这项工作得到了第三批宁波市卫生青年技术干部计划（朱彬斌博士）和浙江省医学会临床研究基金项目（高斌博士）（2018ZYC-A66）的支持。

该研究于2018年12月10日获得宁波大学医学院附属医院伦理委员会（KY20181215）的批准。
1. 入选标准
<ol><li>包括所有接受肺大疱切除术、肺楔形切除术或肺叶切除术的患者（>18 岁）。</li>
</ol>2. 排除标准
<ol><li>根据美国麻醉医师协会 （ASA） 的躯体状态分类 >315 排除患者。</li>
	<li>排除体重指数 （BMI） 16 >30 kg/m2.</li>
	<li>排除食管癌、全肺切除术和切除肋骨的心脏直视手术患者。</li>
	<li>排除既往有支气管扩张症、肺破坏或慢性阻塞性肺病 （COPD） 病史的患者。</li>
	<li>术前排除有明确多发性肺部感染或炎症的患者，以及其他严重的全身性疾病。</li>
	<li>排除凝血障碍和严重精神或神经系统疾病患者。</li>
</ol>3.麻醉前的准备
<ol><li>手术前禁食患者8小时。</li>
	<li>将操作室温度调整为24°C至26°C之间。</li>
	<li>将 20 G 顶翼输液针插入手部的非手术背静脉。</li>
	<li>监测患者的心电图、血压、脉搏血氧饱和度 （SpO2） 和呼吸频率。</li>
	<li>将双光谱指数 （BIS） 四分传感器应用于每位患者的前额。 注意:如有必要，持续监测桡动脉压和中心静脉压。</li>
</ol>4.超声引导下胸椎旁阻滞
<ol><li>将患者置于侧卧位。</li>
	<li>将超声探头直接放置在第三胸椎和第七胸椎的棘突上方，并获得棘突的横截面图像。 注意:图像中间是具有后声阴影的高回声棘突，棘突两侧具有后声阴影的骨结构依次是椎板和横向突。</li>
	<li>横向移动超声探头以显示整个横向过程。</li>
	<li>向外移动超声探头以可视化横向过程、横向肋关节和肋骨。</li>
	<li>向尾部移动超声探头，直到在图像中检测到横突、胸膜和它们之间的胸椎旁间隙。</li>
	<li>通过注射 2 mL 的 1% 利多卡因局部麻醉皮肤。</li>
	<li>在超声引导下，用面内入路将块针从外侧插入到内侧。</li>
	<li>注射前小心增加抽吸。确保没有观察到血液反流。 注意:此步骤的目的是防止局部麻醉剂的全身毒性。</li>
	<li>注射2mL生理盐水，然后用超声观察胸膜的前移和胸椎旁间隙的增宽。</li>
	<li>以T3和T7水平注射15mL的0.375%罗哌卡因。</li>
</ol>5.麻醉诱导
<ol><li>将 1% 左旋布比卡因 （3 mL） 喷洒在喉咙上。</li>
	<li>注射1.5微克/千克芬太尼和1-1.5毫克/千克丙泊酚。</li>
	<li>对于持续供氧，放置面罩或插入喉罩气道（双管面罩;#3用于30-50公斤，#4用于50-70公斤，#5用于70-100公斤）。氧气通过面罩或喉罩 进入 患者的气道。 注意:调整注射剂量以达到40-6016之间的BIS值。</li>
</ol>6. 麻醉的维持
<ol><li>保持0.5-1升/分钟的氧气流速。</li>
	<li>人工气胸后将七氟醚的浓度维持在1.5%-2.0%。 注意:如果术中自主呼吸频率高于20次/分钟或出现纵隔扑动或咳嗽，则注射0.5μg/ kg芬太尼。七氟醚通过面罩或喉罩 进入 患者的气道。</li>
	<li>监测吸入氧浓度和潮气末二氧化碳 （ETCO2 < 60 mmHg）。</li>
	<li>监测体温。监测意识水平，并保持BIS值为40-6016,17。</li>
	<li>如果患者出现窦性心动过缓（HR ≤ 50 次/分钟），则注射 20μg/kg 阿托品。</li>
	<li>如果收缩压低于 30% 或 90 mmHg，则使用输液泵连续灌注 2 μg/kg/h 去甲肾上腺素。</li>
	<li>手术结束前15分钟进行动脉血气分析。</li>
	<li>手术结束前30分钟注射1mg / kg氟比洛芬。</li>
</ol>7.胸腔镜迷走神经阻滞技术与胸膜浸润麻醉
<ol><li>进行右侧手术时，使用 24 G 顶翼输液针在下气管水平的迷走神经附近产生 0.375% 罗哌卡因 （3 mL） 的浸润。</li>
	<li>进行左侧手术时，使用 24 G 顶翼输液针在迷走神经附近主肺窗水平产生 0.5% 罗哌卡因 （3 mL） 的浸润。</li>
	<li>使用 10 mL 注射器将 10 mL 2% 利多卡因喷洒到内脏胸膜表面。</li>
</ol>8.从非插管麻醉转为插管全身麻醉
<ol><li>如果患者满足以下条件之一，则将非插管麻醉转换为插管全身麻醉: -严重低氧血症（脉搏血氧饱和度<80%） -严重高碳酸血症（PaCO2 > 80 mmHg） -血流动力学不稳定:顽固性心律失常和右心室衰竭 -持续咳嗽导致手术变得困难或不可能 -术中出血需要开胸术</li>
</ol>9. 术后护理
<ol><li>完全清醒后，要求患者深呼吸并咳嗽以重新扩张塌陷的肺。</li>
	<li>将患者控制的静脉镇痛 （PCA） 泵连接到静脉导管，并在 PCA 储液袋中加入 100 mL 溶液（含有 1 μg/kg 舒芬太尼和 0.9% 氯化钠注射液），并滴定 2 mL/h 的 PCA 溶液。</li>
	<li>当咳嗽时无漏气，胸部 X 线检查无明显液体气胸，24 小时引流 <300 mL 时，应取出胸腔引流管。</li>
</ol>

