肺隔离症手术的麻醉处理

目的回顾分析肺隔离症手术患者麻醉管理应注意的问题.方法10例左下肺隔离症患者ASAⅠ～Ⅱ级,气管内麻醉下行隔离肺切除术.其中4例选择单腔支气管导管（Mallinckrodt）,6例选择双腔支气管导管（Robertshaw）.术中监测BP、HR、ECG、Paw和SpO2,采取单肺通气.结果术中证实叶外型肺隔离症4例,叶内型肺隔离症6例,行隔离肺肿块或左下肺叶切除术.手术时间2.5～9 h,术中出血量300～1 700 ml.9例患者手术麻醉过程顺利,术后7～10 d康复出院.1例患者术中因出血导致急性气道梗阻和较长时间（6 min）严重低氧血症,术后4 d因多脏器功能衰竭死亡.结论肺隔离症手术患者麻醉前准备、双腔支气管导管的正确使用、单肺通气技术、手术者与麻醉医师间密切配合等诸多因素是确保手术成功的关键.     

改良型Carlens双腔导管在单肺通气时的应用

目的 对改良型Carlens双腔导管与左置Robertshaw双腔导管在单肺通气时的应用进行评价.方法 选择ASA Ⅰ或Ⅱ级术中需行单肺通气的成年患者60例,随机分为改良型Carlens双腔导管组(C组)和左置Robertshaw双腔导管组(R组),每组30例.观察两组患者插管定位时间、盲插成功率、气道峰压增加率、导管移位率、需行纤支镜(FOB)再检查次数及术野暴露情况.结果 C组盲插成功率明显高于R组(P<0.05),导管移位率和需行纤支镜再检查次数明显少于R组(P<0.05),术野暴露情况优于R组(P<0.05).结论 改良型Carlens双腔导管应用于单肺通气方便、快捷,肓插成功率高,其效果可能优于左置Robertshaw双腔导管.     

以气道阻(压)力判断Robertshaw双腔导管插管对位305例临床观察

目的 探讨以气道阻力判断Robertshaw双腔支气管导管插管深度及对位正确与否的可行性.方法 随机选择305例剖胸手术患者,静脉快速诱导后,经口腔插入Robertshaw左双腔支气管导管至遇阻力为止.如左、右单肺通气阻力均高,则在右侧单肺通气状态下,逐渐后退双腔支气管导管至气道阻力开始下降,在此导管深度继续后退1.5cm固定导管.如无病理因素,气道阻力在12～20cm H2O范围.观察左、右单肺通气时气道阻力;双肺通气后20min及单肺通气20min分别行动脉血气分析并比较;随机对其中100例应用纤维支气管镜观察导管对位状况.结果 肺部病变患者,患肺通气气道阻力比健侧肺通气时明显增高(P<0.01);食管纵隔病变患者,左肺通气时气道阻力比右肺通气时气道阻力增高(P<0.05);插管后纤维支气管镜检左、右侧导管开口距左肺上叶支气管开口及隆凸距离分别为(1.18±0.28)cm、(2.16±0.34)cm;305例患者双肺通气20min后健侧单肺通气20min后血气分析结果均在正常范围.结论 以气道阻力判断Robertshaw双腔支气管导管插管对位是否正确,方法简捷、实用可行,可供临床参考.     

右肺下叶切除术中癌栓脱落阻塞气道一例

患者,男,52岁,体重58kg。因反复咳痰1年,咯血伴右侧胸痛半年入院纤维支气管镜检查诊断为右下叶支气管息肉样新生物。拟行右肺下叶切除术麻醉诱导后,插入39Fr左双腔支气管导管,听诊双肺呼吸音分隔、对位良好。左侧卧位下行右侧开胸,开胸后改左侧单肺通气机控呼吸,潮气量8ml/kg,呼吸频率16/min,气道压19cmH2O,SpO2维持在100%,单肺通气历时1h。在使用支气管残端闭合器切除右中、下肺叶,检查支气管残端有无漏气时,发现导管右侧支气管腔完全堵塞,吸痰管不能通过将双腔管退至总气管,右肺上叶膨胀良好,行双肺通气。约10min后脉搏、氧饱和度不明原…     

Coopdech封堵支气管导管与双腔支气管导管单肺通气效果的比较

单肺通气可通过双腔支气管导管(双腔管)技术和支气管堵塞技术来实现.双腔管的有效管腔小、病人术后不易耐受、插管较困难等不利因素,使其应用受限[1].Coopdech封堵支气管导管(Coopdech管)是支气管堵塞导管的一种,通过普通单腔气管导管插入,具有插管容易、定位简单、有效管腔大的特点.本研究拟比较Coopdech封堵支气管导管和双腔支气管导管用于单肺通气的效果.     

