急诊介入栓塞治疗支气管动脉-肺动脉瘘大咯血的效果

目的:观察急诊介入栓塞治疗支气管动脉-肺动脉瘘大咯血患者的疗效,分析栓塞剂的选择及合理应用,为临床研究提供参考。方法:30例支气管动脉-肺动脉瘘大咯血患者采用急诊介入造影检查,使用丙烯酸微球和明胶海绵条对出血动脉行急诊栓塞治疗,对动脉造影表现及治疗结果进行回顾性分析。结果:共找到并成功栓塞42支出血的支气管动脉,28支采用单独丙烯酸微球栓塞治疗,14支行丙烯酸微球与明胶海绵条联合栓塞治疗。栓塞术后随访1年,所有患者栓塞术后均无再次咯血及严重并发症出现。结论:急诊动脉栓塞治疗支气管动脉-肺动脉瘘大咯血是一种安全、有效的微创治疗手段。合理的选择和使用栓塞剂是确保栓塞治疗成功的的关键。     

导管引导介入治疗急性中高危肺动脉栓塞临床研究

目的:评估导管引导介入治疗急性中高危肺动脉栓塞的有效性及安全性。方法:顾性分析2012年1月至2018年6月在柳州市工人医院血管外科诊治的112例急性中高危肺动脉栓塞患者资料。根据治疗方案分单纯抗凝组(共38例)、导管介入+抗凝治疗组(共74例),对比两组肺动脉压及肺动脉栓塞严重指数降低情况、肺栓塞症状改善率、住院时长和出血并发症发生率;以其随访中肺栓塞复发率和慢性血栓性肺动脉高压发生率。根据介入方案不同,介入治疗组包括AngioJet机械吸栓(共13例)、猪尾导管碎栓及溶栓(61例);分别对比两种介入方案术前及术后的动脉血氧分压、指脉氧、心率及肺动脉压、弥勒指数评估治疗效果。结果:两组术前人口学特征、发病时间、DVT并发率、肺动脉压、肺动脉栓塞严重指数等无明显差异(P均0.05)。介入治疗组在降低肺动脉压及肺动脉严重指数、症状的改善率、缩短住院时间上明显优于单纯抗凝组(P分别为0.000、0.001、0.01、0.003);而相关出血并发症发生率无统计学差异(P0.05)。通过分别对比介入治疗两种方案的术前及术后动脉血氧分压、指脉氧、心率及肺动脉压、弥勒指数,两种治疗方案在这五个指标均有明显改善(P值均0.05)。随访6月至7年,肺栓复发率在单纯抗凝组、导管介入+抗凝治疗组分别为10.5%、6.8%,统计学差异显著(P=0.004);慢性血栓性肺动脉高压发生率分别为5.3%、1.4%,统计学差异显著(P=0.000)。结论:导管引导介入治疗对急性中高危肺动脉栓塞治疗是安全有效的,且可明显降低复发及慢性肺动脉高压的发生率。     

慢性栓塞性肺动脉高压的药物治疗进展

药物治疗对不能手术和在围手术期的慢性栓塞性肺动脉高压患者的治疗起重要的作用。传统的药物如抗凝药物、利尿剂、洋地黄类、氧疗等不能改变疾病的预后,治疗效果也有限。近年来,一些新型药物被用于治疗肺动脉高压,包括前列腺环素类似物、内皮素受体拮抗剂和磷酸二酯酶5的抑制剂等。它们在非栓塞性肺动脉高压的治疗中可以明显改善预后,由于相似的病理机制,所以它们对栓塞性肺动脉高压也可能有效,但证据有限。本文将对这些药物在慢性栓塞性肺动脉高压治疗中的应用作一总结。     

