哮喘患者合并气管软化症及右主支气管扩张行食管癌切除术麻醉管理一例

2019-05-18 周超 宋姗 许美利 临床麻醉学杂志

患者,男,54岁,167.5 cm,74.1kg,因“食管胃结合部癌新辅助化疗后为行进一步治疗”入院。既往“支气管哮喘”病史20余年。查体:HR76次/分,RR18次/分,体温36.5℃,动脉血压136/82mmHg。

患者,男,54岁,167.5 cm,74.1kg,因“食管结合部癌新辅助化疗后为行进一步治疗”入院。既往“支气管哮喘”病史20余年。查体:HR76次/分,RR18次/分,体温36.5℃,动脉血压136/82mmHg。
 
体格检查:发育正常,营养中等,神志清楚,心肺听诊未闻及异常。胸部CT示:食管胸段壁增厚,右侧支气管壁稍增厚,两肺多发肺大泡;纤维支气管镜检查见:气管管腔通畅,黏膜光滑。麻醉医师术前访视,阅读CT时发现患者存在气道异常改变,经CT冠状面重建后可见气管狭窄处约8.7mm,右主支气管增宽,约23.2mm。
 
请呼吸内科会诊,患者无明显不适主诉,查体未见明显异常,结合病史和纤维支气管镜检查结果,考虑气道病变:气管软化症?术前诊断:(1)食管结合部癌新辅助化疗后;(2)支气管哮喘;(3)气管软化症?(4)右主支气管扩张。拟在全麻下行腹腔镜游离胃经右胸胸腔镜辅助食管癌切除术,术后转入ICU度过围术期。
 
患者入室后监测ECG、SpO2,开放外周静脉,局麻下行左桡动脉穿刺置管,行有创动脉监测。麻醉诱导前行面罩正压通气无通气困难,静脉注射氢化泼尼松30mg后顺序给予依托咪酯23mg、舒芬太尼40μg和顺式阿曲库铵15mg。3min后行单腔气管插管,插管过程顺利,听诊确认单腔导管位置和深度满意后行机械通气。为核实单腔导管位置及气管、支气管的解剖,行纤维支气管镜检查。镜检可见距气管导管出口0.5 cm处气管塌陷变窄,纤维支气管镜无法通过。按术前讨论方案,采用支气管封堵器实现单肺通气。
 
插入支气管封堵器,连接呼吸回路正压通气后,再次行纤维支气管镜检查,隆突及左、右主支气管可见(图1)。经纤维支气管镜引导将封堵器调整至右主支气管,套囊打气后无法完全将右主支气管封闭(图2),遂将封堵器调整至右肺中间段,行中下叶封堵,可见中下段完全封闭(图3)。
 

图1 纤维支气管镜下隆突图像


 图2 纤维支气管镜下封堵器置入后右主支气管图像


 图3 纤维支气管镜下封堵器置入后右肺中间段图像
 
麻醉维持采用静吸复合全麻,间断追加肌松药维持肌松,BIS监测镇静深度,术中生命体征平稳。术者经腹腔镜完成腹部操作后,患者取左侧卧位,行单肺通气后,中下叶萎陷良好,上肺略膨胀。膨胀肺叶不影响术者清理淋巴结及其他操作,手术顺利。术中术者探查气管,并未见外压性肿物,确实存在气道异常。单肺通气结束后行纤维支气管镜检查未见气道损伤,患者按计划转入ICU,并于术后第1天拔除气管导管,未见插管相关并发症。术后修正诊断为:(1)食管胃结合部癌新辅助化疗后;(2)支气管哮喘;(3)气管软化症;(4)右主支气管扩张。患者于术后第10天康复出院。
 
讨论 
 
气管、主支气管扩张是一类罕见的疾病,仅见于气管软化症、巨气管支气管症。本例患者存在哮喘、气管软化症合并右主支气管扩张并拟行食管癌切除术,单肺通气困难,气道管理难度大。本例患者麻醉医师在术前访视时,发现气道异常后,进行了CT重建,发现了可能存在的气道问题,进行了充分的术前准备,有效避免了紧急气道及气管插管相关并发症的出现。气管软化症是指由于气道壁或者气道支撑性软骨弱化引起的以气管顺应性增加和过度塌陷为特征的疾病,临床表现与支气管扩张、慢性支气管炎和支气管哮喘难以区别。
 
