COPD围术期处理

,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,COPD病人的围术期处理,复旦大学附属中山医院,缪长虹,COPD? gold,G,lobal initiative for chronic,O,bstructive,L,ung,D,isease,United States,United Kingdom,Argentina,Australia,Brazil,Austria,Canada,Canada,Chile,Belgium,China,Denmark,Columbia,Costa Rica,Croatia,Egypt,France,Germany,Greece,Ireland,Italy,Guatemala,Hong Kong China,Japan,Iceland,India,Korea,Kyrgyzstan,Latvia,Lithuania,Mexico,Moldova,Nepal,Macedonia,Malta,Netherlands,New Zealand,Poland,Norway,Portugal,Republic of Georgia,Romania,Russia,Singapore,Slovakia,Slovenia,Saudi Arabia,South Africa,Tatarstan Republic,Spain,Sweden,Thailand,Turkey,Switzerland,Ukraine,United Arab Emirates,Taiwan ROC,Venezuela,Vietnam,Peru,Yugoslavia,Albania,Bangladesh,COPD?,GOLD,“a preventable and treatable disease state characterized by,airflow limitation,that is,not fully reversible.”,- usually progressive- abnormal lung inflammatory response to noxious particles or gases- defined by history plus Spirometry,COPD?,不完全性可逆气流受限,可逆的部分,支气管内炎性细胞、粘液和血浆渗出物的积聚,外周和中央气道平滑肌的收缩,运动状态下气道的过度充气,不可逆的部分,气道的纤维化与狭窄,保持小气道开放的肺泡支撑作用消失,肺泡结构破坏,Leading Causes of DeathsU.S. 2001,All other causes of death,469,314,10.,Septicemia32,275,9.,Nephritis26,295,8.,Alzheimers disease53,679,7.,Pneumonia and influenza 62,123,6.,Diabetes71,252,5.,Accidents97,707,4.,Respiratory Diseases (COPD) 123,974,3.,Cerebrovascular disease (stroke)163,601,2.,Cancer 553,251,1.,Cause of Death Number,Heart Disease 699,697,Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998,0,0.5,1.0,1.5,2.0,2.5,3.0,Proportion of 1965 Rate,1965 - 1998,1965 - 1998,1965 - 1998,1965 - 1998,1965 - 1998,59%,64%,35%,+163%,7%,Coronary,Heart,Disease,Stroke,Other CVD,COPD,All Other,Causes,Source: NHLBI/NIH/DHHS,COPD Age-Adjusted Death Rate, U.S.,by year and sex (CDC, DHHS),Age-Adjusted Death Rates for COPD, U.S., 1960-1998,60,Deaths per 100,000,1960,1965,1970,2000,1975,1980,1985,1990,1995,50,40,30,20,10,0,Ischemic heart disease,Cerebrovascular disease,Lower resp infection,Diarrheal disease,Perinatal disorders,COPD,Tuberculosis,Measles,Road traffic accidents,Lung cancer,Stomach Cancer,HIV,Suicide,6th,3rd,Murray & Lopez. Lancet 1997,Future Mortality Worldwide,1990,2020,病 因,有害颗粒,气体,吸烟,职业暴露,空气污染,Chronic Obstructive Pulmonary Disease (COPD),Slide 13.43,Copyright 2003 Pearson