急性A型主动脉夹层术后急性呼吸功能不全的治疗

目的:探讨急性A型主动脉夹层患者在深低温停循环(DHCA)下行主动脉替换手术后,急性呼吸功能不全(ARD)发生的临床特点及治疗策略。方法:2009年2月至2011年1月,急性A型主动脉夹层患者202例,在DHCA(鼻温降至22℃)下行主动脉弓替换。ARD定义为术后72 h内发生的低氧血症(PaO2/FiO2<150),除外术后心源性肺水肿、肺部感染、血/气胸等因素引起的低氧血症。27例患者术后发生ARD,发生率13.4%(27/202)。所有患者分为两组:ARD组和非ARD组,比较两组的临床特点。ARD诊断后立即采取①肺保护性通气;②膨肺;③提高心排量等综合治疗。结果:ARD组体质量指数和DHCA时间明显高于非ARD组(P<0.05)。27例ARD患者经治疗后,26例成功拔除气管插管,仅1例因机械通气时间>7 d行气管切开,术后20 d拔除气切套管出院。ARD平均持续时间3.2 d,住ICU时间(4.5±2.1)d,ARD组无医院死亡。结论:急性主动脉夹层术后早期ARD发生率为13.4%,肺保护性通气结合综合治疗策略对于急性A型主动脉夹层术后ARD有很好的疗效。

Acute respiratory dysfunction after surgery in patients with acute type A aortic dissection

Objective: To study the clinical impact of acute respiratory dysfunction(ARD) after surgery in patients with acute type A aortic dissection and to assess optional treatment options.Methods: Two hundred and two patients with type A aortic dissection received surgery under DHCA(nose temperasture below 22 degree) from February 2009 to January 2011.Postoperative ARD was diagnosed as hypoxia(PaO2/FiO2<150) that occurred within 72 h of surgery and was not related to cardiogenic pulmonary edema,pneumonia,pleural effusion,pneumothorax and so on.A total of 27 patients(27/202,13.4%) had postoperative ARD.Twenty-one occurred within 24 hours and six occurred within 48 hours.All patients were divided into two groups: ARD group and non-ARD group.Clinical characters between the two groups were compared.Lung protective ventilation was initiated in ARD group.Including protective ventilation,PEEP induced alveolar recruitment and other supportive therapy.Results: The body mass index and DHCA duration in ARD group were significantly higher than those in non-ARD group(P<0.05).26 patients were successfully weaned with lung protection ventilation.Tracheotomy was performed in one patient with prolonged ventilation(> 7 days).The patient was weaned in the 21st day after operation.The mean ARD duration was(3.2±2.4) d and ICU stay was(4.5±2.1) d.There was no hospital mortality in ARD group.Conclusion: The incidence of ARD after surgery in patients with acute type A aortic dissection was 13.4%.Lung protective ventilation combined with PEEP induced alveolar recruitment had good results in therapy of ARD after surgery in patients with acute type A aortic dissection.