CHUYfeH pg: Hpl NGHI KHKT CAC TJNH VUNG DUY£N HAI BAC B Q U H THCT NHAT __^
DANH GIA HIEU QUA HUT RU^A PHE QUAN B A N G N Q I SOI PHE QUAN 6 N G M E M TREN BENH NHAN COPD T H d MAY
TAI KHOA HOI SlTC TICH c i f C BENH VIEN DA KHOA 1 TINH THAI BINH NAM 2011 - 2012
D 3 Minh Dtrong*
T6M TAT
Myc tieu: Danh gla hieu qua hut riiei phe quan qua npi sol phe quan ong miem tren benh nhan benh phoi t3c nghen man tfnh (COPD) thd may. Xac dinh mot so tai bien cua nol sol phe quan ong mem tren benh nhan COPD thd may.
Phu'dng phip nghien cut/: Nghien CIJ'U mo ta npi sol phe quan tren 40 benh nhan COPD thd may. So sanh cac chi so lam sang va khi mau dong mach tru'dc va sau npi soi 1 gid, hinh anh Xquang phoi sau 24 gid.
Ket qua: Mach, huyet ap, tan so thd khong thay doi sau nol soi. Sp02 va the tfch khf lu'u thong thd ra (VtE) tang len, ap li/c dinh du'dng thd giam hcfn so vdi tru'dc khi soi 1 gid. pH, PaOa tang len va nam trong gidi han binh, PaC02giam hpn so vdi tru'dc khl sol 1 gid vdi p < 0,05. Cac benh nhan deu du'dc cai thien tot hPn tren hinh anh Xquang sau npi soi 24 gid. Co 2 benh nhan bj chay mau niem mac phe quan (5%), 1 benh nhan bi tut huyet ap nhe (2,5%). Khong co benh nhan nao bj tai bien nguy hiem nhi/ suy ho hap, tran khf mang phoi, loan nhjp tim.
Ket iuan: Cac chi so lam sang, khi mau dpng mach va hinh anh Xquang phoi du'dc cai thien tot hPn sau npi sol phe quan. Khong co benh nhan nao bi tai bien nguy hiem.
SUMMARY
Objectives: To evaluate the effects nf suction sputum through bronchoscopy In Chronic Obstructive Pulmonany Disease (COPD) patients with mechanical ventilation. Determine some of
* Khoa HOI sue tich ofc. BVDK tinh Thdi Binh
the complications of bronchoscopy In COPD patients with mechanical ventilabon.
Research Methods. Observative researdi about bronchoscopy in COPD patients with mechanical ventilation. Compare dinical parameters and ABG after bronchoscopy 1 hour and chest Xray Images after 24 hours
Results: Pulse, blood pressure, respiratory rate unchange after bronchoscopy. Sp02 and exhaled volume (VtE) Increase, the peak ainvay pressure reduces after bronchoscopy 1 hour. pH, Pa02 increase and stay in the average range, PaC02 deaeases after bronchoscopy 1 hour vflth p <0.05. The X-ray images of the pateints are improved after 24 hours. There are 2 patiens with bronchial mucosal bleeding (5%), 1 patient with mild hypotension (2,5%). No patient witt) serious complications such as respiratoryfailure, pneumothorax, cardiac arrhythmias.
Conclusions: The clinical indecators, arterial blood gases and lung X-ray Images is improved after bronchoscopy. No patient with serious complications.
I- OAT VAN OE
B?nh nhan bi benh phdi tic nghSn man tinh (COPD) phai dm ngi khi quan (NKQ)va;
phai tha may thi thuang co hien tirong ft;
dong doTO gay nhilu bi^n chiing nang nhui xep phoi, nhilm trung va suy ho hap. Khi hut;
dich ph^ quan bang ong hut ddm thong thuang thi chi hut ducrc tai phi quan goc con noi soi p h i quan 6ng m i m co the hiit rite;
Y HQC VlgT NAM THANG 5 - s6 DAC Blgl / 2013
s?ch long phe quan toi tan cac phi quan phan thiiy v^ dudi phan thuy nen lam thong thoang dudng thd tot han [1], [2]. Vi vay dl danh gia hiSu qua cua ndi soi phe qu^n trong hilt rira phi qu^n cho benh nhan COPD thd may, chung toi tien h^nh nghien cuu de tai n^y iih^ muc tiSu;
- Ddnh gid hieu qud hiit rira phe qudn qua ngi soi phi qudn ong mem tren benh nMn b$nh phoi tdc nghen mgn linh (COPD) ithcrmdy.
I - Nhgn xet mot so tai bien cita ngi soi phi qudn ong mem tren benh nhdn COPD
\ thd mdy.
