CT技术预测胸科手术病人双腔支气管导管型号的可行性

目的探讨CT技术用于胸科手术病人选择合适内径型号双腔支气管导管(DLT)的价值。方法胸科手术需行左侧DLT插管的病人60例,其中男性38例,女性22例,年龄30-64岁,利用螺旋CT三维图像重建技术测定气管和左主支气管的内径值,以纤维支气管镜定位或引导插管,采用“气泡溢出法”和“主支气管套囊压力测定法”判断DLT内径型号的合适性和插管的准确性。结果 DLT插管成功所选用的内径型号与气管内径和左主支气管内径的相关系数分别为0．8192、0．7346 (P<0．01),可根据二者测量值选择合适内径的DLT。结论参考气管和主支气管内径的CT测量值有助于胸科手术病人DLT合适型号的选择。     

GlideScope喉镜与Macintosh喉镜辅助双腔气管导管插管术效果的比较

目的 比较GlideScope喉镜与Macintosh喉镜辅助双腔气管导管插管术的效果.方法 选择胸科手术单肺通气的患者70例,ASA分级Ⅰ～Ⅲ级,年龄18 ～ 75岁,性别不限.采用随机数字表法,将患者分为2组(n=35)∶GlideScope喉镜组(G组)和Macintosh喉镜组(M组).麻醉诱导后,按照Cormack-Lehane分级评估Macintosh喉镜暴露声门程度.采用Macintosh喉镜(M组)和GlideScope喉镜(G组)辅助双腔气管导管插管术.记录Macintosh喉镜和GlideScope喉镜下Cormack-Lehane分级以及置入双腔气管导管的难易程度和双腔气管导管反向置管的发生情况;记录气管插管成功情况和气管插管时间.于气管插管前、气管插管后即刻和气管插管后3 min记录血压及心率.记录术后相关不良反应的发生情况.结果 与M组比较,G组气管插管时间延长,双腔气管导管置管困难程度升高,气管插管后即刻和气管插管后3 min血压升高(P＜0.05),首次气管插管成功率、双腔气管导管反向置管率、Comark-Lehene分级和各时点心率差异无统计学意义(P＞0.05);G组GlideScope喉镜下Cormack-Lehane分级优于Macintosh喉镜(P＜0.05).结论 与Macintosh喉镜相比,GlideScope喉镜辅助双腔气管导管插管术时能更好地暴露声门,改善气管插管条件,但方法较复杂,且插管反应较强.     

纤支镜引导下双腔气管插管致气管破裂1例分析

双腔气管导管常用于普胸手术麻醉,但双腔气管导管长,进声门后需转动导管方向,插管不易准确到位,操作不当可导致气管、支气管破裂,这是麻醉中罕见的置管并发症,一旦发生后果严重。故本院采用纤支镜引导下行双腔气管插管,与常规方法对比效果较好,但如操作不当仍可致气管、支气管破裂。1999年至2008年本院在纤支镜引导下双腔气管插管实施普胸手术1465例,其中1例肺癌手术在气管插管时发生气管破裂,为总结经验教训。结合文献复习,分析其原因并探讨气管、支气管破裂修补方法。现报告如下。     

自制气管支气管导管的临床运用

临床常用的双腔支气管导管．插管对位技术要求高,管径粗大,只能经口,很难适应困难气管插管和小儿支气管手术的麻醉;Univent T有患侧不能及时吸引的不足。我科采用普通气管导管制作简易气管支气管导管,成功单肺通气21例,现报道供参考。     

双腔气管插管致气管破裂一例

双腔气管插管致气管破裂的情况比较少见,我院近5年来共进行450例双腔气管插管,发生1例气管破裂,现报道如下。患者,男,47岁,体重62kg,身高173cm,既往无心血管及慢性呼吸系统疾病。因右上肺中央型支气管肺癌入院,拟行开胸探查右上肺叶切除术。麻醉诱导:丙泊酚100mg、咪唑安定5mg、芬太尼0.2mg、维库溴铵8mg。面罩过度通气,待肌肉松弛后,行双腔气管插管,双腔支气管导管(DLBT)为Robertshaw左侧DLBT,型号为F37高容低压梭形囊。声门暴露良好,插管时在气囊通过声门后逆时针方向旋转90度后继续前进,当导管深度距门齿34cm时感觉到轻微的阻抗感,此…     

