气管与支气管支架植入术的麻醉进展

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5. 3　通气方式选择　关于术中通气方式,由于操作部位与呼吸共用同一通道,正常间歇正压通气常无法实施且干扰手术操作,徐美英等^{[ 16 ]}在喉罩上接一能插入FOB 的普通双腔气管导管的接头,作为“T”管应用,一端接麻醉机Y型接管,一端连接喉罩通气,支架定位和释放时通过T管接头行手法控制呼吸,效果较好。

对于伴有声门上病变、无法放置喉罩或气管插管的,高频喷射通气则是另一种较好的通气方式^{[ 17 ]}。与气管导管最大的不同在于,高频喷射通气的导管可以通过气管的病变狭窄段,不影响FOB操作及支架放置,并可与硬质气管镜结合使用,更适合于气管软化和气管严重狭窄的手术患者^{[ 18 ]} 。

20世纪90年代,双向高频喷射通气在国外已经开展研究^{[ 19} ^]。双向高频喷射通气原理是通过两根特制通气管:一根行低频通气,提供相对高的压力,相当于间歇正压通气;另一根行高频喷射通气,提供较低的压力,相当于呼吸末正压。Rezaie2Majd等^{[ 20 ]}通过大样本临床实践证明,双向高频喷射通气对气道损伤小,特别适合儿童、严重气管狭窄及喉气管手术。

总之,严重气道狭窄患者支架植入时麻醉处理的关键在于如何保障气道内操作时的呼吸道的通畅。局部麻醉或表面麻醉、气管插管、喉罩及高频喷射通气等可灵活应用于不同的病例,其选择主要取决于气道梗阻的部位、严重程度及治疗方法。

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