催眠镇痛肌松下选择性患侧肺控压吹张治疗术后顽固性肺不张的疗效
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摘要
目的：
探讨在催眠镇痛肌松下选择性患侧肺支气管插管控压吹张治疗术后顽固性肺不张的临床效果,从而为术后顽固性肺不张的治疗增加新的手段。
方法：
收集2005年1月-2010年5月嘉兴市第一医院20例接受过纤维支气管镜吸痰、胸腔闭式负压引流、拍背、吹气球等常规综合治疗7d仍不能使患肺复张的术后肺不张患者,在催眠镇痛术下行支气管插管选择性患侧肺控压吹张治疗。治疗前常规禁食6h以上,开放外周静脉通路,监测血压、心电图、无创脉搏氧饱和度。患者取平卧位,双肺听诊后面罩吸氧,氧流量>8L/min,静脉注射阿托品0.2mg、异丙酚2mg/kg、琥珀胆碱1mg/kg行麻醉诱导,随即在纤维支气管镜引导下行患侧支气管插管,确认导管位置无误后套囊充气,健侧支气管导管接Newport呼吸机行机控呼吸(IPPV),患侧支气管导管连接Datex-Ohmeda麻醉呼吸机(Datex-Ohmeda公司,美国),行手动人工控压屏持吹张膨肺治疗：开启麻醉呼吸机并切换至人工手动模式,操作者双手合掌挤压呼吸囊,在观察患者胸廓起伏的同时,观察麻醉机电子显示屏上的压力变化,将吹张压力控制在30～50cmH2O (1cmH2O=0.098kPa)，屏持时间为20s/次。重复上述控压吹张操作,直至原不张肺区听诊出现清晰呼吸音、有胸腔闭式引流者引流瓶中基本再无气泡或引流液溢出为止。若膨肺操作过程中患者自主呼吸恢复,可追加异丙酚1mg/kg、琥珀胆碱0.5mg/kg。操作完成后将支气管导管退回至总气管内,待患者自主呼吸恢复、神志清醒后拔管,静脉注射地塞米松0.2mg/kg防止复张性肺水肿,拔管后观察30min,生命体征稳定后送回病房。疗效由胸部听诊及次日胸部X光片评判,1次治疗无效改日再作,3次治疗不能复张者计为治疗无效。
结果：
19例患者在催眠镇痛肌松下借助小儿纤维支气管镜引导、顺利完成选择性患侧支气管插管控压膨肺治疗,其中1例患者治疗过程中发现支气管内炎性肉芽组织增生阻塞而剔除了本研究。术后第2天复查X线胸片,16例患者(84.2%)萎陷肺已全部复张,3例患者萎陷侧肺复张不完全,经第2次控压膨肺治疗后2例复张成功(10.5%,总有效率94.7%),另1例患者经3次膨肺治疗仍无效(5.3%)。期间患者生命体征稳定,无插管损伤及其他并发症发生。
结论：
在催眠镇痛肌松下由纤维支气管镜引导选择性支气管插管控压吹张治疗术后顽固性肺不张是切实可行的。
Objective:
To investigate the effect of bronchial intubation for expanding the collapsed lung with a constant-pressure on postoperatively intractable atelectasis.
Methods:
From January 2005 to May 2010,20 patients with atelectasis were recruited in the prospective study, and the collapsed lung could not been re-expanded by bronchoscopic suctioning, closed thoracic drainage, backslap, blowing hall and other routine treatment for more than a week. All patients fasting for 6 hours before the procedure, on arrival in the operation room, patients were monitored with electrocardiography (ECG), noninvasive blood pressure (BP), oxygen saturation via pulse oximetry (SpO2). Patients were preoxygenated with 100% O2 (8L/min). Propofol, atropine and succinylcholine were used for ipsilateral bronchial intubation, and the intubation was guided by fiberoptic bronchoscope. After correct placement of bronchial intubation was confirmed, the ipsilateral lung was inflated in a manual way. The airway plateau pressure was maintained at 30-50 cmH20 for 20 seconds, and the procedure was repeated until the clear breath sound can be heard at the original collapsed lung or the pleural drainage closed drainage bottle were basically no bubbles or liquid overflow drainage. If the spontaneous breathin resumed during the operation, additional propofol lmg/kg and succinylcholine 0.5mg/kg were infused to maintain anesthesia. After procedure, the bronchial tube was drawn back into tracheal, and postoperative tracheal extubation was performed when breathing approached to normal status, as well consciousness is recoved. After extubation, dexamethasone 0.2mg/kg was infused for preventing reexpansion pulmonary edema, then the patients were sent back to ward 30min later. The therapeutic effect was evaluated by chest X-ray examination and auscultation at the following day. If the collapsed lung was not re-expanded, the simil treatment was performed the next day. Consecutive three times treatment ineffective is regard as treatment failure.
Results:
Under general anesthesia, the constant-pressure expanding of the ipsilateral lung was completed smoothly in 19 patients following fiberoptic bronchoscope guided bronchial intubation. The data of one patient was excluded due to the bronchus was blocked by the endotracheal hyperplasia of inflammatory granulation tissue. Collapsed lung tissue were reexpantion in 16 patients (84.2%) after the first treatment, in 2 patients (10.5%) after twice inflation, while one case failed even after three times treatment (5.3%). During the procedure, the vital signs of all patients'were stable and no complications.
Conclusion:
Constant-pressure expanding of the ipsilateral lung throughout bronchial intubation is a safe and effective treatment for postoperatively intractable atelectasis.
