胸膜固定术论文：内科胸腔镜下滑石粉胸膜闭锁治疗自发性气胸.doc

胸膜固定术论文：内科胸腔镜下滑石粉胸膜闭锁治疗自发性气胸【中文摘要】气胸是呼吸系统常见病之一,临床以自发性气胸最常见,根据肺部有无原发病,通常又可以分为原发性自发性气胸和继发性自发性气胸。气胸危害患者健康、影响其生活质量,同时给社会带来沉重负担。因此,正确治疗气胸成为一个亟待解决的问题。临床治疗气胸的方法很多,其中外科手术治疗气胸疗效确切,复发率低,但是手术创伤大、费用高,很多患者不能接受。胸膜固定术治愈率高,复发率低,并且术后恢复快,成为气胸治疗的一种重要方法。胸膜固定术是指将物理、化学或生物性胸膜刺激剂导入胸膜腔,诱发无菌性炎症,促使脏层和璧层胸膜粘连。1935年,Bethune首次将碘化滑石粉喷入胸膜腔诱使胸膜粘连成功,至今,胸膜硬化剂多种多样,大致可分为：理化硬化剂(如机械摩擦、高渗葡萄糖、滑石粉、四环素、硝酸银),生物硬化剂(如卡介苗、短小棒状杆菌),细胞因子(转化生子因子b2,TGF-b2),自体血,纤维蛋白原及凝血酶等。在以上硬化剂中,以滑石粉应用最为普遍,其疗效确切、安全经济,不良反应少,得到众多学者的认同。胸膜固定剂注入胸腔的方法可选择经胸腔引流管或胸腔镜法。前者要求肺复张完全、胸腔引流液量小于200ml/d,粘连剂悬液注入胸腔后,患者应定期转换体位以使硬化剂均匀的分布到胸膜表面。胸腔镜直视下喷撒硬化剂更有优势：操作者可以在镜下松解粘连带,有利于肺复张,并能使滑石粉更加顺利的进入胸腔；直视下喷撒滑石粉可以确保胸膜被均匀的覆盖,达到胸膜腔的完全闭塞。而且,胸腔镜与经胸腔引流管注药相比,不会造成的伤害,安全性好。按照操作人员不同胸腔镜术可分为内科胸腔镜术与电视辅助的外科胸腔镜手术(VATS),相比之下,前者费用低,不需要全麻,术后恢复快,更容易被患者接受。本文旨在研究内科胸腔镜下滑石粉胸膜固定术对自发性气胸的治疗价值,同时观察其不良反应。方法：研究对象：本组病例为山东省立医院1996年至2009年收住院,行胸腔镜下滑石粉胸膜固定术治疗的51例自发性气胸患者,绝大部分为复发性或持续性气胸。器械：奥林巴斯硬式胸腔镜,硬穿刺套管针,冲洗吸引器,干粉喷粉器,活检钳,胸腔镜电视显示器、冷光源,蘑菇头样引流管。手术环境：胸腔镜术要求严格的无菌操作,在术前对内镜室进行严格消毒,保证所有器械绝对无菌,术者及护士应按外科手术术前要求常规,穿手术衣,戴无菌手套。术前准备：所有患者于术前检查出凝血时间、心电图、血压,行X线胸部检查观察胸膜粘连情况。术前15-30分钟皮下注射阿托品0.5mg,肌注安定10mg,必要时给予度冷丁50mg肌注；也可以给予度冷丁50mg,异丙嗪25mg,东莨菪碱0.3mg术前半小时肌注。给予低流量吸氧,持续监测血氧饱和度和心率。操作方法：患者取健侧卧位,患侧手臂上抬,固定于头架上,在健侧胸部下方置一长枕或卷起的床单,充分的暴露患侧整个胸膜腔,一般选择腋前线第4肋间或腋中线第5肋间及腋后线第6肋间为插入胸腔镜的切口。常规皮肤消毒,铺无菌洞巾,以2%利多卡因自皮肤到胸膜逐层浸润麻醉,一般在皮肤先做1cm长的与肋间平行的皮丘,然后对皮下组织、肌层、胸膜逐层麻醉,直到注射针进入胸腔回抽出气体时为止。麻醉成功后做皮肤小切口,用血管钳钝性分离皮下组织、肋间肌达壁层胸膜,套管针沿肋骨上缘垂直插入胸膜腔,拔出针芯,顺套管插入胸腔镜,全面检查胸膜腔,尤其应注意胸膜下大泡和肺大泡的部位、数量、大小,观察有无胸膜粘连带,寻找漏气部位,然后再插入另一套管针作为活检钳和注入药物的通道；也可以采取单孔操作。在镜下确认粘连带内无大血管后,用活检钳将其松解及离断,对肺大泡用活检钳刺破,胸腔镜直视下向胸膜腔均匀喷洒不含石棉的医用消毒滑石粉3-5g作为胸膜固定剂,喷粉前可肌注哌替啶(杜冷丁)50mg。于观察孔放置蘑菇头引流管接闭式引流瓶,并鼓励患者咳嗽、屏气以利胸腔内气体排出。结果判定：住院期间不需要进一步外科手术治疗即可使患侧肺完全复张为治疗成功。统计分析：所有数据统计分析均使用统计软件包SPSS17.0处理,组间阳性率的比较采用2检验或Fisher精确概率法检验；数值变量资料的比较采用T检验。P0.05为差异有统计学意义。结果：1例闭锁失败转外科行手术治疗；其余50例均治愈后出院,治愈率98.04%；治愈的50例患者平均拔管时间为6.024.33天。术后无急性呼吸衰竭、复张性肺水肿等严重并发症；发热、胸痛常见。体温多在39以下,经抗炎治疗及对症处理后体温一般在2-5天内恢复正常。胸痛多不剧烈,给予肌注布桂嗪或杜冷丁后均缓解。结论：内科胸腔镜下滑石粉胸膜固定术是治疗原发性气胸的有效方法,其治愈率高,不良反应少,无严重并发症。【英文摘要】:Pneumotharox is a commom respiratory disease and spontaneous pneumothorax is more usual.According to whether the primary lung disease exist,SP usually can be divided into primary and secondary spontaneous pneumothorax. Pneumothorax hazards patientshealth, affects their life quality, and is also a heavy burden to society. Therefore, the proper treatment of pneumothorax is a serious problem.Curative surgical treatment has an exact effect:the recurrence rate is lowest, but the trauma of the surgeries and high costs, make suigery impossible to many patients.Pleurodesis is a curative method that physical、chemical or biotical irritats are induced into the pleural cavity where these irritats produce sterile inflammation which make adhesion between vesical and parietal pleura. Since 1935, Bethune use iodized talc for the first time to induce pleurodesis successfully,today there are noumorous agents for pleurodesis:physical and chemical agents (ex.mechanical friction, hypertonic glucose, talc,tetracycline,silver nitrate),bioticalagents(ex.BCG,Corynebacterium),cytokines(ex.TGF-b2),autologous blood,fibrinogen, thrombin and so on.Among these,talc is the