What Are the Different Types of Bronchiectasis Treatment?

Bronchiectasis is a permanent abnormal dilatation of the bronchus in the subsegment. Its etiology can be divided into congenital and acquired. One of the surgical treatments for severe bronchiectasis in the later stage. If the patient has inflammation before the operation, the inflammation should be treated before the operation. Care should be taken to prevent complications after surgery.

Surgical treatment of bronchiectasis

Surgical treatment of bronchiectasis

Surgery for bronchiectasis

Thoracic Surgery / Pulmonary Surgery / Pulmonary Bacterial Infectious Diseases

32.2905

The infection caused congestion and edema of the bronchial mucosa, increased secretions, and caused partial obstruction. Enlargement of the lymph nodes around the bronchi to compress the bronchus is also a factor causing obstruction. Obstruction prevents the discharge of secretions and worsens the infection. Repeated infections cause shedding and hyperplasia of the bronchial epithelium. Some columnar epithelium metamorphose into squamous epithelium, the bronchial endometrium loses the function of clearing the ciliated epithelium, and the elastic fibers and smooth muscles of the tube wall are damaged. Cavity. Neovascularization was formed on the wall of the tube, and hemoptysis or even massive hemoptysis occurred after rupture. Furthermore, bronchiectasis often causes atelectasis due to obstruction of secretion, which affects ventilation and ventilation.

Bronchodilation can be divided into three types: columnar, cystic, and mixed. Cystic bronchiectasis is mainly caused by infection, foreign body obstruction or bronchoconstriction, and is the main object of surgical treatment. Location of bronchiectasis: left side is more than right side, and lower lobe is more than upper lobe. The most common is the left lower lobe combined with the upper lobe tongue segment and the right lower lobe combined with the middle lobe. The range of distribution is often related to the etiology, such as: Kargengener syndrome, hypoglobulinemia, and cystic fibrosis. The affected areas are generally diffuse and bilateral. Tuberculous bronchiectasis is usually distributed in the upper or lower lobe.

(1) Symptoms and signs: Cough, mucus purulent sputum, which often lasts for months or years, and some even have hemoptysis, dyspnea, wheezing, and pleurisy. Due to recurrent episodes, chronic infection and poisoning, patients have wasting and malnutrition. It should be noted that the amount of hemoptysis and the scope and severity of bronchiectasis are often inconsistent. Those with large hemoptysis may have no obvious symptoms before hemoptysis. Signs are closely related to the location, extent and severity of bronchiectasis. Those with mild and localized lesions may have no signs; those with more severe infections may hear wheezing, tube breathing, or snoring in the lungs. Long-term illness may have clubbing fingers.

(2) X-ray chest radiograph: The lung texture on the lesion side is increased and rough, and some of them are cystic or columnar, or incomplete atelectasis, and the lung volume is significantly reduced.

(3) Bronchography: It is an effective method for the location of bronchiectasis and understanding of the degree of lesions. A good bronchogram can show that the bronchus with a lesion is cystic expansion or columnar expansion or mixed expansion. The point to note is that when there is a lot of hemoptysis and purulent sputum, it should be treated until the condition improves, that is, the hemoptysis stops and the sputum volume decreases, and then the examination is performed. In general, infants and young children need general anesthesia, but there is a risk of suffocation. If necessary, bronchoscopy should be performed first. Fortunately, in recent years, high-resolution CT examinations have tended to replace bronchography.

(4) CT examination: High-resolution CT scan images can show bronchiectasis and inflammation around the dilated bronchus. The diseased bronchus extends to the surroundings without tapering, the bronchus is enlarged, the wall is thickened, and the bronchi can still be seen around the lungs.

(5) fiber bronchoscopy: more important for hemoptysis. When hemoptysis is not completely stopped, it helps to identify the bleeding site, and foreign bodies, tumors, and other lesions in the bronchi can also be found.

(6) Esophageal barium radiography or esophagoscopy: the presence of right lower lung bronchiectasis with esophageal bronchial fistula can be excluded.