先天性支气管动脉-肺动脉瘘儿童咯血的介入治疗临床分析

目的:总结先天性支气管动脉-肺动脉瘘患儿的临床特点及诊治经验,探讨介入治疗支气管动脉-肺动脉瘘所致咯血的安全性及有效性。方法:回顾性分析我院自2009年7月至2017年6月收治的先天性支气管动脉-肺动脉瘘所致咯血患儿36例,行支气管动脉数字减影血管造影(DSA),选择300-700μm聚乙烯醇(PVA)微栓颗粒或微球颗粒行支气管动脉栓塞术治疗,评价疗效,患者在术后1个月、3个月、半年、1年门诊复查。结果:多层螺旋CT血管造影(MSCTA)显示支气管动脉-肺动脉瘘直接征象的诊出率为55.5%(20/36),16例为假阴性(44.4%),未发现假阳性病例;36例患者栓塞术后治疗即刻成功率为100%,复发率13.9%(5/36),复发时间出现于术后2-6个月,表现为再次咯血,但咯血量较初次封堵前减少,均行二次栓塞术。结论:介入治疗对于支气管动脉-肺动脉瘘所致咯血是一种创伤小、操作简便、疗效明确、并发症少的治疗方法。为进一步减少复发风险,患者术前应仔细进行MSCTA检查,行全面DSA下血管造影,根据患者病变血管情况选择合适的永久栓塞剂,运用恰当的栓塞技术。     

下肢深静脉血栓形成及其并发症38例护理体会

目的探讨下肢深静脉血栓形成及其并发症的护理措施,以提高护理质量。方法对我科收治的38例下肢深静脉血栓形成行溶栓治疗患者的临床资料进行回顾性分析。结果 38例下肢深静脉血栓形成患者经溶栓治疗及精心护理后,患者临床症状明显缓解、痛苦减轻,未发生肺动脉栓塞。结论下肢深静脉血栓形成患者通过溶栓治疗及实施持续有效的护理措施,避免了肺动脉栓塞的发生,提高患者生存质量的同时也提高了护理满意度。     

肾病综合征合并肺栓塞的临床研究进展

肾病综合征是一种临床常见疾病,其患者体内常呈高凝状态,极易发生血栓栓塞事件,而其中以肾静脉血栓、肺动脉栓塞和 下肢深静脉血栓最为常见。由于肺动脉栓塞早期缺乏特征性的临床表现,病情隐匿,所以极易误诊或漏诊,发现时患者病情往往 已十分严重,致死率极高。目前,对于肾病综合征合并肺栓塞的发生率国内外报道不一,尚无准确的流行病学资料,而对于其发病 原因、危险因素、早期诊断及是否需要预防性抗凝治疗等均存在争议,本文主要结合文献对肾病综合征合并肺栓塞的流行病学、 病因及发病机制、诊断、高危因素和治疗进行了综述,尤其是对目前争议较大的肾病综合征合并肺栓塞患者是否需要早期抗凝治 疗。     

肺动脉栓塞的64层螺旋CT血管成像技术分析

目的从技术上探讨64层螺旋CT肺动脉造影对肺栓塞的诊断的价值。方法对62例临床疑诊肺栓塞的患者行64排螺旋CT肺动脉造影检查,采用最大密度投影(MIP)、多平面重建(MPR)、曲面重建(CPR)、容积漫游(VR)及仿真内窥镜等后处理技术,分析所获得的相关CT资料。结果64排多层螺旋CT肺动脉造影可较准确、清晰、全面地显示24例累及肺动脉及其分支共152处栓子的位置、形态、范围和程度。结论64排多层螺旋CT肺动脉造影是肺栓塞及时准确无创的诊断方法,是临床诊断肺栓塞的首选筛查办法,对肺动脉栓塞的诊断具有明显的技术优势。     

急性肺梗塞误诊分析

急性肺梗塞属于肺血栓栓塞症的一种类型，是各种栓子致使肺动脉支或其分支阻塞，24～48h后引起从栓子阻塞部位至血管末梢的出血性梗塞。急性肺梗塞约占肺血栓栓塞症的17％．国外发病率较高，     

