支气管肺泡灌洗治疗肺炎支原体肺炎合并肺不张的效果及其影响因素

Efficacy of bronchoalveolar lavage and its influence factors in the treatment of Mycoplasma pneumoniae pneumonia with atelectasis

目的 探讨支气管肺泡灌洗（BAL）治疗肺炎支原体肺炎（MPP）合并肺不张的效果及其影响因素.方法 采用回顾性病例对照研究方法,选取2015年1月1日至2017年7月31日在浙江大学医学院附属儿童医院呼吸科诊断为急性MPP合并肺不张并行BAL的患儿为研究对象,以48 h内退热及1周复张作为判断效果的标准.收集并比较治疗有效与无效患儿的年龄、性别、BAL前血象、乳酸脱氢酶（LDH）、细胞因子、并发症、BAL前热程、BAL前病程、是否形成痰栓、肺不张范围及CT值,分析治疗效果相关因素.组间比较采用t检验、Mann-Whitney U检验或χ^2检验.结果 （1）共纳入163例急性MPP合并肺不张并行BAL的患儿,其中男69例、女94例,男：女=1∶1.36,年龄0.5- 12.6岁.（2）BAL时仍发热113例,按照经BAL后48 h退热与否分为有效组（66例）和无效组（47例）,退热有效组中含痰栓者占33％（22例）,比例明显低于无效组（57％,27例）,差异有统计学意义（χ^2=6.499,P=0.011）,两组性别构成、平均年龄、BAL前热程、BAL前病程、BAL前C反应蛋白（CRP）、血乳酸脱氢酶（LDH）及白细胞介素（IL）-2、IL-4、IL-6、IL-10、肿瘤坏死因子（TNF）、干扰素-γ（IFN-γ）水平,还有肺不张范围、肺病灶CT值差异均无统计学意义（P均＞0.05）.（3）BAL后1周有复查影像学资料者122例,按照经BAL后复张与否分为有效组（81例）和无效组（41例）,复张有效组CT值低于复张无效组[（58±9）比（63±8）HU,t=-2.436,P=0.017],BAL前IL-6、IL-10水平[M（Q1,Q3）]亦均低于复张无效组[21.0（1.9,48.4）比36.4（21.8,93.6）、4.9（3.7,9.6）比7.7（4.4,12.0）ng/L,Z=-2.387、-2.009,P=0.017、0.045],但两组性别构成、平均年龄、BAL前热程、BAL前病程、CRP、LDH及细胞因子IL-2、IL-4、TNF、IFN-γ、肺不张范围、痰栓比例差异均无统计学意义（P均＞0.05）.（4）根据气管镜下有无痰栓分为有痰栓组（57例）和无痰栓组（106例）,有痰栓组LDH、CRP、IL-6、IFN-γ水平[M（Q1,Q3）]均高于无痰栓组[585（433,833）比369（312,588） U/L,42（19,103）比25 （12,45）mg/L,38.8 （22.1,71.3）比20.7 （9.2,48.3）ng/L,33.1（13.5,89.3）比12.7（6.5,33.6）ng/L,Z=-4.865、-3.435、-3.098、-3.704,P均＜0.01],胸腔积液发生率、肺外并发症发生率也均较无痰栓组高[73.7％ （42/57）比52.8％ （56/106）,40.4％ （23/57）比17.0％ （18/106）,χ^2=0.010、0.001,P=0.007、0.001].有痰栓组BAL后48 h退热有效率较无痰栓组低[44.9％（22/49）比68.8％（44/64）,χ^2=0.0 11,P=0.009],1周复张有效率两组差异无统计学意义[56.5％（26/46）比72.4％（55/76）,χ^2=0.073,P=0.056].结论 BAL对伴有肺不张的急性MPP有一定的退热和复张效果,复张或退热无效常与气道痰栓的存在、外周血IL-6、IL-10水平明显增高等因素有关.

Objective To investigate the efficacy of bronchoalveolar lavage （BAL） and its influence factors in the treatment of Mycoplasma pneumoniae pneumonia （MPP） with atelectasis.Methods A retrospective case control study was performed on hospitalized MPP patients with atelectasis and received BAL in the Department of Pulmonology,Children＇s Hospital Zhejiang University School of Medicine from January 1,2015 to July 31,2017.Fever relieved in 48 hours and chest imaging improved in one week after BAL were considered effective.Clinical data,including age,sex,blood routine tests,lactate dehydrogenase （LDH）,cytokines,complications,fever duration before BAL,course of disease before BAL,sputum plug,atelectasis area and its CT values of atelectasis site were collected.Student＇s t test,Mann-Whitney U test,or chi square test were used.Results （1） A total of 163 patients were enrolled,including 69 boys and 94 girls,with the ratio of 1 ∶ 1.36.Their ages ranged from 6 months to 12.6 years.（2） On the day of bronchoscope,113 patients still had fever.They were divided into effective group （n=66） and ineffective group （n=47） according to whether fever was relieved in 48 hours after BAL.The effective group were found to have less sputum plug compared with the ineffective group （33% （22/66） vs.57% （27/47）,χ^2=6.499,P=0.011）.The other factors such as sex,age,fever duration before BAL,course of disease before BAL,C reactive protein （CRP）,LDH,IL-2,IL-4,IL-6,IL-10,TNF,IFN-γ atelectasis area and CT value showed no significant difference between the two groups （all P〉0.05）.（3）A total of 122 cases had chest imaging after BAL.According to chest imaging improvement,they were divided into effective group （n=81） and ineffective group （n=41）.The effective group showed lower CT value （（58±9） vs.（63±8） HU,t=-2.436,P=0.017）,IL-6 and IL-10 （M（Q,,Q3）） （21.0 （1.9,48.4） vs.36.4（21.8,93.6）,4.9 （3.7,9.6） vs.7.7 （4.4,12.0） ng/L,Z=-2.387,-2.009,P=0.017,0.045）.Sex,age,fever duration before BAL,course of disease before BAL,CRP,LDH,IL-2,IL-4,TNF,IFN-γ,atelectasis area showed no significant differences between the two groups （all P〉0.05）.（4） Patients were divided into sputum plug group （57 cases） and non sputum plug group （106 cases） according to bronchoscopic findings.The sputum plug group showed higher LDH,CRP,IL-6,IFN-γ,incidence of pleural effusion and extrapulmonary complications （585（433,833） vs.369 （312,588） U/L,42 （19,103）vs.25 （12,45） mg/L,38.8 （22.1,71.3） vs.20.7 （9.2,48.3） ng/L,33.1 （13.5,89.3） vs.12.7 （6.5,33.6） ng/L,73.7% （42/57） vs.52.8% （56/106）,40.4% （23/57） vs.17.0% （18/106））,with statistically significant differences （Z=-4.865,-3.435,-3.098,-3.704,χ^2=0.010,0.001,all P〈0.01）.Additionally,fewer patients showed fever relief within 48 hours after BAL in the cases with sputum plug cases compared those without sputum plug （44.9% （22/49） vs.68.8% （44/64）,χ^2=0.011,P=0.009）.Fewer patients showed chest imaging improvement within one week after BAL in the cases with sputum plug compared with those without sputum plug,but did not show significant difference （56.5% （26/46） vs.72.4% （55/76）,χ^2=0.073,P=0.056）.Conclusions BAL has some therapeutic effect on fever or atelectasis in MPP children complicated with atelectasis.Chest imaging improvement or fever relief may be hampered by sputum plug,increased IL-6 or IL-10.