纤维支气管镜结合胸部多排螺旋CT在婴儿大血管疾病并呼吸道狭窄中的诊断价值

Diagnostic Value of Vascular Anomalies Combined with Airway Stenosis Assessment by Flexible Bronchoscopy and Multidetector Computed Tomography in Infants

目的评价纤维支气管镜(简称纤支镜)结合胸部多排螺旋CT(MDCT)在先天性大血管病变并呼吸道狭窄中的诊断价值及安全性。方法回顾性分析经纤支镜检查和(或)MDCT确诊呼吸道狭窄的先天性大血管病变患儿34例,记录及分析首发临床表现,纤支镜下见到的呼吸道狭窄情况、胸部CT结果及经手术确诊的心血管畸形及呼吸道狭窄情况,记录纤支镜及MDCT检查中的不良事件,呼吸道狭窄的处理及转归。结果 (1)共34例纳入研究。其中主动脉梗阻性病变24例,血管环10例;均在NICU或术中完成纤支镜检查,34例术前(33例)和(或)术后(5例)完成CT检查。(2)血管环10例患儿均先经纤支镜检查发现呼吸道外压性狭窄或严重发育不良,提示血管环,呼吸道狭窄以气管中、下段为主,9例经CT证实,1例经手术证实。其中7例为先天性气管狭窄。(3)主动脉病变24例中仅5例术前CT提示呼吸道狭窄,其中1例术前纤支镜显示呼吸道狭窄,余19例均在术中或术后经纤支镜发现呼吸道外压性狭窄;21例有左主支气管狭窄,右主支气管狭窄2例,右下支气管狭窄1例。(4)纤支镜检查34例中2例出现一过性血氧饱和度下降,5例出现一过性心动过速,余患儿无不良反应;10例上呼吸机患儿带气管插管外出监护室行MDCT检查;4例外出检查后病情加重,需上呼吸机治疗,余20例外出CT检查无严重不良事件发生。(5)转归:血管环患儿中8例行外科手术治疗,7例单纯血管移植解除呼吸道压迫,其中2例死亡,1例同时行气管重建术,死于气管吻合口肉芽形成的再狭窄;主动脉病变组死亡4例,主动脉矫治术后呼吸道狭窄19例,4例行主动脉悬挂固定术解除狭窄。结论纤支镜检查在先天性大血管畸形伴呼吸道狭窄的诊断及治疗中起重要作用,具有准确、安全、经济及方便快捷的优点,结合MDCT检查可对呼吸道周围结构组织及血管畸形提供更多的信息,危重患儿外出行CT检查存在风险,需评估风险,并由有丰富急救经验的团队陪同外出检查。

Objective To evaluate the diagnostic value and safety of flexible bronchoscopy（FB） and multidetector computed tomography（MDCT） in infants with congenital vascular anomaly related airway stenosis.Methods Records of infants with great vessel related airway stenosis diagnosed by FB and（or） MDCT between Oct.2005 and Jun.2009 were respectively retrieved,including the first symptom presented,the status of airway stenosis discovered by FB,the results of chest MDCT and the conditions of airway,heart and great vessels confirmed by operation,adverse events during FB and MDCT examinations.The relationship between airway stenosis and vascular anomaly,treatments and the outcomes of these infants were analyzed.Results（1）Thirty-four infants with airway stenosis were enrolled,including 24 cases with aorta related airway stenosis,10 cases with vascular ring.All FB examinations were performed in neonatal intensive care unit or during cardiovascular operation.Thirty-three infants had MDCT evaluation before operation and 5 cases after operation.（2）Ten infants with vascular ring were found to have compressing airway stenosis or dysplasia of the airway,9 cases of which were confirmed by MDCT and 1 case by operation.Seven cases of these infants were congenital airway stenosis.Most of the stenosis was located in the middle or lower bronchus.（3）Only 5 cases of 24 infants with aorta abnormality were found to have airway stenosis.One of these infants was found by FB and the other 19 infants were diagnosed as outward related airway stenosis during or after operation.Twenty-one of these 24 infants had left primary bronchus stenosis and 2 cases had right primary bronchus stenosis,one case had right down bronchus stenosis.（4）During FB examination,2 cases infants had temporal desaturation,5 cases with tachycardia.The other 27 infants had no adverse events.10 ventilated infants took MDCT outside NICU.Four infants got worse after outward examination and needed mechanical ventilation support.The other 20 infants′ status was steady during MDCT examination.（5）Eight infants with vascular ring had operation correction.Seven cases of which had the vessel removed and two cases died,1 case died due to the restenosis of the operation cut after airway reconstruction.Four cases of the 24 infants with aorta anomaly died,and 19 infants got restenosis after operation correction.Four cases had suspension fixation to relieve stenosis.Conclusions FB had leading effects in the diagnosis and treatment of vascular anomaly related airway stenosis,with accurate,safe,economic and convenient advantages.The combination of FB and MDCT may provide more accurate information of airway stenosis and vascular surrounding.Infants with airway stenosis had risks to take examinations outside neonatal intensive care unit.The evaluation before outward examination and a well trained team were needed.