5．術後気漏・無気肺・肺炎にかかわる周術期管理の留意点

Perioperative Management for Air Leakage, Atelectasis, and Pneumonia in Patients Undergoing Lung Resection

術後気漏・無気肺・肺炎は，呼吸器外科手術後であれば常に念頭にある一般的な合併症であろう．多くの症例では，適切に対応することで重大な転機とはならず軽快していく．しかし，同じ合併症であっても発生のメカニズムや病態によって治療法が異なる場合がある．本稿では，発症時の定型的治療を概説し，加えて早期に鑑別するべき病態や定型的対応で改善が得られないときに想起するべき病態について解説する．本稿で診断の重要性を再確認されたい．発症に関する予測因子や術前予防策（禁煙，吸入薬，理学療法，口腔ケア）の詳細については，別項あるいは成書を参照されたい．

Thoracic surgeons often encounter postoperative air leakage, atelectasis, and pneumonia as common complications of lung resection. Mostly, those are managed and treated properly, which results in avoiding serious outcomes. However, some clinical conditions manifesting initially as common complications could become severe unless an early correct differential diagnosis is made. Regarding air leakage, we summarized intraoperative techniques for pulmonary fistula and pleurodesis as postoperative treatment. Concerning atelectasis, in addition to management for obstructive atelectasis due to bronchial secretion, we described the adaptive displacement of the middle lobe after right upper lobectomy and tips for diagnosis and management of bronchial kinking and/or lobar torsion of the middle lobe. Regarding postoperative pneumonia, we emphasized smoking cessation and overviewed standard management for chronic obstructive pulmonary disease by bronchodilator as preoperative management. Moreover, we summarized standard treatment for hospital-acquired pneumonia and emphasized the importance of differential diagnosis if the initial empiric antibiotic therapy failed because some interstitial pulmonary diseases, such as organizing pneumonia and drug-induced lung injury, may mimic bacterial pneumonia.