.,.,*,呼吸系统疾病术前评估与准备,天津医科大学总医院,王国林,呼吸系统疾病术前评估与准备天津医科大学总医院,1,术前评估,目的:,Identifying patients at,risk for complications,and then attempting to,modify that risk,To decrease perioperative respiratory complication,1.,术前评估,2.术前准备,3.麻醉处理,4.术后处理,术前评估目的:,2,内容,1.,肺部并发症的危险因素,2.,术前评估,3.术前准备,4.,麻醉对呼吸系统的影响,内容1.肺部并发症的危险因素,3,危险因素,Pulmonary complications:,Important form of postoperative morbidity,after major,cardiothoracic,and,abdominal,operations,术后呼吸系统并发症:,大手术可达：25 50%,危险因素Pulmonary complications:,4,危险因素,1.,术前状态,2.,手术部位,3.急诊手术,危险因素,5,术前状态,术前存在呼吸系统疾病、吸烟、肥胖、老龄,慢性肺部疾患:,most significant patient-related risk for post,operative pulmonary complications,Distinguishing patients with lung disease,:,important step in identifying the risk of postoperative pulmonary complications,术前状态术前存在呼吸系统疾病、吸烟、肥胖、老龄,6,COPD,和哮喘,Postsurgical pulmonary complications:,26,78%,Increased risk of morbidity:,麻醉、手术时有症状,Surgery performed when symptom free or,improved,COPD 和哮喘Postsurgical pulmonary,7,手术部位,Pulmonary complications,upper abdominal,and,thoracic operations,:,20,70%,泌尿或骨科手术:4%,腹腔镜技术,可减少呼吸合并症:,less pain and less disruption of abdominal,and diaphragmatic muscle activity,术后恢复更快,手术部位,8,FVC,降低,上腹部和胸部手术:,降低FVC 60%,7-10,天才能恢复正常,下腹部手术:,降低 FVC,40,FVC降低,9,围术期呼吸系统合并症的临床研究,围术期呼吸系统合并症的临床研究,10,危险因素,Variable Description Relative odds,病人因素,年龄,80yrs&2 hrs&70y,肥胖,FVC,80,预计值,FEF,（用力呼吸流量）,60%,的预计值,晶体液输入,6 L,手术时间,5,小时,主要呼吸危险因素ASA IV级,13,PFTs与呼吸并发症,Pathologic preoperative PFTS:,FVC of 50%of normal,Forced expiratory volume(FEV,1,)50 mmHg,呼吸并发症:28.1%,而术前PFTS 正常的病人，呼吸并发症为7.9%,PFTs与呼吸并发症Pathologic preoperat,14,麻醉因素,麻醉时间,麻醉技术:,regional vs general anesthesia,术后镇痛,Anesthetic agents with,shorter elimination half-lives,麻醉因素麻醉时间,15,对,PPC,危险因素的调整,延期手术,改变麻醉方法,药物治疗,病人教育(如戒烟、减肥、呼吸锻炼),对PPC危险因素的调整延期手术,16,延迟手术,Urgency of the proposed operation,Surgical site,Type of operation planned,Fitness of the patient:,type of pulmonary disease,elderly patients,延迟手术Urgency of the proposed op,17,术前评估,1.,病史及体格检查,2.实验室,胸片,ABGA,肺功能试验,术前评估,18,病史及体检,最便宜,为进一步仪器检查打基础,Opportunity to consolidate information about the patient and the planned operation,Modifying risks in special populations of patients with lung disease,explained simple maneuvers directly to the patient,病史及体检最便宜,19,关于肺部疾患的问诊,您是否得过肺炎?何时?,是否施行过肺手术?,有无呼吸困难、喘鸣、胸痛、支气管炎、哮喘或 肺气肿?,是否经常咳嗽、频率(痰)?,过去,4,周中有无发热、寒战、感冒？,是否抽烟?何时戒烟?,关于肺部疾患的问诊您是否得过肺炎?