Bronchiectasis is an irreversible dilatation caused by tissue destruction of the walls of one or more proximal bronchi and medium-sized bronchi. It is a common purulent inflammatory disease of the respiratory system. The main causative factors are infection obstruction and pulling of the bronchi, and some have congenital genetic factors. Patients often have a history of measles, whooping cough or bronchopneumonia in childhood. With the improvement of people’s life, vaccination against measles and pertussis, and the application of antibiotics, this disease has been significantly reduced.
1.Etiology and pathogenesis
The main factors of bronchial dilatation are infection of bronchial-lung tissue and infection of bronchial obstruction causing congestion and edema of the mucosa of the lumen, making the lumen narrow and secretions easily block the lumen, leading to poor drainage and aggravating the infection; poor drainage of bronchial obstruction can induce lung infection. Therefore, the two affect each other and contribute to the occurrence and development of bronchiectasis. Bronchiectasis caused by congenital developmental defects and genetic factors is less common.
Most patients have a history of measles, whooping cough, or bronchopneumonia that persists in childhood, and later often have recurrent infections of the respiratory tract.
Dilation of the trachea and main bronchi is less common because the larger bronchi have intact cartilaginous rings, better airway clearance, and larger diameter tubes with thicker muscular and elastic fibers, so they are less prone to obstruction and severe destruction of the bronchial wall. The small bronchial walls below the lung segments and subsegments have weak scaffolding tissues and small tube diameters, which are prone to sputum retention and obstruction, resulting in bronchial dilatation.
2.Pathology
The disease presents irrecoverable dilatation and deformation in the anatomical structure of bronchial tissue. Bronchial dilatation can be seen by visual examination as a marked thickening of the bronchial wall with varying degrees of deformation, and the lumen can be dilated in a cystic, columnar or shuttle shape. The dilated lumen is often filled with mucus, with marked inflammation and ulceration of the mucosa, and with varying degrees of destruction of the bronchial wall and fibrous tissue hyperplasia. Microscopically, lymphocytic infiltration or lymphoid nodules in the bronchial wall were seen, and mucus glands and lymphocytes were very obvious. The columnar epithelium of the bronchial mucosa often showed squamous epithelial metaplasia. The bronchial wall had varying degrees of destruction, and even normal structures could not be seen, only a few fragments of muscle and cartilage were visible. There is neutrophil infiltration in the wall, and the surrounding lung tissue often has pathological changes such as fibrosis, atrophy or pneumonia.
Generally inflammatory bronchiectasis is seen mostly in the lower lobe. Since the left common bronchus is longer and slender, and the cross angle with the trachea is nearly right angle, it is more difficult to expel the sputum than the right side, especially the lingual lobe and the basal section of the lower lobe are easy to drain poorly and lead to secondary infection, so the left lower lobe bronchial dilatation is more common than the right lower lobe. The bronchial opening of the lingual lobe is close to the dorsal branch of the lower lobe and is susceptible to infection of the lower lobe, so bronchial dilatation of the left lower lobe and the lingual lobe often coexist. Bronchiectasis in the apical or posterior branches of the upper lobe is mostly due to tuberculosis. The pulmonary arteries accompanying the bronchial travel may be thrombosed, and some have been re-communicated. The bronchial arteries may also be hypertrophic and dilated. The anastomotic branches between the bronchial arteries and pulmonary arteries are significantly increased. When the lesion progresses seriously, the alveolar capillaries are extensively destroyed, the resistance of pulmonary circulation increases, and finally pulmonary heart disease and even heart failure can be complicated.
3.Clinical manifestations
The typical symptoms are chronic cough with large amount of purulent sputum and repeated hemoptysis.
The amount of chronic cough with large amount of purulent sputum is related to the change of body position, such as the increase of coughing sputum when rising in the morning or lying in bed at night, and the increase of yellow-green pus sputum when the acute attack of respiratory tract infection is obvious, hundreds of milliliters a day, and if there is anaerobic bacteria mixed infection, there is a foul smell.
