Comparison Of The Effect Of Laryngeal Mask Airway And Endotrachaeal Intubation During NUSS Procedures In Adult Patients

Pectus excavatum is the most common chest wall deformity whose main characteristic is representing a depression in the anterior chest wall like a funnel, it accounting for 90% of all chest wall deformities. Clinically, almost all of PE is associated with a typical posture:thin, tall with a pot-belly and depressive stemum, which could lead to scoliosis. However, the underlying etiology of PE remains unclear. Most cases of PE only show a defect in the posture. While as a result of the special anatomical changes, respiratory infections, dyspnea, chest pain, palpitation and heart related diseases could occur. After the first description in 16 century, PE was attracting more and more attentions. In order to administrate a better treatment of PE, surgical correction was performed from 1911. During a century of time, operation approaches had a tremendous improvement. There were costochondral osteotomy, sternal turnover procedure, sternal elevation procedure and their modified approaches. But these traditional methods had several shortcomings, such as longer operation duration, more blood loss and larger trauma. Now they were gradually dying out. In 1988, Nuss introduced a minimally invasive technique to repair PE which was also called NUSS operation. Then, the treatments of PE made a significant breakthrough. The NUSS procedure, which operated under the assist of thoracoscopic in a minimally incision, has the advantages of shorter operation duration, less blood loss, smaller trauma and quicker recovery. So the NUSS is more and more popular, it is becoming the standard operation method of PE.At present, we usually use general anaesthesia with double-lumen tube to obtain one-lung ventilation for video-assisted thoracoscopic surgery. Endobronchial intubation separates the lung to make one of them collapse to facilitate visualization of the field during operation and ensure the ventilation. If we had no suitable type of double-lumen tube, we could use endobronchial blockade to achieve the same effect. For the high demanding of lung isolation technique during thoracoscopic surgery, fiber bronchoscope was usually needed to make an accurate positioning. During single lung ventilation, close monitoring is very important for it is particularly predisposed to hypoxemia. In addition, on the premise of filling CO2 for artificial pneumoperitoneum, general anesthesia with endotracheal intubation is used. While no matter endobronchial intubation or endotracheal intubation, many complications may appear, like tube into esophagus, oral soft tissue injury, hoarseness, throat pain and aspiration. In order to reduce the intubation complications, thoracic epidural anesthesia was performed. The study found that compared with pure endotracheal intubation, thoracic epidural anesthesia combined endotracheal intubation used less anesthetic dosage. And it has an effect of circulation stability, fast postoperative awake and effective analgesic. In 1983, laryngeal mask airway was invented and applied in clinical. Now LMA was widely used in endoscopic surgery, for example, laparoscopic cholecystectomy, pulmonary lobectomy of spontaneous pneumothorax, gynecological and pediatric endoscopic surgery. During the surgery, we got a stable vital signs and satisfactory operation result.ObjectiveThe aim of the study was to find out the more suitable anesthesia method for NUSS operation according to compare the indexes of endotracheal intubation and LMA, such as change of white blood cells and neutrophils, the haemodynamics changes(MAP and HR), postoperative complications and classification of anesthesia effects.Methods1. GroupsPatients who were PE in NUSS operation during September 1,2012 to March 1, 2014 were randomly divided into endotracheal intubation group and LMA group, each one has 30 cases. The specific information about groups was hand to the third one.2. General informationAll patients were PE in NUSS operation during September 1,2012 to March 1, 2014 whose age were 17 to 24 and classification of anesthesia effects were Ⅰ～Ⅱ. All of them had a history asking, physical examination and other related examination before operation. Those who can not tolerate to operation with serious damage in function of heart, liver and kidney, had poor lung function (FEV1<60%) with pulmonary infection, had a psychiatric disease and central systemic disease, had an allergy history to narcotic drugs were excluded.3. Anaesthesia method1) LMA method and maintaining progressGeneral anesthesia with LMA was induced with intravenous injected midazolam 0.05～0.1 mg/kg, fentanyl 2 ug/kg and propofol 1.5～2 ug/kg in TCI. LMA was placed after patients were consciousness. Respirator was set to SIMV mode. All cases were