本文選題：雙腔支氣管導管　切入點：胸腔鏡手術　出處：《皖南醫(yī)學院》2017年碩士論文

【摘要】：目的:雙腔支氣管導管(Double-lumen endobronchial tubes,DLTs)插管是臨床上進行肺隔離手術最為常用的技術。鑒于左、右支氣管解剖結構的差異及左側插管操作方便、對位準確度高等優(yōu)點,國內、外胸科手術DLTs的選擇一直遵循著“寧左毋右”原則,即在不影響手術操作的前提下,無論是右進胸手術還是左進胸手術均選擇左路DLTs插管。而如今隨著插管設備及技術改進,尤其是纖支鏡的出現,在一定程度上克服了右路DLTs插管定位的難題后,這種傳統觀念是否還具有臨床優(yōu)勢仍值得探討。另外,臨床實踐發(fā)現左進胸手術選擇左路DLTs插管時,由于雙腔管通氣管末端呈約45°斜面,通氣側管口又位于隆突附近,其在受到手術操作牽拉或擠壓肺組織時易發(fā)生貼壁現象,從而引發(fā)間歇性的氣道壓升高乃至氣道梗阻,嚴重時甚至可導致通氣不足和低氧血癥的發(fā)生。因此,本研究擬通過比較非手術側DLTs和手術側DLTs插管術中間歇性高氣道壓和低氧血癥的發(fā)生風險,探討非手術側DLTs插管用于胸科手術單肺通氣的效果,以期為臨床DLTs應用提供依據。方法:選擇我院擇期胸腔鏡下需行單肺通氣手術患者90例,ASA I-II級,年齡40-70歲。排除合并有重要系統疾病、有明顯氣管與支氣管損傷或缺損、胸部X片和CT查氣管或支氣管結構異常、有支氣管哮喘或氣道高反應病史等患者。將符合標準患者隨機分為三組,每組30例,A組:左進胸手術選擇左路DLTs插管;B組:右進胸手術選擇左路DLTs插管;C組:左進胸手術選擇右路DLTs插管。記錄麻醉過程中DLTs插管次數,側臥位前、后FOB定位的次數與時間,單肺通氣后間歇性高氣道壓和低氧血癥的發(fā)生次數,術中FOB定位次數與時間,肺隔離滿意度的分級及DLTs相關性并發(fā)癥。結果:三組患者在性別、年齡、體重、身高及DLTs型號上無統計學意義的差異(P0.05);在DLTs插管與定位方面,三組間在插管次數、插管時間、置管深度及側臥位前、后FOB定位時間上未見統計學差異(P0.05);術中FOB定位次數及定位時間,B、C兩組明顯少于A組,具有統計學差異(P0.05);在術中間歇性高氣道壓及低氧血癥的發(fā)生風險上,B、C兩組明顯低于A組,肺隔離滿意度明顯高于A組,差異具有統計學意義(P0.05)。另外,在術后并發(fā)癥上,三組患者在術后咽喉痛的發(fā)生風險上也無明顯統計學差異(P0.05)。結論:胸腔鏡下非手術側DLTs插管降低了術中間歇性高氣道壓和低氧血癥發(fā)生的發(fā)生風險,增加了肺隔離的滿意度;非手術側DLTs插管用于胸腔鏡手術臨床效果優(yōu)于單純左路DLTs插管,值得推廣應用。
[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.
【學位授予單位】：皖南醫(yī)學院
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R614

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本文編號：1720218