何时?,20,实验室检查及胸片,Chest radiographs(Just as pulmonary function tests):,Rarely abnormal in patients without risk factors for lung disease,Rarely reveal anything that might change decision to perform an operation in patients without other risk factors.,实验室检查及胸片 Chest radiographs(Ju,21,胸片,可能发现新的的病变,Patients believed to be at high risk for pulmonary complications.,胸片,22,实验室检查及动脉血气,Most important factor of respiratory care,PaO,2,:,溶解氧的张力,不反映组织氧合状态,PaCO,2,:,反映肺泡通气状况,Normal pH with PaCO,2,change or,pH change accompanied PaCO,2,change,反映心肺内稳态状况,实验室检查及动脉血气Most important facto,23,实验室检查及动脉血气,动脉血气:,Indicated in patients with lung disease prior to,surgery for two reasons,1,),二氧化碳分压增高:,术后呼吸并发症增加,2),COPD,合并二氧化碳分压增加:,不管何种手术因素，其生存期缩短,实验室检查及动脉血气动脉血气:,24,动脉血气加肺功能,适用于:,病人有呼吸困难和吸烟史,上腹部或冠脉搭桥术,动脉血气加肺功能适用于:,25,PFT,目标:,Altering their outcome by reducing the risk of postoperative ventilatory impairment and other respiratory complications,两大类:,1.,气体交换异常,2.由于肺或胸壁的原因所致通气功能异常,PFT目标:,26,Flow Volume Loop,Flow Volume Loop,27,Flow Volume Loop with,Differing Efforts,Flow Volume Loop with Differin,28,Change of Peak Flow with,Different Lung Volume,Change of Peak Flow with Diff,29,PFT,能预期肺部并发症:不同程度,No more sensitive as indicators of occult pulmonary disease than information gathered from a careful history and physical examination,对个体预后判断价值较小,PFT能预期肺部并发症:不同程度,30,PFT,正常健康者:,75 80 FVC 在第一秒内呼出;其余在,2,、,3,秒内呼出,FEV,1,/FVC:,70%:,轻度梗阻,60%:中度梗阻,50%:严重梗阻,PFT正常健康者:,31,PFT,PEFR,（最大呼气流速）:,依赖病人力量,大气道梗阻,对支气管扩张药的反应,FEF,25,-75%,:,不依赖病人肌力,反映远端小气道梗阻,PFTPEFR（最大呼气流速）:,32,COPD,时的,PFT,COPD,病人术后并发症可达 26 78%,评估疾病严重程度，促使干预措施应用,鉴别术后病死率较高的病人,但并不能否定（拒绝）手术,COPD时的PFT,33,异常PFT的解释:,1.,任何慢性肺部疾患,2.抽烟严重、连续咳嗽,3.劳累后喘息或呼吸困难,4.胸壁或脊柱畸形,5.肥胖,6.胸部手术,7.上腹部手术,8.老年病人(70 以上),异常PFT的解释:1.任何慢性肺部疾患,34,PFT,FVC FEV1 FEV,1,/FVC(%),限制性疾病 下降,下降,正常,梗阻性疾病,正常,降低,降低,PFT FVC,35,限制性通气障碍的常见原因,间质性肺疾患:,肺炎、纤维化、肺水肿,占位性病变,胸膜疾患:,气胸、血胸、胸膜渗出,胸壁疾患:,脊柱后侧凸、脊椎炎,胸外疾患:,肥胖、腹水、妊娠,限制性通气障碍的常见原因间质性肺疾患:,36,梗阻性疾患常见原因,上呼吸道:,异物、肿瘤、狭窄、水肿,中心或外周气道:,支气管炎、支气管扩张、哮喘,实质性病变:,肺气肿,梗阻性疾患常见原因上呼吸道:,37,术前准备,1.,伴有支气管痉挛的炎性疾病,Increased bronchial hyperresponsiveness,by inflammation of airways,Corticosteroids with asthma&COPD,2.近期感染,近期URI:有支气管或喉痉挛危险,约需几周恢复至正常反应性,有脓痰者应给予抗生素,术前准备1.伴有支气管痉挛的炎性疾病,38,术前准备,3.,戒烟,至少,2,个月,4.术前教育,痰浓、多，咳嗽差病人,物理治疗,深呼吸锻炼、拍背,体位引流、IPPB、and incentive,spirometry,术前准备3.戒烟,39,术前准备,5.,药物:,a.皮质激素,b.吸入 Beta-2 激动剂,c.抗胆碱药,d.氨茶碱,e.抗生素,6.需要延迟手术者:伴分泌物多的咳嗽,合并 URI婴幼儿,术前准备5.药物:,40,麻醉药的呼吸影响,使,FRC,减少,减少,TV,、分钟通气量和 肺泡通气,增加通气,/,血流比例失调,降低缺氧和二氧化碳增加的呼吸驱动,咽肌张力降低所致的呼吸道梗阻,麻醉药的呼吸影响使FRC减少,41,结论,1.,术前评估、术前准备:,preoperative consultation to pulmonologist,optimal medical management,2.,很好的麻醉计划与实施,3.适当术后处理,结论1.术前评估、术前准备:,42,