- 學位論文
藉由研究新型影像式呼吸道工具及麻醉藥的細胞保護作用機轉來降低胸腔手術中的肺部傷害
Alleviation of Pulmonary Injuries through Investigation of Various Advanced Video-Assisted Airway Devices and Research of the Cytoprotective Mechanism of Anesthetics in Thoracic Surgery
摘要
在胸腔手術麻醉的管理主要是以兩種技術作為基礎：(1)肺隔離以幫助胸腔內的手術進行，以及(2)單肺麻醉的管理。使用雙腔氣管內管插管技術，特別是左側型，在實現肺隔離和單肺通氣上是胸腔麻醉的黃金標準，但是，就算是在正常呼吸道的病人身上置放雙腔氣管內管，對麻醉醫師來說仍是一項挑戰。雙腔氣管內管插管的困難度將增加插管失敗以及病患缺氧的風險。數種視頻輔助的氣道裝置被開發用來幫助困難呼吸道的氣管內管插管。GlideScope®視頻喉鏡 (Verathon Inc., Bothell, WA, USA) 是具有六十度彎曲葉片的喉鏡，葉片的前端安裝了光源以及數位攝影鏡頭，使聲門以及聲帶的影像能顯示於外接螢幕上。與Macintosh直接式喉鏡相比，它縮短了插管的平均時間，並且也降低了插管後喉嚨痛與聲音沙啞的發生率。另一種視頻輔助設備，Trachway®視頻探針 (Biotronic Instrument Enterprise Ltd., Tai-Chung, Taiwan)，具有可塑性並且無傷害性的前端和可旋轉的顯示器。無論是病人在麻醉下或是清醒的狀態下，它也被應用於困難氣到的插管。與直接式喉鏡相比，Trachway®視頻插管探針有助於在正常氣到的病人上更快速的左側型雙腔氣管內管插管，並且也減少了手術後第一天的聲音沙啞。因此，使用視頻輔助上呼吸道裝置可以幫助左側型雙腔氣管內管的置放。 胸腔麻醉的另一個重要課題是肺部的保護策略。在嚴重的肺感染（例如：肺膿瘍、支氣管擴張、膿胸）的患者，經常會出現急性呼吸窘迫綜合徵 (ARDS)，增加了低血氧症的風險。丙泊酚（2,6-二異丙基苯酚）是一種被廣泛使用的靜脈誘導和維持麻醉劑。其抗氧化性能為肺部保護提供了機會。我們使用人肺上皮細胞系A549來探索丙泊酚細胞保護作用的機制。 結果表明，丙泊酚通過激活核因子紅斑相關因子2（Nrf2）來增強抗氧化防禦作用，以及抑制NOX或COX2藉此降低炎症反應，達成保護肺泡A549細胞以減輕被脂多醣（LPS）造成的傷害。這些細胞保護機制表明了對於急性肺損傷（ALI）/ ARDS接受胸部手術的患者，丙泊酚可能是一種很好的麻醉藥物。 基於本論文，我們希望藉由提供視頻輔助氣道裝置和異丙酚的優勢證據，有助於在未來建立胸腔麻醉臨床操作上包括插管技術和麻醉藥物的選擇的新策略。
並列摘要
Fundamental to anesthetic management for the majority of thoracic procedures are two techniques: (1) lung isolation to facilitate surgical access within the thorax and (2) management of one-lung anesthesia. Intubation with double-lumen tube (DLT), especially left-sided type, to achieve lung isolation and one-lung ventilation (OLV) is the most used technique for thoracic anesthesia, but it remains a challenge to anesthesiologist, even in patients with normal airways. The difficulty of intubating DLT would increase the risks of failed intubation and desaturation. Several video-assisted airway devices have been developed to assist tracheal intubation for difficult airway. The GlideScope® videolaryngoscope (Verathon Inc., Bothell, WA, USA) is a laryngoscope with a 60˚ curved blade which a light source and a digital video camera are positioned at the tip so that pictures of glottis and vocal cords can be displayed on the monitor. Compared with the direct Macintosh laryngoscope, it shortens the mean duration of intubation and decreases the incidences of post-intubation sore throat and hoarseness. Another video-assisted device, Trachway® video stylet (Biotronic Instrument Enterprise Ltd., Tai-Chung, Taiwan), is malleable and has an atraumatic tip and a rotatable monitor. It also has been for tracheal intubation in patients with difficult airways, both anesthetized and awake. Compared with direct laryngoscopy, the Trachway® video stylet facilitates faster left-sided DLT intubation and decreases hoarseness on the first postoperative day in patients with normal airways. Therefore, using video-assisted upper airway devices can facilitate the intubation of left-sided DLT. The other important concern for thoracic anesthesia is lung protection strategy. In patients with severe lung infections (e.g., lung abscess, bronchiectasis, empyema), acute respiratory distress syndrome (ARDS) is usually presented and the risk of hypoxemia is increased. Propofol (2,6-diisopropylphenol) is a widely used intravenous agent for induction and maintenance of anesthesia. Its anti-oxidative property offers the opportunity for lung protection. The human lung epithelial cell line A549 was used to explore the mechanisms of cyto-protective effects of propofol. The results demonstrated that propofol protects alveolar A549 cells against lipopolysaccharide (LPS) by activation of Nuclear factor erythoid-2-related factor 2 (Nrf2) to enhance antioxidant defense and inhibition of NOX or COX2 to decrease inflammatory reaction. These cyto-protective mechanisms of propofol suggested that it might be a good anesthetic of choice for patients with acute lung injury (ALI)/ARDS received thoracic procedures. Based on the present thesis, we hope to provide to advantage evidences of video-assisted airway devices and propofol, and contribute to establish the new strategies of clinical practices for thoracic anesthesia both in intubating techniques and the choice of anesthetic in the future.