心肺功能不全的物理治療診斷與治療：thoracic surgery and pleural disease

1、Thoracic Surgery and Pleural DiseaseThoracic Surgery胸外科Video-assisted thoracic surgery (VATS)可視胸腔鏡手術(shù)Thoracotomy開胸手術(shù)Surgical Approach手術(shù)方式Video-assisted thoracic surgery (VATS)可視胸腔鏡手術(shù)Exploration & procedures helped with a thoracoscope 胸腔鏡下探視及手術(shù)Video-assisted thoracic surgery (VATS)可視胸腔鏡手術(shù)position 體位：側(cè)

2、臥位incision 切口：矩形分布、三角分布（最大的孔15mm,小孔5mm)Video-assisted thoracic surgery (VATS)可視胸腔鏡手術(shù)適應(yīng)癥：胸膜疾病 肺部疾病禁忌癥：不能耐受單側(cè)肺通氣的患者Surgical Approach手術(shù)方式Thoracotomy開胸手術(shù)Thoracotomy開胸手術(shù)Incision切口Thoracotomy開胸手術(shù)Incision切口Thoracia Surgery胸科手術(shù)lung tissue 肺組織 pleural cavity 胸腔 chest wall 胸壁 oesophagus 食管 other organs 其他器官Lu

3、ng Cancer肺癌Wedge resection 楔形切除術(shù)Segmental resection 部分切除術(shù)Lobectomy 肺葉切除術(shù)Pneumonectomy全肺切除術(shù)其他：（Bronchial sleeve lobectomy ）支氣管袖式切除術(shù)、（Sleeve resection of the pulmonary artery肺動脈袖式切除、Superior vena cava replacement 上腔靜脈置換、Lymph nodes dissection 淋巴結(jié)清掃）Lung Tissue肺組織Lung Tissue肺組織Procedures involving lung

4、 tissues肺組織相關(guān)手術(shù)Over-sewing of cysts or blebs 囊腫或肺大泡外部縫合repair of small weakened areas of pulmonary tissue 肺組織修復(fù)Resection of emphysematous bullae 肺氣腫切除術(shù)tie off large over-inflated cystic areas / cysts接扎較大的過度膨脹囊腫區(qū)域/囊腫胸腔相關(guān)手術(shù)Pleurodesis胸膜固定術(shù)Pleurectomy胸膜切除術(shù)Decortication去皮質(zhì)術(shù)心臟相關(guān)手術(shù)Open heart surgery心臟直視手術(shù)

5、sternotomy 胸骨切開術(shù)Coronary artery bypass graft (CABG), valve(s) replacement冠狀動脈旁路搭橋術(shù)、瓣膜重置Closed heart surgery心臟縫合thoracotomy / VATS開胸/鏡下PDA ligation PDA結(jié)扎Procedures involving the chest wall胸壁相關(guān)手術(shù)Rib resection肋骨切除術(shù)for relief of symptoms caused by thoracic outlet syndrome 用于解除胸廓出口綜合癥相關(guān)癥狀for tumors of th

6、e rib肋骨腫瘤*for drainage of empyema膿液導(dǎo)出* not a common 不是目前常見手術(shù)procedure nowProcedures involving the chest wall胸壁相關(guān)手術(shù)Thoracoplasty (uncommon now) 胸廓成形術(shù)（現(xiàn)在不常見） extensive upper rib resection增強(qiáng)的上部肋骨切除術(shù) for collapse of lung segment用于肺段衰竭 Thoracotomy 胸廓切開術(shù)Procedures involving the chest wall胸壁相關(guān)手術(shù)Correction

7、of Pectus Excavatum (funnel chest )漏斗胸矯正術(shù)for cosmetic reasons美觀severing and re-setting of sterno-costal junction切開并重置胸肋關(guān)節(jié)NO side or prone lying for 6 weeks (only supine and sitting allowed)6周禁止側(cè)躺和俯臥（只能仰臥位和坐位）Pectus Excavatum (funnel chest)漏斗胸Procedures involving the chest wall胸壁相關(guān)手術(shù)Correction of Pec

8、tus Carinatum (pigeon chest )雞胸矯正術(shù)for cosmetic reason美觀removal of prominent costal cartilages切除凸顯的肋軟骨NO side or prone lying for 6 weeks (only supine and sitting allowed) 6周禁止側(cè)躺和俯臥（只能仰臥位和坐位）Pectus Carinatum (pigeon chest)雞胸Procedures involving the oesophagus食道相關(guān)手術(shù)Oesophagectomy食管切除術(shù)involves 3 incisio

