术侧肺部分通气法与单肺通气的比较研究

Objective The purpose of this study was to compare oxygenation and airway pressure during partial ventilation of the independent lung( PLV) with one-lung ventilation(OLV). Methods 16 patients undergoing thoracotomy for esophageal carcinoma were randomized divided into two groups and a self -controlled cross -over study was used. Two types of ventilation was used in different sequence after two-lung ventilation(TLV), oxygenation index( OI) and airway pressure was compared between groups. Results OI was significantly lower during OLV and PLV than TLV, while it was significantly higher during PLV than OLV (PLV391±112, OLV134±53, TLV530±92,P<0.05). Airway pressure was also significantly lower during PLV than OLV[Ppeak: (19±3) cm H20 vs(27±5) cm H2O,Pplat: (17±2) cm H2O vs (23±3) cm H20, P<0.05 ]. Conclusion PLV significantly improve oxygenation and respiratory mechanics.     

术侧肺部分通气法与单肺通气的比较研究

目的 与单肺通气(one-lung ventilation,OLV)比较术侧肺部分通气(partial ventilation of independent lung,PLV)情况下的氧合与气道压力.方法 16例接受食道手术的患者随机分为两组,进行自身对照交叉研究.在双肺通气后按不同顺序接受OLV和术侧肺PLV,比较3种通气时氧合指数(oxygen index,OI)及气道压力的变化.结果 两种通气方式下OI均显著低于双肺通气(two-lung ventilation,TLV),但PLV时显著高于OLV(PLV391±112,OLV134±53,TLV530±92,P<0.05);气道压力值在PLV时也显著低于OLV[Ppeak:(19±3)cm H2O vs(27±5)cm H2O,Pplat:(17±2)cm H2O vs(23±3)cm H2O,P<0.05](1 cm H2O=0.098 kPa). 结论PLV显著改善了氧合和呼吸力学指标.     

单肺通气吸入不同氧分量对兔肺组织NF-κB的影响

Objective To study the effects of fraction of inspired oxygen on nuclear factor-κB (NF-κB) of lung tissue in rabbit one-lung ventilation(OLV) models.Methods 12 white Japanese rabbits were randomly divided into 2 groups(n=6).Bronchial intubation was performed with artificial double-lumen tube,and right OLV was conducted for 2 h and then tollowed tow-lung ventilation(TLV) for 1 h.Fraction of inspired oxygen was set as 1.0(group A) or 0.6(group B).NF-κB in lung tissue was detected,and arterial blood gases were analyzed before OLV,at 30 min of OLV and 30 min after TLV reversion.Pathology of lung tissue was examined and wet/dry(W/D) of lung weight was measured.Results After TLV restore,the oxygenation index was higher and lower than 300 in group B and group A,respectively.The W/D,the activation and the level of NF-κB in left lung tissue was less in group B than in group A (P＜0.01),and pathological change in left lung tissue was lighter in group B than in group A.Conclusion OLV with 60% oxygen may attenuate lung injury by decreasing the activation and the level of NF-κB in lung tissue.     

压力和容量通气模式对肥胖患者腹腔镜手术中呼吸功能的影响

Objective To investigate the effects of pressure -controlled ventilation (PCV) and volume -controlled ventilation (VCV) on obese patients undergoing gynecologic laparoscopic surgery by evaluating hemodynamics and respiratory parameters, and arterial oxygenation. Methods Forty obese patients undergoing gynecological laparoscopic surgery were randomly divided into PCV and VCV group (n=20). Patients were all implemented into the program of total intravenous anesthesia, and ventilated with different modes.End-tidal carbon dioxide partial pressure (PETCO2) was maintained between(35-45 ) mm Hg. Arterial blood was collected respectively to analyze blood gas at 5 min before anesthesia (T0), 5 min before the start of pneumoperitoneum (T1),30 min after the start of pneumoperitoneum(T2), 5 min after the end of pneumoperitoneum(T3) and at extubation(T4). Meanwhile, parameters of hemodynamics and respiratory mechanics were monitored and calculated. Results 1 、At T1,T2 and T3, PaO2 and OI (460±78,453±83,463±95)were significantly higher in PCV group (P<0.05), A-aDO2(74±25,80±30,82±26) and RI (0.32±0.08,0.33±0. 10,0.34±0.13 ) was significantly lower (P<0.05) in PCV group. 2. Compared with T0, PaCO2 at T2,T3,T4 in both groups increased significantly and PH decreased significantly (P<0.05); Compared with VCV group, PCV group had no significant difference at each time point. 3. Compared with VCV group, Ppeak(27.8±1.6)in PCV group at T2 was significantly lower(P<0.05). Conclusion The ventilation/perfusion ratio was improved and gas exchange was promoted in obese patients undergoing gynecologic laparoscopic surgery with PCV model.     

