不同月龄先天性心脏病婴儿术后急性呼吸窘迫综合征应用肺表面活性物质治疗的临床研究

目的评价肺表面活性物质(pulmonary surfactant,PS)对不同月龄先天性心脏病(先心病)婴儿术后呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)治疗效果。方法采用PS治疗先心病患儿术后ARDS,其中2012年1月至2017年6月符合入选标准的患者共43例。分为小婴儿组(3个月,12例)、婴儿组(3个月至1岁,31例),比较两组患儿用药前后氧合和换气指标的变化情况。结果小婴儿组体重更低,两组患儿体外循环时间、主动脉阻断时间、机械通气时间、住ICU时间差异无统计学意义,两组患儿在用药前动脉血氧分压(PaO2)、氧吸入浓度(FiO2)、氧合指数(PaO2/FiO2,P/F)及肺泡动脉氧压比(a/A)差异无统计学意义(P0.05)。用药治疗24 h后,两组患儿与用药前比较,PaO2、P/F及a/A均显著升高;FiO2明显降低,差异有统计学意义(P0.05),用药24 h后,小婴儿组PaO2、P/F及a/A显著高于婴儿组,小婴儿组FiO2显著低于对照组。结论 PS治疗对小月龄先心病患儿术后ARDS者有更好的氧合通气改善作用。     

丙泊酚镇静对急性肺损伤/急性呼吸窘迫综合征患者血液动力学及氧合的影响

目的观察丙泊酚镇静对急性肺损伤(ALI)/急性呼吸窘迫综合征(ARDS)患者行机械通气时血液动力学和肺氧合功能的影响。方法18例实施机械通气的ALI/ARDS患者随机分为丙泊酚组(P组,镇静诱导和维持用丙泊酚)和咪唑安定组(M组,镇静诱导和维持用咪唑安定)。根据Ramsay分级标准调整两组用药量。记录两组患者镇静诱导前即刻(T0)、镇静诱导后1h(T1)、5h(T2)、9h(T3)和12h(T4)血液动力学变化,同时采集上述各时点中心静脉血、股动脉血测定血气,计算肺内动静脉分流率(Qs/Qt)和氧合指数(OI)。结果(1)与T0时比较,T1～T4时两组患者MAP、HR下降(P<0.05);(2)与M组比较,T2～T4时P组Qs/Qt下降、OI升高(P<0.05)。结论丙泊酚镇静有利于改善机械通气时ALI/ARDS患者氧合,可为其病因治疗和肺损伤的修复赢得时间。     

肺表面活性物质对胎粪吸入鼠肺功能的影响

目的：探讨外源性肺表面活性物质（PS）对胎粪吸入鼠肺功能的影响。方法：28只Wistar大白鼠进行人工通气，经气道注入3－4ml/kg胎粪溶液，PaO2降至20kPa以下后将动物随机分为4组（每组7只）。A组，气道内注入PS 150mg/kg(50mg/ml,3ml/kg)；B组，气道内注入等量生理盐水；C组，用PS稀溶液75mg/kg(5mg/ml,15ml/kg)进行支气管肺泡灌洗，重复2次；D组，用15ml/kg的生理盐水灌洗双肺。治疗后15min,30min,60min,120min,180min采血进行血气分析。180min后测定各组潮气量，并进行支气管肺泡灌洗（BAL），检测BAL液中总蛋白（TP）和TNF－α含量。结果：治疗后A和C组PaO2均明显升高，而B和D组在治疗后几乎不变，A、C组与B、D组相比，P＜0．05。A与C组间差异均无显著性。A和C组的潮气量明显高于B和D组（P＜0．05）。A和C组的BAL液中TP含量明显低于B和D组（P＜0．05）。TNF－α含量各组间无差异。结论：补充PS明显改善胎粪吸入鼠肺的氧合和顺应性。PS稀溶液灌洗法优于气道注入法。     

肺保护性通气策略应用于全身麻醉及其对患者转归的影响

背景 以小潮气量联合肺开放性通气为主的肺保护性通气策略,已广泛应用于急性呼吸衰竭/急性肺损伤(acute respiratory distress syndrome/acute lung injury,ARDS/ALI)患者的临床治疗.而对于全身麻醉患者,肺保护性通气策略对患者肺功能及术后肺部并发症的影响还不明确. 目的 回顾近年来主要的肺保护性通气策略,及其对患者肺功能和术后转归影响的研究进展. 内容 以小潮气量联合肺开放性通气策略为主的肺保护性通气策略相对于传统通气模式,术中患者的肺部炎症因子下降,但对术后肺部并发症的影响还不明确. 趋向 通过进一步研究,建立一个肺保护性通气策略的应用指南,有效降低全麻患者术后肺部并发症的发生率,改善患者预后.     

