严重慢性阻塞性肺疾病患者的围手术期处理

The management of patients with severe COPD at perioperative period

目的 探讨严重慢性阻塞性肺疾病 (COPD)患者的围手术期处理。方法 择期进行上腹部和胸腔内手术患者 14例 ,均患有严重的COPD ,术前评估围手术期有高度发生呼吸系统并发症的危险。术前准备包括戒烟、预防和控制感染、支气管扩张和呼吸功能锻炼 ,6例患者术前进行无创正压通气 (NPPV)训练 ,手术在硬膜外阻滞复合全身麻醉下完成。术后施行硬膜外镇痛、抗感染、胸部理疗、扩张支气管和氧疗。部分患者间断采用NPPV进行呼吸支持。结果 14例患者术前平均MVV(最大自之通气量 )占预计值 ( 4 2± 9) % ,平均RV/TLC(残气量 /总肺容量 )为 ( 62± 4) % ,平均FEV1( 1s时间肺活量 )为 ( 0 .79± 0 .2 0 )L ,平均FEV1/FVC( 1s时间肺活量 /用力肺活量 )为 ( 3 9± 6) %。 6例患者经术前支气管扩张药物治疗和呼吸功能锻炼后 ,FEF2 5%～ 75% (最大中期呼吸量 )从 ( 0 .4± 0 .2 )L/s增至 ( 0 .95± 0 .3 )L/s(P<0 .0 5 ) ,FEV1从 ( 0 .68± 0 .2 6)L增至 ( 0 .94± 0 .40 )L(P <0 .0 5 )。术后有 4例 ( 2 8.6% )行纤维支气管镜吸痰 ;6例 ( 4 2 .8% )哮喘发作吸入支气管扩张药并静脉注射肾上腺皮质激素后缓解。所有病人术后PaO2均有不同程度的下降 ,以术后第 2、3天最为显著 ,平均从术前 ( 68± 6)mmHg降至 ( 5 6± 4)

Objective To investigate the management of patients with severe COPD at perioperative period.Methods 14 patients with severe COPD who were scheduled for elective upper-abdominal or thoracic operation were enrolled.Preoperative treatment included smoking cessation,control of infection,appropriate bronchodilatation,chest physiotherapy and respiratory function exercises.Six patients received preoperative NPPV training.The operations were accomplished by epidural block combined with general anesthesia.All patients were closely monitored and cared at perioperative period, and NPPV was used for part of severe cases.Results The percentage of predicted value of mean MVV (MVV%),mean RV/TLC ratio,mean FEV 1 and mean FEV 1/FVC ratio was (42±9)%,(62±4)%,(0.79±0.20)L and (39±6)% respectively.In six patients who received bronchodilatation drugs and respiratory exercise before operation,FEF 25%～75% and FEV 1 significantly increased from (0.4±0.2)L/s to (0.95±0.3)L/s and (0.68±0.26)L to (0.94±0.40)L (P<0.05) respectively.After surgery four patients (28.6%) had mucus plug requiring bronchoscopic suctioning.Bronchospasm occurred in six patients (42.8%) and were relieved after inhalation of bronchodilatation drugs and intravenous administration of corticosteroid.PaO 2 significantly decreased especially on 2～3 days after operation from (68±6)mm Hg to (56±4)mm Hg (P<0.05),and increased gradually afterwards.All the patients recovered completely and discharged from hospital.Conclusion The severe COPD is not the absolute contraindication of surgical operation.Preoperative respiratory exercise and NPPV at perioperative period can contribute to the maintenance and recovery of postoperative respiratory function.