I. Reasons
Bronchiectasis can begin in childhood, especially pneumonia after measles, whooping cough and influenza, which will lead to bronchiectasis for a long time. Chronic bronchitis, bronchial asthma, lung abscess and tuberculosis can all cause bronchiectasis, hilar lymphadenopathy (tuberculosis or nonspecific lymphadenitis) and bronchial external pressure obstruction. If it does not subside for a long time, bronchiectasis may also be accompanied by endobronchial infection. If it happens on the right side, bronchiectasis of the middle lobe with atelectasis of the middle lobe often occurs. Some cases also belong to congenital factors. These bronchiectasis are mostly cystic and multiple, involving one lung, and sometimes complicated with other organ abnormalities. In addition, selective IgA deficiency, primary hypoα globulinemia and congenital tracheal cartilage defect can all be complicated with bronchiectasis.
Second, pathology.
The early pathological change is that a large number of lymphocytes gather between the bronchial wall and alveoli and protrude into the lumen, causing bronchial obstruction and then infection. As a result, the elastic fibers in the bronchial wall were destroyed first, then the smooth muscle tissue, and finally the cartilage. These damaged tissues are replaced by fibrous connective tissue, which leads to hardening of bronchial wall and dilatation of lumen. The epithelium of bronchial mucosa also loses the ciliary movement function of excreting secretions, and the dilated bronchi become channels (columnar dilatation) or cysts (cystic dilatation) of infected secretions. The branches of bronchioles are gradually blocked by inflammation and scar, and the corresponding lungs contract due to ventilation disorders and fibrosis, and some show atelectasis.
Bronchiectasis is more on the left side than on the right side, and the lower lobe is more than the upper lobe. Bronchiectasis alone in the middle lobe of the right lung is more common. The middle lobe of the right lower lobe and the tongue lobe of the right lower lobe are more common.
Third, diagnosis
The main clinical manifestations of bronchiectasis are repeated lung infections, purulent sputum or hemoptysis. Patients cough up a lot of sputum every day, and the sputum is yellow-green, mucus purulent, or smelly, and some have repeated hemoptysis, even heavy hemoptysis. Generally, the course of disease is long, from onset to operation 10 years.
Physical examination: Generally, patients with slight and limited lesions have no important signs. In patients with severe lung infection, or during hemoptysis, fixed wheezing or moist rales can be heard. Chronic hypoxia changes such as clubbed fingers (toes) can be seen all over the body. The diagnosis of bronchiectasis is mainly based on bronchography, because this film can show the degree, location and scope of the lesion from different angles. Generally, it can be divided into three types: columnar, cystic and cystic-columnar. X-ray plain film showed increased lung texture or decreased lung volume. If there are bronchial stones, calcification can be seen. Bronchoscopy is of great significance for emergency patients with hemoptysis to determine the bleeding site and determine the surgical treatment plan.
Fourth, treatment.
Because bronchiectasis is an irreversible disease, the symptoms of bronchial and pulmonary inflammation can be alleviated through anti-infection treatment in internal medicine, but it cannot be cured. So once diagnosed, it should be treated surgically.
Indications for operation: According to the medical history, clinical manifestations and bronchography, it is clearly diagnosed that the general condition and physique are good, and there is no heart, lung and kidney organic lesions. The operation method can be selected according to the following conditions.
1. Unilateral bronchiectasis, feasible lobectomy.
2. Unilateral bronchiectasis, the lesion range is more than one lobe, and bilateral lobectomy or lobectomy plus segmental resection can be considered.
3. One lobar bronchiectasis with no obvious lesion on the opposite side. Combined with the analysis of pulmonary function, unilateral pneumonectomy can be considered.
4. Bronchiectasis involves bilateral lobes. According to the patient's condition, bilateral lobectomy and staged lobectomy can be used first.
5. Patients with bronchiectasis and massive hemoptysis still have hemoptysis after drug treatment, and bronchoscopy should be performed urgently. If it is clear that the bleeding comes from the diseased lung, emergency lobectomy can be performed.
Taboo:
1. Patients are generally in poor condition, complicated with heart, liver and renal insufficiency, and cannot tolerate surgery.
2. Bilateral extensive bronchiectasis with obvious cardiopulmonary dysfunction.
3. Elderly people with emphysema, asthma or cor pulmonale.
4. Bronchiectasis complicated with acute infection is not controlled.
Preoperative preparation
1. In addition to routine examination, sputum should be sent for bacterial culture and drug sensitivity test, and effective antibiotics should be selected to control infection. Short-term bronchography is needed to understand the degree of lesion, determine the scope of operation and drain the contrast agent as clean as possible.
2. Control infection: Use antibiotics to control infection 2 weeks before operation. In the case of excessive sputum, antibiotics can be added by ultrasonic atomization inhalation or bronchial instillation of antibiotics. In addition, patients should be instructed to perform postural drainage and expectoration at least once a day, each time for 10 ~ 15 minutes, until the amount of sputum is reduced to less than 50ml/ day.
3. Improve the general situation: Patients with severe bronchiectasis are often accompanied by anemia and hypoproteinemia. Therefore, we should pay attention to preoperative nutrition supplement, blood transfusion or plasma transfusion when necessary, and encourage patients to take appropriate physical exercise and respiratory exercise to enhance their physique.
An important problem of bronchiectasis anesthesia is that tracheal secretions from the affected side are poured into the healthy side during operation, so besides using double-lumen tube, attention should be paid to clearing respiratory secretions during operation.
Postoperative complications: mainly atelectasis, bronchial stump fistula, empyema and bleeding.
The postoperative effect is generally satisfactory, but there are still some symptoms and decreased lung function, which still need conservative treatment and observation.