全肺灌洗术治疗重症误吸的临床研究

Clinical study of severe aspiration by the whole lung lavage

目的探讨全肺灌洗术(WLL)治疗重症误吸(SA)的有效性与安全性。方法回顾分析我院收治并分别接受WLL和经支气管镜肺泡灌洗术(BAL)治疗的33例SA患者,WLL组20例,BAL组13例,比较2种不同方法治疗SA的有效性、安全性和经济性。结果 12组患者咳嗽、咯痰、气喘、发热的临床症状经WLL和BAL治疗后均有好转,WLL组患者临床症状好转速度、程度优于BAL组;2炎症指标:WLL组患者在治疗前、治疗后1 d、7 d分别测血白细胞(WBC)为13.34±3.48 vs.9.56±2.23 vs.6.61±1.12(109/L);中性粒细胞(NG)百分比值为85.22±4.70 vs.80.45±4.85 vs.69.45±4.10(%);C反应蛋白(CRP)值为106.83±30.05 vs.60.06±20.50 vs.20.87±6.67(mg/L);降钙素(PCT)值为2.75±0.59 vs.1.73±0.29 vs.0.51±0.19(μg/L);γ-干扰素(γ-IFN)值为105.40±18.58 vs.90.78±19.78 vs.37.44±7.54(ng/L),治疗1 d较治疗前、治疗7 d较治疗1 d时,各指标测值均有明显下降,其差异有明显统计学意义(P<0.01);BAL组同期测值亦呈类似变化,具体测值分别为:WBC:11.60±3.28 vs.10.34±1.53 vs.7.85±1.73(109/L);NG:86.38±4.93 vs.85.00±4.83 vs.76.15±5.67(%);CRP:115.98±33.45 vs.97.93±6.49 vs.31.03±17.7(mg/L);PCT:2.58±0.64 vs.2.08±0.57 vs.0.59±0.15(μg/L);γ-IFN:105.00±22.13 vs.96.37±18.14 vs.39.17±4.43(ng/L);惟术后1 d时测WBC、γ-IFN较治疗前无明显差异(P>0.05);3动脉血气:WLL组患者在治疗前、治疗后1 d、7 d分别测动脉血氧分压(Pa O2)值为53.72±3.93 vs.70.39±5.69 vs.81.49±6.44(mm Hg);动脉血二氧化碳分压(Pa CO2)为51.54±6.06 vs.47.48±3.22 vs.44.35±3.22(mm Hg);动脉血氧饱和度(Sa O2)值为:86.66±2.54 vs.91.80±1.04 vs.96.31±0.80(%)。治疗1 d、7 d较治疗前均有下降,差异有明显统计学意义(P<0.01);BAL组同期测值亦呈相似变化:PO2:53.26±3.63 vs.63.41±3.98 vs.81.66±3.14(mm Hg);PCO2:49.86±6.16 vs.47.60±2.08 vs.42.84±3.00(mm Hg);Sa O2:86.70±2.23 vs.87.46±2.19 vs.95.80±1.04(%);4WLL组治疗后7 d测用力肺活量(FVC):(3.97±0.17)L;第1s用力呼气量(FEV1.0):(3.32±0.16)L.S;一氧化碳弥散量(DLco):(19.26±1.15)ml·min-1·mm Hg-1,与术前相应的FVC:(3.13±0.14)L;FEV 1.0:(2.17±0.24)L;DLco:(15.31±0.74)ml·min-1·mm Hg-1比较,均有明显升高,差异有明显统计学意义(P<0.01);BAL组呈现类似改变:FVC:3.14±0.15 vs.3.99±0.16(L);FEV1.0:2.16±0.13 vs.3.07±0.17(L);Dlco:14.99±0.90 vs.18.38±1.34(ml·min-1·mm Hg-1),治疗后测值较治疗前有明显好转(P<0.01);5WLL组术后第7天胸部CT评价疗效:Ⅰ级,0例;Ⅱ级,5例;Ⅲ级,13例;Ⅳ级,2例;总有效率为75.0%;BAL组总有效率69.2%;6WLL术后深部痰培养提示病原菌清除17例,未清除2例,菌交替2例,总清除率约85.0(17/20);BAL组总清除率76.9%;7WLL组治疗后出现并发症有:支气管痉挛1例,声带水肿1例;BAL组支气管痉挛2例,声带水肿1例,呼吸功能延迟恢复1例;8WLL组的住院时间短于BAL组,住院费用少于BAL组,两组差异有统计学意义(P<0.05)。结论 WLL和BAL治疗SA,2种疗法均能缓解SA患者临床症状,降低炎症反应,改善呼吸功能,但WLL组相对BAL组而言可更快改善症状、有效降低炎性反应,清除病原菌;安全性和经济性优于BAL组,可作为临床治疗SA的一种有效、独特、安全的疗法。

