不同方法联合应用于左双腔支气管导管定位和插管深度对患者侧卧位后左双腔支气管导管错位的影响
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摘要
目的:胸外科手术麻醉时常用双腔支气管导管(DLT)行肺隔离。判断DLT是否就位是胸外科麻醉的关键。目前常用的DLT是RobertshawDLT导管,RobertshawDLT导管无隆突钩,易插管,减少了对声带、气管的损伤,在临床上普遍应用,插管时无明确手感,不易准确到位,可能出现肺隔离不全或导管错位,影响单肺通气的实施。纤维支气管镜(FOB)检查虽然定位准确,但因设配价格昂贵且需要专业培训在我国普及率不高。单独应用听诊法、或气道压力变化、或呼气末二氧化碳分压(PetCO_2)来定位DLT,其效果也不满意。FOB定位传统的左DLT到达正确位置的标准是:支气管套囊的上缘恰好隆突下可见。目前国外报道采用此标准侧卧位后错位发生率高达43 %～72 %[1,2] ,其中大部分是向头侧移位,Desiderio认为支气管套囊应插入左主支气管至少1cm[3],但导管置入过深,又使并发症增多。本研究联合应用听诊法、气道压力变化及呼气末二氧化碳分压(PetCO_2)判断左侧RobertshawDLT导管位置并通过FOB检查验证其准确率,为左侧RobertshawDLT导管定位提供简单实用安全可靠的方法;同时比较不同插管深度对患者侧卧位后左侧双腔支气管导管错位率的影响,探讨合适的插管深度以降低患者侧卧位后错位率及减轻错位程度,进一步提高麻醉安全性。
方法:选择需行全身麻醉单肺通气的胸科手术患者60例,静脉诱导后插入RobertshawDLT导管。听诊法到位标准是:双肺通气时,双肺呼吸音与气管插管前相同,单肺通气时,通气侧与气管插管前相同,非通气侧呼吸音消失。PetCO_2到位标准是双肺通气时,两侧的呼出气CO_2曲线正常, PetCO_2在正常范围。单肺通气时,各通气侧的呼出气CO_2曲线下降5%作为PetCO_2上限值。气道压力变化到位标准是:单肺通气吸气峰压(Ppeak)不超过双肺通气时的1.65倍,且气道峰压不超过25cmH2O。通过调整达到以上标准后用FOB检查RobertshawDLT的位置,FOB插入右侧管核查DLT的就位状况(Fig. 1),(1)就位准确:隆突嵴水平在L- DLT的支气管套囊近侧缘与右侧管管口黑色圆圈线之间的10～11 mm范围内(A- B) (Fig. 4),(2)就位偏浅:隆突清晰,很小部分膨胀的支气管套囊在隆突嵴水平以上而未向右主支气管口疝出(Fig. 6),(3)就位过深:隆突嵴水平超过L- DLT右侧管管口黑色圆圈线水平以上( A- D) (Fig. 11), (4)就位过浅:支气管套囊向右主支气管口疝出( B- C) (Fig. 8),然后从左支气管腔插入FOB ,可看到左上叶、下叶支气管开口。我们将“就位准确”和“就位偏浅”定义为就位;另选需行全身麻醉单肺通气的胸科手术患者60例在FOB引导下调整双腔管的位置将其随机分为三组:Ⅰ组:患者仰卧,头中立位,从右侧气管腔侧插入FOB ,隆突在正前方清晰可见,调整导管使充气后左侧蓝色支气管套囊上缘正好在隆突下可见,然后从左支气管腔插入FOB ,可看到左肺上叶、下叶支气管开口。Ⅱ组:基本上同Ⅰ组,不同之处在于:将蓝色支气管套囊上缘调整在隆突下恰不可见;从DLT的左支气管腔插入FOB ,透过DLT支气管管壁向右看并调整导管位置,使隆突正好位于蓝色支气管套囊上缘与左支气管腔壁上不透光黑线的正中央,然后从左支气管腔插入FOB ,可看到左上叶、下叶支气管开口。Ⅲ组:从右侧气管腔侧插入FOB,左支气管腔壁上不透光黑线正好在隆突下可见,然后从左支气管腔插入FOB ,可看到左上叶、下叶支气管开口。患者侧卧位后采用FOB检查导管位置,有移位者予以重新调整到位。
结果:平卧位时,三种方法联合应用确认管端正确到位,与FOB检查符合为57例,其中1例过浅,2例过深,左DLT到就率95%。侧卧位后,与FOB检查符合为56例,其中2例过浅,2例过深,DLT就位率93.4%,均无一例因双腔管就位不良引起低氧血症和高碳酸血症并发症的发生;由仰卧位改为侧卧位后,三组向头侧移位存在差别,左DLT头侧移位Ⅱ、Ⅲ组明显低于Ⅰ组( P < 0.05) ,Ⅱ、Ⅲ组间差异无统计学意义,三组导管向尾侧移位的发生率组间差异无统计学意义(P>0.05), DLT位置重新调整率Ⅱ,Ⅲ组明显低于Ⅰ组﹙P<0.05﹚,Ⅱ,Ⅲ组无差异(P>0.05)。
结论:三种方法听诊法,气道压力变化,呼气末二氧化碳分压联合判断DLT到位的方法简单、可行,可反复用于术中患者体位变动后对DLT就位状态的判断,该实验结果表明DLT到就率95%左右,因而均需借助FOB确认导管准确就位状况:FOB确认导管插入使隆突正好位于蓝色支气管套囊上缘与左支气管腔壁上不透光黑线的正中央至左支气管腔壁上不透光黑线正好在隆突下可见,即蓝色支气管套囊插入左主支气管深约0.5 cm至1 cm,明显降低患者侧卧位后错位率并减轻错位程度。
Objective: Thoracic surgery commonly used double-lumen endobronchial tube (DLT). correct positioning of the DLT is the key to thoracic anesthesia,otherwise it happens severe complications in operation. DLT currently is used Robertshaw DLT, there is not bulge hook,because of easy intubation, reducing the vocal cord and trachea injury. It is widely used in clinical practice, intubation feeling is not clear, correct positioning of the DLT is different, it easily happens malposition, affecting one-lung ventilation. Although fiberoptic bronchoscopy is correctly positioned DLT, coverage is not high in our country. Separately auscultation method, airway pressure changes, end-tidal carbon dioxide partial pressure (PetCO_2) to locate the DLT, is also not satisfied. The traditional criteria: the upper surface of the left endobronchial blue cuff just below the carina. Foreign reports that dislocation rate is 43% ~ 72% following lateral positioning of the patient, which is major to proximal malposition, Desiderio, stated that it is actually advantageous to have the endobronchial cuff at least 1 cm inside the left mainstem bronchus,but the catheter intubate too deeply,it increase complications.The research purposes to observe the correctly positioning rate of f left-sided double lumen endobronchial tube by combined adjustment of ausculation, PetCO_2 and airway pressure changes and to explore that different depth can influence incidence of malposition from the supine to the lateral decubitus position.