双肺移植术后支气管吻合口狭窄的治疗体会

目的 总结肺移植术后支气管吻合口狭窄的治疗经验。方法 1例接受双肺移植术的患者术后发生双侧支气管吻合口粘膜坏死和狭窄。经过13个月的球囊导管扩张（22次）和激光烧灼治疗（5次），效果不显著，术后11个月。在使用异丙酚的情况下结合局部麻醉行硬气管镜治疗，用不同口径的中金属空圆柱管做扩张器，左侧治疗2次，右侧治疗3次。结果 左侧支气管吻合口直径维持在8-10mm，以后未再扩张，右侧扩张效果差，右上支气管开口闭死，右中间干虽能勉强扩开，但造影证实其远端以下支气管管腔闭死，后因右肺的反复炎症，不得已行右全肺切除，切下的右肺及支气管壁均有结核病变。现患者一般情况尚可，生活自理。结论 肺移植术后的支气管吻合口狭窄与术后支气管缺血，大剂量使用激素和结核感染有关，应早期在神志镇静，局部麻醉下通过气管镜对狭窄进行治疗，中空金属圆柱状扩张器的效果优于单纯的球囊扩张。     

双腔支气管导管选择

肺隔离术是胸外科手术常用的呼吸管理方法,其将左、右两侧肺通气径路分隔开,可选择性进行单肺通气,防止病侧肺的血、痰液流人健侧,同时术侧肺萎缩可为术者提供良好的暴露。随着医学的进步,支气管肺灌洗术、现代微创胸部外科、肺移植术均要求能有效地实施单肺通气。肺隔离方法包括支气管堵塞、单腔支气管导管、Univent管、双腔支气管导管（以下简称双腔管）等。这些方法中,双腔支气管插管操作简单,双侧气道的可控性强,仍是目前实施单肺通气的主要方法。     

单肺通气时应用Arndt支气管阻塞导管的评价

胸外科手术中进行双肺隔离时需要单肺通气.双腔支气管导管广泛应用于单肺通气,但由于其外径较粗,型号有限,仅适用于成年人,且困难气道病人插管成功率低;对于气管切开、张口困难或需经鼻气管插管的病人无法放置双腔支气管导管;术后需要长期机械通气的病人,必须更换为单腔支气管导管(单腔管).     

45例单侧毁损肺外科治疗

目的总结单侧毁损肺的外科治疗经验。方法回顾性分析我科1984年至2005年45例单侧毁损肺行全肺切除术患者。结果手术失血800~6 500 ml,其中1 000 ml以上32例(71.1%),3 000 ml以上14例(31.1%),治愈45例(100%),无死亡病例。术后发生并发症6例(13.3%)。结论全肺切除治疗单侧毁损肺能够取得较好的外科治疗效果,但要把握手术指征,小心游离肺,处理好肺门,积极治疗并发症。     

单肺通气技术的研究现状

单肺通气技术主要有3种：单腔支气管导管通气，双腔支气管导管通气和支气管阻塞导管通气。单腔支气管导管目前已很少采用。双腔支气管导管由于具有插管操作相对耗时较短，常规操作不需要使用纤支镜，肺的萎陷速度较快的优点，为目前单肺通气的首选，但由于其外径较粗，支气管定位复杂，困难气道病人插管成功率低，术后需要长期通气的病人需更换导管等缺点，在一定程度上限制了其使用范围。支气管阻塞导管是一种新型的单肺通气技术，目前主要有四种导管可供临床使用，Univent导管和Cook导管在胸科手术应用较多。Cook导管具有可用于儿童，困难气道插管成功率高，术后不需更换导管及可实现CPAP通气模式等优点，和需要用纤支镜辅助，肺萎陷时间长，容易移位等缺点。双腔管和支气管阻塞导管优势互补，各自在其擅长的领域里发挥作用。     

