心肺功能不全的物理治疗诊断与治疗：thoracic surgery and pleural disease

1、Thoracic Surgery and Pleural DiseaseThoracic Surgery胸外科Video-assisted thoracic surgery (VATS)可视胸腔镜手术Thoracotomy开胸手术Surgical Approach手术方式Video-assisted thoracic surgery (VATS)可视胸腔镜手术Exploration & procedures helped with a thoracoscope 胸腔镜下探视及手术Video-assisted thoracic surgery (VATS)可视胸腔镜手术position 体位：侧

2、卧位incision 切口：矩形分布、三角分布（最大的孔15mm,小孔5mm)Video-assisted thoracic surgery (VATS)可视胸腔镜手术适应症：胸膜疾病 肺部疾病禁忌症：不能耐受单侧肺通气的患者Surgical Approach手术方式Thoracotomy开胸手术Thoracotomy开胸手术Incision切口Thoracotomy开胸手术Incision切口Thoracia Surgery胸科手术lung tissue 肺组织 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 楔形切除术Segmental resection 部分切除术Lobectomy 肺叶切除术Pneumonectomy全肺切除术其他：（Bronchial sleeve lobectomy ）支气管袖式切除术、（Sleeve resection of the pulmonary artery肺动脉袖式切除、Superior vena cava replacement 上腔静脉置换、Lymph nodes dissection 淋巴结清扫）Lung Tissue肺组织Lung Tissue肺组织Procedures involving lung

4、 tissues肺组织相关手术Over-sewing of cysts or blebs 囊肿或肺大泡外部缝合repair of small weakened areas of pulmonary tissue 肺组织修复Resection of emphysematous bullae 肺气肿切除术tie off large over-inflated cystic areas / cysts接扎较大的过度膨胀囊肿区域/囊肿胸腔相关手术Pleurodesis胸膜固定术Pleurectomy胸膜切除术Decortication去皮质术心脏相关手术Open heart surgery心脏直视手术

5、sternotomy 胸骨切开术Coronary artery bypass graft (CABG), valve(s) replacement冠状动脉旁路搭桥术、瓣膜重置Closed heart surgery心脏缝合thoracotomy / VATS开胸/镜下PDA ligation PDA结扎Procedures involving the chest wall胸壁相关手术Rib resection肋骨切除术for relief of symptoms caused by thoracic outlet syndrome 用于解除胸廓出口综合症相关症状for tumors of th

6、e rib肋骨肿瘤*for drainage of empyema脓液导出* not a common 不是目前常见手术procedure nowProcedures involving the chest wall胸壁相关手术Thoracoplasty (uncommon now) 胸廓成形术（现在不常见） extensive upper rib resection增强的上部肋骨切除术 for collapse of lung segment用于肺段衰竭 Thoracotomy 胸廓切开术Procedures involving the chest wall胸壁相关手术Correction

7、of Pectus Excavatum (funnel chest )漏斗胸矫正术for cosmetic reasons美观severing and re-setting of sterno-costal junction切开并重置胸肋关节NO side or prone lying for 6 weeks (only supine and sitting allowed)6周禁止侧躺和俯卧（只能仰卧位和坐位）Pectus Excavatum (funnel chest)漏斗胸Procedures involving the chest wall胸壁相关手术Correction of Pec

8、tus Carinatum (pigeon chest )鸡胸矫正术for cosmetic reason美观removal of prominent costal cartilages切除凸显的肋软骨NO side or prone lying for 6 weeks (only supine and sitting allowed) 6周禁止侧躺和俯卧（只能仰卧位和坐位）Pectus Carinatum (pigeon chest)鸡胸Procedures involving the oesophagus食道相关手术Oesophagectomy食管切除术involves 3 incisio

9、ns: abdominal, thoracic and cervical3个切口：腹、胸、颈Oesophago-gastrectomy食道-胃切除术involving the lower third of the oesophagus包括下1/3的食管Hiatus hernia repair (VATS)食管裂孔疝修复术Procedures involving the oesophagus食道相关手术Post-op management术后护理head raised on 2 pillows (30 ) to avoid reflux of gastric fluid头下垫2个枕头（抬头30）

10、避免胃液逆流lung expansion exercises are important as lungs are partially collapsed during operation由于手术伴发肺衰竭，术后进行肺部扩张练习Other procedures:其它Thymectomy胸腺切除术removal of a thymoma (associated with Myasthenia Gravis)切除胸腺瘤（伴发重症肌无力）patients tire easily with muscle fatigue 伴随肌肉疲劳病人易疲倦trans-cervical incision or VAT

11、 颈部横切或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心包处于打开状态以方便调节配件Pulmonary Complications肺部并发症Infection感染 (Pneumonia or bronchitis)Atelectasis肺不张Respiratory failure and prolonged mechanical

12、 ventilation呼吸衰竭和机械通气Bronchospasm支气管痉挛Exacebation of underlying chronic lung disease hospital day, morbidity & mortality 潜在的慢性肺疾病的恶化导致住院天数增加，患病率和死亡率的增加Pre-operative Assessment术前评估Patient related risk factors患者因素Procedure related risk factors手术因素Preoperative risk assessment术前风险评估Risk reduction strate

13、gies降低风险的策略Patient related risk factors患者因素Age 年龄Obesity肥胖Smoking吸烟General health status一般健康状况Chronic obstructive pulmonary disease (COPD)慢性阻塞性肺疾病Asthma哮喘Age年龄Minor risk factor次要危险因素Independent predictor (?)独立的预测指标？Obesity肥胖Morbid obesity restrictive lung disease, thoracic compliance, alveolar hypov

14、entilation病理性肥胖导致限制性肺疾病，使胸廓顺应性下降，肺泡的通气减少Smoking吸烟Important risk factor重要的危险因素Smoking history of 40 pack years or more risk of pulmonary complications一年40包烟以上导致肺部并发症风险增加戒烟 2 months = 4:1 (57% : 14.5%) 戒烟 6 months : 未吸烟 = 1:1 (11% : 11.9%)COPD严重COPD患者术后并发症发生增加6倍A careful preoperative evaluation of pat

15、ients with COPD 应对患有COPD的术前患者进行仔细的评估 Asthma哮喘Inadequate control of asthma risk of postoperative complications哮喘的控制不良导致售后并发症的风险增加Well controlled, peak flow measurement of 80% of predicted or personal best average risk PEF预计值80%属于一般风险Asthmatic patients treated with corticosteroids before surgery have

16、a low incidence of complications术前使用内固醇激素可以降低风险Procedure related risk factors手术相关风险因素Surgical site手术切口Size of removed lung parenchyma切除肺的面积Duration and type of anesthesia麻醉的持续时间Type of neuromuscular blockade神经肌肉阻滞方式Preoperative risk assessment术前风险评估Clinical evaluation临床评估Pulmonary function test肺功能测试

17、Spirometry & Blood gas analysis Cardopulmonary exercise test心肺运动测试Pulmonary function testing肺功能测试Risky for Pneumonectomy全肺切除风险指标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肺叶切除安全低限FEV11.5Lor 60% of the predicted valuePulmonary function testing肺功能测试Blood gas analysis血气分析Hypoxemia: SaO2 45mmHgCardiopulmonary exercise test心肺运动测试Maximal oxygen uptake (VO2max)VO2m