most commonly used agent,which is effctive,safe,affordable and recognised by by many scholars.Pleurodesis agent can be injected by the thoracic chest tube or thoracoscopy law. The former requires full lung recruitment, thoracic drainage less than 200ml/d, and patients should regularly convert position to make the suspension evenly distributed to the pleural surface.The later has more advantages:the operator can release adhesions in the microscope, and talc can be more smoothly into the chest; spray talc under direct vision to ensure that the pleural covered uniformly, to complete occlusion of the pleural cavity. Moreover, compared to chest tube, thoracoscopy dose not cause more damage. and to thoracoscopic surgery, requries low-cost, no anesthesia, rapid recovery, which make it more acceptabile to patients.The purpose of this article is to abserve curative value of midical thotascopic talcage for SP and its side effects.Methods:Objects:Fifty-five SP patients are cellected from Shandong provincial hospital bitween 1996-2009, which accepte midical thotascopic talcag,and most are refracory or continued SP.Instument:rigid-thoracoscopy of olpmpus, trachor,aspirator,duster,biospy forcep,monitor, cold light source,mushroom drainegre tube.Preparation:All patients accept the preoperative examination:the clotting time, ECG, chest X-ray to avaluate pleural adhesions; 15 minutes to half an hour bofore tretment intramuscular injection of of 10 mg diazepam, if necessary an injection of pethidine; low-flow oxygen, continuous monitoring of oxygen saturation and heart rate.Steps:Patients atre lying contralateral,exposure the affected side of pleural cavity sufficiently,take 4th at anterior axilarry line or 5th at the middle axilarry line or 6th at the posterior axilarry line intercostal space as the incision, insterile skin,anesthesin from skin to parietal pleural.Then make an incision parellel to intercostal space,dissociate suncutanous tissue to pleural cavity,exan the pleural cavity especially the positon、numbe、rand size bullae,look for the leak;release adhesion after ensure of abbesnce of big vessles;break the bullae and then spray 3-5g talc uniformly under microscopy.Before the spray,injec 50mg pethedine intramuscularly. Leave a mushroom drainage tube,encourage the patient to cough to discharge air. Extubation is after more than 24 hours unleakage and drainage of pleural fluid less than 50 ml/d, before extubation take a chest radiograph to view lung recruitment.In the period of hospital no need of further surgery to the affected side for lung reexpansion completely is seen as successful.All the statistical analyses were carried out using SPSS17.0, the significance of different groups were evaluated by means of2 test or the exact Fishers test. Numeric variable data is tested T tes and P0.05 was considered statistically significant t. Results:1 case need further surgical treatment; the remaining 50 patients were cured, the cure rate is98.04%. The average extubation time of cured 50 patients is day. There are no acute respiratory failure, reexpansion pulmonary edema,or other serious complications;