免插管麻醉於胸腔手術的臨床應用與迷你豬模型

Abstract

近年來胸腔鏡手術快速盛行，除了傷口小、疼痛減輕、復原快，併發症較少，且長期預後類似於傳統開胸手術，因而逐漸成為主流。以往認為胸腔鏡手術必須在全身麻醉下使用特殊的雙腔支氣管導管插管以確保單肺呼吸，但插管相關氣道損傷、手術後殘餘神經肌肉阻滯、機械通氣相關肺損傷…等並非罕見。台大醫院自2009年開始發展免插管胸腔鏡手術，迄今已逾千名病患，其中包括複雜的肺癌肺葉或肺節葉切除手術。潛在好處除了避免傳統插管麻醉不可避免的氣道傷害、呼吸器肺損傷、及減少術後噁心嘔吐之外，也可以加速患者手術後恢復，提高病患滿意度。 本研究針對免插管胸腔鏡手術中的麻醉照護進行一系列的臨床研究，並以迷你豬建立動物模式以提供轉譯研究及團隊訓練平台。臨床研究結果確立區域阻斷減少手術中全身性麻醉止痛藥物需求；單孔免插管胸腔鏡手術跨國多中心的經驗顯示其可行性；常規運用高流量氧氣鼻導管於免插管胸腔鏡手術中提升動脈血氧濃度；肺功能不良患者可能接受免插管胸腔鏡手術進行肺腫瘤切除；免插管胸腔鏡手術治療早期肺癌的長期預後與插管手術相似；新冠肺炎大流行期間免插管胸腔鏡手術患者在術中全程戴口罩以減少分泌物；以及免插管胸腔手術迷你豬模型的建立。 臨床研究證實了免插管麻醉在胸腔鏡的可行性與潛在好處，並能促進術後恢復。回顧性分析提供了在不同國家團隊胸腔外科手術患者應用非插管麻醉的可行性證據。對於早期肺癌手術患者採取免插管胸腔鏡肺葉切除相較插管手術能提供相似的長期預後，成為早期肺癌手術治療的替代方法。新冠肺炎大流行期間，患者接受免插管麻醉免於氣管插管與支氣管鏡檢查，胸腔鏡手術中全程戴口罩以減少分泌物汙染疑慮。迷你豬免插管胸腔手術模型的建立能用來訓練手術和麻醉團隊並為轉譯研究提供了平台。

Thoracoscopic surgery has gained popularity due to its advantages of smaller incisions, reduced pain, faster recovery, and comparable long-term outcomes to traditional open thoracotomy but with fewer complications. In the past, it was commonly believed that thoracoscopic surgery necessitated the use of double-lumen endotracheal tubes and general anesthesia to achieve single-lung ventilation. However, intubation-related complications, such as airway injuries, ventilator-associated lung injury, and residual neuromuscular blockade, are not uncommon. Since 2009, National Taiwan University Hospital has been at the forefront of developing non-intubated thoracoscopic surgery, successfully treating over a thousand patients, including those requiring complex lung cancer lobectomy or segmentectomy. This innovative approach offers several potential benefits. Firstly, it eliminates the inevitable respiratory tract intervention and injury associated with intubated general anesthesia. Additionally, it reduces the incidence of postoperative nausea and vomiting. Moreover, non-intubated thoracoscopic surgery accelerates patient recovery, leading to increased patient satisfaction. This thesis aims to investigate the anesthesia care provided during non-intubated thoracoscopic surgery and presents a series of significant clinical research findings. To facilitate translational research and team training, an animal model using miniature pigs has been established. The results of clinical studies have confirmed that regional blockade effectively reduces the requirement for systemic analgesics during surgery. The feasibility of single-port non-intubated thoracoscopic surgery has been confirmed through experiences across multiple centers and countries. Furthermore, the routine application of high-flow oxygen nasal cannula during non-intubated thoracoscopic surgery has been demonstrated to enhance arterial oxygen preserves. Patients with compromised lung function can safely undergo non-intubated thoracoscopic surgery for the resection of lung tumors. Importantly, the long-term prognosis for clinical stage I non-small cell lung cancer treated with non-intubated thoracoscopic lobectomy is comparable to that of intubated surgery. During the challenging period of the COVID-19 pandemic, patients undergoing non-intubated thoracoscopic surgery have adhered to wearing masks throughout the procedure to minimize aerosol-related risks to the healthcare providers. Additionally, a minipig model for non-intubated thoracic surgery has been successfully established, contributing to further advancements in this field. Non-intubated anesthesia in thoracoscopic surgery has been validated by clinical research, enhancing recovery after surgery. Retrospective analysis supports its feasibility in thoracic surgical patients worldwide. Non-intubated thoracoscopic lobectomy is a validated alternative for early-stage lung cancer treatment with comparable outcomes to intubation surgery. During the COVID-19 pandemic, non-intubated thoracoscopic surgery enables patients to avoid intubation and bronchoscopy, with continuous mask use reducing secretion concerns. A miniature pig model for non-intubated thoracic surgery facilitates team training and translational research in non-intubated thoracic surgery.