原发性肺动脉肉瘤的临床病理学研究

目的：探讨原发性肺动脉肉瘤的临床病理特征、免疫表型及预后。方法：对3例（2例女性,1例男性平均年龄41岁）原发性肺动脉肉瘤的临床资料、组织学及免疫组化标记结果进行分析。结果：临床表现为胸闷、气短、进行性加重的呼吸困难,CT及核磁检查可显示肺动脉腔内充盈缺损。病理检查：巨检组织呈肉瘤样、黏液样或胶冻状肿物,紧贴肺动脉内壁生长,并沿血管腔延伸状似血管塑型。镜下肿瘤组织由梭形细胞和黏液样基质构成,均伴有不同程度的坏死。1例诊断为原发性肺动脉内膜肉瘤,2例为平滑肌肉瘤。结论：原发性肺动脉肉瘤是一种起源于肺动脉的罕见恶性肿瘤,其临床及影像学表现均无特异性,确诊依赖于病理组织学及免疫组织化学;临床预后差。     

高纯度α-亚麻酸抗血栓活性的初步研究

目的:评价从椒目中提取和纯化获得的高纯度α-亚麻酸的抗血栓药理活性。方法:采用小鼠和大鼠在体血栓形成和肺动脉栓塞等模型,分别观察试药对血小板在动-静脉旁路中丝线上的沉积、肺动脉栓塞小鼠的死亡率、体外血小板聚集和出凝血时间等指标。结果:1.50mg/kg,100mg/kg和250mg/kg高纯度α-亚麻酸及混合不饱和脂肪酸(α-亚麻酸/亚油酸=1/1)给小鼠灌胃治疗10天,显著延长出、凝血时间(P<0.01);明显降低胶原蛋白-肾上腺素诱发性肺动脉栓塞小鼠的死亡率(P<0.01)。2、35mg/kg,70mg/kg和175mg/kg高纯度α-亚麻酸及混合不饱和脂肪酸给大鼠灌胃治疗10天,明显抑制血小板在动-静脉旁路中丝线上的沉积(P<0.01)和大鼠体外血小板聚集(P<0.01)。结论:从椒目中提纯的高纯度α-亚麻酸,作为一种木本油脂新的药用资源和其混合不饱和脂肪酸均具有明显抗血小板聚集和溶栓药理作用,并具有一定量效关系;同时还发现,当α-亚麻酸/亚油酸=1/1时,其抗血栓药理活性优于同剂量高纯度的α-亚麻酸。     

肺栓塞的诊治和预防策略

急性肺栓塞(PE)是一种心血管疾病突发事件,具有较高的发病率和死亡率。一旦发生PE,快速、有效的诊治是挽救PE患者生命的关键,但也是呼吸内科医生一直面临的挑战。尽管PE的诊断手段和评估方法已经取得了很大地进步,但由于PE患者临床表现的非特异性和诊断方法的多样、复杂性,如何采取及时、有效的诊治策略仍是呼吸内科医生面临的重要难题。与此同时,由于PE诊断困难,治疗风险大,也使其临床预防势在必行。鉴于此,本文综述了当前欧洲心脏病学会(ESC)等国际心血管研究机构发布的PE诊治指导方针和研究进展,为读者进一步认识和掌握PE快速、有效的诊治和预防策略提供参考。     

“I Can't Find Anything Wrong: It Must Be a Pulmonary Embolism”: Diagnosing Suspected Pulmonary Embolism in Primary Care,a Qualitative Study

Background

Before using any prediction rule oriented towards pulmonary embolism (PE), family physicians (FPs) should have some suspicion of this diagnosis. The diagnostic reasoning process leading to the suspicion of PE is not well described in primary care.

Objective

to explore the diagnostic reasoning of FPs when pulmonary embolism is suspected.

Method

Semi-structured qualitative interviews with 28 FPs. The regional hospital supplied data of all their cases of pulmonary embolism from June to November 2011. The patient''s FP was identified where he/she had been the physician who had sent the patient to the emergency unit. The first consecutive 14 FPs who agreed to participate made up the first group. A second group was chosen using a purposeful sampling method. The topic guide focused on the circumstances leading to the suspicion of PE. A thematic analysis was performed, by three researchers, using a grounded theory coding paradigm.

