肺切除术对围手术期呼吸功能影响的临床研究
摘要
目的:本课题对肺癌患者采用不同的通气方式,观察其围手术期的肺功能及血气指标变化。联合动物实验,比较单肺通气(OLV)方式下大鼠肺组织水通道蛋白-5(aquaporin-5, AQP-5)表达的变化。探讨不同通气方式对患者围手术期呼吸功能产生的影响。
方法:1、动物实验部分:建立两种OLV大鼠模型:夹闭左侧肺门OLV组(A组),过深插管OLV组(B组)。按不同通气时间分亚组A1、A2、A3和B1、B2、B3。设双对照组:双肺通气组(C组),同样分亚组C1、C2、C3;空白对照(D组)。镜下观察肺组织变化,比较单肺通气前后肺组织显微结构的变化,免疫印记法检测肺AQP-5的表达。
2、临床实验部分:测定40例行肺叶切除术的肺癌患者术前、术后2个月的肺功能及血气指标。分析肺功能的变化规律及影响因素。结果:
一、动物实验部分:A、B、C组AQP-5的表达均较D组减少(P<0.05);A、B、C组组内各亚组比较差异均有统计学意义(P<0.05);A1、B1、C1组间比较差异均无统计学意义(P>0.05);A2、B2、C2组间比较,A2比B2和C2均有减少(P<0.05),B2与C2差异无统计学意义(P>0.05);A3、B3、C3组间比较,A3和B3均较C3组减少(P<0.05),A3比B3减少(P<0.05)。
二、临床实验部分:1、术后第1天,患者肺功能降低到术前的(28±11)%,术后第二天继续降低至(27±10)%,术后第3~6天恢复相对较快,术后第10天恢复到术前的(41±11)%。2、单因素分析中,有无抽烟史(F=6.315,P<0.05),性别(F=10.861,P<0.05),术后镇痛方式(F=18.389,P<0.05)对术后早期肺功能有影响。手术方式、麻醉通气方式对术后早期肺功能及血气无影响。3、多因素分析中,术前肺功能、抽烟史、年龄、疼痛等创伤应激反应都是影响术后早期肺功能的因素。
结论:
一、动物实验部分:机械通气可致大鼠AQP-5表达下调,与时间相关,夹闭法OLV和插管过深法OLV对AQP-5表达的影响超过双肺通气,前者更明显。
二、临床实验部分:开胸手术患者术后早期肺功能受抑制严重,随术后时间的延长逐渐恢复。有效改善患者术前肺功能、全民戒烟运动、减少术中创伤及对呼吸肌的损伤、充分的术后镇痛,是减少术后肺功能抑制肺部并发症的重要方法。
Objeetive Observed in patients with unilateral chest lobectomy, wedge resection of lung perioperative pulmonary function and blood gas changes. Joint animal experiments, compared before and after single-lung ventilation changes in lung tissue microstructure.
Methods
1. Animal experiments :The rats were divided into four groups. Group A: Performing OLV by clamping. Group B: Right bronchial intubation OLV. Group A and Group B was divided into A1, A2, A3, and B1, B2, B3 according to different ventilation time. There are two control groups. Group C: total lung ventilation group, which divided into C1, C2, C3 by the corresponding time with the experimental group. Group D: Vacuity contrast group. Take the lung tissue for Western blotting, observed the expression of AQP-5.
2. Part of clinical trials : Pre-and early postoperative pulmonary function was detected in 40 consecutive cases with optimal thoracotomy . chief complaint and preoperative conditions were analyzed using SPSS13.0 medical statistic software.
Results
1. Animal experiments :Compared the expression of AQP-5, group A, B and C were less than group D (P<0.05), A, B, C compared within each group were significant differences (P<0.05); There is no significantly difference among the group A1, B1 and C1 (P>0.05); group A2 was less than group B2 and group C2(P<0.05),and there is no significantly difference between B2 and C2; Group A3 and group B3 were less than group C3 (P<0.05),Group A3 was less than group B3(P<0.05).
2. Part of clinical trials:Postoperative day 1, lung function decreased to the preoperative (28±11)% after the next day to continue to reduce to (27±10)%, 3 to 6 days after surgery restored relatively quickly, after 10 back to the days before surgery (41±11)%. Univariate analysis, with or without smoking history (F = 6.315, P <0.05), gender (F = 10.861, P <0.05), postoperative analgesia (F = 18.389, P <0.05 ) on the impact of early postoperative pulmonary function. Surgical, anesthesia ventilation methods on postoperative lung function had no effect. Multivariate analysis, preoperative pulmonary function, smoking history, age, pain of traumatic stress reactions are the factors of early postoperative pulmonary function .
