高危慢性阻塞性肺病病人的围手术期处理  

Perioperative Management of Patients with COPD at High Risk of Postoperative Pulmonary Complications

作　　者：朱小平[1] 薛张纲[1] 蒋豪[1] 

机构地区：[1]上海医科大学附属中山医院麻醉科,200032

出　　处：《临床麻醉学杂志》2000年第6期269-272,共4页Journal of Clinical Anesthesiology

摘　　要：目的 :探讨高危慢阻肺 (COPD)病人的围手术期处理。方法 :择期进行上腹部和胸腔内手术病人 16例 ,均患有严重的慢阻肺 ,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例病人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。部分病人间断采用NPPV进行呼吸支持。结果 :16例病人术前平均MVV占预计值 40 3 %± 9 0 % ,平均RV/TLC为 6 2 7%± 3 8% ,平均FEV1为 0 80± 0 2 0L ,平均FEV1/FVC为 39 5 %± 6 4%。 6例病人经术前支气管扩张药物治疗和呼吸功能锻炼后 ,FEF2 5%～ 75% 从 0 4± 0 2L/s增至 0 9± 0 3L/s(P <0 0 5 ) ,FEV1从 0 74± 0 30L增至 1 0 2± 0 40L(P <0 0 5 )。术后有 5例 (31 3 % )行纤维支气管镜吸痰 ;6例 (37 5 % )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 ,以后逐渐恢复。 6例术后早期即给予口鼻面罩NPPV支持。所有病人术后痊愈出院。结论 :术前呼吸功能减退的COPD病人并非外科手术的绝对禁忌证。术前锻炼和围手术期NPPV支持有助?Objective:To present the experiences in the perioperative management of high risk COPD patients.Methods:Sixteen COPD patients scheduled for elective upper abdominal or thoracic operations were enrolled.Preoperative treatment included smoking cessation,control of infection,appropriate bronchodilators,chest physiotherapy and breathing exercises.Six patients received preoperative NPPV training.Operations were accomplished with epidural block combined with general anesthesia.All patients were closely monitored and cared perioperatively,together with NPPV for severe cases and patient controlled epidural analgesia.Results:The percentage of predicted value of mean MVV(MVV%),mean RV/TLC ratio,mean FEV 1 and mean FEV 1/FVC ratio were 40 3%±9 0%,62 7%±3 8%,0 80±0 20L and 39 5%±6 4% respectively.In six patients with bronchodiltors administration and chest exercise,FEF 25% 75% and FEV 1 significantly increased from 0 4±0 2L/s to 0 90±0 3L/s and 0 74±0 30L to 1 02±0 40L( P< 0 05) respectively.After surgery,five patients(31 3%) had mucus plug requiring bronchoscopic suctioning.Bronchospasm occurred in six patients(37 5%) and resolved after inhalation of bronchodilator and intravenous administration of corticosteroid.PaO 2 significantly decreased especially in the postoperative 2 to 3 days from 67 0±6 2mmHg to 54 8±35mmHg( P< 0 05),and increased gradually afterwards.All patients recovered rather smoothly and discharged from hospital.Conclusions:Severe COPD is not the absolute contraindication of surgery.Preoperative chest exercise is conducive to maintenance and recovery of postoperative respiratory function.It is necessary to initiate NPPV training perioperatively in patients with high risk of postoperative pulmonary complications.

关 键 词：围手术期 无创正压通气 慢性阻塞性肺疾病 

分 类 号：R730.56[医药卫生—肿瘤]