Methods: sixty adult patients undergoing thoracic surgery were intubated with RobertshawDLTs.ausculation standard: Two Lung ventilation(TLV), the breath sounds is the same to pre-intubation, one-lung ventilation(OLV),the ventilative side is the same to pre-intubation, breath sounds disappear in non-ventilative side.PetCO_2 standard: As TLV, curve of PetCO_2 is normal,PetCO_2 is in the normal range. One-lung ventilation,in the ventilative side,PetCO_2 decline upper limit 5%.airway pressure changes standard: Inspiratory peak airway pressur(ePpeak)doesn’t excess 25 H2O,and there isn’t a increase more than 65% of the baseline in Ppeak when switching from TLV to OLV. DLT position is checked and adjusted by fiberoptic bronchoscope(FOB), via the right tracheal lumen(Fig. 1),(1) accurate place:that the carina is midway between the black radiopaque line and the top of the bronchial cuff,it is 10～11 mm(A- B),(2) shallow place:a small part of the left endobronchial blue cuff is above the tracheal carina,but there is not hernia(Fig. 6),(3) deeper place the black radiopaque line is beyond the tracheal carina(A- D) (Fig. 11),(4) shallower place: the left endobronchial blue cuff becomes hernia to the right main bronchus,looking down the left endobronchial lumen,the orifice of the left superior lobe bronchus and the orifice of the left inferior lobe bronchus should be seen clearly.We define that“accurate place”and“shallow place”are Successful;another 60 adult patients undergoing thoracic surgery were intubated with RobertshawDLTs. To adjust positioning of left double-lumen tube ,and randomly assign three groups: groupⅠ: In the supine Position, via the right tracheal lumen,the endoscopist should see a clear,straight-ahead view of the tracheal carina, it is important to see the upper surface of the left endobronchial blue cuff just below the carina, then looking down the left endobronchial lumen, the orifice of the left superior lobe bronchus and the orifice of the left inferior lobe bronchus should be seen clearly. groupⅡ: The proximal shoulder edge of the blue bronchial cuff should not be visualized at the carina. However, through the left bronchial lumen,and by transparency across the wall of the tube, the position of the tube is adjusted so that the carina is midway between the black radiopaque line and the top of the bronchial cuff.Finally, the orifice of the left superior lobe bronchus and the bronchial carina should be clearly seen. groupⅢ: via the right tracheal lumen, the black radiopaque line should be visualized at the carina,the orifice of the left superior lobe bronchus and the orifice of the left inferior lobe bronchus should be seen clearly.
Results: In the supine position, successful intobution patients is 57 cases by three combined methods,one of cases is shallower,two of cases are deeper,DLT satisfactory rate is 95 percents;In the lateral decubitus position, successful intobution is 56 cases by three combined methods,two of cases is shallower,two of cases are deeper,DLT satisfactory rate is 93.4 percents, without significant hypoxemia and hypercapnia anesthetic complications; L-DLT dislocated to proximal malposition is significantly less in theⅡ,Ⅲgroups compared to theⅠgroup﹙p<0.05﹚,Ⅱ、Ⅲare not different﹙p>0.05﹚,Three groups to caudal displacement are not different﹙p>0.05﹚, The incidence of repositioning is significantly less in theⅡ、Ⅲgroups compared to theⅠgroup﹙p<0.05﹚,Ⅱ、Ⅲare not different﹙p>0.05﹚.
Conclusions: That auscultation method,airway pressure changes and PetCO_2 are combined is simple,reliable can be used repeatedly during postural changes without increasing the opportunities for injury,it is clinically a very good approach,the experimental result shows that DLT satisfactory rate is about 95 percents, FOB is necessary for positioning; depth can reduce incidence of malpositioning from the supine to the lateral decubitus position inⅡ、Ⅲ, suitable depth is that the blue bronchial cuff is intubated into the left main bronchus from 0.5cm to 1cm.
