单肺通气时辅助患侧肺小潮气量高频率通气模式在胸腔镜肺叶切除术的应用

发布时间：2018-01-08 19:14

  本文关键词：单肺通气时辅助患侧肺小潮气量高频率通气模式在胸腔镜肺叶切除术的应用　出处：《青岛大学》2017年博士论文　论文类型：学位论文

  更多相关文章： 单肺通气 患侧肺 不同潮气量 高频率

【摘要】：目的:探讨在单肺通气时辅助患侧肺小潮气量高频率通气模式对胸腔镜肺叶切除患者通气功能及肺保护的效果。方法:1、选择2014年12月1日~2016年5月1日在我院接受胸腔镜肺叶切除术的早期非小细胞肺癌患者67例。采用数字随机表法,将患者随机分为:传统单肺通气组(CV组,n=33)与单肺通气+患侧肺小潮气量高频率通气组(LV组,n=34)。(1)纳入标准:1、ASAⅠ~Ⅱ级;2、术前行胸部增强CT、腹部B超、颅脑核磁共振、全身重要器官放射线检查,未发现肿瘤转移病灶;3、Karnofsky(卡氏功能状态)评分70分,未接受过手术和化疗治疗;4、无长期大量吸烟史,心、肝、肾功能无异常。(2)排除标准:1、术前肺功能检查:第1秒用力肺活量占用力肺活量的百分比(FEV1.0/FCV%)50%;术前血氧饱和度低于93%;术前动脉血氧分压小于70mm Hg;动脉血二氧化碳分压大于50 mm Hg。2、术前心功能分级III级或Ⅳ的患者。3、有严重的心肺疾患及脑血管病史,合并肝肾功能损害,合并神经精神系统疾病、老年性痴呆、心理疾病或活动性肝病、患有严重视力或听力障碍无法与医师进行有效交流等。4、若术中输血或单肺通气时间1小时,或手术时间4小时及术中需要全肺切除的。5术中不能耐受单肺通气者。2、麻醉方法及通气管理(1)术前准备和麻醉过程麻醉前30min,肌注苯巴比妥钠0.1g、盐酸戊乙奎醚0.5mg。可根据患者身高体重和胸部后前位X光片的胸骨锁骨端气管横径选择双腔气管导管(Double-lumen tubes,DLT)的型号,气管内径测量值大于19mm选择41F双腔气管导管,大于17mm选择39F,大于15mm选择37F。患者进入手术室后,建立非手术侧上肢静脉通道输注复方氯化钠溶液,常规监测心电(ECG)、血氧饱和度(Sp O_2)、心率(HR),麻醉深度(BIS),呼气末二氧化碳压力(Pet CO_2),局部麻醉下行桡动脉穿刺置管监测有创血压及采集动脉血标本。面罩通气去氮充氧,依次静脉注射咪达唑仑0.05~0.1mg/kg、舒芬太尼0.3ug/kg、维库溴铵0.1 mg/kg,待患者意识消失、脑电双频指数(BIS)降至50时、肌松完善后,经口明视下插入双腔气管导管(Sheridan,墨西哥)。气管插管后经纤维支气管镜(Fiberoptic bronchoscopy,FOB)调整确定导管位置,固定导管后连接麻醉呼吸机机械通气。插管完成后经右侧颈内静脉穿刺置管监测中心静脉压(CVP)。静脉持续泵注丙泊酚3~8 mg·kg-1·h-1、瑞芬太尼0.2~0.4ug·kg-1·min-1,间断追加维库溴铵0.08 mg·kg-1·h-1维持麻醉,维持脑电双频指数(BIS)值40~50范围。(2)通气管理机械通气采用Aestiva5/7900型麻醉机(Ohmeda,芬兰)行间歇正压通气(IPPV),吸入氧浓度维持在(Fi O_2)100%,氧流量为1.5L/min。双肺通气时,潮气量(VT)7 ml/kg,通气频率12次/min,吸呼比1:1.5;根据手术需要实施单肺通气(CV组)或单肺通气+患侧肺小潮气量高频率通气(LV组)。CV组:VT 6 ml/kg,通气频率12次/min,吸呼比1:1.5;LV组:健侧肺VT 6 ml/kg,通气频率12次/min,吸呼比1:1.5,同时患侧支气管导管接同一型号麻醉机,给予VT 0.3~0.5 ml/kg,通气频率40次/min,吸呼比1:1.5。机械通气期间,对于LV组,如果手术过程中通气影响操作,可以暂停通气,并调整通气量。若术中单肺通气过程中出现Sp O_293%,需调整通气参数者,应退出本次研究。(3)数据和标本收集分别于单肺通气前(T0)、单肺通气30min(T_1)、单肺通气60min(T_2)及双肺通气后5min(T_3)时,采集动脉血进行血气分析,记录Pa O_2,Pa CO_2并计算氧合指数(Pa O_2/Fi O_2)。在手术切除标本后,由术者在远离病灶组织处,切取肺组织标本,进行苏木精-伊红染色,在显微镜下观察肺间质水肿、肺泡水肿、中性粒细胞浸润与肺泡内充血严重程度,进行肺损伤评分。结果:1.本次研究过程中有5例患者单肺通气过程中出现Sp O_293%,经过调整通气参数或再次确定双腔气管导管位置后才得以纠正,其中CV组3例和LV组2例,均退出此次研究。另外LV组有2例患者在患侧肺通气时影响手术操作,调整通气量后仍不满意,退出本次研究。最终有60例患者完成本次应用研究,CV组30例,LV组30例。2.CV组与LV组的单肺通气时间、麻醉时间、术中补液量、尿量没有显著性差异。3.CV组和LV组患者的氧合指数呈先下降后上升的趋势,CV组氧合指数在T_2时达最小值,LV组患者的氧合指数在T_1时达最小值,T0时LV组氧合指数与CV组没有显著性差异,(p0.05);T_1、T_2及T_3时,LV组患者氧合指数明显高于CV组,(p0.05)。4.CV组和LV组患者的Pa CO_2呈先上升后下降的趋势,在T0和T_3时,LV组患者的Pa CO_2与CV组没有显著性差异,(p0.05);单肺通气T_1、T_2时,LV组患者Pa CO_2明显低于CV组,(p0.05)。5.LV组肺间质水肿、肺泡水肿、中性粒细胞浸润与肺泡内充血严重程度均较CV组轻,LV组肺损伤评分2.70±0.71显著低于CV组的3.13±0.73(p0.05)。结论及意义:在胸腔镜肺叶切除手术中应用双侧肺不同潮气量通气模式,即单肺通气时辅助患侧肺小潮气量高频率通气模式,既能满足双肺隔离的目的,又可增加患侧肺氧合,减少了低氧血症和高碳酸血症,减轻单肺通气时所造成的肺损伤程度,从而减少术后肺部并发症的发生。虽然这种通气模式偶尔会影响手术操作,但大部分情况下通过调整通气量后手术都能顺利完成。本次研究中患侧肺高频通气仅仅设定了一个通气频率,以后还可以尝试更多种的通气频率,观察其通气效果,另外此通气模式的缺点是需要两台麻醉机支持,操作较麻烦,还需要未来进一步研究。
[Abstract]:Objective: To explore the effects of single lung ventilation assisted ipsilateral lung ventilation with low tidal volume and high frequency resection patients and lung protective ventilation function of VATS lobectomy. Methods: 1, December 1, 2014 ~2016 year in May 1st received thoracoscopic lobectomy in our hospital 67 cases of patients with early stage non small cell lung cancer were randomly., the patients were randomly divided into: the traditional single lung ventilation group (group CV, n=33) and one lung ventilation + ipsilateral lung high frequency and low tidal volume ventilation group (group LV, n=34). (1) inclusion criteria: 1, ASA I ~ II; 2, preoperative enhanced chest CT, abdominal ultrasound. MRI, all important organs radiographic examination, found no tumor metastasis; 3, Karnofsky (Karnofsky performance status score of 70), did not receive surgery and chemotherapy; 4, without a long history of smoking, heart, liver, renal function abnormalities (2). Exclusion criteria: 1, lung the function of preoperative examination: the first second use Vital capacity FVC% (FEV1.0/FCV% 50%); preoperative oxygen saturation of less than 93%; preoperative arterial oxygen pressure is less than 70mm Hg; arterial carbon dioxide pressure greater than 50 mm Hg.2 patients,.3 heart function class III or IV before operation, with a history of heart and lung disease and cerebrovascular serious, and the damage to liver and kidney function, nervous system diseases complicated with mental, Alzheimer's disease, liver disease or mental activity, unable to communicate effectively with other.4 physicians with severe visual or hearing impairment, if intraoperative blood transfusion or single lung ventilation for 1 hours, or 4 hours of operation time and intraoperative one lung ventilation to pneumonectomy.5 was not tolerated.2, anesthetic method and ventilation management (1) preoperative preparation and anesthesia anesthesia before 30min, intramuscular injection of phenobarbital sodium 0.1g, penehyclidine hydrochloride 0.5mg. according to chest X ray with height weight and chest posteroanterior Clavicle bone end tracheal diameter double lumen tracheal catheter (Double-lumen tubes DLT) model, tracheal diameter measuring value is greater than 19mm 41F double lumen endotracheal tube, more than 17mm 39F, more than 15mm with 37F. after entering the operation room, the establishment of non operative side upper limb vein infusion of compound channel Sodium Chloride Solution, routine monitoring of ECG (ECG), oxygen saturation (Sp O_2), heart rate (HR), the depth of anesthesia (BIS), end tidal carbon dioxide pressure (Pet CO_2), local anesthesia radial artery catheterization monitoring blood pressure and blood oxygenation. Mask ventilation to nitrogen, followed by intravenous injection of midazolam 0.05~0.1mg/kg. 0.3ug/kg 0.1 mg/kg sufentanil, vecuronium, after the patients lost consciousness, bispectral index (BIS) fell to 50, improve muscle relaxation after intraoral injection of double lumen endotracheal intubation (Sheridan, Mexico). After tracheal intubation via fiberoptic bronchoscopy ( Fiberoptic bronchoscopy, FOB) to determine the position of the catheter catheter adjustment, fixed connection after anesthesia ventilator mechanical ventilation. After intubation via right internal jugular vein catheterization monitoring central venous pressure (CVP). Intravenous infusion of propofol 3~8 Mg - kg-1 - H-1 - kg-1 - min-1 0.2~0.4ug, remifentanil, vecuronium 0.08 mg intermittent additional kg-1. H-1 maintain anesthesia, maintain bispectral index (BIS) value is in the range of 40~50. (2) mechanical ventilation ventilation management using Aestiva5/7900 anesthesia machine (Ohmeda, Finland) intermittent positive pressure ventilation (IPPV), inhaled oxygen concentration maintained at 100%, (Fi O_2) 1.5L/min. oxygen flow rate of lung ventilation, tidal volume (VT) 7 ml/kg, 12 /min frequency of ventilation, breathing than 1:1.5; according to the operation needs the implementation of one lung ventilation (group CV) or single lung ventilation + ipsilateral lung small tidal volume and high frequency ventilation (group LV).CV group: VT 6 ml/kg 12 /min, frequency of ventilation, breathing than 1:1.5; LV 缁，

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