肺保护性通气策略对食管癌手术患者围术期炎症反应的影响

目的研究肺保护性通气策略对伴有肺功能异常的食管癌手术患者围术期炎症反应的影响。方法选择40例择期行食管癌根治术患者,术前肺功能检查有一项以上指标异常,随机均分为保护性通气组(PV组)和常规通气组(CV组)。双肺及单肺通气参数设定:PV组患者潮气量5~6ml/kg,吸呼比为1∶1,并给予呼气末正压(PEEP)3~5cmH2O。CV组患者潮气量10ml/kg,吸呼比为1∶1.5。在气管插管后(T1)、单肺通气120min(T2)、术后24h(T3)抽取静脉血3ml检测白细胞介素6(IL-6)及白细胞介素8(IL-8)的浓度;旁气流法监测气道峰压(Ppeak)、平台压(Pplat)、气道阻力(Raw)、动态胸肺顺应性(Cdyn);血气分析并计算出氧合指数(OI)。结果与T1时比较,两组T2、T3时IL-6、IL-8的浓度显著增加(P<0.05),但PV组增加幅度显著低于CV组(P<0.05)。PV组T2时Ppeak、Pplat、Raw显著低于CV组(P<0.05),而CV组Cdyn显著升高(P<0.05),PV组T2、T3时OI显著高于CV组(P<0.05)。结论肺保护性通气策略可有效降低肺功能异常患者机械通气时气道压力及阻力,减少炎性因子的释放,减轻围术期炎症反应。     

肺保护性通气策略在腹部和胸部手术中应用的研究进展

肺保护性通气策略(lung protective ventilation strategy,LPVS)的应用是近年来在急性肺损伤/急性呼吸窘迫综合征(acute lung injury/acute respiratory distress syndrome,ALI/ARDS)治疗中的重要进展。ALI/ARDS患者采用保护性通气策略,能够改善气体交换和氧合,降低肺泡及循环内炎性因子的水平,缩短机械通气时间,降低患者病死率[1,2]。但对于非ALI/ARDS需要全身麻醉进行手术的病人,采用LPVS是否受益尚不明确[3]。胸部和腹部手术时间较长、创伤较大,本文对腹部和胸部手术中LPVS应用的研究进展文献总结如下。     

外源性肺泡表面活性物质在婴儿心脏直视术后的应用

目的　评价外源性肺泡表面活性物质 ( PS)治疗婴儿体外循环后肺损伤的疗效。　方法　选择 7例术后反复撤机失败 ,依赖机械通气 ,胸部 X线片显示大片肺不张和 /或肺间质透亮度降低的婴儿 (年龄 0 .4 9± 0 .82岁 ,体重 4 .87± 2 .18kg) ,在至少 1次撤机失败后经气管内插管应用 PS,初始量按 10 0 mg/kg给药 ,12小时后重复 1次。分别在初始量后 4、6、12、2 4、4 8和 72小时测定氧合指数 ( OI)、动脉血氧饱和度 ( Sa O2 )和动脉血二氧化碳分压 ( Pa CO2 ) ,记录自主呼吸潮气量、胸部 X线片变化以及呼吸机应用时间。　结果　 PS使用 4小时后 OI、Sa O2 显著升高 ,2 4小时后增幅最大 ,分别为给药前的 34.7%和 6 .6 % ;Pa CO2 在给药 4小时后显著降低 ,6小时后最大降幅为 2 2 .8% ( P<0 .0 5 ,0 .0 1)。用药后患者最大自主呼吸潮气量、胸部 X线片明显改善 ,拔管成功率 85 .7%。　结论　外源性 PS替代治疗能显著改善婴儿心脏直视术后肺功能 ,并有效缩短机械通气时间     

