【摘要】：目的單肺通氣期間的機械通氣可損傷肺毛細血管內皮細胞,增加毛細血管通透性,滲透并激活炎性細胞,誘發(fā)炎性反應,從而進一步加重肺組織的損傷。本研究擬通過對照觀察支氣管堵塞器與雙腔支氣管導管對單肺通氣患者氧合和肺毛細血管內皮細胞的影響,旨在探討支氣管堵塞器對單肺通氣肺損傷的保護作用及其可能的機制 方法擇期行食管癌根治術患者40例,ASA (American Society of Anesthesiologists ASA)Ⅰ～Ⅱ級,隨機均分為2組：支氣管堵塞器組(Bronchial blocker tube BBT組)和雙腔支氣管組(Double-lumen bronchial tube DLT組),各20例。兩組采用相同的麻醉誘導方式,誘導成功后,DLT組插入35號或37號雙腔支氣管導管；BBT組插入7.0-7.5ID單腔氣管導管,在纖維支氣管鏡(OLYPUSLF GP,4.0mm日本)引導下,插入一次性支氣管堵塞器于開胸側的支氣管內,兩組均以全憑靜脈維持麻醉。評估記錄以下數據：(1)兩組患者插管前后血流動力學變化；(2)分別抽取兩組患者于麻醉誘導前(T1)、切皮即刻(T2)、單肺通氣60分鐘(T3)、手術結束即刻(T4)四個時間點的動脈血,進行血氣分析,評價兩種方法的氧合情況；(3)兩組患者單肺通氣時的氣道峰壓(peak airway pressures);(4)用酶聯免疫吸附法(ELISA)測定切皮即刻(T2)、單肺通氣60分鐘(T3)、術畢2h(T5)三個時間點血漿血管性假血友病因子(von Willebrand factorvWF)和可溶性細胞間粘附分子(soluble Intercellular adhesion molecule-1sICAM-1)的血漿濃度,評價兩種單肺通氣方法對全身炎性反應的影響;(5)觀察手術開始與手術結束時切取的肺組織的病理改變。 結果與DLT組相比,BBT組插管前后平均動脈壓(mean arterial pressure MAP)和心率(heart rate HR)變化率小(P0.05)；與T2時相比較,兩組患者于T3時Pa02下降、P peak升高,以DLT組變化明顯(P0.05)；兩組血漿vWF水平在T3、T4、T5時升高,sICAM-1水平于T5時升高(P0.05),T5時BBT組vWF和sICAM-1水平低于DLT組(P0.05)；手術開始與手術結束,兩組患者肺組織HE染色病理形態(tài)學比較有變化,以DLT組變化明顯。 結論支氣管堵塞器對單肺通氣肺損傷的保護作用,其機制可能是通過減低單肺通氣時的氣道壓力,減輕了單肺通氣的肺損傷；改善肺內氧合,降低了血漿中的vWF、sICAM-1水平,減輕了因單肺通氣觸發(fā)的全身炎性反應。
[Abstract]:Objective Mechanical ventilation during single lung ventilation can damage pulmonary capillary endothelial cells, increase capillary permeability, infiltrate and activate inflammatory cells, induce inflammatory reaction, and further aggravate lung injury. The purpose of this study was to observe the effects of bronchial occluder and double lumen bronchial catheter on oxygenation and pulmonary capillary endothelial cells in patients with single lung ventilation. To investigate the protective effect of bronchial occluder on lung injury induced by single lung ventilation and its possible mechanism 40 patients with esophageal carcinoma undergoing radical resection of esophageal carcinoma were enrolled in this study. They were randomly divided into two groups: bronchial occluder group (Bronchial blocker tube BBT group) and double lumen bronchus group (Double-lumen bronchial tube DLT group) with 20 cases each. The two groups adopted the same anesthetic induction method. After the induction was successful, the DLT group inserted 35 or 37 double lumen bronchial catheter. In BBT group, 7.0-7.5ID single lumen tracheal catheter was inserted. Under the guidance of OLYPUSLF GP,4.0mm Japan, a disposable bronchial occluder was inserted into the open side of the bronchus. Both groups were treated with total intravenous anesthesia. The following data were recorded: (1) hemodynamic changes before and after intubation in two groups; (2) the arterial blood samples of the two groups were collected before anesthesia induction (T1), immediately after skin incision (T2), 60 minutes after one-lung ventilation (T3), and at the end of operation (T4) for blood gas analysis. To evaluate the oxygenation of the two methods; (3) Airway peak pressure (peak airway pressures);) during one-lung ventilation in two groups (4) (ELISA) was used to determine immediate (T2) skin incision and 60 minutes of one-lung ventilation (T3). Plasma concentrations of plasma von Willebrand factor (von Willebrand factorvWF) and soluble intercellular adhesion molecule (soluble Intercellular adhesion molecule-1sICAM-1) were measured at 2 h after operation (T5) to evaluate the effects of two single lung ventilation methods on systemic inflammatory response. (5) the pathological changes of lung tissue were observed at the beginning and end of operation. Results the mean arterial pressure (mean arterial pressure MAP) and heart rate (heart rate HR) in BBT group were lower than those in DLT group before and after intubation (P0.05). Compared with T2, Pa02 decreased and, P peak increased at T3 in both groups, especially in DLT group (P0.05). Plasma vWF level increased at T3T4T5, sICAM-1 level increased at T5 time (P0.05), vWF and sICAM-1 levels in T5 BBT group were lower than those in DLT group (P0.05). Compared with the end of operation, the pathological changes of HE staining in lung tissue of the two groups were obvious, especially in the DLT group. Conclusion the protective effect of bronchial occluder on lung injury induced by single lung ventilation may be due to the reduction of airway pressure during single lung ventilation. Lung oxygenation was improved, vWF,sICAM-1 levels in plasma were decreased and systemic inflammatory response triggered by single lung ventilation was alleviated.
【學位授予單位】：安徽醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R614

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