支气管封堵技术对左开胸手术肺萎陷分级的研究

发布时间：2018-05-10 22:30

本文选题：食管癌 + 单肺通气　；参考：《河北医科大学》2017年硕士论文

【摘要】：目的:食管癌开左胸手术中,在支气管封堵管(BB)下进行单肺通气,参照Campos肺萎陷和手术野的评估方法[1]和双腔管下肺萎陷和手术野的评估方法[2],计算应用支气管封堵器技术开左侧胸肺萎陷分级的百分比,便于指导临床评估开胸手术患侧肺萎陷程度。方法:由于Campos分级是术侧肺自然萎陷状态下的评估。双腔管下分级是对术侧肺进行小潮气量通气,经过干预后,根据术者对手术野暴露的满意度以及是否影响手术操作的评估分级的定义:Ⅰ级术侧肺基本萎陷,不经过干预后手术野暴露满意,不影响手术操作。Ⅱ级术侧肺部分萎陷,经过干预后手术野暴露可,但不影响手术操作。Ⅲ级术侧肺萎陷差,经过干预后仍严重影响手术野暴露,手术无法进行。支气管封堵技术下分级是对支气管封堵管中心导管进行小潮气量通气,经过氧气通气干预后,根据术者对手术野暴露的满意度以及是否影响手术操作的评估,分级的定义如双腔管分级。随机选取同一组手术医生2016年2月至2016年10月择期的60例食管癌患者,男女不限,体重为49~80kg,身高155~175cm,全部选择开左胸食管癌根治术。ASA分级为Ⅰ~Ⅱ级,术前心电图、心脏超声以及肺功能检查未见异常,依据肺功能报告,记载患者预计肺总量,近期无上呼吸道感染,血常规和生化检查无明显异常,既往体健,无系统疾病。根据研究需要随机分三组:A组(n1=20)、B组(n2=20)和C组(n3=20)。患者被送入手术室,完善三方核对,手术室护士建立外周液路,切皮前30min,戊乙奎醚1mg和咪达唑仑0.05mg/kg入壶。用IntelliVue MP50监护仪记录其脉搏血氧饱和度(SpO2)和心电图(ECG),2%利多卡因局麻后进行有创穿刺,包括深静脉和桡动脉,记录CVP和ABP,进行术前吸空气的动脉血气分析。面罩下100%纯氧吸入,增加氧储备,静脉注射舒芬太尼0.2~0.4μg/kg,依托咪酯0.2~0.3mg/kg,患者入睡后推注顺式阿曲库铵0.3mg/kg,辅助呼吸和面罩人工通气5min后由同一高年资麻醉医生经口明视插入7.5~8.0号单腔气管导管,固定单腔气管导管,然后经单腔管置入支气管封堵管,置入左主支气管。先用听诊法检查封堵管套囊对位是否良好,再用纤维支气管镜检查,确定对位良好,同时检查气道情况,确保通畅。固定支气管封堵管,进行双肺通气。用datex-ohmeda7100呼吸机控制呼吸以及监测气道平台压(pplat)和气道峰压(ppeak)、呼末二氧化碳分压(petco2)。术中麻醉采用瑞芬太尼-七氟烷静吸复合麻醉维持,微量泵瑞芬太尼(0.5~1μg/kg/min)和吸入七氟烷(1~3%),每半小时静推顺式阿曲库铵0.05mg/kg。进胸前双肺通气,呼吸参数设定为:潮气量(vt)8ml/kg,呼吸频率(f)12次/分,吸呼比(i:e)1:2。进胸后改为单肺通气模式,呼吸参数设定:潮气量为6ml/kg,呼吸频率15次/分,吸呼比1:2。在左侧肺完全萎陷后,手术进行到过主动脉弓阶段时给予注入氧气(浓度0.8)干预(附图),使b组和c组分别达到肺萎陷程度分级的Ⅱ级和Ⅲ级(附图),记录下此时的注气总量(v1,v2),给予小潮气量1ml/kg维持萎限程度。同时抽血气记录ph,肺泡动脉氧分压差(a-ado2),动脉血氧分压(pao2),二氧化碳分压(paco2)。并记录三组的有创动脉压(abp)、中心静脉压(cvp)、心率(hr)和脉搏氧饱和度(spo2)。记录术后2天内声音嘶哑、咽痛的发生例数,和术后7天内肺部发生感染的例数。结果:1基本情况:三组患者的性别、年龄、体重、身高、术前pao2、fvc、fev1/fvc(%)、dlco、单肺通气时间、手术时间、血红蛋白含量、手术中补液量、术中尿量,差异均无统计学意义(p0.05)。2与a组比较,b组和c组患者的血气分析中ph值,动脉血二氧化碳分压(paco2),心率(hr),平均动脉压(mbp),中心静脉压(cvp)的差异没有统计学意义(p0.05)。3与a组比较,b组和c组患者的pao2和a-ado2差异有统计学意义(p0.05)。4与b组比较,c组患者的pao2和a-ado2的差异没有统计学意义(p0.05)。5a组的萎陷程度为100%,b组萎陷程度为80.2%,c组萎陷程度为72.2%,6 ABC三组开左胸侧肺萎陷程度的差异有统计学意义(P0.05)。7 ABC三组患者术后2天内声音嘶哑、咽痛的发生情况,和术后7天内肺部发生感染的情况无统计学意义(P0.05)。结论:行左开胸食管癌根治术时,术侧肺通过不同程度的膨胀,能够提高动脉氧分压,降低低氧血症等并发症,保证手术的顺利进行。左侧肺的萎陷分别为Ⅰ级萎陷100%~80.2%,Ⅱ级萎陷80.2%~72.2%,Ⅲ级萎陷低于72.2%。同时,肺萎陷程度在80.2%的情况下既不影响患者的血流动力学又不干扰手术操作。术后声音嘶哑、咽痛和肺部发生感染等并发症的发生率比双腔管低。
[Abstract]:Objective: during the operation of the left thoracic surgery for esophageal cancer, single lung ventilation was carried out under the bronchial plugging tube (BB). The evaluation method of Campos lung collapse and surgical field, [1] and the evaluation method of the pulmonary collapse and surgical field of the double lumen tube, [2], were used to calculate the percentage of the classification of the left thoracic lung collapse with the application of the bronchial occluder technique, so as to guide the clinical evaluation of the thoracotomy hands. Method: the degree of lung collapse in the side of the operation. The Campos classification is an assessment of the natural collapse of the lung. The sub lumen tube classification is a small tidal volume ventilation for the lateral lung. The operation field was satisfactorily exposed to the operation. The operation was not affected by the operation. The second stage of the lung was partly collapsed, and the operation field was exposed after intervention, but it did not affect the operation. After low tidal volume ventilation, after oxygen ventilation, according to the satisfaction of surgical field exposure and the evaluation of surgical operation, the classification was defined as a double lumen tube classification. 