Results

In the FPs'' experience, the suspicion of pulmonary embolism arose out of four considerations: the absence of indicative clinical signs for diagnoses other than PE, a sudden change in the condition of the patient, a gut feeling that something was seriously wrong and an earlier failure to diagnose PE. The FPs interviewed did not use rules in their diagnostic process.

Conclusion

This study illustrated the diagnostic role of gut feelings in the specific context of suspected pulmonary embolism in primary care. The FPs used the sense of alarm as a tool to prevent the diagnostic error of missing a PE. The diagnostic accuracy of gut feelings has yet to be evaluated.     

43例术后疑似急性肺栓塞分析

目的:探讨影响术后急性肺栓塞(Acute Pulmonary Embolism,APE)的发生和预后的相关因素,以提高对术后肺栓塞的认识和诊疗水平。方法:收集2009.01-2014.12期间南方医院术后疑似急性肺栓塞患者的临床资料,总结其临床特征,分析其诱发因素、临床表现、治疗和预后,探讨其发病的高危因素。结果:共收集术后疑似肺栓塞43例,平均年龄56.09±14.08岁(17~80岁),明确诊断为肺栓塞15例(34.9%),共死亡20例(死亡率46.5%)。其临床表现和体征均具有非特异性,呼吸困难、心悸和晕厥是主要的临床表现。不仅可以发生于下肢、胸腹部(包括妇产科)、颅内等大手术后,也可能发生在介入栓塞术后。相关危险因素很多,包括性别、年龄、恶性肿瘤、全身麻醉、手术时间长等。具有高危因素的患者并具有可疑肺栓塞的临床表现时,结合D-二聚体、动脉血气分析、心电图、胸部X线、超声心动图、下肢彩超可检查协助APE的诊断,而胸部增强CT作为检查手段有利于明确诊断。结论:肺栓塞是手术后致命的并发症之一,早期诊断、早期治疗,能降低术后肺栓塞患者的死亡率。     

Role of Transthoracic Lung Ultrasonography in the Diagnosis of Pulmonary Embolism: A Systematic Review and Meta-Analysis

Background

Pulmonary embolism (PE) is a potentially life-threatening condition. Although computed tomography pulmonary angiography (CTPA) is the reference standard for diagnosis, its early diagnosis remains a challenge, and the concerns about the radiation exposures further limit the general use of CTPA. The primary aim of this meta-analysis was to evaluate the overall diagnostic accuracy of transthoracic lung ultrasound (TLS) in the diagnosis of PE.

Methods

PubMed, Web of science, OvidSP, ProQuest, EBSCO, Cochrane Library and Clinicaltrial.gov were searched systematically. The quality of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. The sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and hierarchical summary receiver operating characteristic (HSROC) curves were used to examine the TS performance. The Bayes analysis was used to calculate the post-test probability of PE. Publication bias was assessed with Deeks funnel plot.

Results

The results indicated that the sensitivity, specificity, PLR and NLR were 0.85 (95% confidence interval (CI), 0.78 to 0.90), and 0.83 (95% CI, 0.73 to 0.90). And the DOR and HSROC were 28.82 (95% CI, 17.60 to 47.21), 0.91(95% CI, 0.88, 0.93).

Conclusions

The present meta-analysis suggested that transthoracic lung ultrasonography is helpful in diagnosing pulmonary embolism. Although the application of transthoracic lung ultrasound may change some patients’ diagnostic processes, it is inappropriate to generally use transthoracic ultrasonography in diagnosing pulmonary embolism currently.     