方法:选择需行全身麻醉单肺通气的胸科手术患者60例,静脉诱导后插入RobertshawDLT导管。听诊法到位标准是:双肺通气时,双肺呼吸音与气管插管前相同,单肺通气时,通气侧与气管插管前相同,非通气侧呼吸音消失。PetCO_2到位标准是双肺通气时,两侧的呼出气CO_2曲线正常, PetCO_2在正常范围。单肺通气时,各通气侧的呼出气CO_2曲线下降5%作为PetCO_2上限值。气道压力变化到位标准是:单肺通气吸气峰压(Ppeak)不超过双肺通气时的1.65倍,且气道峰压不超过25cmH2O。通过调整达到以上标准后用FOB检查RobertshawDLT的位置,FOB插入右侧管核查DLT的就位状况(Fig. 1),(1)就位准确:隆突嵴水平在L- DLT的支气管套囊近侧缘与右侧管管口黑色圆圈线之间的10～11 mm范围内(A- B) (Fig. 4),(2)就位偏浅:隆突清晰,很小部分膨胀的支气管套囊在隆突嵴水平以上而未向右主支气管口疝出(Fig. 6),(3)就位过深:隆突嵴水平超过L- DLT右侧管管口黑色圆圈线水平以上( A- D) (Fig. 11), (4)就位过浅:支气管套囊向右主支气管口疝出( B- C) (Fig. 8),然后从左支气管腔插入FOB ,可看到左上叶、下叶支气管开口。我们将“就位准确”和“就位偏浅”定义为就位;另选需行全身麻醉单肺通气的胸科手术患者60例在FOB引导下调整双腔管的位置将其随机分为三组:Ⅰ组:患者仰卧,头中立位,从右侧气管腔侧插入FOB ,隆突在正前方清晰可见,调整导管使充气后左侧蓝色支气管套囊上缘正好在隆突下可见,然后从左支气管腔插入FOB ,可看到左肺上叶、下叶支气管开口。Ⅱ组:基本上同Ⅰ组,不同之处在于:将蓝色支气管套囊上缘调整在隆突下恰不可见;从DLT的左支气管腔插入FOB ,透过DLT支气管管壁向右看并调整导管位置,使隆突正好位于蓝色支气管套囊上缘与左支气管腔壁上不透光黑线的正中央,然后从左支气管腔插入FOB ,可看到左上叶、下叶支气管开口。Ⅲ组:从右侧气管腔侧插入FOB,左支气管腔壁上不透光黑线正好在隆突下可见,然后从左支气管腔插入FOB ,可看到左上叶、下叶支气管开口。患者侧卧位后采用FOB检查导管位置,有移位者予以重新调整到位。
结果:平卧位时,三种方法联合应用确认管端正确到位,与FOB检查符合为57例,其中1例过浅,2例过深,左DLT到就率95%。侧卧位后,与FOB检查符合为56例,其中2例过浅,2例过深,DLT就位率93.4%,均无一例因双腔管就位不良引起低氧血症和高碳酸血症并发症的发生;由仰卧位改为侧卧位后,三组向头侧移位存在差别,左DLT头侧移位Ⅱ、Ⅲ组明显低于Ⅰ组( P < 0.05) ,Ⅱ、Ⅲ组间差异无统计学意义,三组导管向尾侧移位的发生率组间差异无统计学意义(P>0.05), DLT位置重新调整率Ⅱ,Ⅲ组明显低于Ⅰ组﹙P<0.05﹚,Ⅱ,Ⅲ组无差异(P>0.05)。
结论:三种方法听诊法,气道压力变化,呼气末二氧化碳分压联合判断DLT到位的方法简单、可行,可反复用于术中患者体位变动后对DLT就位状态的判断,该实验结果表明DLT到就率95%左右,因而均需借助FOB确认导管准确就位状况:FOB确认导管插入使隆突正好位于蓝色支气管套囊上缘与左支气管腔壁上不透光黑线的正中央至左支气管腔壁上不透光黑线正好在隆突下可见,即蓝色支气管套囊插入左主支气管深约0.5 cm至1 cm,明显降低患者侧卧位后错位率并减轻错位程度。
Objective: Thoracic surgery commonly used double-lumen endobronchial tube (DLT). correct positioning of the DLT is the key to thoracic anesthesia,otherwise it happens severe complications in operation. DLT currently is used Robertshaw DLT, there is not bulge hook,because of easy intubation, reducing the vocal cord and trachea injury. It is widely used in clinical practice, intubation feeling is not clear, correct positioning of the DLT is different, it easily happens malposition, affecting one-lung ventilation. Although fiberoptic bronchoscopy is correctly positioned DLT, coverage is not high in our country. Separately auscultation method, airway pressure changes, end-tidal carbon dioxide partial pressure (PetCO_2) to locate the DLT, is also not satisfied. The traditional criteria: the upper surface of the left endobronchial blue cuff just below the carina. Foreign reports that dislocation rate is 43% ~ 72% following lateral positioning of the patient, which is major to proximal malposition, Desiderio, stated that it is actually advantageous to have the endobronchial cuff at least 1 cm inside the left mainstem bronchus,but the catheter intubate too deeply,it increase complications.The research purposes to observe the correctly positioning rate of f left-sided double lumen endobronchial tube by combined adjustment of ausculation, PetCO_2 and airway pressure changes and to explore that different depth can influence incidence of malposition from the supine to the lateral decubitus position.
