胸腔镜下气管肿瘤切除加隆突成形术中气道管理一例

2019-11-08 孙宗建 胡秀才 张彬 临床麻醉学杂志

患者,男,40岁,75kg,ASAⅡ级,NYHA-A级,因“痰中带血1月余”入院。患者既往有支气管炎病史,长期吸烟史,约40支/天。入院诊断:咯血原因待查,慢性支气管炎。胸部CT强化+气管三维重建示:气管末端左侧不规则结节(图1);纤维支气管镜检查示:气管末端菜花样新生物,体积约1.8 cm×1.2 cm×1.0 cm,上缘距声门约9.5 cm,下缘距隆突约0.5 cm,触之易出血,气管狭窄程度C

患者,男,40岁,75kg,ASAⅡ级,NYHA-A级,因“痰中带血1月余”入院。患者既往有支气管炎病史,长期吸烟史,约40支/天。入院诊断:咯血原因待查,慢性支气管炎。胸部CT强化+气管三维重建示:气管末端左侧不规则结节(图1);纤维支气管镜检查示:气管末端菜花样新生物,体积约1.8 cm×1.2 cm×1.0 cm,上缘距声门约9.5 cm,下缘距隆突约0.5 cm,触之易出血,气管狭窄程度CottonⅠ级。病理结果示:气管腺样囊性癌。血气分析:PaO279.9mmHg,其余各项检查及化验指标未见异常。拟在全身麻醉下行胸腔镜下气管肿瘤切除加隆突成形术。


图1 患者气管肿瘤处的CT扫描图
 
患者入室前30min肌肉注射苯巴比妥钠0.1g和阿托品0.5mg,入室后开放右上肢外周静脉通路,常规监测BP、SpO2、ECG、PETCO2。局部麻醉下行左桡动脉穿刺置管术,监测有创动脉压。局麻下行右颈内静脉穿刺置管术,用于补液及监测CVP。面罩吸氧6L/min,深呼吸1min后,静脉注射咪达唑仑2mg、舒芬太尼45μg、依托咪酯15mg、顺苯磺酸阿曲库铵15mg行麻醉诱导,正压通气3min后插入ID7.5mm加强单腔支气管导管,随后插入Coopdech支气管封堵器(批号:1305EBB001B);采用PENTAX纤维支气管镜(批号:EB-1530T3)确认以及调整气管导管和支气管封堵器位置,满意后固定。接麻醉机行机械通气,吸入纯氧,氧流量2L/min,双肺通气时VT6~8ml/kg,RR12次/分,I:E1:2,PETCO2 35~40mmHg和SpO2 100%。患者取左侧卧位,支气管封堵器右侧封堵,左肺单肺通气,调整呼吸参数,维持各项生命指标稳定。
 
采用“三孔”胸腔镜切口,进镜探查胸腔无异常,游离结扎切断奇静脉弓并游离下段气管,结扎切断右肺上叶第一支动脉后游离右主支气管,清除隆突下淋巴结后游离左主支气管。垂直支气管壁切断左主支气管后,由术者将ID7.0mm气管导管经胸腔镜操作孔插入远端气管置于左主支气管内,连接螺纹管至呼吸机继续行左肺单肺通气。
 
拔除右主支气管封堵器并回撤气管导管,垂直支气管壁切断右主支气管,在肿瘤上方横断气管。间断缝合气管与左主支气管前壁,待左主支气管吻合快结束时,自主操作孔拔除气管导管,同时在术者协助下将气管内气管导管送入左主支气管维持通气,继续完成气管与两侧主支气管端端间断吻合。隆突成形后将气管导管退至吻合口上方气管内,吸痰后双肺通气。
 
手术结束前将下颏用丝线牵拉固定于胸前壁,保持头屈位以防吻合口撕裂。术中除维持生命体征的稳定外,还应该密切观察气道压力的变化,调整潮气量以维持PETCO2在正常范围内,严密监控血气。手术历时180min,术后患者各项生命指标平稳转ICU监护治疗。12h后拔除气管导管,2d后转入普通病房。患者术后恢复良好,10d后痊愈出院。
 
讨论
 
气管及其隆突部肿瘤包括原发于气管、隆突部的良恶性肿瘤以及周围组织恶性肿瘤侵及隆突及下段气管。治疗方法包括手术治疗、放射治疗和气管镜下姑息治疗,其中仅手术切除治疗可能治愈患者并获得长期存活,但是由于肿瘤位于气管或隆突部,不但位置特殊,而且影响正常通气,手术治疗的难度及风险较大。电视辅助胸腔镜技术(video-assisted thoracic surgerg,VATS)以其创伤小、出血少、术野清晰、术后恢复快等特点,已广泛应用于呼吸、心胸外科疾病的诊疗中。以往行左胸行隆突切除加气道重建术因操作位置深,主动脉弓阻挡,显露困难,且奇静脉于右主支气管根部上方横过,一旦损伤致大出血,不易止血,危险性高。所以本例患者选择胸腔镜下经右胸气管肿瘤切除加隆突成形术。
 
