【作者】 周汉鲲；

【导师】 姜春浩；

【作者基本信息】 延边大学 ， 麻醉学， 2011， 硕士

【摘要】 目的：探讨纤维支气管镜(FOB)定位方法在开胸手术单肺通气(OLV)应用中的有效性、可靠性、安全性。方法随机选择200例需行单肺通气(OLV)的开胸患者,ASA分级Ⅱ-Ⅲ级,其中男性112例,女性88例,年龄：18-75岁,平均(53±14)岁,身高146-185cm体重43-88kg,体查气道无外观畸形。所有患者术前心、肺功能检查均正常或在代偿范围之内,双肺通气指端Sp02均大于90%。随机平均分为：听诊(T)组：100例,其中左侧双腔支气管导管(left double-lumen tubes,L-DLT)插管56例,右侧双腔支气管导管(right double-lumen tubes,R-DLT)插管44例。FOB(F)组：100例,其中左侧双腔支气管导管(L-DLT)插管52例,右侧双腔支气管导管(R-DLT)插管48例。两组患者均经充分胸外科术前准备后,被接进入手术间。然后经静脉注射咪达唑仑0.05-0.1mg/kg、芬太尼3-4μg/kg、丙泊酚1-2mg/kg、罗库溴铵0.6mg/kg进行麻醉诱导,诱导后用传统方法插入DLT(现通常为Robertshaw双腔支气管导管)并记录导管插入深度,一般插入深度为29-31cm。导管插入后分别对两组患者进行管端定位。听诊组：听诊法准确定位标准为：气管气囊充气,听诊,调整双腔管位置致双肺都能听到满意的呼吸音,然后支气管气囊充气,听诊,调整双腔管位置致双肺都能听到满意的呼吸音,再双侧肺分别行单肺通气,听诊,调整双腔管位置致通气侧肺能听到满意的呼吸音,而非通气侧肺无明显呼吸音。错误定位标准为：①、双肺通气时,仅一侧肺能听到呼吸音(导管插入过深至一侧主支气管所引起)。②、两肺分别单肺通气时,两肺均能同时听到清晰的呼吸音(导管插入过浅引起)③、单肺通气时,健侧肺上叶未能听到呼吸音(支气管导管或支气管导管套囊阻塞上叶支气管口引起)。④、两肺分别单肺通时,患侧肺呼吸音较弱或未能听到呼吸音,而健侧肺呼吸音清晰(支气管导管套囊部分或完全阻塞对侧主支气管口引起)。FOB组：直接FOB下双腔支气管插管定位,定位标准大多参照PD Slingerm的方法：最佳位置为：1、L-DLT先将FOB插入右侧管,在导管开口处可见气管腔、隆突、右支气管开口,已充气的支气管套囊(蓝套囊)上缘位于隆突下；FOB插入左侧管后可见左上、下叶支气管口。2、R-DLT先将FOB插入左侧管,在导管开口处可见气管腔、隆突、左主支气管开口,已充气的支气管套囊(蓝套囊)上缘位于隆突下；FOB插入右侧管,在导管端口可见右肺中、下叶支气管开口,侧孔可见到右肺上叶支气开口。错位为：(1)、一般错位导管较正确位置移动大于0.5cmm。(2).、严重错位为：①导管插入相反主支气管。②导管插入太深完全进入支气管内。③导管插入太浅未进入支气管内。监测并记录：1、两组在体位改变后气道峰压(Paw)值大于30cmH2O的例数和两组单肺通气后30min、60minSpO2值小于90%的例数。2、记录两组分别在不同类型插管方式下不同体位单肺通气满意的例数、满意率及开胸后发现单肺不满意术中需FOB调整定位的例数。3、记录两组在不同体位单肺通气不满意时,FOB检查导管插入过深或过浅的例数。4、记录两组术中、术后并发症的发生、发现及处置等方面的情况。结果听诊定位法在单肺通气时一次性定位成功率低,不同体位、不同插管类型(L-DLT, R-DLT)单肺通气满意率低,术中、术后并发症较多,且不能用于查找并发症原因及对其进行处置。而FOB定位方法在单肺通气时一次性定位成功率高,不同体位、不同插管类型(L-DLT, R-DLT)单肺通气满意率高,术中术后并发症少,此外,还可用于查找并发症原因及对其进行处理。结论1、在使用DLT实施单肺通气时,单凭听诊对DLT进行定位,存在一定的主观性和盲目性,其准确性、可靠性、安全性不高。2、FOB定位法在使用DLT实施单肺通气时,FOB对DLT进行定位具有直观性,是一种准确、可靠、安全的DLT定位方法,应在胸、心外科手术中实施单肺通气时普遍、常规使用,成为单肺通气时对DLT进行定位的“金标准”。更多还原