Methods: sixty adult patients undergoing thoracic surgery were intubated with RobertshawDLTs.ausculation standard: Two Lung ventilation(TLV), the breath sounds is the same to pre-intubation, one-lung ventilation(OLV),the ventilative side is the same to pre-intubation, breath sounds disappear in non-ventilative side.PetCO_2 standard: As TLV, curve of PetCO_2 is normal,PetCO_2 is in the normal range. One-lung ventilation,in the ventilative side,PetCO_2 decline upper limit 5%.airway pressure changes standard: Inspiratory peak airway pressur(ePpeak)doesn’t excess 25 H2O,and there isn’t a increase more than 65% of the baseline in Ppeak when switching from TLV to OLV. DLT position is checked and adjusted by fiberoptic bronchoscope(FOB), via the right tracheal lumen(Fig. 1),(1) accurate place:that the carina is midway between the black radiopaque line and the top of the bronchial cuff,it is 10～11 mm(A- B),(2) shallow place:a small part of the left endobronchial blue cuff is above the tracheal carina,but there is not hernia(Fig. 6),(3) deeper place the black radiopaque line is beyond the tracheal carina(A- D) (Fig. 11),(4) shallower place: the left endobronchial blue cuff becomes hernia to the right main bronchus,looking down the left endobronchial lumen,the orifice of the left superior lobe bronchus and the orifice of the left inferior lobe bronchus should be seen clearly.We define that“accurate place”and“shallow place”are Successful;another 60 adult patients undergoing thoracic surgery were intubated with RobertshawDLTs. To adjust positioning of left double-lumen tube ,and randomly assign three groups: groupⅠ: In the supine Position, via the right tracheal lumen,the endoscopist should see a clear,straight-ahead view of the tracheal carina, it is important to see the upper surface of the left endobronchial blue cuff just below the carina, then looking down the left endobronchial lumen, the orifice of the left superior lobe bronchus and the orifice of the left inferior lobe bronchus should be seen clearly. groupⅡ: The proximal shoulder edge of the blue bronchial cuff should not be visualized at the carina. However, through the left bronchial lumen,and by transparency across the wall of the tube, the position of the tube is adjusted so that the carina is midway between the black radiopaque line and the top of the bronchial cuff.Finally, the orifice of the left superior lobe bronchus and the bronchial carina should be clearly seen. groupⅢ: via the right tracheal lumen, the black radiopaque line should be visualized at the carina,the orifice of the left superior lobe bronchus and the orifice of the left inferior lobe bronchus should be seen clearly.
Results: In the supine position, successful intobution patients is 57 cases by three combined methods,one of cases is shallower,two of cases are deeper,DLT satisfactory rate is 95 percents;In the lateral decubitus position, successful intobution is 56 cases by three combined methods,two of cases is shallower,two of cases are deeper,DLT satisfactory rate is 93.4 percents, without significant hypoxemia and hypercapnia anesthetic complications; L-DLT dislocated to proximal malposition is significantly less in theⅡ,Ⅲgroups compared to theⅠgroup﹙p<0.05﹚,Ⅱ、Ⅲare not different﹙p>0.05﹚,Three groups to caudal displacement are not different﹙p>0.05﹚, The incidence of repositioning is significantly less in theⅡ、Ⅲgroups compared to theⅠgroup﹙p<0.05﹚,Ⅱ、Ⅲare not different﹙p>0.05﹚.
Conclusions: That auscultation method,airway pressure changes and PetCO_2 are combined is simple,reliable can be used repeatedly during postural changes without increasing the opportunities for injury,it is clinically a very good approach,the experimental result shows that DLT satisfactory rate is about 95 percents, FOB is necessary for positioning; depth can reduce incidence of malpositioning from the supine to the lateral decubitus position inⅡ、Ⅲ, suitable depth is that the blue bronchial cuff is intubated into the left main bronchus from 0.5cm to 1cm.
