初诊肺癌合并阻塞性肺炎临床诊疗专家共识

doi:10.3760/cma.j.cn371439-20250606-00083

摘要/Abstract

摘要：

肺炎是肺癌患者的显著致病和致死因素，其中肺癌合并阻塞性肺炎主要由气道被肿瘤部分或完全阻塞，导致远端肺组织通气不足而出现继发感染，因其具有复杂的形成机制和不典型的临床征象，经常干扰抗肿瘤治疗，需要引起广大临床医师的警惕和关注。尤其对于初诊即合并阻塞性肺炎的患者，如何权衡抗炎治疗和抗肿瘤治疗显得尤为重要。本共识参照国内外最新文献，结合学科内的最新技术和研究，针对肺癌合并阻塞性肺炎的发病机制、诊断、抗炎和抗肿瘤治疗优先顺序等常见问题提出12条推荐意见，旨在为临床医师优化临床诊疗决策提供参考。

关键词: 肺肿瘤, 阻塞性肺炎, 诊断, 治疗, 专家共识

Abstract:

Pneumonia is a major contributor to morbidity and mortality in patients with lung cancer. Lung cancer complicated with obstructive pneumonia refers to a secondary infection that develops when a tumor partially or completely occludes an airway， causing inadequate ventilation of the distal lung parenchyma. Because of its complex pathogenesis and atypical clinical presentation， obstructive pneumonia frequently interferes with anticancer therapy and thus warrants heightened vigilance among clinicians. For patients presenting at initial diagnosis with concurrent obstructive pneumonia， balancing anti‐infective treatment against antitumor therapy is particularly critical. Drawing on the latest domestic and international literature and integrating recent advances in the field， this consensus offers 12 evidence-based recommendations addressing the pathogenesis， diagnostic criteria， prioritization of anti-infective versus antitumor interventions， and other common clinical challenges in managing lung cancer complicated by obstructive pneumonia， with the goal of optimizing therapeutic decision‐making for frontline clinicians.

Key words: Lung neoplasms, Post-obstructive pneumonia, Diagnosis, Therapy, Expert consensus

中国研究型医院学会放射肿瘤学专业委员会, 河北省数理医学学会, 天津市精准医疗学会. 初诊肺癌合并阻塞性肺炎临床诊疗专家共识[J]. 国际肿瘤学杂志, 2025, 52(8): 484-494.

Radiation Oncology Professional Committee of the Chinese Research Hospital Association, Hebei Society of Mathematical and Physical Medicine, Tianjin Precision Medicine Society. Expert consensus on the clinical diagnosis and treatment of post-obstructive pneumonia in newly diagnosed lung cancer patients[J]. Journal of International Oncology, 2025, 52(8): 484-494.

图/表 4

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肺癌合并阻塞性肺炎的危险分层与治疗策略"

项目	低危	中危	高危
临床表现	无发热或低热（37.3~38.0 ℃）咳痰、咳嗽症状轻；无明显呼吸困难	中度发热（38.1~39.0 ℃）咳嗽咳痰较多、呼吸稍急促；活动后气促	高热（>39.0 ℃）咳脓痰，气促明显，可能出现意识障碍
实验室及肺功能检查	CURB-65评分0~1分；PSI：Ⅰ~Ⅱ级；白细胞计数正常或轻度升高[（4~ 12）×10⁹/L]；CRP<50 mg/L；PCT< 0.25 ng/ml；SpO₂≥94%；FEV₁≥80%预计值	CURB-65评分2分；PSI：Ⅲ~Ⅳ级；白细胞计数升高（>12×10⁹/L）；CRP：50~ 100 mg/L；PCT：0.25~0.5 ng/ml； SpO₂：90%~94%；FEV₁：50%~79%	CURB-65评分≥3分；PSI：Ⅴ级；白细胞计数减少或明显升高（>25×10⁹/L）； CRP>100 mg/L；PCT>0.5 ng/ml； SpO₂<90%；FEV₁<50%
影像学检查	局灶性阻塞性肺炎；单侧肺段或小叶受累	多叶或双肺病变；伴支气管阻塞征象	广泛实变或坏死，合并肺不张；可能出现胸腔积液
抗感染+支持治疗	经验性抗生素治疗（如头孢类）；对症支持（雾化吸入）	广谱抗生素±抗真菌治疗；对症支持（雾化吸入、吸氧）；物理排痰	静脉广谱抗生素+抗真菌治疗；高流量吸氧或无创通气；重症监护支持
抗肿瘤治疗	若肿瘤可切除且肺功能可耐受，可择期手术；如没有临床感染表现，且实验室指标仅轻度波动；一般不需要延迟肺癌的治疗；感染控制稳定后1周内可考虑启动肺癌治疗	全身治疗应在肺炎明显改善后2周后启动；感染控制初见效（48~72 h）后，如临床肺部感染评分≤6分且 PCT<0.25 ng/ml，可同步进行局部治疗（支气管镜、放疗等）	感染控制优先，肿瘤治疗推迟或个体化处理；若需缓解气道压迫，可在生命体征高度稳定、感染显著缓解后实施低剂量姑息放疗；若FEV₁<40%预计值或肺一氧化碳弥散量<40%时，需慎选放疗，优先考虑支气管介入解除阻塞；若驱动基因阳性，可在感染部分受控时进行靶向治疗

