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1、第十六章 胸科手术麻醉（Anesthesia in thoracic surgery）,徐州医学院附属医院齐敦益,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,2,目的和要求,熟悉剖胸和侧卧位对呼吸循环的影响熟悉胸科手术的麻醉前评估与准备掌握胸科手术麻醉的基本要求及特点掌握单肺通气管理的注意事项了解常见胸科手术麻醉的处理,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical
2、 College,3,胸腔手术麻醉的特点：麻醉处理与管理要求高。手术开胸影响呼吸（肺）、心脏大血管功能和纵隔丰富的神经反射，要求对胸腔解剖，呼吸、循环生理有深刻的认识，而且对麻醉中发生的异常情况能及时识别加以排除开胸手术麻醉对原来器官功能的影响更为加重。原有急性病变，如肺损伤、气胸，慢性疾病，如慢性阻塞性肺疾患（COPD）及限制性肺疾患（RPD）、支气管扩张症、肺癌、食管癌等的病人均有不同程度的低氧，心肺功能影响，营养障碍，肝肾功能损害等术前估计与准备的重要性。充分考虑麻醉期与麻醉后机体状态及可能发生的危险性,2023/4/30,Department of Anesthesiology,Aff
3、iliated Hospital of XUZHOU Medical College,4,第一节 剖胸及侧卧位对呼吸循环的影响,剖胸所引起的病理生理改变剖胸后对呼吸的影响剖胸侧肺萎陷维持肺充气状态的因素大气压作用于肺泡肺泡本身所具有的弹性及表面张力的相互作用（Pulmonary surfactant，PS）胸膜腔负压的牵拉作用,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,5,2023/4/30,Department of Anesthesiology,Affiliate
4、d Hospital of XUZHOU Medical College,6,第一节 剖胸及侧卧位对呼吸循环的影响,剖胸所引起的病理生理改变剖胸后对呼吸的影响剖胸侧肺萎陷肺萎陷 剖胸后，剖胸侧胸膜腔负压消失，肺泡内及肺表面均受大气压的作用，因而肺泡只受自身回缩力的净作用，导致萎陷。,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,7,第一节 剖胸及侧卧位对呼吸循环的影响,剖胸所引起的病理生理改变剖胸后对呼吸的影响剖胸侧肺萎陷危害肺的弥散面积可减少50%肺血管阻力（萎陷的肺组
5、织压迫肺血管、缺氧性肺血管收缩 hypoxic pulmonary vasoconstriction HPV）肺内分流（pulmonary shunt）,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,8,第一节 剖胸及侧卧位对呼吸循环的影响,剖胸所引起的病理生理改变剖胸后对呼吸的影响纵隔移位及纵隔摆动（Mediastinal shift)纵隔移位：两侧胸腔压力失去平衡纵隔摆动：健侧肺的呼吸运动,2023/4/30,Department of Anesthesiology,
6、Affiliated Hospital of XUZHOU Medical College,9,纵隔移位及纵隔摆动（Mediastinal shift),吸气相,+,剖胸侧,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,10,吸气相,+,剖胸侧,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,11,呼气相,剖胸侧,2023/4/30,Departmen
7、t of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,12,呼气相,+,剖胸侧,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,13,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,14,2023/4/30,Department of Anesthesiology,Affili
8、ated Hospital of XUZHOU Medical College,15,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,16,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,17,第一节 剖胸及侧卧位对呼吸循环的影响,剖胸所引起的病理生理改变剖胸后对呼吸的影响反常呼吸(Paradoxical respiration)及摆动气,2023/4/
9、30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,18,概念：开胸引起纵隔摆动，亦产生肺内气体的摆动。吸气时有部分气体从开胸侧肺被“吸”入健侧肺，呼气时有部分气体从健侧肺“呼”入开胸侧肺，来往于两侧肺之间的气体称为摆动气 危害：无效腔气体（不参加交换）,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,19,第一节 剖胸及侧卧位对呼吸循环的影响,剖胸所引起的病理生理改变剖