Conclusions
1. Animal experiments :Mechanical ventilation can reduce the expression of rat AQP-5, and time-dependent. Performing OLV by clamping and right bronchial intubation OLV have higher effect on the expression of rat AQP-5 than total lung ventilation, the former is more obvious.
2. Part of clinical trials:Early postoperative lung function in patients undergoing thoracic surgery severely damaged, with the gradual recovery time after surgery. Effectively improve the preoperative pulmonary function, national smoking cessation campaign to reduce intraoperative trauma and damage to the respiratory muscles, adequate postoperative analgesia, reduced postoperative pulmonary function is an important method of pulmonary complications.
方法:1、动物实验部分:建立两种OLV大鼠模型:夹闭左侧肺门OLV组(A组),过深插管OLV组(B组)。按不同通气时间分亚组A1、A2、A3和B1、B2、B3。设双对照组:双肺通气组(C组),同样分亚组C1、C2、C3;空白对照(D组)。镜下观察肺组织变化,比较单肺通气前后肺组织显微结构的变化,免疫印记法检测肺AQP-5的表达。
2、临床实验部分:测定40例行肺叶切除术的肺癌患者术前、术后2个月的肺功能及血气指标。分析肺功能的变化规律及影响因素。结果:
一、动物实验部分:A、B、C组AQP-5的表达均较D组减少(P<0.05);A、B、C组组内各亚组比较差异均有统计学意义(P<0.05);A1、B1、C1组间比较差异均无统计学意义(P>0.05);A2、B2、C2组间比较,A2比B2和C2均有减少(P<0.05),B2与C2差异无统计学意义(P>0.05);A3、B3、C3组间比较,A3和B3均较C3组减少(P<0.05),A3比B3减少(P<0.05)。
二、临床实验部分:1、术后第1天,患者肺功能降低到术前的(28±11)%,术后第二天继续降低至(27±10)%,术后第3~6天恢复相对较快,术后第10天恢复到术前的(41±11)%。2、单因素分析中,有无抽烟史(F=6.315,P<0.05),性别(F=10.861,P<0.05),术后镇痛方式(F=18.389,P<0.05)对术后早期肺功能有影响。手术方式、麻醉通气方式对术后早期肺功能及血气无影响。3、多因素分析中,术前肺功能、抽烟史、年龄、疼痛等创伤应激反应都是影响术后早期肺功能的因素。
结论:
一、动物实验部分:机械通气可致大鼠AQP-5表达下调,与时间相关,夹闭法OLV和插管过深法OLV对AQP-5表达的影响超过双肺通气,前者更明显。
二、临床实验部分:开胸手术患者术后早期肺功能受抑制严重,随术后时间的延长逐渐恢复。有效改善患者术前肺功能、全民戒烟运动、减少术中创伤及对呼吸肌的损伤、充分的术后镇痛,是减少术后肺功能抑制肺部并发症的重要方法。
Objeetive Observed in patients with unilateral chest lobectomy, wedge resection of lung perioperative pulmonary function and blood gas changes. Joint animal experiments, compared before and after single-lung ventilation changes in lung tissue microstructure.
Methods
1. Animal experiments :The rats were divided into four groups. Group A: Performing OLV by clamping. Group B: Right bronchial intubation OLV. Group A and Group B was divided into A1, A2, A3, and B1, B2, B3 according to different ventilation time. There are two control groups. Group C: total lung ventilation group, which divided into C1, C2, C3 by the corresponding time with the experimental group. Group D: Vacuity contrast group. Take the lung tissue for Western blotting, observed the expression of AQP-5.
2. Part of clinical trials : Pre-and early postoperative pulmonary function was detected in 40 consecutive cases with optimal thoracotomy . chief complaint and preoperative conditions were analyzed using SPSS13.0 medical statistic software.
Results
1. Animal experiments :Compared the expression of AQP-5, group A, B and C were less than group D (P<0.05), A, B, C compared within each group were significant differences (P<0.05); There is no significantly difference among the group A1, B1 and C1 (P>0.05); group A2 was less than group B2 and group C2(P<0.05),and there is no significantly difference between B2 and C2; Group A3 and group B3 were less than group C3 (P<0.05),Group A3 was less than group B3(P<0.05).
2. Part of clinical trials:Postoperative day 1, lung function decreased to the preoperative (28±11)% after the next day to continue to reduce to (27±10)%, 3 to 6 days after surgery restored relatively quickly, after 10 back to the days before surgery (41±11)%. Univariate analysis, with or without smoking history (F = 6.315, P <0.05), gender (F = 10.861, P <0.05), postoperative analgesia (F = 18.389, P <0.05 ) on the impact of early postoperative pulmonary function. Surgical, anesthesia ventilation methods on postoperative lung function had no effect. Multivariate analysis, preoperative pulmonary function, smoking history, age, pain of traumatic stress reactions are the factors of early postoperative pulmonary function .
