亚甲蓝盐水定位气胸与支气管瘘相关支气管的临床研究

Clinical investigation of detecting the bronchi responsible for pulmonary air leakage by injecting methylene blue saline in 27 cases with intractable pneumothorax and bronchial fistula

目的 探讨经气道有色盐水定位气胸与支气管瘘相关支气管的方法,并评价其效果及安全性.方法 2006年1月至2013年10月,河北医科大学第四医院收治顽固性气胸19例和支气管瘘8例.其中张力性气胸15例、交通性气胸12例.全部患者住院后经胸腔持续负压吸引术≥5d无效,自愿接受本方法治疗.建立胸腔负压吸引,使患者平静呼吸时有持续气体从引流管溢出.经气道插入支气管镜,沿支气管镜工作道送入注射导管,将适量亚甲蓝盐水缓缓注射到可疑段或亚段支气管,当观察到气道内有色盐水不断减少、消失或和胸腔引流管内出现有色盐水提示肺漏气相关支气管.封堵肺漏气相关支气管前,应停止或降低胸腔负压吸引水平,经支气管镜工作道插入注射导管,应用生物蛋白胶或OB胶封堵肺漏气相关支气管.当胸腔引流管气体消失,X线胸片肺复张,观察1周无复发为肺漏气相关支气管封堵成功.结果 27例患者肺漏气相关支气管均定位成功.段支气管定位16例、亚段10例、次亚段1例,其中累及相邻多段3例,多亚段5例.肺漏气相关支气管定位时间平均（51±9）s,其中张力性气胸平均（48±15）s,交通性气胸平均（53±16）s,2种类型气胸平均定位时间比较差异无统计学意义（t =0.416,P=0.699）.相关段支气管有色盐水定位用量平均（42 ±23） ml.定位操作共实施相关支气管封堵61例次,胸腔引流管气流立即终止17例次,缓慢停止10例次,气流减缓持续22例次,气流无变化12例次.剧烈咳嗽4例,发热、胸腔出血各3例,胸痛、肺不张和肺炎各2例.结论 经导管气道内有色盐水注射,是一种操作简单、价格低廉、安全和有效的气胸与支气管瘘相关支气管定位新方法.

Objective To establish a new method for detecting the bronchus responsible for pulmonary air leakage by injecting methylene blue saline and to evaluate its efficacy and safety in cases with intractable pneumothorax and bronchial fistula.Methods From January 2006 to October 2013,a total of 19 cases of intractable spontaneous pneumothorax and 8 cases of bronchial fistula were recruited in the study at the Fourth Hospital affiliated to Hebei Medical University.Of all the cases,15 were diagnosed as having tension pneumothorax and 12 as having communicating pneumothorax.All the cases failed to respond to continuous pleural suction for more than 5 days and consented to the proposed treatment.Before procedure,chest suction was established to allow sustained airflow through the drainage tube while the patients breathed normally.Under direct vision through fiberoptic bronchoscope,injection catheter was inserted into the bronchoscopy channel,and methylene blue saline was slowly injected into the potentially leaking segmental or sub-segmental bronchi.When a steady decline or disappearance in the amount of methylene blue saline in the airways was observed,or methylthionine-tainted saline was detected within the chest drainage tube,the bronchus responsible for air leakage was indicated.Beforc blocking the target bronchus,the negative pressure level of pleural suction should be reduced or stopped,and then porcine fibrin glue or acyanoacrylate was used for sealing the bronchi associated with air leakage.When the air was absent from the drainage tube,and lung recruitment was indicated in the chest Ⅹ-ray for 5 days,and bronchial blockade of air leakage was proved successful.Results The bronchi responsible for air leakage were successfully located in all 27 cases,among them segmental bronchi were located in 16,subsegmental bronchi in 10,and small subsegmental bronchus in only one.Multiple adjacent segmental involvement occurred in 3,and multiple adjacent subsegmental involvement in 5 cases.The average time for locating the target bronchi was （51 ±9） s,among them the average time for tension pneumothorax was（48 ± 15） s compared with（53 ±16） s for communicating pneumothorax （t =0.416,P =-0.699）.The average amount of methylene blue saline consumed for locating the target bronchi was （42 ± 23） ml.During the procedure,the membrane of the bronchi was kept intact,and the vital signs were stable.Blockade of the target bronchi was successful with fibrin glue in 20 cases and with OB glue in 7 cases.A total of 61 times of bronchial blocking were performed,and the airflow of the chest drainage tube was instantly stopped in 17 times,gradually stopped in 10,steadily reduced in 22 and no change in 12 times.Adverse effects included severe cough in 4 cases,fever in 3,pleural hemorrhage in 3,and chest pain,atelectasis,and pneumonia in 2 cases,respectively.Conclusion The bronchi responsible for pulmonary air leakage in patients with spontaneous pneumothorax and bronchial fistula could be determined by injecting methylene blue saline into the airways.This novel method does not require special instruments,and is easy to perform with a high safety and effectiveness.