保留自主呼吸的视频辅助胸腔镜手术的非插管方案

作者没有什么可透露的。

该方案的优点如下:（i）提供七氟醚吸入麻醉方案以减少胸腔镜手术期间的咳嗽反射;（ii） 尽量减少过度镇静，同时为接受胸外科手术的患者提供安全无痛的手术环境;（iii）尽量减少患者在手术过程中的自主呼吸和纵隔振荡，同时考虑到相关的技术挑战。这是通过提供先发制人的术中局部麻醉来实现的。
2004年，蓬佩奥等首次报道了胸腔镜肺结节切除术的完成，无需气管插管，保留了自主呼吸麻醉19。保留自主呼吸的非插管麻醉也成为近年来胸腔麻醉领域的研究热点。与传统气管插管相比，该技术避免了插管引起的气道损伤的可能性，并更好地保留了气管内和支气管粘膜上皮睫状体清除。它还减少了术中麻醉量，避免了肌肉松弛剂20,21的残留作用，并降低了术后缺氧的风险22。此外，与插管相比，喉罩具有较低的咽部和喉部损伤风险，较低的侵入性，并且更容易插入23,24,25。另一方面，与面罩相比，使用喉罩可以更好地确保呼吸稳定26。喉罩缓解了上气道的阻塞并防止了过度换气，从而更好地维持了呼吸稳定性26,27。然而，喉罩可将食管下括约肌的张力降低 15%，从而增加胃反流的风险28.有证据表明，NIVATS 对术后防御机制的影响较小，例如炎症细胞因子或淋巴细胞反应29,30 和血液应激激素水平 31，这可能有助于降低这种方法术后呼吸系统并发症的发生率。
在NIVATS肺部操作期间，咳嗽反射和意外的肺部运动是不可避免的32.咳嗽是由支配气道的机械和化学敏感的迷走神经传入神经的激活引起的。目前和可用的咳嗽抑制技术包括迷走神经阻滞和静脉或雾化局部麻醉剂16,33。然而，后两者不如直接迷走神经阻滞有效。此外，神经阻滞具有局部麻醉、神经损伤或误吸的全身毒性风险34,35,36。近年来，七氟醚麻醉引起了我们的注意。七氟醚麻醉抑制肺刺激性受体并减弱咳嗽反射37。吸入高浓度七氟醚削弱由气道机械刺激引起的支气管收缩反射，并抑制支气管平滑肌的多个离子通道38,39。
这项观察研究的结果表明，NIVATS缩短了胸腔引流的持续时间，减少了失血，减少了PPC。 Hung等人发现，非插管组的患者可以在40之前切除胸腔引流管。机械通气对肺部造成压力相关的损伤，引起肺过度伸展，并促进各种促炎介质的释放41。一项荟萃分析42得出结论，与非插管胸腔镜手术相比，炎症细胞因子水平降低、淋巴细胞活性损伤减少和应激反应减少是术后并发症（如气胸）减少的原因29,31,40。此外，非插管手术对患者的正常呼吸生理机能只有轻微影响，患者恢复得更快19。
Hung等招募了238名肺癌患者接受非插管胸腔镜肺叶切除术，研究发现非插管组40名失血较少。非插管组术中失血量较低可能有两个原因:（i）非插管组43的镇痛效果可能更好，从而稳定控制术中血压，从而减少术中出血;（ii）根据我们的观察，未插管组肺塌陷状态较好，外科医生能够更快地识别关键解剖区域并快速完成手术，因此使用该技术的失血量可能相对较少。
此外，我们的研究还发现，与气管插管麻醉相比，非插管麻醉缩短了手术时间，减少了住院时间，减少了患者在PACU的时间，并降低了患者术后转移到ICU的可能性。与Wu等人44相似，非插管组的麻醉诱导时间较短。一项荟萃分析还发现，非插管组的手术时间比插管组短42。与全世界的插管手术相比，非插管的持续时间更短，这可以解释为局部麻醉下的非插管手术不需要气管插管和随后的支气管镜检查42。
研究还表明，与插管手术相比，非插管手术可显着减少住院时间30,45。众所周知，全身麻醉需要使用肌肉松弛剂和静脉镇痛药等药物。它们与重要的术后并发症有关，这会降低患者的舒适度，增加术后镇痛的需求，并延长术后住院时间14,46。Bevilacqua Filho等人发现，术后肺部并发症与长期住院的患病率增加有关47。在我们的研究中，非插管组患者的PPC少于GA组，我们认为这是非插管组住院时间较短的原因之一。
在非插管组中观察到的相对良好的结果可能部分是由于对这些非插管患者的回顾性评估而偏倚的。事实上，这是一项来自单个中心的回顾性研究，因此我们承认存在一些局限性。由于这项研究的回顾性，没有随机化，也没有消除选择偏倚。为了解决这个问题，我们的目标是在未来设计一项随机比较研究，以阐明这种非插管视频辅助胸腔镜手术的安全性和益处。小样本量也是本研究的主要限制。随着外科医生和麻醉师精通NIVATS，该技术可能更常用于不想全身麻醉和气管插管的患者的手术。
NIVATS 的方案基于多模式镇痛，包括超声引导下胸椎旁阻滞、胸腔镜迷走神经阻滞和胸膜浸润麻醉。多模式镇痛可有效缓解术中疼痛，抑制咳嗽反射。此外，将镇静水平设置为达到 40 至 60 的双光谱指数值至关重要。最后，重要的是在摆动姿势时始终注意患者喉罩气道的对齐。
该技术有一些局限性。该手术不适用于特定患者群体，例如肺功能严重受损的患者和广泛胸膜粘连、持续缺氧或出血需要转为开放胸部的患者。该技术的具体纳入标准和禁忌症尚不明确。需要进一步的方案来设定从非插管局部麻醉到插管全身麻醉的转换的适当标准42.