【Abstract】 Objective:To investigate the fiberoptic bronchoscope (FOB) positioning method in open heart surgery one-lung ventilation (OLV) application, the validity, reliability and security.Methods 200 patients were randomly selected to be line of one-lung ventilation (OLV) for thoracotomy patients, ASA gradeⅡ-Ⅲ-class, male 112 cases,88 cases of women, age:18-75 years, mean (53±14) years old 146-185cm tall and weight 43-88kg, without the appearance of the airway physical examination abnormalities. All patients with preoperative cardiac and pulmonary function tests were normal or within the scope of the compensation, lung ventilation was more than 90% SpO2 finger. Randomly divided into:auscultation (T) group:100 cases, of which the left double-lumen endoendobronchial tube (left double-lumen endoendobronchial tube, L-DLT) intubation in 56 cases, the right double-lumen endoendobronchial tube (right double-lumen endoendobronchial tube, R-DLT) intubation in 44 cases. FOB (F) group:100 cases, of which the left double-lumen endoendobronchial tube (L-DLT) intubation in 52 cases, the right double-lumen endoendobronchial tube (R-DLT) intubation 48. All patients after adequate preoperative preparation of thoracic surgery, they were received into the operating room. And then by the intravenous injection of midazolam 0.05-0.1mg/kg, fentanyl 3-4μg/kg, propofol 1-2mg/kg, rocuronium 0.6mg/kg for anesthesia induction, after induction of the traditional method [10] into the DLT (now usually Robertshaw double lumen endobronchial tube) and record the depth of catheter insertion, the general insertion depth of 29-31cm [11]. After catheterization, respectively, two groups of patients on the pipe end position. Auscultation Group:auscultation [12] accurate positioning criteria: endotracheal balloon inflated, auscultation, adjust the position of double-lumen tubes can be heard with satisfaction the lungs caused by breathing sounds, and endobronchial balloon inflated, auscultation, adjust the position of double-lumen tube To the satisfaction of lung breath sounds can be heard, and then bilateral lung were performed one-lung ventilation, auscultation, adjust the position of double-lumen tube side of the lungs caused by ventilation can hear breath sounds satisfactory, rather than non-ventilated lung was breathing sound. Fault location criteria:①,lung ventilation, only one side of the lung could hear breath sounds (too deep to the side of the catheter caused the main bronchus).②, lungs were single-lung ventilation, the lungs can also hear a clear breath sounds (caused by too shallow catheterization)③, one-lung ventilation, the contralateral upper lobe not hear breath sounds (endobronchial catheter obstruction or endobronchial tube cuff upper lobe bronchus causing mouth).④, lungs were single-lung pass, the ipsilateral lung is weak or can not hear breath sounds breath sounds breath sounds clear and the contralateral lung (endobronchial tube cuff partial or complete obstruction of the contralateral main bronchus caused by mouth). FOB Group: FOB directly under the double-lumen endobronchial tube positioning, targeting mostly the standard reference PD Slingerm [13] method:the best place to:1, L-DLT FOB into the right side of the first tube, the openings can be seen in the tracheal lumen catheter, carina, right endobronchial openings, has been inflated endobronchial cuff (blue cuff) on the edge in the subcarinal; FOB tube inserted into the left shows the upper left, lower lobe bronchus mouth.2, R-DLT first FOB into the left tube, the openings can be seen in the tracheal lumen catheter, carina, left main bronchus opening, has been inflated endobronchial cuff (blue cuff) on the edge in the subcarinal;FOB insert right side of the tube, the catheter port can be seen in the right lung, lower lobe bronchus opening side of the hole can be seen right upper lobe bronchus opening. Dislocation:(1), the general dislocation of catheter movement is greater than the correct position than 0.5cm. (2), severe dislocation to:①catheter inserted into the opposite main bronchus.②full catheter deep into the bronchus.③catheter into the bronchus is not too shallow. Monitored and recorded: 1, the two groups after the change in the position peak airway pressure (Paw) is greater than the number of cases 30cmH20 and two one-lung ventilation after 30min,60minSpO2 value of less than 90% of the number of cases.2, recording two groups were intubated in the way different types of single-lung ventilation in different position the number of patients satisfaction, satisfaction rate and thoracic surgery are not satisfied with single lung was found to be FOB in the number of cases adjust the positioning.3, the two groups in different positions are not satisfied with one-lung ventilation, FOB check catheter too deep or too shallow the number of cases.4, recorded two postoperative complications, discovery and disposal aspects.Results auscultatory location in one-lung ventilation in the low success rate of one-time positioning, different positions, different tube types (L-DLT, R-DLT) low satisfaction with one-lung ventilation, postoperative complications are more, and can not used to find the causes and complications of its disposal. The FOB location method in single-lung ventilation time targeting a. high success rate, different positions, different tube types (L-DLT, R-DLT) satisfaction with one lung ventilation rate, fewer postoperative complications, in addition, can also be used to find the causes and complications of its treatment.Conclusion 1, the use of one-lung ventilation DLT, DLT positioning on auscultation alone, there is a certain subjectivity and blindness, its accuracy, reliability, safety is not high.2, FOB location for DLT in the use of one-lung ventilation, FOB positioning of DLT intuitive, is an accurate, reliable and secure method of DLT positioning, it should be generally routine used in the one-lung ventilation of the chest, heart surgery and become a "gold standard" in one-lung ventilation for DLT positioning更多还原