臺灣博碩士論文加值系統

肺切除術 (Pneumonectomy : PnX) 至今仍舊是一項極具挑戰性的外科手術，由於解剖構造上發生巨大的改變，因此由肺部基本架構所主導的血流和氣流分佈勢必有很大的變化。「更換姿勢」是重症加護病房例行的護理措施之ㄧ，並且已有臨床報告指出PnX後因肺水腫而嚴重缺氧的病人，其姿勢由仰臥翻到健側肺在上方的側躺姿勢時，能使動脈血氧濃度大幅增加，但其機制未明。本實驗室利用「螢光微粒技術 (FMS)」來觀測左肺切除以及肺切除後左側躺姿勢對肺的局部血流和氣流之空間分佈的影響，藉由這些結果可以得知左側躺姿勢是如何改善動脈血氧濃度。利用23.4 ± 1.9 kg的豬仔，於正常狀態、左側肺切除、肺切除後右側躺、以及肺切除後左側躺四種狀況下，同時從靜脈注射 (15微米) 並由氣管噴入 (1微米) 不同顏色的螢光微粒，以代表該狀況下的通氣和血流分佈情形；利用多重惰性氣體技術 (MIGET) 來測量通氣/血流比值在肺整體的分佈。將肺取出風乾後，切成約1.7 cm3的肺小塊，平均可以切成431 ± 36個肺小塊，偵測每小塊內各種顏色螢光值的強弱，經過重量校正後再進行統計分析。根據實驗結果顯示，左肺切除後動脈血氧濃度顯著下降，MIGET圖形中通氣和血流皆呈現雙峰的分佈情形，並且兩者皆往「高通氣/血流比值」區域移動。從FMS結果來看，血流有顯著的重新分佈，且空間分佈的變異性增加；此時血流向背側和中心部份移動但氣流則是向腹側和周邊增加，兩者之間的相關係數 (R值) 顯著降低。翻至左側躺姿勢後，MIGET圖形在靠近通氣/血流比值為1之處出現單一高峰，通氣和血流的相關係數由0.13 ± 0.03增加為0.50 ± 0.20，表示吻合程度顯著改善，同時動脈血氧濃度也由148.6 ± 18.6 mmHg顯著上升至 200.9 ± 14.1 mmHg。由此可知左肺切除後會造成血流的重新分佈，而使通氣/血流的吻合度變差。左側躺姿勢可使肺部的血流分佈較一致，並減低心臟和橫膈膜對肺造成的壓迫，使得功能性肺餘容積顯著增加而改善通氣情形，藉此通氣/血流的吻合程度明顯增高，而達到提升動脈血氧濃度顯著的效果。

Pneumonectomy (PnX) still remains a challenging surgical intervention. It causes major anatomical changes that must have an extensive effect on spatial distribution of ventilation (VA) and perfusion (Q) in the lung. Turning and positioning of critical ill patient are well-accepted routine nursing activities. There has a clinical report that patients of life-threatening hypoxemia occurring during postpneumonectomy edema (PPE) successfully managed with lateral decubitus (LD), with the remaining lung placed uppermost. However, the mechanism remains unclear. Our study uses fluorescent microspheres (FMS) technique to measure the spatial distribution of regional VA and Q post left PnX and on left and right LD. According to the FMS we may tell how the LD improves oxygenation. Pulmonary Q and VA were analyzed with intravenous and inhaled FMS (15 and 1 micro meter) in piglets (23.4 ± 1.9 kg) studied in baseline – supine (BS), postPnX – supine (PS), postPnX – RLD (PR) and postPnX – LLD (PL) four conditions. Using the multiple inert gas elimination technique (MIGET), we determined the distribution of VA/Q ratio in whole lung. Lungs were dried and sectioned into approximately 431 ± 36 pieces (about 1.7 cm3) per animal. Fluorescence was read on a spectrophotometer. Signals were analyzed after corrected for pieces weight and normalized to mean VA and mean Q. According to the results, arterial O2 pressure (PaO2) was decreased post left PnX, and both VA and Q became bimodal distribution, and both of them moved to high VA/Q region. Base on FMS data, we found Q had huge redistribution and its spatial distribution become more heterogeneous. Q moved to dorsal and central part while VA moved to ventral and peripheral part of the remaining lung. The coefficient of correlation (R value) between VA and Q decreased significantly in PS. After turning to LLD posture, both VA and Q became one peak distribution, and was centered at VA/Q – ratio = 1 region. The R value between VA and Q significantly increased from 0.13 ± 0.03 to 0.50 ± 0.20, and PaO2 also improved from 148.6 ± 18.6 to 200.9 ± 14.1 mmHg in PL. In conclusion, VA and Q become mismatching as a result of Q redistribution post PnX, and PaO2 also decreased. LLD posture can make the spatial distribution of Q becomes homogenous, and it also can less the compression of heat and abdomen to the lung, and the functional residual capacity also increases significantly that could improve the ventilation. Therefore, LLD posture can increase PaO2 significantly through the improvement of VA/Q – matching.

總目錄
【碩士論文目次】………………………………………………………【頁次】
正文目錄……………………………………………………………………….Ⅰ
「表」目錄……………………………………………………………………...Ⅱ
「圖」目錄……………………………………………………………………...Ⅲ
中文摘要……………………………………………………………………….Ⅴ
英文摘要……………………………………………………………………….Ⅶ
第一章、緒言……………………………………………………………………1
第二章、實驗材料與方法……………………………………………………..17
第三章、實驗結果……………………………………………………………...30
第四章、討論…………………………………………………………………...46
第五章、未來展望與臨床運用……….………………………………………..57
第六章、結論…………………..……….………………………………………58
第七章、參考文獻……………………………………………………………..88

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