9、ns: abdominal, thoracic and cervical3個切口：腹、胸、頸Oesophago-gastrectomy食道-胃切除術(shù)involving the lower third of the oesophagus包括下1/3的食管Hiatus hernia repair (VATS)食管裂孔疝修復(fù)術(shù)Procedures involving the oesophagus食道相關(guān)手術(shù)Post-op management術(shù)后護(hù)理head raised on 2 pillows (30 ) to avoid reflux of gastric fluid頭下墊2個枕頭（抬頭30）

10、避免胃液逆流lung expansion exercises are important as lungs are partially collapsed during operation由于手術(shù)伴發(fā)肺衰竭，術(shù)后進(jìn)行肺部擴(kuò)張練習(xí)Other procedures:其它Thymectomy胸腺切除術(shù)removal of a thymoma (associated with Myasthenia Gravis)切除胸腺瘤（伴發(fā)重癥肌無力）patients tire easily with muscle fatigue 伴隨肌肉疲勞病人易疲倦trans-cervical incision or VAT

11、 頸部橫切或VATInsertion of a permanent pacemaker永久性起搏器植入pacemaker embedded in pectoral or abdominal pocket起搏器放入胸部或腹部口袋中pericardium is opened for pacing wire attachment心包處于打開狀態(tài)以方便調(diào)節(jié)配件Pulmonary Complications肺部并發(fā)癥Infection感染 (Pneumonia or bronchitis)Atelectasis肺不張Respiratory failure and prolonged mechanical

12、 ventilation呼吸衰竭和機(jī)械通氣Bronchospasm支氣管痙攣Exacebation of underlying chronic lung disease hospital day, morbidity & mortality 潛在的慢性肺疾病的惡化導(dǎo)致住院天數(shù)增加，患病率和死亡率的增加Pre-operative Assessment術(shù)前評估Patient related risk factors患者因素Procedure related risk factors手術(shù)因素Preoperative risk assessment術(shù)前風(fēng)險評估Risk reduction strate

13、gies降低風(fēng)險的策略Patient related risk factors患者因素Age 年齡Obesity肥胖Smoking吸煙General health status一般健康狀況Chronic obstructive pulmonary disease (COPD)慢性阻塞性肺疾病Asthma哮喘Age年齡Minor risk factor次要危險因素Independent predictor (?)獨(dú)立的預(yù)測指標(biāo)？Obesity肥胖Morbid obesity restrictive lung disease, thoracic compliance, alveolar hypov

14、entilation病理性肥胖導(dǎo)致限制性肺疾病，使胸廓順應(yīng)性下降，肺泡的通氣減少Smoking吸煙Important risk factor重要的危險因素Smoking history of 40 pack years or more risk of pulmonary complications一年40包煙以上導(dǎo)致肺部并發(fā)癥風(fēng)險增加戒煙 2 months = 4:1 (57% : 14.5%) 戒煙 6 months : 未吸煙 = 1:1 (11% : 11.9%)COPD嚴(yán)重COPD患者術(shù)后并發(fā)癥發(fā)生增加6倍A careful preoperative evaluation of pat

15、ients with COPD 應(yīng)對患有COPD的術(shù)前患者進(jìn)行仔細(xì)的評估 Asthma哮喘Inadequate control of asthma risk of postoperative complications哮喘的控制不良導(dǎo)致售后并發(fā)癥的風(fēng)險增加Well controlled, peak flow measurement of 80% of predicted or personal best average risk PEF預(yù)計值80%屬于一般風(fēng)險Asthmatic patients treated with corticosteroids before surgery have

16、a low incidence of complications術(shù)前使用內(nèi)固醇激素可以降低風(fēng)險Procedure related risk factors手術(shù)相關(guān)風(fēng)險因素Surgical site手術(shù)切口Size of removed lung parenchyma切除肺的面積Duration and type of anesthesia麻醉的持續(xù)時間Type of neuromuscular blockade神經(jīng)肌肉阻滯方式Preoperative risk assessment術(shù)前風(fēng)險評估Clinical evaluation臨床評估Pulmonary function test肺功能測試

17、Spirometry & Blood gas analysis Cardopulmonary exercise test心肺運(yùn)動測試Pulmonary function testing肺功能測試Risky for Pneumonectomy全肺切除風(fēng)險指標(biāo)FEV1 60% of the predicted value or 2LDLCO 60% of the predicted value MVV 80% of the predicted value or 2LSafe lower limit for Lobectomy肺葉切除安全低限FEV11.5Lor 60% of the predicted valuePulmonary function testing肺功能測試Blood gas analysis血?dú)夥治鯤ypoxemia: SaO2 45mmHgCardiopulmonary exercise test心肺運(yùn)動測試Maximal oxygen uptake (VO2max)VO2m