發(fā)布時(shí)間：2018-01-08 19:14

  本文關(guān)鍵詞：單肺通氣時(shí)輔助患側(cè)肺小潮氣量高頻率通氣模式在胸腔鏡肺葉切除術(shù)的應(yīng)用　出處：《青島大學(xué)》2017年博士論文　論文類(lèi)型：學(xué)位論文

  更多相關(guān)文章： 單肺通氣 患側(cè)肺 不同潮氣量 高頻率

【摘要】：目的:探討在單肺通氣時(shí)輔助患側(cè)肺小潮氣量高頻率通氣模式對(duì)胸腔鏡肺葉切除患者通氣功能及肺保護(hù)的效果。方法:1、選擇2014年12月1日~2016年5月1日在我院接受胸腔鏡肺葉切除術(shù)的早期非小細(xì)胞肺癌患者67例。采用數(shù)字隨機(jī)表法,將患者隨機(jī)分為:傳統(tǒng)單肺通氣組(CV組,n=33)與單肺通氣+患側(cè)肺小潮氣量高頻率通氣組(LV組,n=34)。(1)納入標(biāo)準(zhǔn):1、ASAⅠ~Ⅱ級(jí);2、術(shù)前行胸部增強(qiáng)CT、腹部B超、顱腦核磁共振、全身重要器官放射線(xiàn)檢查,未發(fā)現(xiàn)腫瘤轉(zhuǎn)移病灶;3、Karnofsky(卡氏功能狀態(tài))評(píng)分70分,未接受過(guò)手術(shù)和化療治療;4、無(wú)長(zhǎng)期大量吸煙史,心、肝、腎功能無(wú)異常。(2)排除標(biāo)準(zhǔn):1、術(shù)前肺功能檢查:第1秒用力肺活量占用力肺活量的百分比(FEV1.0/FCV%)50%;術(shù)前血氧飽和度低于93%;術(shù)前動(dòng)脈血氧分壓小于70mm Hg;動(dòng)脈血二氧化碳分壓大于50 mm Hg。2、術(shù)前心功能分級(jí)III級(jí)或Ⅳ的患者。3、有嚴(yán)重的心肺疾患及腦血管病史,合并肝腎功能損害,合并神經(jīng)精神系統(tǒng)疾病、老年性癡呆、心理疾病或活動(dòng)性肝病、患有嚴(yán)重視力或聽(tīng)力障礙無(wú)法與醫(yī)師進(jìn)行有效交流等。4、若術(shù)中輸血或單肺通氣時(shí)間1小時(shí),或手術(shù)時(shí)間4小時(shí)及術(shù)中需要全肺切除的。5術(shù)中不能耐受單肺通氣者。2、麻醉方法及通氣管理(1)術(shù)前準(zhǔn)備和麻醉過(guò)程麻醉前30min,肌注苯巴比妥鈉0.1g、鹽酸戊乙奎醚0.5mg�？筛鶕�(jù)患者身高體重和胸部后前位X光片的胸骨鎖骨端氣管橫徑選擇雙腔氣管導(dǎo)管(Double-lumen tubes,DLT)的型號(hào),氣管內(nèi)徑測(cè)量值大于19mm選擇41F雙腔氣管導(dǎo)管,大于17mm選擇39F,大于15mm選擇37F�；颊哌M(jìn)入手術(shù)室后,建立非手術(shù)側(cè)上肢靜脈通道輸注復(fù)方氯化鈉溶液,常規(guī)監(jiān)測(cè)心電(ECG)、血氧飽和度(Sp O_2)、心率(HR),麻醉深度(BIS),呼氣末二氧化碳?jí)毫?Pet CO_2),局部麻醉下行橈動(dòng)脈穿刺置管監(jiān)測(cè)有創(chuàng)血壓及采集動(dòng)脈血標(biāo)本。面罩通氣去氮充氧,依次靜脈注射咪達(dá)唑侖0.05~0.1mg/kg、舒芬太尼0.3ug/kg、維庫(kù)溴銨0.1 mg/kg,待患者意識(shí)消失、腦電雙頻指數(shù)(BIS)降至50時(shí)、肌松完善后,經(jīng)口明視下插入雙腔氣管導(dǎo)管(Sheridan,墨西哥)。氣管插管后經(jīng)纖維支氣管鏡(Fiberoptic bronchoscopy,FOB)調(diào)整確定導(dǎo)管位置,固定導(dǎo)管后連接麻醉呼吸機(jī)機(jī)械通氣。插管完成后經(jīng)右側(cè)頸內(nèi)靜脈穿刺置管監(jiān)測(cè)中心靜脈壓(CVP)。靜脈持續(xù)泵注丙泊酚3~8 mg·kg-1·h-1、瑞芬太尼0.2~0.4ug·kg-1·min-1,間斷追加維庫(kù)溴銨0.08 mg·kg-1·h-1維持麻醉,維持腦電雙頻指數(shù)(BIS)值40~50范圍。(2)通氣管理機(jī)械通氣采用Aestiva5/7900型麻醉機(jī)(Ohmeda,芬蘭)行間歇正壓通氣(IPPV),吸入氧濃度維持在(Fi O_2)100%,氧流量為1.5L/min。