纤维支气管镜引导胸腔镜下肺癌肺叶切除术的临床研究

目的 探讨纤维支气管镜引导在胸腔镜下肺癌肺叶切除术中的应用.方法 选择2009年2月至2013年9月行胸腔镜下肺叶切除术肺癌患者70例,美国麻醉医师协会分级Ⅰ～Ⅱ级,心功能分级Ⅰ～Ⅱ级.完全随机分为研究组和对照组,各35例,均采用静吸复合全身麻醉行胸腔镜肺叶切除术.2组患者均采用双腔支气管插管,研究组应用纤维支气管镜进行双腔支气管插管调整定位,对照组采用以往临床最常用的双肺听诊法、气道压力变化法以及呼气末二氧化碳分压波形法调整双腔支气管插管位置.术中行单肺通气,监测项目包括有创血压、中心静脉压、心率、5导联心电图、脉搏血氧饱和度、呼气末二氧化碳分压以及动脉血气分析.对比2组患者血气及术后并发症情况.结果 研究组术中失血量、术后引流量、尿量、手术时间、单肺通气时间分别为（95±27）ml、（130±66）ml、（566±81）ml、（132±47）min、（95±34）min;对照组分别为（220±35）ml、（260±67）ml、（580±75）ml、（130±33）min、（113±27）min,研究组术中失血量、术后引流量及单肺通气时间均小于对照组,差异均有统计学意义（P＜0.05）.研究组仅1例术中出现低氧血症.对照组患者单肺通气过程中,有5例出现低氧血症.研究组单肺通气5 min平均动脉压、动脉血氧分压、呼气末二氧化碳分压、脉搏血氧饱和度分别为（78±7）mmHg（1 mmHg=0.133 kPa）、（134±26）mmHg、（34.7±2.4）mmHg、（97.5±1.4）%;单肺通气15 min分别为（77±7）mmHg、（122±28）mmHg、（35.2±2.4）mmHg、（98.1±0.7）%.对照组单肺通气5 min平均动脉压、动脉血氧分压、呼气末二氧化碳分压、脉搏血氧饱和度分别为（77±7）mmHg、（113±27）mmHg、（35.7±2.2）mmHg、（93.6±3.6）%,单肺通气15 min分别为（76±7）mmHg、（106±24）mmHg、（36.6±2.2）mmHg、（90.5±6.3）%.对照组单肺通气5、15 min动脉血氧分压与脉搏血氧饱和度均明显低于研究组,差异均有统计学意义（P＜0.05）.70例患者拔管后均无再次气管插管.术后随访患者3 d,2组共有7例患者出现低氧血症.有9例患者出现声音嘶哑.结论 利用纤维支气管镜引导双腔气管导管准确定位,使双肺隔离满意,有效避免单肺通气时的低氧血症,纤维支气管镜可直视观察,方便快捷,适用于双腔气管插管对位.

Analysis of anesthesia management of thoracoscopic lobectomy for lung cancer

Objective To study the application and the relative treatment of complication during thoracoscopic lobectomy treating lung cancer patients under fiberoptic bronchoscopy（FOB）. Methods Seventy patients with lung cancer underwent thoracoscopic lobectomy from February 2009 to September 2013 were divided into study group（35 cases） and control group（35 cases） randomly. The American society of anesthesiologists （ASA） grade was Ⅰ-Ⅱ; cardiac functional grading （NYHA） wasⅠ-Ⅱ. Both groups were given double-lumen endotracheal intubation; study group were given bronchoscopy; control group were given lung auscultation. In the operation, single lung ventilation was used; invasive blood pressure（ABP）, central intravenous pressure（CVP）, heart rate（HR）, 5-medical ECG, saturation of pulse oxygen（SpO2 ）, PET CO2 and blood gas analysis were monitored. The blood gas and complications were compared. Results Intraoperative blood loss, postoperative drainage, urine output, operation time, single-lung ventilation time in study group were （95±27）ml, （130±66）ml, （566±81）ml, （132±47）min, （95±34）min; those in control group were （220±35） ml, （260±67） ml, （580±75）ml, （130±33）min, （113±27）min; intraoperative blood loss, postoperative drainage, and one-lung ventilation in study group were lower than those in control group, the difference was statistically significant P〈0.05）.There was only one case of hyoxmia in study group. Five cases of hyoxmia occurred in control group. During single lung ventilation, especially 15 minutes later, the statistics of SpO2, PaO2, PETCO2 was different. The SpO2, PaO2, PaCO2 in 15 minutes in study group were （77±7）mmHg,（122±28）mmHg,（35.2±2.4）mmHg and （98.1±0.7）%; the SpO2, PaO2, PETCO2 in 15 minutes in control group were （76±7）mmHg,（106±24）mmHg,（36.6±2.2）mmHg and （90.5±6.3）%. There was no statistics significance for average arterial pressure. There was no need of second time tracheal intubation for 70 studied cases. Three days after operation, seven cases of hyoxmia and nine cases hoarseness were found. Conclusions The DLT locating is accurate by using FOB and the isolation of double lungs is good. The hyoxmia is avoided during single lung ventilation.