改良高频喷射通气在喉显微手术中的应用研究

Application of improved high-freqenucy jet ventilation in laryngeal microsurgery

目的比较全身麻醉下改良高频喷射通气与其他频率通气在喉显微手术中应用的通气效果及不良反应。方法将ASAⅠ～Ⅱ级,拟在全身麻醉下行择期喉显微手术的患者120例随机均分为高频喷射通气组(H1组),改良高频喷射通气组(H2组)、常频喷射通气组(C组)和气管插管间歇正压通气组(T组)各30例。4组患者均以咪达唑仑、舒芬太尼、丙泊酚、琥珀胆碱静脉注射行麻醉诱导,术中间断追加丙泊酚及琥珀胆碱维持麻醉。H1、H2和C组成功放置支撑喉镜后,借助喷射呼吸机在放置的支撑喉镜侧方以不同频率进行喷射通气,T组经口明视下插入小口径气管导管接麻醉机行控制呼吸。记录4组患者在麻醉前(T0)、支撑喉镜放置成功后(T1)、通气5 min后(T2)及支撑喉镜取出5 min后(T3)各时间点的平均动脉压(MAP)及心率(HR),并分析T0、T2和T3三个时间点的平均动脉血气指标,如pH值、二氧化碳分压(PaCO_2)、动脉血氧分压(PaO_2)及血氧饱和度(SaO_2)。同时比较4组患者不良反应发生情况。结果 4组在T1时间点的MAP、HR均较同组T0时间点显著升高,且T组在T1时间点的MAP、HR显著高于H1组、H2组及C组同时间点,差异均有统计学意义(P<0.05)。H1组在T2、T3时间点的pH值下降幅度和PaCO_2上升幅度与本组T0相比差异有统计学意义(P<0.05),同时H1组在T2、T3时间点的pH值下降幅度和PaCO_2上升幅度较其他3组同时间点变化更明显,组间比较差异有统计学意义(P<0.05)。4组的PaO_2在T2、T3时间点与同组T0时间点比较差异有统计学意义(P<0.05),但无临床意义。H1组CO_2蓄积率高于H2、C组及T组,T组拔管时躁动率高于H1、H2组及C组,C组术中声带振动发生率高于H1、H2组及T组,差异均有统计学意义(P<0.05)。结论在喉显微手术时,将改良高频喷射通气频率控制在40次/min时,能确保手术视野的清晰化,并取得了理想的通气效果,不良反应发生较少,通气方法可行性较高。

Objective To compare the ventilation effect and adverse reactions of modified high-frequency jet ventilation and other frequency ventilation in laryngeal microsurgery under general anesthesia.Methods 120 patients(ASAⅠ~Ⅱ)who were scheduled to undergo elective laryngeal microsurgery under general anesthesia were randomly divided into high-frequency jet ventilation group(H1 group),modified high-frequency jet ventilation group(H2 group),and frequent-frequency jet ventilation(C group)and tracheal intubation intermittent positive pressure ventilation group(T group).All four groups received intravenous anesthesia for midazolam,sufentanil,propofol and succinylcholine for induction of anesthesia.During the operation,propofol and succinylcholine were added to maintain anesthesia.After the laryngoscopes were successfully placed in the H1,H2 and C groups,the jets were used to spray at different frequencies on the side of the placed laryngoscope.T group underwent light-gauge tracheal cannula under the mouth and then the anesthesia machine was controlled to breathe.Four patients the mean arterial pressure(MAP)and heart rate(HR)were analyzed.Mean arterial blood gas indexes at three time points T0,T2 and T3 were analyzed,and the pH,PaCO2,PaO2 and at the time point before the anesthesia(T0),after the success of the support laryngoscope(T1),5 minutes after the ventilation(T2),and 5 minutes after the time of the support laryngoscope(T3).SaO2 were compared.At the same time,the adverse reactions of four groups of patients were compared.Results The MAP and HR of the 4 groups at the T1 time point were significantly higher than the T0 time points of the same group,and the MAP and HR of the T group at the T1 time point were significantly higher than the H1 group,the H2 group and C group,the difference was statistically significant(P<0.05).The decrease of pH value and the increase of PaCO2 in H1 group at the T2 and T3 time points were statistically significant compared with the T0 of this group(P<0.05).At the same time,the decrease of pH value and the increase of PaCO2 in H1 group at T2 and T3 were more obvious than those in the other three groups,the difference between the groups was statistically significant(P<0.05).There were significant differences in PaO2 between the 4 groups at the T2 and T3 time points and the T0 time points of the same group(P<0.05),but there was no clinical significance.The rate of CO2 accumulation in H1 group was higher than that in H2,C and T group;The rate of agitation in T group was higher than that in H1,H2 group and C group;the incidence of vocal cord vibration in C group was higher than that in H1,H2 group and T group,and the difference was statistically significant(P<0.05).Conclusion During laryngeal microsurgery,the frequency of modified high-frequency jet ventilation was controlled at 40 beats/min,which can ensure the clarification of the operative field,achieve ideal ventilation effect,fewer adverse reactions,and more feasibility of ventilation.