胸科麻醉(英文版)

AnesthesiaforThoracicSurgeryMar2018ChongqingHospitalofTraditionalChineseMedicineLiangZhang1、PhysiologicalConsiderationsDuringThoracicAnesthesia2、TechniquesforOne-LungVentilation3、AnesthesiaforLungResection4、AnesthesiaforTrachealResection5、AnesthesiaforVideo-AssistedThoracoscopicSurgery(VATS)6、AnesthesiaforDiagnosticThoracicProcedures7、AnesthesiaforLungTransplantation8、AnesthesiaforEsophagealSurgeryMaincontents1、PhysiologicalConsiderationsDuringThoracicAnesthesiaTheAwakeStateInductionofAnesthesiaMediastinalShiftTHEOPENPNEUMOTHORAXParadoxicalRespirationDuringone-lungventilation,themixingofunoxygenatedbloodfromthecollapsedupperlungwithoxygenatedbloodfromthestillventilated

dependentlungwidensthealveolar-toarterial

(A-a)O2

gradientandoftenresultsinhypoxemia.Fortunately,bloodflowtothenonventilated

lungisdecreasedbyhypoxicpulmonaryvasoconstriction(HPV)andpossiblysurgicalcompressionoftheupperlung.ONELUNGVENTILATIONFactorsknowntoinhibitHPVVeryhighorverylowpulmonaryarterypressures;Hypocapnia;HighorverylowmixedvenousPO2;Vasodilatorssuchasnitroglycerin,nitroprusside,phosophodiesteraseinhibitors(milrinoneandinamrinone),β-adrenergicagonists,calciumchannelblockers;Pulmonaryinfection;Inhalationanesthetics.Factorsthatdecreasebloodflowtotheventilated

lungHighmeanairwaypressuresintheventilatedlungduetohighpositiveend-expiratorypressure(PEEP),hyperventilation,orhighpeakinspiratorypressures;AlowFiO2

,whichproduceshypoxicpulmonaryvasoconstrictionintheventilatedlung;Vasoconstrictorsthatmayhaveagreatereffectonnormoxicvesselsthanhypoxicones;IntrinsicPEEPthatdevelopsduetoinadequateexpiratorytimes.Indicationsforone-lungventilation.2、TechniquesforOne-LungVentilationThreetechniquescanbeemployedPlacementofadouble-lumenbronchialtube;Useofasingle-lumentrachealtubeinconjunctionwithabronchialblocker;Insertionofaconventionalendotrachealtubeintoamainstembronchus.

Double-lumentubesaremostoftenused.DOUBLELUMENBRONCHIALTUBESTheuseofaright-sideddouble-lumentubeisrecommendedDistortedanatomyoftheleftmainbronchusbyanintrabronchialorextrabronchialmass;Compressionoftheleftmainbronchusduetoadescendingthoracicaorticaneurysm;Left-sidedpneumonectomy;Left-sidedsinglelungtransplantation;Left-sidedsleeveresection.TheprincipaladvantageRelativeeaseofplacement;Theabilitytoventilateoneorbothlungs;Theabilitytosuctioneitherlung.CharacteristicsAlongerbronchiallumenthatenterseithertherightorleftmainbronchusandanothershortertracheallumenthatterminatesinthelowertrachea;

Apreformedcurvethatwhenproperly“aimed”allowspreferentialentryintoabronchus;

Abronchialcuff;

Atrachealcuff.PlacementofDouble-LumenTubesSelectionoftubesizePlacementofDouble-LumenTubesDepthofinsertion(Theaveragedepthofinsertionisabout29cm[attheteeth])12+height/10PlacementofDouble-LumenTubesA.Initialposition;B.Rotateit90°;C.Finalposition.FiberopticBronchoscopeThecarinashouldbevisible;Thebronchiallimbofthetubeshouldbeseenenteringtherespectivebronchus;Thetopofthebronchial

cuff(usuallycoloredblue)

shouldbevisible;Shouldnotextendabove

thecarina;Alignmentofthe

endobronchialsideportal

withtheopeningofthe

rightupperlobebronchus.ComplicationsofDouble-LumenTubesHypoxemia;Traumaticlaryngitis;Tracheobronchialrupture;Inadvertentsuturingofthetubetoabronchus.Bronchialblockersareinflatabledevicesthatarepassedalongsideorthroughasingle-lumentrachealtubetoselectivelyoccludeabronchialorifice.Tubewithnaturalcurve;Theinnerlumencontainsanylonwire,whichexitsthedistalendasawireloop;viaaflexiblebronchoscope.SINGLELUMENTRACHEALTUBESWITHABRONCHIALBLOCKERA,Theoriginalelliptical(left)andthenewerspherical(right)ArndtdsignsofbronchialblockerB,TheCohen(left)andFujiUniblocker(right)Themajoradvantage：itdoesnotneedtobereplacedwithaconventionaltrachealtubePatientremainsintubatedpostoperatively;Difficulttointubateusingdirectlaryngoscopy;Priortracheostomies.Themajordisadvantage

：thesmallsizeofthechannelwithintheblocker.Morepronetodislodgement;Donotallowefficientsuctioningofsecretions;Donotallowefficientrapidcollapseofthelung.PREOPERATIVECONSIDERATIONSANESTHETICCONSIDERATIONSSPECIALCONSIDERATIONSFORPATIENTSUNDERGOINGLUNGRESECTION3、AnesthesiaforLungResectionIndicationTumors

