三种通气方式在老年患者纤支镜检查术中的效果比较

目的 探讨三种通气管理方式用于老年患者纤支镜检查术的效果.方法 120例麻醉风险评估（ASA）为Ⅰ～Ⅲ级的老年患者,按分层抽样原则分为3组：局麻自主呼吸组（S组）;全麻内镜面罩通气组（E组）;全麻三通喉罩（TLMA）通气组（T组）,每组各40例患者.3组均采用超声雾化器吸入2％利多卡因15 min进行表面麻醉;E组和T组静脉注射芬太尼1.0 μg/kg、异丙酚1.5 mg/kg,微泵连续输注异丙酚5.0 mg·kg^-1·h^-1,T组另加微泵连续输注瑞芬太尼0.2 μg·kg^-1·min^-1维持麻醉.E组通过内镜面罩供氧,T组插入TLMA行控制呼吸.记录患者基础值（T0）以及纤支镜入声门前（T1）、入声门时（T2）、入声门后5 min时（T3）、活检或涮检时（T4）、出声门时（T5）的心率（HR）、收缩压（SBP）、舒张压（DBP）和血氧饱和度（SpO2）的变化;应用高效液相色谱分析法测定T0、T1、T2、T3、T4、T5时的静脉血血浆肾上腺素（E）、去甲肾上腺素（NE）和多巴胺（DA）水平.结果 S组完成手术33例（82.5％）,7例（17.5％）患者放弃手术;E组全部病例完成手术,9例（22.5％）发生呼吸抑制,10例（25.0％）发生呼吸道梗阻;T组全部手术顺利完成,无明显并发症.S组收缩压（SBP）、舒张压（DBP）和心率（HR）在T2、T3、T4、T5时均显著高于T0（P ＜0.05）,也显著高于E组和T组（P＜0.05）.S组的E、NE和DA在T2、T3、T4、T5时显著高于E组和T组（P＜0.05）.结论 老年患者纤支镜检查术时表面麻醉复合静脉麻醉,并应用内镜面罩或TLMA行气道管理较单纯表面麻醉更加安全有效,TLMA通气效果满意,血流动力学和应激激素水平更稳定.

Comparison of three ventilatory patterns during bronchoscopy in elder patients

Objective To compare the effects of three ventilatory patterns during bronchoscopy in elder patients. Methods 120 patients （ASA class Ⅰ or Ⅲ ） aged 65-89yrs undergoing bronchoscopy were divided into 3groups according to the stratified sampling principle （ n = 40 each ） ： group S topical anesthesia with spontaneous respiration; group E intravenous anesthesia with endoscopy mask and group T intravenous anesthesia with three-way laryngeal mask airway （TLMA）. Topical anesthesia with 2% lidoeainc 20 ml was used in all three groups ; In group E fentanyl 1.0 μg/kg and propofol 1.5 mg/kg were given i.v. followed by i. v. of propofol at a ration of 5.0 mg· kg^- 1 · h ^- 1 ; In group T fcntanyl 1.0 μg/kg and propofol 1.5 mg/kg were given i.v. followed by i.v. of propofol at a ration of 5.0 mg· kg^- l · h^ - l and remifentanil at a ration of 0.2 μg · kg^- 1 · min^- l ; In group T vecuronium 0.08 mg/kg was given i. v. to provide muscle relaxation. SpO2 ,SBP, DBP and HR were continuously monitored during anesthesia and measured at 5 min after entering the surgery room （T0）, immediately before the bronchoscope entering the glottis （T1）, immediately after the bronchoscope entering the glottis, （T2 ）, 5min after the bronchoscope entering the glottis （ T3 ）, at the time of biopsy （ T4 ） and at the immediately after the bronchoscope extubating the glottis （ T5 ）. Blood samples were taken at To, T1, T2, T3, T4, T5 time points for the measurements of epinephrine （E）, norepinephrine （NE） and dopamine （DA） levels with HPLC （ high performance liquid chromatography）. Results The bronchoscopy was much easier in group E and T. Bronchoscopy failed in 7 （17.5%） patients in group S. In group S SBP, DBP and HR increased significantly at T2 , T3 , T4 , T5 compared to the baseline values （P 〈 0.05 ） , and were also significantly higher than in group E and T at T2 , T3 , T4 , T5 （ P 〈 0.05 ）. The E, NE and DA were significantly higher in group S than those in gro