小儿先天性心脏病术后静脉-动脉体外膜氧合支持中支气管镜的应用价值

The value of bronchoscopy in veno-arterial extracorporeal membrane oxygenation support for children after open-heart surgery

目的回顾性分析先天性心脏病(CHD)术后患儿因循环衰竭在静脉-动脉体外膜氧合(V-A ECMO)支持下完成支气管镜的安全性和应用价值。方法回顾性分析2020年1月至2022年10月上海交通大学附属上海儿童医学中心CHD术后V-A ECMO支持的患儿,按照是否行支气管镜分为行支气管镜组(A组)及未行支气管镜组(B组)。结果共纳入101例,A组患儿42例(41.6%)。行支气管镜的中位数时间为ECMO支持第5天。相比较B组患儿,A组患儿ECMO持续时间长,肺不张及肺部感染发生率高,但撤离ECMO后的机械通气时间较B组患儿缩短,两组在ICU总滞留时间及死亡率方面无差异。ECMO期间肺不张发生率在所有患儿中达49.5%,A组患儿37例,B组13例;肺不张开始中位数时间为ECMO支持第3天。肺部感染总发生率为54.5%,A组患儿30例,B组患儿25例。在A组患儿中,支气管镜发现支气管受压或狭窄15例,占比35.7%;发现痰栓阻塞者24例,占比57.1%;其中12例患儿在ECMO撤离实验中表现低氧血症,予以支气管镜检查及治疗后呼吸机通气条件下降,次日再次行撤离实验过程顺利,最终成功撤离ECMO。42例支气管镜检查中2例有轻微气道出血、肺出血,无ECMO流量变化、循环波动、气胸等并发症。支气管镜肺泡灌洗液送检标本发现致病微生物者22例。结论ECMO期间支气管镜是安全的,支气管镜有益于小儿CHD术后V-A ECMO支持患儿的肺部并发症的诊疗,缩短了V-A ECMO患儿ECMO撤离后的机械通气时间,而且对ECMO的成功撤离具有一定的临床价值。

Objective To retrospectively analyze the safety and clinical value of bronchoscopy with veno-arterial extracorporeal membrane oxygenation(V-A ECMO)support for circulatory failure in children with congenital heart defect heart disease(CHD).Methods A retrospective analysis was performed on patients who received V-A ECMO support after CHD surgery between January 2020 and October 2022 in Shanghai Children’s Medical Center.They were divided into two groups according to whether or not bronchoscopy was performed:bronchoscopy group(Group A)and no bronchoscopy group(Group B).Results A total of 101 cases were enrolled,42 cases in Group A(41.6%).The median time of bronchoscopy was day 5 of ECMO support.Compared with Group B,Group A had longer duration of ECMO,higher incidence of atelectasis and pulmonary infection,but shorter duration of mechanical ventilation after ECMO withdrawal.There was no difference in the total length of ICU stay and mortality between the two groups.The incidence of atelectasis during ECMO was 49.5%,37 cases in Group A and 13 cases in Group B.The median time of atelectasis onset was the third day of ECMO support.The total incidence of pulmonary infection was 54.5%,30 cases in Group A and 25 cases in Group B.In Group A,15 cases(35.7%)were found to have constriction or stenosis of bronchus,and 24 cases(57.1%)were found to have obstruction of sputum by bronchoscopy.In 12 of them,hypoxemia was found in the ECMO withdrawal test.After bronchoscopy and treatment,the ventilation condition of the ventilator was decreased.The next day,the withdrawal test was carried out again,and the ECMO was successfully withdrawn.Among 42 cases of bronchoscopy,2 cases had slight airway hemorrhage and pulmonary hemorrhage,and no complications such as ECMO flow change,circulation fluctuation and pneumothorax.Pathogenic microorganisms were found in bronchoalveolar lavage fluid of 22 cases.Conclusion The bronchoscopy is safe during ECMO,it is beneficial to the diagnosis and treatment of pulmonary complications in children with V-A ECMO after CHD,and it can shorten the time of mechanical ventilation in children with V-A ECMO after ECMO withdrawal,it is of clinical value for the successful withdrawal of ECMO.