Education, Inc. publishing as Benjamin Cummings,Figure 13.13,症 状,慢性咳嗽,慢性咳痰,呼吸困难,有害颗粒与气体接触史,吸烟,职业暴露,室内/室外污染,肺功能测试,COPD的诊断,严重程度分级,Stage Characteristics,0: At risk,Normal spirometry,Chronic symptoms (cough, sputum),I: Mild,FEV,1,/FVC 70%; FEV,1,80% predicted With or without chronic symptoms (cough, sputum),II: Moderate,FEV,1,/FVC 70%; 50%,FEV,1, 80% predicted,With or without chronic symptoms (cough, sputum,dyspnea),III: Severe,FEV,1,/FVC 70%; 30%,FEV,1, 50% predicted,With or without chronic symptoms (cough, sputum,dyspnea),IV: Very Severe,FEV,1,/FVC 70%; FEV,1, 30% predicted or FEV,1,0.8L),PaCO,2,45,mmHg,按照现有的临床标准来筛选病人，可能使相当一部分手术指征强烈，尚具备手术条件的患者失去最佳治疗机会,COPD的术前评估,FEV1 指标,男，46y,体重:72kg,食道中段MT,肺功能,最大通气量占预计值：31.5%,RV/TLC ：61%,FEV1:33.4%(FEV1.0:940ml),FEV2:54%,FEV3:59%,血气分析,PH: 7.48,PaO2: 74mmHg,PaCO2:47mmHg,COPD的术前评估,运动试验,登四层楼梯,等楼前后血气变化,pH: 7.46 7.45,PaCO2:47mmHg 49mmHg,PO2: 74mmHg 72mmHg,COPD的术前评估,肺功能减损手术（肺）,单一的FEV1测试不能体现COPD,复杂的临床状态,三 条腿评估体系,病人的生活质量,综合评价：BODE计分,COPD的术前评估,“三 条腿”评估系统,COPD的术前评估,心肺储备功能,肺实质功能,呼吸动力学,COPD的术前评估,最大氧消耗(,VO,2,),当患者运动达到极限时，其氧耗量VO,2,不再随功率的上升而发生改变，此时的VO,2,称为VO,2max,临床上考虑到安全因素，只让患者作亚极量运动，运动终止时的VO,2,称VO,2,peak,VO,2,peak,20mL/kg/min,中危 = VO,2,max 15 20mL/kg/min,高危 = VO,2,max 1 英里,运动过程中SpO2下降 15 mL/kg/min,COPD的术前评估,医院有条件,VO,2,max 15 mL/kg/min,VO,2,peak10ml/kg/min,VO,2,peak10ml/kg/min,内科治疗,通气灌流扫描,病变肺V/Q失调，剩余肺V/Q正常,病变肺V/Q情况优于剩余肺,12周的术前准备,手术,ICU,经过严密监护和积极治疗看是否出现围术期死亡，以验证CPX在用于此类患者手术指征判定的可行性,筛选出PPCs和NPPCs患者存在显著差异的静态肺功能指标和运动试验指标，对PPCs的发生作Logistic回归，进一步发现可独立预示PPCs的发生的指标,技术路线,COPD的术前评估,日常活动明显受限,严重的不可逆性气道梗阻：,15%FEV1 100%,预计值,& RV 150%,预计值,所有的内科治疗失败,LVRS,COPD的术前评估,LVRS的高危指标,肺功能极差：FEV1 20% 预计值,两侧均匀性的肺气肿,D,L,CO,2,: 20% 预计值,非上叶气肿,30天-死亡率 16%,COPD的术前评估,对COPD严重程度的评估，BODE评分,B(BMI): severe malnutrition 70% (BMI 130%,O(obstruction): FEV1/FVC70%;50%;30%,D(dyspnea): 0,1,2,3,4,5,E(exercise): 6-minute walk distance 300m,COPD 的术前准备,标准的内科治疗,体能锻练,肺功能锻练,适应性无创正压面罩通气,COPD 的术前准备,stage0:at risk,特 点 推 荐 治 疗,慢性症状,-,咳嗽,-,咳痰,肺功能侧试无异常,COPD 的术前准备,stage,:mild COPD,特 点 推 荐 治 疗,FEV,1,/FVC ,80 %,预计值,有或无慢性症状,需要短效的气管扩张剂治疗,COPD 的术前准备,stage,: moderate COPD,特 点 推 荐 治 疗,FEV,1,/FVC 70%,50%,FEV,1, 80%,预计值,有或无慢性症状,短效的支气管扩张剂,有规律进行一种或一种以上长效的支气管扩张剂治疗,康复治疗,COPD 的术前准备,stage,: severe COPD,特 点 推荐,FEV,1,/FVC 70%,30%,FEV,1, 50%,预计值,有或无症状,短效支气管扩张剂,有规律进行一种或一种以上长效的支气管扩张剂治疗,病情加重恶化时吸入糖皮质激素,康复治疗,COPD 的术前准备,stage,V,: very severe COPD,特 点 