胸科手术的麻醉管理进展
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B. 1.Heavy sedation may impair postoperative deep breathing, coughing, and airway protection.
C. 2.Patients with poor pulmonary function will be more prone to hypoxemia when their respiratory drive（呼吸动 力） is suppressed. When sedating these patients, it is wise to monitor oxygenation and administer supplemental oxygen.
7
Preoperative evaluation
Patients for thoracic surgery should undergo the usual preoperative assessment as detailed in Chapter 1. Any patient undergoing elective thoracic surgery should be carefully screened for underlying bronchitis or pneumonia and treated appropriately before surgery. Diagnostic procedures such as bronchoscopy and lung biopsy（活检） may be intended for persistent infection. Infection beyond an obstructing lesion（损害）may not resolve（解决） without surgery.
1
胸科手术的麻醉
遵义医学院麻醉学教研室 朱昭琼
2
Baidu Nhomakorabea求
掌握剖胸及侧卧位时呼吸、循环病理生 理的改变 掌握剖胸手术病人麻醉前的估计和方法 及麻醉的基本要求 熟悉单肺通气的生理变化、及单肺通气 的术中管理 熟悉常见胸科手术的麻醉处理
3
第一节 剖胸及侧卧位时对呼吸、 循环的影响(p 119)
剖胸所引起的病理生理改变—自主呼吸时
4
剖胸及侧卧位时对呼吸、循环的影响
4 心排出量降低 其原因（1）（2）（3）
5 心律失常 其原因（纵隔摆动时对部位神经的刺激、通气功
能紊乱、 VA／Q比失常、PaO2↓和PaCO2↑)
6 体热的散失
5
侧卧位对呼吸生理的影响
清醒状态下侧卧位 (function residual capacity;FRC下降 VA／Q比 基本正常)
1 剖胸侧通气与肺血流比例失调肺内分流 （hypoxic pulmonary vasoconstriction; HPV有 限，并受麻醉药及扩管药抑制） 2 反常呼吸（paradoxical respiration) 摆动气 死腔增大 3 纵隔移位 纵隔摆动(mediastinal swaying )
15
血气分析
PaO2 了解肺的氧合情况 PaCO2 肺通气功能 A-aDO2 肺换气功能
16
Preoperative preparation
A. Preoperative sedation should be given carefully to patients with tracheal or pulmonary disease.
19
麻醉前准备
停止吸烟 控制肺部感染，尽力减少痰量 保持气道通畅，防治支气管痉挛
控制感染外，常用的解痉和扩张支气管药： 1）氨茶碱 2）肾上腺糖皮质激素 3）色甘酸钠 4）β2受体激动药
锻炼呼吸功能 低浓度氧吸入 对并存的心血管方面情况进行处理
20
第三节 胸科手术麻醉的特点与 处理
一、胸科手术麻醉的基本要求
18
Preoperative preparation
B. Aspiration（吸引） prophylaxis（预防）, with an oral histamine-2 receptor antagonist and metoclopramide （胃复安), should be considered in patients undergoing major thoracic surgery. Patients with esophageal disease should be considered at high risk for aspiration.
有术后呼吸功能不全的可能
13
FVC<50%，FEV1 < 50%，肺切除术预后差 FEV1/ FVC < 60%，术后并发症发生率高 如术前FEV1/ FVC < 50%、FEV1 <2L、MVV < 50%预计值、PaCO2 >45mmHg、 RV/TLV(余气量/肺总量） > 50%，全肺切除 术后风险↑
Arterial blood gas (ABG) determinations may help to clarify the severity of underlying pulmonary disease but are not routinely necessary.
Pulmonary function tests are useful in assessing the pulmonary risk of lung resection. Both exercise function (maximal oxygen uptake [O2max]) and spirometry (forced expiratory volume in 1 second) have been used to stratify risks of resection. In marginal cases, split-function radionuclide scans and ventilation/perfusion ( ) scans can determine the relative contribution of each lung and individual lung regions.
11
麻醉前评估
一般情状： 吸烟、年龄、肥胖、手术时间
临床病史和体征: 有无呼吸困难、哮喘、咳嗽、咳痰、胸痛、吞 咽困难 气管受压移位、液气胸、异常呼吸音 胸部拍片、CT
肺功能测定及血气分析:
12
肺功能测定
屏气试验 吹气试验 肺功能测定: “平板运动试验” 临床常用的指标（TVC、FEV1、FVC、FEV1/ FVC、MVV） 肺活量＜60﹪ 通气储备量＜70﹪ FEV1/FVC＜60﹪
10
Introduction
Preoperative evaluation
Tracheal tomography or three-dimenional reconstruction from CT is used to assess the caliber of stenotic airways and can be used to predict the size and length of the endotracheal tube that will be appropriate for the patient. Severe airway stenosis（狭窄）observed preoperatively may change the anesthetist's plans for induction and intubation.