InfectionBronchiectasisAnatomicstagingChestradiographyComputedtomography(CT)Magneticresonanceimaging(MRI)BronchoscopyMediastinoscopyPREOPERATIVECONSIDERATIONSSurgeryLobectomyorVATSSegmentalorwedgeresectionsPneumonectomysleeveresectionEvaluationforLungResectionPostoperativeforcedexpiratoryvolumeinonesec(FEV1)Diffusionlungcapacityforcarbonmonoxide(DLCO);Ventilation-perfusion(V/Q)scintigraphy;ExercisetestingStairclimbing;Laboratoryexercisetesting.1.PreoperativeManagementEchocardiographyChestradiographsandCTorMRimagesANESTHETICCONSIDERATIONS2.IntraoperativeManagementPreparationVenousAccessMonitoringInductionofAnesthesiaPositioning2.IntraoperativeManagementMaintenanceofAnesthesiaAdvantagesofthehalogenatedagents;Advantagesofanopioid;Epiduralopioids;Neuromuscularblockade;Intravenousfluids;Acutelunginjury;Airleak.2.IntraoperativeManagementManagementofOne-LungVentilationLowertidalvolumes(6–8mL/kg);RoutineuseofPEEP(5–10cmH2O);LowerFiO2(50%to80%);Lowerventilatorypressures(plateaupressure<25cmH2O;Peakairwaypressure<35cmH2O);Pressurecontrolledventilation;Permissivehypercapnia;Theoperativelungisinflated;Arterialbloodgasanalysis;PetCO2.2.IntraoperativeManagementManagementofHypoxiaAdequatepositionofthebronchialtube(orbronchialblocker)mustbeconfirmed;IncreaseFiO2

to1.0;Recruitmentmaneuvers;OptimizePEEPtothedependent,nonoperativelung;Ensureadequatecardiacoutputandadequateoxygencarryingcapacity;CPAPorblow-byoxygentotheoperativelung;Pulmonaryarteryclamp;Chronicobstructivelungdisease.2.IntraoperativeManagementAlternativestoOne-LungVentilation

ofHypoxia100%oxygenisinsufflated(apneicoxygenation);High-frequencypositive-pressureventilation;High-frequencyjetventilation.3.PostoperativeManagementGeneralCareExtubation;PACU（hypoxemia,respiratoryacidosis,hemorrhage）.PostoperativeAnalgesiaParenteralopioids;Intercostalorparavertebralnerveblocks;Epiduralanalgesia.PostoperativeComplicationsAtelectasis;Bronchopleuralfistulae;Torsionofalobeorsegment;Acuteherniationoftheheart;Postoperativephrenicnervepalsy.MassivePulmonaryHemorrhageAfullstomach;Thedouble-lumentube;Thebronchialblocker;Alarge(>8.0-mminnerdiameter)single-lumentube.PulmonaryCyst&BullaTensionpneumothorax;Inductionofanesthesiawithmaintenanceofspontaneousventilation;Avoidexcessivehypercarbia;N2Oiscontraindicated.SPECIALCONSIDERATIONSFORPATIENTSUNDERGOINGLUNGRESECTIONLungAbscessArapidsequence

intravenousinduction;Theaffectedlunginadependentposition;Thebronchialcuffshouldmakeatightseal.BronchopleuralFistulaUnabletoeffectivelyventilatethepatientwithpositivepressure;Thepatientshouldbeextubatedassoonaspossibleaftertherepair.PreoperativeConsiderationsTrachealstenosis,tumors,or,lesscommonly,congenitalabnormalities4、AnesthesiaforTrachealResectionAnestheticConsiderationsAninhalationinduction(in100%oxygen)SevofluraneSpontaneousventilationNMBsaregenerallyavoidedLaryngoscopyIntravenouslidocaine(1–2mg/kg)atrachealtubesmallenoughtobepassedAnestheticConsiderationsHigh-frequencyventilation;Cardiopulmonarybypass(CPB).Anestheticmanagementissimilartothatforopenprocedures,exceptthatone-lungventilationisrequired(asopposedtobeingdesirable)fornearlyallprocedures.5、AnesthesiaforVideo-AssistedThoracoscopicSurgery(VATS)BronchoscopySharetheairwaywiththesurgeon(1)Apneicoxygenationusingasmallcatheterpositionedalongsidethebronchoscopetoinsufflateoxygen;(2)Conventionalventilationthroughthesidearmofaventilatingbronchoscope;(3)Jetventilationthroughaninjector-typebronchoscope.6、AnesthesiaforDiagnosticThoracicProceduresMediastinoscopyPreoperativeCTorMR;Generaltrachealanesthesia;Venousaccesswithalarge-bore(14-to16-gauge)

intravenouscatheter;bloodpressureshouldbemeasuredintheleftarm;ComplicationsBradycardia;Excessivehemorrhage;Cerebralischemia;Pneumothorax;Airembolism;Recurrentlaryngeal

nervedamage;Phrenicnerveinjury.BronchoalveolarLavageUniquechallengestoensureadequateoxygenationduringlavageofthesecondlung;Generalanesthesiawithadouble-lumenbronchialtube;Supineposition;Asingle-lumentrachealtube.IndicationsforisolatedlungtransplantationCysticfibrosis;Bronchiectasis;ObstructiveChronicobstructivepulmonarydisease;α1-antitrypsindeficiency;Pulmonarylymphangiomatosis.RestrictiveIdiopathicpulmonaryfibrosis.Primarypulmonaryhypertension.7、AnesthesiaforLungTransplantationInduction&MaintenanceofAnesthesiaAvoidprecipitousdropsinbloodpressure;AvoidHypoxemiaandhypercarbia;Hypo