氨溴索预先给药对单肺通气患者炎性反应及脂质过氧化反应的影响

Objective To investigate the effect of ambroxol pretreatment on the inflammatory response and lipid peroxidation during one-lung ventilation (OLV) .Methods Forty-five ASA I or II patients aged 37-64 yr weighing 53-65 kg undergoing thoracotomy under general anesthesia were randomly divided into 3 groups ( n = 15 each): group A two-lung ventilation (TLV); group B OLV and group C ambroxol 1 mg/kg + OLV. Anesthesia was induced with midazolam, fentanyl, propofol and atracurium and maintained with propofol infusion and intermittent iv boluses of fentanyl and atracurium. The patients were mechanically ventilated (VT8-10 ml/kg, RR 12 bpm during TLV, VT 6-7 ml/kg, RR 16 bpm during OLV, I: E 1:2, FiO2 100% ). In group C ambroxol 1 mg/kg in normal saline ( NS) 100 ml was infused at 25 min before OLV (infusion rate 4 ml/min) , while in group A and B equal volume of NS was infused instead of ambroxol. Blood samples were obtained from radial artery before induction of anesthesia and OLV (T0.1 ) and at 0.5, 1, 2 h of OLV (T2-4 ) and 1, 2 h of TLV (T5,6 ) and at 24 h after operation (T7) in group B and C for determination of serum SOD activity and TNF-α, IL-6 and IL-8 concentrations and WBC and neutrophil granulocyte counts. The same indexes were detected in group A at the corresponding time points.Results Serum SOD activity was significantly lower and serum TNF-α, IL-6 and IL-8 concentrations and WBC and neutrophil granulocyte counts were significantly higher in group B than in group A. Serum SOD activity was significantly higher and serum TNF-a, IL-6 and IL-8 concentrations and WBC and neutrophil granulocyte counts were significantly lower in group C than in group B. Conclusion Pretreatment with ambroxol 1 mg/kg can inhibit inflammatory response and lipid peroxidation during OLV.     

氨溴索预先给药对单肺通气患者炎性反应及脂质过氧化反应的影响

Objective To investigate the effect of ambroxol pretreatment on the inflammatory response and lipid peroxidation during one-lung ventilation (OLV) .Methods Forty-five ASA I or II patients aged 37-64 yr weighing 53-65 kg undergoing thoracotomy under general anesthesia were randomly divided into 3 groups ( n = 15 each): group A two-lung ventilation (TLV); group B OLV and group C ambroxol 1 mg/kg + OLV. Anesthesia was induced with midazolam, fentanyl, propofol and atracurium and maintained with propofol infusion and intermittent iv boluses of fentanyl and atracurium. The patients were mechanically ventilated (VT8-10 ml/kg, RR 12 bpm during TLV, VT 6-7 ml/kg, RR 16 bpm during OLV, I: E 1:2, FiO2 100% ). In group C ambroxol 1 mg/kg in normal saline ( NS) 100 ml was infused at 25 min before OLV (infusion rate 4 ml/min) , while in group A and B equal volume of NS was infused instead of ambroxol. Blood samples were obtained from radial artery before induction of anesthesia and OLV (T0.1 ) and at 0.5, 1, 2 h of OLV (T2-4 ) and 1, 2 h of TLV (T5,6 ) and at 24 h after operation (T7) in group B and C for determination of serum SOD activity and TNF-α, IL-6 and IL-8 concentrations and WBC and neutrophil granulocyte counts. The same indexes were detected in group A at the corresponding time points.Results Serum SOD activity was significantly lower and serum TNF-α, IL-6 and IL-8 concentrations and WBC and neutrophil granulocyte counts were significantly higher in group B than in group A. Serum SOD activity was significantly higher and serum TNF-a, IL-6 and IL-8 concentrations and WBC and neutrophil granulocyte counts were significantly lower in group C than in group B. Conclusion Pretreatment with ambroxol 1 mg/kg can inhibit inflammatory response and lipid peroxidation during OLV.     