Hemoptysis can occur repeatedly in varying degrees, from small amounts of sputum and blood to large amounts of hemoptysis, and the amount of hemoptysis is sometimes inconsistent with the severity of the disease bronchiectasis hemoptysis is generally not obvious toxic symptoms.
If the repeated secondary infection bronchial drainage is poor, sputum is not easy to cough up, can feel chest discomfort inflammation extended to the lung tissue around the lesion, appear high fever, poor sweating, wasting, anemia and other symptoms.
In chronic severe bronchiectasis, when the lung function is seriously impaired, the labor force is obviously reduced, and there is shortness of breath and cyanosis with pestle-like fingers (toes) when there is slight activity.
4.Complications
Pleurisy, abscess chest, pericarditis and pulmonary heart disease, and even heart failure.
5.Signs
The patient’s signs depend on the extent of the lesion and the degree of dilatation. Mild bronchial dilatation may have no obvious signs, and wet rales of varying size can generally be heard in the dilated area, which are characterized by persistence. In addition, signs of obstructive pneumonia, atelectasis or emphysema may be present. In patients with chronic course of bronchiectasis, pestle-like fingers and toes and poorer general nutrition are seen.
On physical examination a rhotic sound may be heard at the site of the lesion. Mortar and pestle fingers are seen in about 1/3 of cases.
6.Auxiliary examination
X-ray chest film: in mild cases, there are no abnormal findings, but in severe cases, the lung texture is increased, thickened and disorganized, and sometimes the bronchi are seen in columnar thickening or “orbital sign”, typically in the form of honeycomb or curly shadows, with a cystic area of fluid plane between them.
This is the most basic X-ray examination. A small percentage of patients with bronchial enlargement (less than 10%) have completely normal plain films, but when the films are read carefully, most of them have some changes, but these changes are often non-specific and cannot make a reliable judgment.
Bronchial enlargement from mild to severe, the pathological changes are very complex, involving bronchi, lung parenchyma and pleura, the chest film is a reflection of the general pathological anatomy, so the film is also seen in a variety of ways.
(1) Due to chronic infection of the bronchial wall, thickening of the wall and proliferation of the surrounding connective tissue, the lung texture in the lesion area increases, thickens and disorganizes until the outer zone of the lung is still obvious, and if the thickened wall contains air, parallel double thick lines are seen on the film, called “double track sign”. The enlarged bronchus shows a circle shadow in the cross-section, and if multiple small circles are clustered together, it appears honeycomb-like. In large cystic dilatation, multiple round or ovoid translucent areas are seen, which can range in size from a few millimeters to 2-3 cm, with the lower edge of the wall thickening and shadowing, resembling curly hair, also known as the “curly hair sign”, and sometimes there are fluid levels in the cystic lumen.
(2) Bronchiectasis is accompanied by substantial inflammation of the lung, with localized lamellar shadows during acute attacks, and often leaves small lamellar and small mass lesions and fibrosis after the acute infection disappears, so the lung volume often decreases, with corresponding changes: lung texture clustering, increased density, lung fissure displacement, narrowing of the hilar shadow, transposition and displacement, compensatory emphysema without lesion area, and finally pulmonary atelectasis. Bilateral lower lobe pulmonary atelectasis, if small in size, can be affixed to the mediastinal surface and is not easily detected on plain film. Right upper lobe atelectasis may appear to be a widening of the upper mediastinum. Right middle lobe atelectasis may only be a blurred piece of the right cardiac margin, and is sometimes poorly differentiated from oblique fissure thickening on lateral films.
The left lower lobe is the site of branched enlargement, and when the lower lobe is reduced in size, it overlaps completely with the heart shadow on plain film, so it is easy to miss the diagnosis, but it is not difficult to detect if there is a lateral film and pay attention to the left hilar and left lung texture changes.