Lung isolation during port-access cardiac surgery: double-lumen endotracheal tube versus single-lumen endotracheal tube with a bronchial blocker

OBJECTIVE: The purpose of this study was to compare the use of a double-lumen endotracheal tube to a single-lumen tube combined with a bronchial blocker for lung isolation during Port-Access cardiac surgery. DESIGN: Prospective, randomized, controlled trial. SETTING: Tertiary care university hospital. PARTICIPANTS: Thirty-two patients undergoing Port-Access cardiac surgery via a right minithoracotomy. INTERVENTIONS: Patients were randomized to intubation with either a left-sided double-lumen tube (double-lumen group) or a single-lumen tube with concomitant use of a bronchial blocker (blocker group). Comparisons between groups included (1) intubation time, (2) number of laryngoscopy attempts, (3) time required for tube exchange at the end of the operation, and (4) surgical satisfaction with the lung deflation (1-5 scale: 5 = excellent). MEASUREMENTS AND MAIN RESULTS: The initial intubation time was similar between groups (118 +/- 82 seconds, double-lumen v 144 +/- 32 seconds, blocker; p = 0.2781). An additional 105 +/- 37 seconds was needed to exchange the double-lumen tube at the end of the operation. The double-lumen group also required more laryngoscopy attempts compared with the blocker group (2.3 +/- 0.6, double-lumen v 1.1 +/- 0.4, blocker; p = 0.0001). The lung deflation was better in the double-lumen group (5 [4-5], double-lumen v 4 [3-5], blocker, p = 0.0414). CONCLUSIONS: Compared with a single-lumen tube/bronchial blocker combination the double-lumen endotracheal tube required more laryngoscopy attempts and additional time to replace the tube at the end of the case but resulted in slightly better overall lung deflation.     

Differential changes of alveolar gas concentrations during anesthetic induction of a patient with an absent right pulmonary artery

A 38-yr-old man with congenital right pulmonary artery agenesis, whose right lung was perfused with collateral systemic arterial blood, presented for right pneumonectomy. Because of a likely difference in gas exchange between the two lungs, we sampled end-tidal gases from each lung individually, as well as from the common gas outlet of a double-lumen endobronchial tube. Our results indicated a higher end-tidal CO2 from the left, normally perfused, lung than from the right, systemically perfused, lung. We also determined uptake of sevoflurane from each lung, demonstrating a more rapid uptake in the left lung than in the right. In conclusion, we report the rare case of unilateral pulmonary artery agenesis with systemic arterial collateralization and characterize the differences in gas exchange.     

Ein-Lungenventilation bei einem nasal intubierten Patienten mit Hilfe eines einlumigen Endobronchialtubus

We report the case of a 57-year-old patient who underwent a right-sided thoracotomy. The preoperative examination of the patient already revealed a clear diminution of the mouth opening (Mallampati class 4). Ventilation per mask following the induction of anaesthesia was unproblematic. As oral intubation with a double-lumen tube seemed to be impossible because of the difficult anatomic conditions, nasal intubation was carried out. For this we used a left-sided single-lumen endobronchial tube of Rüsch (size 8.0). The tube was inserted into the left mainstem bronchus using a fiberoptic bronchoscope. Intraoperatively we were able to ventilate exclusively the dependent left lung by inflating the bronchial cuff. The operation itself was performed on the collapsed right lung. At the end of the operation the right lung could be ventilated once again by deflating the bronchial cuff (tracheal cuff inflated). This example demonstrates that one-lung ventilation is possible even under difficult intubation conditions.     

