单肺通气预处理对儿童胸腔镜手术围术期氧合的影响

Effect of one lung ventilation preconditioning on oxygenation during pediatric videoassisted thoracoscopic surgery

目的观察单肺通气(OLV)预处理对儿童不同种类胸腔镜手术围术期氧合的影响。方法择期胸腔镜辅助胸科手术OLV患儿171例,年龄5 d^11岁,3岁以下127例。其中,脓胸廓清+脓肿切除术(脓胸组)55例,纵膈肿瘤切除术(纵膈肿瘤组)34例,膈疝修补或膈肌折叠术(膈疝组)21例,肺叶切除或肺活检(肺疾病组)43例,食管手术(食管组)18例。采用5Fr国产支气管堵塞器,侧卧位后行OLV预处理5~8 min,恢复双肺通气5 min,切皮前再次启动OLV。若Sp O2<95%,管端位置无异常,给予呼末气道正压5 cm H2O;Sp O2<90%,则间歇双肺通气。结果 OLV术野优良率93.56%。脓胸组2例、食管组3例术中需要间歇双肺通气,其余166例患儿可耐受OLV。食管组手术时间、OLV时间、术后机械通气时间、术后住院时间(LOS)长于其他组别,术后肺不张例数高于膈疝组和肺疾病组;脓胸组、食管组在肺完全萎陷后、拔除气管导管后的氧合指数低于纵隔肿瘤组(P<0.05或0.01)。结论 OLV预处理法可维持大部分患儿OLV期间的氧合,手术时间、OLV时间长的患儿,术后机械通气时间、LOS较长。

Objective To observe the effect of one lung ventilation（OLV） preconditioning on perioperative oxygenation during pediatric video-assisted thoracoscopic surgeries（VATS）. Methods A total of 171 children aged 5 days to 11 years underwent VATS for empyema dissection and abscess excisions（n=55）, mediastinal tumor resection（n=34）, repair of the diaphragmatic hernia or diaphragmatic plication（n=21）, pulmonary lobectomy or biopsy（n=43）, or esophageal disease（n=18）. Of these patients, 127 were younger than 3 years of age. A 5-Fr pediatric endobronchial blocker was used for OLV with a delivered inspired oxygen fraction（Fi O2） of 1.0. After lateral decubitus, a sequential protocol of a 5-to 8-min OLV preconditioning and a5-min two lung ventilation（TLV） was performed followed by OLV again before incision for VATS. In cases of a SpO2〈95%without malposition of the blocker during OLV, a 5 cm H2 O positive end expiratory pressure was applied; TLV was maintained for a SpO2〈90%. Results OLV provided good surgical conditions in 160 cases. Acceptable saturations were achieved in 166 cases during OLV. In 2 cases in empyema group and 3 in esophageal disease group, the ventilation protocol was converted to intermittent TLV during the operation due to hypoxemia. In esophageal disease group, the procedure and OLV duration,postoperative ventilation time and length of stay（LOS） were the longest among the groups, and the number of cases developing postoperative atelectasis was greater than that in diaphragmatic hernia and pulmonary disease groups. In empyema and esophageal disease groups, the oxygenation index（Pa O2/Fi O2） after total collapse of the lung in OLV and after extubation were lower than that in mediastinal tumor group（P〈0.05 or 0.01）. Conclusion OLV preconditioning can maintain an acceptable oxygenation during pediatric OLV. A longer procedure and OLV duration is associated with a prolonged postoperative length of ventilation and LOS.