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1、09年会-麻醉相关新技术、新业务进展09年会-中青年论文大赛参赛支气管堵塞器行左下肺叶隔离对患者肺内分流及氧合作用的影响叶靖1, 2 ，古妙宁1，张朝群1（1南方医科大学南方医院麻醉科，2现在广州医学院第一附属医院麻醉科工作，广东 广州 510515） 摘要：目的 比较支气管堵塞器（BB）行左下肺叶隔离与左双腔支气管导管（DLT）行右单肺通气对肺功能正常患者肺内分流（Qs/Qt）和氧合作用影响的差异。 方法 拟行左侧剖胸下段食管手术患者36例，年龄3264岁，随机分成BB组和DLT组，每组各18例。丙泊酚靶控输注静脉诱导后，BB组插入ID8.0单腔气管导管，纤维支气管镜（FOB）引导9Fr C
2、oopdech BB置入左下肺叶支气管，DLT组插入左DLT。两组均作双肺间歇正压通气，吸入氧浓度50%，潮气量68 ml / kg，呼吸频率15次/min，保持呼末二氧化碳分压3540 mm Hg。20min后摆放右侧卧位，DLT组行右单肺通气，BB组对堵塞器套囊充气行右肺和左上肺叶通气。20min后手术开始，全程采用丙泊酚靶控输注维持麻醉，间歇追加舒芬太尼和顺阿曲库铵。于双肺通气后20min（T1），右单肺通气或右肺和左上肺叶通气后20min（T2），开胸见左肺或左下肺叶完全萎陷后（T3），术毕拔出气管导管前（T4）抽取足背动脉血及右心房血进行血气分析计算Qs/Qt。并请手术医生在开胸后即
3、刻评价术野清晰度。术后第一天作动脉血气分析和胸片检查。 结果 两组患者的年龄、身高、体质量、性别比，手术时间、术中丙泊酚、舒芬太尼和顺阿曲库铵用药量，晶体、胶体输入量，失血量、尿量无统计学差异。BB组把支气管堵塞器置入满意位置所需的时间较DLT组长（18820s vs. 174 14s），需要FOB检查的次数较DLT组多（2.781.00次vs. 2.170.38次）（P 0.05）。两组患者各观察时点的CVP、体温，pH、PaCO2、血红蛋白无统计学差异。BB组与DLT组在T1的Qs/Qt（4.451.93vs 4.641.92）、PaO2（25052mmHg vs 27851 mmHg）、
4、PO2（6712mmHg vs 6319 mmHg）、氧合指数（44492 vs 49290）无统计学差异。在T2T4时点，BB组的Qs/Qt分别为7.513.36%，8.573.37%，5.242.10%，低于DLT组的13.534.68%，22.795.36%，11.015.79%；BB组的PaO2分别为21158mmHg，18558mmHg，26577mmHg，高于DLT组的14745 mmHg，12047 mmHg，24466 mmHg；BB组的P O2分别为6010mmHg，5910mmHg，599mmHg，高于DLT组的436 mmHg，426 mmHg，4520 mmHg；BB组
5、的氧合指数分别为374103，324112，41872，高于DLT组25786，20988，32772（P 0.05或0.01）。BB组术后无肺不张病例，DLT组有2例发生左下肺不张。BB组术后第一天的PaO2、氧合指数高于DLT组，术后住院天数比DLT组短（10.110.76d vs. 11.782.32d）（P 0.01）。结论 支气管堵塞器行左下肺叶隔离能在左侧剖胸下段食管手术中减少患者的肺内分流、改善术中术后的氧合，这种新型肺隔离方法尤其适用于需要肺萎陷的肺外手术。 关键词：肺叶隔离；支气管堵塞器；单肺通气；双腔支气管导管；肺内分流Effects of selective left l
6、ower lobar blockade by Coopdech endobronchial blocker on patients intrapulmonary shunt and arterial oxygenation: a comparison with double-lumen endobronchial tubeYE Jing1, GU Miao-ning2, ZHANG Chao-qun2 1,2Department of Anesthesiology, Nanfang Hospital; 1 Working in Department of Anesthesiology, Fir
7、st affiliated hospital of Guangzhou medical college, Guangzhou 510515, China Abstract：Objective To compare the difference of intrapulmonary shunt (Qs/Qt) and arterial oxygenation between selective left lower lobar blockade by Coopdech endobronchial blocker(BB) and one lung ventilation (OLV) by left-
8、sided double-lumen endobronchial tubes(DLT) in patients with normal pulmonary function. Methods 36 patients (aged 32-64 yr) scheduled for left-sided lower esophageal surgery were allocated randomly to two groups: BB or DLT (n = 18). Anesthesia was induced and maintained with Propofol by target contr
9、olled infusion, administered sufentanil and cisatracurium intravenously if needed. A 35 to 39 French tube was placed in the DLT group and a 8.0-mm internal diameter single-lumen endotracheal tube was used in the BB group, a 9 French Coopdech blocker was advanced into the left lower lobar bronchus gu
10、iding by a fiberoptic bronchoscope in the latter group. The variables recorded were blood gas analyses data took by mixed-venous blood and arterial blood sample at four surgical times: 20 minutes after two-lung ventilation in supine position (T1), 20 minutes after initiation of one-lung ventilation
11、or selective left lower lobar blockade by inflating BB balloons in right lateral decubitus position (T2), total collapse of left lung or left lower lobe after the pleura was opened (T3) and before tracheal extubation(T4). Ventilation was accomplished with flow volume control. Tidal volume, respirato
12、ry rate and minute volume were kept constant at each time. Qs/Qt was calculated using a standard formula based on the three-compartment model. Once the pleura was opened, the effectiveness of lung collapse was evaluated by the surgeon who performed the surgery. Chest radiograph and arterial blood ga
13、s analyses were performed the day after the operation. Results All groups were similar with regard to sex, age, weight, height, ASA, rank of surgical exposure; pH, PaCO2, hemoglobin from T1 to T4; Qs/Qt, PaO2, P O2, oxygenation index at T1. Significant trends were found toward a higher decrease in Q
14、s/Qt and a better improvement in PaO2, P O2, oxygenation index during T2, T3 and T4 with the BB compared to DLT (P0.05 or 0.01). No lobe collapse was observed in the postoperative period in group B, but 2 patients of group D were found left lower lobe atelectasis. A better postoperative arterial oxy
15、genation and less postoperative length of stay were shown in group B (P 0.01). Conclusion Selective left lower lobar blockade by Coopdech endobronchial blocker during left-sided esophageal surgery provides a lower intraoperative intrapulmonary shunt and a better intraoperative and postoperative arterial oxygenation. Key words：selective lobar blockade; endobronchial blocker; double-lumen endobronchial tube; one lung ventilation; intrapulmonary shunt