结核毁损肺单侧全肺切除的麻醉处理

目的探讨结核毁损肺单侧全肺切除的麻醉处理. 方法 80例结核毁损肺行单侧全肺切除病人,术前肺功能减损轻度者30例(G组),中度者35例(M组),重度者15例(S组).56例行左侧全肺切除:44例使用双腔支气管导管(Carlon管10例、White管20例、左侧Robertshaw管8例、右侧Robertshaw管6例)、右单腔支气管导管7例、气管导管5例.24例行右侧全肺切除:21例使用双腔支气管导管(Carlon管19例、左侧Robertshaw管2例)、左单腔支气管导管2例、气管导管1例.痰量>50 ml/d的16例病人中,采用双腔支气管导管7例、右单腔支气管导管7例、左单腔支气管导管2例. 结果 G组、M组未发生围手术期并发症,S组术后发生急性呼吸衰竭5例(33.33%).痰量>50 ml/d的病人中,2例使用左单腔支气管导管的病人术后均发生健侧支气管病灶播散;而使用双腔支气管导管和右单腔支气管导管未发生结核播散. 结论结核毁损肺重度肺功能减损者,术前FEV1占预计值的百分比<35%,MVV占预计值的百分比<40%,行单侧全肺切除手术要慎重.术前痰量＞50 ml/d的病人,应选择双腔支气管导管或右单腔支气管导管,确保两肺分隔满意,以防止术后健侧支气管病灶播散.     

双腔支气管导管型号选择分析

胸科手术麻醉时常用双腔支气管导管（ｄｏｕｂｌｅ－ｌｕｍｅｎ－ｅｎｄｏｂｒｏｎｃｈｉａｌ ｔｕｂｅ，ＤＬＴ）行肺隔离。ＤＬＴ型号的正确选择直接影响通气阻力、分泌物引流及插管成功率。本文重点探讨选择适宜ＤＬＴ型号的规律，并分析插管失败的原因。资料与方法1９９１年 １０月～２０００年４月胸科手术麻醉拟用 ＤＬＴ行肺隔离的患者２ ４１２例。麻醉前测量胸部Ｘ线后前位平片锁骨胸骨端水平气管内径值（单位：ｍｍ）和左、右支气管与气管的夹角。选用导管的厂牌和型号包括：Ｍａｌｉｎｃｋｒｏｄｔ ＤＬＴ3９Ｆｒ、３７Ｆｒ、３…     

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).     

支气管内麻醉在胸内手术应用的几点体会

我院自1983年以来施行支气管内麻醉于各种胸内手术共3a2例,其中采用双腔支气管导管309例(左288,右21)、单腔支气管导管23例。无1例麻醉并发症。我们体会到作右侧双腔支气管插管时,为避免上叶支气管开口部分或完全堵塞,可将导管上针对右上叶开口的裂隙向远端剪开,延伸至导管前端,以确保     

