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 stretching of the bronchi, and some have congenital genetic factors. Most patients have a history of childhood measles pertussis or bronchopneumonia. With the improvement of people’s life, vaccination against measles pertussis, and the application of antibiotics, the disease has been significantly reduced.
Etiology and pathogenesis
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 hair shadows, interspersed with cystic areas of fluid planes.
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.
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 gas, parallel double thick lines are visible on the film, called the “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, branched expansion are accompanied by substantial inflammation of the lung, acute attacks with localized lamellar shadow, acute infection disappears, but also often leaves small lamellar, small lesions and fibrosis, so the lung volume is often reduced, and accompanied by corresponding changes: lung texture agglomeration, increased density, lung fissure displacement, lung door shadow reduction, 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, when the volume of the lower lobe is reduced, the flat film and the heart shadow completely overlap, easy to miss the diagnosis, but if there is a lateral film and pay attention to the left lung door and the left lung texture changes, it is not difficult to find.
Pleural changes: Patients with branched enlargement often have repeated lung infections, which sometimes also affect the pleura and produce inflammatory adhesions, so many pleural changes are seen on the film. With extensive and severe branched enlargement, pulmonary atelectasis and fibrosis, the thickened pleura can cause dense shadows on one side of the lung, diaphragm rise, mediastinal shift, and translucent areas of branched enlargement can be seen in the dense shadows, becoming the so-called “destroyed lung”.
4, Advanced branched enlargement may affect the heart, and pulmonary hypertension may appear, with dilated pulmonary arteries at the pulmonary hilum and slender peripheral lung texture, and the heart shadow may also 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 the scope can be clarified with a frontal and lateral film.
Thin layer CT scan of the chest
It has some value in the diagnosis of bronchiectasis.
Sputum bacteriological culture
It has a guiding significance for the rational application of antibiotics.
Fibroscopy
Fiberoptic bronchoscopy is generally not required for the diagnosis of bronchiectasis, but the following cases should be investigated.
(1) In order to exclude the foreign body blockage caused by the transport expansion, the elderly, frail, children, psychiatric patients, anesthesia and people sleeping with sleeping pills, etc. may swallow foreign bodies without being aware of it, and the foreign body can cause bronchial expansion by blocking the bronchus for a long time, and may recover after removal.
(2) Know whether there are bronchial masses: lung cancer develops quickly and obstructive pneumonia or atelectasis occurs in a short period of time; benign tumors and polyps may be blocked for a long time and cause expansion because of 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 site of bleeding, and there is a danger of checking before embolization if the hemoptysis is too large, which can be checked immediately after embolization, when blood still remains in the bronchus, which can verify whether the embolized locust site is appropriate.
(5) If the bronchogram is unsatisfactory, such as a branch filling well or not filling, fibrinoscopy can be found as a problem of imaging technique or other reasons, such as sputum, swelling, blockage of granulation or scar formation at the opening, etc. If necessary, selective imaging of the branch is performed (injection of contrast from the biopsy hole of fibrinoscopy).
(6) If you have hemoptysis or more pus sputum again after bronchiectomy, check the bronchial stump for granulation, threads, ulcers, etc. and understand the source of bleeding to provide material for further treatment.
(7) Suspect some kind of specific infection such as mycobacteria, which can be examined by taking distal bronchial secretions through fibronectomy without contamination of respiratory secretions.
Pulmonary function and nuclide examination
Pulmonary function tests: including ventilation and blood gases, repeat tests can compare and favor the treatment effect and estimate the prognosis in patients treated with internal medicine. If surgical treatment is considered, it is possible to find out whether surgery can be tolerated, to facilitate better design of the surgical plan, and to serve 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, the pulmonary artery is often thrombosed, and the unilateral destruction of the pulmonary artery may be obstructed at the common trunk. Removal of the lung that is no longer perfused is expected to result in a better postoperative recovery.
Diagnosis
I. 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 of sputum and nature of sputum; some have hemoptysis, with varying amounts of hemoptysis and triggers; most have intermittent fever, malaise, nausea, panic, shortness of breath, etc.
Physical examination findings: there may be chronic infectious lesions in the paranasal sinuses and oropharynx; early and mild cases have no abnormal signs; dry and wet rales and croup may be heard in the lungs after infection; in the late stage, there may be emphysema, pulmonary hypertension, pestle finger (toe) and other signs.
Differential diagnosis
The disease should be differentiated from chronic bronchitis, pulmonary tuberculosis, lung abscess and other diseases.
1. Chronic bronchitis patients with chronic bronchitis mostly have cough and sputum symptoms in spring and winter, with white mucus foamy sputum, and the age of onset is mostly in middle and old age. Advanced patients are often accompanied by bronchial dilatation.
