Permissive hypercapnia during thoracic anaesthesia

BACKGROUND: While permissive hypercapnia is commonly practised in critical care, it remains unclear if the comparable manoeuvres are clinically acceptable during anaesthesia. This retrospective study aimed at describing the anaesthetic implications of hypercapnia associated with deliberate hypoventilation during thoracic surgery in patients with severe emphysema. METHODS: Thirteen patients with emphysema who required thoracic surgery under similar anaesthesia were reviewed: 3 patients were managed to maintain normocapnia (normocapnia group) whereas 10 patients developed hypercapnia (PaCO2 >70 mmHg) as a result of restricting peak airway pressures (hypercapnia group). RESULTS: In the normocapnia group (PaCO2: 45+/-1 mmHg, mean+/-SD), no event which required therapeutic intervention during the surgery was seen, whereas 2 of 3 patients showed postoperative air leakage which persisted over 5 days. In the hypercapnia group, the maximum PaCO2 during anaesthesia ranged between 70 mmHg and 135 mmHg (98-21 mmHg). During anaesthesia, all 10 patients required inotropic support to prevent hypotension, 4 patients required tracheal gas insufflation of oxygen to the operated lung to avoid hypoxaemia and 3 patients required lidocaine to treat ventricular arrhythmia. However, the trachea was extubated in the operation theatre in 9 of 10 patients and no organ dysfunction was observed postoperatively. Four patients showed postoperative air leak on the first postoperative day, one of which persisted over 5 days. CONCLUSION: Although there are some limitations, this preliminary study indicates that hypercapnia around 100 mmHg during anaesthesia for thoracic surgery may not be associated with serious consequences.     

合并肺气肿的肺或食管肿瘤切除术中同期行肺减容术

目的评价在肺或食管肿瘤手术中同期行肺减容术（LVRS）的可行性和效果。方法45例肺肿瘤和37例食管肿瘤病人，随机分为甲组和乙组，甲组在肿瘤切除手术中同期行开胸侧LVRS，根据术前胸部CT、灌注通气肺扫描结果，确定肺无功能区，切除一侧肺叶的20％～30％；乙组为单纯肿瘤切除术组。随访6～12个月，对比手术前、后肺功能、血气、呼吸困难指数、6min行走距离（6MWD）等指标。结果两组均无围术期死亡，术后FEW1、PaO2、PaCO2、呼吸困难指数以及6MWD甲组病人较术前改善，乙组较术前变化不明显或有轻度下降。结论对合并肺气肿的肿瘤病人，同期LVRS不仅增加了病人的手术机会，而且提高了病人术后生活质量。LVRS扩大了肿瘤病人的手术适应证。     

Quantification of single-breath underestimation of lung volume in emphysema

The extent to which a single breath measurement represents available gas dilutional as well as compressible thoracic volume in emphysema patients has not been quantified. We therefore measured single breath (TLC_SB) and rebreathe helium dilution (TLC_RB), and plethysmographic lung volume (TLC_pleth), in fifty-five outpatients with clinical and radiographic emphysema, and in twenty-one normal controls. Among emphysema patients, TLC_SB increasingly underestimated both TLC_pleth and TLC_RB as FEV₁% predicted decreased (p for interaction = 0.001 for both) by a mean of 1.7 l for TLC_RB (p < 0.001) and 2.2 l for TLC_pleth (p < 0.001). In contrast, TLC_RB underestimated TLC_pleth by a mean of 0.5 l (p < 0.001) regardless of FEV1% (p for interaction = 0.25). TLC_SB, TLC_RB, and TLC_pleth showed strong agreement among normal subjects. We conclude that TLC_SB underestimates available gas dilutional and compressible lung volume as physiologic emphysema severity increases. In contrast, TLC_RB and TLC_pleth show closer agreement which is unaffected by physiologic emphysema severity.     

布地奈德、异丙托溴铵气雾剂联合雾化吸入治疗对肺气肿患者肺功能及血液相关指标的影响

目的 探究布地奈德、异丙托溴铵气雾剂联合雾化吸入治疗对肺气肿患者肺功能及血液相关指标的影响。方法 以抽签分组法将我院接收的50例肺气肿患者分成A组（n=26）和B组（n=24）,其中B组采用异丙托溴铵雾化吸入治疗,而A组采用布地奈德与异丙托溴铵联合雾化吸入治疗。比较两组患者肺功能及血液相关指标的改善效果。结果 A组治疗后肺功能改善情况优于B组,并且A组治疗后PaO2（12.44±0.86）kPa和SaO2（92.15±4.55）kPa均高于B组的PaO2（9.37±0.41）kPa和SaO2（83.66±3.14）kPa,差异有统计学意义（P＜0.05）。结论 对肺气肿患者实施治疗期间联合使用布地奈德和异丙托溴铵气雾剂实施雾化治疗,有助于提高患者肺功能水平,有利于改善患者PaO2及SaO2,疗效可靠。     