(3) Pleural changes. Patients with branched enlargement often have repeated lung infections, which sometimes also affect the pleura and produce inflammatory adhesions, so there are many pleural changes on the film. In extensive and severe branched enlargement, pulmonary atelectasis and fibrosis, the thickened pleura may cause dense shadow on one side of the lung, diaphragm rise and mediastinal shift, and the translucent area of branched enlargement can be seen in the dense shadow, which becomes the so-called “destroyed lung”.
(4) In the advanced stage of branched enlargement, the heart may be affected and pulmonary hypertension may appear, with dilated pulmonary arteries at the hilum and slender peripheral lung texture, and the heart shadow may be enlarged.
Bronchial enlargement occurs in the bilateral lower lobe, middle lobe, left lower lobe plus lingual segment, and right middle and lower lobe, so the changes on the chest film are often limited to these parts, and there is a positive lateral film to clarify the scope, and even in bilateral extensive bronchial enlargement there are often some normal bronchi.
(2) Bronchial oil iodography: Bronchial angiography on both sides can make a clear diagnosis, not only to understand the morphology of the dilatation, but also to clarify the location and extent of the lesion. Cystic, columnar or cystic-columnar changes can be found. Because the examination process is extremely painful for the patient’s self-conscious symptoms, it is rarely used now.
(3) Thin layer CT scan of the chest: the diagnostic accuracy of bronchial dilatation is high, and it has basically replaced bronchial iodine oil imaging as an important basis for the diagnosis of bronchial dilatation.
(4) Sputum bacteriological culture: it has guiding significance for the rational application of antibiotics.
(5) Fibrinoscopy
Diagnosis of bronchiectasis generally does not require fiberoptic bronchoscopy, but the following cases should be investigated.
(1) To exclude bronchial dilatation caused by foreign body blockage, the elderly, frail, children, psychiatric patients, anesthesia and people sleeping with sleeping pills may swallow a foreign body without being aware of it, and the foreign body may cause bronchial dilatation by blocking the bronchus for a long time, and may recover after removal.
(2) To understand the presence of bronchial masses: lung cancer develops quickly and obstructive pneumonia or atelectasis occurs in a short period of time; benign tumors and polyps may block the bronchus for a long time and cause expansion because of their slow growth.
(3) If there is a lot of pus sputum and the effect of postural drainage and drug treatment is not good, fibrinoscopy can understand the source of pus sputum, clarify the lesion site, determine the appropriate postural drainage position, and make the patient improve as soon as possible by aspiration and injection of drugs (antibiotics, bronchodilators such as ephedrine, etc.) to facilitate surgery.
(4) Large hemoptysis requires bronchial artery embolization of the vessels at the bleeding site. If the hemoptysis is too large, the examination before embolization is dangerous, and the examination can be done after the completion of embolization, at which time the bronchus still remains blood, and the appropriateness of the embolization site can be verified.
(5) If hemoptysis or more pus sputum is present again after bronchiectomy, check the bronchial stump for granulation, threads, ulcers, etc., and understand the source of bleeding to provide materials for further treatment.
(6) Suspect some kind of specific infection such as mycobacteria, which can be examined by taking distal bronchial secretions by fibronectomy without contamination of respiratory secretions.
(6) Pulmonary function and nuclide examination
Pulmonary function tests: including ventilation and blood gas, patients treated by internal medicine, repeated tests can compare and favor the treatment effect and estimate the prognosis. If surgical treatment is considered, it is possible to find out whether surgery can be tolerated, to facilitate better design of surgical plans, and as a criterion for observing the efficacy of surgery.
Nuclear scan examination: to understand the bilateral lung perfusion, which is helpful in deciding the resection method and predicting the postoperative situation. When the lung is diseased, there is often thrombosis in the pulmonary artery, and the unilateral destruction of the pulmonary artery may be blocked at the common trunk. Removal of the lung that is no longer perfused is expected to result in a better postoperative recovery.
