纤维支气管镜下生理盐水灌洗在重症吸入性肺炎患者中的应用

The application of saline lavage under fiberoptic bronchoscope in patients with severe aspiration pneumonia

目的:探索纤维支气管镜(以下简称纤支镜)下生理盐水灌洗在重症吸入型肺炎患者中的应用价值。方法:选择2017年10月至2018年10月,中日友好医院收治的重症吸入性肺炎患者64例,所有患者均气管插管机械通气治疗。将患者随机分为常规组和纤支镜组,2组均给予抗感染、补液、镇痛、营养支持等综合治疗。从患者气管插管开始,常规组使用普通吸痰管自气管插管处吸痰,每2～3 h1次。纤支镜组在此基础上加用纤维支气管镜下生理盐水灌洗,吸引气道内痰液和异物,每2天1次。检测2组患者自气管插管第1、4、8天的氧合指数、C-反应蛋白(Creactive protein, CRP)、胸部CT分析比较。患者出院或死亡后,比较2组患者发热持续天数、抗生素使用时间、机械通气时间、住院时间、住院病死率以及气道内出血情况。结果:2组患者治疗后氧合指数均逐渐升高,纤支镜组治疗4、8天时氧合指数均高于常规组,差异均有统计学意义[(375.59±22.70)mmHg vs.(325.65±27.97) mmHg,(441.67±19. 89)mmHg vs.(379.44±21.68) mmHg, P均<0.05]; 2组患者治疗后CRP均逐渐降低,纤支镜组治疗第4、8天时CRP均明显低于常规组,差异均有统计学意义[(102.34±12.47)mg·L^(-1) vs.(153.45±11.44) mg·L^(-1),(62.12±13.35) mg·L^(-1) vs.(88.90±8.57) mg·L^(-1),P均<0.05];纤支镜组治疗第4、8天影像学好转率明显高于常规组,差异均有统计学意义(46.9%vs. 23.3%,81.3%vs.56. 7%,P均<0.05);纤支镜组体温控制时间(4.78±2.45)dvs.(8.12±2.67) d、抗生素使用时间(16.77±5.00)d vs.(24.68±3.56) d、机械通气使用时间(14. 94±3. 45)d vs.(20. 22±4.34) d、住院时间(27. 61±3.84)d vs.(34. 75±4. 51) d、住院病死率(6. 7%vs.25.0%),均明显少于常规组,差异均有统计学意义(P均<0.05);治疗期间2组发生气道内出血的比率均为23. 3%,差异无统计学意义(P>0.05)。结论:纤支镜下生理盐水灌洗治疗可以作为重症社区获得性吸入型肺炎患者的有效辅助手段。

Objective: To investigate the treatment value of saline lavage under fiberoptic bronchoscope in severe aspiration pneumonia(SAP). Methods: Totally 64 SAP cases admitted to emergency department(ED) from October 2017 to October 2018 were selected and received the mechanical ventilation treatments. All patients divided randomly into routine group and fiberbronchoscope group. Anti-infection, fluid infusion, analgesia, and nutritional support were given in both groups. From the beginning of tracheal intubation, the patients in routine group used ordinary suction tube to suck sputum from the tracheal intubation, once/2-3 h, while patients in fiberbronchoscope group was given the extra bronchoscopic treatment including saline lavage on the base of routine group, to suck sputum and foreign matters in airway(once/2-3 d). The oxygenation index, serum CRP levels, and chest CT scan on the first day( dl), fourth day( d4) and eighth day( d8) from endotracheal intubation in the 2 groups was compared. After discharge or death, the duration of fever, antibiotic use time, mechanical ventilation time, hospitalization time, in-hospital mortality and intra-airway hemorrhage were analyzed. Results: Oxygenation index increased after therapy in both 2 groups, and fiberbronchoscope group increased more than the routine group on d4 and d8 [(375.59 ± 22.70) mmHg vs.(325.65 ± 27.97) mmHg,(441. 67 ± 19. 89) vs.(379.44 ±21.68) mmHg, P <0. 05)]. The serum CRP levels in 2 groups were decreased after treatment. and fiberbronchoscope group decreased more than the routine group on d4 and d8 [(102. 34 ±12.47) mg ·L-1 vs.(153.45 ±11.44) mg ·L-1(62. 12 ± 13. 35) mg ·L-1 vs.(88. 90 ±8. 57) mg ·L-1, P <0.05)]. The improvement rate of imaging in fiberbronchoscope group was significantly higher than that in the routine group on d4 and d8 after treatment, and the difference was statistically significant(46. 9% vs. 23. 3%, 81. 3% vs. 56.7%, P < 0. 05). The duration of fever control[(4. 78 ±2.45) d vs.(8. 12 ±2.67) d], duration of antibiotics [(16. 77 ±5. 00) d vs.(24. 68 ± 3.56) d], duration of mechanical ventilation[(14. 94 ±3.4 d) vs.(20. 22 ±4. 34) d], hospitalization days [(27. 61 ±3. 84) dvs.(34. 75 ±4. 51) d] and mortality(6.7% vs. 25.3%) in fiberbronchoscope group was significantly less than the routine group, and the difference was statistically significant(P < 0. 05). The incidence of intra-airway hemorrhage was 23. 3% in both groups during treatment, and there was no significant difference between the two groups(P >0. 05). Conclusion :Saline lavage under fiberoptic bronchoscopic can be used as an effective adjuvant for patients with severe community acquired inhalation pneumonia.