Ⅰ-Gel喉罩联合气管导管和支气管封堵器在食管癌根治术单肺通气中的应用

目的 探讨Ⅰ-Gel喉罩联合气管导管和支气管封堵器在食管癌根治术单肺通气的可行性和效果. 方法 择期行食管癌根治手术患者60例,年龄40岁～80岁,美国麻醉医师协会(ASA)分级Ⅰ-Ⅲ级,采用随机数字表法分为3组(每组20例):双腔支气管导管组(D组)、单腔气管导管联合支气管封堵器组(B组)、Ⅰ-Gel喉罩联合气管导管和支气管封堵器组(Ⅰ组).记录各组支气管封堵器或双腔支气管导管的定位时间、术中支气管封堵器或双腔支气管导管移位的次数、肺萎陷的程度及单肺通气的气道峰压,记录诱导前(T0)、气管插管或喉罩置人前(T1)、气管插管或喉罩置入后1 min (T2)、气管插管或喉罩置入后5 min(T3)、术后气管导管或喉罩拔除前5 min(T4)、拔管或喉罩拔除后1 min(T5)、拔管或喉罩拔除后5 min(T6)患者的血压、心率及拔管或喉罩期间的呛咳例数,记录术后2d内患者咽痛、声音嘶哑等副作用. 结果 Ⅰ组除T1时收缩压(117±9) mmHg(1 mmHg=0.133 kPa)和舒张压(65±9) mmHg低于术前收缩压(145±12) mmHg和舒张压(75±9) mmHg(P＜0.05)外,诱导期间及术后恢复期各时点患者血压与术前比较差异无统计学意义(P＞0.05),B组和D组麻醉插管后及术后恢复期T2～T6时患者心率及血压高于术前(P＜0.05);Ⅰ组(0例)拔管期间呛咳反应少于B组(8例)和D组(15例)(P＜0.05);Ⅰ组(O例)术后咽痛和声嘶的发生例数低于D组(16例)、B组(7例)(P＜0.05).Ⅰ组定位时间(4.2±1.2) min长于B组(2.8±0.7) min和D组(2.7±0.4) min(P＜0.05),D组、B组和Ⅰ组术中移位例数及肺萎陷程度相似(P＞0.05),Ⅰ组[(22±3) mmHg]和B组[(21±4) mmHg]单肺通气期间气道峰压力低于于D组[(28±4) mmHg](P＜0.05),而Ⅰ组和B组气道峰压差异无统计学意义(P＞0.05). 结论 Ⅰ-Gel喉罩联合气管导管和支气管封堵器可减轻全身麻醉诱导期和苏醒期的刺激,可安全用于食管癌根治术中气管管理.     

Catheter-induced pulmonary artery haemorrhage resulting from a pneumothorax

We present a case of pulmonary artery perforation in a patient who developed a pneumothorax after cardiac surgery. In the process of inserting a chest tube the patient became tachypnoeic, and developed haemoptysis. The trachea was intubated, and right bronchial intubation was performed with persistent bleeding. The pulmonary artery catheter was gently withdrawn and the balloon inflated, with cessation of bleeding. The patient was taken to the operating room, a bronchial blocker was placed in the right lower lobe bronchi, and the pulmonary artery catheter was removed. The bronchial blocker was removed the following day with no bleeding. The aetiology of perforation was secondary to the pneumothorax, which caused a shift of the mediastinum to the right, elevated pulmonary artery pressures, and the distal migration of the catheter through the pulmonary artery. It is recommended that treatment include tracheal intubation, inflation of the pulmonary artery catheter balloon, and the placement of a right lower lobe bronchial blocker.     

Palliative intubation of the tracheobronchial tree

Sixteen patients with far-advanced neoplastic lesions in the trachea and main-stem bronchi were studied. Ten of them were admitted to the ward in extremely poor general condition with marked cyanosis and dyspnea at rest. Palliative intubation was undertaken with two types of tubes: a Neville tracheal prosthesis and a Tracheoflex tracheostomy tube. Both types of tubes had to be specially prepared, as they had originally been designed for other purposes. The tubes were placed in the stenotic sections of the trachea and, depending on anatomical relations, within the right or left main bronchus as well. Intubation of the bronchus in the case of changes involving only the trachea was necessary to properly position and fasten the tube in the bronchial tree and to prevent displacement of the prosthesis inside the trachea. In two patients the esophagus was intubated as well. An improvement in the general condition of all patients was observed. Intubation resulted in reexpansion of a completely collapsed lung in two patients. The longest time of intubation was 9 months. The method is simple, and every physician experienced in endoscopy can use it. The results obtained encourage its further and wider application.     