60 cases of esophageal cancer who were selected by the same group of surgeons from February 2016 to October 2016 were selected randomly, the weight was 49~80kg, and the height was 155~1. 75cm, all selected open left thoracic esophagus cancer radical operation.ASA grade I to grade I ~ II, before the operation electrocardiogram, echocardiography and lung function examination no abnormal, according to the lung function report, record the patient's estimated lung total, no upper respiratory tract infection, blood routine and biochemical examination no obvious abnormalities, previous body health, no systemic disease. According to the research needs The patients were divided into three groups: group A (n1=20), group B (n2=20) and C group (n3=20). The patients were sent to the operation room to perfect the three party check. The nurses in the operation room set up the peripheral liquid, 30min before cutting the skin, the amyl quetidine 1mg and midazolam 0.05mg/kg into the pot. The pulse oxygen saturation (SpO2) and electrocardiogram were recorded with IntelliVue MP50 monitor, and 2% lidocaine local anesthesia was followed. Invasive puncture, including deep vein and radial artery, CVP and ABP, arterial blood gas analysis before operation, 100% pure oxygen inhalation under mask, increased oxygen reserve, intravenous injection of sufentanil 0.2~0.4 mu g/kg, etomidate 0.2~0.3mg/kg, patients after falling asleep, followed by CIS atracurium 0.3mg/kg, assisted breathing and mask artificial ventilation 5min after 5min The same senior anaesthetized anesthesiologist inserted the single lumen tracheal tube of 7.5~8.0, fixed a single lumen tracheal tube, and then inserted the single lumen tube into the bronchial tube and placed the left main bronchus. First, the auscultation method was used to check the position of the closure of the trachea well, and then the bronchoscopy was used to determine the good position, and the airway was checked, and the airway situation was confirmed. Keep the bronchus blocked and double lung ventilation, control breathing with datex-ohmeda7100 respirator, airway pressure (pplat) and airway peak pressure (ppeak), end of the respiratory pressure (PetCO2). Intraoperative anesthesia was maintained by remifentanil - seven fluoroalkanes combined anesthesia, micro Reventa Ni (0.5~1, g/kg/min) and inhalation seven Halothane (1~3%) was injected into the chest with 0.05mg/kg. per half hour. The parameters of respiratory parameters were as follows: tidal volume (VT) 8ml/kg, respiratory frequency (f) 12 / sub, i:e 1:2. into the chest and the single lung