Nghien cifu khoa hpc
Gia t n chan doan cua phiTdng phap sinh thiet xuyen thanh phe quan qua noi soi phe quan dng mem trong chan doan benh ly nhu mo phdi
Nguyin Dieu Hdng*, Ngo Quy Chau*
TOM TAT
Sinh thiit xuyen thanh phi quan (STXTPQ) qua ndi soi phi quan la mot trong so cac ky thuat liy benh phim chin doan md benh hgc, ky thuat cd gia tri chin doan cao, ty le tai bien thip. Muc tieu:
nhan xet gia tri chan doan va mot si tai biin cua ky thuat sinh thiit xuyen thanh phi quan qua ngi soi phi quan ing mim trong chin doan benh ly nhu md phdi. Ddi tt/ang va phifong phap nghien ci?u:
nghien cdu tiin cdu md ta tren 52 benh nhan diiu trj noi tru tai Khoa Hd hip, Benh vien Bach Mai td 01/08/2007 din 01/10/2008. Ket qua; ky thuat STXTPQ cho cac tdn thuang phdi lan tda va dam md d ngoai vi cd hieu qua chin doan 42,31% trong dd ung thu: 21,16%, lao: 19,23%, silicosis: 1,92%. Ty 1$
tai biin Chung: 17,31%, tran khi mang phdi: 3/52 BN (5,77%), chay mau: 6/52 BN (11,54%). Sdtsauspi phi quan 3/52 BN (5,77%). Khdng cd trudng hgp nao cd tai biin nang hoac td vong. Ke'tluan; STXTPQ qua ndi soi la ky thuat tuang ddi an toan va nen dugc ap dung cho cac benh nhan cd tdn thuang phdi ke hdac u phdi d ngoai vi ma khdng thiy hinh anh tin thudng qua ndi soi.
rpATVANDE
Sinh thiet xuyen thanh phe quan qua NSPQ la ky thuat de thuc bien va co ty le tai bien thap. Ky thuat dugc chi djnh eho nhung tdn thuong ng )ai vi ml bien phip sinh thiet tdn thuang bang kim qua ngi soi phe quan tiep can dugc. Ky thuat giup ban che nhiing trudng bgp phai sinh thigt phdi md' de phan dpan.[8]
Tren thi gidi, lin diu tien STXTPQ qua NSPQ dng cung dugc Anderson H.A va Fontana R.S.[3]
ap dpng nam 1965 ddi vdi cae tdn thuong phdi lan tda cho hieu qua chan doan: 84%. Ty le tai bien tran khi mang phdi (TKMP): 14%, tran khi trung that va ehly mau nlng: 1%, khdng ed trudng bgp tii vong.
Nam 2006, Berbeseu EA va cdng su tien hanh STXTPQ tren 21 BN duge chan doln xle dinh viern phdi ke bang sinh thiet phdi mgthay rang: cd the phat hien dugc cac thay ddi md benh bgc dae trung eiia viem phdi ke qua STXTPQ nhieu hon, hieu qua hon so vdi nhiing quan sat trudc dly. CIc
* Khga Ho Hap - Bfph viin Bach Ma;
S5'43 (Thang 08/2009) Y HOC LAM SANG I 25
Nghien cifu khoa hpc
bao clo khac ciing nhan manh tinh hieu qua eiia STXTPQ trong trudng hgp khdi u phdi d ngoai vi, STXTPQ cho phep chan doln xlc dinh tdi 60%
ddi vdi cac tdn thuong ed kich tbudc > 2,5 cm [5].
6 Viet Nam, ky thuat STXTPQ qua NSPQ dng mem de chan doan cac tdn thuang phdi khu trii d ngoai vi va tdn thirang phdi lan tda la ky thuat ed gia ti, chan doan cao. Tuy nhien, ky thuat nay mdi dugc Ip dung d mdt sd tmng tam Idn ve benh phdi va Idng nguc. Cho den nay, chua ed nhieu nghien eiiu danh gia ve hieu qua cung nhu tai bien ciia ky thuat nay. Chinh vi vay, chiing tdi tien hanh nghien ciiu de tai nham muc tieu:
nghien cuu gid tii vd tai bien ciia ky thudt sinh thiet xuyen thdnh phe quan qua ngi soi phe quan ong mem trong chdn doan benh ly nhu mophoL
II. DOI mm VA PHU^ffNG PHAP NGHIEN CUU
1. Doi tuong nghien cihi
52 benh nhan dieu tri ndi trii tai Khoa Hd hap, Benh vien Bach Mai tiiOI/08/2007 dSn 01/10/2008.