Objective To explore the therapeutic effects and safety of whole lung lavage （WLL） in treatment of severe aspiration（SA）. Methods It was analyzed retrospectively that 33 severe aspiration eases underwent whole lung lavage and broncho-alveolar lavage （BAL） treatment, evaluated the effects, safety and cost. Results： （1）After the WLL or BAL, the symptoms of cough, expectorate, asthma and fever relieved. The WLL group showed a more rapid improvement; （2）Inflammation biomarkers： After the treatment, the WLL group showed a significant and sustain improvement of inflammation biomarkers in peripheral blood as follows： before treatment, after the 1 d, 7 d, the count numeration of WBC were 3.34±3.48 vs. 9.56±2.23 vs. 6.61± 1.12 （109/L） ; the neutrophile granulocyte（NG） were 85.22±4.70 vs. 85.22±4.70 vs. 80.45±4.85 vs. 69.45± 4.10（%） ; the C-reactive protein（CRP） were 106.83±30.05 vs. 60.06±20.50 vs. 20.87±6.67（mg/L） ; the pre-calcitonin（PCT） were 2.75±0.59 vs. 1.73 ±0.29 vs. 0.51±0.19 （μg/L） ; the γ-interferon （γ-IFN） were 105.40± 18.58 vs. 90.78± 19.78 vs. 37.44±7.54（ ng/L）, The difference was statistically significant （ P〈0.01 ）. The BAL group showed same changes except the WBC and γ-IFN on dl after treatment with the actual datas as following： WBC ： 11.60±3.28 vs. 10.34± 1.53 vs. 7.85± 1.73 （109/L） ; NG： 86.38±4.93 vs. 85.00±4.83 vs. 76.15±5.67（%）; CRP：115.98±33.45 vs. 97.93±6.49 vs. 31.03±17.7（mg/L） ; PCT：2.58±0.64 vs. 2.08±0.57 vs. 0.59±0.15（μg/L） ;γ-IFN ： 105.00±22.13 vs. 96.37± 18.14 vs. 39.17±4.43 （ng/L） ; （3）Arterial blood gas testing：Before and 1 d, 7 d after the treatment, the WLL group showed a notable improvement in PaO2, PaCO2 and SaO2, with the datas as follows：PaO2：53.72±3.93 vs. 70.39±5.69 vs. 81.49±6.44（mmHg） ; PaCO2：51.54 ±6.06 vs. 47.48±3.22 vs. 44.35±3.22（mmHg） and SaO2：86.66±2.54 vs. 91.80±1.04 vs. 96.31±0.80（%） ; The difference was statistically significant （P〈0.01）. Similar phenomenon was observed in BAL group; （4）Lung function： the result of FVC, FEV1.0 and DLco in WLL group on 7 d after the treatment were 3.97±0.17（L） , FEV1.0：3.32±0.16（L.S） ; DLco： 19.26± 1.15 （ ml·min-1·mmHg-1 ）, were higher than the corresponding data before the WLL, which were FVC ： 3.13± 0.14 （L） ; FEV 1.0 ： 2.17± 0.24 （ L. S ） ; DLco： 15.31 ± 0. 74 （ ml· min-1·mmHg-1）. The difference was statistically significant （P〈0.01）. Similar phenomenon was observed in BAL group： FVC：3.14±0.15 vs. 3.99±0.16（L） ; FEV1.0：2.16±0.13 vs. 3.07±0.17（L） ; DLco：14.99±0.90 vs. 18.38±1.34（ml· min-1·mmHg-1） ; （5）The change in characters of CT before and after the different treatment were divided four bands： Ⅰ band：0 case; Ⅱband, 5cases; Ⅲband, 13cases;Ⅳ级, 2cases; the total efficiency was 75.0%; BAL group, was 69.2%; （6）Microbiology from sputum culture： in WLL group, 17 strains were eliminated and 2 strains were not. The number of bacteria alternation were 2 strains, the total removal rate was 85.0%（17/20） ; in BAL group, the total removal rate was 76.9%（9/13） ; （7）Complication： WLL group ： bronchial spasm, 1 case ; vocal cord edema： 1 case ; BAL group ： bronchial spasm, 2 case ; vocal cord edema 1 case; delayed recovery of respiratory function, 1 cases; （8） Hospitalization time：WLL group： 9.65± 1.53（d）vs. BAL group： 15.08± 1.26 （d） ; hospitalization cost （RMB） ： WLL group： 14 339.67±948.19 （yuan） vs. BAL group ： 16 330.65± 1150.13 （yuan）. The difference was statistically significant （ P〈0.05 ）. Conclusions In treatment of SA, both WLL and BAL can relieve the clinical symptoms, reduce inflammatory reaction, improve respiratory function. However, the WLL group maybe improve symptoms, reduce inflammatory reaction, and eliminate pathogenic bacteria. Comparing with BAL, the WLL maybe a more safe and economic therapy used as an noble treatment for SA.