气管内肿瘤手术的插管方式和通气方式一直是麻醉科医师关注的问题,也是手术成败及患者安全的关键。本例患者气道特点为气管内生肿瘤位置低,下缘距隆突约0.5 cm且需要行隆突成形术,不能采用双腔气管内导管插管进行气道管理;气管轻度狭窄,纤维支气管镜和支气管封堵器套囊可通过管腔最狭窄处。选择经口腔将气管导管插至气管内肿瘤的上方,然后在纤维支气管镜引导下插入Coopdech支气管封堵器至右主支气管封堵的方法,过程顺利。
 
麻醉科医师应与术者密切沟通,熟悉主要的手术步骤并密切配合。本例患者手术台上经胸腔镜操作孔插入左主支气管内的气管导管长度不够,采用将两根气管导管头尾相接、贴膜封闭结合处的方法,效果满意。术中除了应手术要求退管送管以确保手术操作的顺利和肺的通气外还应注意吸引防止血液反流至健侧。术后气道维持及管理同样重要。行气管重建术的患者,由于气管部分切除而缩短,术毕必须保持头屈位,以减轻气管缝合处张力,为此手术结束前应将下颏用丝线牵拉固定于胸前壁。
 
综上所述,胸腔镜下经右胸气管肿瘤切除加隆突成形术被证实是一种可行的手术方式,支气管封堵器可以提供安全有效的通气方案,为手术的顺利实施创造条件,提高麻醉的安全性,可作为肿瘤位置较低、不能行双腔气管插管患者的气道管理措施。
 
原始出处:

孙宗建,胡秀才,张彬,单士强.胸腔镜下气管肿瘤切除加隆突成形术中气道管理一例[J].临床麻醉学杂志,2018,34(11):1141-1142.