ventilation mode, and the breathing parameters were set: the tidal volume was 6ml/kg, the respiratory rate was 15 times per cent, and the respiratory rate was completely collapsing in the left lung. After the operation, the oxygen (0.8) was injected into the aortic arch (0.8), and the group of C and the group of the group of B and C were divided into grade II and grade III (attached map) respectively, and the total gas injection (V1, V2) was recorded at this time, and the small tidal volume 1ml/kg was maintained. Meanwhile, the blood gas was recorded and the oxygen differential of alveolar artery (A-aDO2) was recorded. Arterial oxygen pressure (PaO2), carbon dioxide pressure (PaCO2) and three groups of invasive arterial pressure (ABP), central venous pressure (CVP), heart rate (HR) and pulse oxygen saturation (SpO2). The number of cases of hoarseness, sore pain within 2 days after operation, and cases of pulmonary infection within 7 days after the operation were recorded. Results: 1 basic cases: the sex, age, age, and sex of the three groups of patients. Weight, height, preoperative PaO2, FVC, fev1/fvc (%), DLCO, single lung ventilation time, operation time, hemoglobin content, fluid volume, intraoperative urine volume, difference were not statistically significant (P0.05).2 and a group, B and C group of patients with pH value, arterial carbon dioxide partial pressure (PaCO2), heart rate (HR), mean arterial pressure (HR), mean arterial pressure, central vein The difference of pressure (CVP) was not statistically significant (P0.05).3 and a, the difference between PaO2 and A-aDO2 in group B and C group was statistically significant (P0.05), and there was no significant difference between.4 and B group. There was no statistically significant difference between the C group and the B group. The degree of collapse of the group was 100%, the degree of collapse was 80.2%, the degree of collapse was 72.2%, and 6 of the three groups were open. The difference in the degree of left chest lateral lung collapse was statistically significant (P0.05) the hoarseness in the.7 ABC three group, the occurrence of sore throat within 2 days after operation, and the incidence of pulmonary infection within 7 days after the operation were not statistically significant (P0.05). Conclusion: during the radical operation of left open thoracic esophagus cancer, the operation of the lung through different degrees of expansion could improve the oxygen partial pressure of the artery, The complications such as hypoxemia and other complications were reduced to ensure the smooth operation. The left lung collapse was grade I 100%~80.2%, stage II collapsing 80.2%~72.2%, stage III depression lower than 72.2%., and the degree of lung collapse in the case of 80.2% did not affect the patient's hemodynamics without interfering with the operation. The incidence of complications, such as infection, is lower than that of the double lumen tube.

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R614;R735.1

【参考文献】