支气管镜术在儿童哮喘持续状态治疗中的应用

Application of bronchoscopy in the therapy of pediatric status asthmaticus

目的探讨支气管镜术在儿童哮喘持续状态治疗中的作用。方法2008年1月至2010年8月，对入住儿科重症监护室的16例哮喘持续状态患儿进行常规药物治疗（常规组），对2010年9月至2012年7月人住儿科重症监护室的10例哮喘持续状态患儿，在常规药物治疗基础上进行纤维支气管镜检查及肺泡灌洗术（气管镜组）。观测气管镜检查前1h及检查后6、24h氧合指数[动脉血氧分压／吸氧浓度（PaO2／FiO2）]、PaCO2、血氧饱和度（SaO2）、心率、呼吸次数、两组患者哮鸣音消失时间、住重症监护室时间和总住院时间。结果纤维支气管镜下，气管镜组患儿支气管内均有中量至大量黏稠分泌物及黏液痰栓，8例肺泡灌洗液中性粒细胞增多，4例嗜酸性粒细胞增多，4例灌洗液培养阳性；检查前1hPaO2／FiO2、PaCO2、SaO2、心率、呼吸次数分别为255±24、（54±5）mmHg（1mmHg=0．133kPa）、（89．2±2．6）％、（148±10）次／min和（50±6）次／min，检查后6h分别为319±19、（40±4）mmHg、（92．6±1．5）％、（128±12）次／min和（35±4）次／min，两者比较差异均有统计学意义（P〈0．01）。气管镜操作24h后，气管镜组和常规组PaO2／FiO2、PaCO2、SaO2、心率和呼吸分别为354±21和317±21、（40±3）和（46±4）mmHg、（93．4．±1．1）和（90．1±2．5）％、（125±9）和（138±8）次／min、（34±3）和（43±3）次／min，两者比较差异均有统计学意义（P〈0．01）；气管镜组和常规组患者哮鸣音消失时间、住重症监护室时间、总住院时间分别为（67±22）和（98±23）h、（1．6±0．7）和（2．6±0．7）d、（5．0±0．7）和（6．6±1．2）d，两者比较差异均有统计学意义（P〈0．01）。气管镜组患者无一例发生严重并发症。结论应用纤维支气管镜进行肺泡灌洗安全有效，可以明显缓解哮喘持续状态患儿的临床症状，缩短哮喘急性发作病程，减少住院日。

Objective To explore the therapeutic value of bronchoscopy in pediatric status asthmaticus. Methods A total of 16 children with status asthmaticus received standard medical therapies （therapy group） from January 2008 to August 2010 in pediatric intensive care unit （PICU） at First Hospital, Xiamen University. However, 10 of them underwent fiberoptic bronchoscopy and bronchoalveolar lavage （BAL） （bronchoscopy group） along with standard medical therapies from September 2010 to July 2012. The values of oxygenation index （ PaO2/FiO2 ）, arterial partial pressure of carbon dioxide （ PaCO2 ）, blood oxygen saturation （ SaO2 ）, heart rate （ HR）, respiratory rate （RR） within 1 hour before bronchoscopy procedure, within 6 hour post procedure and within 24 hour post procedure were observed. The extinction time of wheezing sound, PICU length of stay and admission length of stay were observed between therapy and bronchoscopy groups. Results Bronchoscopies revealed a lot of thick mucus plugs and secretions. Large airways were lavaged for clearance of obstructive secretions with normal saline. Within BAL fluid counts of the bronchoscopy group, there were neutrophilia （n = 8 ）, eosinophilia （n = 4 ） and neutrophilia/ eosinophilia （ n = 3）. Within BAL fluid cultivation of the bronchoscopy group, 4 patients had positive results for Streptococcus pneumoniae （ n = 2 ）, Pseudomonas aeruginosa （ n = 1 ） and Staphylococcus aureus （ n = 1 ）. In bronchoscopy group, the values of PaO2/FiO2, PaCO2, SaO2, HR and RR were 319 ± 19, （40 ± 4） mm Hg（ 1 mm Hg = 0. 133 kPa）, （ 92. 6 ± 1.5 ） %, （ 128 ± 12 ） rates/min and （ 35 ± 4 ） breaths/minwithin 6 hour post procedure versus 255 ± 24, （ 54 ± 5 ） mm Hg, （ 89.2 ± 2. 6） %, （ 148 ± 10） rates/min and （50 ± 6）breaths/min within 1 hour before procedure （P 〈 0. 01 ）. At 24 hour post procedure, the values of PaO2/FiO2 , PaCO2 , SaO2, HR, RR for bronchoscopy group were 354 ±21, （40 ±3）mm Hg, （93.4 ± 1.1）%, （125±9）rates/rain and（34±3）breaths/min versus 317 ±21, （46 ±4）ram Hg, （90.1± 2. 5） % , （ 138 ± 8 ） rates/min and （43 ± 3 ） breaths/rain respectively for therapy group （ P 〈 0. 01 ）. The extinction time of wheezing sound was （67 ± 22） hours for bronchoscopy group vs. （ 98 ± 23 ） hours for therapy group（P 〈0. 01 ）. The mean PICU length of stay was （ 1.6 ±0. 7） days for bronchoscopy group vs. （ 2. 6 ± 0. 7 ） days for therapy group（ P 〈 0. 01 ）. The mean admission length of stay was （ 5.0 ± 0. 7 ） days for bronchoseopy group vs. （6. 6 ± 1.2） days for therapy group（ P 〈 0. 01 ）. All patients for bronchoseopy group tolerated the procedure without any complications. Conclusion As a safe adjunctive therapy in pediatric status asthmatieus, flexible bronchoscopy with bronchial lavage may reduce the admission and PICU length of stay and alleviate elinical symptoms.