Clinical And Experimental Study On The Application Of Single Lung Anesthesia In Thoracic Surgery

PART1. THE APPLICATION OF ONE-LUNG VENTILATION IN THORACIC SURGERRIES ANG ITS VENTILATION-RELATED LUNG IN JURISThe development and improvement of one-lung ventilation technique had such a great influence on thoracic surgeries that it made possible some sort of operations like tracheoplasty、bronchoplasty、bronchial sleeve resections as well as it provided good conditions for radical lung cancer resections and radical esophageal cancer resections. Especially, in recent years one-lung ventilation technique became fundamental guarantee for vedio-assisted thoracoscopy surgeries.However, during the course of one-lung ventilation, some complications were present in few patients like:hypoxia during the course of ventilation、 reexpansion edema after lung detelectasis.Since the safety of one-lung ventilation was still questioned, we here reviewed related literature on topics such as influences of one-lung ventilation on thoracic surgeries、adverse reactions of one-lung ventilation and its complications、clinical researches on one-lung ventilations home and abroad and in vivo tests in animal with one-lung ventilation technique. In the mean time, in order to search for research methods for one-lung ventilation-related lung injuries, we also reviewed advances in this field and research methods used by other experts. We were in the hope of finding some basis for project establishment and technique routes for our further researches in this try.PART2. AN UNCONDITIONAL LOGISTIC REGRESSION ANALYSIS OF FACTORS OF PROLONGED PACU RETENTION TIME FOR THORACIC PATIENTSObjective:To explore the incidence and the possible risk factors which cause prolonged retention time at post-anesthetic care unit for patients undergoing thoracic surgeries and provide theoretical basis and references for future jobs dealing with such patients.Methods:In the archives room of anesthesia department, we searched out all the recording sheets of all the inpatients in thoracic department who underwent operations. We got in total495cases which were well recorded. Extract all useful data from anesthesia recording sheets and previous electronic medical records. For details see sheet1. We typed in each piece of information extracted one by one and established an Excel form. Analysis of univariate and multivariate unconditional logistic regression was taken with the use of SPSS13.0software package.Outcome:when PACU retention time(Y) was greater than or equal150minutes, we make Y=1. When PACU retention time Y was less than150minutes, we make Y=0. Finally,113of the495cases with the ratio between male and female2.36were found to have Y=1. The total rate was22.8%. Analysis of univariate and multivariate unconditional logistic regression showed the main risk factors were age(OR=0.000)、operation method(OR=0.094)、 urine output (OR=0.000)、ASA grading (OR=0.004) and administration of cardiovascular-activity agents(OR=0.002).Conclusion:staff working on post-anesthesia recovery of thoracic patients should pay attention to the main risk factors, find and solve related problems in time. The risk factors deserve future research. PART3. ONE-LUNG VENTILATION VERSUS TWO-LUNG VENTILATION IN ANESTHESIA FOR NON-CARDIAC THORACIC SURGERIES:A SYSTEMATIC REVIEWObjective:To evaluate the safety of One-lung ventilation and two-lungventilation in anesthesia for non-cardiac thoracic surgeriesMethods:A computerized search of articles published between1980and September2008was performed using The Cochrane Library、MHDLINE、 EMBASE and Chinese Biomedicine Database(CBM) to identify the clinical trials comparing One-lung ventilation and two-lung ventilation in anesthesia for non-cardiac thoracic surgeries.The quality of included studies was critically assessed and data analyses were performed with Cochrane Collaboration’s RevMan5.0.Results:Five studies were included, involving3randomized trials、1non-randomized trial and1retrospective trial. Meta-analyses showed that rates of blood-associated complications (including hypoxia and