推 荐 治 疗,FEV,1,/FVC 70%,FEV,1, 30%,预计值,或,FEV,1, 50%,预计值伴慢性呼衰,短效支气管扩张剂,有规律进行一种或一种以上长效的支气管扩张剂治疗,病情加重恶化时吸入糖皮质激素,康复治疗,治疗并发症,如有呼衰时长期氧疗,外科治疗,COPD 的术前准备,是否需要抗凝药(个人观点）,COPD尸检肺栓塞发生率2050%,严重者有长期慢性低氧病史,红细胞增多，血粘度增高,内源性PEEPi形成，静脉回流受影响,活动受限,右心功能障碍,术,前体能准备：鼓励患者每日登楼4层以上，并以症状自限,肺功能锻练：采用激励型肺量仪（Incentive Spirometer）训练深慢呼吸,适应性无创正压面罩通气：术前3天，让患者在ICU进行无创正压面罩通气训练，通气模式采用压力支持模式（PSV）每天12小时,COPD的术前准备,麻醉选择：硬膜外复合全麻，硬膜外穿刺点选择T6-7或T5-6（BJC:T4), (,Ann Surg 2006,243(1):131,),诱导:地塞米松、长托宁、芬太尼（0.1mg)丙泊酚（TCI)罗库溴铵（琥珀酰胆碱）方案,维持：采用异氟醚/七氟醚吸入/TCI维库溴铵+硬膜外间断给予0.250.375%布比卡因,根据手术需要采用双腔管（Robertshaw）或单腔管维持气道,术后均采用硬膜外自控镇痛,COPD的术中处理,COPD的术中处理,选用硬膜外的理由,通气方式及策略,允许性高碳酸血症,拔气管导管的时机,LT,COPD的术中处理,选用硬膜外的理由,Preserved ability to cough and clear secretions,Decrease airway resistance,Improve phrenic nerve function,Stabilization of coronary ET function,Improve myocardial perfusion,Earlier return of bowel function,Preservation of immunocompetence,Decreased cost of perioperation care through reduction of perioperative complication,COPD的术中处理,通气方式及策略,控制气道压40cmH,2,O,I/R ratio was set 1:2-4.5,避免小气道的陷闭和肺过度充气,合理选用PEEP（选择7585%的PEEPi),单肺通气时：CPAP/PEEP,潮气量和气道压之间难取舍时，牺牲潮气量,小潮气量,允许性高碳酸血症,COPD的术中处理,允许性高碳酸血症,允许多少(168mmHg),男，67岁，2001-9-15，LVRS,时间,PH,PCO2,PO2,13：19,7.197,69.5,96,14：04,7.253,60.9,92,15：48,7.289,57.3,94,16：22,7.195,69.1,92,16：46,7.256,56.4,92,17：00,7.259,62.7,127,17：17,7.263,62.4,138,17：43,7.325,59.1,64,19：16,7.364,51.3,62,COPD的术中处理,女，68岁，37kg,2004-9-21,单肺移植(EPI+GA),时间,PH,7.401,PCO2,PO2,85,入室,47,85,双肺通气,7.096,103,109,单肺通气,7.042,118,66,单肺通气,7.027,115,64,吻合气管,7.021,115,66,开放再灌,7.09,78.9,85,术后1h,7.07,84,111,术后5h,7.12,76,123,脱机后30,7.37,44,98,COPD的术中处理,拔管的时机,早拔管还是晚拔管好,什么时候拔管,23名患者手术结束拔管,PaO2/FiaO2 : 17934mmHg,PaCO2: 59 11mmHg,(Minerva Anestesiol,2001 ;67(5):371-80),有标准吗？,COPD的术中处理,COPD的术中处理,肺移植,COPD的术中处理,肺移植术中关键,术中是否要用 CPB,术前判断,钳夹肺动脉时情况,CPB,Bleeding,Heparin/protamine reaction,Oxygenation,Pulmonary infiltrate,Prolonged intubation,Long-term surviral?,COPD的术中处理,术前预测指标,300m/6min,A treadmill(1 mph and 4%gradient),saO285%,FiO2:5L/min during exercise.,RVEF27%,COPD的术中处理,术中应用CPB判断标准,多伦多 MGH,MAP5060mmHg SaO290%,SaO285% CI3.0L/min/m2,SvO260% SBP90mmHg,pH7.1,CI肋间神经阻滞硬膜外阻滞,合并应用NSAIDS，对肺功能有保护作用,COPD的术后处理,氧疗,定期的气道湿化，采用糜蛋白酶沐舒坦地塞米松 雾化吸入4次/日,气道解痉治疗：必可酮（糖皮质激素）、鲨丁胺醇（,2,受体激动剂）、异丙托品（M受体阻断剂），定期及按需喷雾吸入,鼓励患者取坐位，用激励型肺量仪作深呼吸运动及定期自主咳嗽,NPPV,通气支持：人工气道采用无创加压面罩（中山医院科技开发公司研制）或鼻罩,