AnesthesiaforThoracicSurgeryZhao-QiongZhu,M.D.Departmentof

Anesthesiology,AffiliatedHospital

ofZunyiMedicalCollege,Zunyi,

Guizhou,563003,China

1

胸科手術(shù)的麻醉

遵義醫(yī)學(xué)院麻醉學(xué)教研室朱昭瓊2要求掌握剖胸及側(cè)臥位時(shí)呼吸、循環(huán)病理生理的改變掌握剖胸手術(shù)病人麻醉前的估計(jì)和方法及麻醉的基本要求熟悉單肺通氣的生理變化、及單肺通氣的術(shù)中管理熟悉常見(jiàn)胸科手術(shù)的麻醉處理3第一節(jié)剖胸及側(cè)臥位時(shí)對(duì)呼吸、

循環(huán)的影響(p119)剖胸所引起的病理生理改變—自主呼吸時(shí)

1剖胸側(cè)通氣與肺血流比例失調(diào)肺內(nèi)分流（hypoxicpulmonaryvasoconstriction;HPV有限，并受麻醉藥及擴(kuò)管藥抑制）2反常呼吸（paradoxicalrespiration)擺動(dòng)氣死腔增大3縱隔移位縱隔擺動(dòng)(mediastinalswaying)4剖胸及側(cè)臥位時(shí)對(duì)呼吸、循環(huán)的影響

4心排出量降低其原因（1）（2）（3）5心律失常其原因（縱隔擺動(dòng)時(shí)對(duì)部位神經(jīng)的刺激、通氣功能紊亂、VA／Q比失常、PaO2↓和PaCO2↑)6體熱的散失5側(cè)臥位對(duì)呼吸生理的影響清醒狀態(tài)下側(cè)臥位(functionresidualcapacity;FRC下降VA／Q比基本正常)全麻下側(cè)臥位FRC下降VA／Q比失常：下側(cè)肺VA／Q下降，上側(cè)肺VA／Q升高6第二節(jié)麻醉前評(píng)估與準(zhǔn)備必要性（胸科手術(shù)術(shù)后肺部并發(fā)癥發(fā)生率較高）肺部并發(fā)癥最常見(jiàn)圍術(shù)期死亡率居第二位肺功能異常者并發(fā)癥是正常者23倍（切除肺病變，肺通氣面積↓；手術(shù)操作肺損傷，出血、水腫↑；術(shù)后痛疼，分泌物墜積或肺不張etc.)7Preoperativeevaluation

PatientsforthoracicsurgeryshouldundergotheusualpreoperativeassessmentasdetailedinChapter1.Anypatientundergoingelectivethoracicsurgeryshouldbecarefullyscreenedforunderlyingbronchitisorpneumoniaandtreatedappropriatelybeforesurgery.Diagnosticproceduressuchasbronchoscopyandlungbiopsy（活檢）maybeintendedforpersistentinfection.Infectionbeyondanobstructinglesion（損害）maynotresolve（解決）withoutsurgery.8

Inpatientswithtrachealstenosis（狹窄）,thehistoryshouldfocusonsymptomsorsignsofpositionaldyspnea,staticversusdynamicairwaycollapse,andevidenceofhypoxemia.Thehistorymayalsosuggesttheprobablelocationofthelesion.Arterialbloodgas(ABG)determinationsmayhelptoclarifytheseverityofunderlyingpulmonarydiseasebutarenotroutinelynecessary.Pulmonaryfunctiontestsareusefulinassessingthepulmonaryriskoflungresection.Bothexercisefunction(maximaloxygenuptake[O2max])andspirometry(forcedexpiratoryvolumein1second)havebeenusedtostratifyrisksofresection.Inmarginalcases,split-functionradionuclidescansandventilation/perfusion()scanscandeterminetherelativecontributionofeachlungandindividuallungregions.Preoperativeevaluation