Tieu chudn chon benh nhdn
- Cd tdn thuong nhu md phdi tren phim X - quang phdi thang, nghieng hoac tren phim chup HRCT Idng nguc dang: kinh md, dim md, tdn thuong ke, tdn thuong phe nang lan tda.
- Soi phe quan khdng thay tdn thuang trong long phe quan.
- Khdng cd chdng ehi djnh vdi ky thuat NSPQ cung nhu STXTPQ.
Tieu chudn loai trie
- Theo kinh dien da neu [1]. Benh nhan khdng ddng y. Rdi loan nhip tim nang tinh trang tim khdng dn djnh. Giam oxy mau nang. Rdi loan ddng mau (ty le prothrombin < 50%, tieu ciu < 50giga/lit).
- Xet nghiem ddm cd true khuan khIng cdn khIng toan.
2. Phuong phap nghien cuu
Tien cihi md td. Cdc budc tien hdnh:
- Khim lam sang chi tiet theo mau benh an.
- CIc xet nghiem: chup X-quang phdi chuin, chup HRCT Idng nguc, cdng thiic mau, ddng mau ca ban.
sinh boa mau, xet nghiem ddm (tim true khuin khang cdn khang toan), do chiic nang thdng khi phdi.
- Benh nhan dugc giai thich rd vl muc dich ciing nhu eac tai bien cd the xly ra khi thuc hien ky thuat. Hudng dan benh nhan ele thao tie theo menh lenh etia ky thuat vien.
- Chgn benh nhan vao nghien eiiu khi cd dii cac tieu chuIn chgn benb nhan va khdng ed bat cii tieu chuan loai trii nao.
- Tien hanh soi phe quan voi dng ngi soi phe quan Olympus va kim sinh thiet PRESISOR cua Nhat Ban theo quy trinh kinh dien [1].
- Ky thuat sinh thiet xuyen thanh phe quan qua ngi soi phe quan dng mem:
+ Xac dinh chinh xac nhanh phe quan phln thiiy noi tien hanh sinh thiSt dua tren phim X quang, CLVT nguc, binh anh ndi soi phe quan.
-I- Cd dinh dng soi tai nhanh phe quan djnh sinh thiet.
-I- Day kim sinh thiet ra xa cho den khi thay cam giac vudng hoac cam gilc bi day, riit kim ra 2 em, md kim, day kim den khi vudng, kep kim lai.
-I- Neu benh nhan cd cam giac dau thi rut kim trd lai va dua tdi phe quan duoi phan thiiy khlc va lap lai thao tic tuong tu. Neu khdng dau, kep chat kim va thuc hien sinh thiet vao cudi thi thd ra.
+ Sau khi eat benh pham, dng soi van dugc giii cd dinh tai nhlnh phe quan dudi phan thiiy vira duge sinh thiet. Xii tri chay mlu neu cd.
- Theo ddi sau thii thuat:
-h Lam sang: khd thd, ho mlu, dau nguc, khIm phdi phat hien TKMP
H- Chup phim X quang phdi thang sau sinh thiit 2 - 5 deng kiem tra de phat hien tran khi mang phdi va chay mlu phe nang.
III. KET QUA NGHIEN CUU
Chung tdi da tiin hanh STXTPQ cho 52 benh nhin: 29 nam (55,8%), 23 nir (44,2%). Tudi thIp nhit: 19, cao nhat: 80, tudi trung binh:
54,75 ± 15,18. Nhdm tudi > 40 chiim ty le cao nhit 84,62%.
