[Guidelines for the diagnosis and treatment of tracheobronchial tuberculosis (2025 Edition)].

内容摘要

Tracheobronchial tuberculosis (TBTB) is a special clinical type of pulmonary tuberculosis (MTB), belonging to lower respiratory tract tuberculosis. Due to its non-specific clinical manifestations, it is prone to misdiagnosis, underdiagnosis, mistreatment, and missed treatment in clinical practice. To enhance the early and accurate diagnosis and timely and standardized treatment of TBTB in clinical practice, the Tuberculosis Branch of the Chinese Medical Association organized experts in relevant fields, adopted evidence-based medical methods, basing on the original consensus and guidelines (trial), and mainly made the following updates: New evidence quality evaluation, recommendation strength, consensus rate, and molecular biological detection methods were added; the original term "bacteriology" was revised to "etiology"; the diagnostic methods and criteria were supplemented and improved, with emphasis on revising the original clinical classification and staging diagnosis to bronchoscopic classification and staging diagnosis; the treatment methods for TBTB were comprehensively and systematically introduced; the interventional treatment principles for different classifications and stages were recommended, especially emphasizing the emergency treatment methods for extremely severe and severe tracheal tuberculosis combined with tracheal stenosis in order to improve the diagnosis and treatment.This guideline specifically presents 31 recommendations around the following 22 common clinical issues, with the aim of improving the diagnosis and treatment level of TBTB in clinical practice and benefiting more patients.The recommendations are listed below:Recommendation 1: Definition of TBTB: Tuberculosis that occurs in the mucosa, submucosa and outer membrane of the tracheas and bronchi.Recommendation 2: Typical clinical manifestations of TBTB: Irritating cough, expectoration, hemoptysis, wheezing and varying degrees of breathing difficulties lasting more than 2 weeks, and wheezing sounds in the lungs, dry and wet rales, weakened or absent breathing sounds, tracheal deviation, etc.Recommendation 3: Typical imaging signs that should be paid special attention to: during clinical review of chest CT scans, not only the lung window, mediastinal window and soft tissue signs should be emphasized, but also the signs within the airway, on the airway wall and outside the airway should be closely observed. When TBTB is suspected, it is recommended to perform multi-dimensional airway reconstruction imaging technology with chest CT.Recommendation 4: Etiological testing of TBTB: Biopsy tissues, brush specimens, lavage fluids, lavage fluids and puncture materials can be obtained with bronchoscopy. Relevant acid-resistant staining, culture & drug sensitivity tests and molecular etiology of Mycobacterium tuberculosis should be conducted.Recommendation 5: Pathological features of TBTB: It is consistent with tuberculosis changes that the histopathology of the lesion tissue sampled by bronchoscopy indicates. Further acid-fast staining of tissue specimens and molecular pathological detection of Mycobacterium tuberculosis should be conducted.Recommendation 6: The role and status of bronchoscopy in the diagnosis of TBTB: Currently, bronchoscopy remains an indispensable interventional examination method for the confirmed diagnosis of TBTB.Recommendation 7: The value of immunological indicators in the diagnosis of TB: Serological immunological indicators are only used as an important reference basis for the clinical diagnosis of tuberculosis.Recommendation 8: Pulmonary function and blood gas analysis: For severe TBTB, it is recommended to conduct pulmonary function and blood gas analysis tests.Recommendation 9: Diagnostic methods for TBTB: Currently, it mainly relies on bronchoscopy, combining with etiological, pathological and molecular biological evidence.Recommendation 10: Diagnostic types and criteria of TBTB: Diagnostic types are divided into suspected diagnosed cases, clinically diagnosed cases and confirmed cases. The criteria for a confirmed case are typical lesions of TBTB that are directly visible under bronchoscopy, and a positive result in one of the following: etiology, pathology, or molecular biology. There are corresponding standards for clinical diagnosis and suspected diagnosis.Recommendation 11: Classification diagnosis of TBTB under bronchoscopy: Based on the main anatomical morphological changes of local airway lesions under direct bronchoscopy at that time, combined with the reactions before and after interventional therapy, it is recommended that TBTB be classified into nine bronchoscopic types: Type Ⅰ (inflammatory infiltration type), type Ⅱ (ulcer necrosis type), type Ⅲ (granulation tissue proliferation type), type Ⅳ (lymph node fistula type), type Ⅴ (wall fistula type), type Ⅵ (wall softening type), type Ⅶ (scar stenosis type), type Ⅷ (lumen occlusion type), and type Ⅸ (repeated retraction type).Recommendation 12: Staging diagnosis of TBTB under bronchoscopy: Based on the different development stages of local airway inflammation under direct bronchoscopy, TBTB can be divided into two bronchoscopic stages: active stage and inactive stage. Type I to Ⅳ & inflammatory fistulas in type V are manifestations of active stage under the bronchoscopy, while purification fistulas in type V & type Ⅳ to Ⅸ are manifestations of inactive stage under the bronchoscopy.Recommendation 