9

Cardiacfunctionshouldbeassessedifthereisquestionoftherelativecontributionofcardiacandpulmonarydiseaseinthepatient'sfunctionalimpairment.Echocardiographycanestimatepulmonaryarterypressureandrightventricularfunction.Imagingstudies,suchaschestradiography,computedtomography(CT),andmagneticresonanceimaging,areusefultodeterminethepresenceoftrachealdeviation,thelocationofpulmonaryinfiltrates,effusionorpneumothorax,andtheinvolvementofadjacentstructuresinthedisease.Preoperativeevaluation

10Trachealtomographyorthree-dimenionalreconstructionfromCTisusedtoassessthecaliberofstenoticairwaysandcanbeusedtopredictthesizeandlengthoftheendotrachealtubethatwillbeappropriateforthepatient.Severeairwaystenosis（狹窄）observedpreoperativelymaychangetheanesthetist'splansforinductionandintubation.IntroductionPreoperativeevaluation

11麻醉前評(píng)估一般情狀：

吸煙、年齡、肥胖、手術(shù)時(shí)間臨床病史和體征:有無(wú)呼吸困難、哮喘、咳嗽、咳痰、胸痛、吞咽困難氣管受壓移位、液氣胸、異常呼吸音胸部拍片、CT肺功能測(cè)定及血?dú)夥治?12肺功能測(cè)定

屏氣試驗(yàn)吹氣試驗(yàn)肺功能測(cè)定:“平板運(yùn)動(dòng)試驗(yàn)”臨床常用的指標(biāo)（TVC、FEV1、FVC、FEV1/FVC、MVV）肺活量＜60﹪通氣儲(chǔ)備量＜70﹪FEV1/FVC＜60﹪有術(shù)后呼吸功能不全的可能13FVC<50%，F(xiàn)EV1

<50%，肺切除術(shù)預(yù)后差FEV1/FVC<60%，術(shù)后并發(fā)癥發(fā)生率高如術(shù)前FEV1/FVC<50%、FEV1<2L、MVV<50%預(yù)計(jì)值、PaCO2>45mmHg、RV/TLV(余氣量/肺總量）>50%，全肺切除術(shù)后風(fēng)險(xiǎn)↑14全肺切病人術(shù)前肺功能測(cè)定最低限度應(yīng)合以下標(biāo)準(zhǔn)：（1）FEV1>

2L、FEV1/FVC>50%（2）MVV

>80L/min或>50%預(yù)計(jì)值（3）RV/TLC<50%，預(yù)計(jì)術(shù)后FEV1>

0.8L

不附合上述標(biāo)準(zhǔn)應(yīng)行分側(cè)肺功能測(cè)定（4）平肺動(dòng)脈壓<35mmHg（5）運(yùn)動(dòng)后PaO2>

45mmHg肺葉切除術(shù)的要求可稍低運(yùn)動(dòng)時(shí)最大氧攝取量（VO2max>20L/(kg.min)15血?dú)夥治?/p>

PaO2了解肺的氧合情況PaCO2肺通氣功能

A-aDO2肺換氣功能16

Preoperativesedationshouldbegivencarefullytopatientswithtrachealorpulmonarydisease.1.Heavysedationmayimpairpostoperativedeepbreathing,coughing,andairwayprotection.2.Patientswithpoorpulmonaryfunctionwillbemorepronetohypoxemiawhentheirrespiratorydrive（呼吸動(dòng)力）issuppressed.Whensedatingthesepatients,itiswisetomonitoroxygenationandadministersupplementaloxygen.Preoperativepreparation17

3.Inthepresenceofairwayobstruction,sedationmustbecarefullybalanced.

Oversedationmayprofoundly（深深地)suppressventilation,butananxiouspatientmaymakeexaggerated(夸大的,夸張的)