hypercapnia [OR=0.68,95%CI [0.31-1.51]P=0.46]、tube intubation-associated complications(including tube malposition, poor isolation, hoarseness, bronchial erosion)[OR=153,95%CI [0.25-9.58] P=0.65]、cardiovascular complications (including unstable hemodynamics, arrhythmia)[OR=1.00,95%CI[0.17-6.05],P=1.00]、respiration system complications (including pneumonia, pulmonary edema, atelectasis, ARDS)[OR=0.68,95%CI [0.31-1.51] P=0.35] were similar between one-lung ventilation and two-lung ventilation groups.Conclusions:Based on these evidences, One-lung ventilation for non-cardiac thoracic surgeries is as safe as two-lung ventilation, but hematological complications and surgical complications were not demonstrated. Due to the poor quality of the included trials, more high-quality randomized trials are needed. PART4. ROLE OF IL-6AND IL-8IN THE INFLAMMATORY OF LUNG INJURY INDUCED BY ONE-LUNG VENTILATIONObjective:To observe the changes of IL-6, IL-8in the arterial blood with one lung ventilation in pulmonary lobectomy.To investigate the influence and mechanism of action on lung injury during OLVMethods:Twenty ASA Ⅰ～Ⅱ patients scheduled for elective pulmonary lobectomy were randomly divided into two groups of ten each,namely one-lung group and double-lung group. There were no obvious difference in the methods of anesthesia and test facility between two groups.One-lung group were immediately practiced one-lung ventilation after anesthesia induction and double lung ventilation immediately after the surgery in the chest were over. Two milliliters of blood samples were obtained from radial artery for Hct before anesthesia(To),30minutes after mechanical ventilation (T1),one hour after mechanical ventilation(T2), two hours after mechanical ventilation(T3),one hour after completing surgery in the chest (T4), two hours after completing surgery in the chest(T5),24hours from operation(T6),48hours from operation(T7).Three mils artery blood samples were collected on above-mentioned time points for determination of blood concentrations of IL-6and IL-8which were measured by ELISA.Result:(l)IL-6:compared with the time point of before anesthesia(T0),two groups all began to increase with one hour after mechanical ventilation(T2)(P <0.01).reached climax two hours after completing surgery in the chest (T5) decreased gradually at24hours from operation(T6),could not restore to the level before anesthesia(T0)(P<0.05). One-lung group were higher than those in double lung group at time points of T2,T3,T4,T5, T6,(P<0.05)(2)IL-8:compared with the time point of before anesthcsia(T0),two groups with all began to increase with one hour after mechanical ventilation(T2)(P<0.05),reached climax two hours after completing surgery in the chest (T5),decreased gradually at24hours from operation(T6),could not restore to the level before anesthesia(T0)(P<0.05).One-lung group were significantly higher than those in double lung group at time points of T3,T4, T5, T6(P< 0.05).Conclusion:(1) Mechanical ventilation consist of one-lung ventilation and double-lung ventilation resulted in increase of IL-6and IL-8,which implied ventilation resulted inflammatory reaction.(2)After a period of ventilation the level of IL-6and IL-8in One-lung group were higher than those in double lung group. The inflammatory reaction in one-lung ventilation were more serious than double lung ventilation.(3) The level of IL-6and IL-8in One-lung group at48hours from operation were almost stepped down to the level of double lung group.So if we could control the time of one-lung ventilation, the inflammatory reaction from one-lung ventilation was not more serious than double lung ventilation anesthesia after a period of postoperative recovery. PART5. EFFECT ON THE METABOLISM OF XOD、MPO AND PMN WITH ONE-LUNG VENTILATION IN LOBECTOMYObjective:Compare the one lung and total lung ventilation with lobectomy for the metabolism of Xanthineoxidase(XOD)、Myeloperoxidase(MPO) and Polymorphonuclear leucocyte(PMN).Methods:20lung cancer patients with lobectomy were classified in experiment group (n=10) and control group (n=10)(O group and D group). A group,OLV lobectomy group. B group,TLV lobectomy group. The A group was ventilated with OLV when the operation was began; TLV was applied again when the operation was compeleted.In DG,TLV was used during the operative procedure only. The blood sampling protocol were collected, XOD and MPO plasma activity were measured, and the PMN were counted.Results:①PMN was no different in O group and D group.