单肺通气诱发兔急性肺损伤模型的建立

目的 建立单肺通气诱发兔急性肺损伤模型.方法 清洁级健康新西兰白兔16只,体重2.3～2.7 kg,采用随机数字表法,将兔随机分为VT 6 ml/kg组(Ⅰ组)和VT 12 ml/kg组(Ⅱ组),每组8只.气管切开插入单腔气管导管行右侧单肺通气,Ⅰ组和Ⅱ组VT分别为6、12 ml/kg,余通气参数均为FiO2 50%.通气频率40次/min,I∶E为1∶2.于单肺通气前即刻(T0)、单肺通气1、2、3 h(T1-3)时记录气道峰压,采集动脉血行血气分析,计算氧合指数;于单肺通气3 h时处死动物,取肺组织,观察病理学结果,行肺损伤评分,计算肺湿/干重比,测定左、右支气管肺泡灌洗液蛋白浓度,计数中性粒细胞.结果 与T0时比较,Ⅱ组T1～3,时气道峰压升高,两组T2,3时氧合指数降低(P＜0.05);与左肺比较,两组右肺湿/干重比和肺损伤评分降低(P＜0.05);与Ⅰ组比较,Ⅱ组T1～3,时气道峰压升高,T3时氧合指数降低,右肺湿/干重比、支气管肺泡灌洗液蛋白浓度、中性粒细胞计数及肺损伤评分升高(P＜0.05).结论 采用VT 12 ml/kg单肺通气3 h成功建立了兔急性肺损伤模型.

Abstract：

Objective To establish a rabbit model of acute lung injury induced by one-lung ventilation (OLV) .Methods Sixteen New Zealand white rabbits weighing 2.3-2.7 kg were randomly divided into 2 groups (n=8 each):conventional tidal volume(VT) group (group Ⅰ) and high VT group (group Ⅱ).All the rabbits were tracheostomized and a tracheal tube was inserted into the right bronchus for right lung ventilation in the two groups. VT was set at 6 ml/kg in group Ⅰ and at 12 ml/kg in group Ⅱ and the other ventilatory parameters were the same in the two groups (FiO2 50% , RR 40 bpm, I∶E=1∶2). Immediately before OLV(T0) and at 1, 2 and 3 h of OLV (T1-3), peak airway pressure was measured and arterial blood samples were taken for blood gas analysis and oxygenation index (OI) was calculated. The animals were sacrificed at 3 h of OLV and lung tissues obtained for microscopic examination.The lung injury was scored. W/D lung weight ratio was calculated. Bron-choalveolar lavage fluid (BALF) was collected for measurement of protein concentrations and neutrophil counts. Results The peak airway pressure was significantly higher at T1-3 in group Ⅱ and OI was significantly lower at T2,3 in the two groups than those at T0(P＜0.05) .W/D lung weight ratio and lung injury scores of the right lung were significantly lower than those of the left lung in the two groups(P＜0.05).The peak airway pressure was significantly higher at T1-3, OI was significantly lower at T3, and W/D lung weight ratio, protein concentrations and neutrophil counts in BALF and lung injury scores of the right lung were significantly higher in group Ⅱ than in group Ⅰ(P＜0.05). Conclusion OLV with VT of 12 ml/kg for 3 h can successfully establish a rabbit model of acute lung injury.     

