激光消融术在良性肉芽肿型气管狭窄中的临床应用价值

Application value of laser ablation in benign granulomatous tracheal stenosis

目的:探讨激光消融术在良性肉芽肿型气管狭窄中的临床应用价值。方法:本研究为观察性研究。采用非随机抽样的方法选取2019年1月至2022年9月在南京医科大学附属常州第二人民医院呼吸与危重症医学科采用激光消融术治疗的30例良性肉芽肿型气管狭窄患者。激光消融术治疗必要时联合其他介入治疗措施,如电圈套、氩气刀等。对治疗前后所有患者的气道直径、气管狭窄程度改善情况、气促评分、呼吸困难指数、肺功能指标、不良反应发生情况,以及动脉血氧分压(PaO 2)、动脉血二氧化碳分压(PaCO 2)和动脉血氧饱和度(SaO 2)等血气分析指标进行统计分析。定期复查气管镜或胸部CT,分析再狭窄情况,随访并采用卡氏功能状态评分(KPS)评估患者生活质量。结果:30例患者中气管切开术后肉芽组织增生22例,气管插管术后肉芽组织增生4例,气管支架置入术后肉芽组织增生4例。所有患者均在气管镜直视下进行激光消融术治疗。30例患者共进行激光消融术治疗43次。经过激光消融术治疗后1周观察气道直径[治疗前比治疗后:(2.63±1.61)mm比(8.96±2.25)mm,t=13.55]、气管狭窄程度[治疗前比治疗后:(80.63±11.96)%比(31.87±9.56)%,t=20.22]、气促评分[治疗前比治疗后:(3.53±0.57)分比(1.13±0.35)分,t=19.48]、呼吸困难指数[治疗前比治疗后:0级0例(0.0%)比18例(60.0%),Ⅰ级0例(0.0%)比4例(13.3%),Ⅱ级0例(0.0%)比7例(23.3%),Ⅲ级4例(13.3%)比1例(0.3%),Ⅳ级10例(33.3%)比0例(0.0%),Ⅴ级16例(53.3%)比0例(0.0%),Z=46.32]、肺功能指标[治疗前比治疗后:第1秒用力呼气容积(1.37±0.13)L比(1.76±0.15)L,t=12.64;用力肺活量(2.31±0.15)L比(2.70±0.15)L,t=11.55]、血气分析指标[治疗前比治疗后:PaO 2(84.57±6.03)mmHg(1 mmHg=0.133 kPa)比(94.57±4.07)mmHg,t=8.14;PaCO 2(59.50±4.03)mmHg比(42.30±2.77)mmHg,t=18.57;SaO 2(82.63±4.41)%比(93.60±1.57)%,t=12.64]和KPS评分[治疗前比治疗后:<50分17例(56.7%)比5例(16.7),50~80分12例(40.0%)比16例(53.3%),>80分1例(3.3%)比9例(30.0%),Z=3.64]均较治疗前改善,差异均有统计学意义(均P<0.05)。对激光消融术治疗后气道扩大的狭窄患者进行5个月的随访观察,有13例气道扩大后发生再狭窄。所有患者中,有1例术后出现气管软化,其他患者无严重不良反应发生。经5个月的随访有效率为90.0%(27/30)。结论:良性肉芽肿型气管狭窄患者经激光消融术治疗后近期疗效显著,远期疗效有待进一步评估。

Objective To explore the clinical application of laser ablation to benign granulomatous tracheal stenosis.Methods It was an observational study involving 30 patients with benign granulomatous tracheal stenosis who were treated with laser ablation in the Department of Respiratory and Critical Care Medicine,Changzhou Second People's Hospital Affiliated to Nanjing Medical University from January 2019 to September 2022 using the non-random sampling method.Other interventional treatment measures like electric snares and argon gas knife were combined with laser ablation if necessary.The airway diameter,improvement of tracheal stenosis,shortness of breath score,dyspnea index,pulmonary function indicators,occurrence of adverse reactions,partial pressure of oxygen in the arterial blood(PaO2),partial pressure of carbon dioxide in the arterial blood(PaCO2)and arterial oxygen saturation(SaO2)were recorded.Bronchoscopy or chest CT was regularly re-examined to analyze restenosis.Patients were followed up and the quality of life was assessed using the Karnofsky Performance Scale(KPS).Results Among the 30 patients,22 cases had granulation tissue hyperplasia after tracheostomy,4 cases had granulation tissue hyperplasia after tracheal intubation,and 4 cases had granulation tissue hyperplasia after tracheal stent placement.All patients were treated with laser ablation under a direct vision of the bronchoscope.A total of 43 laser ablations were performed on 30 patients.One week after laser ablation treatment,the airway diameter([2.63±1.61]mm vs[8.96±2.25]mm,t=13.55),degree of tracheal stenosis([80.63±11.96]vs[31.87±9.56],t=20.22),and shortness of breath score([3.53±0.57]points vs[1.13±0.35]points,t=19.48),dyspnea index(Grade 0:0[0.0%]vs 18[60.0%],GradeⅠ:0[0.0%]vs 4[13.3%],GradeⅡ:0[0.0%]vs 7[23.3%],GradeⅢ:4[13.3%]vs 1[0.3%],GradeⅣ:10[33.3%]vs 0[0.0%],Grade V:16[53.3%]vs 0[0.0%],Z=46.32),lung function indicators(forced expiratory volume in 1 second:[1.37±0.13]L vs[1.76±0.15]L,t=12.64;forced vital capacity:[2.31±0.15]L vs[2.70±0.15]L,t=11.55),blood gas analysis indicators(PaO2:[84.57±6.03]mmHg vs[94.57±4.07]mmHg,t=8.14;PaCO2:[59.50±4.03]mmHg vs[42.30±2.77]mmHg,t=18.57;SaO2:[82.63±4.41]mmHg vs[93.60±1.57]mmHg,t=12.64;1 mmHg=0.133 kPa)and KPS score(<50 points:17[56.7%]vs 5[16.7%];50-80 points:12[40.0%]vs 16[53.3%];>80 points:1[3.3%]vs 9[30.0%],Z=3.64)were all significantly improved compared with those before treatment(all P<0.05).After 5-month follow-up on stenotic patients with enlarged airways,13 cases developed restenosis after airway enlargement.Among all patients,1 case developed tracheomalacia after surgery,and no serious adverse events were reported.After 5 months of the follow-up,effective rate was 90.0%(27/30).Conclusions The short-term efficacy of laser ablation in patients with benign granulomatous tracheal stenosis is significant,but the long-term efficacy needs further evaluation.