2, tuberculosis early tuberculosis patients cough light, sputum is not much, with cavitation sputum is often mucus-like or purulent, sputum examination can be detected more tuberculosis bacteria. The whole body condition may be accompanied by weakness, emaciation, low fever in the afternoon, night sweating and other symptoms.
3.Pulmonary abscess has clinical manifestations of rapid onset, chill, high fever, cough, and large amount of yellow or yellow-green pus sputum. The lung lesion is characterized by turbid percussion, decreased breath sounds and wet rales. x-ray examination shows a cavity with fluid level and dense inflammatory shadows around it.
Treatment
The condition of bronchiectasis is complex, the symptoms vary and the severity is related to many factors, 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 can be easily controlled, it can be treated by internal medicine, otherwise surgery should be considered.
2. History of hemoptysis
Some so-called “dry bronchiectasis”, which usually does not have many lung infection symptoms, may suddenly hemoptysis. Bronchiectasis is a benign disease, and in today’s world of antibiotics, most infections can be controlled and the disease can survive for many years, but hemoptysis is life-threatening.
3. The extent of the lesion
This is one of the most important factors in deciding the 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
In some case analysis, it is seen that patients after 40 years of age often have remission and not many progress, while patients over 50 years of age have poor physical strength, have other diseases and tolerate surgery poorly, so the surgery is conservative for patients over 40 to 50 years of age.
5.Combination of other lesions
If the branch expansion is caused by benign tumor blockage, resection is mainly for the treatment of tumor; if the branch expansion is caused by pulmonary tuberculosis (mostly upper lobe), the tuberculosis lesion has been stabilized at this time, so surgery is not necessary.
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 used.
7.Living, working and medical conditions
If the living and medical conditions are good, and the work is not too strenuous, the lesion can remain stable after conservative treatment. If the lesion is deteriorating and there are difficulties in treatment, it is better to remove the lesion if it is field work, physical labor, students in study, and medical conditions are not good.
8.Whether the patient and his family agree to the surgery
Bronchiectasis usually develops in childhood, the bronchial and lung parenchymal lesions are irreversible, and the repeated deterioration of lung lesions obviously affects the quality of life and labor force, so it is better to remove the lesions if there are conditions. 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 considered individually in terms of treatment, weighing the pros and cons.
The treatment of branchial enlargement consists of 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.
(4) Surgical 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.
(6) Special causes, such as immunodeficiency, congenital genetic disease caused by bronchiectasis, if the original cause can not be corrected, the only treatment with thoracic medicine.
The principle of treatment for bronchiectasis is to eliminate the pathogen, promote sputum discharge, control infection and other conservative medical treatment, and if necessary, surgical procedures.
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 the infection and relieve the symptoms
If the branched expansion is not operated, it is a lifelong disease, and the symptoms are sporadic, sometimes mild and sometimes severe. 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 to mucus. If there is yellow-green pus sputum, it means that the inflammation progresses and the lung continues to be destroyed, so 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” but 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 tissues 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 use are not consistent, some believe that about 2 weeks of drug use is effective, some advocate the use of drugs for 6 to 10 months to reduce the destruction of the lung by inflammation and avoid fibrosis, and there are few studies in this area. Since the vast majority of the diseases seen clinically are chronic, 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 in the inferior part of the lung 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 and coughing up sputum after 10-15 min are performed several times a day, together with 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 action 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, the patient should be assisted to clean the oral secretions.
3.Treatment of hemoptysis
Hemoptysis is a common symptom of bronchiectasis 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. Bronchoscopy (preferably with a rigid mirror), local injection of ice water, blockage with a thin strip of gauze or Fogarty tube.
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. Eat a nutritious diet 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 bedtime 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
Surgical operation: recurrent hemoptysis, lung infection with poor effect by long-term medical treatment, lesions not exceeding 2 lung lobes, and no serious heart and lung function impairment can be considered for surgical resection.
1. Indications for surgery
(1) The lesion is limited, with obvious symptoms, or recurrent lung infection, which is the main indication for complete resection of the diseased lung tissue and good results.
(2) Bilateral 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 lesion on the opposite side still has symptoms can be drug therapy.
(3) Double rules, both have limited heavier lesions, if there are symptoms such as hemoptysis, the heavy side is removed first, thereafter, if the lesion on the opposite side is stable, observation and medical treatment, if the lesion progresses, then resection.
(4) Emergency resection of hemoptysis, existing bronchial artery embolization, most of which can be changed to elective surgery after first using this method to stop the hemorrhage. 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. Some people decide on resection based on physical signs (e.g., auscultation), chest radiographs and unintentional fibrillation.
