本文選題：雙腔支氣管導(dǎo)管　切入點(diǎn)：胸腔鏡手術(shù)　出處：《皖南醫(yī)學(xué)院》2017年碩士論文

【摘要】：目的:雙腔支氣管導(dǎo)管(Double-lumen endobronchial tubes,DLTs)插管是臨床上進(jìn)行肺隔離手術(shù)最為常用的技術(shù)。鑒于左、右支氣管解剖結(jié)構(gòu)的差異及左側(cè)插管操作方便、對(duì)位準(zhǔn)確度高等優(yōu)點(diǎn),國(guó)內(nèi)、外胸科手術(shù)DLTs的選擇一直遵循著“寧左毋右”原則,即在不影響手術(shù)操作的前提下,無(wú)論是右進(jìn)胸手術(shù)還是左進(jìn)胸手術(shù)均選擇左路DLTs插管。而如今隨著插管設(shè)備及技術(shù)改進(jìn),尤其是纖支鏡的出現(xiàn),在一定程度上克服了右路DLTs插管定位的難題后,這種傳統(tǒng)觀念是否還具有臨床優(yōu)勢(shì)仍值得探討。另外,臨床實(shí)踐發(fā)現(xiàn)左進(jìn)胸手術(shù)選擇左路DLTs插管時(shí),由于雙腔管通氣管末端呈約45°斜面,通氣側(cè)管口又位于隆突附近,其在受到手術(shù)操作牽拉或擠壓肺組織時(shí)易發(fā)生貼壁現(xiàn)象,從而引發(fā)間歇性的氣道壓升高乃至氣道梗阻,嚴(yán)重時(shí)甚至可導(dǎo)致通氣不足和低氧血癥的發(fā)生。因此,本研究擬通過(guò)比較非手術(shù)側(cè)DLTs和手術(shù)側(cè)DLTs插管術(shù)中間歇性高氣道壓和低氧血癥的發(fā)生風(fēng)險(xiǎn),探討非手術(shù)側(cè)DLTs插管用于胸科手術(shù)單肺通氣的效果,以期為臨床DLTs應(yīng)用提供依據(jù)。方法:選擇我院擇期胸腔鏡下需行單肺通氣手術(shù)患者90例,ASA I-II級(jí),年齡40-70歲。排除合并有重要系統(tǒng)疾病、有明顯氣管與支氣管損傷或缺損、胸部X片和CT查氣管或支氣管結(jié)構(gòu)異常、有支氣管哮喘或氣道高反應(yīng)病史等患者。將符合標(biāo)準(zhǔn)患者隨機(jī)分為三組,每組30例,A組:左進(jìn)胸手術(shù)選擇左路DLTs插管;B組:右進(jìn)胸手術(shù)選擇左路DLTs插管;C組:左進(jìn)胸手術(shù)選擇右路DLTs插管。記錄麻醉過(guò)程中DLTs插管次數(shù),側(cè)臥位前、后FOB定位的次數(shù)與時(shí)間,單肺通氣后間歇性高氣道壓和低氧血癥的發(fā)生次數(shù),術(shù)中FOB定位次數(shù)與時(shí)間,肺隔離滿意度的分級(jí)及DLTs相關(guān)性并發(fā)癥。結(jié)果:三組患者在性別、年齡、體重、身高及DLTs型號(hào)上無(wú)統(tǒng)計(jì)學(xué)意義的差異(P0.05);在DLTs插管與定位方面,三組間在插管次數(shù)、插管時(shí)間、置管深度及側(cè)臥位前、后FOB定位時(shí)間上未見(jiàn)統(tǒng)計(jì)學(xué)差異(P0.05);術(shù)中FOB定位次數(shù)及定位時(shí)間,B、C兩組明顯少于A組,具有統(tǒng)計(jì)學(xué)差異(P0.05);在術(shù)中間歇性高氣道壓及低氧血癥的發(fā)生風(fēng)險(xiǎn)上,B、C兩組明顯低于A組,肺隔離滿意度明顯高于A組,差異具有統(tǒng)計(jì)學(xué)意義(P0.05)。另外,在術(shù)后并發(fā)癥上,三組患者在術(shù)后咽喉痛的發(fā)生風(fēng)險(xiǎn)上也無(wú)明顯統(tǒng)計(jì)學(xué)差異(P0.05)。結(jié)論:胸腔鏡下非手術(shù)側(cè)DLTs插管降低了術(shù)中間歇性高氣道壓和低氧血癥發(fā)生的發(fā)生風(fēng)險(xiǎn),增加了肺隔離的滿意度;非手術(shù)側(cè)DLTs插管用于胸腔鏡手術(shù)臨床效果優(yōu)于單純左路DLTs插管,值得推廣應(yīng)用。
[Abstract]:Objective: Double-lumen endobronchial tubeslts (DLTs) catheterization is the most commonly used technique for lung isolation surgery.In view of the differences between left and right bronchus anatomical structure and the advantages of convenient operation of left side intubation and high accuracy of orthopedic operation, the choice of DLTs in external chest surgery has always followed the principle of "better left than right", that is, without affecting the operation,Left DLTs catheterization was performed in both right and left thoracotomy.However, with the improvement of intubation equipment and technique, especially the appearance of fiberoptic bronchoscope, the difficulty of positioning right DLTs intubation is overcome to a certain extent, so it is worth discussing whether this traditional idea still has clinical advantages.In addition, the clinical practice showed that in the choice of left DLTs intubation in the left thoracic surgery, the end of the double lumen tube was about 45 擄oblique plane, and the orifice of the ventilation side was located