respiratoryefforts.Inthiscase,theincreasedturbulencemaycauseworsenedairwayobstruction,leadingtoincreasedanxiety.Benzodiazepines,reassuring(安慰的)words,carefulmonitoring,andanexpeditious(迅速的）starttotheprocedureisthebestapproach.Preoperativepreparation18PreoperativepreparationAspiration（吸引）prophylaxis（預(yù)防）,withanoralhistamine-2receptorantagonistandmetoclopramide（胃復(fù)安),shouldbeconsideredinpatientsundergoingmajorthoracicsurgery.Patientswithesophagealdiseaseshouldbeconsideredathighriskforaspiration.19麻醉前準(zhǔn)備停止吸煙控制肺部感染，盡力減少痰量保持氣道通暢，防治支氣管痙攣控制感染外，常用的解痙和擴(kuò)張支氣管藥：1）氨茶堿2）腎上腺糖皮質(zhì)激素3）色甘酸鈉4）β2受體激動(dòng)藥鍛煉呼吸功能低濃度氧吸入對(duì)并存的心血管方面情況進(jìn)行處理20第三節(jié)胸科手術(shù)麻醉的特點(diǎn)與處理

一、胸科手術(shù)麻醉的基本要求消除或減輕縱隔擺動(dòng)與反常呼吸避免肺內(nèi)物質(zhì)的擴(kuò)散負(fù)壓吸引的注意事項(xiàng)：1）適當(dāng)麻醉深度2）吸引時(shí)間3）負(fù)壓和相對(duì)無(wú)菌操作4）吸引要及時(shí)支氣管插管21保持Pa02和PaCO2于基本正常水平盡力縮小VA／Q比失常：1）高濃度氧吸入，通氣量10ml/kg；定時(shí)膨脹塌陷肺，術(shù)側(cè)肺以不完全肺萎陷為宜2）保持生理范圍內(nèi)的PaCO2。如出現(xiàn)PaCO2增高，不宜增大每次通氣量，可適當(dāng)增加每分鐘的通氣頻率PETCO2和SPO2監(jiān)測(cè)減輕循環(huán)障礙1）增加輸液量2）維持較高CVP3）適當(dāng)麻醉深度4）適當(dāng)估計(jì)出血量。全肺切避免肺水腫保持體熱22二、One-lungventilation單肺通氣

慨念適應(yīng)癥濕肺支氣管胸膜瘺胸腔鏡手術(shù)肺葉\全肺部手術(shù)(相對(duì)適應(yīng)癥)23(一)單肺通氣的生理變化

非通氣側(cè)肺產(chǎn)生肺內(nèi)分流通氣側(cè)肺VA/Q異常若缺氧性肺血管收縮（HPV）反應(yīng)良好，雙肺分流量約20-25％若缺氧性肺血管收縮受損，雙肺分流量約≥25％若非通氣側(cè)肺病變?cè)絿?yán)重，分流量越小單肺通氣均有不同程度的肺內(nèi)分流（單肺通氣時(shí)，PaO2在67.5-70mmHg可接受）24單肺通氣時(shí)呼吸管理處理的原則：減少非通氣側(cè)的肺血流和避免通氣肺的肺不張和肺泡順應(yīng)性降低25呼吸管理具體方法盡可能采用雙肺通氣在由雙肺通氣改為單肺通氣時(shí)，應(yīng)先手控通氣量不能過(guò)低或過(guò)高，一般10ml/kg適當(dāng)增加呼吸頻率（比正常增加20％）應(yīng)監(jiān)測(cè)PETCO2和SPO2及血?dú)夥治鋈绨l(fā)現(xiàn)低氧血癥或PaO2↓，其處理：261）停用氧化亞氮2）檢查操作、導(dǎo)管、吸引3）術(shù)側(cè)肺通氣；非通氣肺內(nèi)可用純氧吹脹，然后關(guān)閉呼吸口，約20分鐘重復(fù)一次4）通氣側(cè)適當(dāng)用PEEP呼吸，壓力≤5cmH2O5）如前處理無(wú)效，SPO2↓，通知術(shù)者雙肺通氣6）術(shù)者可壓迫或鉗夾術(shù)側(cè)肺動(dòng)脈7.單肺通氣恢復(fù)雙肺通氣時(shí)，進(jìn)行手法通氣，首先使非通氣肺膨脹，進(jìn)行手法通氣27第四節(jié)常見(jiàn)胸科手術(shù)麻醉處理肺部手術(shù)靜脈通道體位測(cè)壓關(guān)胸前應(yīng)檢查有無(wú)漏氣、肺是否膨脹接