胸科手术的单肺通气策略

背景 在胸科手术的麻醉中进行单肺通气(one-lung ventilation,OLV),不但可以为手术提供良好的术野,而且可以隔离并保护肺脏.但是,这是一种非生理状态下的通气方式,OLV期间的气压伤和氧毒性等因素常导致机械通气相关性肺损伤(ventilator-induced lung injury,VILI). 目的 探讨适合胸科手术的OLV策略. 内容 在OLV期间,采用肺泡复苏策略(alveolar recruitment strategy,ARS)和“小潮气量+呼气末正压通气(positive end-expiratory pressure,PEEP)”的保护性通气策略,使吸气平台压(plateau pressure,Pplat)＜25 cmH2O(1 cmH2O=0.098 kPa)和气道峰压(peak inspiratory pressure,Ppeak)＜35 cmH2O;限制FiO2;依据动脉血气分析的结果,酌情调整呼吸频率. 趋向 在OLV期间,应避免肺泡的过度膨胀和循环性的萎陷-复张,避免高浓度氧导致氧化应激加重,可以接受短时间内的高碳酸血症.对患者进行个体化管理,降低ICU的入住率及住院时间,提高患者的生存率及生存质量.     

开胸手术时双肺两种不同通气方式可行性应用

开胸手术行健侧单肺通气,所出现的肺内分流和低氧血症,倍受人们关注.我院在开胸手术中采用健侧肺间歇正压通气(intermittent positive pressure ventilation,IPPV),患侧肺采用持续正压通气(continuous positive airway pressure,CPAP),收到满意疗效.     

单肺通气中低氧血症的防治进展

单肺通气为剖脑手术提供了良好的手术条件，但因其引起低氧血症的发生率高，威胁病人的安全，是对麻醉医生的重大挑战。本文介绍了单肺通气中低氧血症的原因及其防治方法进展。     

不同潮气量单肺通气对呼吸力学及血气的影响

本研究拟评价不同潮气量单肺通气对呼吸力学、血气的影响,为临床工作提供参考。 资料与方法 28例病人,年龄19～65岁,男17例,女11例,均为肺叶切除手术。术前肺功能基本正常。入手术室后,行心电、血压、血氧饱和度监测。呼吸力学监测用Bicore 2000(USA)进行连续监测,其中20例病人行桡动脉穿刺置管行动脉血气监测。常规吸氧去氮后,预注维库溴铵及静注硫喷妥钠、琥     

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.     

呼气末正压通气对单肺通气期间肺顺应性和呼吸指数影响的动态观察

呼气末正压通气对单肺通气期间肺顺应性和呼吸指数影响的动态观察刘流＊周建美＊陈启智呼气末正压通气（ＰＥＥＰ）能有效地防止单肺通气时低氧血症的发生，是单肺通气时常采用的通气方式。研究证实，ＰＥＥＰ对双肺通气时肺顺应性和呼吸指数有不同程度的影响，可明显改善...     

不同单肺通气模式对开胸手术患者血流动力学的影响

目的 评价不同单,肺通气模式对开胸手术患者血流动力学的影响.方法 选择拟行肺叶切除术或食道癌根治术的患者45例,年龄45～64岁,采用随机数字表法,将患者随机分为3组(n=15),间歇正压通气组(IPPV组);IPPV+呼气末正压组(IPPV+PEEP组):IPPV+5 cm H2O PEEP单肺通气30 min后,再行IPPV+10 cm H2O PEEP单肺通气30 min:IPPV+持续气道正压通气组(IPPV+CPAP组)通气侧肺采用IPPV模式,术侧肺加用5 cm H2OCPAP模式1h.于麻醉诱导前、气管插管后10 min、双肺通气30 min、单肺通气30 min、1h及术毕(T1-6)时记录MAP、HR,心排血量(CO)、心指数(CI)、每搏量(SV)和每搏指数(SVI).并于 T1,2,4-6时采集动脉血样行血气分析,记录血糖(Glu)和血乳酸(Lac)水平,计算氧供(DO2)及氧供指数(DO2I).结果 与IPPV组比较,IPPV+PEEP组T4,5时SV、SVI、CO、CI、DO2,DO2I降低(P＜0.05),Glu和Lac水平差异无统计学意义,IPPV+CPAP组上述各指标比较差异无统计学意义(P＞0.05).与IPPV+ PEEP组比较,IPPV+ CPAP组T4,5时SV、SVI、CO、CI、DO2、DO2I升高(P＜0.05),Glu和Lac水平差异无统计学意义(P＞0.05).结论 开胸手术患者通气侧肺采用IPPV模式,术侧肺加用5 cm H2O CPAP模式对患者血流动力学无明显影响,而通气侧肺IPPV+ PEEP模式虽然可导致血流动力学波动,但程度较小,可维持正常的机体氧供.     