7.Diagnosis
(1) Medical history and symptoms: history of measles, whooping cough, bronchopneumonia, tuberculosis, etc. may be present in early childhood; symptoms are chronic cough and sputum, with varying amounts and nature of sputum; some have hemoptysis, with varying amounts and triggers; most have intermittent fever, malaise, nausea, panic, shortness of breath, etc.
(2) Physical examination findings: paranasal sinuses and oropharynx may have chronic infectious lesions; early and mild cases have no abnormal signs; dry and wet rales and croup may be heard in the lungs after infection; late stage may have emphysema, pulmonary hypertension, pestle finger (toe) and other signs.
8.Differential diagnosis
The disease should be differentiated from chronic bronchitis, pulmonary tuberculosis, lung abscess and other diseases.
(1) Chronic bronchitis Patients with chronic bronchitis tend to have cough and sputum symptoms in spring and winter, with white mucus foamy sputum, and the onset of the disease is mostly in middle and old age. Patients with advanced bronchitis are often accompanied by bronchial dilatation.
(2) Patients with early tuberculosis have a light cough and sputum, and those with cavitation often have mucus-like or purulent sputum, and sputum examination can detect tuberculosis bacteria. The whole body condition may be accompanied by weakness, emaciation, low fever in the afternoon, night sweating and other symptoms.
(3) Lung abscess has clinical manifestations of rapid onset, chills, high fever, cough, and copious yellow or yellow-green pus sputum. The lung lesion is characterized by turbid percussion, decreased breath sounds, and wet rales. x-ray examination reveals a cavity with fluid level and dense inflammatory shadows around it.
9.Treatment
The condition of branched enlargement is complex, with different symptoms and a lot of correlation between lightness and severity, and the determination of the treatment plan should take into account various factors.
(1) the presence or absence of symptoms, the severity of symptoms, the history of recurrent lung infections, the number of episodes and the effectiveness of treatment: if the symptoms are mild and the infection is easily controlled, it can be treated internally, otherwise surgery should be considered.
(2) History of hemoptysis: It is important to consider that some so-called “dry bronchial dilatation”, which usually does not have many symptoms of lung infection, may suddenly hemoptysis. Bronchiectasis is a benign disease, and in today’s world of multiple antibiotics, most infections can be controlled and the disease can survive for many years, but hemoptysis is life-threatening, and although bronchial artery embolization is now available for emergency treatment, in the long run, surgery is best for hemoptysis or recurrent hemoptysis.
(3) The extent of the lesion: this is one of the most important factors in determining medical and surgical treatment. If the lesion is limited, it can be removed, and if the lesion is more extensive, but some parts are light and some are heavy, and the symptoms are obvious, the heavier lesion can be removed to obtain palliative treatment, but if the lesion is bilateral and there is not much correlation between light and heavy, surgery cannot be considered.
(4) Age: some case analysis, see after 40 years of age patients often remission, progress of not many, and more than 50 years of age patients have poor physical strength, have other diseases, tolerate surgery is poor, so for patients over 40 to 50 years of age surgery conservative a little.
(5) Combined with other lesions: such as benign tumor blockage caused by branch expansion, resection is mainly for the treatment of tumor; tuberculosis caused by branch expansion (mostly upper lobe), at this time, the tuberculosis lesions have been more stable, no need for surgery.
(6) Systemic condition and the presence of other diseases: if there are serious lesions in the heart, liver, kidney and other systems, or poor cardiopulmonary function, which cannot withstand surgery, only internal medicine can be treated.
(7) Living, working and medical conditions: If the living and medical conditions are good and the work is not too strenuous, the lesions can mostly remain stable after conservative treatment. If the lesion is difficult to treat because of field work, physical labor, students in study, and medical condition, it is better to remove the lesion.
(8) Whether the patient himself and his family agree to the surgery: bronchial expansion generally develops in childhood, bronchial and lung parenchymal lesions are irreversible, lung lesions repeatedly deteriorate, obviously affecting the quality of life and labor force, if there are conditions, it is best to remove the lesions. However, in recent years, new antibiotics have emerged, which can strongly control lung infections, and a significant proportion of bronchial lesions can be kept in a “stable state”, so that patients are healthy and continue to work, and the need for surgery is obviously reduced, but it is not correct to think that surgery is no longer needed. Since thoracic surgery is already a fairly safe procedure with good surgical results, each patient should be treated on an individual basis, weighing the pros and cons.