maintained with propofol 2～4ug/ml in TCI and remifentanil 0.1-0.2 ug/(kg-min). We can modulate drugs according to vital signs to ensure HR was 50～100 times per minute, SPO2 was above 95%, BP was at the range of 20% of the preoperation pressure and the depth of anesthesia was 50 to 64. At the end of operation, we gave 2 ug/kg fentanyl. When patients can answer, open eyes and raise their heads, they can get out of respirator. After breathing smoothly and RR maintained 14 to 20 times per minute and SPO2 was above 95% with air, patients can pull out LMA. Following 15 minutes observation, they were send to ward and continue to achieve oxygen 2 L/min through nasal oxygen tube.2) Endotracheal intubation method and maintaining progressGeneral anesthesia with endotracheal intubation was induced with midazolam 0.05-0.1 mg/kg, fentanyl 2 ug/kg and propofol 1.5～2 ug/kg in TCI in intravenous way. After patients were consciousness, atracurium was injected, then endotracheal intubation was used. Respirator was set to SIMV mode. All cases were maintained with propofol 2-4ug/ml in TCI and remifentanil 0.1-0.2 ug/(kg·min) and atracurium 2 ug/(kg·min). According to vital signs, we modulate drugs to make sure of HR was 50-100 times per minute, SPO2 was above 95%, BP was at the range of 20% of pressure before operation and the depth of anesthesia was 50 to 64. At the end of operation, we gave 2 ug/kg fentanyl. Patients got out of respirator when they can answer, open eyes and raise their heads. Following breathing smoothly and RR maintained 14 to 20 times per minute and SPO2 was above 95% with air, patients can pull out LMA. After 15 minutes observation, they were send to ward and continue to achieve oxygen 2 L/min through nasal oxygen tube.4. Management after operationPatients remained recumbent and given the conventional analgesia pump with nonsteroidal medicine in intravenous way. After 2 hours, patients were allowed ad libitum access to food and water. X-ray was checked at the morning the second day following operation. If there was no bubbles leap out of drainage tube or the total volume of 24 hours were less than 100ml, we can consider to pull out drainage tube.5. Index observationsHaemodynamics changes before and after operation (AMAP and AHR), AWBC and ANEU% at the first day following operation were observed. The resuscitation time、dosage of muscle relaxant drugs、the peak value of EtCO2 and classification of anesthesia effects were included. Of course, we needed to be careful with the amount of blood loss、operation duration、the time beginning to eat、 conditions about digestive tract and throat、hoarse or not and hospital stays.6. Statistical analysisMeasurement data were presented as mean±SD (x±s), an unpaired t-test was used for comparisons between two groups. Classified variables were presented as percentage, X2 test was used. All data were statistically analyzed by the software of SPSS22.0. A difference was considered significant if the probability was<5%.Results1. General informationGeneral information about endotracheal intubation and LMA group included age、gender、height、weight、BMI、Haller index and smoker. All of them had no significant difference (P<0.05). It showed that there was a comparable between the two groups.2. Index observations during operationDuring endotracheal intubation group and LMA group, the progress of operation was smooth and safe, there was no open surgery and anesthesia method altered happen. We were satisfied with the process of anesthesia, no serious complications happened and had no emesis、regurgitation and aspiration. In LMA group, ΔWBC and ANEU% at the first day following operation were lower than that in endotracheal intubation group, there was a significant difference (P<0.05). Haemodynamics changes before and after operation (AMAP and ΔHR) was more steady in LMA compared to endotracheal intubation, the difference was significantly (P<0.05). The resuscitation time also had a significant difference (P<0.05), time in LMA group shorter than that in endotracheal intubation group. In endotracheal intubation, muscle relaxant drugs were necessary while LMA was not. There was no significant difference in the peak value of EtCO2、the amount of blood loss、operation duration、anesthesia duration and classification of anesthesia effects (P>0.05).3. Index observations after operationIn LMA group, the time beginning to eat、conditions about digestive tract and throat、hoarse was all smaller than that in endotracheal intubation group, there was a significant difference (P<0.05). While hospital stays have no significant difference between two groups (P>0.05).ConclusionsLMA has advantages than endotracheal intubation in airway management in adults VATS-NUSS operation. Compare to endotracheal intubation, LMA reduce stimulation and achieve better postoperative situation.