The decision to resect is based on signs (e.g., on auscultation), chest radiographs, and unintentional cilia. The source of the bleeding can be seen with a ciliofibroscope, but it is dangerous to examine when the hemoptysis is very large, and the lens may be stained soon after the ciliofibroscope 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 at an early age, 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 mostly compensatory emphysema. 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 post-bronchial pneumonectomy has residual symptoms 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 ineffective, the remaining lung tissue can be removed if other conditions allow.
5. The outcome of surgical treatment and the choice of indications are highly relevant
The precedent is strictly surgical mortality <1%, and in experienced units, there is essentially no surgical death, 80% of postoperative symptoms disappear, 15% improve, remain somewhat symptomatic, and 5% do not improve or worsen. 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 issues related to anesthesia and surgery
It is better to have double-lumen tracheal intubation for anesthesia. Even in 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 body position for sputum removal when sputum is abundant. 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, because of repeated lung infections, almost all of the pulmonary hilum has tight or even scarred adhesions, and various anatomical structures and lymph nodes are stuck 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, the bronchial artery 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 next to them can be sutured in bundles to avoid injury to the vessels not intended for lung resection due to forced separation.
(C) Chinese medicine treatment
1, wind-heat offending the lung, release of heat: hemoptysis, cough, chest tightness, body heat and thirst, dry nose and throat, or vicious cold and fever, red tongue with thin yellow coating, floating pulse.
Treatment: Relieve heat from the surface, promote the lung and stop cough.
Herbs: Mulberry leaf 10g, almond 10g, tempeh 10g, raw gardenia 10g, sage 15g, forsythia 10g, forsythia 15g, scutellaria 10g, orris 10g, white foxglove 30g, cynthia 15g, roasted loosestrife 10g.
Chinese patent medicine: Cough Orange Red Pill.
2.Phlegm-heat in the lung: cough with shortness of breath, yellow or pus-colored sputum, hemoptysis, chest pain, chest tightness, heartburn and dry mouth, red face and eyes, constipation and urination, red tongue with yellow coating and smooth pulse.
Treatment: Clearing heat and resolving phlegm, dipping fire to stop bleeding.
Herbs: 6 grams of roasted ephedra, 10 grams of almonds, 30 grams of gypsum (first), 6 grams of licorice, 10 grams of mulberry bark, 10 grams of ground bark, 10 grams of scutellaria, 30 grams of fishy grass, 10 grams of dandan bark, 10 grams of raw gardenia, 15 grams of senghu cao, 10 grams of small thistle, 30 grams of white foxglove, 10 grams of dabei mu, 3 grams of panax ginseng powder (for dosing).
Proprietary Chinese medicine: Ermu Ningxu Wan, Yunnan Baiyao.
3, qi and yin two: face cyst white or zygomatic red, shortness of breath and weakness, dry cough with little phlegm, dry mouth and throat red, shortness of breath and weakness, light red tongue with little coating, thin and weak pulse.
Treatment: Benefit Qi and nourish Yin, moisten the lung and stop cough.
Herbs: 15 grams of prunus ginseng, 15 grams of sage, 30 grams of lily of the valley, 15 grams of yucca, 10 grams of almond, 10 grams of phyllanthus, 10 grams of dried lotus grass, 10 grams of cypress, 10 grams of mulberry bark, 10 grams of ground bark, 10 grams of Zhi Mu, 6 grams of Chuan Bei powder (for dosing).
Traditional Chinese medicine: Nourishing Yin and clearing lung cream.
4.Chinese medicine prescription treatment
Bai He powder 5g, Ginseng Panax notoginseng powder 3g, Colla Corii Asini 10g (melted) and then take Bai He powder and Panax notoginseng powder. Used for hemoptysis.
Acupuncture treatment for bronchial dilatation
Acupuncture treatment for bronchial dilatation is as follows.
(1) Body acupuncture treatment: select Kong most, Diaphragm Yu, Lung Yu, and Sanyinjiao as the main points. If the phlegm and dampness are in full bloom, match with Tanzhong and Fenglong; if the yin is in full bloom, match with Taixi and Laogong; if the liver fire offends the lung, match with Taichong and Yanglingquan; if the lung and kidney are deficient in qi, match with Spleen Yu and Foot Sanli. Needle 1 time a day, flat tonic and flat diarrhea, can stay for 10 to 20 minutes.
(2) Acupuncture point dressing: 3 grams of cinnamon, 18 grams of sulfur, 9 grams of ice chips, and 1 garlic head, pounded together to take the right amount of the above medicine and put it on the bilateral Yongquan points.