2 6 IY HOC LAM SANG So 43 (Thang 08/2009)
Nghien cii'u khoa hpc
1. Dac diem lam sang va X quang
Bdng 1. Trieu chiing Idm sdng
Trieu chiing Kho tha Dau nguc Ho khan Ho khac dam Ho mau
s6t
Gay sut can Hach ngoai vi Ran no Ran am Ran ngay Ran rit HC dong dac
Ton thuong lan toa n
14 4 10
6 1 11 5 0 14
2 2 0 2
% 77,8 22,2 55,6 33,3
5,6 61,1 27,8 0 77,8 11,1 11,1 0 11,1
Ton thutmg khu trii n
12 18 9 12
6 13 13 2 13
7 3 3 5
% 35,3 52,9 26,5 35,3 17,6 38,2 38,2 5,9 38,2 20,6 8,8 8,8 14,7
Chung n 26 22 19 18 7 24
18 2 27
9 5 3 7
% 50 42,3 36,5 34,6 13,6 46,2 34,6 3,8 51,9 17,3 9,6 5,8 13,5
P
<0,02 0,021
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05 0,034
>0,05
>0,05
>0,05
>0,05 Nhdn xet: ran nd, khd thd d nhdm tdn thuang lan toa gap nhieu ban nhdm tdn thuong khu trii, vdi p
< 0,05. Dau nguc d nhdm tdn thuang phdi khu trii nhieu ban nhdm lan tda vdi p<0,05.
Dac diem tdn thuong tren phim chup Xquang vd CLVT nguc:
- Hinh anh tdn thuong tren X quang phdi chu yeu la dam md: 71,15%, dang ke: 30,77%.
81,25% cic benh nhan tdn thuang dang ke ed tdn thuang lan tda c l hai ben phdi.
- Tren HRCT: vi tri tdn thuong gap nhieu d phdi phai, trong dd thiiy giira 68%, thiiy dinh phai 46%, dinh trai 30%, day phai 42%, day trai 34%.
Bdng 2. Hinh dnh tdn thuong tren phim HRCT nguc (n=50)
Hinh anh tdn thuong
Dam ma
Ton thuang phoi ke Tran djch mang phoi Hach trung that Hach ron phoi
Phoi phai n 27 18 2 8 2
%
54 36,0
4,0 16,0
4,0
Phoi trai n 5 16
2 1 0
% 10,0 32,0 4,0 2,0 0
Hal ben n 2 16
0 0 0
% 3,85 32,0 0 0 0
Tong so n
32 18 4 9 2
%
64,0 36,0 7,84 17,65
3,9
Nhdn xet: trong sd 52 BN nghien ciiu cd 50 BN ed phim chup HRCT. Hinh anh tdn thuang dang dam md gap d 64% BN. Tdn thuong dang ke 36%. 88,89% cd tdn thuang lan tda c l hai ben.
Ket qua gidi phau benh cua STXTPQ
Ung thu 11/52 (21,16%), viem lao 10/52 (19,23%), silicosis 1/52 (1,92%), viem man tinh 30/52 (57,69%).
- 1/30 BN cd tdn thuang day, xo vich phe nang kem tham nhiem nhieu bach cau li toan.
- 8/30 BN cd td'n thuong xo hdi md phi nang.
Sd 43 (Thang 08/2009) Y HOC LAM SANG I 2 7
Nghien cii'u khoa hpc
Bdng 3. Tuffng quan giita hinh dnh tdn thuong tren X quang vdi ket qua md benh hoc cua STXTPQ (n=52)
^^"^'"^"""^"-^-^-i-T-^-X-fluang va HRCT
Mp benh hoc ~~-——_____
Ung thu Viem lao Silicosis Viem rnan Tdng
Dam mu n
9 6 19 34
% 26,47 17,64 55,89 100
Ton thuong phoi ke n
2 4 1 11 18
% 11,11 22,22 5,56 61,11
100
Nhdn xet: -- Trong so 34 BN ed tdn thuong la dim md: ung thu: 9/34 BN (26,47%), lao: 6/34 BN (17,64%), viem man dnh: 19/34 BN (55,89%).
= Trpng 18 benh nhan tdn thuang ke gap: lao: 4 BN ( 22,22%), ung thu: 2 BN (11,11%), silicosis IBN (5,56%), yiim man tinh 11 BN (61,11%), 8/11 BN cd td'n thuang xo hda md phi nang.
Tai bien cda ky thudt
-- Tai bien eua ky thuat gap: chay mau 6 BN (11,54%), TKMP ya sdt diu ep 3 benh nhan chiim 5,77% (TKMP ipd mang ph0i but din luu). Khdng eg trPOTg hgp nag tii vong.
Bang 4- Li$n quan giiia tai bien cua ky thudt vdi so luong mdnh sinh thiet (n=52)
- TKMP va chay mau gap nhieu d tdn thuang phdi ke trong dd chay mlu: 22,22%, TKMP:
16,67%. Sir khac biet ed y nghla thdng ke vdi ele gil tri p tinh dugc < 0,01.
