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1、1,单肺通气低氧血症综合防治进展,广州中医药大学第一附属医院马 武 华,2,病 例 (一),患者，男，66岁。 行左肺叶切除术 插入右侧双腔导管,在纤支镜下定位。右上中下肺叶对位良好。右侧卧位开胸后即开始单肺通气，30min后SpO2就开始下降,一直到87-88%。,3,病 例 (一),立即进行纤支镜检查,发现右上肺开口已错位,没有通气 .,4,病 例 (一),经调整后, SpO2逐渐上升98-99%.,5,病 例 (二)男，73岁 。右上叶肺癌行肺叶切除术。 插入左侧双腔导管,在纤支镜下定位。左上下肺叶对位良好。左侧卧位开胸后即开始单肺通气，发现气道压上升到35-40cmH20, SpO2逐
2、渐开始下降。,6,病 例 (二),纤支镜检查:导管过深到左下叶支气管，左上肺通气不良,7,病 例 (二),经调整后, SpO2逐渐上升98-99%.,8,病 例 (三),男，53岁，68公斤。因“右上叶肺癌” 行右肺叶切除术。插入左侧双腔导管,在纤支镜下定位。左上下肺叶对位良好。单肺通气40min后血氧就开始下降,一直到90%以下。纤支镜检查对位良好。,9,立即给予非通气侧2-5cmH20 CPAP,SpO2逐渐上升98-99%.,10,一、低氧血症的原因1 导管位置不正确2 单肺通气及侧卧位的影响3 缺氧性肺血管收缩（HPV）4 其他因素的影响每年广东省晋升高级职称考题,11,一 导管位置不
3、正确是出现低氧血症最常见的原因,12,一 导管位置不正确左侧,左侧过浅示意图,13,一 导管位置不正确左侧,左侧过浅实图,14,导管位置不正确左侧,左侧过深示意图,15,导管位置不正确左侧,左侧过深实图,16,那么下面这种情况呢?,左侧插管,未看到窿突. 即可能过深也可能过浅,17,导管位置不正确右侧,右侧过深示意图,18,导管位置不正确右侧,右侧过深实图,19,插 反,20,一、导管位置不正确 例1患者左肺手术，插入右侧双腔气管，右上肺对位不好，这在临床是非常常见的情况。特别是在没有纤维支气管镜定位的情况下就更容易发生。,21,一、导管位置不正确,即使在有纤支镜的情况下，平卧位-侧卧位后：右
4、上肺开口错位率可达50-70%，偶达80%以上。因此，在已有一侧肺未通气的情况下，再加上右上肺通气不良，V/Q比更加失衡，则低氧血症就在所难免。,22,一、导管位置不正确,例2和例3患者右肺手术，插入的是左侧双腔气管。在插管的处理和对位方面也比插入右侧双腔气管要容易得多，但这同样不能保证不产生低氧血症，只是低氧血症的发生率要低于右侧插管。但如果左侧插管时的位置同样不理想的话，则和右侧插管相比也没有优势可言。,23,二、单肺通气及侧卧位的影响,单肺通气单肺通气时，术侧肺无通气，使通气/灌注比值下降，因此肺内分流增加。在开始的10min左右，虽然流经无通气肺泡的血流，可利用肺内剩余的氧，而在20-
5、30min后PaO2就明显下降.,24,二、单肺通气及侧卧位的影响,侧卧位下肺被压 1:纵隔和心脏 2:体位垫 3:上横隔下肺顺应性低于上肺，增加闭合肺容量，如通气不足易发生微小肺不张，功能残气量减少，也引起PaO2下降。,25,（三）缺氧性肺血管收缩（HPV）被抑制,肺泡缺氧刺激肽类内皮素 ，血栓素A ,血小板激活因子,白三烯，内皮细胞依赖收缩因子 很强的血管收缩作用形成缺氧性肺血管收缩 从而使病侧肺血流减少，低氧血症有所缓解 全麻抑制HPV,26,四、其他因素的影响,剖胸后胸腔负压消失 手术操作刺激 低血容量 心律不齐及心肌抑制等因素 使心排血量减少都是引起低氧血症的原因之一。,27,二、
6、低氧血症的处理1 导管位置2 V/Q3 HPV,28,低氧血症的处理：（1）导管位置不正确的危害：缺氧肺不张高气道压分泌物积蓄术后感染率增加,29,最理想的方法,一、常规使用纤支镜纠正双腔导管错位首要问题是对位问题二、首选插左侧双腔导管（左肺2叶，右肺3叶） 更加容易对位良好.,30,理想的位置:Golden standard,侧管:兰色套囊 的边缘和窿突平齐主管:直接看到上(中)下肺叶支气管开口 The ideal position was defined as that in which the carina was located at the same level with the m
7、iddle 5 mm between the proximal margin of the endobronchial balloon and the circumferential black mark,31,低氧血症的防治,我们的观察发现靠听诊方法的定位满意的病人，再用纤支镜定位，发现接近 50% 的导管不在一种理想的位置,32,一、使用纤支管镜纠正双腔导管错位,听诊:导管位置正确的172例病人中， 经纤支镜发现46%例是导管错位的，其中15%情况严重。 再转为侧卧位后，发现54%例双腔气管导管错位，其中28%情况严重。 右侧导管 明显比左侧导管错位的发生率高。 Klein等,33,Rel
8、iability of auscultation in positioning of double-lumen endobronchial tubes. Alliaume B Can J Anaesth. 1992 Sep;39(7):687-90.,Auscultation is a well-established technique to confirm the position of double-lumen endobronchial tubes (DLTs). However, some authors have recommended that fibreoptic bronch
9、oscopy (FOB) is also indicated. The aims of this study were to determine first if bronchoscopy after blind placement of DLTs improved positioning; and second if preoperative bronchoscopy could detect difficult intubation. Twenty-four patients undergoing aortic or lung surgery were studied. After int