全麻下侧卧位 FRC下降 VA／Q比失常：下侧肺VA／Q下降， 上侧肺VA／Q升高
6
第二节 麻醉前评估与准备
必要性（胸科手术术后肺部并发症发生率较高）
肺部并发症最常见 围术期死亡率居第二位 肺功能异常者并发症是正常者23倍 （切除肺病变，肺通气面积↓；手术操作肺损 伤，出血、水肿↑；术后痛疼，分泌物坠积 或肺不张 etc.)
Anesthesia for Thoracic Surgery
Zhao-Qiong Zhu, M.D. Department of Anesthesiology, Affiliated Hospital of Zunyi Medical College, Zunyi , Guizhou,563003, China
17
Preoperative preparation
3. In the presence of airway obstruction, sedation must be carefully balanced.
Oversedation may profoundly（深深地) suppress ventilation, but an anxious patient may make exaggerated(夸大的, 夸张的) respiratory efforts. In this case, the increased turbulence may cause worsened airway obstruction, leading to increased anxiety. Benzodiazepines, reassuring(安慰的)words, careful monitoring, and an expeditious(迅速的）start to the procedure is the best approach.
9
Preoperative evaluation
Cardiac function should be assessed if there is question of the relative contribution of cardiac and pulmonary disease in the patient's functional impairment. Echocardiography can estimate pulmonary artery pressure and right ventricular function. Imaging studies, such as chest radiography, computed tomography (CT), and magnetic resonance imaging, are useful to determine the presence of tracheal deviation, the location of pulmonary infiltrates, effusion or pneumothorax, and the involvement of adjacent structures in the disease.
14
全肺切病人术前肺功能测定最低限度应合以下标准： （1） FEV1 > 2L 、 FEV1/ FVC > 50% （2）MVV >80L/min或>50%预计值 （3）RV/TLC < 50%，预计术后FEV1 > 0.8L 不附合上 述标准应行分侧肺功能测定 （4）平肺动脉压< 35mmHg （5）运动后PaO2 > 45mmHg肺叶切除术的要求可稍低 运动时最大氧摄取量（VO2max > 20L/(kg.min)
8
Preoperative evaluation
In patients with tracheal stenosis（狭窄）, the history should focus on symptoms or signs of positional dyspnea, static versus dynamic airway collapse, and evidence of hypoxemia. The history may also suggest the probable location of the lesion.
消除或减轻纵隔摆动与反常呼吸 避免肺内物质的扩散
C. 2.Patients with poor pulmonary function will be more prone to hypoxemia when their respiratory drive（呼吸动 力） is suppressed. When sedating these patients, it is wise to monitor oxygenation and administer supplemental oxygen.
7
Preoperative evaluation
Patients for thoracic surgery should undergo the usual preoperative assessment as detailed in Chapter 1. Any patient undergoing elective thoracic surgery should be carefully screened for underlying bronchitis or pneumonia and treated appropriately before surgery. Diagnostic procedures such as bronchoscopy and lung biopsy（活检） may be intended for persistent infection. Infection beyond an obstructing lesion（损害）may not resolve（解决） without surgery.
1
胸科手术的麻醉
遵义医学院麻醉学教研室 朱昭琼
2
Baidu Nhomakorabea求
掌握剖胸及侧卧位时呼吸、循环病理生 理的改变 掌握剖胸手术病人麻醉前的估计和方法 及麻醉的基本要求 熟悉单肺通气的生理变化、及单肺通气 的术中管理 熟悉常见胸科手术的麻醉处理
3
第一节 剖胸及侧卧位时对呼吸、 循环的影响(p 119)
剖胸所引起的病理生理改变—自主呼吸时
4
剖胸及侧卧位时对呼吸、循环的影响
4 心排出量降低 其原因（1）（2）（3）
5 心律失常 其原因（纵隔摆动时对部位神经的刺激、通气功
能紊乱、 VA／Q比失常、PaO2↓和PaCO2↑)
6 体热的散失
5
侧卧位对呼吸生理的影响
清醒状态下侧卧位 (function residual capacity;FRC下降 VA／Q比 基本正常)
1 剖胸侧通气与肺血流比例失调肺内分流 （hypoxic pulmonary vasoconstriction; HPV有 限，并受麻醉药及扩管药抑制） 2 反常呼吸（paradoxical respiration) 摆动气 死腔增大 3 纵隔移位 纵隔摆动(mediastinal swaying )
15
血气分析
PaO2 了解肺的氧合情况 PaCO2 肺通气功能 A-aDO2 肺换气功能
16
Preoperative preparation
A. Preoperative sedation should be given carefully to patients with tracheal or pulmonary disease.
19
麻醉前准备
停止吸烟 控制肺部感染，尽力减少痰量 保持气道通畅，防治支气管痉挛
控制感染外，常用的解痉和扩张支气管药： 1）氨茶碱 2）肾上腺糖皮质激素 3）色甘酸钠 4）β2受体激动药
锻炼呼吸功能 低浓度氧吸入 对并存的心血管方面情况进行处理
20
第三节 胸科手术麻醉的特点与 处理
一、胸科手术麻醉的基本要求
18
Preoperative preparation
B. Aspiration（吸引） prophylaxis（预防）, with an oral histamine-2 receptor antagonist and metoclopramide （胃复安), should be considered in patients undergoing major thoracic surgery. Patients with esophageal disease should be considered at high risk for aspiration.