? --
11- OOI TUONG VA PHUONG PHAP NGHIEN cOu
2.1. Doi tirong nghien cihi
40 benh nhan COPD thd may duoc npi soi hut nia phi quan tai khoa Hdi siic tich cue nam 2011 -2012.
Tieu chudn l^a chgn
• Benh nhan dugc chan doan COPD (theo Gold 2010) [3]
^, + Ho man tinh: moi dot keo dai it nhat 3 thang/nam va trong 2 nam lien tuc
+ khac ddm man tinh
+ Khd thd thudng xuyen, tang dan + FEV1/FVC<70%
- Benh nhan da dugc chan doan la COPD tir trudc.
- Benh nhan dugc dat NKQ hoac MKQ .va thd may
' - Benh nhan cd nhieu ddm, phai hut nia ' phe quan bSng 6ng hut > 5 lln/ngay
Tiiu chain loai trir
- B?nh nhan khdng du tieu chuSn chan ' doan 1^ COPD.
- Benh nhan chi phai hut rira phi quan Jbang 6ng hut < 5 l4n/ngay.
2.2.Phiroiiig phap nghiSn ciru Thiit lii nghien curu: Mo ta tien ciiu Chpn mdu nghien cii-u: Mau thuan tien Phu'O'ng ti^n nghiin cii'u
- Mky npi soi phe quan ong mem Xion (CHLB Dire).
- Monitor theo doi mach, nhiet dp, huyet ap, tan sd thd, SpOz-..
May thd: Vella, Newport, Puritan Bennet, Esprit,...
- May xet nghiem khi mau dgng mach, chup Xquang phdi tai giudng.
Thudc: Thudc gay te (Lidocain 2%), thudc gay me (Midazolam, Fenthanyl), thuoc ciim mau (Adrenalin Img), dich rira PQ (Natri Clorua 9%o)
Tien hdnh ngltien cu-u
* Chuan bj benh nhan:
- Benh nhan dugc dat ngi khi quan hoac md khi quan dng sd 8 va thd may mode VCV.
- Gay me biing Midazolam 5 mg tiem tmh mach, Fenthanyl 0,1 mg tiem tinh mach.
Gay te niem mac phe quan bang Lidocain 2%
- Mac may monitor theo doi mach, nhiet do, huyet ap, tan sd thd...
* Tiln hanh ngi soi phe quan:
* Thu thap sd lieu vao benh an nghien ciru:
- Ten, tudi, gidi, nghe nghiep.
- Thdng sd may thd: ap lire dinh, the tich khi luu thdng...
- Cac chi sd lam sang khi soi phe quan:
mach, huylt ap, tan sd thd, Sp02...tai thdi dilm trudc soi va sau khi soi 1 gid. Chup Xquang sau ndi soi 24 gid
Tai biln: Chay mau, tran khi mang phdi, loan nhip tim, tut huyet ap
Phu-ffng phdp phdn tich so lieu: So lieu dugc xir ly bdng phuong phdp ihong ke y hgc
CHUYfeM Bi: Hpl HBH! KHKT cAC TINH VUNG DUYtN HAI BAC B 6 U H T H I ? HHAT
nhta la 71,7 ± 9,2, thip nhit la 50, cao nhat la 85. Ty le benh nhan nam la 82,5%. ThM gian soi phj qu4n trung binh la 15 ± 3 phiit,.a III- KET QUA NGHIEN CUU
Nghien ciru tren 40 b?nh nhan COPD, tho may dupc npi soi phe quan ong mem nam 2011 va 2012. Tu6i trung binh cua b$nh
Bangl: Thay doi cac chi s6 lam s4ng va thong s6 may tha sau khi npi soi
Mach HA toi da HA toi thieu Tan so thd SpOj VtE
Ap IUc dlnh du'dng t h d
Tru'dc soi 91,25 ± 4,4 114,1 ± 9,4 69,5 ± 7,7 25,6 ± 1,1 92,8 ± 1,5 365,9 ± 5,7 32,9 ± 1,9
S a u soi 1 g i d 94,68 ± 4,6 106,1 ± 8,7 67,5 ± 6,3 23,8 ± 1,1 96,4 ± 1,4 391,6 ± 7,1 26,9 ± 1,3
P
> 0 , 0 5
> 0 , 0 5
> 0 , 0 5
> 0 , 0 5
<0,05
<0,0S
<0,0S
- Mach, huyet ap, tan sd thd trudc va sau ngi soi 1 gid thay doi khdng cd y nghia thdng ke.
- Sp02 va the tich khi luu thdng thd ra (VtE) tSng len sau ngi soi 1 gid.