10、ubation with a single-lumen tube, an initial FOB was performed by an independent observer to check the airway anatomy. Then, the single-lumen tube was replaced by a DLT using a classical “blind“ intubation method. Subsequent FOB was performed first by the independent observer to record the DLT posit
11、ion and next by the investigators for improvement or correction of their positioning under visual control. Fibreoptic bronchoscopy after blind placement of DLTs resulted in repositioning 78% left-sided DLTs and 83% right-sided DLTs. Preoperative bronchoscopy did not always detect an airway abnormali
12、ty which might lead to difficult positioning of the DLTs. In conclusion, auscultation is an unreliable method of confirming the position of DLTs and should be followed by fibreoptic bronchoscopy.,34,转为侧卧位后如何？,METHODS: Eighty patients undergoing elective thoracotomy that required an anesthesia with t
13、he use of left DLT were studied. An Olympus LF-P broncho-fiberscope was used to estimate the distance between the carina and the distal end of the DLT via the tracheal lumen before and after patient positioning. RESULTS: All DLT were confirmed to be in the correct position in eighty patients before
14、patient positioning. After patient positioning, the DLT moved proximally 1.5 cm, 1 cm and 0.5 cm in eighteen (22.5%), sixteen (20%) and eight (10%) patients respectively. In nine patients (11.25%) DLT displacement after positioning resulted in a failure to ventilate the lungs separately and required
15、 readjustment of the DLT. CONCLUSIONS: Our result suggests that there is a high incidence of DLT displacement during patient positioning.,35,平卧位定位很好 侧卧位定位很好,是不是就,？,36,手术牵拉导致的导管移位,37,38,肺大泡破裂导致的移位,39,Double-lumen tube position should be confirmed by fiberoptic bronchoscopy.,Cohen E.Department of Anes
16、thesiology, Mount Sinai Medical Center, New York, USA.PURPOSE OF REVIEW: This review is part of Pro and Contra use of fiberoptic bronchoscopy to confirm the position of a double lumen tube. The purpose of this review is to highlight the circumstances where fiberoptic bronchoscopy should be used in c
17、onjunction with lung separation, right sided double-lumen tube positioning, and to identify fine malposition for generally missed by clinical signs. RECENT FINDINGS: Until several years ago, confirmation of a double-lumen tube (DLT) position was limited to inspection and auscultation. Fiberoptic bro
18、nchoscopes were usually only available in the bronchoscope suite for the exclusive use of the pulmonary personnel. Today, in most institutions, fiberoptic bronchoscopes of different diameters are available in the operating room for use by the anesthesia personnel. SUMMARY: Advances in technology and improved quality of the endoscopes image make the technique easy to use with a relatively simple learning curve. In fact, fiberoptic workshops, thoracic workshops and difficult airway workshops are offered in nearly all important anesthesia meetings.Curr Opin Anaesthesiol. 2004 Feb;17(1):1-6.,
