支气管镜在儿童迁延性细菌性支气管炎中的应用价值

The application value of bronchoscopy in children with protracted bacterial bronchitis

摘要:

目的： 探讨支气管镜在儿童迁延性细菌性支气管炎（protracted bacterial bronchitis，PBB）的应用。方法： 回顾性分析2016年9月至2020年9月重庆医科大学附属儿童医院呼吸一病房收治的均行支气管镜检查的50例诊断PBB住院患儿的临床资料。结果： 50例PBB患儿中，年龄6个月8 d至12岁8个月，平均（55.1+33.0）个月，其中<1岁4例（8.0%），1~3岁12例（24.0%），~7岁24例（48.0%），~12岁9例（18.0%），>12岁1例（2.0%）；临床表现除慢性湿性咳嗽外，伴有喘息者占50.0%；50例患儿均行支气管镜检查及支气管肺泡灌洗液（bronchoalveolar lavage fluid，BALF）培养，镜下见慢性支气管内膜炎改变，24例吸出中-大量白色分泌物，22例吸出中-大量黄色分泌物，3例吸出少量白色分泌物，1例有痰栓，BALF中性粒细胞比值波动在5%~94%；BALF培养阳性及痰培养阳性者均26例，阳性率为52.0%，主要致病菌为流感嗜血杆菌及肺炎链球菌，药物治疗以阿莫西林克拉维酸钾及三代头孢为主，根据临床症状、支气管镜下表现及BALF培养结果20例患者调整了抗菌药物使用，同时有17例患儿再入院进行多次支气管镜检查灌洗，个别患儿根据情况选择完善灌洗液第二代测序（next generation sequencing，NGS）、黏膜活检、全外显基因检测明确病原病因。结论： PBB以幼儿及学龄前期儿童多见，持续性湿性咳嗽为主要特征，易伴喘息，支气管镜下可见慢性支气管内膜炎改变及较多分泌物，BALF培养的特异度及灵敏度较高，可指导抗菌药物治疗，而针对病原不明、治疗效果差的患儿可进一步行NGS、黏膜活检及全外显基因检测协助诊治，支气管镜协同抗菌药物治疗PBB，能提高治疗效果改善预后，具有较高的临床应用价值。

Abstract:

Objective: To explore the application of bronchoscopy in children with protracted bacterial bronchitis (PBB). Methods: The clinical data of 50 hospitalized children diagnosed with PBB were retrospectively analyzed, who admitted to the Department of Respiratory of Children's Hospital of Chongqing Medical University from September 2016 to September 2020. Bronchoscopy was performed on all cases. Results: Among the 50 PBB children, the age ranged from 6 months and 8 days to 12 years and 8 months, with an average age of (55.1±33.0) months, including 4 cases (8.0%) less than 1 year old, 12 cases (24.0%) between 1-3 years old, 24 cases (48.0%) between 3-7 years old, 9 cases (18.0%) between 7-12 years old, and 1 case (2.0%) older than 12 years old. In addition to chronic wet cough, the children with wheezing accounted for 50.0%. All the 50 cases were examined by bronchoscopy and culture of bronchoalveolar lavage fluid (BALF). Bronchoscopy showed a chronic endobronchial inflammation. There were 24 cases with large amount of white secretions, 22 cases with large amount of yellow secretions, 3 cases with little white secretions, and 1 case with phlegm thrombus. The neutrophil ratio of bronchial alveolar lavage fluid fluctuated between 5% and 94%. There were 26 positive cases in both sputum culture and BALF culture, and the positive rate was 52.0%. The main pathogens were Haemophilus influenzae and Streptococcus pneumoniae. The therapeutic drug was mainly amoxicillin clavulanate potassium and the third-generation cephalosporin. Twenty patients adjusted the use of antibiotics according to their clinical symptoms, bronchoscopic manifestations and BALF culture results. At the same time, 17 children were re-hospitalized for multiple bronchoscopic lavage. Individual children chose to improve next generation sequencing (NGS), mucosal biopsy and total exome gene detection to determine the etiology. Conclusion: PBB is commonly seen in toddler and pre-school age, characterized by persistent wet cough, and easy to be accompanied by wheezing. Bronchoscopy shows chronic endobronchial inflammation changes and more secretions. The specificity and sensitivity of BALF culture can guide the treatment of antibiotics, while NGS, mucosal biopsy and total exome gene detection can be used to assist in the diagnosis and treatment of children with unknown pathogen and poor therapeutic effect. Bronchoscopy combined with antibiotics in the treatment of PBB, can improve the therapeutic effect and prognosis, which has high clinical application value.