16层螺旋CT后处理技术在气管异物检查中的应用

目的探讨16层螺旋CT后处理技术在气管及支气管异物检查中的方法,评价应用价值。方法对32例临床疑为气管、支气管异物的患者进行检查。首先进行常规成像,然后进行二维重建技术:多平面重建(MPR)、曲面重建(CMPR);三维重建技术:最小密度投影(MinIp)、容积再现(VR)及三维显示技术:CT仿真内窥镜(CTVE)等技术方法成像。结果 6例未发现异常,26例误吸异物存在于气管、支气管中。其中位于主气管4例,左主支气管8例,右侧主支气管13例;左、右主气管内均有异物的1例,均获得满意的后重建图像。后重建图像实现单独或联合显示气管、支气管树等结构,并任意切割、旋转及三维解剖测量,较常规图像清楚、直观,显示解剖、异物位置全面、准确。以上病例均行纤维支气管镜检查或临床证实。结论 16层螺旋CT扫描及多种后处理技术的运用是气管、支气管异物准确诊断的方法,无创伤、定位准、简便易行。后重建图像处理技术能很好显示气管、支气管树结构及异物的位置关系,为影像诊断及临床制定科学的方案提供可靠的解剖依据。     

Tracheobronchial injury

We studied 6 cases of tracheobronchial injury due to the blunt chest truma in our department. All patients were male of 19 to 60 years of age. Injured sites were main bronchus in 2, tracheobronchial portion in 2, cervical trachea and main bronchus in 1, cervical trachea in 1. In a case of cervical tracheal injury and 2 cases of tracheobronchial injury, emergent operation was performed on the day of accident. Other cases with the main bronchial injury underwent conservative treatment at first, but subsequent bronchoplasty was necessary for them due to the bronchial stenosis. After the surgery for 2 cases of tracheobronchial injury, mechanical ventilation with double lumen tube was continued to reduce the airway pressure for the anastomotic sites. In conclusion, early surgical treatment is recommended for the airway injury and the respiratory management using double lumen tube after surgery may be helpful in preventing trouble at the anastomosis.     

A case of left main bronchial rupture due to bronchocath tube

A 68-year-old woman underwent a right upper lobectomy for lung cancer. After resection, we noticed the left main bronchial rupture due to bronchocath tube (polyvinyl chloride double lumen tube). The lesion of the rupture was repaired by interrupted sutures with 4-0 prolene. Subsequent course of the patient was uneventful. Tracheobronchial rupture is rare complication of intubation with polyvinyl chloride double lumen tube. There are 6 cases of this complication last five years in Japan. The cause and prevention of this complications are described. It is important to use an adequate tube size, to prevent malposition of the tube and overinflation of the bronchial balloon.     

Selective right bronchial intubation using tracheal tubes under fibroscopic guidance]

We have evaluated the technique of right bronchial intubation for selective right pulmonary ventilation using one lumen tracheal tubes as an alternative to double lumen tubes. We studied 20 patients ASA II-III with a relatively preserved pulmonary function who were programmed for left thoracotomy. We used Shiley nr. 9 or Mallinckrodt nr. 11 tubes. After endotracheal intubation the tube was blindly advanced to the main right bronchus. The position of the tube was assessed by auscultation and it was verified and modified, if necessary, by fibroscopic visualization. The tube was advanced in such a way that Murphy's hole of the endotracheal tube remained in front of the exit of the right superior lobar bronchus. In three patients (15%) blinded placement of the tube was appropriate and in 4 patients (20%) fibroscopic replacement of the tube was required. In the remaining 13 patients (65%) placement of the tracheal tube was considered incorrect: tube rotation in 7 cases, upper placement of the Murphy's hole with respect to the origin of the superior lobar bronchus in 4 cases, and excessive distal placement of Murphy's hole with respect to the superior lobar bronchus in 2 patients. Complications related with the incorrect position of the tube were: leaking of gas into the left bronchium in 5 patients (25%), displacement of the tracheal tube into the main left bronchus requiring withdrawal of the tube to the trachea in one case (5%), hypoxemia (saturation of O2 lower than 90%) in spite of ventilation with FiO2 = 1 in two patients, moderate hypercapnia in three cases, and atelectasis of the right superior lobe during the postoperative phase in three patients (15%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Jet ventilation via a Univent tube for sleeve pneumonectomy.