近十年来，非插管视频辅助胸外科（NIVATS）麻醉逐渐被临床实践所接受1,2,3。尽管这种新策略提高了患者的快速恢复，并避免了全身麻醉（GA）和单肺通气的并发症4，但许多外科医生认为这种方法不如传统的肺隔离技术理想。
血氧水平随着年龄的增长而下降，一些患者可能出现肺功能下降或接近肺功能。GA 可能与此类患者并发症风险增加有关，包括麻醉延迟出现、气道并发症、声音嘶哑、缺氧和样肛脱位 5,6,7,8,9。相比之下，多项研究记录了接受NIVATS治疗的患者住院时间缩短，低风险患者与全身麻醉相比，呼吸系统并发症减少10;此外，甚至在肺功能非常差的高危患者中也报道了成功的手术11,12,13。
手术期间的自主通气是通过仔细施用的局部麻醉或辅以镇静剂的区域神经阻滞来实现的，但在NIVATS期间，咳嗽反射伴意外的肺运动可能会出现问题。对于可能干扰外科手术的纵隔扑动、刺激性咳嗽或呼吸急促，很少强调也没有标准治疗方法。初步观察结果显示，七氟醚在保持自主呼吸的同时，可降低NIVATS期间的呼吸频率和纵隔扑动的发生14。因此，可以假设七氟醚吸入可以预防咳嗽并减少机械通气的需求，从而减少术后肺部并发症（PPCs）。
首先，本报告提供了一个分步方案，详细说明了非插管视频辅助胸腔镜手术的执行。其次，进行回顾性研究，调查非插管麻醉对术后结局的潜在益处。

