急性呼吸衰竭是重症监护病房(ICU)最常见的呼吸危重症,病因复杂,有时采用常规手段很难获得病因诊断。肺组织活检技术对于不明原因呼吸衰竭的危重症患者的救治具有重要潜在临床应用价值,而国内目前开展较少。本文基于经支气管镜肺活检、经支气管冷冻肺活检与超声引导下经皮穿刺活检三种活检手段在呼吸危重症患者中的大量临床经验,着重介绍适应证与禁忌证的把握、根据不同活检方式的优缺点与患者肺内病灶的特点进行综合选择、不同呼吸支持方式下肺活检技术的操作要点,介入操作场景的选择以及相关并发症的防治与处理,旨在推广相关肺活检手段在呼吸危重症患者中的应用,以期提高危重患者救治成功率。
一、呼吸危重症肺组织活检技术概述
二、适应证与禁忌证
三、不同呼吸支持方式下肺活检技术的操作要点
(一)高流量氧疗
四、不同呼吸支持方式下的场景及策略选择
(一)操作场景宜选择在ICU
五、常见活检并发症的预防及处理
(一)气胸
(二)出血
(三)气体栓塞
气体栓塞是一种罕见而潜在致命的并发症,肺活检时进入肺静脉的空气回到体循环导致系统性气体栓塞。部分患者无明显症状,因此总体发生率可能被低估。严重者可表现为心脏/神经系统相关症状,如循环衰竭、意识丧失、黑曚等[45,46]。危险因素包括通过正常通气肺脏的针道长度、活检组织条数、俯卧位或右侧卧位等[47]。理论上,咳嗽、深吸气或气道内压力增加也可能促进气栓的发生。患者尽量选择平卧位,操作时避免气道内压力大幅度波动可能有助于减少气体栓塞的发生。
(四)其他
六、标本处理
活检标本均应尽快处理送检。根据临床考虑疾病的可能性,拟送常规病理者直接将标本放入带福尔马林液体的无菌小瓶送检,标本可室温下长时间保存。拟送微生物检查者应将取出的组织块小心放入少量无菌生理盐水的无菌容器中,以保持标本湿度及微生物活性。普通培养在室温保存,2 h内送检[51]。放入过程需注意无菌操作,无菌生理盐水没过组织块即可。低温保存可适当延长保存时间,若非工作时间或不能及时送检的标本,建议 4 ℃冰箱保存,最长保存时间不超过24 h。
执笔
冯莹莹(中日友好医院呼吸与危重症医学科);周国武(中日友好医院呼吸与危重症医学科);吴晓东(同济大学附属东方医院呼吸与危重症医学科);冯靖(天津医科大学总医院呼吸与危重症医学科)
委员(以姓氏拼音为序)
白冲(海军军医大学第一附属医院呼吸内科);陈成水(温州医科大学附属第一医院);程真顺(武汉大学中南医院呼吸与危重症医学科);董宇超(海军军医大学第一附属医院呼吸内科);冯靖(天津医科大学总医院呼吸与危重症医学科);郭述良(重庆医科大学附属第一医院呼吸与危重症医学科);顾晔(上海市肺科医院肺内科);淦鑫(南昌大学第一附属医院呼吸与危重症医学科);侯刚(中日友好医院呼吸与危重症医学科);胡轶(武汉市中心医院呼吸与危重症医学科);蒋进军(复旦大学附属中山医院呼吸科);罗凤鸣(四川大学华西医院呼吸与危重症医学科);罗红(中南大学湘雅二医院呼吸与危重症医学科);李强(同济大学附属东方医院呼吸与危重症医学科);李时悦(广州医科大学附属第一医院呼吸内科);黎毅敏(广州医科大学附属第一医院);潘频华(中南大学湘雅医院呼吸与危重症医学科);孙加源(上海市胸科医院呼吸与危重症医学科);孙忠民(西安交通大学第一附属医院呼吸与危重症医学科);谢俊刚(华中科技大学同济医学院附属同济医院呼吸与危重症医学科);邢丽华(郑州大学第一附属医院呼吸与危重症医学科);解立新(解放军总医院呼吸与危重症医学部);许能銮(福建省立医院呼吸科);姚孟英(郑州大学第一附属医院呼吸与危重症医学科);张波(中日友好医院超声科);张杰(北京天坛医院呼吸内科);周庆涛(北京大学第三医院呼吸与危重症医学科);詹庆元(中日友好医院呼吸与危重症医学科);张伟(海军军医大学第一附属医院呼吸内科);张新(复旦大学附属中山医院呼吸科);曾奕明(福建省医科大学附属第二医院呼吸与危重症医学科)
利益冲突
所有作者均声明不存在利益冲突
通信作者
詹庆元
李强
参考文献
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