目的探讨实施无痛支气管镜检查可行的麻醉方法。
方法将首都医科大学附属北京天坛医院2018年2月8日至5月4日接受支气管镜检查120例患者按照数字表法随机分为A组（利多卡因组）41例、B组（利多卡因+咪达唑仑+芬太尼组）38例、C组（利多卡因+丙泊酚+舒芬太尼组）41例。记录各组各时点的收缩压、舒张压、心率和血氧饱和度（SpO 2）的变化。通过记录生命体征及不良事件以观察不同麻醉方式的安全性，并于术后用视觉模拟评分（VAS）观察患者对支气管镜检查的耐受度和满意度。
结果C组术中各时点收缩压及舒张压均明显低于A组和B组[A组术中各时点收缩压分别为（149.51±26.40），（150.29±22.09），（147.32±19.62）和（144.54±18.13）mmHg（1 mmHg=0.133 kPa）；B组术中各时点收缩压分别为（137.84±22.85），（144.39±25.09），（144.95±24.04）和（146.79±27.66）mmHg；C组术中各时点收缩压分别为（127.76±23.47），（126.27±20.93），（121.02±23.73）和（119.98±21.58）mmHg；A组术中各时点舒张压分别为（85.44±11.90），（86.22±10.37），（86.10±10.08）和（82.66±8.52）mmHg；B组术中各时点舒张压分别为（76.79±10.68），（79.66±10.43），（79.00±10.32）和（79.79±12.15）mmHg；C组术中各时点舒张压分别为（68.51±10.54），（70.27±10.67），（64.93±9.53）和（66.02±10.68）mmHg]，差异有统计学意义（均 P<0.05），C组6例患者出现低血压（收缩压<90 mmHg），其中3例患者需要短暂应用升压药。3组术中SpO 2的差异无统计学意义[A组术中各时点SpO 2分别为（97.12±3.54），（97.07±2.58），（97.51±1.87）和（97.17±2.27）mmHg；B组术中各时点SpO 2分别为（96.55±5.25），（97.13±2.57），（97.66±1.85）和（97.76±2.28）mmHg；C组术中各时点SpO 2分别为（97.85±2.17），（96.32±3.37），（95.80±5.34）和（97.00±2.924）mmHg，均 P>0.05]，但C组患者容易出现血氧饱和度下降，18例患者术中出现低氧血症，改善通气后SpO 2可恢复正常。A组和B组患者比C组患者明显感觉到不适（ F=36.002， P<0.05），咳嗽明显（ F=22.717， P<0.05），更多咽部疼痛（ F=8.147， P<0.05），但A组和B组之间术中咳嗽及咽部疼痛程度差异无统计学意义（ t值分别为1.432和0.372，均 P>0.05）。C组大多数患者术中完全不知晓（ F=1387.043， P<0.05），再次检查的意愿明显高于A组和B组（ F=24.826， P<0.05）。
结论丙泊酚复合舒芬太尼更能达到无痛苦的效果，更能提高患者的舒适度和耐受度，更能减少术中记忆，但易发生低氧血症和低血压，术中血氧饱和度下降可以通过建立人工气道予以纠正，血压下降可以短暂应用升压药，相对安全。
ObjectiveThis study aimed to explore a feasible method of anesthesia for painless bronchoscopy.
MethodsA total of 120 patients receiving flexible bronchoscopy in Beijing Tiantan Hospital during the period from February, 8, 2018 to May, 4, 2018, were randomly divided into 3 groups, including group A (using lidocaine for local anesthesia), group B (using lidocaine + midazolam + fentanyl), and group C (using lidocaine + propofol + sufentanil). There were 41 patients in group A, 38 in group B and 41 in group C. The changes in systolic blood pressure, diastolic blood pressure, heart rate and pulse oxygen saturation(SpO 2) in each group were recorded in different points of time. The safety of different methods of anesthesia was observed by recording vital signs and adverse events. Moreover, the visual analogue scale (VAS) was used to observe the patient′s tolerance and satisfaction of the operation.
ResultsThe intraoperative systolic blood pressure and diastolic blood pressure in group C were significantly lower than those in group A and B ( P<0.05). Six cases in group C had hypotension, 3 of whom required vasoactive drugs. The differences of SpO 2 between the 3 groups showed no statistical significance ( P>0.05), while patients in group C were prone to decrease in SpO 2. Eighteen patients in group C had hypoxemia during operation. But after treated with improving ventilation, the SpO 2 of those patients could be restored to normal. Compared with those in group C, patients in group A and group B showed significant discomfort, cough, and more pharyngeal pain ( P<0.05). However, there were no significant differences in the degree of cough and pain between group A and group B ( P>0.05). Most patients in group C had no uncomfortable sensation during the operation ( P<0.05), and the willingness to re-examination was significantly higher than that in group A and group B ( P<0.05).
ConclusionPropofol combined with sufentanil could achieve better painless effect, improve patient comfort and tolerance, and reduce intraoperative memory, but was prone to causing hypoxemia and hypotension. The decline of intraoperative SpO 2 could be corrected by establishing artificial airway, while the decrease of blood pressure could be corrected by applying vasoactive drugs, which were relatively safe.
袁媛,张杰,岳红丽,等. 无痛支气管镜检查麻醉方法的初步探讨[J]. 中华结核和呼吸杂志,2019,42(2)：106-113.
DOI:10.3760/cma.j.issn.1001-0939.2019.02.006版权归中华医学会所有。
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