单肺通气与非通气侧肺不同给氧方式对开胸食管手术病人肺内分流的影响

双腔管可以使左右肺分开以保护健侧肺,且健侧肺通气与麻醉[以下简称单肺麻醉(OLV)]保持术野安静,故而给开胸手术带来极大方便,但由于非通气侧肺仍被灌注,分流率(Qs/Qt)增加,结果导致动脉血氧分压降低。本研究探讨单肺麻醉时非通气侧肺高频喷射通气(HFJV)和持续气流吹氧对Qs/Qt的影响,探讨胸外科麻醉预防低氧血症的最佳通气方法,以保障病人的安全。     

不同压力持续气道正压对单肺通气氧化应激反应的影响

目的比较不同压力持续气道正压(CPAP)对单肺通气氧化应激反应的影响。方法择期行食管癌根治术患者48例,随机均分为双肺通气组(A组)、单肺通气组(B组)、单肺通气非通气肺给予2cmH2OCPAP组(C组)及5cmH2OCPAP组(D组)。分别于开胸前(T0)、单肺通气后(A组于开胸后)30min(T1)、90min(T2)、150min(T3)、手术结束(T4)时测定血清超氧化物歧化酶(SOD)活性、丙二醛(MDA)、NO浓度。结果 T1～T4时B、C组及T2～T4时D组的SOD活性明显低于A组,T1～T4时B、C、D组MDA及NO浓度高于A组(P0.05)。T1～T4时C、D组MDA及NO浓度均显著低于B组(P0.05),T3时C、D组SOD活性显著高于B组(P0.05);T3时D组MDA及NO浓度高于C组(P0.05)。结论 CPAP能减轻单肺通气氧化应激反应,且2cmH2OCPAP优于5cmH2OCPAP。     

不同通气模式对单肺通气影响的Meta分析

目的 采用Meta分析的方法评价压力控制通气(pressure controlled ventilation,PCV)与容量控制通气(volume controlled ventilation,VCV)对术中单肺通气(one lung ventilation,OLV)患者呼吸力学及循环的影响. 方法 检索PubMed、Embase、Cochrane图书馆,检索时间从建库至2016年2月.收集术中OLV使用PCV与VCV的临床随机对照试验(randomizedcontrolled trim,RCT).采用Cochrane协作网系统评价法评价纳入文献的质量,采用RevMan 5.0软件对收集的患者资料进行Meta分析评价. 结果 共纳入14项研究,包括964例患者,其中PCV组480例,VCV组484例.与VCV组比较:在开胸前双肺通气时(T1),PCV组气道平均压(mean airway pressure,Pmean)比值比(odds ratio,OR)[0R=-0.22,95％CI(-0.42,-0.01),P＜0.05]较低;OLV时(T2),PCV组气道峰压(peak airway pressure,Ppeak)[加权均数差(weighted mean difference,WMD)=-1.37,95％CI(-1.69,-1.05)]及气道平台压(pause pressure,Plateau)较低[WMD=-0.29,95％CI(-0.51,-0.07)],而PaO2高[WMD=0.52,95％CI(0.08,0.95)];关胸后双肺通气时(T3),PCV组Ppeak较低[WMD=-0.63,95％CI(-1.09,0.17)]. 结论 与VCV比较,OLV期间PCV可提供较低的气道压,可能是一种较好的通气模式.     