引文
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15 ALL IAUME B,CODDENS J,DELOOF T.Reliability of anscultantion in Positioning of double - lumen endobronchial tubes[ J ].Can J Anaesth, 1992,39:687-690
16 Hurfor W E,Alfille P H,Bailin M T,etal.Placementand complication of double-lumen endotracheal-tubes[J].Anesth Analg,1992,74:14
17 Klein U,Karzai W,Bloos F,et al . Role of fiberoptic bronchoscopy in conjonction with the use of double-lumen tubes for thoracic anest hesia:a prospective study.Anest hesiology,1998,88:346-350
18石翊飒,李体中.全麻术中应用PetCO2监测的临床体会[J].麻醉与监护论坛, 2005,12(4):225-226
19 Chang P J,Sung Y H,Wang I K,etal.Estimation of the depth of left-sided double-lumenendobmn-tube placement using preoperative chest radio-graphs[J].Acta Anaesthesiol Sin,2002,40(1):25-29
20 ShowMY,Gob MH,Ti LK,et al.Predicting the depth of insertion of left-sided double-lumen en-dobronchial-tubes[J].Cardiothorac Vasc Anesth,2002,16(2):456-458
21 Slinger P.New trends in anesthesia for thoracic surgery including thoracoscopy[J]. Can J Anaesth,1995,42:R77
22欧阳葆怡,梁丽霞,叶靖.左双腔支气管导管管端位置与吸气峰压变化的关系[J].临床麻醉学杂志,2004,20(6):349-352
23 Inoue S,Nishimine N,Kitaguchi K,et al.Double lumen tube location predicts tube malposition and hypoxaemia during one lung ventilation[J].Br J Anaesth,2004,92(2):195-201
24 Yoon TG,Chang HW,Ryu HG,et al.Use of a neck brace minimizes double-lumen tube displacement during patient positioning[J].Can Anaesth,2005,52(4):413-417
1 Allen MS. Video-assisted thoracic surgical procedures: the Mayo experience.Mayo Clin Proc,1996,71(4): 351- 359
2 Rodney J. Video-assisted thoracoscopic surgery: basic technical concepts and intercostal approach strategies. Ann Thorac Surg,1992,54:800-807
3 Ferson PF. The role of video-assisted thoracoscopy in pulmonary metastases.Chest Clin N Am,1998, 8:59-76
4 Mukaida T, Andou A, Date H, et al Thoracoscopic operation for second pneumothorax under local and epidural anesthesia in high-risk patients. Ann Thorac Surg,1998, 65:924-926
5 Rau B, Huneerbein M, Below C, et al. Video-assisted thoracic surgery: staging and management of thoracic tumors. Surg Endosc,1998, 12:133-136
6 Brodsky JB,Harry J,Lemmens M.Left double-lumen tubes:clinical experience with 1170 patients[J]. Cardiothor Vasc Anesth,2003, 17(3):289- 99
7 Chow MY, Goh MH, Ti LK. Predicting the depth of insertion of left-sided double-lumen endobronchial tubes[J]. Cardiothorac Vasc Anesth,2002,16: 456-458
8 Yer RA, Heijke SAM, Russell WJ, et al. Can insertion length for a double-lumen endobronchial tube be predicted? Anaesth Intens Care, 2000, 28: 666-668
9 Yasumoto M, Higa K, Nitahara K, et al. Hamada Optimal depth of insertion of left-sided double-lumen endobronchial tubes cannot be predicted from body height in below average-sized adult patients European Journal of Anaesthesiology,2006,23: 42-44
10 Brodsky JB, Lemmens JM. Left double-lumen tubes:clinical experience with 1170 patients[J]. Cardiothorac Vasc Anaesth, 2003,17:289-298.
11 Smith B, Hersch N, Ehrenwerth J. Sight and sound: can double-lumen endothracheal tubes be placed accurately without fiberoptic bronchoscopy? Br J Anaesth,1987,58:1317
12 Klein U, Karazi W, Bloos F, et al. Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia. Anesthes- iology,1998,88:346-350
13 Slinger P. Lung isolation in thoracic anesthesia state of the art. Can J Anesthesia,2001,48:R3
14 Benumof JL, Partridge BL, Salvatierra C, et al. Margin of safety in positioning modern double-lumen endotracheal tubes. Anesthesiology,1985,67:729-738
15 Saito S, Dohi S, Naito H. Alteration of double-lumen endobronchial tubes position by flexion and extension of the neck. Anesthesiology,1985, 62:696-697
16 Fortier MD, CotéMD, Bergeron MD, et al. New landmarks improve the positioning of the left Broncho-CathTM double-lumen tube-comparison with the classic technique. Mdcan J Anesth,2001,48(8): 790-794
17 Campos JH, Gomez MN. Pro: right-sided double-lumen endotracheal tubes should be routinely used in thoracic surgery. J Cardiothorac Vasc Anesth 2002,16: 246-248
18 Cohen E. Con: right-sided double-lumen endotracheal tubes should not be routinely used in thoracic surgery. J Cardiothorac Vasc Anesth, 2002; 16: 249 -252
19 Ramsay MA. Right-sided double-lumen endobronchial tubes for left-sided thoracic surgery. Anesth Analg,2000,91: 762
20 Shulman MS. Right versus left double-lumens for left-sided thoracic surgery. Anesth Analg,2000,91: 762-763