(1) Medical treatment: antibacterial drugs must be used for acute infection of bronchiectasis. Use antibiotics that are sensitive to bacteria. Pseudomonas aeruginosa and anaerobic bacteria are common pathogens of secondary infection of bronchiectasis, but empirical antibacterial treatment should cover Pseudomonas before obtaining sputum bacterial culture results. Therefore, in severe infections, -lactams are commonly used in combination with macrolides or quinolones, and quinolones (such as ciprofloxacin) with strong anti-Pseudomonas activity can also be used in combination with macrolides. When combined with aminoglycosides. Anaerobic bacteria can choose clindamycin or metronidazole. For those with high sputum volume, use expectorants, atomize inhalation, and postural drainage to keep the airway open. Correct and effective postural drainage is more important than antibiotic treatment. The method is that the diseased lung is at a high position, and the drainage bronchus is opened downwards for deep breathing and coughing, so that the sputum is drained down the bronchus to the trachea and coughed. If the lesion is in the lower lobe, you should take a prone position, with your front chest resting on the edge of the bed, with your hands on the ground, your head down, your back coughing, and sputum discharge. If the lesion is in the upper lobe, take a sitting position or other appropriate posture to facilitate drainage. If the sputum is viscous, it can be diluted and washed by injecting normal saline through a bronchoscope, sucking out the sputum and injecting antibacterial drugs. Large hemoptysis can be treated with bronchial arterial embolization.

(2) Surgical treatment: Bronchodilation, which is not easily controlled by drug treatment, or repeated infections, or large hemoptysis, and those with limited lesions should be resected with corresponding lung segments or lobes.

The surgical treatment of bronchiectasis is suitable for:

1. There are obvious symptoms of bronchiectasis, such as repeated respiratory infections, purulent sputum, and repeated attacks after long-term medical treatment, and more and more severe. To the extent permitted by lung function, pneumonectomy or lobectomy, pneumonectomy should be carefully considered.

2. Repeated hemoptysis or massive hemoptysis, the lesion site has been identified, after the disease is stable, surgically remove the diseased lung segment or lung lobe. When bleeding is life-threatening, emergency surgery should be performed.

3. For bilateral lesions, in principle, the heavier lesion is removed first, and the other side of the surgery should be based on the recovery of postoperative respiratory function to determine whether surgery and the scope of surgery.

Patients with extensive bronchiectasis and severe respiratory insufficiency cannot undergo surgery.

Those with more pus and sputum should be actively prepared before surgery, such as aerosolized inhalation, postural drainage and sputum control, control sputum volume below 50ml / 24h, and do sputum culture and smear examination, and choose sensitive and effective antibiotics. For patients with large hemoptysis, hemostatic treatment should be done.

Intratracheal double-lumen cannula intubation, combined intravenous anesthesia. It is more important for those with large sputum volume or large hemoptysis before surgery, and those who are not suitable for double-lumen catheterization can do unilateral bronchial intubation. Posture: The lateral position is often taken with the affected side up and the posterolateral incision. There is also a choice of the supine position, with the shoulder and back on the affected side elevated, for an external incision or a small incision, suitable for small-scale lung resection of the right middle lobe or upper right lobe and the left lung tongue segment.

Pay attention to the scope of surgery. Sometimes, the lung segment resection decided before surgery, but nodules or small clumps of different sizes are found in the whole lung lobe. At this time, the lung lobe should be decided decisively. If palliative lung segment or wedge resection is performed, there are more complications after operation, but it is better to do lobectomy. Those with right lower lobe bronchiectasis should carefully identify the cable-like fistulas present in the esophagus and bronchus during surgery. The anatomical adhesions should be carefully treated and handled properly. In this way, postoperative esophageal pleural fistulas can be avoided. Furthermore, patients with bronchiectasis often suffer from chronic inflammation, enlarged hilar lymph nodes, and calcification, which makes it difficult to free the pulmonary blood vessels. At this time, large sutures can be used, or bronchial sutures are used to close the bronchial blood vessels and remove the disease. The lungs were then sutured with 4-0 non-invasive, absorbable sutures.

