非手术侧双腔支气管导管应用对胸腔镜手术单肺通气效果的影响

发布时间：2018-04-07 17:48

  本文选题：双腔支气管导管　切入点：胸腔镜手术　出处：《皖南医学院》2017年硕士论文

【摘要】：目的:双腔支气管导管(Double-lumen endobronchial tubes,DLTs)插管是临床上进行肺隔离手术最为常用的技术。鉴于左、右支气管解剖结构的差异及左侧插管操作方便、对位准确度高等优点,国内、外胸科手术DLTs的选择一直遵循着“宁左毋右”原则,即在不影响手术操作的前提下,无论是右进胸手术还是左进胸手术均选择左路DLTs插管。而如今随着插管设备及技术改进,尤其是纤支镜的出现,在一定程度上克服了右路DLTs插管定位的难题后,这种传统观念是否还具有临床优势仍值得探讨。另外,临床实践发现左进胸手术选择左路DLTs插管时,由于双腔管通气管末端呈约45°斜面,通气侧管口又位于隆突附近,其在受到手术操作牵拉或挤压肺组织时易发生贴壁现象,从而引发间歇性的气道压升高乃至气道梗阻,严重时甚至可导致通气不足和低氧血症的发生。因此,本研究拟通过比较非手术侧DLTs和手术侧DLTs插管术中间歇性高气道压和低氧血症的发生风险,探讨非手术侧DLTs插管用于胸科手术单肺通气的效果,以期为临床DLTs应用提供依据。方法:选择我院择期胸腔镜下需行单肺通气手术患者90例,ASA I-II级,年龄40-70岁。排除合并有重要系统疾病、有明显气管与支气管损伤或缺损、胸部X片和CT查气管或支气管结构异常、有支气管哮喘或气道高反应病史等患者。将符合标准患者随机分为三组,每组30例,A组:左进胸手术选择左路DLTs插管;B组:右进胸手术选择左路DLTs插管;C组:左进胸手术选择右路DLTs插管。记录麻醉过程中DLTs插管次数,侧卧位前、后FOB定位的次数与时间,单肺通气后间歇性高气道压和低氧血症的发生次数,术中FOB定位次数与时间,肺隔离满意度的分级及DLTs相关性并发症。结果:三组患者在性别、年龄、体重、身高及DLTs型号上无统计学意义的差异(P0.05);在DLTs插管与定位方面,三组间在插管次数、插管时间、置管深度及侧卧位前、后FOB定位时间上未见统计学差异(P0.05);术中FOB定位次数及定位时间,B、C两组明显少于A组,具有统计学差异(P0.05);在术中间歇性高气道压及低氧血症的发生风险上,B、C两组明显低于A组,肺隔离满意度明显高于A组,差异具有统计学意义(P0.05)。另外,在术后并发症上,三组患者在术后咽喉痛的发生风险上也无明显统计学差异(P0.05)。结论:胸腔镜下非手术侧DLTs插管降低了术中间歇性高气道压和低氧血症发生的发生风险,增加了肺隔离的满意度;非手术侧DLTs插管用于胸腔镜手术临床效果优于单纯左路DLTs插管,值得推广应用。
[Abstract]:Objective: Double-lumen endobronchial tubeslts (DLTs) catheterization is the most commonly used technique for lung isolation surgery.In view of the differences between left and right bronchus anatomical structure and the advantages of convenient operation of left side intubation and high accuracy of orthopedic operation, the choice of DLTs in external chest surgery has always followed the principle of "better left than right", that is, without affecting the operation,Left DLTs catheterization was performed in both right and left thoracotomy.However, with the improvement of intubation equipment and technique, especially the appearance of fiberoptic bronchoscope, the difficulty of positioning right DLTs intubation is overcome to a certain extent, so it is worth discussing whether this traditional idea still has clinical advantages.In addition, the clinical practice showed that in the choice of left DLTs intubation in the left thoracic surgery, the end of the double lumen tube was about 45 掳oblique plane, and the orifice of the ventilation side was located near the protuberance, which was prone to adhere to the wall when the lung tissue was pulled or squeezed by the operation.It can cause intermittent airway pressure and even airway obstruction, and even lead to lack of ventilation and hypoxemia.Therefore, the aim of this study was to compare the risk of intermittent hyperairway pressure and hypoxemia during DLTs and DLTs intubation on the non-operative side, and to explore the effect of DLTs intubation on the non-operative side for one-lung ventilation in thoracic surgery.In order to provide the basis for clinical application of DLTs.Methods: 90 patients (40-70 years old) with ASA I-II grade undergoing thoracoscopic ventilation in our hospital were selected.Patients were excluded with important systemic diseases, obvious tracheal and bronchial injuries or defects, abnormal tracheal or bronchial structure by chest X-ray and CT examination, and history of bronchial asthma or airway hyperresponsiveness.The patients were randomly divided into three groups: group A (30 cases): left thoracic operation: left DLTs intubation group B: right thoracic operation choice left DLTs intubation group C: left thoracic operation choice right DLTs intubation.The number and time of DLTs intubation during anesthesia, the number and time of FOB localization before and after lateral position, the frequency of intermittent hyperairway pressure and hypoxemia after one-lung ventilation, the number and time of FOB localization during operation were recorded.Grade of pulmonary isolation satisfaction and complications associated with DLTs.Results: there was no significant difference in sex, age, weight, height and DLTs model among the three groups (P 0.05). In DLTs intubation and positioning, the three groups had no significant difference in intubation times, intubation time, depth of intubation and lateral position.There was no statistical difference in the time of FOB localization (P 0.05), the number and time of FOB localization in group C were significantly lower than those in group A (P 0.05), and the risk of intermittent hyperairway pressure and hypoxemia in group C was significantly lower than that in group A.The satisfaction degree of pulmonary isolation was significantly higher than that of group A, and the difference was statistically significant (P 0.05).In addition, there was no significant difference in the risk of postoperative throat pain among the three groups (P 0.05).Conclusion: DLTs intubation under thoracoscope can reduce the risk of intermittent hyperairway pressure and hypoxemia and increase the satisfaction of pulmonary isolation.The clinical effect of non-operative side DLTs intubation in thoracoscopic surgery is better than that of left side DLTs intubation alone, which is worth popularizing.
【学位授予单位】：皖南医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R614

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