肺动脉灌注低温保护液减轻体外循环肺内炎性反应

目的　研究肺动脉灌注低温保护液减轻体外循环肺内炎性反应的作用。方法　 4 0例行法洛四联症 (TOF)根治术的病儿随机分为肺保护组 2 0例 ,对照组 2 0例。肺保护组体外循环期间肺动脉灌注低温肺保护液 ,对照组行常规TOF根治术。围手术期监测血浆肿瘤坏死因子 (TNF α)水平。收集术后6h气管吸出物 ,检测其中炎性介质白细胞介素 (IL) 6、IL 8水平。征得病儿家属同意 ,术后取右下肺组织活检 ,观察组织内炎性反应情况。同时监测围手术期肺功能及临床指标。结果　肺保护组血浆中TNF α水平低于对照组 ,以回ICU 0h、2 4h差异显著 (P <0 0 1、P <0 0 5 ) ;术后 6h内气管吸出物中IL 6和IL 8水平肺保护组低于对照组 (P <0 0 1) ;肺组织活检对照组可见中性粒细胞浸润 ,肺保护组无明显病理改变。肺保护组术后肺泡 -动脉氧分压差 (A aO2 )较对照组低 ,以回ICU 0h、12h和 2 4h差异显著(P <0 0 5、P <0 0 1和P <0 0 5 ) ;肺保护组呼吸机辅助通气时间短于对照组 (P <0 0 1)。结论　肺动脉灌注低温保护液可明显减轻体外循环中肺内的炎性反应和改善肺功能。     

乌司他丁对兔在体肺缺血再灌注损伤的保护作用

目的　探讨乌司他丁对活体肺缺血再灌注损伤的保护作用。方法　将 2 0只新西兰大白兔随机分成缺血再灌注损伤组 (A组 )和乌司他丁组 (B组 ) ,B组阻断前给乌司他丁 (1 0 0 0 0U/kg体重 )。两组阻断 2h和再灌注 1h后采血检测血气、白细胞介素 6(IL 6)和肿瘤坏死因子 α(TNF α)。摘取左肺测定湿干重比 (W/B)和病理学检查。结果　阻断 2h后 ,两组血氧分压 (PO2 )接近 ;恢复灌注 1h后 ,B组PO2 高于A组 (77.61± 5 .0 4 )mmHg(1mmHg =0 .1 33kPa)和 (1 0 0 .85± 6 .73)mmHg ;TNF α值 (A值 ) ,A组各时段均显著高于B组 (2 54 .0 2± 1 4 .31和 50 4 .0 2± 33 .52比 1 4 8.63± 2 1 .0 6)和 1 60 .54± 1 6 .93) ;A组肺湿干重比高于B组 ;肺外观苍白肿胀 ,病理检查见组织结构损伤。结论　乌司他丁能保护在体肺缺血再灌注中肺组织结构的损伤     

肺保护性通气策略对腹腔镜胃癌根治手术老年患者肺氧合功能及术后肺部并发症的影响

目的探讨肺保护性通气策略(lung protective ventilation strategy,LPVS)对腹腔镜胃癌根治手术老年患者肺氧合功能及术后肺部并发症(postoperative pulmonary complications,PPCs)的影响。方法选择接受腹腔镜胃癌根治手术的老年患者115例,男69例,女46例,年龄≥65岁,ASAⅠ—Ⅲ级,随机分为两组:常规容量控制通气组(CV组,n=57)和肺保护性通气组(PV组,n=58)。记录插管后10 min(T_1)、气腹后10 min(T_2)、气腹后60 min(T_3)、气腹结束10 min(T_4)时的气道峰压(Ppeak),计算肺顺应性(Cdyn),并在T_1—T_4时抽取动脉血进行血气分析,计算氧合指数(OI)、肺泡动脉血氧分压差(A-aDO_2);记录术后第2天改良肺部感染评分(mCPIS);记录术后7 d内PPCs发生情况。结果与T_1时比较,T_2时两组Cdyn均明显降低(P0.05);T_3—T_4时PV组Cdyn明显高于CV组(P0.05);T_3—T_4时PV组OI明显高于CV组、A-aDO_2明显低于CV组(P0.05)。术后第2天PV组mCPIS明显低于CV组(P0.05)。术后7 d内PV组PPCs发生率明显低于CV组(P0.05)。结论肺保护性通气策略能明显改善老年腹腔镜胃癌根治手术老年患者的肺氧合功能,降低术后肺部并发症,具有一定的肺保护作用。     

Horseshoe lung with left lung hypoplasia.

Horseshoe lung is an uncommon congenital malformation in which the bases of the right and the left lungs are fused to each other by a narrow isthmus posterior to the cardiac apex. So far 22 cases have been described: most of these were associated with right lung hypoplasia and the scimitar syndrome. A horseshoe lung anomaly with left lung hypoplasia is described.     

