供肺保存的研究现状

供肺保存是肺移植领域中亟待解决的重大课题。近年来供肺保存的研究取得了一定的进展，本文从保存液、保存条件及辅助措施三方面予以总结。     

肺保存的临床状况及实验研究进展

近十年来,肺移植手术已成为临床终末期肺疾病有效的治疗手段之一。而肺移植的成功与良好的肺保存密切相关。目前,临床上供防保存方法主要有轴心冷却和单纯灌洗,其缺血安全时限仅为6小时。而长时限的成功的肺保存不仅能够增加供肺的来源,而且可以减少排异反应的强度和频度,并为HLA配型提供充裕的时间。为延长缺血的安全时限及改善保存肺的质量,     

肺移植术的供肺保存研究现状

肺移植术是治疗终末期肺疾病的有效方法，而供肺的保存技术关系到肺移植术的成败。而且，这已成为近10年来肺移植研究的焦点。本文就肺移植术中供肺保存的相关问题作一综述。     

供肺保存的研究现状

供肺保存是肺移植领域中亟待解决的重大课题。近年来供肺保存的研究取得了一定的进展,本文从保存液、保存条件及辅助措施三方面予以总结。     

低温保存供体兔肺离体再灌注模型的建立

目的：用离体兔肺连续温血再灌注模型评价低温保存后供体肺功能。方法：将未经灌洗和保存的对照组（ｎ＝６）供体左肺，与低温１０℃下保存１８小时后的实验组（ｎ＝６）供体左肺，分别在离体状态下，连续通气和温静脉血灌注３０分钟，将离体左肺引流出的动脉血，泵入另一兔体内，通过交叉循环使之静脉化后连续再灌注。结果：对照组氧分压显著优于实验组，两组间的肺动脉平均压、呼吸道峰压及再灌注后离体肺的湿／干重量比率结果无显著性差异。结论：该方法的建立为供体肺保存的研究提供了较理想的动物模型。     

不同剂量乌司他丁对离体兔肺保护作用的实验研究

目的研究不同剂量乌司他丁对离体兔肺的保护作用。方法选择36只新西兰大白兔作为研究对象,采用随机分组的方法,分为A、B、C 3组,各12只。A组给予UW液,为对照组;B组给予UW液+乌司他丁2万U/kg;C组给予UW液+乌司他丁5万U/kg。切取实验兔整体心肺作为离体心肺模型,分别在2h末和4h末,取肺部分标本做电镜分析,4h末取右肺检测测肺气道压力(Paw)、肺湿/干重比(W/D),用负压吸引真空试管取左心房血液做血气分析。结果 3组4h后Paw、W/D、二氧化碳分压(PCO2)、氧分压(PO2)比较,差异均有统计学意义(P<0.05)。B组、C组Paw、W/D、PCO2、PO2与对照组比较,差异均有统计学意义(P<0.01);C组上述指标与B组比较,差异有统计学意义(P<0.05)。超微结构分析:B组和C组的Ⅰ型细胞形态稍好于A组,C组稍好于B组。结论乌司他丁对离体肺的保护具有显著作用,大剂量乌司他丁对离体兔肺保护作用更明显。     

器官保存原则和离体心脏的保存特点

本文主要介绍了器官保存中共同适用的基本原则,以及离体心脏保存中不同于其他器官的一些特点。     

单肺通气左心转流萎陷侧肺损伤的实验研究

对6只犬建立单侧（右）肺通气＋阻断降主动脉＋左心转流模型。分为正常左房压转流组（对照）和左心转流期间短暂左房压增高组（实验）各3只。结果示实验组出现以美陷侧肺明显的含水量增多，肺泡腔内不同程度出血，上皮细胞变性、线粒体肿胀等形态学改变，以及肺组织血管紧张素转换酶活性减低。认为肺美陷时肺泡压减低为零，肺血管壁周围的对抗力被削弱，肺血管跨壁压增大，加之美陷侧肺组织因缺氧而耐受性差，当左房压升高时，易发生肺水肿和肺出血的病理改变。     