21 Campos JH, Massa FC, Christopher F, et al. The incidence of right upper-lobe collapse when comparing a right sided double lumen tube versus a modified left double lumen tube for left-sided thoracic surgery: a comparison of two types. Anesth Analag ,2000, 90:535-540
22 Jean S. Bussières MD, Yves Lacasse MD, et al. Modified right-sided Broncho-Cath? double lumen tube improves endobronchial positioning: a randomized study.Can J Anesth, 2007,54(4):276-282
23 Ho AM. Bronchial blocker placement through the lumen of an in situtracheal tube [Procedures And Techniques].The Journal of Trauma:Injury,Infection, and Critical Care,1999,47:423-425
24 Nino M, Body SC, Hartigan PM. The use of a bronchial blocker to rescue an ill-fitting double-lumen endotracheal tube. Anesth Analg,2000,91:1370- 1371
25 Ng, JM, Hartigan PM. Selective Lobar Bronchial blockade following contralateral pneumonectom. Anesthesiology,2003,98:268-270
26 Harvey SC,Alpert CC,Fishman RL. Independent placement of a bronchial blocker for single-lung ventilation:an alternative method for the difficult airway.Anesth Analg,1996,83:1330-1331
27 Roscoe A , Kanellakos GW, McRae K,et al . Pressures exerted by endobronchial devices. Anest h Analg ,2007 ,104 :655-658
28 Takeraka I, Anoyoshi K, Kadoya T. Use of the univent bronchial-blocker tube for unanticipated difficult endotracheal intubation. Anesthesiology, 2000,93:590-591
29 McMullen MC ,Girling LG,Graham MR , et al .Biologically variable ventilation improves oxygenation and respiratory mechanics during one lung ventilation[J ] . Anesthesiology ,2006 ,105 (1) :91-97
30 Neustein SM. One-lung ventilation provided by anesthesiologists having minimal experience with thoracic anesthesia[J].Anesthesiology, 2006 ,105 (5) :1060
31 Campos JH.Effects on oxygenation during selective lobar versus total lung collapse with or without continuous positive airway pressure. Anesth Analg,1997,85:583-586
32 Ozcan PE ,Sentürk M,Sungur Ulke Z, et al . Effects of thoracic epidural anaesthesia on pulmonary venous admixture and oxygenation during one-lung ventilation[J].Acta Anaesthesiol Scand,2007,51 (8) :1117-1122
33 Campos JH,Kernstine KH. A structural complication in the torque control blocker univent?:fracture of the blocker cap connector.[LETTERS TO THE EDITOR]Anesth Analg,2003,96:630-631
34 Thielmeier KA, Anwar M. Complication of the univent? tube [letter]. Anesthesiology,1996,84:491
35 Hee-Pyung P, Jae-Hyon B, Yong-Seok O, et al. Case report: pulmonary soiling after one-lung ventilation with a bronchial blocker. Can J Anesth, 2002,49:874-876
36 Arndt GA,Kranner PW,Rusy DA,et al. Single-lung ventilation in a criticallyⅢpatient using a fiberoptically directed wire-guided endobronchial blocker [CaseReports]. Anesthesiology,1999,90:1484-1486
37 Arndt GA, De Lessio ST, Kranner PW, et al. One-lung ventilation when intubation is diffcult:presentation of a new endobronchial blocker. Acta Anaesthesiol Scand,1999,43:356-358
38 Kabon B, Waltl B, Leitgeb J, et al. First experience with fiberoptically directed wire-guided endobronchial blockade in severe pulmonary bleeding in an emergency setting. Chest, 2001,120(4):1399-1402
39 LEHMANN A. A comparison of the Arndt endobronchial blocker with a double lumen tube in robotic cardiac surgery[J]. Anasthe siol Intensivmed Notfallemd Schmerzther, 2004, 39 ( 6 ) : 353 - 359
40 Campos JH,Kernstine KH.A comparison of a left-sided broncho-cath,with the torque control blocker univent and the wire-guided blocker. Anesth Analg,2003,96:283-289
41 Prabhu MR,Smith JH.Use of the arndt wire-guided endobronchial blocker [letter]. Anesthesiology,2002,97:1325
42 Sandberg WS. Endobronchial blocker dislodgement leading to pulseless electrical activity. Anesth Analg, 2005,100:1728-1730
43 McMullen MC ,Girling LG,Graham MR , et al .Biologically variable ventilation improves oxygenation and respiratory mechanics during one2lung ventilation[J ] . Anesthesiology ,2006 ,105 (1) :91-97
44 Neustein SM. One-lung ventilation provided by anesthesiologists having minimal experience with thoracic anesthesia[J].Anesthesiology,2006 ,105 (5) :1060
45 Wald SH,Mahajan A,Kaplan MB,et al.Experience with the arndt paediatric bronchial blocker. Br J Anesth,2005,94:92-94
2 Cheng KS,Wu RS,Tan PP.Displacement of double-lumen tubes after patient positioning.Anest hesiology,1998,89:1282-1283
