Stanopoulos I T, Beamis J F, Martinez F J, Vergos K, Shapshay S M
Section of Pulmonary and Critical Care Medicine, Lahey Clinic Medical Center, Burlington, MA 01805.
Crit Care Med. 1993 Mar;21(3):386-91. doi: 10.1097/00003246-199303000-00016.
To examine the value of laser bronchoscopy in patients with inoperable carcinoma of the lung who required ventilatory assistance for acute respiratory failure.
Retrospective review of the medical records of all patients undergoing laser bronchoscopy.
The Lahey Clinic Medical Center, a tertiary referral center.
The medical records of 311 patients undergoing laser bronchoscopy at the Lahey Clinic Medical Center between 1982 and 1990 were reviewed. The 17 patients who required mechanical ventilation at the time of laser surgery formed the study group.
All patients underwent neodymium:yttrium-aluminum-garnet laser bronchoscopy through a rigid bronchoscope in the operating room with use of jet ventilation and general anesthesia throughout the procedure. Postoperative care was directed by the same physician for all patients.
The following data were extracted from medical records: age and sex of patient, cell type and location of tumor, length of time between diagnosis and laser therapy, treatment before and after laser therapy, number of days receiving mechanical ventilation before and after laser therapy, medical and operative complications, survival, and cause of death. The patients were divided into two groups on the basis of clinical improvement that permitted elective discontinuation of mechanical ventilation. Group 1 included patients who experienced clinical improvement permitting endotracheal extubation. Group 2 was composed of patients who died while still receiving mechanical ventilatory support or who were extubated before institution of comfort measures. The two groups were compared using nonparametric tests of significance, including the Mann-Whitney test. No significant differences were apparent between groups 1 and 2 regarding clinical characteristics before laser treatment. Patients in group 1 had significantly (p = .03) shorter requirements for mechanical ventilation after laser treatment than patients in group 2 (1 vs. 6 days). Similarly, patients in group 1 were more likely to receive additional treatment after laser therapy than patients in group 2 (seven of nine patients vs. two of eight patients; p = .048). Patients in group 1 had significantly (p = .0038) longer survival than patients in group 2 (98 vs. 8.5 days). A greater endobronchial component to airway obstruction appeared to exist in patients in group 1 (nine of nine patients) vs. patients in group 2 (three of eight patients; p = .009). Extrinsic compression and submucosal tumor were more commonly seen in patients in group 2. In addition, patients in group 2 appeared to have a greater number of postoperative medical complications than patients in group 1. Operative complications were minor in both groups.
In nine of 17 patients, laser bronchoscopy appeared to improve the clinical status, permitting removal of mechanical ventilation and extubation and provided the opportunity for further treatment modalities in seven of the nine patients. Survival was improved in this subgroup, and requirement for mechanical ventilatory support was shortened. The improved outcome after laser therapy was related to the presence of obstructing endobronchial tumor as the cause of the respiratory insufficiency. Patients with inoperable carcinoma of the lung and respiratory failure should be evaluated for the presence of an endobronchial lesion that might be responsive to laser bronchoscopy.
探讨激光支气管镜检查在因急性呼吸衰竭需要通气支持的无法手术切除的肺癌患者中的价值。
对所有接受激光支气管镜检查患者的病历进行回顾性研究。
三级转诊中心拉希诊所医疗中心。
回顾了1982年至1990年间在拉希诊所医疗中心接受激光支气管镜检查的311例患者的病历。激光手术时需要机械通气的17例患者组成研究组。
所有患者均在手术室通过硬支气管镜接受钕：钇铝石榴石激光支气管镜检查，整个过程使用喷射通气和全身麻醉。所有患者术后均由同一位医生进行护理。
从病历中提取以下数据：患者的年龄和性别、肿瘤的细胞类型和位置、诊断与激光治疗之间的时间长度、激光治疗前后的治疗情况、激光治疗前后接受机械通气的天数、医疗和手术并发症、生存率及死亡原因。根据临床改善情况将患者分为两组，临床改善允许选择性停止机械通气。第1组包括临床改善允许气管插管拔除的患者。第2组由在仍接受机械通气支持时死亡或在采取舒适措施前拔除气管插管的患者组成。使用非参数显著性检验（包括曼-惠特尼检验）对两组进行比较。第1组和第2组在激光治疗前的临床特征方面无明显差异。第1组患者激光治疗后机械通气需求明显短于第2组患者（1天对6天，p = 0.03）。同样，第1组患者激光治疗后比第2组患者更有可能接受额外治疗（9例患者中的7例对8例患者中的2例；p = 0.048）。第1组患者的生存期明显长于第2组患者（98天对8.5天，p = 0.0038）。第1组患者（9例患者中的9例）气道阻塞的支气管内成分似乎比第2组患者（8例患者中的3例；p = 0.009）更严重。第2组患者中更常见外在压迫和黏膜下肿瘤。此外，第2组患者术后医疗并发症似乎比第1组患者更多。两组手术并发症均较轻。
在17例患者中的9例中，激光支气管镜检查似乎改善了临床状况，允许撤除机械通气并拔除气管插管，并且为9例患者中的7例提供了进一步治疗的机会。该亚组患者的生存期得到改善，机械通气支持需求缩短。激光治疗后结果改善与作为呼吸功能不全原因的阻塞性支气管内肿瘤的存在有关。对于无法手术切除的肺癌和呼吸衰竭患者，应评估是否存在可能对激光支气管镜检查有反应的支气管内病变。