正、负压通气对离体兔肺血流动力学和氧合效果的影响

目的 :运用离体兔肺灌流模型 （IPL ）比较正、负压两种通气对肺循环血流动力学及通气效果的影响。方法 :建立 18只肺负压通气 （NPV ）的 IPL模型 ,控制灌流液流量 （133.33m l/ m in）不变 ,在相同的潮气量及呼气末跨肺压下 ,对 12只 IPL更换为正压通气 （PPV ） ,2 0 min后重新进行 NPV。在两种通气下 ,测定灌流压力 （Pa）、回流压力（Pv）、气道压力 （Paw）、肺重量 （L Wt）等指标并连续同步描记。检测灌流液血氧分压 （Po2 ）值。另 6例 IPL一直行NPV.结果 :PPV可使 Pa、肺血管阻力增高 ,L Wt下降。 PPV吸气时 Pa增加 ,Pv下降 ,L Wt略有上升 ;NPV吸气时 Pa,Pv均下降 ,L Wt显着增加。 NPV时血氧增加幅度高于 PPV。结论 :本实验条件下 PPV导致肺血管阻力增加 ;NPV的氧合效果优于 PPV     

肺移植供肺保存的现状与进展

肺移植是治疗终末期肺部疾病的唯一有效办法,但目前也是大脏器移植中最为复杂、难度最大的手术之一,仍然有许多相关问题尚待解决。供肺的保存便是其中之一,而且供肺保存成功与否,直接关系着移植手术的成功与失败。现就供肺的保存现状与进展综述如下。     

320排螺旋CT肺动脉造影与核素肺通气灌注扫描评价肺动脉栓塞的对照研究

目的探讨以核素肺通气灌注扫描为参照,评价320排螺旋CT肺动脉造影诊断肺动脉栓塞的临床价值。方法 23例可疑PE患者为研究对象,分别采用核素肺通气灌注扫描和320排螺旋CT肺动脉造影进行检测,并以核素肺通气灌注扫描为诊断标准,评估320排螺旋CT肺动脉造诊断肺动脉栓塞临床价值。结果 23例患者460个有效肺段中核素肺通气灌注扫描显示128个肺段出现V/Q失衡,320排螺旋CT肺动脉造影显示124个肺段动脉血管充盈缺损。以NLVPS为参考,320排螺旋CT肺动脉造影诊断肺动脉栓塞的敏感性为0.95(95%CI:0.89-0.98),特异性为0.96(95%CI:0.94-0.98),阳性似然比为26.33(95%CI:14.71-47.12),阴性似然比为0.06(95%CI:0.03-0.11),诊断优势比为475.06(95%CI:179.99-1253.91)和受试者工作特征曲线下面积为0.98。结论 320排螺旋CT肺动脉造影可作为肺动脉栓塞的无创快速诊断方法。     

Diagnosis of pulmonary embolus using ventilation/perfusion lung scintigraphy: more than 0.5 segment of ventilation/perfusion mismatch is sufficient