10、胸后对循环的影响心输出量降低回心血量降低大血管扭曲肺血管阻力增加手术操作压迫,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,20,第一节 剖胸及侧卧位对呼吸循环的影响,剖胸所引起的病理生理改变剖胸后对循环的影响心律失常缺氧、二氧化碳蓄积手术操作刺激术前心血管疾患或已有心律失常,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,21,第一节 剖胸及侧卧位对
11、呼吸循环的影响,剖胸所引起的病理生理改变剖胸后其他病理生理改变胸膜肺刺激综合症胸膜腔及肺内压力改变手术操作对肺门、纵隔及胸壁等部位的刺激胸膜腔壁层胸膜干燥引起的刺激体热和体液散失过多,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,22,第一节 剖胸及侧卧位对呼吸循环的影响,开胸手术时体位改变的生理影响功能残气量（FRC）：清醒状态下，直立位仰卧位，FRC 0.8L；全麻状态下，FRC 在原有的基础上0.4L；剖胸后，FRC 进一步下降。,2023/4/30,Departm
12、ent of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,23,第一节 剖胸及侧卧位对呼吸循环的影响,开胸手术时体位改变的生理影响通气血流比值（VA/Q）两肺血流分配：仰卧位 左/右 45/55左侧卧 左/右 55/45右侧卧 右/左 65/35卧侧/对侧平均：60/40全麻剖胸后，血流分配异常，VA/Q,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,24,2023/4/30,Departmen
13、t of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,25,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,26,第二节 麻醉前的评估与准备,麻醉前评估（Preanesthetic evaluation）一般情况评估肺功能状态 性质（阻塞性、限制性、混合性）吸烟情况 碳氧血红蛋白、支气管黏膜纤毛年龄 呼吸道分泌物清除能力、肺泡变薄、肺大泡体重 肥胖，闭合气量增大，A-aDO2增加,2023/4/3
14、0,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,27,术后肺病发症的相对发病率,肺功能异常/正常吸烟者/不吸烟者年龄60/60体重超重（20%标准体重）/不超重,23/16/13/12/1,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,28,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XU
15、ZHOU Medical College,29,吸烟,年龄超过60,肥胖,手术广泛而手术时间在3小时以上,危险因素,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,30,第二节 麻醉前的评估与准备,麻醉前评估（Preanesthetic evaluation）呼吸系统情况估计临床病史及体征呼吸道感染史咳嗽呼吸困难紫绀哮喘杵状指呼衰史等影像学诊断技术，X线，支气管造影术，CT，MRI,2023/4/30,Department of Anesthesiology,Affilia
16、ted Hospital of XUZHOU Medical College,31,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.Arterial blood gas(ABG
17、)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 secon
18、d)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.,Preoperative evaluation,2023/4/30,Department of Anesthesiology,Affiliated Hospital of
19、 XUZHOU Medical College,32,第二节 麻醉前的评估与准备,麻醉前评估（Preanesthetic evaluation）呼吸系统情况估计简易肺功能测定体力活动负荷试验：3MPH（3miles per huor）转动踏板（倾斜10）2分钟能否走完时间肺活量：（Timed vital capacity）深吸气后最大呼气，正常3秒，5秒，气道阻塞性肺疾患屏气试验：平和呼吸（15 20秒）深呼吸（30秒）心肺储备功能不足 登楼试验：登四楼，10分钟HR、RR恢复。,2023/4/30,Department of Anesthesiology,Affiliated Hospita
