经支气管肺活检在尘肺病诊断中的应用

Application of transbronchial lung biopsy in pneumoconiosis diagnosis

目的探讨经支气管肺活检在尘肺诊断中的价值。方法以2003年1月至2010年6月在上海市肺科医院就诊、x线胸片有尘肺样改变、提供的接尘性质或累计剂量与X线胸片表现不相符或缺乏系列x线胸片、要求明确诊断并接受支气管肺活检（TBLB），取得满意标本的尘肺诊断病例379例为研究对象。进行TBLB检查和肺组织病理观察。2005年5月起对TBLB标本增加普鲁士蓝铁反应检查。根据GBZ70．2002及GBZ70．2009《尘肺病诊断标准》，参考病例自述和TBLB病理检查进行集体诊断。结果在379例病例中，376例（99．2％）表现肺间质纤维化改变，228例（60．2％）粉尘沉着；111例（29．3％）的偏光镜检双折光晶粒阳性。接触矽尘、陶土尘、水泥尘、煤矽尘和铸造尘病例的偏光晶粒阳性率为37．8％（62／164），高于接触其他粉尘（电焊烟尘、石棉尘、铝尘等）者的22．7％（49／215），差异有统计学意义（P〈0．05）。接触电焊烟尘或打磨尘者普鲁士蓝铁反应阳性率为53．1％（94／177），明显高于接触其他粉尘（水泥尘、铸造尘、矽尘等）者的23．2％（13／56），差异有统计学意义（P〈0．01）。接触电焊烟尘尘肺组病例纤维组织增生率高于无尘肺组，差异有统计学意义（P〈0．05）。接触矽尘、铸造尘、打磨尘、石棉尘的尘肺组和无尘肺组（观察对象）的肺纤维组织增生率、粉尘沉积率和偏光晶粒阳性率的差异均无统计学意义（p〉0．05）。结论经支气管肺活检能获得接触粉尘的依据和相关肺部病变，对协助尘肺病诊断具有积极意义。

Objective To evaluate the role of transbronchial lung biopsy （TBLB） pathology in pneumoconiosis diagnosis. Methods During Jan 2003 to Jun 2010 in our hospital. 418 patients exposed to dusts were examined with TBLB. The chest radiographs of all subjects showed the pneumoconiosis-like opacities. Because the dust property or accumulated doses didn＇t match with abnormality on chest radiographs or there were no a series of chest radiographs, it was required for subjects to perform the TBLB for diagnosis. Three hundred seventy nine cases with satisfying samples served as the study subjects. The dust deposition, fibrosis and birefringent particles were found in TBLB pathological examinations. From May 2005, the Prussian blue iron reaction test was conducted on the TBLB samples. A panel made pneumoconiosic diagnosis according to GBZ 70-2002 and GBZ 70-2009 Pneumoconiosis Diagnostic Criteria, consulting subjects＇ accounts and pathologic results. Results Among 379 subjects, 376 cases （99.2%） showed the lung interstitial fibrosis, 228 cases （60.2%） demonstrated the dust deposition, 111 cases （29.3%） expressed the birefringent particles by polarized light microscopy. Birefringent particles positive rate was 37.8% （62/164） in 164 patients exposed to either silica or potter dusts or cement dusts or coal-silica dusts or foundry dusts, which was much higher than that （22.7%, 49/215） in patients exposed to other dusts （welding fume or asbestos or aluminum dusts） （P〈 0.05）. The positive rate of Prussian blue iron reaction in 177 patients exposed to welding fume or burnishing dusts was 53.1% （94/177）, which was significantly higher than that （23.2% ,13/56） in patients exposed to other dusts （cement dusts, casting dusts or silica） （P〈0.001）. There were no significantly differences in rates of lung fibrosis, dust deposition and birefringent particles between pneumoconiosis and none-pneumoconiosis subjects. The rate of lung fibrosis in pneumoconiosis cases was significantly higher than that in non- pneumoconiosis cases （P〈0.05）. Conclusion TBLB could provide the evidence of exposure to dusts and pathological changes, which may be useful to the pneumoconiosis diagnosis.