Conclusions
1. Animal experiments :Mechanical ventilation can reduce the expression of rat AQP-5, and time-dependent. Performing OLV by clamping and right bronchial intubation OLV have higher effect on the expression of rat AQP-5 than total lung ventilation, the former is more obvious.
2. Part of clinical trials:Early postoperative lung function in patients undergoing thoracic surgery severely damaged, with the gradual recovery time after surgery. Effectively improve the preoperative pulmonary function, national smoking cessation campaign to reduce intraoperative trauma and damage to the respiratory muscles, adequate postoperative analgesia, reduced postoperative pulmonary function is an important method of pulmonary complications.
引文
[1] Pezzdla AT,Adebon jo SA,HookersG,et a1.Complications ofgener-althoracic surgery [ J ] .Curt Probl Surg,2000,37(11) :733 - 858.
[2]郑劲平,用力肺活量检测的质量控制及注意事项,中华结核和呼吸杂志,2005,28(2):77-78
[3] 1wata T. Inoue K.Long—term outcome of surgical treatment for non—small cell lung cc er with comorbid liver cirrhosis [ J ].Ann Thorao—ie Surg,2007 84(6):1810-1817.
[4] Mu-kos ,T, Mullan BP, Hillman DB, et al. Preoperative assessment as a predictor of mortality and morbidity after lung resection. Am Rev BesPirDis, 1989, 139: 902- 910.
[5] Korst RJ, Ginsherg RJ, Ailawadli M,et al .lobectomy improves ventilatorv function in selected patients with severe COPD;Ann Thorac Surg, 1998, 66: 898-902
[6] Miyoshi S, Yoshimasu T,H i1aiT, et al. Exercise capacity of thoracotomy patients in early postoperative period. Chest,2000, 118:384-390.
[7] Bastin R ,Moraine JJ, BardocskvG, et al. Incentive spirometly perfonnance a reliable indicator of pulmonary function in the early postoperative period after lobectomy chest, 1997, I I I: 555-563.
[8]陈灏珠,主编.实用内科学[M].北京:人民卫生出版社, 1998 . 137721511
[9]许广润,主编.现代呼吸疾病诊疗手册[M].北京:北京医科大学、中国协和医科大学联合出版社, 1998. 3852391.
[10]丁东杰1吸烟对肺功能的影响及与慢阻肺和肺源性心脏病的关系[ J]1实用肺科杂志, 1998, 5( 1) :1~ 3
[11]苏跃全麻下单肺通气对肺功能的影响中华麻醉学杂志1999 ,10 (19)584-586
[12]徐旭仲,应斌宇,杨拔贤.剖胸术后持续输注布比卡因合芬太尼复合液硬膜外镇痛对肺功能的影响.中国疼痛医学杂志, 1997; 3∶73
[13]李锡初,曾庆诗,孙来保,等.胸段硬膜外镇痛对先天性动脉导管未闭术后高血压反应的影响.中华麻醉学杂志, 2002; 22∶535
[14] Winter J , Bevan S, Campbell EA. Capsincin and pain mecanisms . B r Anaesth, 1995; 75∶157
[15] Jenal A,Siegel R,Ward E,et al.Cancer statistics,2008[J].CA Cancer J Clin,2008,58(2):71-96.
[1]陈秉学,许梅曦,李伟,等.胸科肿瘤麻醉学[M] .郑州:郑州大学出版社, 2001. 24225.
[2]周明娟.肺功能与胸腹外科手术[ J] .国外医学呼吸系统分册,2003, 23( 3) : 1632166.
[3]张海燕,梁伟.肺癌患者肺切除术前的肺功能评估[ J] .中国处方药, 2005, 10( 43) : 17218.
[4]农青,李爱军,杨芳.食管癌经胸入路外科手术对肺功能的影响[ J] .武警医学, 1998, 9( 11) : 6272629.
[5]吴煌福,林伟民,李标.重度肺功能减退胸部肿瘤患者外科治疗及围手术期管理[ J] .中国热带医学, 2005, 5( 4) : 7832784.
[6]王振文,尤胜义,王鹏志.腹部外科患者术后肺功能的变化[ J] .天津医药, 2000, 28( 4) :3952397.
[7] Stephan F, Boucheseiche S, Hollande J, et al . Pulmonary complications following lung resect ion: a comprehensive analysis of incidence and pos2sible risk factors[ J] . Chest, 2000, 118(5) : 126321270.
[8] Reilly J.Evidence2based preoperative evaluation of candidates for thoracotomy[ J] . Chest, 1999, 116( 6) : 474s2476s.