Supreme喉罩用于腹腔镜手术患者气道管理的效果

Objective To assess the efficacy of laryngeal mask airway Supreme (LMA Supreme) used in patients undergoing laparoscopic surgery. Methods One hundred and twenty ASA I or Ⅱ patients of both sexes aged 35-60 yr weighing 48-85 kg undergoing elective laparoscopic surgery were randomized to 2 groups ( n = 60 each): LMA Supreme group (group S) and tracheal intubation group (group T). Mallampati test was performed before operation in both groups. The patients were classified as I - Ⅲ . In group S the LMA Supreme was inserted after induction of anesthesia with sufentanil 0.2 fig/kg, propofol 2-3 mg/kg and vecuronium 0.1 mg/kg. A gastric tube was inserted through the drain tube of the LMA Supreme. In group T the patients were intubated under direct laryngoscopy. The success rate, LMA placement/intubation time, success rate of gastric tube placement, airway seal pressure, SpO2, PETCO2 , peak airway pressure and complications (hypoxemia, nausea and vomiting, choking hoarseness, sore throat and regurgitation of gastric contents) were recorded. The duration of surgery, anesthesia time, extubation time and emergence time were also recorded. Results There was no significant difference in the success rate between the two groups. The placement and removal time and recovery time were significantly shorter in group S than in group T. The airway seal pressure was (25 ±4) cm H2O in group S. SpO2, PETCO2 and peak pressure were within normal range in both groups. The incidence of postoperative hypoxemia, choking and sore throat were significantly lower in group S than in group T. Conclusion LMA Supreme can provide adequate ventilation during operation with less complications and can be used effectively for laparoscopic surgery.     

Supreme喉罩用于腹腔镜手术患者气道管理的效果

Objective To assess the efficacy of laryngeal mask airway Supreme (LMA Supreme) used in patients undergoing laparoscopic surgery. Methods One hundred and twenty ASA I or Ⅱ patients of both sexes aged 35-60 yr weighing 48-85 kg undergoing elective laparoscopic surgery were randomized to 2 groups ( n = 60 each): LMA Supreme group (group S) and tracheal intubation group (group T). Mallampati test was performed before operation in both groups. The patients were classified as I - Ⅲ . In group S the LMA Supreme was inserted after induction of anesthesia with sufentanil 0.2 fig/kg, propofol 2-3 mg/kg and vecuronium 0.1 mg/kg. A gastric tube was inserted through the drain tube of the LMA Supreme. In group T the patients were intubated under direct laryngoscopy. The success rate, LMA placement/intubation time, success rate of gastric tube placement, airway seal pressure, SpO2, PETCO2 , peak airway pressure and complications (hypoxemia, nausea and vomiting, choking hoarseness, sore throat and regurgitation of gastric contents) were recorded. The duration of surgery, anesthesia time, extubation time and emergence time were also recorded. Results There was no significant difference in the success rate between the two groups. The placement and removal time and recovery time were significantly shorter in group S than in group T. The airway seal pressure was (25 ±4) cm H2O in group S. SpO2, PETCO2 and peak pressure were within normal range in both groups. The incidence of postoperative hypoxemia, choking and sore throat were significantly lower in group S than in group T. Conclusion LMA Supreme can provide adequate ventilation during operation with less complications and can be used effectively for laparoscopic surgery.     

单肺通气时机械通气模式的研究进展

背景 单肺通气(one lung ventilation,OLV)实施过程中最常见的并发症是低氧血症,也是麻醉医师遇到的最严重的挑战. 目的 近来研究表明OLV本身能够引起低氧血症和急性肺损伤(acute lung injury,ALI).因此,如何实施OLV时机械通气模式,降低肺内分流率(pulmonary shunt fraction,Qs/Qt)、预防低氧血症一直是临床研究的热点. 内容 综述提高吸入氧分数(fraction of inspiration O2,FiO2)、控制通气模式、高频通气(high frequency ventilation,HFV)、潮气量(tidal volume,Vt)、反比通气、部分液体通气(partial liquid ventilation,PLV)、持续气道正压通气(continuous positive airway pressure,CPAP)、呼气末正压通气(positive end-expiratory pressure,PEEP)等通气模式,以及实施联合多种模式的保护性肺通气策略. 趋向 综合运用多种预防OLV期间低氧血症的通气模式取得良好的效果,但应针对患者和手术情况制定OLV时机械通气模式.     

肥胖患者单肺通气期间的通气策略

背景 肥胖人群比例不断升高,肥胖影响正常生理功能,给麻醉带来不少问题,尤其在单肺通气(one-lung ventilation,OLV)过程中. 目的 减少肥胖患者OLV过程对预后转归的影响,降低肥胖患者围手术期呼吸系统并发症的发生率. 内容 探讨肥胖患者围手术期OLV期间的通气策略,包括通气模式的选择、保护性通气策略、高碳酸血症、肺泡复张策略和吸氧浓度的选择. 趋向 肥胖患者OLV期间采用小潮气量联合呼气末正压通气(positive end-expiratory pressure, PEEP)、间断肺泡复张和低到中度Fi02等通气策略有助于改善氧合、降低肺不张发生率,高碳酸血症在无肺部疾病患者中是否具有肺保护作用尚待研究.     