单肺通气期间雷米芬太尼和硬膜外镇痛对血液氧合及肺内分流的影响

目的比较单肺通气（OLV）期间雷米芬太尼和胸段硬膜外镇痛对血液氧合及肺内分流的影响.方法14例择期开胸食管癌根治术患者,ASA Ⅰ～Ⅱ级.于全麻双肺通气（TLV）、雷米芬太尼输注OLV 30 min和停雷米芬太尼胸段硬膜外镇痛OLV 30 min,分别进行动、静脉血气分析,并计算肺内分流率（Qs/Qt）.结果与TLV时比较,OLV时动脉血氧分压（PaO2）明显下降,Qs/Qt明显升高（P＜0.01）,混合静脉血氧分压（PvO2）、动脉血氧饱和度（SaO2）、动脉血氧含量（CaO2）均明显下降（P＜0.05）.但OLV时输注雷米芬太尼与硬膜外镇痛相比,PaO2、Qs/Qt、PvO2、SaO2、CaO2均无显著性差异.结论OLV期间输注雷米芬太尼和硬膜外镇痛对血液氧合和肺内分流无明显影响.     

“Open lung ventilation optimizes pulmonary function during lung surgery”

Background

We evaluated an “open lung” ventilation (OV) strategy using low tidal volumes, low respiratory rate, low FiO₂, and high continuous positive airway pressure in patients undergoing major lung resections.

Materials and methods

In this phase I pilot study, twelve consecutive patients were anesthetized using conventional ventilator settings (CV) and then OV strategy during which oxygenation and lung compliance were noted. Subsequently, a lung resection was performed. Data were collected during both modes of ventilation in each patient, with each patient acting as his own control. The postoperative course was monitored for complications.

Results

Twelve patients underwent open thoracotomies for seven lobectomies and five segmentectomies. The OV strategy provided consistent one-lung anesthesia and improved static compliance (40 ± 7 versus 25 ± 4 mL/cm H2O, P = 0.002) with airway pressures similar to CV. Postresection oxygenation (SpO₂/FiO₂) was better during OV (433 ± 11 versus 386 ± 15, P = 0.008). All postoperative chest x-rays were free of atelectasis or infiltrates. No patient required supplemental oxygen at any time postoperatively or on discharge. The mean hospital stay was 4 ± 1 d. There were no complications or mortality.

Conclusions

The OV strategy, previously shown to have benefits during mechanical ventilation of patients with respiratory failure, proved safe and effective in lung resection patients. Because postoperative pulmonary complications may be directly attributable to the anesthetic management, adopting an OV strategy that optimizes lung mechanics and gas exchange may help reduce postoperative problems and improve overall surgical results. A randomized trial is planned to ascertain whether this technique will reduce postoperative pulmonary complications.     

Intracuff pressure during one-lung ventilation in infants and children

ObjectiveWe prospectively evaluated intracuff pressure (IP) during one-lung ventilation (OLV) to characterize potential risk associated with overinflation of the cuff used for OLV.DesignProspective observational study over a 2-year period, in infants and children undergoing thoracic surgery. The IPs of the tracheal and bronchial balloon were measured using a manometer and compared to a previously recommended threshold of 30 cmH2O. Data were compared by the device type used to achieve OLV.SettingFreestanding tertiary-care pediatric hospital.ParticipantsPatients ≤ 18 years of age undergoing thoracic procedures requiring OLV.InterventionsMeasurement of IP.Measurements and main resultsThirty patients were enrolled (age 5 months–18 years) with a median weight of 28 kg. Median tracheal and bronchial IPs were 32 cmH2O (range: 11, 90) and 44 cmH2O (range: 10, 100), respectively. The tracheal and bronchial IPs exceeded 30 cmH2O in 13 of 20 patients (65%) and 21 of 30 patients (70%), respectively.ConclusionsIP was high and in excess of recommended levels in most children undergoing OLV. Continuous monitoring of IP may be indicated during OLV to address the risks involved and ensure the prevention of complications related to high IP.Type of studyProspective comparative study.Level of evidenceLevel II.     