②the activity of MPO in O group is more than D group (P<0.05).③The activity of XOD was no different in O group and D group.Conclusion:Lobectomy with OLV had a higher production of oxygen free radicals than TLV. PART6. MONITOR EXTRAVASCULAR LUNG WATER AFTER ONE-LUNG VENTILATION BY PICCOPLUS SYSTEM IN PATIENTS WITH PULMONARY LOBECTOMYObjective:Monitor changes in EVLW by the pulse index continuous carciac output(PiCCO)system during intraoperative and postoperative stages of lung resection using one-lung ventilation, to understand the influence of one-lung ventilation (OLV) on FVLW.Methods:20lung cancer patients undergoing pulmonary lobectomy were enrolled in the study.Invasive hemodynamic parameters were measured by transpulmonary arterial thermodilution using the PiCCO system with a femoral artery catheter. Central venous pressure(CVP)、cardiac output(CO)、mean artery pressure(MAP)、Systemic vascular resistance index(SVRI)、 extravascular lung water index(EVLWI)、Global enddiastolie Volume Index(GEDVI)、Intrathoracic blood volume index (ITBVI)、 Pulmonary vascular Permeability index (PVPI)were recorded with the patient in intraoperatively after15min、30min、60min、120min、150min, and postoperatively after30min、1h、2h、3h、5h、7h、20h.Results:The one-lung ventilation on hemodynamic parameters were not identified statistically significant differences when compared with two-lung ventilation(TLV)(P>0.05). CO increased obviously before extubation, and then remained at a high level;A upside down V variation occurred in CVP within two hours after operation;MAP increased perioperatively and decreased postoperatively, but maintain at a higher level than before;SVRI reduced preoperatively and increased intraoperatively, whereas it quickly eased back to the preoprative level after operation. Both EVLWI and PVPI depress gradually with prolongation of exposure time. While GEDVI and ITBVI remained constant throughout. Further more, E VLWI and PVPI、GEDVI had significant positive correlation. However, There were no correlation between EWLWI and CO、CVP、MAP、SVRI、ITBVI.Conclusion:OLV does not appear to reflect EVLW in this study. And it is a safe Anesthesia procedure. PART7. EFFECTS OF ONE-LUNG VENTILATION ON POSTOPERATIVE PULMONARY FUNCTION IN PATIENTS WITH PULMONARY LOBECTOMYObjective:investigate the effects of one-lung ventilation on postoperative pulmonary function to understand the influence of one-lung ventilation (OLV) on EVLW.Methods:20lung cancer patients undergoing pulmonary lobectomy were enrolled in the study. Pulmonary functions were performed in patients before and after submitted to lung exeresis. Routine methods of pulmonary functions was tested. Forced vital capacity (FVC), forced expiratory volume in1s(FEV1), maximal mid-expiratory flow (MMEF)、maximal ventilatory volume(MVV), FEV to FVC ratio(FEV1%) were measured with the patient in Preoperatively and postoperatively at each of the visits days1,2,3,4,5,6,7,8,9and10. All the indexes is expressed as percentage in predicted value(PV).Results:The one-lung ventilation on pulmonary function was not identified statistically significant differences between the2groups (P>0.05) except for MMF%index (P≤0.05). All the corresponding indexes increased with smoothly increasing altitude since the first day. Besides FEV1/FVC%, none of the indexes reached the preoperative level in the observation period.Conclusion:OLV does not appear to reflect postoperative pulmonary function in this study. One-lung ventilation may aggravate the incipient small airway dysfunction. PART8. COMPAEATIVE STUDY ON THE EFFECTS OF THE RAT AQP-5EXPRESSION IN TWO DIFFERENT WAYS OF ONE-LUNG VENTILATIONObjective:To study the effect of two different