^ ~ \ ^ a i bien S6 manh ^ ^ ^
<3
> 4 P
Khong tai bien n
16 27
% 94,1 77,1 0,279
Tran khi mang phoi n
0 3
% 0 8,6 0,169
Chay mau n 1 5
% 5,9 14,3 0,114
Tong s6 17 35
Nhdn xSt: khdng tbly §u khlc biet cd y nghla thdpg ke giua so lugng manh sinh thiet va tai bien trong thii thuat.
IV, BAN LUP
Sinh thiet xuyen thanh phe qpin cd gia tri trong chan doln cac benh phdi lan toa va bfnb phdi da d nia hinh anh NSPQ Kinh thugng. Ky thuat dugc thue hien ddng thoi vdi NSPQ n§n gia thanh re. Qua phln tich tren 52 tnidng hgp duoe STXTPQ qua NSPQOM ehnng tdi thu dugc ket qua chan doan duong tinh 42,31% (22/52 BN), trong do ung thu: U BN (21,15%), lag: 10 BN (19,23%), silicosis 1 BN (1,92%) va 30 BN (59,62%) cd kit qua viem man tinh,
Chiing tdi ehia thInh 2 nhdm tdn thugng, trong so 34 BN eg ton thugng la dam mg: ung thu, 9/34 BN (26,47%), lap; 6/34 BN (17,64%), viem man tinh: 19/34 BN (55,89%).
Trong 18 benh nhan ton thuong kl gap: lao: 4 BN (22,22%), png thu: 2 BN (11,11%), silicosis
IBN (5,56%), viem man tinh 11 BN (61,11%), 8/11 BN eg ton thugng xg hoa md phe nang. Ket qua eua ehiing tdi ciing tuong tu nhu nghien ctiu cua Curley FJ va cdng su (1998), ty le chan doan duong tinh la 43,1% trong do gap chii yeu tdn thuong phoi kl (35,9%), ung thu 7,2%[4]. Tuy nhien, chan doan md benh hgc viem phdi ke cua chiing tgi cdri han che, Dg danh gil hieu qua eiia ky thuat mot each ehinh xac ddi hdi phai nghien ctiu tren mdt sd lugng benh nhin Idn hon, cd nhu v^y mgi eg thg tinh dugc dp nhay, dd dae hieu eiia ky thuat.
Chiing tdi cung nhgn thay ky tbult STXTPQ lak|
tbupt de thuc hien, tai bien ciiii ky thuat khdng nhieu, Uiy nhien tai biin hay gap II chay mlu va TKMP.
Theo EUis J.H vacgng su(1999) nghien cflu trgn 107 BN ty le tai biin s^u sinh thiit la 10,5%, trong dd 2,3% la hg mau >10 ml va 8,2% !a he mlu <10 ml yl
IY HOC l i M SANG So 43 (Thang 08/200?)
DIEN DAN Y HOC
Nghien cii'u khoa hoc
khdng can can thiep diiu tri.[6] Trong nghien ciiu ciia chiing tdi, ty le tai biin gap 17,31% trong dd tran khi mang phdi chiing tdi gap 3 benh nhin (5,77%), 6 trudng hop chay mau khi sinh thiit (11,54%). Ba benb nhan TKMP ciia chiing tdi da duge md mang phdi hiit dan luu khi hen tuc, sau bdn ngay dugc riit dan luu.
Trong eac trudng hgp ho mau thi lugng mau chay ra khdng nhieu (<30ml), cac trudng hgp chay mau deu dugc xu tri bang bom dung dich Adrenalin pha loang 0,01% len be mat vung chay mau va cd 2 benh nhan tiem lOmg Mgrpbin tiem dudi da.
