机械通气合并重症肺部感染患者胸部CT定位下床旁无痛纤维支气管镜气道灌洗临床价值

Clinical study of the value in bronchoalveolar lavage in patients with severe lung infection by bed side painless fiberoptic bronchoscopy under chest CT guidance and mechanical ventilation

目的 探讨胸部CT定位下床旁无痛纤维支气管镜（bronchofibroscope,BFS）气道灌洗治疗机械通气合并重症肺部感染中的临床疗效.方法 应用无痛纤维支气管镜气道灌洗（bronchoalveolar lavage,BAL）对重症医科大学重症医学科内131例机械通气合并重症肺部感染患者随机（随机数字法）分为CT检查组（C组）、X线胸片检查组（X组）和未做放射检查组（N组）,三组患者均行有创呼吸机辅助通气,后行无痛纤维支气管镜气道灌洗治疗.监测患者生命体征,灌洗前和灌洗后1h、2h、4h的呼吸力学指标,同时记录BAL持续时间,监测术后3d、5d感染相关性指标,有效病原菌检出率、有创机械通气时间和机械通气时间.对三组各项监测指标进行统计学对比分析.结果 术中及术后10 min,C组和X组的心率（HR）、呼吸频率（Br）低于N组,差异具有统计学意义（P＜0.05）,收缩压（SBP）、舒张压（DBP）组间差异无统计学意义（P＞0.05）.C组、X组灌洗后1h、2h气道峰压（PIP）、呼吸功（WOBvent）和吸气阻力（RAW）均低于N组,肺动态顺应性（Cdyn）优于N组（P＜0.05）;C组、X组灌洗后4 h Cdyn优于N组（P＜0.05）,PIP、WOBvent和RAW差异无统计学意义（P＞0.05）.C组机械通气时间（MV-t）为（16.81 ±2.62） min,较X组（20.12 ±3.81）min、N组（23.69 ±2.76） min均短（P＜0.05）.BAL治疗后3d,C组、X组中心体温（T）、外周血WBC计数（WBC）和降钙素原（PCT）降低低于N组（P＜0.05）,且C组低于X组（P＜0.05）,BAL治疗后5d,C组、X组WBC和PCT降低低于N组（P＜0.05）,且C组低于X组（P＜0.05）.C组有效病原菌检出率为80.55％（29/36）,较X组（72.09％,31/43）、N组（59.65％,34/57）均高（P＜0.05）.C组MV-t为（114.36±38.39）h,较X组（132.07 ±42.51）h、N组（165.28 ±67.28）h均短（P＜0.05）.结论 对机械通气合并重症肺部感染患者使用胸部CT定位下无痛纤维支气管镜气道灌洗治疗能有效降低应激状态,减轻气道高反应性,缩短手术时间,提高肺部感染病灶引流,增加有效病原菌检出率、缩短ICU住院时间及机械通气时间,提高该类患者综合救治水平.

Objective To explore the effects of bed side painless fiberoptic bronchoscopy for bronchoalveolar lavage （BAL） under chest computed tomography （CT） guidance and mechanical ventilation in the patients with severe pulmonary infection （SPI）.Methods A total of 131 cases of SPI undermechanical ventilation support were randomly （random number） divided into CT group （C group）,chest Xray examination group （X group） and without radiological examination group （N group）.The bronchoalveolar lavage （BAL） by using painless fiberoptic bronchoscopy with invasive mechanical ventilation was carried out in patients of these three groups.Vital signs and variables of respiratory mechanics ofpatients were monitored before and 1 h,2 h,and 4 h after BAL and the time consumed for BAL was simultaneous recorded.Meanwhile,infection related biomarkers on the 3rd d and 5thd after BAL,positive detection rate of pathogenic bacteria,the time of invasive mechanical ventilation used during BAL and total duration of mechanical ventilation support were measured.Results During BAL and at 10 min after BAL,heart rate and respiratory rate of C group and X group were lower than those of N group （P 〈 0.05）,however,there was no significant difference in SBP and DBP among groups （P 〉 0.05）.One and two hours after BAL,peak inspiratory pressure （PIP）,work of breathing ventilation （WOBvent） and airway resistance （RAW） in C group and X group were lower than those in N group,therefore,dynamic compliance （Cdyn） in C and X groups was better than that in N group （P 〈0.05）.Four hours after BAL.Cdyn in C group and X group was better than that in N group （P 〈 0.05）,But there were no significant differences in PIP,WOBvent and RAW among groups （P 〉 0.05）.BAL time （BAL-t） in C group （16.81 ±2.62） min was shorter than that in X group （20.12 ± 3.81） min and N group （23.69 ± 2.76） min,（P 〈 0.05）.Three and five days after BAL,core body temperature,WBC and procalcitonin （PCT） in C and X group were lower than those in N group （P 〈0.05）,and those in C group was lower than those in X group （P 〈0.05）.Pathogenic micro-organism detection rate in C group （80.55%,29/36） was higher than that in X group （72.09%,31/43） and N group （59.65%,34/57） （P 〈 0.05）.Total mechanical ventilation time （MV-t） in C group （114.36 ± 38.39） h was shorter than that in X group （132.07 ± 42.51） h and N group （165.28 ± 67.28） h （P 〈 0.05）.Conclusions BAL by using painless fiberoptic bronchoscopy under chest CT guidance can effectively reduce the stress on patients with severe pulmonary infection supported with mechanical ventilation,decrease airway hyper-reactivity,shorten the BAL time,ICU stay and duration of mechanical ventilation,facilitate drainage of lung infection exudates and pathogen detection rate and improve efficacy of comprehensive treatment.