Hagl C, Harringer W, Gohrbandt B, Haverich A
Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Germany.
Chest. 1999 Mar;115(3):757-61. doi: 10.1378/chest.115.3.757.
Coronary artery bypass graft (CABG) surgery using the left internal mammary artery (LIMA) impairs postoperative pulmonary function. We studied the changes in pulmonary function and subjective pain relative to the site of chest tube insertion.
Thirty patients undergoing CABG surgery using the LIMA were randomized into two groups. Group A (n = 15) received a left chest tube inserted from the midline (subxyphoid). Group B (n = 15) had a tube placed in the sixth intercostal space at the anterior axillary line. All of the patients underwent bedside pulmonary function testing preoperatively and on postoperative days (PODs) 1, 3, and 5. Pain sensation was quantified by a standardized score (1 to 10).
A significant impairment of pulmonary function parameters was observed in both groups until POD 5. For group A, the decline in percent predicted (+/-SD) in the vital capacity (VC) from before surgery to POD 5 was, respectively, 92.3+/-30.6% to 56.9+/-12.6% (p < 0.001). For group B, the decline in the VC was from 88.0+/-18.2% to 55.5+/-14.8% (p < 0.001). The FEV1 declined concomitantly in group A from 86.2+/-18.2% to 50.8+/-12.1%, and in group B from 83.5+/-16.4% to 53.9+/-12.5% (p < 0.001). On POD 1, a significantly lower decrease in the VC was measured in group A than in group B, respectively: 45.3+/-15.5% vs 28.6+/-8.7% (p < 0.001). A significantly lower decrease in the FEV1 was also seen in group A than in group B, respectively: 36.9+/-12.9% vs 28.0+/-10.6% (p < 0.05). Pain experienced during deep inspiration was also significantly less in group A than in group B, respectively: 1.2+/-1.1 vs 2.5+/-0.9 (p < 0.01).
Subxyphoid insertion of the pleural drain leads to a significantly lower impairment of pulmonary function and less subjective pain than insertion at the intercostal position. The drainage of the left pleural space is equally effective with both techniques.
使用左乳内动脉（LIMA）的冠状动脉旁路移植术（CABG）会损害术后肺功能。我们研究了肺功能变化以及与胸管插入部位相关的主观疼痛情况。
30例行LIMA冠状动脉旁路移植术的患者被随机分为两组。A组（n = 15）从正中（剑突下）插入左胸管。B组（n = 15）在腋前线第6肋间放置胸管。所有患者在术前及术后第1、3和5天进行床边肺功能测试。疼痛感觉通过标准化评分（1至10分）进行量化。
两组患者直到术后第5天肺功能参数均出现显著损害。对于A组，从术前到术后第5天，肺活量（VC）预测值百分比（±标准差）的下降分别为92.3±30.6%至56.9±12.6%（p < 0.001）。对于B组，VC的下降从88.0±18.2%至55.5±14.8%（p < 0.001）。A组第1秒用力呼气容积（FEV1）随之从86.2±18.2%下降至50.8±12.1%，B组从83.5±16.4%下降至53.9±12.5%（p < 0.001）。在术后第1天，A组测量的VC下降幅度显著低于B组，分别为：45.3±15.5%对28.6±8.7%（p < 0.001）。A组FEV1的下降幅度也显著低于B组，分别为：36.9±12.9%对28.0±10.6%（p < 0.05）。A组深吸气时的疼痛也显著低于B组，分别为：1.2±1.1对2.5±0.9（p < 0.01）。
与肋间位置插入相比，剑突下插入胸膜引流管导致的肺功能损害显著更低，主观疼痛更少。两种技术对左胸膜腔的引流效果相同。