<table><tbody><tr><td>20-G top-winged infusion needle</td><td>BD Intima II</td><td>383012</td><td>Puncture with a 20-G top-winged infusion needle into the dorsal vein of the non-operative side of the hand.</td></tr><tr><td>24-G top-winged infusion needle</td><td>BD Intima II</td><td>383033</td><td>Thoracoscopic vagal block techniques</td></tr><tr><td>Anesthesia&amp;nbsp;machine</td><td>Drager</td><td>A300</td><td>Maintenance of respiratory function; Inhalation anesthesia; Monitor for electrocardiography, blood pressure, pulse oxygen saturation (SpO2), end-tidal carbon dioxide and respiratory rate</td></tr><tr><td>Atropine</td><td>Jiuquan Dadeli Pharma</td><td>H62020772</td><td>Control of heart rate</td></tr><tr><td>BIS</td><td>COVIDIEN</td><td>B277243</td><td>Monitor the level of consciousness</td></tr><tr><td>Disposable nerve block needle</td><td>Tuoren Medical Device&amp;nbsp;</td><td>202303007</td><td>Nerve block</td></tr><tr><td>Facial mask</td><td>Emedica</td><td>EM01-105S</td><td>Provides an effective non-invasive breathing circuit</td></tr><tr><td>Fentanyl.</td><td>Renfu Pharma</td><td>21D04021</td><td>Analgesia</td></tr><tr><td>Flurbiprofen</td><td>Daan Pharma</td><td>H20183054</td><td>Analgesia</td></tr><tr><td>Laryngeal mask&amp;nbsp;</td><td>Ambu Aura-i</td><td>2012-2664652</td><td>Airway management to preserve voluntary breathing</td></tr><tr><td>Levobupivacaine</td><td>Rundu Pharma</td><td>H20050403</td><td>Local Anaesthesia</td></tr><tr><td>Lidocaine</td><td>Kelun Pharma</td><td>F221129C</td><td>Local skin infiltration</td></tr><tr><td>Norepinephrine</td><td>Lijun Pharma</td><td>H61021666</td><td>Control of blood pressure</td></tr><tr><td>Portable color doppler ultrasound</td><td>SonoSite</td><td>M-Turbo</td><td>Guided nerve block</td></tr><tr><td>Propofol</td><td>Guorui Pharma</td><td>H20030114</td><td>Sedation and hypnosis</td></tr><tr><td>Ropivacaine</td><td>Aspen Pharma</td><td>6091403219940</td><td>Paravertebral nerve block</td></tr><tr><td>Saline</td><td>Kelun Pharma</td><td>c221201E1</td><td>Assisted subsonic localisation</td></tr><tr><td>Sevoflurane</td><td>&amp;nbsp;Shanghai Hengrui Pharmaceutical Co.,Ltd</td><td>9081931</td><td>Anesthesia induction and maintenance</td></tr><tr><td>Sufentanil</td><td>Jiangsu Enhua Pharmaceutical Co., Ltd</td><td>H20203650</td><td>Postoperative analgesia</td></tr></tbody></table>

non-intubated video-assisted thoracoscopic surgery

全身麻醉下的双腔插管是目前肺切除术、肺楔形切除术和肺叶切除术最常用的插管技术。然而，气管插管全身麻醉引起的肺部并发症发生率很高。保留自主呼吸的非插管是麻醉的替代方法。非插管操作可最大限度地减少气管插管和全身麻醉的不良反应，例如插管相关的气道创伤、通气引起的肺损伤、残留的神经肌肉阻滞以及术后恶心和呕吐。然而，许多研究没有详细说明非插管程序的步骤。在这里，我们提出了一个简明的非插管方案，用于在保留自主呼吸的情况下进行视频辅助胸腔镜手术。本文确定了从非插管麻醉转换为插管麻醉的必要条件，并讨论了非插管麻醉的优点和局限性。在这项工作中，对58名患者进行了这种干预。此外，还介绍了回顾性研究的结果。与插管全身麻醉相比，非插管视频辅助胸外科组患者术后肺部并发症发生率更低，手术时间更短，术中失血更少，PACU住院时间更短，胸引流移除天数更少，术后引流更少，住院时间更短。