Technetium-fibrinogen lung scanning in canine lung contusion

To detect experimentally induced acute lung contusion in anesthetized dogs, serial radionuclide images of the lung were recorded following intravenous infusion of 99mTc-labelled human fibrinogen (Tc-HF). The accumulation of Tc-HF in canine lungs was serially quantitated for up to 20 hours after lung contusion. A contusion (#1) was produced in one lung, Tc-HF was injected IV after 15 minutes, and 75 minutes later a contralateral lung contusion (#2) was produced in a series of 14 dogs. At autopsy the excised lungs were scanned, sectioned, and counted for radioactivity. Radiolabelled fibrinogen accumulated within 2-4 minutes of contusion #2 and remained stable over the next 20 hours in 14 dogs; contusion #1 was barely visible in four dogs. Lung Tc-HF activity in the central region of contusion #2 remained sixfold higher than in normal lung tissue. These data suggest that following lung contusion, fibrinogen deposition occurs rapidly and remains stable over a 20-hour interval of observation.     

Septic lung and shock lung in man.

Two series of patients were studied by serial measurements of blood gas exchange and pulmonarmonary dysfunction and to evaluate the dangers of respiratory failure in post traumatic patients. There were 27 patients who had sustained profound hemorrhagic shock and massive blood replacement averaging 9.7 liters and 38 patients who suffered general peritonitis or other forms of fulminating nonthoracic sepsis. All were supported by endotrachael intubation and volume controlled ventilators. The overall mortality for the post shock patients without sepsis was 12% while in the septic patients it was 35%. The maximal pulmonary arteriovenous shunt encountered in the post hemorrhagic shock patients at 36 hours averaged 20 plus or minus 8% and was accompanied by high cardiac indices (average 5.1 plus or minus 1.3 L/M-2/min) but no significant rise of pulmonary arterial pressure or peak inspiratory pressure (PIP). Severe pulmonary dysfunction subsequently occurred only in those patients who later became septic. The studies on the septic patients were divided according to the magnitude of the cardiac indices (the high indices averaged 4.8 plus or minus 1.6L/M-2/min) and thelow indices averaged 1.9 plus or minus 1.0 L/M-2/min. In the former, the average maximal shunt of 30 plus or minus 6% was sustained for 4 or more days, accompanied by an elevation of PIP to 36 plus or minus 6 cm H2O and by Pa pressure of 28 plus or minus 5 mm Hg. The patients in low output septic shock usually had an associated bronchopneumonia and had an average venous admixture of 34 plus or minus 8% and PIP values of 41 plus or minus 8 cm H2O. The mean Pa pressure in this group was 29 plus or minus 6 mm Hg.     

Living-donor lobar lung transplantation for infectious lung diseases

The rate of infection among lung transplant recipients is several times higher than that among recipients of other organs and is most likely related to the exposure of the allograft to the external environment. Meticulous peri-operative management is mandatory in performing living-donor lobar lung transplantation for patients with infectious lung diseases. All 5 patients with end-stage infectious lung diseases are currently alive for 17-104 months after receiving living-donor lobar lung transplantation at Okayama University Hospital.     

Videothoracoscopy-assisted surgical lung biopsy for interstitial lung diseases

Objectives

Surgical lung biopsy (SLB) by videothoracoscopy for diffuse interstitial lung diseases is recommended for detailed diagnosis. Because substantial mortality and morbidity are associated with this procedure, its safety and diagnostic yield should be validated.

Methods

Sixty-four patients with diffuse interstitial lung disease who received SLB by videothoracoscopy between 2007 and 2013 were retrospectively analyzed for mortality, surgical complication, and diagnosis. Criteria for the procedure included patients <70-year old, who had at least 60 % vital capacity and at least 40 % diffusion capacity. Patients with radiologically definite usual interstitial pneumonia were not eligible.

Results

One conversion from the 3-port approach to thoracotomy due to bleeding occurred. Mean operation and anesthesia times were 63 and 133 min, respectively. The mean hospital stay was 6 days. Only 10 patients (16 %) received prophylactic steroid and/or elastase inhibitor administration. Neither deaths nor acute exacerbations of interstitial pneumonia occurred within 60 days after surgery. Pneumothorax occurred in four cases (6 %) after discharge, which was associated with lower % vital capacity and intraoperative steroid administration. Prolonged air leak and postoperative pneumonia were observed in 2 and 1 patients, respectively. Postoperative diagnosis was obtained in all patients. A group of connective tissue disease-related interstitial pneumonia (n = 15) and chronic hypersensitivity pneumonitis (n = 18) were the major diagnoses. Discordance between pre- and postoperative diagnoses was observed among usual interstitial pneumonia, non-specific interstitial pneumonia, and chronic hypersensitivity pneumonia.

Conclusions

Surgical lung biopsy for diffuse interstitial lung diseases is safe under appropriate inclusion criteria and provides definite diagnosis.