Coopdech封堵支气管导管联合加强型气管导管用于上纵隔肿瘤切除术患者气道管理的效果

目的 评价Coopdech封堵支气管导管联合加强型气管导管用于上纵隔肿瘤切除术患者气道管理的效果.方法 拟经前外侧开胸行上纵隔肿瘤切除术患者22例,年龄24～66岁,体重48～78 kg,ASA分级Ⅱ或Ⅲ级,采用随机数字表法,将患者随机分为双腔支气管导管组(Ⅰ组)和Coopdech封堵支气管导管联合加强型气管导管组(Ⅱ组),每组11例.Ⅰ组术中采用双腔支气管导管技术行单肺通气;Ⅱ组采用Coopdech封堵支气管导管联合加强型气管导管进行气道管理,需单肺通气时可应用Coopdech封堵支气管导管进行肺隔离.两组均应用纤维支气管镜辅助气管内导管定位.记录气管插管时间、定位时间、导管移位情况、纤维支气管镜检查次数、气道峰压增加情况、肺萎陷程度、术后咽痛声嘶的发生情况、呼吸机辅助通气情况.结果 与Ⅰ组比较,Ⅱ组气管插管时间缩短,导管移位的发生率、气道峰压增加率和术后咽痛声嘶发生率降低(P＜0.05或0.01),定位时间、纤维支气管镜检查次数、肺萎陷程度及术后呼吸机辅助通气发生率差异无统计学意义(P＞0.05).结论 Coopdech封堵支气管导管联合加强型气管导管用于前外侧开胸行上纵隔肿瘤切除术患者气道管理的效果优于双腔支气管导管.

Abstract：

Objective To evaluate the efficacy of Coopdech bronchial blocker combined with a strengthened single-lumen tube for airway management in patients undergoing upper mediastinal tumor resection. Methods Twenty-two ASA Ⅱ or Ⅲ patients, aged 24-66 yr, weighing 48-78 kg, scheduled for elective resection of upper mediastinal tumor, were randomly divided into 2 groups (n=11 each):double-lumen tube group(groupⅠ) and Coopdech bronchial blocker combined with a strengthened single-lumen tube group(group Ⅱ).One-lung ventilation was achieved with a double-lumen tube in groupⅠ. The Coopdech bronchial blocker combined with a strengthened single-lumen tube was used for airway management and the Coopdech bronchial blocker was used for lung isolation when one-lung ventilation was required in group Ⅱ. The fiberoptic bronchoscope was used to assist endotracheal tube positioning in both groups. The intubation time, positioning time, the number of patients required for tube displacement, the number of fiberoptic bronchoscopy, increase in airway peak pressure, degree of lung collapse, postoperative sore throat and hoarseness, and the number of patients needing ventilator-assisted ventilation were recorded. Results The intubation time was significantly shorter, the number of patients required for tube displacement was significantly smaller,and the rate of increase in airway peak pressure and incidences ofpostoperative sore throat and hoarseness were significantly lower in group Ⅱ than in group Ⅰ (P＜0.05 or0.01). Conclusion The efficacy of the Coopdech bronchial blocker combined with a strengthened single-lumen tube for airway management is better in patients undergoing upper mediastinal tumor resection than the double-lumen tube.     

Right bronchial intubation using a left-sided double-lumen tube in a patient with situs inversus

A 74-year-old man was scheduled for resection of a pulmonary tumor in the left upper lobe. He had asymptomatic complete situs inversus, and therefore his left lung had three lobes whereas his right lung had two. Since the tumor had been growing through the left upper bronchus into the left main bronchus, it seemed that the use of a bronchial blocker in the left bronchus should be avoided. A 37-Fr left-sided double-lumen tube was rotated in the opposite direction (clockwise) and advanced easily into the right (anatomically left) main bronchus under fiberoptic guidance. One lung ventilation during the operation was performed successfully and there was no postoperative airway complication. Several ways of achieving one lung ventilation in patients with situs inversus are discussed in this report. The use of a bronchial blocker should be considered first-choice, but sometimes its use is inappropriate as in this case. Commercially available double-lumen tubes are not intended for use in cases of situs inversus. If a double-lumen tube is desired, intentional right bronchial insertion of a left-sided double-lumen tube seems to be an easy and reliable option.     

Surgical advantages of selective unilateral ventilation

Two hundred major thoracic operations have been performed using controlled selective unilateral pulmonary ventilation with no morbidity or mortality related to this technique. A group of 20 patients ventilated selectively with a double-lumen endotracheal tube and 5 additional patients ventilated with a single-lumen tube were studied to determine the physiological effects of each technique. Blood gases and physiological shunt determinations showed better values with selective ventilation, whereas some derangement was noticed in the group ventilated with a single-lumen tube. The physiological and technical advantages provided by the double-lumen endobronchial tube make selective ventilation safer and more practical.     