回顾性收集了2016年1月至2022年12月连续接受非插管视频辅助胸腔镜手术的58例患者的临床数据。麻醉师对患者进行了术前访问，并在麻醉前对麻醉知情同意书的内容进行了详细说明。允许患者选择麻醉的两组（NIVATS组或GA组）之一，并签署知情同意书。
GA组患者诱导咪达唑仑0.04mg/kg、丙泊酚2.5mg/kg、依托咪酯0.3mg/kg、舒芬太尼0.5μg/kg、罗库溴铵1.2mg/kg。正性肌力药物完全起效后，使用视觉喉镜引导经口插入双腔支气管插管或带支气管闭塞器的单腔气管插管。术前胸部X线照相，在胸锁关节水平测量气管内径。气管内径为≥19 mm则选择41 Fr，气管内径为≥17 mm则选择39 Fr，气管内径为≥15 mm则选择37 Fr，气管内径为≥13 mm则选择35 Fr，气管内径为≥11 mm，则选择32 Fr。插入双腔管后，用光纤支气管镜在水平和侧面位置评估和调整管的位置。术中麻醉维持，连续滴注丙泊酚2-6mg/kg/h和瑞芬太尼0.25μg/kg/min，均以静脉麻醉方式给药。接受非插管视频辅助胸腔镜手术的外科医生和患者如图 1、 图2和 图3所示。
两名研究助理（G.B.和L.W.J.）从患者那里收集围手术期信息，包括他们的年龄，BMI，麻醉，手术持续时间，术中出血，住院时间，ICU住院时间，病史，术后胸片结果，以及他们的体温和其他实验室测试在每个术后一天进行直到出院。
术后肺部并发症（PPCs）的测量 参考欧洲围手术期临床结局（EPCO）定义联合工作组发布的指南，并考虑到本研究18的特点，PPCs诊断工具如下:（i）气胸:胸膜腔内的空气;（ii）胸腔积液:胸片显示肋膈角变钝，直立半膈同一侧的清晰轮廓丧失;（iii） 肺炎:使用新的抗生素、放射学改变、发烧或白细胞计数 >12,000 μL−1;（iv） 肺不张:肺混浊，纵隔、肺门或半膈向患处移动;（v）肺栓塞:未定义;（vi）急性呼吸窘迫综合征（ARDS）:通气状态下PaO 2:FIO2≤300，胸片显示双侧浸润。
统计分析 对于数据分析，使用了95%置信区间。 P < 0.05 的值被认为具有统计学意义。使用双向插值法调整丢失的数据。连续变量表示为平均值（标准差[SD]）或中等数字（四位数范围），并使用独立样本t检验或Mann-Whitney U检验进行比较。分类变量以数字形式表示，并通过皮尔逊卡方检验、费舍尔精确检验或连续校正卡方检验进行比较。上述数据分析由两位数据分析师独立进行和完成。所有统计分析均使用SPSS26.0软件进行。
结果 总体而言，58名患者符合分析条件，包括GA组31名患者和NIVATS组27名患者。两组临床特点见 表1。两组在性别、年龄、BMI和ASA评分方面差异无统计学意义（P > 0.05）。
主要结局 NIVATS组（3.7%;1例）的肺部并发症发生率显著低于GA组（25.8%;8例）（P =0.051）。首先，GA组6例患者出现术后气胸;然而，NIVATS组中没有患者发生气胸。两组间差异有统计学意义（P =0.026）。其次，GA组有3例患者发生胸腔积液，NIVATS组有1例发生胸腔积液，但两组间差异无统计学意义（P =0.707）。此外，GA组有7例患者发生肺炎，而NIVATS组无肺炎，两组间差异有统计学意义（P =0.012）。
此外，GA组中有3例患者发生肺不张，而NIVATS组则无肺不张。在GA组中，两名患者发生肺栓塞，而NIVATS组没有。两组肺不张或肺栓塞比较差异无统计学意义（P=0.240和P=0.494）。在两组中，没有患者发生ARDS。
次要结局 使用非插管胸腔镜麻醉可显著减少术中失血量（100mL [50-200] vs 20mL [5-50];P < 0.001）。此外，NIVATS组的平均手术持续时间（P = 0.024）和PACU停留时间较短（P = 0.004）。此外，NIVATS组和GA组在胸腔引流移除天数的差异显著（分别为第3天[2-4]与第2天[1-3];P < 0.001）。此外，NIVATS组（260mL [100-380]）和GA组（672mL [452.5-1,197.5]）术后胸腔引流量差异显著（P=0.001）。在GA组中，有3例患者在ICU中停留时间较长（>48小时），而NIVATS组没有患者（P = 0.240）。GA组4例术后胸闷和呼吸短促，NIVATS组1例（P=0.483）。最后，与GA组相比，NIVATS组的住院时间明显缩短（6天[5-7]比5天[4-6];P < 0.001）。
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/65235/65235fig01.jpg"> 图 1:进行非插管视频辅助胸腔镜手术的外科医生。 <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/65235/65235fig01large.jpg" target="_blank">请点击此处查看此图的大图。</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/65235/65235fig02.jpg"> 图2:非插管视频辅助胸腔镜手术下受影响的肺。 <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/65235/65235fig02large.jpg" target="_blank">请点击此处查看此图的大图。</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/65235/65235fig03.jpg"> 图3:戴着面罩的患者正在接受非插管视频辅助胸腔镜手术。 <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/65235/65235fig03large.jpg" target="_blank">请点击此处查看此图的大图。</a>
表1:每组患者人口统计和术后结果。 <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/65235/Table%201.xlsx" target="_blank">请按此下载此表格。</a>

Watch this Scientific Journal Video about A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia at JoVE.com

作者聚焦: 一种具有多模式镇痛和七氟烷吸入麻醉的非插管视频辅助胸腔镜手术 

在这里，我们提出了一种非插管方案，用于在保留自主呼吸的情况下进行视频辅助胸腔镜手术。

非插管视频辅助胸腔镜手术

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the ...

本研究提出了一个分步方案，详细说明了非插管视频辅助胸腔镜手术的执行。NIVATS 的方案基于多模式镇痛，包括超声引导的胸椎旁阻滞。胸腔镜做阻滞，复数浸润麻醉。多模式镇痛可有效缓解术中疼痛，抑制咳嗽反射。该方案提供了一种七氟醚吸入麻醉方案，以减少胸腔镜手术期间的咳嗽反射，最大限度地减少过度镇静，同时为患者提供安全无痛的操作环境。我们保持患者的自主呼吸，并尽量减少手术过程中的纵隔振荡，同时考虑到相关的辅助技术挑战。

non-intubated-video-assisted-thoracoscopic-surgery

Nanyang Technological University

Research

JoVE Journal

Medicine

Non-Intubated Video-Assisted Thoracoscopic Surgery

1.4K 次观看.  Second Affiliated Hospital of Zhejiang University School of Medicine. 本研究提出了一个分步方案，详细说明了非插管视频辅助胸腔镜手术的执行。NIVATS 的方案基于多模式镇痛，包括超声引导的胸椎旁阻滞。胸腔镜做阻滞，复数浸润麻醉。多模式镇痛可有效缓解术中疼痛，抑制咳嗽反射。该方案提供了一种七氟醚吸入麻醉方案，以减少胸腔镜手术期间的咳嗽反射，最大限度地减少过度镇静，同时为患者提供安全无痛的操作环境。我们保持...