(3) Acupuncture point injection: select the most points on both sides of the hole, using a syringe with a No. 5 needle to extract 2-4 ml of fishy grass injection quickly stabbed vertically into the acupuncture point about 0.5 cm, and then slowly stabbed into the deep about 1 cm, pumping no return blood, the drug solution will be injected deeply. During hemoptysis three times a day, each time each point inject 2 ml of fishy grass injection, 3 days as a course of treatment. After the hemoptysis stops, it is changed to once a day with the same dosage as above, and the treatment is consolidated for 2-3 days by injecting into both acupuncture points or alternately every other day.
The efficacy criteria are not yet unified, and most medical units adopt the following criteria.
Clinical cure: coughing, sputum and hemoptysis completely stop, other respiratory symptoms and signs basically or completely disappear, and can insist on working.
Apparent effect: cough and sputum are significantly reduced, hemoptysis stops, lung rales are significantly reduced or disappear, and inflammatory shadows on lung x-ray are significantly absorbed.
Effective: cough and sputum improved, massive hemoptysis stopped, but sputum still had blood or blood clots in it, and respiratory symptoms and signs reduced.
Ineffective: Symptoms and signs did not improve after treatment.
Prognosis: Bronchial dilatation itself is irreversible pathological changes, actively controlling infection, eliminating sputum, controlling and reducing the development of bronchial dilatation are closely related to the prognosis of the disease.
According to Chinese medicine, the underlying pathogenesis of this disease is fire-heat burning the lung ligaments, and the damaged lung ligaments are difficult to recover, so the latent pathogenesis always exists. The prognosis is good if the disease is controlled by timely treatment and proper management in the early and middle stages. The prognosis is poorer if the disease is recurrent or remains untreated for a long time, with massive hemoptysis and the formation of yin deficiency and fire symptoms.
Conditioning
1. Prevent cold and flu.
2. Avoid smoking, alcohol, spicy
3. Avoid emotional stimulation.
Suitable foods: For people with bronchial dilatation, it is appropriate to take the foods described in “lung-heat cough” and “lung-dry cough”, such as pear, Luohan fruit, persimmon, loquat, fig, water chestnut, radish, winter melon, loofah, mint, fat sea, houttuynia cordata, jellyfish, tofu, white chrysanthemum, golden chrysanthemum, and jellyfish. Tofu, white chrysanthemum, honeysuckle, lily, sugar cane, soy milk, honey, syrup, white fungus, persimmon cream, northern ginseng, sea pine nuts, peanuts, mandarin, orange, celery, wild rice, water spinach, water spinach, chrysanthemum brain, spinach, lettuce, coronary, wolfberry head, marjoram, lotus root, groundnut, cucumber, mung bean sprouts, snail, snail, banana, bitter melon, tomato, bamboo shoots, gourd, vegetable gourd, kelp and other foods (for details, see the section “Cough”). “Cough” section), in addition to the following foods.
Persimmon cream
It is cool in nature and sweet in taste, and has good effects on clearing heat, moistening dryness and resolving phlegm. It is well described in the book “Medical Science”: “Persimmon cream enters the lung and is sweet, cool and smooth. Its sweet also, can benefit the lung gas; its cool also, can clear the lung heat; its smooth also, can benefit the lung phlegm; its moist also, can nourish the lung dryness.” The Materia Medica Huiyin says: “Persimmon cream is also a medicine to clear the deficiency fire in the upper jiao.” The Classic of the Materia Medica also says: “Persimmon cream, its function is long in clearing the upper jiao fire evil.” Therefore, it is most beneficial for patients with bronchial dilatation who are suffering from phlegm and heat in the lungs or dry heat in the lungs.
Loofah
Cool and sweet in nature, it can clear heat, resolve phlegm, cool the blood and detoxify the toxin.
Winter melon
It is a cool food, can eliminate phlegm, clear heat and detoxify. It is said in the “Derivatives of the Materia Medica” that it “moistens the lungs, eliminates phlegm and heat, and stops coughing.” The “Materia Medica” also believes that winter melon can “cure heat in the chest and diaphragm and clear heat and toxicity”. Therefore, it is recommended for those who have phlegm-heat in the lung and cough with yellow pus and thick phlegm to eat more of it.
Tofu
It is cool in nature and sweet in taste, and has the effect of moistening dryness and clearing heat and detoxification. It is also said in the “Medical Forest Codification” that it can “clear lung heat, stop coughing and eliminate phlegm.” People with bronchial dilatation should often take tofu cold.
