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1、Respiratory Support for Tracheal Surgery,prof. Vyzhigina M.A., Titov V.A., prof. Parshin V.D., prof. Rusakov M.A., Aleksander AlekseevSechenov First Moscow State Medical University, Moscow, Russia,High Frequency Jet Ve

2、ntilation 高頻噴射通氣Bypass-Breathing with periods of Apnea 旁路通氣ECMO 體外膜肺Apneic Oxygenation 無通氣氧合,Respiratory Techniques,1944 - Draper – Diffusion respiration 彌散呼吸1956 – Holmdahl – Diffusion oxygenation 彌散氧合1956 – Na

3、has – Apneic oxygenation 無通氣氧合,Background,min,Physiology,Draper W. B., Whitehead R. W. & Spencer, J. N. (1947). Studies on diffusion respirations. III. Alveolar gases and venous blood pH of dogs during diffusion resp

4、iration. Anesthesiology, 8, 524-533.,Hemoglobin – Oxygen Pump,Continuous Insufflation of humidified O2 into distal part of trachea via catheter (Ø 14 Fr. ) FiO2=1, 12 L/min通過導(dǎo)管給氣管遠(yuǎn)端持 續(xù)供應(yīng)濕化的氧氣Duration of AO

5、 from 10 to 40 min (25±12.9 min) according to surgical need 根據(jù)手術(shù)需要實行無通氣氧合,Apneic oxygenation,Apneic oxygenation,,,warming,humidification,,22.02.2014 Patient S. 25 y.o. Circular resection of trachea,,,

6、Endotracheal tube,Catheter,25 patients (from 18 to 58 y.o.) with tracheal stenosis 25例（18歲到58歲）氣管狹窄患者Tracheal reconstructive surgeries氣管重建術(shù): Circular resection of trachea 氣管環(huán)切術(shù)Tracheoplasty 氣管成型術(shù)Tracheoesophageal

7、fistula and double level cicatricial tracheal stenosis repair 氣管食管瘺與氣管瘢痕性狹窄修補術(shù),Patients and Surgeries,Phase of operation before opening lumen of trachea 暴露氣管內(nèi)腔之前- Conventional Ventilation (CV) FiO2=0,5 常規(guī)通氣模式- Hyperox

8、ygenation (5 min before the main phase FiO2=1) 高濃度氧合（主要步驟前5分鐘）Main phase of resection and anastomosis 氣管切除與縫合- Apneic oxygenation 無通氣氧合After anastomosis 氣管吻合后- Conventional Ventilation FiO2=0,5 常規(guī)通氣模式,Modes,Invasive

9、 有創(chuàng)監(jiān)測Radial artery catheterization: Blood pressure and heart rate 橈動脈穿刺置管：血壓與心率Gases of arterial blood - PaO2, PaCO2動脈血氣分析：氧分壓與二氧化碳分壓Acid-base balance of arterial blood - pH, BE 動脈血酸堿平衡分析- Noninvasive 無創(chuàng)監(jiān)測SpO2, E

10、TCO2 血氧飽和度，呼氣末二氧化碳ECG 心電圖,Monitoring,Results,Results (M±?),,Speed of PaCO2 increasing during AO was 2.5 ± 0.5 mmHg per min (min – 1.46, max – 3.1)無通氣氧合模式：動脈血二氧化碳分壓上升速度2.5 ± 0.5 mmHg/分鐘Speed of PaCO2 i

11、ncreasing during apnea is 4 – 5 mmHg per min (Vyzhigina M.A. et all, 2010)窒息模式：動脈血二氧化碳分壓上升速度4± 5mmHg/分鐘,Results,Results (M±?),Conclusions,AO in tracheal surgery is accompanied with a progressively increasing o

12、f hypercapnic acidosis and provides a high level of blood oxygenation無通氣氧合模式在氣管手術(shù)中的應(yīng)用可導(dǎo)致高碳酸性酸中毒和血中氧濃度過高The rate of CO2 accumulation during AO in two less than when using the bypass-breathing二氧化碳蓄積速度比旁路通氣模式每分鐘慢2mmHgAc

13、idosis due to AO does not cause hemodynamic disturbances無通氣氧合引起的酸中毒不會影響血流動力學(xué)Parameters of PaO2, PaCO2 and pH completely reversible in 20 min after reconnection to the CV恢復(fù)常規(guī)通氣模式20分鐘后氧分壓，二氧化碳分壓，和PH值將恢復(fù)正常,AO can be used

14、 as a respiratory technique for reconstructive tracheal surgery無通氣氧合模式可作為一種通氣技術(shù)應(yīng)用于氣管重建術(shù)The choice of respiratory support is determined by the level and type of injury of trachea, the degree of stenosis, characteristics

15、 of the surgical approach and individual of a surgeon通氣模式的選擇與以下因素有關(guān)，氣管損傷的類型和位置，狹窄程度，手術(shù)醫(yī)生的個人習(xí)慣Proper communication between the anesthesiologist and the surgeon ensures patient safety and improves the results of surgical

16、 treatment麻醉醫(yī)生與手術(shù)醫(yī)生之間良好的溝通可以確?；颊甙踩⑻岣咝g(shù)后治愈率,Conclusions,tactics of anaesthesia management during transesophageal balloon dilatation of tracheal stenosis,經(jīng)食道球囊擴張氣管狹窄部位的麻醉策略transesophageal tracheal intubation經(jīng)食道氣管內(nèi)插管and

17、respiratory techniques during the separation of tracheoesophageal fistula and tracheal resection氣管食管瘺氣管切除術(shù)中的隔離通氣技術(shù),Case report,Diagnosis: Tracheoesophageal fistula and double level tracheal stenosis診斷：氣管食管瘺合并兩個氣管環(huán)水平的氣道狹

18、窄After 38 days of conventional mechanical ventilation in the ICU due to acute violation of cerebral circulation腦循環(huán)障礙后在重癥監(jiān)護(hù)室經(jīng)過38天常規(guī)機械通氣治療后形成氣管食管瘺,Patient М., 45 y.o. ASA III,3D-CT,Balloon dilatation with "Inspir

19、a Air",,,,,,One-Lung Apneic Oxygenation,Alekseev A.V., Vyzhigina M.A., Parshin V.D., Fedorov D.S. Apneic oxygenation. Anesteziol Reanimatol. 2013 Sept-Oct;(5):69-74. (Review in Russian)Titov V.A., Parshin V.D., Rus

20、akov M.A., Alekseev A.V., Kozhevnikov V.A. Case report of transesophageal tracheal intubation in patient with tracheoesophageal fistula and cicatricial tracheal stenosis. Anesteziol Reanimatol. 2014 (4):74-77. (in Russia

21、n)Jiménez, M.J. Sadurní, M. Tió, M. Rovira, I. Fita, G. Martínez, E. Gimferrer, J.M. Gomar, C. Macchiarini, P. Apnoeic oxygenation in complex tracheal surgery: O-58. Eur J Anaesthesiol. 2006 May;

22、Vol. 23 – suppl. 38: p. 20.Kolettas AA, Tsaousi GG, Grosomanidis V, Karakoulas KA, Thomareis O, Kotzampassi K, Vasilakos DG. Influence of apneic oxygenation on cardiorespiratory system homeostasis. J Anesth. 2013 Sep 24