Trachea, bronchial stenosis
Introduction
Introduction to trachea and bronchoconstriction Tracheobronchial stenosis is caused by airway obstruction causing shortness of breath and difficulty in breathing. When physical activity and respiratory secretions increase, it is often aggravated. Patients with previous tracheotomy and intubation who present the above symptoms should first consider tracheal scar stenosis. The anterior, lateral, and oblique tracheal tomograms clearly show the location, extent, length, and morphological changes of the stenosis. basic knowledge Sickness ratio: 0.05% Susceptible people: no specific population Mode of infection: non-infectious Complications: pneumothorax, tracheoesophageal fistula
Cause
Causes of trachea and bronchoconstriction
Cause:
The disease is common after tracheotomy, when the tracheotomy is too high, the first cartilage ring is damaged, which can lead to ring cartilage erosion, inflammatory lesions and difficult subtotal cartilage under severe stenosis. When tracheotomy is performed, excessive resection The anterior wall tissue of the trachea can form a large amount of granulation tissue and fibrous scar tissue in the future. The tracheal tube compresses the anterior wall of the trachea, causing the inward collapse of the tissue above the incision and the excessively connected tubing outside the tracheal tube to compress the tracheal wall, causing the tissue to be crushed and smashed. In addition, the fibrous scar tissue can be formed in the future. In addition, the outer balloon of the tracheal tube used to seal the tracheal tube is too high in inflation, and the whole end of the tracheal wall can be pressed, causing tissue erosion and necrosis, and a severe scarring stenosis is formed in the future. Or even the tracheal esophageal fistula and tracheal innominate arterial spasm, the latter two cases of high mortality, so the tracheotomy and intubation should pay attention to the tracheotomy site, the removal of the tracheal anterior wall tissue should not be too much, the selected The size and length of the tracheal tube should be appropriate, the inflation pressure of the airbag should not be too high, and the connected pipes should be light and soft to reduce the narrowing of the trachea. The incidence of complications.
Prevention
Tracheal and bronchial stricture prevention
The prevention of this disease is mainly early detection, early diagnosis, early treatment of primary diseases, the possibility of airway stenosis should be considered for the lesions occurring in the trachea and bronchus, and the occurrence of airway stenosis should be prevented in advance. At the time, tracheal lipiodol imaging is valuable for diagnosing tracheal stenosis and understanding the extent of stenosis, but it is associated with an increased risk of tracheal obstruction, and is not recommended unless it is not clearly diagnosed by other means of examination.
Complication
Tracheal and bronchial stricture complications Complications, pneumothorax, tracheal esophagus
Different treatments can cause different complications:
1. For patients who need tracheotomy for tracheobronchial stenosis, the following complications are likely to occur:
(1) Subcutaneous emphysema: It is the most common complication after operation, and it is separated from the soft tissue before the trachea. The short internal length of the tracheal incision or the suture of the skin incision is too tight. The gas escaping from the tracheal cannula can be along the incision. Enter the subcutaneous tissue space, spread along the subcutaneous tissue, emphysema can reach the head, chest and abdomen, but generally limited to the neck, most of them can be absorbed after a few days, no special treatment is needed.
(2) Pneumothorax and mediastinal emphysema: When the trachea is exposed, the downward separation is too much, too deep, and after the pleura is damaged, the pneumothorax can be caused, and the position of the right pleural apex is higher, especially for children, so the chance of injury is lower than that of the left side. More, lighter, no obvious symptoms, severe cases can cause asphyxia, such as the patient's tracheotomy, dyspnea relief or disappear, and soon after the emergence of breathing difficulties, you should consider pneumothorax, X-ray film can be diagnosed, this time should Pleural pleural puncture, gas removal, severe closed drainage is feasible.
Excessive separation of the anterior fascia of the trachea during surgery, the gas enters the mediastinum along the anterior fascia of the trachea, forming a mediastinal emphysema. If there is more gas in the mediastinum, it can be separated downward along the anterior wall of the trachea to allow air to escape upward.
(3) Bleeding: a small amount of bleeding in the wound during surgery, can be stopped by pressure to stop bleeding or filled with gelatin sponge. If there is more bleeding, there may be vascular injury. The wound should be examined and the bleeding point should be ligated.
(4) Difficulty in extubation: If the site is too high during operation, the cartilage may be damaged, and the subglottic stenosis may be caused after surgery. The tracheal incision is too small. When the tracheal cannula is placed, the wall is pressed into the trachea; postoperative infection, Granulation tissue proliferation can cause tracheal stenosis, which is difficult to extrude. In addition, the inserted tracheal tube type is too large, and can not be successfully pulled out. Some patients with long tube length are afraid of breathing difficulties after extubation. When the tube is blocked, the patient may consciously breathe poorly. The small casing should be replaced gradually. Finally, if the tube is not difficult to breathe, the tube should be removed. For those who have difficulty in extubation, the cause should be carefully analyzed. X-ray film or CT examination should be performed. Mirror, bronchoscopy or fiber bronchoscopy, according to different reasons, as appropriate.
(5) Tracheal esophageal fistula: rare, in the case of laryngeal dyspnea, due to the negative pressure in the trachea, the posterior wall of the trachea and the anterior wall of the esophagus protrude into the tracheal cavity, and the posterior wall of the trachea can be damaged to the posterior wall. Smaller, less prolonged pupils can sometimes heal themselves. The fistula is larger or longer. The epithelium has grown into the mouth and can only be repaired.