有术后呼吸功能不全的可能
13
FVC<50%，FEV1 < 50%，肺切除术预后差 FEV1/ FVC < 60%，术后并发症发生率高 如术前FEV1/ FVC < 50%、FEV1 <2L、MVV < 50%预计值、PaCO2 >45mmHg、 RV/TLV(余气量/肺总量） > 50%，全肺切除 术后风险↑
Arterial blood gas (ABG) determinations may help to clarify the severity of underlying pulmonary disease but are not routinely necessary.
Pulmonary function tests are useful in assessing the pulmonary risk of lung resection. Both exercise function (maximal oxygen uptake [O2max]) and spirometry (forced expiratory volume in 1 second) have been used to stratify risks of resection. In marginal cases, split-function radionuclide scans and ventilation/perfusion ( ) scans can determine the relative contribution of each lung and individual lung regions.
11
麻醉前评估
一般情状： 吸烟、年龄、肥胖、手术时间
临床病史和体征: 有无呼吸困难、哮喘、咳嗽、咳痰、胸痛、吞 咽困难 气管受压移位、液气胸、异常呼吸音 胸部拍片、CT
肺功能测定及血气分析:
12
肺功能测定
屏气试验 吹气试验 肺功能测定: “平板运动试验” 临床常用的指标（TVC、FEV1、FVC、FEV1/ FVC、MVV） 肺活量＜60﹪ 通气储备量＜70﹪ FEV1/FVC＜60﹪
10
Introduction
Preoperative evaluation
Tracheal tomography or three-dimenional reconstruction from CT is used to assess the caliber of stenotic airways and can be used to predict the size and length of the endotracheal tube that will be appropriate for the patient. Severe airway stenosis（狭窄）observed preoperatively may change the anesthetist's plans for induction and intubation.
全麻下侧卧位 FRC下降 VA／Q比失常：下侧肺VA／Q下降， 上侧肺VA／Q升高
6
第二节 麻醉前评估与准备
必要性（胸科手术术后肺部并发症发生率较高）
肺部并发症最常见 围术期死亡率居第二位 肺功能异常者并发症是正常者23倍 （切除肺病变，肺通气面积↓；手术操作肺损 伤，出血、水肿↑；术后痛疼，分泌物坠积 或肺不张 etc.)
Anesthesia for Thoracic Surgery
Zhao-Qiong Zhu, M.D. Department of Anesthesiology, Affiliated Hospital of Zunyi Medical College, Zunyi , Guizhou,563003, China
17
Preoperative preparation
3. In the presence of airway obstruction, sedation must be carefully balanced.
Oversedation may profoundly（深深地) suppress ventilation, but an anxious patient may make exaggerated(夸大的, 夸张的) respiratory efforts. In this case, the increased turbulence may cause worsened airway obstruction, leading to increased anxiety. Benzodiazepines, reassuring(安慰的)words, careful monitoring, and an expeditious(迅速的）start to the procedure is the best approach.
9
Preoperative evaluation
Cardiac function should be assessed if there is question of the relative contribution of cardiac and pulmonary disease in the patient's functional impairment. Echocardiography can estimate pulmonary artery pressure and right ventricular function. Imaging studies, such as chest radiography, computed tomography (CT), and magnetic resonance imaging, are useful to determine the presence of tracheal deviation, the location of pulmonary infiltrates, effusion or pneumothorax, and the involvement of adjacent structures in the disease.
14
全肺切病人术前肺功能测定最低限度应合以下标准： （1） FEV1 > 2L 、 FEV1/ FVC > 50% （2）MVV >80L/min或>50%预计值 （3）RV/TLC < 50%，预计术后FEV1 > 0.8L 不附合上 述标准应行分侧肺功能测定 （4）平肺动脉压< 35mmHg （5）运动后PaO2 > 45mmHg肺叶切除术的要求可稍低 运动时最大氧摄取量（VO2max > 20L/(kg.min)
8
Preoperative evaluation
In patients with tracheal stenosis（狭窄）, the history should focus on symptoms or signs of positional dyspnea, static versus dynamic airway collapse, and evidence of hypoxemia. The history may also suggest the probable location of the lesion.
消除或减轻纵隔摆动与反常呼吸 避免肺内物质的扩散