Use of a Fogarty catheter as a bronchial blocker through a single-lumen endotracheal tube in patients with subglottic stenosis

One-lung ventilation can be achieved with a double-lumen tube or a bronchial blocker. However, the larger outer diameters of double-lumen or Univent tubes may prevent their passage through an area of subglottic stenosiss. We present five cases of subglottic stenosis in which a Fogarty catheter was used as a bronchial blocker through a single-lumen endotracheal tube. The outer diameters of a double-lumen tube, Univent tube and single-lumen tube were compared. Despite special equipment designed for one-lung ventilation, the use of a bronchial blocker through a single-lumen tube, which has the thinnest available wall thickness, seems to be one of the most effective and safest ways of achieving one-lung ventilation in patients with subglottic stenosis or narrowing.     

Unilateral pulmonary fibrosis following ipsilateral single-lung ventilation and anesthesia]

We experienced a rare case of unilateral pulmonary fibrosis following ipsilateral single-lung ventilation and anesthesia. A 75-year-old man with a 1-pack a day smoking history for 50 years was scheduled for right upper and middle lobectomy for lung cancer. The trachea and left bronchus were intubated with a 37-Fr double-lumen endobronchial tube, and anesthesia was maintained with oxygen, nitrous oxide, isoflurane, and epidural lidocaine. Left single-lung ventilation was maintained for 3.5 hours with FIO2 at 0.8-1.0, vital capacity at 10 ml.kg-1, and peak inspiratory pressure at 25 cmH2O. On postoperative day 55, reticular nodular density in chest roentogenography appeared only in the left lung while right lung showed pleural fluid and pneumonia. On postoperative day 105, a high-resolution computed tomographic scan revealed honeycomb pattern in the left lung and organized pneumonia in the right lung. The patient died from respiratory failure on postoperative day 155, and autopsy was not performed. Although the causative mechanisms of unilateral pulmonary fibrosis in this case was unclear, the patient had not been exposed to any drugs and inhalation agents known to induce pulmonary fibrosis. We speculate that high oxygen concentration, high peak inspiratory pressure, and overdistension of the left lung during the left single-lung ventilation and anesthesia were likely major initiating and contributing factors.     

Anesthetic management of a patient with tracheal bronchus with one lung ventilation]

A 56-year-old-male with malignant pleural mesothelioma of the left lung underwent pneumonectomy and pleurectomy. Fiberoptic bronchoscopy was not done preoperatively. Anesthesia was induced rapidly and a double-lumen endobronchial tube was inserted. When we checked the position of the tube with a fiberoptic bronchoscope, we found that the normal right upper lobe bronchus was absent and that the inflated tracheal cuff had obstructed the right upper lobe bronchus originating above the carina. Then we changed the double-lumen endobronchial tube to a endotracheal tube with the blocker. Thereafter, the surgery was completed safely and his postoperative course was uneventful. Routine bronchoscopy is essential just after intubation and before extubation of the endobronchial tube in safe airway management. How to use a fiberoptic bronchoscope to check the position of a double-lumen endobronchial tube is also discussed.     

Postoperative management in single-lung transplantation for lymphangioleiomyomatosis

A 35-yr-old woman presented with dyspnea has been diagnosed as having lymphangioleiomyomatosis (LAM). Despite treatment with estrogen, her pulmonary function deteriorated progressively. In January 2001, a left single-lung transplantation was performed on her from a cadaveric donor. On admission to the ICU after the transplantation, arterial blood gas analysis showed a severe respiratory acidosis. A double-lumen endotracheal tube (ETT) was replaced by a single-lumen ETT for a better suctioning of secretion. Gas exchange improved after the replacement of ETT and suctioning of secretion by bronchoscopy. Five hours after the admission to the ICU, the breath sound decreased over the right thorax. The chest X-ray showed right pneumothorax, and a chest tube was inserted. The patient was weaned from mechanical ventilation gradually and extubated on the 6th ICU day. The patient was discharged from ICU to the general ward on the 9th ICU day without pneumonia and other complications. The development of pneumothorax in the recipient lung should be kept in mind during the perioperative period of lung transplantation for LAM.