支气管结核278例临床特征及诊断标准和分型的探讨

Clinical characteristic,diagnostic standard and types of endobronchial tuberculosis:An analysis of 278 cases

目的探讨支气管结核(BTB)临床特征、诊断标准和分型。方法对上海市肺科医院2002年1月至2007年5月278例确诊为气管、支气管结核患者的临床特点、影像学表现、支气管镜下表现、细菌及组织学检查、治疗及转归等结果进行分析。结果278例中,男86例,女192例,青年女性多发。CT扫描显示,支气管管腔狭窄138例,支气管管腔阻塞48例,肺炎26例,肺不张31例,未发现异常者8例。支气管镜检查结果发现,病变位于单侧支气管233例,右侧129例,左侧104例,双侧均有病变45例。有多部位病变108例。充血水肿型123例,急性干酪型77例,溃疡型19例,颗粒结节型11例,肿瘤型8例,纤维狭窄型40例。支气管无狭窄45例,狭窄157例,阻塞76例。纤维狭窄型和肿瘤型均导致了支气管狭窄或阻塞,其次为急性干酪型,与其他三种类型相比差异有统计学意义(P<0.01)。两种及两种以上类型并存者147例。疗程结束时,初治病例痰菌转阴106例,转阴率90.60%;复治病例痰菌转阴32例,转阴率84.21%,两组间差异无统计学意义(χ2=1.20,P=0.27)。经支气管内注药的168例患者经3～12个月治疗后随访,急性干酪型和充血水肿型治疗前后支气管管腔的变化有统计学意义(P<0.01),纤维狭窄型治疗前后支气管管腔无明显变化。急性干酪型的治疗效果较充血水肿型差(χ2=5.72,P=0.021)。结论BTB以青年女性多发,刺激性咳嗽伴局限性哮鸣音是BTB的重要特征,支气管镜检查并活检是确诊BTB最重要的方法,胸部CT检查并气道重建技术对BTB的诊断具有重要价值。我们的分型能充分展示BTB病变的演变趋势及全面地反映BTB的镜下变化,并有助于对BTB的预后进行判断。

Objective To investigate the clinical characteristics, diagnostic standard and types of endobronchial tuberculosis. Methods We analyzed the clinical characteristics, radiologieal manifestation, hronchoscope manifestation, bacterial and histology examination, treatment and lapse in Z78 patients with confirmed tracheal or endohronchial TB in our hospital from Jan. 2002 to May 2007. Results The 278 patients included 86 male cases and 192 female cases. Young females dominated in the above cohort. It was shown in CT scans that bronchial stenosis in 138 cases ,bronchial obstruction in 48 cases, pneumonia in 26 cases, atelectasis in 31 cases, normality in 8 cases. It was also shown by bronchoscope that injury occupied unilateral bronchus in 233 cases with the right in 129 cases, the left in 104 cases. 45 cases had bilateral injury. 108 cases had multi-position injury. Congestive edema was seen in 123 cases while acute caseation in 77 cases,ulceration in 19 cases, granulous nodes in 11 cases, neoplasm in 8 cases, fibrotie stenosis in 40 cases. 157 patients had bronchial stenosis while 45 without. Obstruction could be seen in 76 patients. Bronchial stenosis was mostly induced by fibrotie stenosis and neoplasm. Its second reason was acute caseation. When it was compared with other three types, highly significant difference could be drawn （P 〈0. 01 ）. Two or more than two types cohabited in 147 patients. When the regimen was wrapped off, 106 cases with first-time treatment got sputum Conversion ,whose rate was 90. 60%. 32 re-treated cases got sputum conversion,whose rate was 84.21%. The difference between these two groups showed no significant （Х^2= 1.20,P = 0. 27 ）. 169 patients received medicine injection through bronchus. After 3 to 12 months treatment,difference in bronchial changes between acute caseation type and congestive edema type of these patients was highly significant （ P 〈 0. 01 ）. No bronchial change established in fibrotic stenosis type after treatment. The therapeutic effect of acute caseation type was worse than congestive edema type （ Х^2 = 5.72, P = 0. 021 ）. Conclusions Endobronchial TB has a predilection of young females. Incentive cough and local wheeze remain its characteristics. Bronchoscope and biopsy are important methods to diagnose endobronchial TB. Chest CT and airway tract reconstruction are of great value. Our classification method fully presents its unfolding trend and developments under endoscopy. At the mean time, it is useful to the prognosis of this disease.