视频: 作者聚焦: 一种具有多模式镇痛和七氟烷吸入麻醉的非插管视频辅助胸腔镜手术 

A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which works especially well with poor mask fit.
Can not intubate, can not ventilate" (CICV) is a potentially life threatening situation. In this video we present a simulation of the technique we used in a case of CICV where oxygenation and ventilation were maintained by inserting an endotracheal tube (ETT) nasally down to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation.
A 13 year old patient was taken to the operating room for incision and drainage of a neck abcess and direct laryngobronchoscopy. After preoxygenation, anesthesia was induced intravenously. Mask ventilation was found to be extremely difficult because of the swelling of the soft tissue. The face mask could not fit properly on the face due to significant facial swelling as well. A direct laryngoscopy was attempted with no visualization of the larynx. Oxygen saturation was difficult to maintain, with saturations falling to 80%. In order to oxygenate and ventilate the patient, an endotracheal tube was then inserted nasally after nasal spray with nasal decongestant and lubricant. The tube was pushed gently and blindly into the hypopharynx. The mouth and nose of the patient were sealed by hand and positive pressure ventilation was possible with 100% O2 with good oxygen saturation during that period of time. Once the patient was stable and well sedated, a rigid bronchoscope was introduced by the otolaryngologist showing extensive subglottic and epiglottic edema, and a mass effect from the abscess, contributing to the airway compromise. The airway was secured with an ETT tube by the otolaryngologist.This video will show a simulation of the technique on a patient undergoing general anesthesia for dental restorations.

We describe a technique to maintain oxygenation and ventilation using an endotracheal tube inserted nasally to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation.

一个新型插管困难和困难通风救援技术

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which ...

科研

医学

Substernal Thyroid Biopsy Using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the lack of a standardized definition for STG. Biopsy is often required to differentiate benign from malignant lesions. Unlike cervical thyroid, the overlying sternum precludes ultrasound-guided percutaneous fine needle aspiration of STG. Consequently, surgical mediastinoscopy is performed in the majority of cases, causing significant procedure related morbidity and cost to healthcare. Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) is a frequently used procedure for diagnosis and staging of non-small cell lung cancer (NSCLC). Minimally invasive needle biopsy for lesions adjacent to the airways can be performed under real-time ultrasound guidance using EBUS. Its safety and efficacy is well established with over 90% sensitivity and specificity. The ability to perform EBUS as an outpatient procedure with same-day discharges offers distinct morbidity and financial advantages over surgery. As physicians performing EBUS gained procedural expertise, they have attempted to diversify its role in the diagnosis of non-lymph node thoracic pathologies. We propose here a role for EBUS-TBNA in the diagnosis of substernal thyroid lesions, along with a step-by-step protocol for the procedure.

Substernal thyroid lesions are common, and need to be differentiated from malignancy. Obtaining percutaneous fine needle biopsy is not possible due to its retrosternal location. This article proposes a protocol for biopsy of substernal thyroid lesions using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA).

胸骨后甲状腺活检使用支气管内超声引导下经支气管针吸

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the ...

The Rigid Tube as an Alternative in Controlling the Problematic Airway

The unexpected problematic airway represents a large proportion of anesthesia-related morbidity and mortality. The retromolar or paraglossal approach is an alternative to the majority of the rigid instruments used for tracheal intubation, which follow the midline to access the glottis. This single-center, prospective case-series study offers an option to conventional laryngoscopy in case of a poor glottic view, introducing an instrument (the rigid tube for laryngoscopy) that uses the retromolar approach to accomplish tracheal intubation. If after anesthesia induction, the modified Cormack-Lehane glottis view grade &#62;2b, the intubation is carried further with the rigid tube. The tube follows the direction of the thyroid cartilage while advancing from the labial commissure, displacing the tongue to the contralateral side. Adjusting the position of the larynx with the nondominant hand by gently pushing the thyroid cartilage and following an imaginary line towards it while advancing it improves the time needed for proper glottis visualization. Once the epiglottis is in sight, the practitioner progresses slowly, lifting the epiglottis and aiming the tip of the tube more anteriorly. When the glottis appears in the visual field, the intubating tube introducer is placed in the trachea, and a lubricated cuffed intubating tube is advanced over the introducer after the rigid tube is extracted. This tool was tested on 30 patients with an unsatisfactory glottic view when using the Macintosh laryngoscope and obtained excellent results with respect to intubation time and complications. The reduced visual field is the main limitation of this method, which requires a training period for reasonable expertise. This simple, robust, and cheap instrument could be a rescue option in case of a difficult airway.

