儿童隐匿性支气管异物的诊断思路

Diagnosis of children with occult bronchial foreign body

目的 探讨儿童隐匿性支气管异物的临床特点,分析误诊原因及诊断思路.方法 回顾分析重庆医科大学附属儿童医院2009年3月1日至2014年2月28日支气管异物1 710例中经支气管镜术确诊的隐匿性支气管异物22例的诊治经过.结果 22例中男15例,女7例;年龄9月8 d至14岁6个月;病程6d至1年.22例均无明确或可疑异物吸入史;无刺激性呛咳表现;体检未见气管偏移,未闻及气管拍击音;影像学检查未见直接支气管异物征象.行支气管镜术前诊断肺炎21例,肺结核1例;术前抗感染治疗病情反复7例,无效8例,使用特殊抗生素2例（万古霉素1例,注射用亚胺培南西司他丁钠1例）,抗痨治疗1例.异物并发感染22例次,肺不张15例次,肺实变10例次,肺气肿4例次,胸腔积液5例次,支气管扩张4例次,呼吸衰竭1例次,败血症1例次.经支气管镜诊治后患儿临床症状基本缓解,肺部影像学征象痊愈3例,好转19例.结论 儿童隐匿性支气管异物临床表现复杂,诊断困难,并发症多,危害大,对于婴幼儿反复肺部感染、有呼吸道阻塞间接征象、治疗困难的病例应高度警惕支气管异物可能,早期行支气管镜术有助于提高诊断正确率.

Objective To investigate the clinical manifestation of children with occult bronchial foreign body,to analyze the reasons of misdiagnosis,to summarize the way of diagnosis and to emphasize the value of bronchoscopy in diagnosis and treatment of children with such disease.Method A retrospective analysis of 22 cases of occult bronchial foreign body diagnosed and treated with bronchoscopy in Children＇s Hospital of Chongqing Medical University during the period from March 1,2009 to February 28,2014.Result Of the 22 cases,15 were male and 7 female.Their age ranged from nine months and eight days to fourteen years and six months.The course of disease ranged in length from six days to one year.It took us one to thirty-three days in diagnosing the problem.They or their parents all denied aspirating foreign body and the patients did not have irritating chokes.They did not have tracheal displacement or flapping sound.There were no direct signs of bronchial foreign body in their imaging examination.Twenty-one patients were diagnosed as pneumonia before bronchoscopy,and the remaining one was diagnosed as tuberculosis.All of the patients were complicated with infection; atelectasis was found in 15 cases/times,lung consolidation in 10 cases/times,emphysema in 4,pleural effusion in 5,bronchiectasis in 4,one case had respiratory failure,one case had septicemia.The clinical symptoms were relieved in the patients after bronchoscopy,3 cases were cured,19 cases were improved.Conclusion Occult bronchial foreign body with certain complications and great harm is hard to diagnose.We should pay more attention to the important clues,such as a child with repeated pulmonary infection,indirect signs of airway obstruction and difficult to treat.Early bronchoscopy will be useful to improve diagnostics once the vital clue is found.