20、l of XUZHOU Medical College,33,第二节 麻醉前的评估与准备,麻醉前评估（Preanesthetic evaluation）呼吸系统情况估计肺功能测定（PFTs）：有助于诊断肺病变类型：慢性限制性疾病（CRD），如肺间质性、纤维性病变或过度肥胖；慢性阻塞性疾病（COPD），如慢性支气管炎、肺气肿等有助于了解病者是否能耐受开胸或全肺切除术,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,34,PFTs主要指标：（1）肺总量（TLC）包括潮气量（VT
21、）、功能余气量（FRC）、余气量（RV）和肺活量（VC）（2）时间肺活量包括肺活量（FVC），第一秒时间肺活量（FEV1.0）及第2、3秒时间肺活量。FEV1.0/FVC比率（正常8085%）较单纯时间肺活量有意义。如COPD患者FEV1.0降低而FVC可正常（3）呼气中期流速（MMFR）是测定COPD另一敏感方法，最高呼气流速（PEFR）减低提示气道阻塞性病变，最大自主通气量（MVV）是肺功能储备的敏感指标,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,35,肺手术有危
22、险的术前肺功能测定,测定方式 测定内容 有手术危险的测定值,5.98kPa（45mmHg）预计正常值的50%2L或用力肺活量的50%50%0.85L肺动脉平均压5.32kPa（40mmHg）PaCO27.98kPa或PaO25.98kPa,呼吸空气时的PaCO2值最大通气量（MVV）第一秒用力肺活量（FEV1）余气量/肺总量的比值健侧肺术后FEV1预计值暂时阻断病侧肺动脉,全肺试验分侧肺试验模拟肺切除后情况,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,36,第二节 麻醉
23、前的评估与准备,麻醉前评估（Preanesthetic evaluation）循环系统情况的评估肺血管与右心功能 慢性肺疾患者，肺血管也发生病变，表现为肺血管阻力（PVR）增高，右室肥厚与扩张。这类患者麻醉期及术后低氧血症或呼吸衰竭发生率增高,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,37,心排血量增加倍数,肺血管阻力增高,肺血管阻力正常,1 2 3 4 5,肺动脉压（mmHg）,60 45 30 15 0,2023/4/30,Department of Anesth
24、esiology,Affiliated Hospital of XUZHOU Medical College,38,第二节 麻醉前的评估与准备,麻醉前准备全身准备积极治疗伴随疾病改善人体机能状态口腔卫生注意并存心血管方面情况,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,39,第二节 麻醉前的评估与准备,麻醉前准备术前改进肺功能的准备停止吸烟 改进粘膜纤毛运动功能，2-4周见效，6-8周效果最佳。术前24-48小时停止吸烟反而增加气道分泌物及敏感性。吸烟者术后并发症是非吸
25、烟者6倍。,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,40,第二节 麻醉前的评估与准备,麻醉前准备术前改进肺功能的准备保持气道通畅，防治支气管痉挛控制气道感染，尽量减少痰量 抗感染，湿化，拍背及体位排痰锻炼呼吸功能低浓度氧吸入（23L/min）,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,41,第二节 麻醉前的评估与准备,麻醉前准备术前思想准备
26、向病人说明麻醉及手术的大体情况，术后胸部切口疼痛呼吸受限制，胸腔引流管引起的不适感等术后病人主动配合项目如咳痰、深呼吸、在床上大小便等，争取病人的主动合作,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,42,第二节 麻醉前的评估与准备,麻醉前准备术前用药1 镇静镇痛药呼吸功能减退或年老体弱患者，气管、支气管严重狭窄病人（静息状态哮鸣）应慎用或不用吗啡、哌替啶等药物；COPD或哮鸣患者禁用吗啡2 抗胆碱能药湿肺及呼吸道分泌物较多的病人应在尽量排痰（必要时行体位引流或纤支镜吸
27、引）后，方可使用，心率快或发热病人避免应用阿托品3 对估计不合作的幼儿，应先给基础麻醉,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,43,第二节 麻醉前的评估与准备,麻醉前准备器械准备导管选择、喉罩监测（ECG、SPO2、ETCO2、A-V穿刺测压）吸引装置呼吸机（有时需两台，进行两肺分别通气）,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,44,
28、第三节 胸科手术麻醉的特点与处理,胸科手术麻醉的原则（基本要求）减轻纵隔摆动与反常呼吸；避免肺内物质扩散；保持Pao2和Paco2的基本正常水平；减轻循环障碍；保持体热。,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,45,第三节 胸科手术麻醉的特点与处理,麻醉选择气管和支气管内麻醉吸入麻醉 镇痛完善，不增加呼吸道分泌物，扩张支气管，但高浓度下对循环有抑制，有肝毒性，气道开放，有溢出的情况，也不宜多次吸引气道，而且抑制HPV，肺内分流增大。静吸复合全麻全凭静脉麻醉 适用于