Presented here is a protocol of tracheal intubation over an intubating tube introducer using a rigid tube for laryngoscopy with an attached light source. The main characteristics of this maneuver are the retromolar approach and the use of the thyroid cartilage as a landmark while advancing the rigid tube.

刚性管作为控制问题气道的替代方案

The unexpected problematic airway represents a large proportion of anesthesia-related morbidity and mortality. The retromolar or paraglossal approach is ...

Endotracheal Intubation Using a Flexible Intubation Endoscope as a Standardized Model for Safe Airway Management in Swine

Endotracheal intubation is often a basic requirement for translational research in porcine models for various interventions that require a secured airway or high ventilation pressures. Endotracheal intubation is a challenging skill,&#160;requiring a minimum number of successful endotracheal intubations to achieve a high success rate under optimal conditions, which is often unachievable for non-anaesthesiology researchers. Due to the specific porcine airway anatomy, a difficult airway can usually be assumed. The impossibility of establishing a secure airway can result in injury, adverse events, or death of the laboratory animal. Using a prospective, randomized, controlled evaluation approach, it has been shown that fiberoptic-assisted endotracheal intubation takes longer but has a higher first-pass success rate than conventional intubation without causing clinically relevant drops in oxygen saturation. This model presents a standardized regimen for endoscopically guided endotracheal intubation, providing a secured airway, especially for researchers who are inexperienced in the technique of endotracheal intubation via direct laryngoscopy. This procedure is expected to minimize animal suffering and unnecessary animal losses.

The use of pigs in research has increased in recent years. Nevertheless, pigs are characterized by difficult airway anatomy. By demonstrating how to perform endoscopically guided endotracheal intubation, the present protocol aims to further increase laboratory animals' safety to avoid animal suffering and unnecessary death.

使用柔性插管内窥镜作为猪安全气道管理的标准化模型的气管插管

Endotracheal intubation is often a basic requirement for translational research in porcine models for various interventions that require a secured airway ...

Image Acquisition using Portable Sonography for Emergency Airway Management

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of patients, but also to address the potential benefits of employing ultrasound in airway management. The benefits of point of care ultrasound (POCUS) include its portability, the speed at which it can be utilized, and its lack of invasiveness or exposure of the patient to radiation of other imaging modalities.
Two primary indications for airway POCUS include confirmation of endotracheal intubation and identification of the cricothyroid membrane in the event a surgical airway is required. In this article, the technique of using ultrasound to confirm endotracheal intubation and the relevant anatomy is described, along with the associated ultrasonographic images. In addition, identification of the anatomy of the cricothyroid membrane and the ultrasonographic acquisition of appropriate images to perform this procedure are reviewed.
Future advances include utilizing airway POCUS to identify patient characteristics that might indicate difficult airway management. Traditional bedside clinical exams have, at best, fair predictive values. The addition of ultrasonographic airway assessment has the potential to improve this predictive accuracy. This article describes the use of POCUS for airway management, and initial evidence suggests that this has improved the diagnostic accuracy of predicting a difficult airway. Given that one of the limitations of airway POCUS is that it requires a skilled sonographer, and image analysis can be operator dependent, this paper will provide recommendations to standardize the technical aspects of airway ultrasonography and promote further research utilizing sonography in airway management. The goal of this protocol is to educate researchers and medical health professionals and to advance the research in the field of airway POCUS.

Point of care ultrasound (POCUS) is increasingly being utilized in airway management. Presented here are some clinical utilities of POCUS, including differentiating endotracheal and esophageal intubation, identification of the cricothyroid membrane in the event a surgical airway is required, and measuring anterior neck soft tissue to predict difficult airway management.

使用便携式超声采集图像进行紧急气道管理

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of ...

Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine position with extension and fixation of the neck. One 20 mm transverse incision and two 5 mm incisions are made through the mucosa of the oral vestibule for camera and instrument placement after disinfection of the skin and oral cavity. The workspace is established and maintained by the skin suspension device, which is made of unabsorbable string (3-0) and rubber bands, and the CO2 insufflation pressure. Lobectomy using a medial-to-lateral technique and prophylactic ipsilateral central neck dissection is performed simultaneously on patients with papillary thyroid cancer (PTC). The specimen is extracted through the 20 mm incision. The parathyroid gland is immediately searched for in the specimen and auto-transplanted to the left brachioradialis. A drainage tube is inserted through the retractor hole into the bed of the thyroid gland, and absorbable sutures are used to close the mucosal incisions in the oral vestibule and the linea alba cervicalis. Prophylactics administered intravenously are recommended for the first 24 h after surgery, and oral antibiotics are used for 7 days postoperatively.