One-lung ventilation

We applied positive end expiratory pressure to the nondependent, nonventilated lung, or both nondependent and dependent, ventilated lung during one lung anaesthesia, and compared the results to those obtained by other techniques, such as increasing the inspired oxygen concentration in the dependent lung, or insufflating with oxygen using positive end expiratory pressure in the nondependent lung. Our study suggests that arterial oxygenation and intrapulmonary shunt can be lessened during one lung ventilation by continuous oxygen insufflation of the nondependent lung at 0.98 kPa positive end expiratory pressure while the dependent lung is ventilated with 0.49 kPa positive end expiratory pressure.     

High-frequency ventilation

High-frequency ventilators (HFV) use increased respiratory rates and decreased tidal volumes to achieve gas exchange similar to conventional mechanical ventilators (CMV). This reverses the relative importance of convection and diffusion to gas exchange. There are currently 3 major types of HFV. They differ from each other in how gas is delivered, how they work, and what physiological effects they have. Conclusions drawn using one type of HFV cannot necessarily be applied to the others. This review examines the different types of HFV as well as the studies that have been conducted using HFV. It stresses the role that HFV may play in the surgical intensive care unit. The one certain indication presently for HFV is in patients with a bronchopleural fistula. It may also be useful as an adjunct to endoscopy and in adult respiratory distress syndrome (ARDS). If the underlying lung disease cannot be reversed (i.e., end-stage fibrotic ARDS), HFV has little to offer.

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Resumen Los ventiladores de alta frecuencia (VAF) utilizan elevadas frecuencias respiratorias y bajos volúmenes corrientes para lograr un intercambio gaseoso similar al que producen los ventiladores mecánicos convencionales (VMC), lo cual revierte la importancia relativa de la convección y la difusión en el intercambio gaseoso. Actualmente existen 3 tipos principales de VAF. Estos se diferencian en cuanto a la manera como se administra el gas, a la manera como funcionan, y a los efectos fisiológicos que producen. Las conclusiones que puedan derivarse del uso de un tipo determinado de VAF no necesariamente pueden ser aplicadas a los otros. La presente revisión hace un examen de los diferentes tipos de VAF y de los estudios realizados con el uso de VAF, y hace énfasis en el papel que los VAF pueden jugar en la unidad de cuidado intensivo quirúrgico. La indicatión más clara para VAF es la fistula broncopleural. También pueden ser útiles como adyuvantes en endoscopia y en el síndrome de dificultad respiratoria del adulto (SDRA). Si la conditión del pulmón afectado es irreversible (por ejemplo en la fase terminal fibrótica del SDRA), los VAF tienen muy poco que ofrecer.

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Résumé L'emploi de ventilateurs à haute fréquence (HFV) repose sur l'augmentation de la fréquence respiratoire et la diminution des volumes du flux gazeux qui permettent d'obtenir des échanges gazeux similaires à ceux fournis par les ventilateurs mécaniques conventionnels (CMV). Ceci inverse l'importance relative de la convection et de la diffusion des échanges gazeux. Trois types de ventilateurs à haute fréquence sont actuellement disponibles. Ils sont différents les uns des autres en ce qui concerne la manière dont le gaz est distribué, la façon dont ils travaillent, les effets physiologiques qu'ils entrainent. Les conclusions tirées de l'emploi de l'un d'eux ne peuvent s'appliquer nécessairement aux autres. Cet article est consacré à l'étude des différents types de ventilateurs à haute fréquence ainsi qu'aux travaux dont ils ont été l'objet. Il souligne le rôle que peut jouer le ventilateur à haute fréquence dans une unité de soins intensifs. L'indication élective de l'emploi de ce type de ventilateur est la fistule broncho-pleurale. Il peut jouer un rôle complémentaire au cours de l'endoscopie et du syndrome de détresse respiratoire de l'adulte. En revanche si la maladie pulmonaire est irréversible (le stade terminal du syndrome précité: la fibröse) il est de peu d'efficacité.