非结核感染相关良性气道狭窄的临床分析

Clinical features of benign tracheal stenosis caused by infections rather than tuberculosis

目的:分析非结核感染相关良性气道狭窄的支气管镜下表现和治疗方式。方法:本研究为观察性研究,采用目的抽样法收集2018年1月至2023年12月在首都医科大学附属北京天坛医院确诊的9例非结核感染相关良性气道狭窄病例,对其临床特点、实验室检查、影像学、支气管镜下表现、诊治过程和预后进行回顾性分析。结果:9例患者中女5例,男4例;年龄(55.33±5.84)岁,年龄范围为22~79岁;既往2型糖尿病4例、气道损伤史4例、新型冠状病毒感染后1例。临床表现为呼吸困难7例,咳嗽2例,发热1例。多数患者(5/9)的白细胞计数正常。病原学结果为铜绿假单胞菌4例、金黄色葡萄球菌3例、毛霉1例、副血链球菌1例。影像学结果显示7例患者为主气管受累,CT表现主要有气道管壁增厚管腔狭窄、黏膜下低密度(脓肿)、软骨环显示不清、气管变形塌陷。支气管镜下表现为气道黏膜弥漫充血水肿(呈颗粒叠瓦状),气管脓肿,肉芽增生,瘢痕狭窄、管壁塌陷。9例患者的病理均为呼吸道上皮黏膜急、慢性炎细胞浸润。治疗上,4例黏膜充血水肿型给予抗感染治疗,5例在抗感染基础上联合气管镜下介入治疗。介入方式依赖于病变类型,对于气管脓肿型,给予电刀切割引流脓液、球囊扩张、冷冻冻融治疗;对于肉芽增生型,给予支气管镜下机械清除;对于瘢痕狭窄、管壁塌陷型,感染控制后置入硅酮支架、气管T管。治疗后9例患者症状均缓解,呼吸困难指数和气道狭窄程度均降低。结论:非结核感染相关良性气道狭窄少见,感染急性期特异性镜下可表现为气道黏膜弥漫性充血水肿(呈颗粒叠瓦状)、气管脓肿、肉芽增生;炎症消退后修复阶段的镜下表现为瘢痕狭窄、管壁塌陷。治疗方式依赖于病因、病变类型、病情严重程度。全身和局部药物治疗联合支气管镜介入治疗可取得较好的临床疗效。

Objective To analyze bronchoscopic manifestations and treatment of benign tracheal stenosis(BTS)caused by infections(except for tuberculosis).Methods This study was an observational study.Between January 2018 to December 2023,9 BTS patients caused by infections,rather than tuberculosis and treated in Beijing Tiantan Hospital,Capital Medical University were recruited by objective sampling.Their clinical characteristics,laboratory data,imaging findings,bronchoscopic manifestations,diagnosis,treatment and prognosis were retrospectively analyzed.Results A total of 9 patients,including 5 women and 4 men with the mean age of(55.33±5.84[22-79])years were enrolled.Four patients had history of type 2 diabetes mellitus,4 had history of tracheal injury and 1 had history of COVID-19.The clinical manifestations included shortness of breath(7 cases),cough(2 cases)and fever(1 case).Most patients(5/9)had normal white blood cell counts.The infectious etiologies included P.aeruginosa(4 cases),Staphylococcus aureus(3 cases),Mucormycosis(1 case)and Streptococcus parasanguis(1 case).Imaging findings showed the main trachea involvement in 7 cases,including the radiologic manifestations of thickening of airway wall and narrowing of lumen,submucosal low-density(abscess),unclear display of cartilage ring,tracheal deformation and collapse.Bronchoscopic manifestations included diffuse congestion and edema of the airway mucosa(granular shingles),tracheal abscess,granulation hyperplasia,scar stenosis,and collapse of the tube wall.Pathology in 9 patients revealed acute and chronic inflammatory cell infiltration of the respiratory epithelial mucosa.Four patients with mucosal congestion and edema were given antibiotic therapies,and 5 were managed by antibiotic therapy plus interventional therapy under bronchoscopy.The endoscopic interventional treatments were modified based on the pathological characteristics,including electrocautery for pus drainage,balloon dilation and cryotherapy for tracheal abscess;mechanical removal of granuloma under bronchoscopy;antibiotic therapy and placement of silicon stent and tracheal T-tube for scar stenosis and collapse of the tube wall.Symptoms of all patients were significantly relieved,with decreased medical research council(mMRC)dyspnea scale score and the degree of airway stenosis.Conclusions BTS caused by infections but not tuberculosis is a rare condition.In the acute infection period,endoscopic changes are diffuse congestion and edema of airway mucosa(in the form of granules and tiles),tracheal abscess,and granulation hyperplasia.In the recovery period without infections,endoscopic findings include scar stenosis,and collapse of the tube wall.The treatment regimens rely on the causes,pathology,and severity.Systematic and local medications combined with interventional bronchoscopy are useful to BTS caused by infections.