选择性肺叶隔离技术在电视辅助胸腔镜手术中的应用

目的探讨选择性肺叶隔离技术在电视辅助胸腔镜手术（VATS）中的应用价值。方法拟行VATS右中下肺楔形切除或肺活检术成年患者38例,随机分为肺叶隔离组和单肺通气组各19例。丙泊酚靶控输注静脉诱导后,肺叶隔离组插入单腔气管导管,纤维支气管镜引导下将9 Fr Coopdech支气管堵塞管置入右中间支气管。单肺通气组插入左双腔支气管导管。两组均行双肺正压通气,20 min后摆放左侧卧位,肺叶隔离组对堵塞管套囊充气行左肺和右上肺叶通气;单肺通气组行左单肺通气。于双肺通气后20 min（T1）、左单肺通气或左肺和右上肺叶通气后20 min（T2）、胸腔镜下见右肺或右中下肺叶完全萎陷后（T3）、术毕拔出气管导管前（T4）及术后第1天（T5）行动脉血气分析,记录T1～T4的吸气峰压（Ppeak）、肺顺应性（Cdyn）。结果肺叶隔离组T2、T3、T5时点PaO2、氧合指数均明显高于单肺通气组;T2、T3时点Ppeak均明显低于单肺通气组,Cdyn明显高于单肺通气组（P〈0.05或0.01）。结论选择性右中下肺叶隔离技术用于右侧VATS,可提供清晰术野,改善术中低氧血症,复合短时间单肺通气可使气道控制更精确合理。

Application of selective lobar blockade in video-assisted thoracic surgery

Objective To investigate the value of selective lobar blockade（SLB） in patients undergoing video-assisted thoracic surgery（VATS）.Methods Thirty-eight adult patients scheduled for right middle and lower lung wedge resection or biopsy under VATS were allocated randomly to SLB group and one lung ventilation（OLV） group with 19 in each.Anesthesia was induced and maintained with Propofol by target controlled infusion,single-lumen Endotracheal tube was used in the SLB group,and 9 French Coopdech endobronchial blocker tube was advanced into the bronchus intermedius by the guidance of a fiberoptic bronchoscope.The left-sided double-lumen endobronchial tube was placed in the OLV group.After two-lung ventilation for 20 mins,the patients were placed in the left lateral decubitus position.The bronchial balloon of BBT was fully inflated in the SLB group,collapse of the right middle and lower lobes was achieved while ventilation of the right upper lobe and left lung was maintained;left lung ventilation was performed in the OLV group.Arterial blood gas analyses were performed at five surgical times： 20 mins after two-lung ventilation in supine position（T1）,20 min after initiation of OLV or SLB by inflating balloon of the blocker in left lateral decubitus position（T2）,total collapse of right lung or right middle and lower lobes after placing the trocar and thoracoscope（T3）,before tracheal extubation（T4） and the first postoperative day（T5）,the peak inspiratory airway pressure（Ppeak）,dynamic lung compliance（Cdyn） were recorded at T1～T4.Results The PaO2,oxygenation index of the SLB group at T2,T3,T5 were significantly higher than those of the OLV group;the Ppeak at T2,T3 were significantly lower than those of the OLV group,the Cdyn were significantly higher than those of the OLV group（P0.05 or 0.01）.Conclusion The application of SLB during VATS can provide good surgical exposure,improve perioperative arterial oxygenation,and can make the airway management accurately and reasonably when combined with temporary-OLV.