The scope of bronchiectasis lung resection: left lower lobe or tongue resection, simple right middle lobe resection, right lower lobe resection or right middle lobe resection, respectively. Bronchiectasis caused by tuberculosis is more common in the upper right or left upper lung, so it is often used for right upper lobe resection or left upper lobe resection. One side pneumonectomy should be performed with caution. Minimal wedge resection for bronchiectasis.

1. Posture, breathing exercise and expectoration

Patients under general anesthesia should lie supine until they are fully awake and their blood pressure is stable (usually more than 6 hours after surgery) before they can change to the semi-sitting position. After the anesthesia is awake, the patient should be encouraged to do deep breathing exercises and expectoration. You can also use the hand to press the incision site to help the patient take a deep breath and expectoration, 5 to 6 times a day, to sputum in the bronchi and possible hemostasis. Benefit from lung expansion and chest drainage to avoid secondary infections in the lungs. Coughing must be hard, but it also causes pain, but it can't sputum. Instead, you need to repeat the cough, causing more pain. If the sputum is thick and difficult to come out, it can be used for steam inhalation, 3 times a day, 15 minutes each time, and oral expectorants. On the first day after surgery, the patient should be lifted up and sit up straight, sitting up 3 to 4 times a day. Usually 3 days after partial lung resection, after the thoracic drainage tube is removed (after 1 week of pneumonectomy), the patient can get out of bed. 3 to 4 days after the operation, the patient should help the patient to raise the surgical arm to avoid adhesion of chest wall muscles near the incision in the future, which will affect the movement of the arm; never start exercising until the incision is painless. These aspects of treatment play an important role in the recovery of postoperative illness, the expansion of the surplus lung, and the prevention of complications, which should be paid special attention.

2. Oxygen inhalation problem

If the patient does not have hypoxia after lung resection, oxygen may not be needed. For patients with poor lung function, intermittent low-flow oxygen can be given through the nasal tube. When administering oxygen, the catheter should be inserted into the nasopharynx so that oxygen can be effectively inhaled. Sometimes the patient has a large amount of sputum, which is sticky and difficult to come out, which seriously affects breathing; or due to insufficient preoperative estimates, pulmonary ventilation and ventilatory insufficiency occur after lung resection, resulting in hypoxia; or due to blood transfusion, excessive infusion, Excessive speed, severe cases such as pulmonary edema, the trachea should be opened in time, so that the sputum in the respiratory tract can be cleared at any time, and thus the dead space in the respiratory tract can be reduced by 50%, and the alveolar ventilation can be increased by 25%. At the same time, a thin plastic tube can be used to inhale oxygen more effectively through the tracheal cannula; however, a certain humidity and temperature should be maintained to prevent the respiratory tract from drying up and sputum crusting. When the sputum is thick, chymotrypsin can be dripped through the tracheal cannula to make the sputum thin. When the breathing is weak, the anesthesia machine can be connected to the tracheal cannula to assist breathing. When there is pulmonary edema, oxygen should be given under pressure, and a small amount of 95% alcohol will be inhaled to destroy the sticky sputum foam and increase the alveolar ventilation area. At the same time, intravenous injection of aminophylline 0.25 to 0.5 g will be used to relieve bronchospasm. In addition, the infusion should be stopped, and 50% glucose or 20% mannitol 250ml should be quickly dripped into the vein to diuresis, dehydration, relieve pulmonary edema, and consider adding digitalis to strengthen the heart.

3. Management of pleural effusion

After lung resection, generally within 24 hours, there will be 200 to 400 ml of oozing and exudate flowing out of the chest through the drainage tube, and the blood color of the drainage liquid should gradually fade. After about 24 to 72 hours, the effusion can be drained and the drainage tube can be removed. When removing the drainage tube, the section of the drainage tube close to the skin and the skin around the drainage port should be disinfected first, and the fixed line should be cut. One hand put 4 to 5 layers of vaseline gauze cotton pad on the drainage port, and hold the drainage tube with the other hand. After instructing the patient to inhale deeply and hold their breath, quickly pull the drainage tube out; at the same time, press the vaseline gauze and cotton pads tightly against the drainage port [Fig. 18], and apply pressure bandaging to prevent air from leaking into the chest cavity.