版权声明:
本网站所有内容来源注明为“梅斯医学”或“MedSci原创”的文字、图片和音视频资料,版权均属于梅斯医学所有。非经授权,任何媒体、网站或个人不得转载,授权转载时须注明来源为“梅斯医学”。其它来源的文章系转载文章,或“梅斯号”自媒体发布的文章,仅系出于传递更多信息之目的,本站仅负责审核内容合规,其内容不代表本站立场,本站不负责内容的准确性和版权。如果存在侵权、或不希望被转载的媒体或个人可与我们联系,我们将立即进行删除处理。
在此留言
评论区 (4)
#插入话题
  1. [GetPortalCommentsPageByObjectIdResponse(id=1686965, encodeId=67021686965d0, content=<a href='/topic/show?id=468a82841d7' target=_blank style='color:#2F92EE;'>#肿瘤切除#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82841, encryptionId=468a82841d7, topicName=肿瘤切除)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0c0b28305155, createdName=12498561m41(暂无昵称), createdTime=Fri Aug 07 06:02:00 CST 2020, time=2020-08-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2004730, encodeId=14f62004e3016, content=<a href='/topic/show?id=4e8a5400816' target=_blank style='color:#2F92EE;'>#成形术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54008, encryptionId=4e8a5400816, topicName=成形术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7fb6449, createdName=ZGMFX24A, createdTime=Wed Jul 15 21:02:00 CST 2020, time=2020-07-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1393951, encodeId=5a0813939516f, content=<a href='/topic/show?id=ddb96388638' target=_blank style='color:#2F92EE;'>#气道管理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=63886, encryptionId=ddb96388638, topicName=气道管理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=198d2500149, createdName=12498bd5m16暂无昵称, createdTime=Sun Nov 10 07:02:00 CST 2019, time=2019-11-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1420092, encodeId=eebc14200921b, content=<a href='/topic/show?id=51208416264' target=_blank style='color:#2F92EE;'>#胸腔镜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84162, encryptionId=51208416264, topicName=胸腔镜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=bb933558102, createdName=yinxm8304, createdTime=Sun Nov 10 07:02:00 CST 2019, time=2019-11-10, status=1, ipAttribution=)]
  2. [GetPortalCommentsPageByObjectIdResponse(id=1686965, encodeId=67021686965d0, content=<a href='/topic/show?id=468a82841d7' target=_blank style='color:#2F92EE;'>#肿瘤切除#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82841, encryptionId=468a82841d7, topicName=肿瘤切除)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0c0b28305155, createdName=12498561m41(暂无昵称), createdTime=Fri Aug 07 06:02:00 CST 2020, time=2020-08-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2004730, encodeId=14f62004e3016, content=<a href='/topic/show?id=4e8a5400816' target=_blank style='color:#2F92EE;'>#成形术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54008, encryptionId=4e8a5400816, topicName=成形术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7fb6449, createdName=ZGMFX24A, createdTime=Wed Jul 15 21:02:00 CST 2020, time=2020-07-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1393951, encodeId=5a0813939516f, content=<a href='/topic/show?id=ddb96388638' target=_blank style='color:#2F92EE;'>#气道管理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=63886, encryptionId=ddb96388638, topicName=气道管理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=198d2500149, createdName=12498bd5m16暂无昵称, createdTime=Sun Nov 10 07:02:00 CST 2019, time=2019-11-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1420092, encodeId=eebc14200921b, content=<a href='/topic/show?id=51208416264' target=_blank style='color:#2F92EE;'>#胸腔镜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84162, encryptionId=51208416264, topicName=胸腔镜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=bb933558102, createdName=yinxm8304, createdTime=Sun Nov 10 07:02:00 CST 2019, time=2019-11-10, status=1, ipAttribution=)]
  3. [GetPortalCommentsPageByObjectIdResponse(id=1686965, encodeId=67021686965d0, content=<a href='/topic/show?id=468a82841d7' target=_blank style='color:#2F92EE;'>#肿瘤切除#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82841, encryptionId=468a82841d7, topicName=肿瘤切除)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0c0b28305155, createdName=12498561m41(暂无昵称), createdTime=Fri Aug 07 06:02:00 CST 2020, time=2020-08-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2004730, encodeId=14f62004e3016, content=<a href='/topic/show?id=4e8a5400816' target=_blank style='color:#2F92EE;'>#成形术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54008, encryptionId=4e8a5400816, topicName=成形术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7fb6449, createdName=ZGMFX24A, createdTime=Wed Jul 15 21:02:00 CST 2020, time=2020-07-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1393951, encodeId=5a0813939516f, content=<a href='/topic/show?id=ddb96388638' target=_blank style='color:#2F92EE;'>#气道管理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=63886, encryptionId=ddb96388638, topicName=气道管理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=198d2500149, createdName=12498bd5m16暂无昵称, createdTime=Sun Nov 10 07:02:00 CST 2019, time=2019-11-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1420092, encodeId=eebc14200921b, content=<a href='/topic/show?id=51208416264' target=_blank style='color:#2F92EE;'>#胸腔镜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84162, encryptionId=51208416264, topicName=胸腔镜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=bb933558102, createdName=yinxm8304, createdTime=Sun Nov 10 07:02:00 CST 2019, time=2019-11-10, status=1, ipAttribution=)]
  4. [GetPortalCommentsPageByObjectIdResponse(id=1686965, encodeId=67021686965d0, content=<a href='/topic/show?id=468a82841d7' target=_blank style='color:#2F92EE;'>#肿瘤切除#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82841, encryptionId=468a82841d7, topicName=肿瘤切除)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0c0b28305155, createdName=12498561m41(暂无昵称), createdTime=Fri Aug 07 06:02:00 CST 2020, time=2020-08-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2004730, encodeId=14f62004e3016, content=<a href='/topic/show?id=4e8a5400816' target=_blank style='color:#2F92EE;'>#成形术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54008, encryptionId=4e8a5400816, topicName=成形术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7fb6449, createdName=ZGMFX24A, createdTime=Wed Jul 15 21:02:00 CST 2020, time=2020-07-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1393951, encodeId=5a0813939516f, content=<a href='/topic/show?id=ddb96388638' target=_blank style='color:#2F92EE;'>#气道管理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=63886, encryptionId=ddb96388638, topicName=气道管理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=198d2500149, createdName=12498bd5m16暂无昵称, createdTime=Sun Nov 10 07:02:00 CST 2019, time=2019-11-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1420092, encodeId=eebc14200921b, content=<a href='/topic/show?id=51208416264' target=_blank style='color:#2F92EE;'>#胸腔镜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84162, encryptionId=51208416264, topicName=胸腔镜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=bb933558102, createdName=yinxm8304, createdTime=Sun Nov 10 07:02:00 CST 2019, time=2019-11-10, status=1, ipAttribution=)]

相关资讯

1例合并原发性巨球蛋白血症患者胸腔镜下右上肺结节楔形切除术的麻醉处理

原发性巨球蛋白血症(Waldenstrom macroglobulinemi,WM)是一种源于能分化为成熟浆细胞的B淋巴细胞的恶性增生性疾病,主要表现为骨髓中有浆细胞样淋巴细胞浸润,并合成单克隆IgM,占所有血液恶性肿瘤的2%。临床表现特征是贫血、出血倾向及高黏滞血症。由于本病较为罕见,很少有其麻醉管理的报道,现有1例WM患者胸腔镜下行右上肺结节楔形切除术,报告如下。