探讨在催眠镇痛肌松下选择性患侧肺支气管插管控压吹张治疗术后顽固性肺不张的临床效果,从而为术后顽固性肺不张的治疗增加新的手段。
方法：
收集2005年1月-2010年5月嘉兴市第一医院20例接受过纤维支气管镜吸痰、胸腔闭式负压引流、拍背、吹气球等常规综合治疗7d仍不能使患肺复张的术后肺不张患者,在催眠镇痛术下行支气管插管选择性患侧肺控压吹张治疗。治疗前常规禁食6h以上,开放外周静脉通路,监测血压、心电图、无创脉搏氧饱和度。患者取平卧位,双肺听诊后面罩吸氧,氧流量>8L/min,静脉注射阿托品0.2mg、异丙酚2mg/kg、琥珀胆碱1mg/kg行麻醉诱导,随即在纤维支气管镜引导下行患侧支气管插管,确认导管位置无误后套囊充气,健侧支气管导管接Newport呼吸机行机控呼吸(IPPV),患侧支气管导管连接Datex-Ohmeda麻醉呼吸机(Datex-Ohmeda公司,美国),行手动人工控压屏持吹张膨肺治疗：开启麻醉呼吸机并切换至人工手动模式,操作者双手合掌挤压呼吸囊,在观察患者胸廓起伏的同时,观察麻醉机电子显示屏上的压力变化,将吹张压力控制在30～50cmH2O (1cmH2O=0.098kPa)，屏持时间为20s/次。重复上述控压吹张操作,直至原不张肺区听诊出现清晰呼吸音、有胸腔闭式引流者引流瓶中基本再无气泡或引流液溢出为止。若膨肺操作过程中患者自主呼吸恢复,可追加异丙酚1mg/kg、琥珀胆碱0.5mg/kg。操作完成后将支气管导管退回至总气管内,待患者自主呼吸恢复、神志清醒后拔管,静脉注射地塞米松0.2mg/kg防止复张性肺水肿,拔管后观察30min,生命体征稳定后送回病房。疗效由胸部听诊及次日胸部X光片评判,1次治疗无效改日再作,3次治疗不能复张者计为治疗无效。
结果：
19例患者在催眠镇痛肌松下借助小儿纤维支气管镜引导、顺利完成选择性患侧支气管插管控压膨肺治疗,其中1例患者治疗过程中发现支气管内炎性肉芽组织增生阻塞而剔除了本研究。术后第2天复查X线胸片,16例患者(84.2%)萎陷肺已全部复张,3例患者萎陷侧肺复张不完全,经第2次控压膨肺治疗后2例复张成功(10.5%,总有效率94.7%),另1例患者经3次膨肺治疗仍无效(5.3%)。期间患者生命体征稳定,无插管损伤及其他并发症发生。
结论：
在催眠镇痛肌松下由纤维支气管镜引导选择性支气管插管控压吹张治疗术后顽固性肺不张是切实可行的。
Objective:
To investigate the effect of bronchial intubation for expanding the collapsed lung with a constant-pressure on postoperatively intractable atelectasis.
Methods:
From January 2005 to May 2010,20 patients with atelectasis were recruited in the prospective study, and the collapsed lung could not been re-expanded by bronchoscopic suctioning, closed thoracic drainage, backslap, blowing hall and other routine treatment for more than a week. All patients fasting for 6 hours before the procedure, on arrival in the operation room, patients were monitored with electrocardiography (ECG), noninvasive blood pressure (BP), oxygen saturation via pulse oximetry (SpO2). Patients were preoxygenated with 100% O2 (8L/min). Propofol, atropine and succinylcholine were used for ipsilateral bronchial intubation, and the intubation was guided by fiberoptic bronchoscope. After correct placement of bronchial intubation was confirmed, the ipsilateral lung was inflated in a manual way. The airway plateau pressure was maintained at 30-50 cmH20 for 20 seconds, and the procedure was repeated until the clear breath sound can be heard at the original collapsed lung or the pleural drainage closed drainage bottle were basically no bubbles or liquid overflow drainage. If the spontaneous breathin resumed during the operation, additional propofol lmg/kg and succinylcholine 0.5mg/kg were infused to maintain anesthesia. After procedure, the bronchial tube was drawn back into tracheal, and postoperative tracheal extubation was performed when breathing approached to normal status, as well consciousness is recoved. After extubation, dexamethasone 0.2mg/kg was infused for preventing reexpansion pulmonary edema, then the patients were sent back to ward 30min later. The therapeutic effect was evaluated by chest X-ray examination and auscultation at the following day. If the collapsed lung was not re-expanded, the simil treatment was performed the next day. Consecutive three times treatment ineffective is regard as treatment failure.
Results:
Under general anesthesia, the constant-pressure expanding of the ipsilateral lung was completed smoothly in 19 patients following fiberoptic bronchoscope guided bronchial intubation. The data of one patient was excluded due to the bronchus was blocked by the endotracheal hyperplasia of inflammatory granulation tissue. Collapsed lung tissue were reexpantion in 16 patients (84.2%) after the first treatment, in 2 patients (10.5%) after twice inflation, while one case failed even after three times treatment (5.3%). During the procedure, the vital signs of all patients'were stable and no complications.
Conclusion:
Constant-pressure expanding of the ipsilateral lung throughout bronchial intubation is a safe and effective treatment for postoperatively intractable atelectasis.
引文
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