near the protuberance, which was prone to adhere to the wall when the lung tissue was pulled or squeezed by the operation.It can cause intermittent airway pressure and even airway obstruction, and even lead to lack of ventilation and hypoxemia.Therefore, the aim of this study was to compare the risk of intermittent hyperairway pressure and hypoxemia during DLTs and DLTs intubation on the non-operative side, and to explore the effect of DLTs intubation on the non-operative side for one-lung ventilation in thoracic surgery.In order to provide the basis for clinical application of DLTs.Methods: 90 patients (40-70 years old) with ASA I-II grade undergoing thoracoscopic ventilation in our hospital were selected.Patients were excluded with important systemic diseases, obvious tracheal and bronchial injuries or defects, abnormal tracheal or bronchial structure by chest X-ray and CT examination, and history of bronchial asthma or airway hyperresponsiveness.The patients were randomly divided into three groups: group A (30 cases): left thoracic operation: left DLTs intubation group B: right thoracic operation choice left DLTs intubation group C: left thoracic operation choice right DLTs intubation.The number and time of DLTs intubation during anesthesia, the number and time of FOB localization before and after lateral position, the frequency of intermittent hyperairway pressure and hypoxemia after one-lung ventilation, the number and time of FOB localization during operation were recorded.Grade of pulmonary isolation satisfaction and complications associated with DLTs.Results: there was no significant difference in sex, age, weight, height and DLTs model among the three groups (P 0.05). In DLTs intubation and positioning, the three groups had no significant difference in intubation times, intubation time, depth of intubation and lateral position.There was no statistical difference in the time of FOB localization (P 0.05), the number and time of FOB localization in group C were significantly lower than those in group A (P 0.05), and the risk of intermittent hyperairway pressure and hypoxemia in group C was significantly lower than that in group A.The satisfaction degree of pulmonary isolation was significantly higher than that of group A, and the difference was statistically significant (P 0.05).In addition, there was no significant difference in the risk of postoperative throat pain among the three groups (P 0.05).Conclusion: DLTs intubation under thoracoscope can reduce the risk of intermittent hyperairway pressure and hypoxemia and increase the satisfaction of pulmonary isolation.The clinical effect of non-operative side DLTs intubation in thoracoscopic surgery is better than that of left side DLTs intubation alone, which is worth popularizing.
【學(xué)位授予單位】：皖南醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R614

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