Background: To determine the optimal diagnostic cut‐off point using a simplified criterion for the detection of pulmonary embolus (PE) and to evaluate the criterion’s utility and reporter reproducibility. Methods: Lung scintigraphy was carried out in 924 patients for the diagnosis of PE. This group consisted of 316 men and 608 women with median age of 63 years (range 18–94 years). Ventilation imaging was carried out with Tc‐99m Technegas followed by perfusion imaging using 190 MBq Tc‐99m macroaggregated albumin. Studies were classified using a 6‐category probability criterion of incremental ventilation/perfusion (V/Q) mismatch: A, normal; B, low (minor matched V/Q defects or segmental matched V/Q defects without opacity on chest X‐ray); C, low‐moderate (a partial segment of V/Q mismatch); D, moderate (1 segment of mismatch); E, moderate‐high (1–2 segments of V/Q mismatch) and F, high probability (=2 segments of V/Q mismatch). Clinical end‐points at 3 and 6 months were death by PE or PE treated with anticoagulation therapy. Three‐reporter reproducibility was determined by kappa statistic on a subgroup of patients (53/924). Results: A total of 122 patients (13%) had a confirmed diagnosis of PE at 3 months and no additional cases were registered at 6 months. The lung scintigraphy probability classification showed: normal 152 (16%), low 620 (67%), low‐moderate 20 (2%), moderate 28 (3%), moderate‐high 24 (3%) and high 80 (9%). The respective sensitivities and specificities, where the diagnostic cut‐offs were established at F, high; E, moderate‐high; D, moderate and C, low‐moderate probability, were F, 64 and 100%; E, 82 and 99%; D, 95 and 98% and C, 98 and 96%. The respective false‐negative cases for F, E, D and C cut‐offs were 44, 22, 7 and 3. Using the revised Prospective Investigation of Pulmonary Embolism Diagnosis reporting classification reporter agreement showed kappa values of 0.31–0.48. Using a simplified 2‐category (>0.5 segment of V/Q mismatch positive, all others negative) criterion resulted in a higher reporting agreement (kappa 0.74–0.83). There were only 3% of indeterminate cases if this was defined by the D category and a maximum of 8% if categories C, D and E were included. Conclusions: Using a simplified diagnostic criterion where all studies showing >0.5 segments of V/Q mismatch are regarded as positive and all others as negative, lung scintigraphy, incorporating Tc‐99m Technegas ventilation imaging or its equivalent, can achieve a very high diagnostic accuracy for the detection of PE. Using this technique, less than 5% of scans are indeterminate. A simplified, unambiguous approach to reporting is recommended.     

Biomarkers of lung injury after one-lung ventilation for lung resection

Background and objective: Acute lung injury contributes to the mortality of patients after lung resection and one‐lung ventilation (OLV). The objective of this study was to characterise the effect of lung resection and OLV on proposed biomarkers of lung injury in exhaled breath condensate (EBC) and plasma. Methods: In adults undergoing lung resection, EBC was collected before and at 30‐min intervals during OLV. Inflammatory mediators were assayed in plasma samples taken preoperatively, immediately postoperatively and 24 h postoperatively. Results: EBC pH decreased from 6.51 ± 0.43 preoperatively, to 6.17 ± 0.78 and 6.09 ± 0.83 at 30 and 60 min, respectively (mean ± SD, P = 0.034, n = 20). Plasma concentrations of the receptor for advanced glycation end‐products, von Willebrand factor and interleukin‐6 increased comparing preoperative and postoperative samples (all P < 0.001, n = 30). By contrast, levels of Krebs von den Lungen‐6 and surfactant protein‐D decreased (P < 0.001, n = 30), and correlated inversely with the extent of lung resected. Conclusions: Lung resection and OLV was associated with a rapid reduction in EBC pH and differential changes in plasma biomarkers of lung injury. Further investigation of EBC pH as a marker of ventilator‐induced lung injury is warranted.     

Severe Legionella pneumonia successfully treated by independent lung ventilation with intrapulmonary percussive ventilation

Abstract:   A case of severe Legionella pneumonia was successfully treated by independent lung ventilation (ILV) with intrapulmonary percussive ventilation (IPV). A 57-year-old man with lobar pneumonia was intubated and mechanically ventilated because of his deteriorating respiratory status. The diagnosis of Legionella pneumonia was made on the fourth day after admission and appropriate antibiotic therapy was commenced. On the fifth hospital day, ILV was commenced because the right unaffected lung was over-distended, his haemodynamic state was unstable and his left lung was producing copious amounts of purulent sputum. His right lung was ventilated and his left lung was treated with IPV owing to the existence of massive atelectasis. After treatment with antibiotics and ILV combined with IPV, his respiratory and haemodynamic status gradually improved. On the tenth day after admission, ILV was changed to conventional bilateral ventilation. The patient was extubated on the sixteenth hospital day and discharged from the intensive care unit 30 days after admission. The combination of ILV and IPV was therapeutically effective during the acute phase of unilateral severe Legionella pneumonia.     

