高水平呼气末正压通气联合肺复张在肥胖患者全麻俯卧位手术中的应用研究

Application of high level positive expiratory pressure ventilation combined with lung recruitment maneuvers in prone position operation of obese patients under general anesthesia

目的评价高水平呼末正压通气(PEEP)联合肺复张(RM)在肥胖患者全麻俯卧位手术中的应用效果。方法选择60例BMI≥28 kg/m^(2)择期拟行全麻下腰骶椎手术的肥胖患者,采用随机数字表法分为两组:对照组(A组)和实验组(B组),每组30例。A组设置PEEP=5 cmH_(2)O,B组设置PEEP=10 cmH_(2)O联合肺复张手法。观察并记录两组患者麻醉前(T0)、气管插管后仰卧位机械通气10 min(T1)、气管插管后俯卧位机械通气10 min(T2)、俯卧位机械通气1 h(T3)和气管拔管后脱氧30 min(T4)的血流动力学指标、呼吸力学指标、动脉血气分析指标、T0、T4和术后1 d(T5)时肺部超声评分(LUS)总分以及术后5 d内呼吸系统并发症的发生情况。结果两组患者心率(HR)、平均动脉压(MAP)比较差异无统计学意义;B组在T2、T3、T4时刻的氧合指数(OI)均显著高于A组,肺泡动脉氧分压差(A-aDO_(2))均低于A组(P<0.05);与T1时刻相比,T2、T3时刻两组患者的气道峰压(Ppeak)和驱动压(ΔP)呈上升趋势,肺动态顺应性(Cdyn)呈下降趋势(P<0.05)。B组术中的Ppeak、Cdyn相比于A组明显升高,而ΔP均低于A组(P<0.05);B组LUS评分在T4和T5时刻低于A组(P<0.05);两组术后5 d内呼吸系统并发症发生率比较差异无统计学意义。结论对于需行全麻俯卧位手术的肥胖患者,高水平PEEP联合肺复张有助于改善肺顺应性和氧合状态,提高患者氧储备和肺功能的恢复能力,但并未发现能够降低患者术后呼吸系统并发症的发生率。

Objective To evaluate the effect of high level positive expiratory pressure ventilation(PEEP)combined with lung recruitment maneuvers(RM)in the prone position of obese patients under general anesthesia.Methods A total of 60 obese patients with BMI≥28 kg/m^(2)who were scheduled to undergo elective lumbar and sacral surgery were selected and divided into two groups by random number table method:control group(group A)and experimental group(group B),with 30 cases in each group.PEEP=5 cmH_(2)O was set in group A,and PEEP=10 cmH_(2)O was set in group B combined with RM.Hemodynamic indexes,respiratory mechanics indexes,arterial blood gas analysis indexes before anesthesia(T0),mechanical ventilation in supine position for 10 min(T1),mechanical ventilation in prone position for 10 min(T2),mechanical ventilation in prone position for 1 h(T3),deoxygenation after tracheal extubation for 30 min(T4),the total lung ultrasound scores(LUS)at T0,T4,1 day after surgery(T5)and the occurrence of respiratory complications within 5 days after surgery were observed and recorded.Results There was no significant difference in HR and MAP between the two groups.OI in group B was significantly higher than that in group A at T2,T3 and T4,and A-aDO_(2)was lower than that in group A(P<0.05).Compared with T1,Ppeak andΔP at T2 and T3 in both groups showed an increasing trend,while Cdyn showed a decreasing trend(P<0.05).Ppeak and Cdyn in group B were significantly higher than those in group A,whileΔP were lower than that in group A(P<0.05).The LUS scores of group B were lower than that of group A at T4 and T5(P<0.05);There was no significant difference in the incidence of respiratory complications within 5 days after surgery between the two groups.Conclusion For obese patients requiring general anesthesia prone position surgery,high level PEEP combined with lung recruitment maneuvers can improve lung compliance and oxygenation status,improve patients'oxygen reserve and lung function recovery ability,but it has not been found to reduce the incidence of postoperative respiratory complications.