表4

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项目	危险因素	说明
一般特征	年龄≥65岁	随年龄增长，免疫功能及修复能力下降
	吸烟史	基础肺功能差，气道易狭窄、通气受限
	免疫抑制状态（如长期使用糖皮质激素、化疗后或合并人类免疫缺陷病毒）	淋巴细胞减少，感染清除能力降低
	营养不良或体重下降>10%	机体耐受性差，易并发感染
肿瘤相关因素	中央型肿瘤	容易发生机械性阻塞，导致远端肺不张及细菌易聚集
	肿瘤体积大或局部浸润（阻塞程度>75%）	阻塞范围广，通气损害严重
	伴发肿瘤坏死或空洞形成	坏死组织为细菌滋生提供生长条件
感染易感性	既往抗生素用药史/耐药菌感染	常规经验治疗失败，需覆盖多耐药病原体
感染易感性	反复急性加重史（≥2次/年）	慢性阻塞性肺疾病急性加重期患者因气道高分泌状态及菌群失调，较稳定期更易继发阻塞性肺炎
肺功能状态	FEV₁/FVC<70%；FEV₁<50%预计值	严重气流受限，肺泡排痰和通气功能差
	胸部CT：大范围实变、肺不张或脓胸	影像上广泛病灶提示感染控制难度大
	PaO₂/FiO₂<300或SpO₂<90%（未吸氧）	氧合不足，呼吸衰竭风险高
心肺合并症	心功能不全（NYHA Ⅲ~Ⅳ级）慢性阻塞性肺疾病	心肺联合受累时，呼吸支持及抗感染更困难
心肺合并症	糖尿病、慢性肾病、肝功能损害	代谢及免疫功能减弱，增加全身并发症风险

项目	肺癌合并阻塞性肺炎	社区获得性肺炎
定义	由支气管内肿瘤阻塞导致气道通畅受限，引发远端肺实变和继发感染	患者在院外或住院≤48 h内发生的肺组织感染
易感人群	肺癌患者（特别是中央型肿瘤）、支气管狭窄历史、局部放疗后管腔狭窄	老年人、吸烟者、慢性心肺病、免疫功能低下者
病原体特点	兼有常见社区菌，也易并发耐药菌（耐甲氧西林金黄色葡萄球菌、革兰阴性杆菌、厌氧菌）、真菌感染	以肺炎链球菌、流感嗜血杆菌、嗜肺军团菌等常见社区菌为主
临床表现	症状隐匿或慢性进行（咳嗽、反复发热、脓痰）；可有消瘦、乏力、夜汗	发热、咳嗽（黏痰或脓痰）、呼吸窘迫，症状出现较突然
影像学特征	阻塞侧肺叶或段肺大范围实变/肺不张，常伴空洞；肿瘤局灶在阻塞处可见结节或软组织肿块	局灶或弥漫性斑片状浸润影；CT可见毛玻璃或实变
肺功能变化	严重气流受限（FEV₁/FVC<70%）、分段肺不张，需雾化或支气管镜干预	通常无明显气流受限；呼吸功能可快速恢复
实验室指标	白细胞、CRP、PCT常持续高位；淋巴细胞减少时提示免疫抑制	可有白细胞、CRP或PCT升高；多数在治疗后48~72 h下降
预后及并发症	复发率高、病程长；易并发肺不张、脓胸、多器官功能障碍，整体预后较差	早期诊治预后好；少数可并发脓胸、呼吸衰竭

项目	低危	中危	高危
临床表现	无发热或低热（37.3~38.0 ℃）咳痰、咳嗽症状轻；无明显呼吸困难	中度发热（38.1~39.0 ℃）咳嗽咳痰较多、呼吸稍急促；活动后气促	高热（>39.0 ℃）咳脓痰，气促明显，可能出现意识障碍
实验室及肺功能检查	CURB-65评分0~1分；PSI：Ⅰ~Ⅱ级；白细胞计数正常或轻度升高[（4~ 12）×10⁹/L]；CRP<50 mg/L；PCT< 0.25 ng/ml；SpO₂≥94%；FEV₁≥80%预计值	CURB-65评分2分；PSI：Ⅲ~Ⅳ级；白细胞计数升高（>12×10⁹/L）；CRP：50~ 100 mg/L；PCT：0.25~0.5 ng/ml； SpO₂：90%~94%；FEV₁：50%~79%	CURB-65评分≥3分；PSI：Ⅴ级；白细胞计数减少或明显升高（>25×10⁹/L）； CRP>100 mg/L；PCT>0.5 ng/ml； SpO₂<90%；FEV₁<50%
影像学检查	局灶性阻塞性肺炎；单侧肺段或小叶受累	多叶或双肺病变；伴支气管阻塞征象	广泛实变或坏死，合并肺不张；可能出现胸腔积液
抗感染+支持治疗	经验性抗生素治疗（如头孢类）；对症支持（雾化吸入）	广谱抗生素±抗真菌治疗；对症支持（雾化吸入、吸氧）；物理排痰	静脉广谱抗生素+抗真菌治疗；高流量吸氧或无创通气；重症监护支持
抗肿瘤治疗	若肿瘤可切除且肺功能可耐受，可择期手术；如没有临床感染表现，且实验室指标仅轻度波动；一般不需要延迟肺癌的治疗；感染控制稳定后1周内可考虑启动肺癌治疗	全身治疗应在肺炎明显改善后2周后启动；感染控制初见效（48~72 h）后，如临床肺部感染评分≤6分且 PCT<0.25 ng/ml，可同步进行局部治疗（支气管镜、放疗等）	感染控制优先，肿瘤治疗推迟或个体化处理；若需缓解气道压迫，可在生命体征高度稳定、感染显著缓解后实施低剂量姑息放疗；若FEV₁<40%预计值或肺一氧化碳弥散量<40%时，需慎选放疗，优先考虑支气管介入解除阻塞；若驱动基因阳性，可在感染部分受控时进行靶向治疗