支气管镜检是诊断该病的金标准,其镜下表现为气管膜部增宽、皱襞,用力呼气时明显塌陷,甚至气道膜部与软骨环紧贴导致气管管腔完全闭塞。本例患者支气管镜下可见气管膜部增宽,气管插管后停止通气,经纤支镜可见气管塌陷,管腔闭塞,正压通气后气管塌陷恢复,符合气管软化症支气管镜下表现。因此考虑该患者气道异常是由气管软化引起。
 
术前对该患者给予肌松剂后可能出现气道塌陷进行了重点讨论,方案有如下两种:(1)清醒表麻气管插管后行全麻诱导;(2)快速顺序诱导后行气管插管。考虑到患者有支气管哮喘病史,清醒表麻气管插管可能会诱发患者哮喘发作,诱导前行面罩正压通气实验没有通气困难,给予正压通气后可能出现的气道塌陷也不会影响通气,所以选择了第2种麻醉诱导插管方案。结果也证实了术前评估的准确。本例麻醉最大的难题在于单肺通气方式的选择。
 
常用实现单肺通气的3种方式均有各自缺陷:
 
(1)应用纤维支气管镜将单腔气管导管引导进入左主支气管。患者全麻诱导后存在气道塌陷的可能,纤维支气管镜无法引导单腔气管导管进入左主支气管,同时考虑到患者存在哮喘病史及患者气道条件,应用盲插法将单腔气管导管插入左主支气管难度较大,反复操作可能引起哮喘发作、气道损伤等并发症,所以放弃该方案。
 
(2)应用左双腔气管导管也存在困难,患者气管存在狭窄,气管膜部及长轴弹性纤维萎缩,可能存在双腔气管导管无法通过狭窄,甚至引起气管膜部损伤等严重并发症;再者该患者有支气管哮喘病史,术毕转ICU治疗,若采用双腔气管导管术毕需更换单腔导管,存在增加气道损伤和诱发哮喘风险。
 
(3)应用支气管封堵器行右全肺封堵,患者右主支气管扩张明显,支气管封堵器无法完全封闭右主支气管。根据本例患者特点,拟定应用支气管封堵器行右肺中下叶封堵,既可以解决单肺通气的问题满足术者要求,又可以最大限度地降低气管插管对气道的损伤。若右肺中下叶萎陷不能满足术者要求,影响手术操作,可将封堵器退至气管导管内,在正压通气下将气管导管经纤支镜引导入左主支气管,进行单肺通气,使右肺完全萎陷。经实践检验,证实了上述常规方案的确存在缺陷,并证实了右肺中下叶封堵可行。考虑患者手术时间长、创伤大并存在气管导管拔除后出现气管塌陷的可能,术后患者转入ICU进行过渡。
 
本例患者属于“高风险”拔管,所以选择延迟拔管。在拔管前做了再次插管及气管切开的准备。患者拔管前意识清醒,肌张力恢复完全,给予患者充分吸氧、清理气道及口腔分泌物等准备工作后拔除气管导管。拔管后面罩吸氧,观察30min,SpO2稳定在99%~100%,患者未诉呼吸困难等不适。麻醉医师术前进行了明确分工:麻醉的维持及循环系统的管理,气道的管理,麻醉记录及药品准备均有专人负责,并有一名上级医师统筹安排,保证麻醉准备及麻醉管理有序、安全进行。
 
综上所述,气道异常患者行胸科手术麻醉难度大,单肺通气方案制定、选择困难,详细的术前访视,深入的研究胸部CT,充分的气道评估,合理的个体化的麻醉方案,精细的术中、术后管理是麻醉成功的关键。
 
原始出处:

周超,宋姗,许美利,裴焕爽.哮喘患者合并气管软化症及右主支气管扩张行食管癌切除术麻醉管理一例[J].临床麻醉学杂志,2018,34(05):516-517.

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    2019-05-20 zhouqu_8

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