Trong nghien ciiu nay, sd benb nhan dugc sinh thiit < 4 minh la nhiiu nhat 43/52 (82,699.). So lugng minh sinh thiet trung binh la3,88±l,08. Ket qua eiia ehung tdi ciing tuong tu nghien eiiu eua tac gia Fengyl O thuc hien STXTN tren 174 benh nhan cd sd manh trung binh 3,5±1 vdi ty le tai bien 4,55%. Chiing tdi thay khdng ed su lien quan giiia sd lugng manh sinh thiet voi tai bien ciia ky thu|t,
V, KET LUAN
Nghien eihi tiin haph STXTPQ qua NSPQOM cho 52 benh nhan cd tdn thuang dang dam md va tdn thuang phdi ke, khdng cd tdn thuang trong long phe quIn, chiing tdi cd mgt so ket luan sau:
1. Gia tri cua sinh thiet xuyen thanh phe quan
< Chan doan dtrong tinh 42,31 % trong dd xac djnh ung thu: 21,16%, lao: 19,23%, silicgsis: 1,92%..
2. Tai bien ciia ky thu§t
- Tran khf mang phoi: 5,77%, Chay mau khi sinh thi|t: 11,54%, sd lugng mlu chay khdng nhiep < 30ml. Khdng eg trugng hgp nao cd tai bign nlng hgag tu vgng »|»
TM LIEU THAM KHAO
1. Ngd Quy Chau (2007). Noi soi phi quan. Nhd xudt bdn Y Hoc, Hd Noi
2. Nguyin Chi Lang (1992). "Gdp phdn nghiinn ciiu chdn doan ung thu phi quan bdng ky thuat soi phi quan dng mem, xuyin thdnh phi quan vd chai riia phi quan mu". Luan dn phd tiin si Y hoc Truang dai hoc Y Hd Noi, Ndi Khoa.
3. Nguyin Chi Lang (1992). "Nghiin ciiu hiiu qua vd do an todn cua ky thudt sinh thiet xuyin thdnh phi quan trong khi soi phi quan dng mim". Ndi san lao vd benh phdi, Tdng hdi Y ducfc hoc Viet Nam, Hd Ndi, tap 38, tr 96 - 101.
4. Anderson HA; Fontana RS; Harrison EG (1965).
"Transbronchoscopic lung biopsy in diffuse pul- monary disease". Dis Chest; 48; 187-92.
5. Berbeseu EA; Katzenstein AL; Snow JL; Zisman DA (2006). "Transbronchial biopsy in usual Interstitial pneumonia". Chest. May; 129(5): 1126-31.
6. Curley FJ, Johal JS, Burke ME and Fraire AE (1998)
" Tranbronchial lung biopsy: can specimen quality be predicted at the dine of biopsy". Chest, 113: 1037 - 1041.
7. JH Ellis. (1999). "Transbronchial lung biopsy via the fiberoptic bronchoscope. Experience with 107 consecutive cases and comparison with bronchial brushing ", Chest, 68: 524 - 532.
8. Levin DC; Wicks AB; Ellis JH (1974).
"Transbronchial lung biopsy via the fiberoptic bron- choscope". Am Rev Respir Dis; 110: 4-12.
9. Leslie KQ; Grudm JF; Parish JM: Scholand MB (2007). "Tranbronchial biopsy interpretation, iti tjie patient with diffuse parenchymal Inng disease'', Arch Pathol Lad Med Mar;13](3);407r23.
SUMMARY
THE VALUE OF TRANSBRONCHIAL LLJNG HQPSYVIA F L i X I | L i BR©NCHQSS©PY IN DIAGNOSIS OF PULMONARY DISEASES
Background; transbronchial lung biopsy (TBLB) is one of technique^ for getting lung speeimens for his-^
tological diagnosis.. Objective: to assess diagnostic vglu^ and ccimplications ofTElL.13 via flexible Isran- choscppy in diagnosis of pulmonary diseases. Patients and method: a prospective study on 52 inpatients ill Respiratory department - Bach Mai hpspitql froni 01/0^/2007 to 01/10/2008, Results;on interstitial and peripheral nodule lesions, TBL.B had diagripstic yield in 42.31%, qnipng those, lung cancer;
21.16%, tuberculosis; 19.23%, silicosis: 1.92%. Overall complications: 17.31% (pneumothorax: 3/52 cqses (5:77%), parenchymal lung haemorrhage: 6/52 cases (11,54%). Post bronchoscopy fever: 3/52 cases (5.77%). NQ severe- complicaUoiis or dead was abservered, Conclusion; TBLB is a safe techniqiie and should be applied for all patients with interstitiql and peripheral lung lesions who do not have lesion fecund in brorichoscopy,
§o: 43 (Thang 08/2009) Y HOC LAIVI SANG I 2 9