Second, the use of tracheal stents to treat patients may also lead to the following complications:
(1) 1 to 7 days after the placement of airway edema stent, due to the expansion of mucosal tear, stent and stent support and other factors lead to congestion and edema of the tracheal mucosa, and the symptoms of dyspnea are more serious than before, so special attention should be paid to the respiratory condition. If the symptoms of dyspnea are improved, respiratory rate, rhythm, depth and oxygen saturation, such as increased dyspnea, chest tightness, shortness of breath, cyanosis, oxygen saturation decreased to below 90%, etc. should be notified immediately Physician treatment, after intravenous injection of succinylated hydrocortisone 200mg and ultrasonic atomization inhalation can significantly improve the symptoms, should explain the reasons and treatment and outcome to patients and their families, so that patients relieve anxiety and tension, so as to effectively Take a deep breath and cough, drain your sputum and keep your airway open.
(2) After pharyngeal discomfort and foreign body bronchoscopy and stent placement, patients have different degrees of pharyngeal discomfort and foreign body sensation. Foreign body sensation often causes paroxysmal irritating cough, and most patients have less cough. Significantly reduced or disappeared within 2 weeks, no drug treatment, but a few cases with obvious symptoms, the application of tramadol intramuscular injection and oral administration of codeine can significantly relieve symptoms.
(3) Hemorrhage is easy to produce blood during expansion and tracheal stenting. After the expansion, the tissue is torn and caused by vascular injury. Most of them are oozing blood, which can stop on their own. The patient shows blood in the sputum. It is a normal phenomenon, you should first explain to the patient, so that it is not nervous, gently cough up the blood, keep the airway open, if the bleeding is more, and the cough is weak, you need to use the fiberoptic bronchoscope, and give 2 ~ 3ml 0. 005%0. 01% adrenaline local spray to stop bleeding.
(4) Mucus obstruction at the distal end of the stent Because the placement of the stent affects the airway cilia activity, hindering the elimination of mucus and causing the accumulation and obstruction of the distal secretion of the stent, so the stent should be aerosolized after inhalation, 2 times/d, each time. 0. 5h, regularly turn over and shoot back, encourage patients to cough up, if necessary, give a fiberoptic suction.
(5) The stent displacement is mainly caused by forced coughing or intubation during tracheal intubation. In addition, the stent model may be small and cannot be firmly fixed to the appropriate site. Thoracic X-ray examination or fiberoptic bronchoscopy should be performed regularly after stent placement. Observe the placement of the stent. If the patient has a stent displacement, the stent can be removed and placed into a suitable stent.
(6) The granulation and tumor tissue growth and proliferation in the stent cavity grow into the stent cavity through the stent mesh, forming a new airway stenosis, especially in the case of secondary infection, it is easier to form granulation, so the condition should be strengthened after surgery. In particular, observing body temperature, changes in breathing, coughing and coughing, whether there is blood in the sputum and difficulty in breathing, the patient has tumor tissue growth in the stent cavity, and microwave ablation is performed under the fiberoptic bronchoscope.
Symptom
Trachea, bronchoconstriction symptoms Common symptoms Breathing difficulty, asthma, shortness of breath, low cough, foam, mucus, dryness, phlegm, phlegm, bronchial stenosis, snoring, wheezing
1. Difficulty breathing at different levels, inspiratory or expiratory breathing difficulties, or both, often accompanied by shortness of breath, wheezing, coughing, convulsions, phlegm and viscous, laborious, physical activity And increased respiratory secretions, often wheezing, patients who have undergone tracheotomy and intubation presented the above symptoms, should first consider tracheal scar stenosis, anterior and posterior, lateral and oblique tracheal tomography can be clear The ground shows the location, extent, length and morphology of the stenosis.
2. The bronchial stenosis of the affected side of the thoracic respiratory motility, tremor can be weakened or disappeared, sputum is voiced, auscultation of breath sounds low or disappear, there may be dry, wet rales.
Examine
Trachea and bronchoconstriction examination
1, x-ray tracheal tomography can be found in the narrow trachea.
2, endoscopy can effectively find narrow tracheal and bronchial lesions.
3, tracheal lipiodol angiography examination is valuable for the diagnosis of tracheal stenosis and understanding of the scope of stenosis, but there is a risk of increased tracheal obstruction, it is worth noting.
Diagnosis
Diagnosis and identification of trachea and bronchoconstriction
diagnosis
Diagnosis can be based on medical history, clinical symptoms, and laboratory findings.
Differential diagnosis
Patients with trachea and bronchoconstriction can be diagnosed by clinical symptoms and X-ray examination or endoscopy. The main need to identify the differential diagnosis of the primary disease is of great significance for the correct treatment of this disease. From this point of view, the treatment of tracheal stents is a palliative method in the case where the primary disease is not cured. The primary diseases of the trachea and bronchoconstriction are as follows:
1. Scarring caused by tuberculosis, trauma, etc.
2. Scarred tracheobronchial stenosis caused by tracheotomy.
3. Tracheobronchial stenosis caused by malignant tumors.