侧卧位和分侧肺通气对单侧急性肺损伤犬的影响

目的观察体位和分侧肺通气对单侧急性肺损伤(ALI)犬的影响,探讨单侧ALI时合理的机械通气方式。方法健康杂种犬28只,建立盐酸所致单侧ALI,行容量控制通气(VCV),分为常规通气组(A组)、常规通气+健侧卧位组(B组)、不同步分侧肺通气组(C组)、同步分侧肺通气组(D组)。通气240min后,每组随机选取4只犬行核素显像。监测氧合、血流动力学、呼吸力学和肺损伤指标。结果(1)通气30min后B、C、D组氧合指数(PaO2/FiO2)[(277±23)、(296±31)、(299±22)mmHg,1mmHg=0.133kPa]显著高于A组[(180±25)mmHg,P均<0.01],通气60min后C、D组PaO2/FiO2[(348±34)、(343±29)mmHg]显著高于B组[(314±33)mmHg,P均<0.05]。(2)通气120min后B组静态肺顺应性(Cst)[(23±4)ml/cmH2O]较A组[(19±2)ml/cmH2O]显著改善,通气60min后C、D组左侧Cst[(11±1)、(11±1)ml/cmH2O]均较ALI状态时显著改善[(7±2)、(6±1)ml/cmH2O,P均<0.01]。(3)B、C、D组损伤侧血流/总血流(Q损伤/Q总)[(31.3±4.6)%和(27.5±1.3)%、(27.3±2.8)%]与A组比较差异均有统计学意义[(38.3±2.2)%,P均<0.01]。结论健侧卧位和分侧肺通气均能明显改善单侧ALI犬的氧合和肺的顺应性,分侧肺通气改善氧合较健侧卧位更有效,改善氧合的机制可能与影响双侧血流分布有关。     

充血性心力衰竭无创机械通气的肺功能变化

目的：观察充血性心力衰竭患者无创通气治疗后肺功能改变。方法：一组予强心、利尿、扩血管药物治疗，另一组加用无创机械通气治疗。分别测定治疗前后的肺功能指标。结果：充血性心力衰竭合并有程度不同的肺功能障碍，用药组和无创机械通气组除CO弥散量(Dlco)外其他肺功能指标均有显著改善，而无创机械通气组与用药组相比以上指标平均改善10％以上。结论：无创机械通气能迅速改善充血性心力衰竭和呼吸功能不全，是治疗充血性心力衰竭的重要手段。     

Principles of low temperature cell preservation

Cell transplantation is becoming an important technique for treatment of heart failure. Preservation is an integral step in any procedure using cells. There are two primary modes of cell preservation at low temperature, hypothermic preservation at temperatures above freezing and cryogenic preservation at temperatures below freezing. Optimal preservation protocols require a fundamental understanding of the principles involved. This review briefly describes the basic mechanisms of damage during hypothermic and cryogenic preservation and the basic principles for developing optimal protocols for preservation of cells.     

胸腔镜下肺癌手术时单肺通气的临床麻醉分析

目的 探讨胸腔镜下行肺癌手术时单肺通气的临床麻醉情况.方法 分析218例胸腔镜下行肺癌手术患者,均采用静脉快速诱导插入双腔支气管导管,运用纤维支气管镜进行定位后进行间歇性正压通气（IPPV）,而单肺通气则采用IPPV或加呼气末正压呼吸和萎缩肺持续正压通气,对呼吸参数进行调整.结果 MAP、HR和SaO2在麻醉前、双肺IPPV和单肺的IPPV30 min、IPPV60 min、IPPV 90 min、IPPV 120 min和双肺IPPV15 min比较无明显差异性（P〉0.05）,而PaCO2和PETCO2则有明显的差异性（P〈0.05）;其中双肺IPPV和单肺IPPV在FiO2和TV方面比较也有差异性（P〈0.05）.结论 单肺通气可使胸腔镜下治疗肺癌手术时患侧肺萎缩满意,可顺利度过手术期.