- Ap lire dinh dudng thd giam han so vdi trudc khi soi.
Bang 2: Cai thien ve khi mau dgng mach
pH PaOj PaC02 HCO3"
Tru'dc soi 7,34±0,1 74,3±10,2 49,5±7,3 29,2±5,4
Sau soi 1 g i d 7,42±0,2 83,5±11,5 45,5±6,6 28,7±5,1
P
<0,05
<OfiS
<0,0S
> 0,05
- pH, PaOi tang len va nam trong gidi han binh thudng sau ndi soi 1 gid.
- PaCOigiam hon so vdi trudc khi soi vdi p < 0.05.
12 (30'
1
Cai thien tot I Cai thien mot phSr
28 (70%)
Bieu do I: Cdi thien tren liinh dnh Xquangp/tSisau 24gid Cac benh nhan dju co hinh anh Xquang phai cai thien t6t hon sau ngi soi. Trong do 28 benh nhan (70%) co cai thien t6t.
Y HQC VlgT NAM THANG 5 - S6 DAC B1|T / 2013 B a n g 3: T a i b i e n do gay me v a n d i soi phe qudn Tai bien
:iiav mau niem mac PQ rut huyet ap juv ho hap ioan nhip tim I'an khl mang phoi
^ phan ve, dj iing thuoc
n 2 1 0 0 0 0
T y i | % 5%
2,5%
0 0 0 0
I Co 2 benh nhan bi chay mau niem mac 'M quan khi soi (5%). Cd 1 benh nhan bj tyt miylt ap sau khi gay me (2,5%), mdc huyet h giam xudng 80/50 mmHg nhung khi Suyen bd sung dich Natri Clorua 0,9% thi iuylt ap dEin trd ve miic binh thudng.
V. BAN LUAN
Chung tdi thuc hien ngi soi phe quan tren (0 b?nh nhan COPD cd dat ngi khi quan hoac 40 khi quan va thd may. Trong qua trinh ndi soi ]m quan, benh nhan deu dugc su dung focain 2% (2 ml/dng) x 4 - 6 dng/benh nhan
•« gay te bl m&t niem mac phe quan. Cd 32 'Knh nhan dugc su dung Midazolam gay me i n thuk vdi lilu 0,1 mg/kg tiem tTnh mach -mdc khi bit d4u npi soi 5 den 7 phiit. 8 benh ihan kich thich nhieu trong khi soi nen phai su iung Midazolam phdi hgp vdi Fenthanyl vdi ieu 1 microgam/kg. Trouillet ciang cho rang )enh nhan ngi soi phe quan chii yeu phai dung Widazolam 0,1 mg/kg de gay me [5].
Bang 1 cho thay sau khi ti8n lianh ndi soi iM quan 1 gid thi mach, huyet ap tdi da, jtoyet ap tdi thidu va tan sd thd cua benh liian tiiay doi khdng cd y nghTa thdng ke.
Wirc huygt ap tang cao nhdt cua benh nhan
^i n6i soi la 140/90 mmHg. Cd 1 benh nhan H tilt huy^t ap xudng 80/50 mmHg sau khi
?ay me lihung sau khi truydn dich, huyet ap 'ang Ien 90/60 mmHg. Nghien cuu cua Trouillet va cgng su tren 107 benh nhan thd I'^y thi cung thky huyk ap tdi da giam sau
^ gay me va bat dku ndi soi nhung tang trd W trong qua trinh ngi soi [5].
Sp02 tang len sau ndi soi phe quan I gid, tir 92,8 ± 1,5 len 96,4 ± 1,4 vdi p < 0,05.
Nghien cuu cua Lindgren va cgng sir cung cho thay sir thay ddi SpOi tir 96 ± 2% xudng 94 ± 4% khi tien hanh ngi soi phe quan nhimg tang len sau ngi soi [4].
The tich khi luu thdng tlid ra (VtE) giam di khi ndi soi nhung tang cao han ban dau sau ngi soi 1 gid. Mure tang tir 365,9 ± 5,7 ml len 391,6 ± 7,1 ml vdi p < 0,05. Lindgren va cdng su cung cho thay the tich khi luu thdng thd ra (VtE) giam trong khi hut rira phe quan (tir 484 ± 89 xudng 278 ± 153 ml vdi mode thd VCV va tir 483 ± 100 xudng 178 ± 113 vdi mode thd PCV) nhung sau dd tang len sau ngi soi [4].