Here, we present a protocol to describe the methodology for the transoral endoscopic thyroidectomy vestibular approach in detail.

经口内窥镜甲状腺切除术甲状腺叶切除术前庭入路甲状腺叶切除术

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine ...

Anesthetic Thoracoscopy for Diagnosis of Pleural Effusions

Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion

Local anesthetic thoracoscopy (LAT) is a minimally invasive diagnostic procedure gaining recognition among chest physicians for managing undiagnosed pleural effusions. This single-port procedure is conducted with the patient under mild sedation and involves a contralateral decubitus position. It is performed in a sterile setting, typically a bronchoscopy suite or surgical theater, by a single operator with support from a procedure-focused nurse and a patient-focused nurse.
The procedure begins with a thoracic ultrasound to determine the optimal entry point, usually in the IV-V intercostal space along the midaxillary line. Lidocaine/mepivacaine, with or without adrenaline, is used to anesthetize the skin, thoracic wall layers, and parietal pleura. A designated trocar and cannula are inserted through a 10 mm incision, reaching the pleural cavity with gentle rotation. The thoracoscope is introduced through the cannula for systematic inspection of the pleural cavity from the apex to the diaphragm. Biopsies (typically six to ten) of suspicious parietal pleura lesions are obtained for histopathological evaluation and, when necessary, microbiological analysis. Biopsies of the visceral pleura are generally avoided due to the risk of bleeding or air leaks. Talc poudrage may be performed before inserting a chest tube or indwelling pleural catheter through the cannula. The skin incision is sutured, and intrapleural air is removed using a three-compartment or digital chest drainage system. The chest tube is removed once there is no airflow, and the lung has satisfactorily re-expanded. Patients are usually discharged after 2-4 h of observation and followed up on an outpatient basis. Successful LAT relies on careful patient selection, preparation, and management, as well as operator education, to ensure safety and a high diagnostic yield.

Local anesthetic thoracoscopy (LAT) is essential for diagnosing recurrent, undiagnosed pleural effusion when a guideline-based workup fails to provide a specific cause. LAT can be performed as a day-case procedure by chest physicians. Here, we present a step-by-step approach for a successful and safe procedure.

局部麻醉胸腔镜检查未确诊的胸腔积液

Local anesthetic thoracoscopy (LAT) is a minimally invasive diagnostic procedure gaining recognition among chest physicians for managing undiagnosed ...

<meta charset="utf8"></head><body>基于气管切开术的气管插管方案，用于非存活大鼠模型

Endotracheal Intubation via Tracheotomy and Subsequent Thoracotomy in Rats for Non-Survival Applications

Endotracheal intubation and subsequent ventilation are often basic requirements for translational research in rat models for various interventions that require controlled or high ventilation pressures or access to the thoracic cavity and organs. Conventional endoorotracheal intubation using the anatomically existing route through the mouth is well suited for survival experiments. However, this procedure poses some challenges, including generally higher levels of the required experience and technical skill, more advanced equipment, and greater time effort with relevant intubation failure rates and complications such as tracheal perforation, temporary systemic hypooxygenation, and relevant aerial leakage.
This manuscript, therefore, presents a detailed step-by-step protocol for endotracheal intubation through tracheotomy in non-survival rat models when guaranteed intubation success, constant oxygenation levels, high ventilation pressures, or open thoracotomy are required.
The protocol emphasizes the importance of meticulous surgical technique to ensure consistent and reliable outcomes, especially for researchers who are inexperienced or lack routine in the technique of endoorotracheal intubation via direct laryngoscopy. This procedure is, therefore, expected to minimize animal suffering and unnecessary animal losses.

<meta charset="utf8"></head><body>大鼠气管切开术气管插管和随后的开胸术用于非存活应用

Here we introduce a standardized procedure for endotracheal intubation via tracheotomy followed by thoracotomy in rats, aimed at enhancing the precision and reproducibility of non-survival applications requiring invasive ventilation and exposure of thoracic organs in in vivo rat models.

大鼠气管切开术气管插管和随后的开胸术用于非存活应用

Endotracheal intubation and subsequent ventilation are often basic requirements for translational research in rat models for various interventions that ...

非插管视频辅助胸腔镜手术

副本

摘要

探索更多视频

一个新型插管困难和困难通风救援技术

胸骨后甲状腺活检使用支气管内超声引导下经支气管针吸

刚性管作为控制问题气道的替代方案

使用柔性插管内窥镜作为猪安全气道管理的标准化模型的气管插管

使用便携式超声采集图像进行紧急气道管理

经口内窥镜甲状腺切除术甲状腺叶切除术前庭入路甲状腺叶切除术

局部麻醉胸腔镜检查未确诊的胸腔积液

大鼠气管切开术气管插管和随后的开胸术用于非存活应用

大鼠气管切开术气管插管和随后的开胸术用于非存活应用

大鼠气管切开术气管插管和随后的开胸术用于非存活应用