110例肺栓塞实验室结果分析

目的:探讨肺栓塞患者的危险因素、临床表现及实验室检查,提高临床对肺栓塞的认识。方法:收集本院2006年1月至2009年2月住院期间确诊为肺栓塞的110名患者的一般资料、危险因素、临床表现、相关检查等数据,对所统计的数字进行SPSS13.0分析。结果:呼吸困难组74例(67.3%),无呼吸困难组(32.7%),两组比较危险因素无统计学差异,比较发现氧分压、二氧化碳分压、肺动脉内径无差异,但是右心室内径检查显示两组具有明显的差异。结论:1.不可过分依赖三联征诊断肺栓塞,以免误诊、漏诊。2.危险因素:外伤、手术、制动、深静脉血栓,慢性支气管炎,高血压对呼吸困难组与非呼吸困难组中的肺栓塞形成无统计学差异。3.肺栓塞患者呼吸困难与心功能不全具有明显相关性,呼吸困难组应住监护病房,密切观察病情变化。     

Geneva量表在肺栓塞诊断中的意义

随着认识水平的提高,已发现肺栓塞是临床很常见的疾病。对于如何更好地进行肺栓塞危险性的评估和组织相对复杂的检查,Geneva量表将是临床非常实用的工具。Geneva量表更精确和稳定,较少受临床经验的影响。对于合并慢性阻塞性肺病的患者诊断也有意义。同时,对于预测肺栓塞后3月内不良事件也有价值,临床试验证实对CT检查阴性患者Geneva量表评分为低中度危险不进行抗凝治疗也是安全的。本文将对目前国际上对Geneva量表的应用进展做一综述。     

Acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) can be associated with various disorders. Among these, coronavirus infection may cause life-threatening severe acute respiratory syndrome (SARS). In this review, we present animal models and techniques for the study of ARDS, and discuss the roles and possible mechanisms of various chemical factors, including nitric oxide (NO). Our early work revealed that cerebral compression elicits severe hemorrhagic pulmonary edema (PE), leading to central sympathetic activation that results in systemic vasoconstriction. The consequence of systemic vasoconstriction is volume and pressure loading in the pulmonary circulation. Vasodilators, but not oxidant radical scavengers, are effective in the prevention of centrogenic PE. In isolated perfused lung, exogenous and endogenous NO enhances lung injury following air embolism and ischemia/reperfusion. In contrast, NO synthase (NOS) inhibitors reverse such lung injury. Although NO is important in maintaining vasodilator tone, hypoxia-induced pulmonary vasoconstriction is accompanied by an increase instead of a decrease in NO release. In animal and isolated lung studies, endotoxin produces acute lung injury that is associated with increases in cytokines and inducible NOS mRNA expression, suggesting that NO is toxic to the lung in endotoxin shock. Recently, we reported several rare cases that indicate that ARDS in patients with Japanese B encephalitis, lymphangitis with breast cancer and fat embolism is caused by different mechanisms. Our early and recent studies on ARDS and PE may provide information for clinical practice and the understanding of the pathogenesis of SARS.     

Inhibition of CINC-1 decreases right ventricular damage caused by experimental pulmonary embolism in rats

Right ventricular (RV) dysfunction is a strong risk factor for poor clinical outcome following pulmonary embolism (PE), the third most prevalent cardiovascular disease. Previous studies in our laboratory demonstrated that RV failure during PE is mediated, in part, by neutrophil-dependant cardiac inflammation. In this study we use DNA microarray analysis of gene expression to demonstrate that PE results in increased expression of the CXC chemokines CINC-1 and CINC-2 between 6 and 18 h after the start of PE in a rat model of PE. Neutrophils accumulate in RV tissue by 18 h, and this inflammation is associated with decreased right heart function. Treatment of rats with Abs to CINC-1 significantly suppressed neutrophil accumulation in RVs during PE (52% reduction in tissue myeloperoxidase) and ameliorated RV failure. In addition, plasma concentration of cardiac troponin I, an established diagnostic marker for cardiac damage, was reduced by 90%. These results suggest that selective anti-inflammatory therapies targeted at neutrophil chemoattractants will reduce cardiac inflammation and reduce RV damage in the setting of PE.