帕瑞昔布钠对食管癌根治术患者单肺通气时肺内分流的影响

目的 探讨帕瑞昔布钠对食管癌根治术患者单肺通气(OLV)时肺内分流的影响.方法 择期行食道癌根治术患者45例,年龄47～57岁,体重42～59kg,ASA分级Ⅰ或Ⅱ级,随机分为2组:生理盐水组(C组,n=23)和帕瑞昔布钠组(P组,n=22).P组静脉注射帕瑞昔布钠40 mg(生理盐水稀释至10 ml),C组静脉注射等容量生理盐水.随后两组均靶控输注异丙酚(效应室靶浓度4μg/m1)和舒芬太尼(效应室靶浓度0.3 ng/ml)行麻醉诱导,静脉注射罗库溴铵0.9 mg/kg,光纤支气管镜引导下插入双腔气管导管,行机械通气.于麻醉诱导开始后30 min(T0)、单肺通气15 min(T1)、30 min(T2)、1 h(T3)、恢复双肺通气30 min(T4)和1 h(T5)时测定CVP、HR、MAP和气道平均压(Pmean),同时采集颈内静脉和桡动脉血样,进行血气分析,计算肺内分流率(Qs/Qt).结果 与T0时比较,两组T1-3时Pmean 和Qs/Qt升高(P＜0.05);与T1时比较,两组T2.3.时Qs/Qt降低(P＜0.05);两组各时点Pmean、Qs/Qt、CVP、HR和MAP比较差异无统计学意义(P＞0.05).结论 帕瑞昔布钠40 mg对食管癌根治术患者单肺通气时缺氧性肺血管收缩反应无影响.     

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.     

异丙酚和氯胺酮对单肺通气犬肺内分流的影响

目的 对比观察异丙酚和氯胺酮对单肺通气犬肺内分流的影响,探讨异丙酚对缺氧性肺血管收缩反应(HPV)的影响程度。方法 杂种犬12只,随机分为异丙酚组、氯胺酮组。两组均于单肺通气(OLV)前30 min开始静滴异丙酚或氯胺酮6 mg·kg-1·h-1,后行单肺通气,于双肺通气(TLV)30 min、单肺通气2、10、30、60 min同时采集动脉血及混合静脉血行血气分析,并计算分流率(Qs/Qt)。结果 两组TLV 30 min Qs/Qt差异无显著性(P>0.05),OLV 2 min时Qs/Qt均较TLV时明显增高(P<0.01),但两组间无明显差异(P>0.05)。OLV 10、30及60 min时两组间Qs/Qt差异有显著性(P<0.05),组内不同时间Qs/Qt差异也有显著性(P<0.05)。结论 异丙酚与氯胺酮相比轻度增加单肺通气时肺内分流。     

Effects of desflurane and propofol on arterial oxygenation during one-lung ventilation in the pig

Background: Desflurane depresses hypoxic pulmonary vasoconstriction (HPV) in vitro. During one-lung ventilation (OLV), HPV may reduce venous admixture and ameliorate the decrease in arterial O₂ tension by diverting blood from the non-ventilated to the ventilated lung. Accordingly, this study compares the effects of desflurane with those of propofol on oxygenation during two-lung (TLV) and OLV in vivo. Methods: Ten pigs (25–30 kg) were premedicated (flunitrazepam 0.4 mg/kg im), anaesthetized (induction: propofol 2 mg/kg iv; maintenance: N₂O/O₂ 50%/50%, desflurane 3%, propofol 50 μg kg^?1 min^?1, and vecuronium 0.2 mg kg^?1 h^?1 iv), orally intubated and mechanically ventilated. Femoral arterial and thermodilution pulmonary artery catheters were placed, and the orotracheal tube was replaced by a left-sided 28-Ch double-lumen tube (DLT) via tracheotomy. After DLT placement, N₂O and propofol were discontinued, FiO₂ was increased to 0.85, and anaesthesia continued randomly with either desflurane (1 MAC) or propofol 200 μg kg^?1 min^?1. Using a cross-over design, in each animal the effects of a), changing from TLV to OLV (left lung) during both desflurane and propofol and b), the effects of changing between the two anaesthetics during OLV were studied. Results: When changing from TLV to OLV, PaO₂ decreased more (P<0.05) during desflurane (mean 75%) than during propofol (mean 60%). Changing between desflurane and propofol during OLV resulted in small but consistent (P<0.05) increases in PaO₂ (mean 15%) during propofol. Conclusion: Consistent with in vitro results on HPV, 1 MAC desflurane impaired in vivo oxygenation during OLV more than did propofol.