Objective To compare the effect of high thoracic epidural anesthesia(hTEA) with levobupivacaine and bupivacaine on pulmonary function during breast surgery.Methods Thirty two ASA Ⅱ-Ⅲ female patients with chronic obstructive pulmonary disease (COPD) and asthma undergoing breast surgery were randomly divided into L(levobupivacaine) and B(bupivacaine) groups,with 16 patients in each group.The epidural space T2-4 was selected.The patients received sequential local anesthetic until sensory blockate to C4.7 was established and the anesthesia was maintained with epidural administration.A local anesthetic dosage,effect of sensory block,analgesia,hemodynamic,lung function and adverse reaction were recorded and compared.Results The onset time of sensory block in the levobupivacaine group was (12±5) min; average time reaching the highest plane was (12 ±5) min; highest sensory block plane was C4.The onset time of sensory block in the bupivacaine group was(12 ±6)min; average time reaching the highest plane was (24 ± 8)min; highest sensory block plane was C5 ;there was no significant difference in both groups (P ＞ 0.05).There were 3 cases with intraoperative visual analog score ＞ 2 poimts in Levobupivacaine group.There were 2 cases with additional epidural local anesthetic in Levobupivacaine group.Forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) in both groups were significantly lower than before operation [Levobupivacaine group showed,(2.01 ± 0.41),(1.69 ± 0.43) Lvs (2.38 ± 0.48)L;(62 ± 6)％,(57 ± 5)％ vs (66 ± 6)％; bupivacaine group showed (2.02 ± 0.43),(1.71 ± 0.42) Lvs (2.37 ± 0.46)L,(62 ± 6)％,(58 ±6)％ vs (67 ± 6)％ ; the differences were statistically significant (P＜0.05)].30 min and 2 h after surgery,FEV1/ FVC in both groups was significantly higher than before operation [levobupivacaine group (72 ± 7),(72 ± 6) vs (67 ± 7),bupivacaine group (71 ± 6),(71 ± 5) vs of (67 ± 5)].After epidural infusion for30 minutes,FVC,FEV1 decreased and FEV1/FVC increased (P ＜ 0.05).FVC,FEV1 increased slightly (P ＞ 0.05) and FEV1/FVC increased (P ＜ 0.05) after operation 2 h.Conclusions Levobupivacaine and bupivacaine in high thoracic epidural anesthesia have similar effects on pulmonary function during breast surgery.The anesthesia can reduce the airway resistance and improve FEV1/FVC,therefore hTEA can be used in the patient with COPD and asthma.%目的 比较左旋布比卡因和布比卡因高位胸段硬膜外阻滞乳腺手术的麻醉效果和对肺通气功能的影响.方法 32例有合并慢性阻塞性肺疾病(COPD)和哮喘、女性、美国麻醉医师协会(ASA)分级Ⅱ～Ⅲ级择期乳腺手术患者,完全随机分为左旋布比卡因组和布比卡因组,每组16例.取T2～4硬膜外注入左旋布比卡因组或布比卡因组局麻药初量,术中酌情追加用药.对局部麻醉药用量,感觉阻滞、镇痛效果、血流动力学、肺通气功能和不良反应进行比较.结果 左旋布比卡因组感觉阻滞起效时间(12±5)min,达最高平面平均时间(26 ±8)min,感觉阻滞最高平面为C4,布比卡因组:感觉阻滞起效时间(12±6)min,达最高平面平均时间(24±8)min,感觉阻滞最高平面为C5.左旋布比卡因组术中视觉模拟评分＞2分者3例,布比卡因组7例,左旋布比卡因组术中静脉注射芬太尼者2例,布比卡因组7例,左旋布比卡因组硬膜外追加局部麻醉药者2例,布比卡因组6例.布比卡因组麻醉后20 min,左旋布比卡因组麻醉后30 min血压、心率低于麻醉0 min(麻醉前)时.左旋布比卡因组2例静脉注射麻黄碱,布比卡因组7例静脉注射麻黄碱;术中硬膜外静脉注射阿托品,左旋布比卡因组7例,平均(0.52 ±0.15)mg,布比卡因组12例,平均(0.66±0.24)mg,2组患者注射麻黄碱、注射阿托品,使用阿托品的平均剂量差异亦无统计学意义(P＞0.05).术前2d平卧位和硬膜外麻醉后30min用力肺活量(FVC)、第1秒钟用力呼气容积(FEV1)均明显低于术前2d坐位,左旋布比卡因组(2.01 ±0.41)、(1.69 ±0.43)L比(2.38 ±0.48)L,(62±6)％、(57±5)％比(66±6)％;布比卡因组(2.02±0.43)、(1.71 ±0.42)L比(2.37 ±0.46)L,(62±6)％、(58±6)％比(67±6)％;差异均有统计学意义(P＜0.05).术后2h FVC、FEV1与术前2d平卧位比较,差异无统计学意义(P＞0.05).硬膜外麻醉30 min与术后2 h FEV1/FVC均明显高于术前2d平卧位[左旋布比卡因组为(72 ±7)、(72 ±6)比(67 ±7),布比卡因组为(71 ±6)、(71 ±5)比(67±5)].结论 左旋布比卡因和布比卡因在高位胸段硬膜外阻滞乳腺手术有相似的麻醉效果和对肺通气功能影响,左旋布比卡因感觉阻滞优于布比卡因并显示有较低的心血管抑制作用,其麻醉使呼吸道阻力降低并对FEV1/FVC有明显改善作用,因此左旋布比卡因与布比卡因高位胸段硬膜外阻滞可用于有合并COPD和哮喘患者.
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