The treatment of branched enlargement includes several parts: ① antibiotic treatment for infection. (2) Treatment of comorbidities that cause bronchiectasis, such as sinusitis. (3) Symptomatic treatment such as hemoptysis and copious pus sputum. ④Surgical resection or lung transplantation. ⑤ Respiratory training and physical therapy to improve the quality of life and work capacity, which is often neglected by clinicians. ⑥Special causes, such as immunodeficiency, congenital genetic disease caused by bronchiectasis, if the original cause can not be corrected, only with thoracic internal medicine treatment.
The treatment principle of bronchiectasis is to eliminate the pathogen, promote sputum discharge, control infection and other conservative medical treatment, and if necessary, surgical operation.
Medical treatment is the basis, even if there is a clear indication for surgery, it is necessary to go through a period of medical treatment first, some people believe that at least six months of treatment, because some bronchial dilatation may return to normal after the control of lung infection, and surgery is safer and more effective when the acute inflammation disappears. In cases that cannot be operated, long-term medical treatment is required.
(A) Medical treatment of branched enlargement
1, control infection to relieve symptoms: branched expansion is a lifelong disease if not operated, the symptoms are sporadic, sometimes light and sometimes heavy, internal medicine should consider when to use, what drugs to use, how to use (dose, route and duration). Antibiotics are not necessary if there is no fever, the cough has not increased, there is only mucous sputum, and the patient is not in obvious discomfort. If the sputum is purulent (often after upper respiratory tract infection), use broad-spectrum antibiotics in standard doses for at least 1 to 2 weeks until the sputum turns mucusy. If there is yellow-green pus sputum, it means that the inflammation progresses and the lung continues to be destroyed, and the medicine should be used actively, but it is not easy to make the sputum turn into mucus. If the disease has always been “stable”, once it deteriorates, active treatment is also required. In cases of frequent mucopurulent sputum, it is questionable whether antibiotics are effective. The choice of antibiotics depends on experience and the patient’s response after treatment, and sputum culture and drug sensitivity tests are not completely reliable. Acute infections such as pneumonia, with congested tissue and high antibiotic concentrations in the lungs and blood, are effective. Chronic purulent lesions do not respond well to drugs, probably because: ① antibiotics cannot penetrate the bronchial wall into the lumen, and bacteria double in the purulent secretions of the lumen. ② Bacteria are not sensitive to the drug itself, and anaerobic bacteria (coughing foul sputum) are also resistant to the drug.
Opinions on the duration of drug administration are not consistent, with some believing that about 2 weeks of drug administration is effective, and some advocating 6 to 10 months of drug administration to reduce the damage to the lung from inflammation and avoid fibrosis, and little research has been done in this area. Because the vast majority of the clinical see is chronic disease, even long-term medication is unlikely to prevent the destruction of the lung, cure until the symptoms disappear.
2. Postural drainage: bronchial dilatation mostly occurs at the site of pulmonary hypoplasia with poor drainage. Therefore, it is best to use gravity to perform postural drainage, so that the surrounding phlegm can flow to the larger bronchi at the lung door and then cough out. According to the different directions of each bronchus, after positioning, deep breathing, cough up sputum after 10-15 min, and perform several times a day, and add physical therapy methods such as chest percussion. If the sputum is more than 30ml a day, it should be drained in the morning and evening.
Keeping the respiratory flow, eliminating the secretions in the trachea, reducing the accumulation of sputum in the airway and lung bronchus, and removing the place for bacterial growth and reproduction are the main links to control the infection.