If there is a lot of drainage, the blood color does not fade, and the pulse is fast and the blood pressure is low, you should be alert for active bleeding. Therefore, in addition to observing the breathing, pulse, and blood pressure after surgery, you should also pay attention to whether the liquid level in the drainage tube fluctuates with breathing and whether it is higher than the horizontal level in the bottle. If the liquid level in the tube does not fluctuate, it means that the drainage tube has been blocked, and it should be immediately checked whether the zigzag pressure is under the patient's body. If there is no abnormality, you can squeeze the drainage tube and squeeze it up by hand to squeeze the clot clot in the tube into the chest to release the blockage. If it is still unobstructed, the possibility of the inner tube of the drainage tube being blocked by diaphragm, chest wall, or residual lung compression should be considered. The drainage tube can be slightly rotated to leave the mouth away from the blockage in order to reopen. If it still cannot be unobstructed, you have to remove it. According to the amount of drainage in the previous stage and the situation of the chest, consider another drainage tube, or change to a thoracentesis. In addition, you should also observe whether the hourly drainage volume gradually decreases, and whether the drainage fluid becomes light. When active bleeding is suspected, in addition to adding hemostatic drugs, you can repeatedly check the hemoglobin of circulating blood and drainage fluid. If there is more drainage, the hemoglobin of circulating blood will gradually decrease, while the hemoglobin of drainage fluid will gradually increase or remain unchanged, that is, there may be active bleeding.

4. Treatment of residual lung dilatation and residual cavity

After partial lung resection, the residual cavity in the thorax will be filled with excess lung that is overdilated (ie, compensatory emphysema). However, if the residual lung has fibrosis after inflammation, it will not be easy to expand excessively, so that the residual cavity cannot be eliminated; and the air in the residual cavity will gradually be absorbed by the pleura, forming a high negative pressure, which will cause the pleura to continuously leak fluid. The formation of bronchopleural fistula and secondary empyema provide the conditions. This situation is particularly common in patients with tuberculosis. In addition, in patients with tuberculosis, if the residual lung has residual lesions, it may cause recurrence and spread of the lesions when it is excessively expanded. Therefore, before and during partial lung resection, care should be taken to check the condition of the remaining lung. If there is a thickened pleura on the surface of the remaining lung, it should be exfoliated. If it is estimated that the surplus lung cannot be overdilated, or there are more residual tuberculosis lesions in the surplus lung, thoracotomy should be added. Generally, it is estimated that thoracoplasty must be added before and during surgery, and when the patient's physique, lung function and conditions during surgery allow, pneumonectomy and thoracoplasty or pleural peeling at the top of the thorax can be performed at the same time to make the peeled wall layer The pleura covers the remaining lungs, forming an extrapleural space, so as not to suffer the pain of two surgeries. If conditions do not allow, thoracotomy is performed within 3 to 6 weeks after lung resection. In some patients, it is not necessary to add thoracotomy even before surgery. If the lung is not expanded to the fourth posterior costal plane within 2 to 3 weeks after the operation, effusions continue to appear in the residual cavity despite repeated punctures, and even It was found that the patient was struggling to produce a small amount of old bloody fluid, indicating that a bronchial pleural fistula had occurred. Thoracoplasty should be performed in time to avoid empyema. This type of thoracotomy does not cut the first rib or keep the posterior segment longer, which is not required as in tuberculosis collapse therapy.

After pneumonectomy, the residual cavity will be gradually filled with exudate, and this exudate will gradually mechanize and contract, causing the diaphragm to rise, the chest wall to collapse, the mediastinum to the surgical side, and healthy lung compensatory emphysema. Sometimes the effusion is too much and too fast within 1 to 2 days after operation. When the mediastinum is pushed to the healthy side, when the breathing and circulation are affected, the clamped thoracic drainage tube should be opened slightly, and some pleural effusion is slowly released until the mediastinum gradually recovers. So far. If there is no thoracic drainage tube, fluid can be punctured to reduce surgical pressure. Pulmonary tuberculosis patients need total pneumonectomy, and there are more tuberculosis lesions in the contralateral lung. It is estimated that postoperative compensatory emphysema may cause recurrence and dissemination of the lesions, which can be performed at the same time as the lung resection or after 3 to 6 weeks. For thoracotomy. Sometimes the residual effusion is mechanized and contracted after pneumonectomy, which can cause excessive displacement of the mediastinum to the surgical side, causing distortion of the trachea and large blood vessels, and the patient manifests obvious shortness of breath and palpitations. In such patients, thoracotomy can also be performed to correct mediastinal displacement.