ways of One-lung ventilation (OLV) on rat lung aquaporin protein-5(AQP-5) expression.Methods:The rats were divided into four groups. Group A:Performing OLV by clamping. Group B:Right bronchial intubation OLV. Group A and Group B was divided into Al, A2, A3, and B1, B2, B3according to different ventilation time. There are two control groups. Group C:total lung ventilation group, which divided into Cl, C2, C3by the corresponding time with the experimental group. Group D:Vacuity contrast group. Take the lung tissue for Western blotting, observed the expression of AQP-5.Results:The results of immunohistochemistry:Compared the expression of AQP-5. group A. B and C were less than group D (P<0.05), A, B, C compared within each group were significant differences (P<0.05); There is no significantly difference among the group A1, B1and C1(P>0.05); group A2was less than group B2and group C2(P<0.05), and there is no significantly difference between B2and C2; Group A3and group B3were less than group C3(P<0.05), Group A3was less than group B3(P<0.05). The results of Western blot:Compared the expression of AQP-5, group A, B and C were less than group D (P<0.05), A, B, C compared within each group were significant differences (P<0.05); There is no significantly difference among the group A1, Bl and Cl (P>0.05), and there is no significantly difference among the group A2, B2and C3(P>0.05); Group A3and group B3were less than group C3(P<0.05), Group A3was less than group B3(P<0.05).Conclusions:Mechanical ventilation can reduce the expression of rat AQP-5, and time-dependent. Performing OLV by clamping and right bronchial intubation OLV have higher effect on the expression of rat AQP-5than total lung ventilation, the former is more obvious. PART9. THE EFFECT OF ONE LUNG VENTILATION ON LUNG TISSUE APOPTOSIS AND PULMONARY SURFACTANT PROTEIN IN RATS LUNGObjective:To determine the effects of one lung ventilation on apoptosis of alveolar cell and then expression of Caspases-3,pulmonary surfactant protein A(SP-A) and pulmonary surfactant protein B (SP-B)in rats lung tissue.Methods:Forty-Two Sprague-Dawley rats were randomly divided into:Control group (group C),Two lung ventilation group (group B),One lung ventilation group (group A), group C were unventilated. According to different ventilation time, group A and group B were respectively divided into three subgroup A1,A2,A3and B1,B2,B3.The groups of A1,A2and A3performed one lung ventilation for0.5,1,1.5h respectively,which were all followed with two lung ventilation for0.5h. The groups of B1,B2,B3performs two lung ventilation for1,1.5,2h respectively. Artificial endotracheal tube was pushed into the right main bronchus to perform one lung ventilation.Lung pathological changes were examined under light microscopic, TdT-mediated dUTP nick end labeling (TUNEL) was used to define the extent and distribution of apoptosis in lung tissues.The expression of Caspase-3,SP-A and SP-B was determined by Western blot.Result:As the time extend, group A and group B gradually showed intra-alveolar exudates,hemorrhage and interstitial edema in histopathology, and group A showed more seriuos. As compared with the subgroup in group B,TUNEL assay exhibited the incease of apoptosis on the lung tissues in group A2and group A3,and the Western blot study also showd Caspase-3,a key role in apopotsis,was expressed more in group A2and group A3.And as compared with group C, SP-A and SP-B were deceased in A1,A2,A3(P<0.05), with the OLV time extension the levels decreased obviously (P<0.05),as compared with the subgroup in group B.the levels of SP-A and SP-B in A1,A2,A3were respectively less than B1,B2,B3(P<0.05)Conclusion:As the time extend, OLV contributed to apoptosis, and cause the levels of SP-A and SP-B in lung tissues decreased, compared with two lung ventilation,one lung ventilation can aggravate apoptosis in rat lungs,and the levels of SP-A and SP-B decreased obviously. We conclude that apoptosis and the pulmonary surfactant protein decreased may be the important factor of more serious lung injury caused by one lung ventilation.