A 51-year-old man presented with a right upper lobe adenocarcinoma with carinal extension. He underwent a right sleeve pneumonectomy, which involved a carinal resection with anastomosis between the trachea and left main bronchus. This report describes the successful use of jet ventilation, administered via the lumen of the bronchial blocker of a Univent tube. During 15 min of carinal resection, oxygenation of his left lung was maintained with the bronchial blocker bridging the airway discontinuity.     

A case of difficult intubation with tracheobronchial anomaly]

We experienced a case of difficult intubation with tracheobronchial anomaly. A 66-year-old male was scheduled for subtotal esophagectomy. We used a univent bronchial blocker tube (UBT) to separate the lungs because of difficulty with tracheal intubation using a 37 F double lumen tube (DLT). Intraoperatively, we could not separate the lungs due to tracheobronchial anomaly in the right lung, and attempted to change the tube. We could insert a 35 F DLT to the trachea and separate the lungs. In the case of difficult or impossible conventional direct-vision intubation, the use of DLT is a relative contraindication. However, in this case, the separation of the lungs with UBT was difficult because of tracheobronchial anomaly.     

Anatomical bases for bronchial arterial revascularization in double lung transplantation]

A study of the bronchial arterial blood supply was conducted to facilitate in surgical attempts of bronchial revascularization in double lung transplantation. This study consisted of 20 cadaveric anatomical dissections of the bronchial arterial blood supply as well as a retrospective review of 50 bronchial arteriograms. The right bronchial tree was supplied by an artery originating from the right intercostal bronchial arterial trunk in 76 to 95% of the cases. This artery also supplied the distal trachea and the carina in over 80% of cases as well as the proximal left bronchial tree via a network of small collaterals found in the subcarinal compartment and adventitial tissues located on the anterior surface of the descending aorta. A common arterial trunk for both the right and left bronchial trees was found in 12 of the 20 dissections (60%). Left bronchial arteries were much smaller and less consistent. Proximity of the bronchial arteries orifices was frequently observed: in 10 of the 20 dissections it allowed simultaneous reperfusion of more than one vessel. To maintain the vascular anastomotic network in between the right and left trees, extensive vascular dissection and carinal resections are prohibited. This will allow revascularization of the whole tracheal bronchial tree via the supply of the origin of the RICBA.     

Fatores de risco para hipoxemia intraoperatória durante ventilação monopulmonar: estudo observacional

BackgroundLeft double‐lumen endotracheal tubes have been widely used in thoracic, esophageal, vascular, and mediastinal procedures to provide lung separation. Lacking clear objective guidelines, anesthesiologists usually select appropriately sized double‐lumen endotracheal tubes based on their experience with 35 and 37 Fr double‐lumen endotracheal tubes, which are the most commonly used. We hypothesized the patients with a left main bronchus of shorter length (<40 mm) had a greater chance of experiencing desaturation during one lung ventilation, due to obstruction in the orifice of the left upper lobe with the bronchial tube.MethodsWe included 360 patients with a left double‐lumen intubated between September 2014 and August 2015. The patient's age, sex, height, weight, and underlying disease were recorded along with type of surgical procedure and the desaturation episodes. In addition, the width of the trachea and the width and length of the left bronchus were measured using computed tomography.ResultPatients with a left main bronchus length of less than 40 mm who underwent intubation with a left double‐lumen endotracheal tubes had significantly higher incidence of desaturation (Odds Ratio (OR: 8.087)) during one‐lung ventilation. Other related factors of patients identified to be at risk of developing hypoxia were diabetes mellitus (OR: 5.368), right side collapse surgery (OR: 4.933), and BMI (OR: 1.105).ConclusionsWe identified that patients with a left main bronchus length of less than 40 mm have a great chance of desaturation, especially if other desaturation risk factors are present.