儿童硬性支气管镜下异物取出术二次手术原因分析及应对措施

Re-operation of Tracheobronchial Foreign Body Removal Under the Rigid Bronchoscope in Children:Cause Analysis and Management

目的分析儿童呼吸道异物二次及以上手术患儿的临床特征,探讨硬性支气管镜下儿童呼吸道异物取出术二次手术的高危因素及应对方法。方法回顾性分析2009年1月至2020年12月间因呼吸道异物行二次手术儿童的临床特征,包括:临床表现、异物种类、异物停留部位,及诊治和手术过程。结果共收集气管支气管异物二次手术患儿41例,其中异物部位在左肺(23例,56.10%)、多发异物(5例,12.20%)、金属类等特殊异物(7例,17.07%)、异物伴发炎性肉芽(11例,26.83%)构成比较总体偏高;异物深度以二级及以下支气管为主(29例,70.73%)。所有患儿均有明确异物吸入史;首次手术中53.66%(22例)患儿发生血氧耐受不良,发生剧烈气道反应的患儿术中血氧耐受不良发生率较高。二次手术术前抗感染治疗1周,采用静吸复合麻醉或联合表面麻醉,9.76%(4例)术中出现血氧耐受不良;95.12%(39例)经再次硬性支气管镜成功取出异物,术中辅以潜窥镜导航系统及肾上腺素盐水支气管肺泡灌洗术;2例未能经硬性支气管镜取出,转入胸外科开胸取出异物。结论有剧烈气道反应病史的患儿在硬性支气管镜异物取出术中易出现血氧耐受不良;多发部位、左侧肺及二级以下支气管的呼吸道异物、特殊属性异物及伴发炎性肉芽组织异物的取出手术难度较高,是二次手术的高危因素。二次手术前控制感染,术中麻醉加强气道管理,选择合适器械辅以潜窥镜显像导航系统、盐酸肾上腺素盐水支气管肺灌洗技术是有效的应对措施。

Objective To analyze the clinical characteristics of children underwent re-operations for foreign body in respiratory tract,and to explore the risk factors and countermeasures of re-operation for removal of foreign body in respiratory tract under rigid bronchoscopy.Methods A retrospective study was performed in children underwent re-operation of bronchial foreign body removal from January 2009to December 2020.The clinical characteristics were analyzed including clinical manifestations,foreign body propeties,foreign body residence sites and the course of primary and secondary operations.Results A total of 41patients with tracheobronchial foreign bodies who required re-operation were collected,among which left lung foreign body(56.10%,23cases)and multiple foreign body(12.20%,5cases)accounted for higher proportions in total tracheobronchial foreign bodies in children.The proportions of special foreign body(17.07%,7cases)and foreign body with inflammatory granulation(26.83%,11cases)were comparatively higher.The residence sites of foreign body were mainly secondary or lower bronchial foreign body in 29cases,accounting for 70.73%.All patients had a clear history of foreign body inhalation.In all,22cases(53.66%)had blood oxygen intolerance in one operation.The incidence of blood oxygen intolerance in children with airway hyperreaction was high,and the difference was significant.After one week of anti-infection treatment before the second operation,4cases(9.76%)had intraoperative blood oxygen intolerance.The foreign bodies of 39cases(95.12%)were successfully removed in re-operation under rigid bronchoscopy,and intraoperative bronchoalveolar lavage was supplemented by speculum navigation system and adrenalin saline.The foreign bodies in 2cases were not successfully removed,who were further transferred to thoracic surgery department for thoracotomy.Conclusion The removal of foreign body under rigid bronchoscope in children who had a history of airway hyperreaction,foreign bodies in multiple sites,left lung and bronchial respiratory tract below grade 2,or foreign bodies with special characteristics and packing with inflammatory granulation tissue are prond to have re-operation.Preoperative inflammation control,airway management in intra-operative anesthesia,selection of appropriate instruments with endoscopic imaging navigation system,epinephrine hydrochloride saline bronchopulmonary lavage technology are effective measures.