Care of bronchial drainage: Firstly, expectorants should be given to make sputum thinner and easier to cough up to reduce bronchial infection and systemic toxic reaction. Instruct the patient to make the affected side upward and the opening downward according to the site of the lesion, make deep breathing and coughing, and assist in patting the back to make the secretion oscillate in the trachea and be discharged out of the body by the effect of gravity, and if necessary, nebulized inhalation can be performed for better effect.
Patients should be drained in the fasting position, 2 to 4 times a day, 15 to 20 minutes each time. Observe the patient’s breathing, pulse and other changes when doing drainage, if there is dyspnea, panic, cold sweat and other symptoms should stop the drainage, give semi-recumbent or lying position oxygen. After the drainage is completed, the patient should be assisted in cleaning the oral secretions.
3. Treatment of hemoptysis: hemoptysis is a common symptom of branched expansion and is the main cause of life-threatening hemoptysis, which often has no clear cause and is not necessarily parallel to other symptoms, such as fever and coughing up pus. Small amounts of hemoptysis can usually be stopped by rest, sedatives and hemostatic drugs. Large amounts of hemoptysis can be stopped with bronchial artery embolization. Tracheoscopy (preferably with a rigid mirror), local injection of ice water, blockage with thin strips of gauze or Fogarty tubes.
4.Other therapies: In acute infection, attention to rest, nutrition, and supportive therapy are indispensable. Bronchodilators may be useful, in the pulmonary function test found to have airway blockage, after the drug FEV1 has improved, can continue to use the drug, ineffective can try prednisone, after using if the subjective symptoms do not improve, do not give. In some rare cases such as immunosuppression, human globulin can be used.
5. Those who have chronic paranasal sinusitis, gingivitis and tonsillitis should be given active treatment at the same time.
Care
In case of co-infection with fever, cough, sputum or hemoptysis, rest in bed, avoid exertion and mood swings, and keep your mood relaxed. Diet should be nutritious, with high protein, high calorie and high vitamin food. Pay attention to oral hygiene, gargle with compound borax solution or chlorhexidine solution in the morning, before going to bed and after meals. In case of poor sputum discharge, various drainage methods should be adopted. The patient’s pus sputum should not be spit anywhere, but should be disinfected and treated centrally.
(II) Surgical treatment
Surgery: Up to now, surgery is the only way to cure bronchial dilatation, and as long as the diagnosis is clear, surgical removal can be considered.
1. Indications for surgery
(1) The main indications are limited lesions, obvious symptoms, or repeated lung infections, which can completely remove the diseased lung tissue and achieve good results.
(2) Both sides have lesions, one side is serious, the opposite side is very light, the symptoms are mainly flat from the heavy side of the disease, you can remove the side, after surgery, if the lesions on the opposite side still have symptoms can be drug therapy.
(3) Both rules have limited heavy lesions, and if there are symptoms such as hemoptysis, the heavy side should be removed first, and thereafter, if the lesion on the opposite side is stable, observation and medical treatment, and then removed if the lesion progresses.
(4) Emergency resection of hemoptysis. Most of the existing bronchial artery embolization can be changed to elective surgery after first stopping the hemorrhage with this method. If the original bronchogram is available and the lesion is clear, emergency resection of hemoptysis can also be performed under the current level of technology. If the original bronchogram is not available and the site and extent of the lesion is unknown, surgery is very difficult. The decision to resect has been made based on physical signs (e.g., rales on auscultation), chest radiographs, and unintentional views of the cilia, but it is not very reliable. The source of the bleeding can be seen by the cilio-scope, but it is dangerous to examine when the hemoptysis is very large, and the lens may be stained soon after the cilio-scope is put in and nothing can be seen. If blood is everywhere in the bronchial tree, or if blood is not seen coming out of any bronchus for a short time after aspiration, it is impossible to locate it. Sometimes blood is seen in the total bronchus, but not necessarily all of one side of the lung is diseased. The bronchial lumen is very small and the bronchial wall is lubricated by secretions, so the bleeding can easily flow to a low position (such as the dorsal segment of the lower lobe in supine or the whole lower lobe), which makes it easy to judge wrongly. In conclusion, if there is no special need, it is better not to perform emergency pneumonectomy because of the high technical requirements of anesthesia. After opening the chest, sometimes blood is seen in most of the lungs, which is purple-red in color, and it is impossible to determine the extent of resection, or even mistakenly cut more lung tissue. After lung resection, the remaining lung may be poorly expanded or infected due to the presence of inhaled blood, so the complications and mortality rate of emergency surgery are higher.