29、“湿肺”及气管再造。硬膜外麻醉,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,46,第三节 胸科手术麻醉的特点与处理,麻醉选择硬膜外与静复全麻的联合应用 气管插管副反应术中镇痛，循环稳定，降低心律失常发生率苏醒快，适于湿肺，气管再造患者术后镇痛,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,47,第三节 胸科手术麻醉的特点与处理,麻醉管理麻醉深度的控
30、制注意几个环节：诱导（气管插管）切皮、骨膜刺激、探查（肺门）关胸拔管,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,48,第三节 胸科手术麻醉的特点与处理,麻醉管理呼吸管理单侧肺通气生理变化：肺内分流通气侧肺通气/灌流比值失调HPV肺血流减少药物影响,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,49,第三节 胸科手术麻醉的特点与处理,麻醉管理呼吸管
31、理单侧肺通气管理Carlen or White氏管和Robertshaw氏管的问题；（前者插管困难，刺激窿凸，但相对容易定位。后者插管容易，但定位相对容易，并且支气管侧偏深时，易造成上肺通气不佳。）尽量采用纤支镜定位,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,50,Carlen与White双腔管,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,51
32、,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,52,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,53,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,54,Carlen or White氏管和Robertshaw定位分析,20
33、23/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,55,第三节 胸科手术麻醉的特点与处理,麻醉管理呼吸管理单侧肺通气管理动静脉血混杂（Qs/Qt：20%40%）；TV的控制（8-10mL/kg）;频率控制；（内源性PEEP）最佳PEEP（避免气压伤，保证肺血流在上下两肺的恰当分布）Paw3035cmH2O；,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,56
34、,第三节 胸科手术麻醉的特点与处理,麻醉管理呼吸管理单侧肺通气管理高浓度吸氧（FiO2 1.0）尽量缩短单肺通气时间；或尽量使用双肺通气尽早阻断切除肺的肺动脉血管动态血气分析监测,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,57,第三节 胸科手术麻醉的特点与处理,麻醉管理呼吸管理单侧肺通气管理低氧血症的处理：检查支气管位置吹张上肺4 5次连接CPAP（5 7.5厘米水柱）于上肺上肺支气管持续吹氧2L/min上肺高频通气PEEP(Positive end expirato
35、ry pressure)5 10厘米水柱于下肺结扎肺动脉,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,58,第三节 胸科手术麻醉的特点与处理,麻醉管理呼吸管理气道的清理有足够的麻醉深度每次吸引时间不宜过长(10s)吸引负压小于25厘米水柱连续监测呼吸音，及时发现及时处理预防肺不张(Atelectasis)手术操作中肺萎陷时间不宜过长，定期吹张肺。尤其是由单肺通气向双肺通气的过渡的处理,2023/4/30,Department of Anesthesiology,Affi
36、liated Hospital of XUZHOU Medical College,59,第三节 胸科手术麻醉的特点与处理,麻醉管理循环管理维持好循环血量预防和处理心律失常正确处理肺心病人在术中的并发症输液输血 液体丢失多，注意及时补充，全肺切除病人，注意肺血管床骤然减少，输液应减速减量，以免发生急性肺水肿。,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,60,第三节 胸科手术麻醉的特点与处理,麻醉管理术后处理必要的呼吸支持术后镇痛给氧,2023/4/30,Departm
37、ent of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,61,第四节 常见胸科手术的麻醉处理,肺部手术肺叶切除肺切除术（一侧全肺切除）支气管胸膜瘘胸腔镜手术食管手术纵隔手术气管重建术,2023/4/30,Department of Anesthesiology,Affiliated Hospital of XUZHOU Medical College,62,思考题,基本概念：纵隔移位与摆动、反常呼吸、摆动气、单肺通气、HPV肺萎陷、纵隔摆动及反常呼吸的危害是什么？剖胸导致心排出量降低的原因是什么？胸科手术有关肺功能评估的方法有哪些？危险因素有哪些？胸科手术麻醉的基本要求是什么？单肺通气管理时应注意哪些问题？,