3 Fortier G,Cote D,Bergeron C,et al.New landmarks improve t he positioning of t he left Broncho-Cat h double-lumen tube comparison wit h t he classic technique.Can J Anaest h,2001,48:790-794
4陈秉学,许梅曦,李伟等,主编.胸科肿瘤麻醉学.第1版.郑州:郑州大学出版社,2001.223-225
5刘建明,李明星,赵如明,等.体位改变对胸科手术病人双腔支气管导管位置的影响[J].中华麻醉学杂志,2006,26(11):991-993
6 Klein U,Karzai W,Bloos F,et al.Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia:a prospective[J].Anaesthesiology,1998,88(2):346-350
7 Klein U,Karzai W,Bloos F,et al. A role of fibreoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia. Anesthesiology,1998,88(2);364-350
8欧阳葆怡,温晓晖,梁丽霞.双腔支气管导管型号选择分析[J].中华麻醉学杂志,2001,21(6):366- 367
9 Brodsky JB Con:proper positioning of a doublelumen endobronchial tube can only be accomplished with the use of endoscopy. J Cardiothorac Anesth,1988,2 :105-109
10高元兴,黄秀芳,蒋柳明,等.电视胸腔镜手术的麻醉处理[J].浙江临床医学, 2006,8(6): 649
11 Hurfor W E,Alfille P H,Bailin M T,etal.Placementand complication of double-lumen endotracheal-tubes[J].Anesth Analg,1992,74:14
12 Hartrey R,Kestin IG.Movement of oral and nasal tracheal tubes as a result of changes in head and neck position[J].Anaesthesia,1995,50(8):682-7
13 Klein U ,Karzai W,Bloos F ,et al.Role of fiberoptic bronchoscopy in conjonction with the use of double-lumen tubes for t horacic anest hesia:a prospective study.Anest hesiology,1998,88:346-350
14 Inoue S,Nishimine N,Kitaguchi K,et al.Double lumen tube location predicts tube malposition and hypoxaemia during one lungventilation[J].Br J Anaesth,2004,92(2):195-201
15 ALL IAUME B,CODDENS J,DELOOF T.Reliability of anscultantion in Positioning of double - lumen endobronchial tubes[ J ].Can J Anaesth, 1992,39:687-690
16 Hurfor W E,Alfille P H,Bailin M T,etal.Placementand complication of double-lumen endotracheal-tubes[J].Anesth Analg,1992,74:14
17 Klein U,Karzai W,Bloos F,et al . Role of fiberoptic bronchoscopy in conjonction with the use of double-lumen tubes for thoracic anest hesia:a prospective study.Anest hesiology,1998,88:346-350
18石翊飒,李体中.全麻术中应用PetCO2监测的临床体会[J].麻醉与监护论坛, 2005,12(4):225-226
19 Chang P J,Sung Y H,Wang I K,etal.Estimation of the depth of left-sided double-lumenendobmn-tube placement using preoperative chest radio-graphs[J].Acta Anaesthesiol Sin,2002,40(1):25-29
20 ShowMY,Gob MH,Ti LK,et al.Predicting the depth of insertion of left-sided double-lumen en-dobronchial-tubes[J].Cardiothorac Vasc Anesth,2002,16(2):456-458
21 Slinger P.New trends in anesthesia for thoracic surgery including thoracoscopy[J]. Can J Anaesth,1995,42:R77
22欧阳葆怡,梁丽霞,叶靖.左双腔支气管导管管端位置与吸气峰压变化的关系[J].临床麻醉学杂志,2004,20(6):349-352
23 Inoue S,Nishimine N,Kitaguchi K,et al.Double lumen tube location predicts tube malposition and hypoxaemia during one lung ventilation[J].Br J Anaesth,2004,92(2):195-201
24 Yoon TG,Chang HW,Ryu HG,et al.Use of a neck brace minimizes double-lumen tube displacement during patient positioning[J].Can Anaesth,2005,52(4):413-417
1 Allen MS. Video-assisted thoracic surgical procedures: the Mayo experience.Mayo Clin Proc,1996,71(4): 351- 359
2 Rodney J. Video-assisted thoracoscopic surgery: basic technical concepts and intercostal approach strategies. Ann Thorac Surg,1992,54:800-807
3 Ferson PF. The role of video-assisted thoracoscopy in pulmonary metastases.Chest Clin N Am,1998, 8:59-76
4 Mukaida T, Andou A, Date H, et al Thoracoscopic operation for second pneumothorax under local and epidural anesthesia in high-risk patients. Ann Thorac Surg,1998, 65:924-926
5 Rau B, Huneerbein M, Below C, et al. Video-assisted thoracic surgery: staging and management of thoracic tumors. Surg Endosc,1998, 12:133-136
6 Brodsky JB,Harry J,Lemmens M.Left double-lumen tubes:clinical experience with 1170 patients[J]. Cardiothor Vasc Anesth,2003, 17(3):289- 99
7 Chow MY, Goh MH, Ti LK. Predicting the depth of insertion of left-sided double-lumen endobronchial tubes[J]. Cardiothorac Vasc Anesth,2002,16: 456-458
8 Yer RA, Heijke SAM, Russell WJ, et al. Can insertion length for a double-lumen endobronchial tube be predicted? Anaesth Intens Care, 2000, 28: 666-668
9 Yasumoto M, Higa K, Nitahara K, et al. Hamada Optimal depth of insertion of left-sided double-lumen endobronchial tubes cannot be predicted from body height in below average-sized adult patients European Journal of Anaesthesiology,2006,23: 42-44
10 Brodsky JB, Lemmens JM. Left double-lumen tubes:clinical experience with 1170 patients[J]. Cardiothorac Vasc Anaesth, 2003,17:289-298.