Cigu
Li Shizhen, a great pharmacologist of the Ming Dynasty, considered Cigu “bitter-sweet and slightly cold”. Dian Nan Ben Cao” also said it can “stop coughing, blood in the sputum or coughing up blood”, and introduced the treatment of lung deficiency coughing blood with several pieces of raw cigu, pounded and mixed with honey and rice slop, steamed on rice, while hot to eat method. Bronchial dilatation coughing up blood is also suitable.
In addition, it is also advisable to eat bok choy, houttuynia cordata, chrysanthemum brain, pear, silver flower and other heat-clearing and cooling foods.
Dietary methods.
Fang 1, lily and loquat paste: 3000 grams of fresh lily, 1000 grams of loquat (peel and core removed), 300 grams of honey. Wash the lily with loquat and honey in a pot with water and mix well, simmer with a gentle fire, then fry with a light fire until it is not sticky, remove and cool. Take 2 tablespoons twice daily with boiling water. This formula is suitable for people with bronchial dilatation cough, bright red hemoptysis and dry mouth and throat.
Formula 2: Fresh root porridge with silver fungus: 50 grams of silver fungus, 500 grams of fresh root (remove the nodes) and 50 grams of glutinous rice. Wash the lotus root and extract its juice, add water to the silver fungus and glutinous rice and cook the porridge as usual, add the lotus root juice when the porridge is thickened, and add the right amount of rock sugar when it is cooked. This formula is suitable for people with bronchial dilatation hemoptysis and dry cough with little sputum.
Prevention
Quit smoking and avoid inhaling irritating gases.
Control secondary infections and thoroughly treat respiratory diseases such as pediatric measles, whooping cough, bronchopneumonia, etc. Actively prevent and treat measles, whooping cough, bronchopneumonia, etc. in early childhood and make sure to vaccinate against infectious diseases. To prevent the bronchial lumen from being damaged and developing into bronchiectasis.
Enhance physical fitness, improve resistance to disease, and insist on participating in appropriate physical exercise, such as running, walking, and tai chi, etc., which can help prevent the onset of this disease.
Prevention of colds, active eradication of rhinitis, pharyngitis, chronic tonsillitis and other upper respiratory tract infections are important for the prevention and treatment of the disease.
Bronchiectasis hemoptysis care
According to the general nursing routine of internal medicine and diseases of this system.
Observation of disease condition.
1. Observe the changes in color, character, odor and amount of sputum, and keep sputum specimens for testing if necessary.
2. Observe changes in condition and the presence of infection and hemoptysis.
3. Observe the change of body temperature.
4. Observe the presence of aura symptoms of asphyxia and take timely measures.
5. Observe the effects and side effects of various drugs.
Symptomatic care.
1. Administer oxygen reasonably according to the condition.
2. Postural drainage
(1).Make postural drainage according to different parts of the lesion.
(2).Drainage time is 15min each time, encourage patient to cough. Give mouth rinse after drainage.
(3).Drainage is done once or twice a day (early in the morning and before going to sleep), and the amount and nature of sputum drained are recorded.
(4), drainage should be done before meals and should assist in patting the back.
3. Clear sputum and keep the airway open, ultrasonic nebulized inhalation can be performed twice a day.
4. Patients with hemoptysis according to hemoptysis care routine
(1) Give spiritual comfort and encourage the patient to gently hemoptysis out.
(2) Give warm and cool, easily digestible semi-liquid, fasting in case of hemoptysis.
(3) Closely observe the effect and side effects of hemostatic drugs.
(4) Closely observe the color and amount of hemoptysis, and record.
(5) Ensure smooth venous access and calculate the drip rate per minute correctly.
(6) Give the patient with hemoptysis to lie with the head on the affected side to one side.
(7) Prepare resuscitation items and suction device.
(8) Properly record the intensive care sheet when necessary.
(9) Closely observe the presence of aura symptoms of asphyxia.
(10) Ensure that the ward is quiet and avoid noise stimulation by rabbits. Remove blood-stained items in a timely manner and keep the bed unit neat and tidy.
General care.
1. dietary care encourage patients to eat more high-protein, high vitamin food.
2. Oral care rinse or brush teeth in the morning, before going to bed, after eating, etc. to reduce bacteria down to the respiratory tract causing infection.
3. Proper rest and appropriate bed activity to facilitate sputum drainage.
Health guidance.
1. Pay attention to keep warm and prevent upper respiratory tract infections.
2. Pay attention to oral cleaning, rinse your mouth regularly, brush your teeth more often, and change your toothbrush regularly.
3. Exercise to enhance the ability to resist diseases.
4. Keep the respiratory tract open, pay attention to drainage and sputum.
5. Regularly do sputum bacterial culture, and use symptomatic medicine as early as possible.