13: Naming principles for TBTB: For the naming of TBTB, it is recommended to adopt a comprehensive naming method that takes into account the cause & anatomical location, and its relationship with the airway & the degree of stenosis.Recommendation 14: Differential diagnosis of TBTB: It should be differentiated diagnosis from bronchial asthma, airway fungal infections, bronchiectasis, chronic obstructive pulmonary disease, airway tumors and other rare airway diseases.Recommendation 15: The main objective and general principles of TBTB treatment: The primary objective of treatment is to prevent and cure central airway stenosis, occlusion and softening caused by tuberculosis, as well as the resulting poor airway drainage and atoptasis, and to correct poor pulmonary ventilation function and respiratory failure as soon as possible. The overall principle of treatment is to conduct bronchoscopic interventional therapy for TBTB with indications on the basis of systemic chemotherapy with anti-tuberculosis drugs.Recommendation 16: The systemic chemotherapy regimen and course of anti-tuberculosis drugs recommended against TBTB: The systemic chemotherapy regimen of anti-tuberculosis drugs is basically the same as the treatment regimen for pulmonary tuberculosis. It is recommended to formulate the chemotherapy regimen in reference to the relevant consensus and guidelines of the World Health Organization and China. It is specifically determined based on whether the patient is a sensitive or drug-resistant case, as well as the different types and stages under bronchoscopy.Recommendation 17: Implementation of local airway aerosol inhalation of anti-tuberculosis drugs for TBTB: On the basis of systemic chemotherapy with anti-tuberculosis drugs, for the active TBTB under the bronchoscopy, airway aerosol inhalation of anti-tuberculosis drugs is recommended. However, the local drugs used must be consistent with the systemic chemotherapy regimen.Recommendation 18: Application of glucocorticoids: For those with indications for glucocorticoids,on the basis of systemic chemotherapy with anti-tuberculosis drugs, it is recommended to use glucocorticoids in the local airway for a short-term.Recommendation 19: Surgical treatment: If good results cannot be achieved after systemic chemotherapy with anti-tuberculosis drugs and interventional treatment with bronchoscopy, and there are indications for surgical treatment, thoracic surgery is recommended.Recommendation 20: Purpose, principles and measures for interventional treatment of TBTB with bronchoscopy: For TBTB patients with indications for interventional treatment with bronchoscopy, based on different bronchoscopic stages and types, it is recommended to adopt a comprehensive interventional treatment combining multiple interventional methods with bronchoscopy on the basis of systemic chemotherapy with anti-tuberculosis drugs.Principles and objectives of interventional treatment for different types and stages of TBTB under the bronchoscopy:Recommendation 21: For the Type Ⅰ (inflammatory infiltration type), aspiration clearance, cryotherapy and local drug administration are recommended.Recommendation 22: For the Type Ⅱ (ulcer necrosis type), cryotherapy, argon plasma coagulation(APC) combined cryotherapy and local drug administration are recommended.Recommendation 23: For the type Ⅲ (granulation tissue proliferation type), thermal ablation combined with cryotherapy and local drug administration are recommended.Recommendation 24: For the type Ⅳ (lymph node fistula type), thermal ablation combined with cryotherapy and local drug administration are recommended.Recommendation 25: For the type Ⅴ [wall fistula type (inflammatory fistula)], ablation and local administration are recommended to promote the healing of the wall fistula.Recommendation 26: For the type Ⅴ [wall fistula type (purification fistula)], it is recommended to seal the wall fistula with bronchoscopy to restore airway integrity.Recommendation 27: For the type Ⅵ (wall softening type), patients with wall softening central airway stenosis combined with dyspnea and recurrent severe infections, airway stent implantation is recommended to support the collapsed airway, reshape the airway structure and maintain airway patency.Recommendation 28: For the type Ⅶ (scar stenosis type), balloon dilation is recommended as the first choice to expand the narrowed airway.Recommendation 29: For the type Ⅷ (lumen occlusion type), patients with lumen occlusion who have indications for recanalization, it is recommended to use ablation to open the occluded airway, and then combine balloon dilation to expand the narrowed airway after opening.Recommendation 30: For the type Ⅸ (repeated retraction type), it is necessary to keep the airway open and prevent airway retraction.Recommendation 31: Interventional treatment for tracheal tuberculosis with extremely severe or severe tracheal stenosis: When tracheal tuberculosis with extremely severe or severe tracheal stenosis poses a threat to the patient's life, it is recommended to urgently adopt measures such as balloon dilation, stent placement, T-tube placement, and tracheotomy for emergency interventional treatment. 气管支气管结核（TBTB）为肺结核特殊临床类型，属于下呼吸道结核，由于其临床表现不具有特异性，临床上极易被误诊漏诊、误治漏治。为加强临床对TBTB的早期正确诊断、及时规范治疗，中华医学会结核病学分会组织相关领域专家，采用循证医学方法，在原有共识、指南（试行）基础上，主要做了以下工作：新增了证据质量评价、推荐强度及共识率、分子生物学检测方法；将原细菌学改为病原学；补充完善了诊断方法及诊断标准，重点将原来临床分型分期诊断修改为镜下分型分期诊断；原则性地简单介绍了TBTB的治疗方法，重点推荐了针对不同镜下分型分期的介入治疗原则，尤其是强调了针对极重度及重度气管结核并气管狭窄的急救处理等。指南具体围绕22个临床常见问题形成31条推荐意见，以期提高临床TBTB的诊治水平，造福更多患者。.