[9] Markos J,Mullan BP, Hillman DR, et al . Preoperat ive assessment as apredictor of mort ality and morbidity aft er lung resect ion[ J] . Am RevResp Dis, 1998, 139( 5) : 9022910.
[10] Kearney DJ,Lee TH, Reilly JJ, et al . Assessment of operate risk in pat ients undergoing lung resection[ J] . Chest, 1994, 105( 3) : 7532759.
[11]任少华.术前肺功能检查的临床意义[ J] .综合临床医学, 1994,10( 1) : 9210.
[2]郑劲平,用力肺活量检测的质量控制及注意事项,中华结核和呼吸杂志,2005,28(2):77-78
[3] 1wata T. Inoue K.Long—term outcome of surgical treatment for non—small cell lung cc er with comorbid liver cirrhosis [ J ].Ann Thorao—ie Surg,2007 84(6):1810-1817.
[4] Mu-kos ,T, Mullan BP, Hillman DB, et al. Preoperative assessment as a predictor of mortality and morbidity after lung resection. Am Rev BesPirDis, 1989, 139: 902- 910.
[5] Korst RJ, Ginsherg RJ, Ailawadli M,et al .lobectomy improves ventilatorv function in selected patients with severe COPD;Ann Thorac Surg, 1998, 66: 898-902
[6] Miyoshi S, Yoshimasu T,H i1aiT, et al. Exercise capacity of thoracotomy patients in early postoperative period. Chest,2000, 118:384-390.
[7] Bastin R ,Moraine JJ, BardocskvG, et al. Incentive spirometly perfonnance a reliable indicator of pulmonary function in the early postoperative period after lobectomy chest, 1997, I I I: 555-563.
[8]陈灏珠,主编.实用内科学[M].北京:人民卫生出版社, 1998 . 137721511
[9]许广润,主编.现代呼吸疾病诊疗手册[M].北京:北京医科大学、中国协和医科大学联合出版社, 1998. 3852391.
[10]丁东杰1吸烟对肺功能的影响及与慢阻肺和肺源性心脏病的关系[ J]1实用肺科杂志, 1998, 5( 1) :1~ 3
[11]苏跃全麻下单肺通气对肺功能的影响中华麻醉学杂志1999 ,10 (19)584-586
[12]徐旭仲,应斌宇,杨拔贤.剖胸术后持续输注布比卡因合芬太尼复合液硬膜外镇痛对肺功能的影响.中国疼痛医学杂志, 1997; 3∶73
[13]李锡初,曾庆诗,孙来保,等.胸段硬膜外镇痛对先天性动脉导管未闭术后高血压反应的影响.中华麻醉学杂志, 2002; 22∶535
[14] Winter J , Bevan S, Campbell EA. Capsincin and pain mecanisms . B r Anaesth, 1995; 75∶157
[15] Jenal A,Siegel R,Ward E,et al.Cancer statistics,2008[J].CA Cancer J Clin,2008,58(2):71-96.
[1]陈秉学,许梅曦,李伟,等.胸科肿瘤麻醉学[M] .郑州:郑州大学出版社, 2001. 24225.
[2]周明娟.肺功能与胸腹外科手术[ J] .国外医学呼吸系统分册,2003, 23( 3) : 1632166.
[3]张海燕,梁伟.肺癌患者肺切除术前的肺功能评估[ J] .中国处方药, 2005, 10( 43) : 17218.
[4]农青,李爱军,杨芳.食管癌经胸入路外科手术对肺功能的影响[ J] .武警医学, 1998, 9( 11) : 6272629.
[5]吴煌福,林伟民,李标.重度肺功能减退胸部肿瘤患者外科治疗及围手术期管理[ J] .中国热带医学, 2005, 5( 4) : 7832784.
[6]王振文,尤胜义,王鹏志.腹部外科患者术后肺功能的变化[ J] .天津医药, 2000, 28( 4) :3952397.
[7] Stephan F, Boucheseiche S, Hollande J, et al . Pulmonary complications following lung resect ion: a comprehensive analysis of incidence and pos2sible risk factors[ J] . Chest, 2000, 118(5) : 126321270.
[8] Reilly J.Evidence2based preoperative evaluation of candidates for thoracotomy[ J] . Chest, 1999, 116( 6) : 474s2476s.
[9] Markos J,Mullan BP, Hillman DR, et al . Preoperat ive assessment as apredictor of mort ality and morbidity aft er lung resect ion[ J] . Am RevResp Dis, 1998, 139( 5) : 9022910.
[10] Kearney DJ,Lee TH, Reilly JJ, et al . Assessment of operate risk in pat ients undergoing lung resection[ J] . Chest, 1994, 105( 3) : 7532759.
[11]任少华.术前肺功能检查的临床意义[ J] .综合临床医学, 1994,10( 1) : 9210.