoscopy or even tracheotomy can be used to aspirate sputum when necessary. If you have severe respiratory insufficiency, you can use a ventilator for artificial assisted breathing.
After bronchiectasis, the curative effect is satisfactory. About 90% patients' symptoms disappeared or improved significantly. Those who have residual symptoms after operation are mostly residual lesions, or because of improper treatment of residual cavities after operation, the residual lobes or segmental bronchi are twisted, leading to bronchiectasis and recurrence.
On the basis of systemic medication, local treatment with antibiotics can be added. If 300,000 units of penicillin are diluted in 5 ~ 65,438+00 ml of normal saline, and 4% procaine or 2% procaine is used for local anesthesia, then antibiotics are instilled into the trachea through nasal catheter or cricothyroid membrane puncture, the patient will lie still for 65,438+0 hours according to the abscess site, 65,438+0 times a day. When conditions permit, the bronchiole catheter can be inserted into the drainage bronchus near the lesion through fiberoptic bronchoscope under X-ray fluoroscopy, and antibiotic solution can be injected directly.
Postural drainage is beneficial to expectoration and promote healing, but patients with more pus and weak constitution should be monitored to avoid suffocation caused by a large number of pus and phlegm.
Patients with chronic lung abscess that cannot be closed due to active medical treatment, as well as patients with recurrent infection or massive hemoptysis, need to consider surgical resection; Lung abscess with bronchial obstruction and poor drainage also needs surgical treatment, especially those suspected of cancerous obstruction or severe bronchiectasis with massive hemoptysis; For patients with empyema or bronchopleural fistula, intercostal incision and closed drainage can be used when the treatment effect is not good after aspiration and irrigation.
Blood-borne lung abscess, usually caused by Staphylococcus aureus. In addition, the treatment of sepsis should be combined with blood culture and bacterial drug sensitivity. In addition, we should actively deal with purulent lesions outside the lung.