运用肺气肿自动定量软件CIP评估COPD患者 肺叶功能的研究

目的 探讨运用CIP软件自动分割肺叶、定量分析单个肺叶及全肺肺气肿指数在评估慢性阻塞性肺疾病患者肺叶功能中的价值。方法 选取2018年7月~12月在我院就诊和住院的稳定期COPD患者23例,行胸部CT薄层扫描,运行CIP软件对其肺叶进行自动分割,定量测定各肺叶及全肺肺气肿指数。结果 CIP软件能将肺叶进行自动分割及计算肺气肿指数,直观了解病变分布的位置,能得到各个肺叶的损伤数据,23例COPD患者中肺气肿1级18例,2级5例。结论 CIP软件可以较好的消除人为因素的影响,快速准确的定量计算肺气肿指数,明确责任肺叶组织的损伤程度,为评估肺储备功能及外科肺减容手术提供参考依据。     

Quantitative analysis of emphysema in 3D using MDCT: influence of different reconstruction algorithms

PURPOSE: The aim of the study was to compare the influence of different reconstruction algorithms on quantitative emphysema analysis in patients with severe emphysema. MATERIAL AND METHODS: Twenty-five patients suffering from severe emphysema were included in the study. All patients underwent inspiratory MDCT (Aquilion-16, slice thickness 1/0.8mm). The raw data were reconstructed using six different algorithms: bone kernel with beam hardening correction (BHC), soft tissue kernel with BHC; standard soft tissue kernel, smooth soft tissue kernel (internal reference standard), standard lung kernel, and high-convolution kernel. The only difference between image data sets was the algorithm employed to reconstruct the raw data, no additional radiation was required. CT data were analysed using self-written emphysema detection and quantification software providing lung volume, emphysema volume (EV), emphysema index (EI) and mean lung density (MLD). RESULTS: The use of kernels with BHC led to a significant decrease in MLD (5%) and EI (61-79%) in comparison with kernels without BHC. The absolute difference (from smooth soft tissue kernel) in MLD ranged from -0.6 to -6.1 HU and were significant different for all kernels. The EV showed absolute differences between -0.05 and -0.4 L and was significantly different for all kernels. The EI showed absolute differences between -0.8 and -5.1 and was significantly different for all kernels. CONCLUSION: The use of kernels with BHC led to a significant decrease in MLD and EI. The absolute differences between different kernels without BHC were small but they were larger than the known interscan variation in patients. Thus, for follow-up examinations the same reconstruction algorithm has to be used and use of BHC has to be avoided.     

Single-lung transplantation in emphysema: Retrospective study analyzing survival and waiting list mortality

AIM: To performed remains a subject of debate and is the principal aim of the study. METHODS: This retrospective analysis included 73 patients with emphysema (2000-2012). The outcomes of patients undergoing single-lung transplantation (SL) (n = 40) or double-lung transplant (DL) (n = 33) were compared in a Cox multivariate analysis to study the impact of the technique, postoperative complications and acute and chronic rejection on survival rates. Patients were selected for inclusion in the waiting list according to the International Society of Heart Lung Transplantation criteria. Pre and postoperative rehabilitation and prophylaxis, surgical technique and immunosuppressive treatment were similar in every patients. Lung transplantation waiting list information on a national level and retrospective data on emphysema patient survival transplanted in Spain during the study period, was obtained from the lung transplantation registry managed by the National Transplant Organization (ONT). RESULTS: Both groups were comparable in terms of gender and clinical characteristics. We found significant differences in the mean age between the groups, the DL patients being younger as expected from the inclusion criteria. Perioperative complications occurred in 27.6% SL vs 54% DL (P = 0.032). Excluding perioperative mortality, median survival was 65.3 mo for SL and 59.4 mo for DL (P = 0.96). Bronchiolitis obliterans and overall 5-year survival were similar in both groups. Bacterial respiratory infection, cytomegalovirus and fungal infection rates were higher but not significant in SL. No differences were found between type of transplant and survival (P = 0.48). To support our results, national data on all patients with emphysema in waiting list were obtained (n = 1001). Mortality on the waiting list was 2.4% for SL vs 6.2% for DL. There was no difference in 5 year survival between 235 SL and 430 DL patients transplanted (P = 0.875). CONCLUSION: Our results suggest that SL transplantation in emphysema produce similar survival than DL with less postoperative complication and significant lower mortality in waiting list.     

肺顺应性有效值的间接测定法及其临床应用

介绍测定用力呼气肺量图部分平均通过时间和该部分平均呼气流量,以及按公式计算肺顺应性有效值(Ceff)的原理和方法。对100例正常人和99例慢性支气管炎、阻塞性肺气肿和弥漫性肺间质纤维化患者的测定结果表明:Ceff的高低对肺气肿和弥漫性肺间质纤维化等疾病具有辅助诊断价值,尤其对早期肺气肿的诊断可能具有较大的临床意义。     

煤工尘肺肺功能损害特点的研究

通过140例煤工尘肺(CWP)的通气功能和部分换气功能测定,综合分析和评价CWP呼吸功能损害的特点。CWP早期即有肺气肿及低氧血症的存在,小气道阻力增加及尘斑气肿是CWP的重要病理基础,低氧血症与肺气肿有密切关系,DLco降低Ⅲ期最明显与间质纤维化程度增高有关。