(5) In patients with extensive bilateral lesions, deteriorating general condition and lung function, ineffective medical treatment, estimated survival time of no more than 1 to 2 years, and age below 55 years, bilateral lung transplantation can be considered. Human homologous lung transplantation has been successful in 1983, and more than 8000 cases have been performed worldwide until 1998, with a certain percentage of branched expansion among the indications. 1-year survival rate can reach 79%-90%, which is quite satisfactory for a dying patient.
2.Design of surgical plan
(1) If the lesion is limited and it is normal, a section to the whole lung can be removed, most often the left lower lobe plus the lingual segment, the left or right lower lobe and the right middle lobe.
(2) It is not uncommon to have a lesion in the basal segment of the lower lobe while the dorsal segment is normal, and the dorsal segment can be preserved. However, even if the basal segment is not fully affected, individual basal segment resection is usually not performed because the intersegmental boundaries are not very clear and the volume of each basal segment is not very large, so reluctant separation will result in limited preserved pulmonary function and significantly increased complications.
(3) The supraglottic segment is sometimes not affected, and subglottic segment can be resected alone.
(4) In bilateral lesions, if both are relatively limited, the patient is young and in good general condition, they can be resected simultaneously at one time, with bilateral anterior incisions in the anterior thorax or sequentially with bilateral lateral incisions. If the general condition does not allow, one side will be done first, and the opposite side will be done after 3-6 months, with the length of the interval depending on the physical recovery, and individual patients may not be able to do the surgery on the opposite side eventually due to complications on the operated side or greater lung function damage.
Bilateral branched dilatation is not uncommon: for example, massive hemoptysis and recurrent lung infections make treatment difficult. Because branched enlargement often develops from children, it can be removed in stages as long as there is enough normal lung tissue left, and there are reports in the literature of three operations in three stages, leaving only the left upper lobe and the right upper lobe bilaterally with a total of eight segments of the lung at the end. Due to the great respiratory potential of the lungs, this point lung can also sustain party life. The important thing is that each surgery needs to be done with care. No complications should occur.
The amount of lung tissue removed by bronchiectomy is entirely based on what is seen on preoperative bronchography, and what is seen on surgical open-chest exploration is for reference only. A significant number of patients have normal lung appearance and no abnormalities on palpation, and the extent of the lesion cannot be determined. The pathological changes seen during surgery range from severe to mild, and may include reduced lung volume, non-distension or solidity; small lesions in the lung parenchyma; sometimes the pigmentation of the diseased lung is significantly reduced and pink emphysema-like, probably due to the disease in early childhood, not participating in respiratory ventilation and not inhaling external dust. The lesions have reached the pleura with adhesions. The lung hilum has almost always been inflamed, with enlarged lymph nodes and tight adhesions between the tissues. The ipsilateral normal lung had more compensatory emphysema. All of these intraoperative findings had an impact on the decision of the surgical plan. If the lung in the upper lobe of the left lung is also unhealthy and has little volume after the addition of the lower lobe resection, the residual cavity left behind is too large and sometimes the whole lung has to be resected instead to avoid serious complications.
3.Preoperative preparation
(1) Various routine laboratory tests, with special attention to sputum culture and drug allergy test.
(2) Pulmonary function, blood gas, nuclear, lung perfusion examination.
(3)Improvement of nutrition.
(4) Give appropriate antibiotics for sputum, preferably when sputum volume is reduced to less than 30ml/d and sputum changes from purulent to mucus before surgery, and the duration of medication may be as long as 2 weeks or more.