Ap lire dinh dudng thd tang len khi ngi soi nhimg sau ngi soi thi ap lire dinh dirdng thd thap han ban dau. Dieu nay la do sau khi hut rira phe quan thi dudng thd dugc thdng thoang lam giam sire can dudng thd, mat khac nhu cau v8 ddng dinh (Peak flow) va the tich khi liru thdng tang Ien cung lam cho ap lire dudng thd giam xudng. T.sao va cdng sir nghien ciru tren 14 benh nhan bi xep phdi thi thdy ap lire dirdng thd trong khi soi la 30 cm H2O, trung binh tang 10 cm H2O trong khi soi va sau khi soi 1 dgn 2 phiit thi trd ve mirc binh thudng [6].
Khi mau ddng mach cung dugc cai thien tdt han sau ndi soi phd quan 1 gid (bang 2).
pH mau tang tir 7,34±0,1 len 7,42±0,2, PaO;
tang tir 74,3±10,2 Ien 83.5±_11,5 mmHg, PaCOi giam tir 49,5±7,3 xudng 45,5±6,6 mmHg vdi p < 0 , 0 5 .
CHUYEN oi: Hpl NGH| KHKT CAC TJNH VUNG DUYfeN HAI BAC B 6 LAN THtf NHAT
Sau 24 gid ndi soi phg quan chung tdi chyp lai Xquang phdi cho b?nh nhan va thky tkt ck cae benh nhan dgu cd sir cdi thign tren phim chup thg hi?n qua mirc dg md d phoi giam di. Trong dd cd 28 benh nhan (70%) cdi thi?n tot, 12 benh nhdn (30%) cdi thi^n mgt phan.
Chiing tdi thay ehi cd 2 b?nh nhdn bj chay mau niem mac phe quan chidm 5%
(bdng 3). Day Id nhifng b?nh nhan bj nhiem triing n^ng, niem mac vigm va phii ng. Tuy nhien sau khi bam rira sach vd diing Adrenalin de cam mau thi deu dat ket qua tdt.
Bdng 3 cung cho thay cd 1 benh nhan bi tut huygt ap nh? sau khi gay me bdng Midazolam va Fenthanyl, miirc huyet dp Id 80/50 mmHg. Chiing Idi chi truyen djch de ndng huygt dp md khdng phai sir dung thudc van mach. Nghien cuu ciia Trouillet va cgng sir ciing cho thay huygt dp tdi da gidm sau khi gay mg va bat dau ngi soi nhung tang trd lai trong qua trinh ngi soi [5]. Chiing tdi khdng gap cdc tai bien nguy hiem nhu sdc phdn ve do thudc te, thudc me, suy hd hap hay loan nhip tim, tran khi mdng phdi.
V- KET LUAN
Hieu qua cua noi soi hiit riia phe quan:
- Mach, huyet dp vd tan sd thd khong thay ddi sau ngi soi.
- Ndng do bao hda oxy mau (Sp02) tang Ien sau ndi soi.
- Thg tich khi luu thong tang len, dp lire dinh dudng thd giam di so vdi tnrdc khi ndi soi.
- Khi mdu ddng mach dugc cai thien tdt han sau ngi soi phe qudn 1 gid.
- Hinh dnh Xquang phdi cai thien tk^
sau ngi soi. ***
Tai bien cua ngi soi phe qudn:
- Cd 2 benh nhan bj chay mdu niem mac phg qudn (5%), 1 benh nhan bj tut huySt if nh? (2,5%).
- Khdng cd b?nh nhan nao bj tai bign nguy hiem nhu suy hd hap, trdn khi mim phoi, loan nhjp tim...
TAI UEU THAM KHAO
I Ngo Quy Chau (2007) "Ngi soi ph^
quan", Nhd xudt hdn y hoc. '^1 2. Andrew B. (2009) "Primum Non
Nocere: How To Cause Chaos With a' Bronchoscope in the ICU", Chesl: 135;2-4.
3. Gold (2010), "Global strategy the diagnosis, management and prevent of chronic obstractive palmonary diseas ."•"
4. Lindgren S., Odenstedt H., Erlandssoir<
K., et al (2008) "Bronchosco^*
suctioning may cause lung collapse: f\
lung model and clinical evaluation", i4c/ff Anaesthesiol Scand 52(2):209-18, PMID-
18005383
5. Trouillet J.L., Guiguet M., Gibert C^i et al (1990) "Fiberoptic Bronchoscoi^:
Ventilated Patients. Evaluation *ofV;
Cardiopulmonary Risk under Midazolam- Sedation", Chesi:97:927-933. a 6. Tsao T.C, Tsai Y.H., Lan R.S., et at;
(1990) "Treatment for collapsed lung in critically ill patients. Selectiy^'i intrabronchia! air insufflation using the, fiberoptic bronchoscope", Chest;97;0- ••
438.