雙肺通氣時(shí),潮氣量(VT)7 ml/kg,通氣頻率12次/min,吸呼比1:1.5;根據(jù)手術(shù)需要實(shí)施單肺通氣(CV組)或單肺通氣+患側(cè)肺小潮氣量高頻率通氣(LV組)。CV組:VT 6 ml/kg,通氣頻率12次/min,吸呼比1:1.5;LV組:健側(cè)肺VT 6 ml/kg,通氣頻率12次/min,吸呼比1:1.5,同時(shí)患側(cè)支氣管導(dǎo)管接同一型號(hào)麻醉機(jī),給予VT 0.3~0.5 ml/kg,通氣頻率40次/min,吸呼比1:1.5。機(jī)械通氣期間,對(duì)于LV組,如果手術(shù)過(guò)程中通氣影響操作,可以暫停通氣,并調(diào)整通氣量。若術(shù)中單肺通氣過(guò)程中出現(xiàn)Sp O_293%,需調(diào)整通氣參數(shù)者,應(yīng)退出本次研究。(3)數(shù)據(jù)和標(biāo)本收集分別于單肺通氣前(T0)、單肺通氣30min(T_1)、單肺通氣60min(T_2)及雙肺通氣后5min(T_3)時(shí),采集動(dòng)脈血進(jìn)行血?dú)夥治?記錄Pa O_2,Pa CO_2并計(jì)算氧合指數(shù)(Pa O_2/Fi O_2)。在手術(shù)切除標(biāo)本后,由術(shù)者在遠(yuǎn)離病灶組織處,切取肺組織標(biāo)本,進(jìn)行蘇木精-伊紅染色,在顯微鏡下觀(guān)察肺間質(zhì)水腫、肺泡水腫、中性粒細(xì)胞浸潤(rùn)與肺泡內(nèi)充血嚴(yán)重程度,進(jìn)行肺損傷評(píng)分。結(jié)果:1.本次研究過(guò)程中有5例患者單肺通氣過(guò)程中出現(xiàn)Sp O_293%,經(jīng)過(guò)調(diào)整通氣參數(shù)或再次確定雙腔氣管導(dǎo)管位置后才得以糾正,其中CV組3例和LV組2例,均退出此次研究。另外LV組有2例患者在患側(cè)肺通氣時(shí)影響手術(shù)操作,調(diào)整通氣量后仍不滿(mǎn)意,退出本次研究。最終有60例患者完成本次應(yīng)用研究,CV組30例,LV組30例。2.CV組與LV組的單肺通氣時(shí)間、麻醉時(shí)間、術(shù)中補(bǔ)液量、尿量沒(méi)有顯著性差異。3.CV組和LV組患者的氧合指數(shù)呈先下降后上升的趨勢(shì),CV組氧合指數(shù)在T_2時(shí)達(dá)最小值,LV組患者的氧合指數(shù)在T_1時(shí)達(dá)最小值,T0時(shí)LV組氧合指數(shù)與CV組沒(méi)有顯著性差異,(p0.05);T_1、T_2及T_3時(shí),LV組患者氧合指數(shù)明顯高于CV組,(p0.05)。4.CV組和LV組患者的Pa CO_2呈先上升后下降的趨勢(shì),在T0和T_3時(shí),LV組患者的Pa CO_2與CV組沒(méi)有顯著性差異,(p0.05);單肺通氣T_1、T_2時(shí),LV組患者Pa CO_2明顯低于CV組,(p0.05)。5.LV組肺間質(zhì)水腫、肺泡水腫、中性粒細(xì)胞浸潤(rùn)與肺泡內(nèi)充血嚴(yán)重程度均較CV組輕,LV組肺損傷評(píng)分2.70±0.71顯著低于CV組的3.13±0.73(p0.05)。結(jié)論及意義:在胸腔鏡肺葉切除手術(shù)中應(yīng)用雙側(cè)肺不同潮氣量通氣模式,即單肺通氣時(shí)輔助患側(cè)肺小潮氣量高頻率通氣模式,既能滿(mǎn)足雙肺隔離的目的,又可增加患側(cè)肺氧合,減少了低氧血癥和高碳酸血癥,減輕單肺通氣時(shí)所造成的肺損傷程度,從而減少術(shù)后肺部并發(fā)癥的發(fā)生。雖然這種通氣模式偶爾會(huì)影響手術(shù)操作,但大部分情況下通過(guò)調(diào)整通氣量后手術(shù)都能順利完成。本次研究中患側(cè)肺高頻通氣僅僅設(shè)定了一個(gè)通氣頻率,以后還可以嘗試更多種的通氣頻率,觀(guān)察其通氣效果,另外此通氣模式的缺點(diǎn)是需要兩臺(tái)麻醉機(jī)支持,操作較麻煩,還需要未來(lái)進(jìn)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 緇，

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