尘肺全肺大容量灌洗的改良操作方法

To improve a procedural management of patients with pneumoconiosis of whole-lung lavage

目的通过改良尘肺全肺大容量肺灌洗(whole-lung lavage,WLL)操作方法,减少原有操作方法不良反应,并验证改良方法的安全性和有效性。方法选择全身麻醉下尘肺WLL患者40例,随机分成A组(观察组)和C组(对照组),每组20例。全部患者实行非双肺同期肺灌洗术。常规监护并麻醉诱导、插入39Fr左支气管导管并纤维支气管镜定位,验证气密性。每位患者双侧肺分别灌洗时间间隔为3 d。A组患者采用每次灌注灌洗液1000 mL,先负压吸引500 mL后,实施灌洗侧机控正压单肺通气5次,然后继续负压吸引灌洗液残液。待灌洗液残液无明显残余,进行第二次灌洗操作程序,直到灌洗液清亮的处理方案;C组应用传统WLL操作方法即每次灌注灌洗液1000 mL,并负压吸引灌洗液,于灌洗第3、6、9、12次进行机控正压通气并负压吸引灌洗液,直到灌洗液清亮。两组患者灌洗结束后均采用负压吸引灌洗液残液、呼气末正压通气、应用扩张支气管药物等方法促进灌洗侧肺功能恢复。于灌洗操作结束后60 min停用全部麻醉药品,复苏并拔管。记录患者灌洗液变清亮的灌洗次数、灌洗手术操作时间、最低血氧饱和度、手动辅助通气提升血氧饱和度、恢复双肺通气操作次数,气道压力监测参数,血气分析指标,残液量,术后咳痰量、术后第24小时动脉血气分析参数。结果A组病例灌洗操作次数、手动辅助提升血氧饱和度和恢复双肺通气次数均明显少于C组(P<0.05),并较好保证安全范围的氧合水平,降低高碳酸血症发生概率。A组相较C组气道峰压、气道平台压在灌洗结束、气管拔管前时点显著降低(P<0.05)。A组术后灌洗液残液量、咳痰量少于C组(P<0.05);并且术后第24小时时点A组PaO2优于C组(P<0.05)。结论通过改良尘肺WLL方法,能够减少肺灌洗次数、手动辅助通气提升血氧饱和度操作次数和双肺通气次数,保持良好氧合和安全血氧水平;能够降低灌洗过程中气道压;减少灌洗液残留、术后咳痰量,提高术后血氧水平,从而保证患者安全有效实施WLL,促进患者康复。

Objective To improve a procedural management of patients with pneumoconiosis of wholelung lavage(WLL)to reduce the adverse reactions and evaluate security and effectiveness about the new method.Methods 40 patients with pneumoconiosis who presented for WLL which were conducted by general anesthesia were divided into A group(experiment group,20 cases)and C group(control group,20 cases)by random number table.All the patients were conducted by WLL of the left lung first.The right lung was done by the same way three days later.After induction and intubation of 39 Fr.double-lumen tube,fiber bronchoscope was used to rigidly divided and seal the two lungs.A group was infused by NS 1000 mL in one lung first,about 500 mL NS was extracted by suction pump,then OLV was conducted 5 times by anaesthesia machine at the lung and then NS was extracted once more.C group was conducted by WLL with traditional method:NS 1000 mL was infused and extracted for 3 times,then OLV was conducted by anaesthesia machine at the lung.OLV was conducted at the 6^th/9^th/12^th times and et al.After suction,the procedural management of the both two group should be repeated till NS was founded clearly.Positive end-expiratory pressure(PEEP),lung recruitment maneuver,bronchodilator agents were applied to improve the pulmonary function.Times of WLL(t),time of the duration(T),SpO2 min,times of manual operation to improve SpO2(M),times of DLV,the parameters of the airway and arterial blood gas analysis,amount of residue of NS,amount of sputum after WLL,the parameters of blood gas analysis at the 24^th hour postoperation were all recoded.Results Times of WLL,times of manual operation,double-lung ventilation of A group was lower than it of C group respectively(P<0.05).Ppeak,Pplat of A group was lower than it of C group respectively(P<0.05),at the time-point of after WLL and before extubation.Amount of residue of NS and amount of sputum after WLL of A group was lower than it of C group respectively(P<0.05).PaO2 at the 24^th hour postoperation of A group was higher than it of C group respectively.Conclusions The new method can reduce times of WLL,times of manual operation to improve SpO2,amount of residue of NS,amount of sputum after WLL.It can lower down Ppeak,Pplat,and enhance SpO2 at the 24^th hour postoperation.The new procedural management of patients with pneumoconiosis of whole-lung lavage maybe more safe and effective than the traditional method.