(5) Postural drainage for sputum.
(6) Respiratory training and physical therapy to improve lung function.
(7) If bronchography has been done recently, those with iodine oil should wait until the iodine oil is emptied. Usually it can be drained in a few days. However, individual iodine oil has entered the fine bronchi or alveoli and may remain for a long time and cannot be waited for. In terms of lung function, there is no effect on the surgery 3 days after the imaging.
4, part of the branched pneumonectomy after the residual symptoms of its causes
(1) surgery glue bilateral bronchogram, some branches filling poorly, not found, surgery is not removed clean, residual branch expansion with symptoms.
(2) The original bilateral lesion, only the heavy side was removed, and the lighter side still has branch expansion.
(3) After partial lung resection on one side, the remaining lung is overinflated with bronchial distortion, poor drainage, infection, and even the formation of new bronchial enlargement.
(4) The bronchial stump is left long after pneumonectomy, and there is secretion retention, or there is nematocystic irritation and granulation formation due to the stump, resulting in coughing and hemoptysis.
(5) Factors related to the original cause of bronchial expansion, such as untreated nasal vacuolitis, chronic bronchitis or immune-related defects.
(6) There may be an occult bronchial fistula with a bronchial stump leading to a small pus cavity. Postoperative coughing and yellow sputum is sometimes a general respiratory infection and is not necessarily related to the original bronchial expansion and surgery. The bronchial stump is often normal on fibrinoscopy, and the residual bronchial augmentation is not always present on the remainder of the lung angiogram. If embolization is not effective, if other conditions allow, the remaining lung tissue can be removed.
5, the outcome of surgical treatment and the choice of indications have a great relationship
Precedent strictly surgical mortality <1%, in experienced units, basically no surgical death, 80% of postoperative symptoms disappeared, 15% improved, still some symptoms, 5% no improvement or deterioration. The relationship between symptom improvement and surgery is sometimes difficult to determine, and the residual lung conditions that produce symptoms, some of which are clear preoperatively, cannot be treated by surgery.
6. Some problems related to anesthesia and surgery
It is better to have double-lumen tracheal intubation for anesthesia. Even for patients with little sputum before surgery, a large amount of pus sputum may come out during surgery due to pulmonary compression, which may not be suctioned out in time if single-lumen intubation is used, and frequent suctioning of sputum may affect respiratory ventilation. In patients with hemoptysis who hemoptysis between operations, double-lumen intubation can avoid blood flow to the opposite side and help in the localization of hemoptysis. When the bronchus of the bronchial dilated lung is clamped there should be no more blood aspirated, and if there is persistent blood, other sites of bleeding should be considered.
In pediatric or female patients with younger trachea who are unable to insert bilateral tubes, consider prone position with the help of postural sputum drainage when there is a lot of sputum. Single-lumen insertion to one side is also available, and then returned to the orthotracheal tube after bronchial clamping between operations. If the lesion affects the pleura and the adhesions are tight, there are mostly body-pulmonary vascular traffic branches, and attention should be paid to hemostatic ligation during separation.
In bronchial dilatation, there may be no adhesions in the pleura, but because of repeated lung infections, the pulmonary hilum almost always has tight or even scarred adhesions, and various anatomical structures and lymph nodes stick together, with almost no loose connective tissue layer between them. The degree of bronchial artery dilatation and distension is the most serious among the common lung diseases, and the diameter of the bronchial artery at the normal hilar rarely exceeds 1 to 2 mm, but from our large number of bronchial arteriograms, patients with bronchial dilatation can be as thick as 5 to 6 mm. The soft tissues next to the bronchus should be completely sutured first. In cases of tight hilar adhesions, sometimes the lung can be separated from the periapical area and all tissue to the diseased lung can be treated last. The bronchi are hard and easy to identify, so they can be cut off if necessary and sutured when the lumen is seen. The vessels adjacent to them can be sutured in bundles to avoid injury to vessels not intended for lung resection due to forced separation.