11 Smith B, Hersch N, Ehrenwerth J. Sight and sound: can double-lumen endothracheal tubes be placed accurately without fiberoptic bronchoscopy? Br J Anaesth,1987,58:1317
12 Klein U, Karazi W, Bloos F, et al. Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia. Anesthes- iology,1998,88:346-350
13 Slinger P. Lung isolation in thoracic anesthesia state of the art. Can J Anesthesia,2001,48:R3
14 Benumof JL, Partridge BL, Salvatierra C, et al. Margin of safety in positioning modern double-lumen endotracheal tubes. Anesthesiology,1985,67:729-738
15 Saito S, Dohi S, Naito H. Alteration of double-lumen endobronchial tubes position by flexion and extension of the neck. Anesthesiology,1985, 62:696-697
16 Fortier MD, CotéMD, Bergeron MD, et al. New landmarks improve the positioning of the left Broncho-CathTM double-lumen tube-comparison with the classic technique. Mdcan J Anesth,2001,48(8): 790-794
17 Campos JH, Gomez MN. Pro: right-sided double-lumen endotracheal tubes should be routinely used in thoracic surgery. J Cardiothorac Vasc Anesth 2002,16: 246-248
18 Cohen E. Con: right-sided double-lumen endotracheal tubes should not be routinely used in thoracic surgery. J Cardiothorac Vasc Anesth, 2002; 16: 249 -252
19 Ramsay MA. Right-sided double-lumen endobronchial tubes for left-sided thoracic surgery. Anesth Analg,2000,91: 762
20 Shulman MS. Right versus left double-lumens for left-sided thoracic surgery. Anesth Analg,2000,91: 762-763
21 Campos JH, Massa FC, Christopher F, et al. The incidence of right upper-lobe collapse when comparing a right sided double lumen tube versus a modified left double lumen tube for left-sided thoracic surgery: a comparison of two types. Anesth Analag ,2000, 90:535-540
22 Jean S. Bussières MD, Yves Lacasse MD, et al. Modified right-sided Broncho-Cath? double lumen tube improves endobronchial positioning: a randomized study.Can J Anesth, 2007,54(4):276-282
23 Ho AM. Bronchial blocker placement through the lumen of an in situtracheal tube [Procedures And Techniques].The Journal of Trauma:Injury,Infection, and Critical Care,1999,47:423-425
24 Nino M, Body SC, Hartigan PM. The use of a bronchial blocker to rescue an ill-fitting double-lumen endotracheal tube. Anesth Analg,2000,91:1370- 1371
25 Ng, JM, Hartigan PM. Selective Lobar Bronchial blockade following contralateral pneumonectom. Anesthesiology,2003,98:268-270
26 Harvey SC,Alpert CC,Fishman RL. Independent placement of a bronchial blocker for single-lung ventilation:an alternative method for the difficult airway.Anesth Analg,1996,83:1330-1331
27 Roscoe A , Kanellakos GW, McRae K,et al . Pressures exerted by endobronchial devices. Anest h Analg ,2007 ,104 :655-658
28 Takeraka I, Anoyoshi K, Kadoya T. Use of the univent bronchial-blocker tube for unanticipated difficult endotracheal intubation. Anesthesiology, 2000,93:590-591
29 McMullen MC ,Girling LG,Graham MR , et al .Biologically variable ventilation improves oxygenation and respiratory mechanics during one lung ventilation[J ] . Anesthesiology ,2006 ,105 (1) :91-97
30 Neustein SM. One-lung ventilation provided by anesthesiologists having minimal experience with thoracic anesthesia[J].Anesthesiology, 2006 ,105 (5) :1060
31 Campos JH.Effects on oxygenation during selective lobar versus total lung collapse with or without continuous positive airway pressure. Anesth Analg,1997,85:583-586
32 Ozcan PE ,Sentürk M,Sungur Ulke Z, et al . Effects of thoracic epidural anaesthesia on pulmonary venous admixture and oxygenation during one-lung ventilation[J].Acta Anaesthesiol Scand,2007,51 (8) :1117-1122
33 Campos JH,Kernstine KH. A structural complication in the torque control blocker univent?:fracture of the blocker cap connector.[LETTERS TO THE EDITOR]Anesth Analg,2003,96:630-631
34 Thielmeier KA, Anwar M. Complication of the univent? tube [letter]. Anesthesiology,1996,84:491
35 Hee-Pyung P, Jae-Hyon B, Yong-Seok O, et al. Case report: pulmonary soiling after one-lung ventilation with a bronchial blocker. Can J Anesth, 2002,49:874-876
36 Arndt GA,Kranner PW,Rusy DA,et al. Single-lung ventilation in a criticallyⅢpatient using a fiberoptically directed wire-guided endobronchial blocker [CaseReports]. Anesthesiology,1999,90:1484-1486
37 Arndt GA, De Lessio ST, Kranner PW, et al. One-lung ventilation when intubation is diffcult:presentation of a new endobronchial blocker. Acta Anaesthesiol Scand,1999,43:356-358
38 Kabon B, Waltl B, Leitgeb J, et al. First experience with fiberoptically directed wire-guided endobronchial blockade in severe pulmonary bleeding in an emergency setting. Chest, 2001,120(4):1399-1402
39 LEHMANN A. A comparison of the Arndt endobronchial blocker with a double lumen tube in robotic cardiac surgery[J]. Anasthe siol Intensivmed Notfallemd Schmerzther, 2004, 39 ( 6 ) : 353 - 359
40 Campos JH,Kernstine KH.A comparison of a left-sided broncho-cath,with the torque control blocker univent and the wire-guided blocker. Anesth Analg,2003,96:283-289
41 Prabhu MR,Smith JH.Use of the arndt wire-guided endobronchial blocker [letter]. Anesthesiology,2002,97:1325
42 Sandberg WS. Endobronchial blocker dislodgement leading to pulseless electrical activity. Anesth Analg, 2005,100:1728-1730
43 McMullen MC ,Girling LG,Graham MR , et al .Biologically variable ventilation improves oxygenation and respiratory mechanics during one2lung ventilation[J ] . Anesthesiology ,2006 ,105 (1) :91-97
44 Neustein SM. One-lung ventilation provided by anesthesiologists having minimal experience with thoracic anesthesia[J].Anesthesiology,2006 ,105 (5) :1060
45 Wald SH,Mahajan A,Kaplan MB,et al.Experience with the arndt paediatric bronchial blocker. Br J Anesth,2005,94:92-94