5. Postoperative atelectasis

After lower lobe resection, especially after left lower lobe resection, if the patient sits too high, the upper lobe of the upper lobe may occasionally fall and cause bronchial distortion, causing upper lobe atelectasis. At this time, patients with shortness of breath, sweating, hypoxia, repeated heavy sputum, trachea moved to the operation side and the disappearance of breathing sound (or tube-like) on the operation side, etc., can be confirmed by chest perspective. Once atelectasis occurs, the semi-sitting position should be lowered immediately, even lying flat or lying to the healthy side, to encourage the patient to expectorate vigorously, if necessary, pull out the tip of the tongue, and insert a catheter through the nostril during deep inhalation Trachea stimulates expectoration [Figure 19]. After the bronchi returned to the original position and the sputum accumulated in the bronchi was spit out, the patient's shortness of breath gradually improved, and the alveolar breathing sound returned to the surgical side. If the patient is weak and unable to expectorate; or the atelectasis has been absorbed for a long time, the alveolar gas has been completely absorbed, and it is impossible to expel the secretion by coughing. Multiple times).

6. Management of empyema

The cause of empyema is mostly caused by the rupture of the lesion during surgery or the discharge of secretions when the bronchus is severed, which contaminates the chest cavity. Bronchial stump has poor healing after operation, and bronchopleural fistula occurs; or pleural effusion is not exhausted in time, which provides favorable conditions for bacterial reproduction and is also a common cause of empyema. Therefore, each time a thoracentesis is taken, in addition to strict aseptic operation, penicillin and streptomycin should be injected into the chest after aspiration to prevent infection. Once the turbid fluid or obvious pus is extracted, after the diagnosis of empyema, closed drainage of the thorax should be performed again, and the thoracotomy should be performed in time after the symptoms of poisoning have improved.

7. Management of bronchopleural fistula

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Atelectasis, pneumonia

If the patient has difficulty breathing, the auscultation side's breathing sound is significantly reduced or disappeared, the trachea and mediastinum are shifted to the side of the operation, the negative pressure in the water-sealed bottle is increased, and atelectasis is often indicated. It is confirmed that those with weak sputum should immediately take sputum by fiberoptic bronchoscope at the bedside.

2. Intrathoracic bleeding

Patients with extensive pleural adhesions have more bloody exudation after surgery, and the thoracic closed drainage tube should be kept unobstructed, and hemostatic drugs should be given if necessary. If the thoracic drainage is more than 100 200ml / h, the chest should be opened again to stop bleeding and clear the blood clot.

3. Empyema and bronchopleural fistula

Because bronchiectasis is a contaminated operation, bronchial opening and bronchial stump sterilization are not strict during the operation, which can cause chest infections and empyema. If the patient has a high fever after thoracic drainage tube is removed and a pleural effusion is found on the chest radiograph, the disease should be suspected. A thoracentesis should be performed immediately. The pleural fluid should be removed for bacterial culture and drug sensitivity tests and antibiotics should be injected into the chest. , The tube should be placed and drained in time. Bronchial pleural fistula is the most serious complication after pneumonectomy. If the patient coughs a lot of pleural fluid like sputum or pus while having high fever, a bronchial pleural fistula should be considered. The size and location of the fistula can be confirmed by angiography. Closed thoracic drainage should be done immediately, and surgery should be performed after the patient is stable.

4. Esophageal pleural fistula

If the patient has a high fever after surgery and finds food residues in the drainage fluid or puncture fluid, the esophageal pleural fistula should be suspected and methylene blue can be diagnosed by oral administration. Those diagnosed within 24 hours can open the thorax to repair the fistula, cover with mediastinal pleura, pedicled intercostal muscle or diaphragm muscle flap.