肺复张对预防老年非体外冠状动脉旁路移植术后患者肺部并发症的作用

Preventive effect of lung recruitment maneuver on pulmonary complications in elderly patients after off-pump coronary artery bypass surgery

目的观察肺复张(LRM)治疗对预防老年非体外冠状动脉旁路移植术后患者肺部并发症的作用。方法纳入了2012年1～12月106例年龄≥60岁的首次非体外冠状动脉旁路移植(OPCABG)术后的老年患者,其中男性82例,女性24例,平均年龄(66±4)岁(60～75岁),采用完全随机化分组法将患者随机分为常规机械通气组(对照组,53例)及肺复张治疗组(治疗组,53例),对照组患者入住监护室后按常规机械通气治疗,治疗组患者常规机械通气同时分别于入住监护室后1 h及2 h应用压力控制法(PCV)进行两次肺复张治疗。对比治疗前后两组患者氧合指数(OI)、机械通气时间等指标的变化,并观察两组患者术后低氧血症、肺不张、肺部感染等并发症发生情况。低氧血症定义为OI<200,延迟拔管定义为机械通气时间≥24 h。结果全部患者无住院死亡。治疗组患者入监护室后3 h及试停呼吸机前OI明显好于对照组(272±45比251±48及287±32比262±41,P<0.01),低氧血症(16例,30.2%比2例,3.8%,P=0.0003)、肺部感染(4例,7.5%比0例,0%,P=0.041)、延迟拔管(9例,17%比2例,3.8%,P=0.026)以及拔管后需无创机械通气辅助(12例,22.6%比3例,5.7%,P=0.012)的发生率明显低于对照组,且肺不张及肺部感染的发生率也低于对照组。治疗期间无因血流动力学不稳定而终止LRM的患者。结论术后早期适当肺复张治疗可改善老年OPCABG术后患者的氧合,缩短机械通气时间,减少低氧血症等并发症的发生。

Objective To observe the role of lung recruitment maneuver in preventing pulmonary complications for eldly patients after off-pump coronary artery bypass surgery. Methods A total of 106 patients aging above 60 years old who underwent primary off pump coronary artery bypass grafting from Jan 2012 to Dec 2012 were enrolled in this research, including male 82, female 24, aging from 60-70 years old （ mean 66± 4）. The patients were randomize divided into mechanical ventilation group （ control ） and lung recruitment maneuver group （ treatment group ） . The control group received routine mechanical ventilation therapy while the treatment group received twice lung recruitment maneuver respectively after back in ICU 1 h and 2 h besides the routine management. The oxygen index （ OI ） , ventilation time and the complications such as hypoxemia, pulmonary atelectasis and pulmonary infection were observed and compared between the two groups. The hypoxemia was defined as OI 〈 200 and the delay of extubation was defined as ventilation time〉24 h. Results No patients were dead in hospital. The treatment group was superior to control group in OI at 3h after in ICU and the moment weaning from respirator（272 ±45 vs. 251 ±48 and 287 ± 32 vs.262 ±41, both P 〈 0. O1 ） . The treatment group was also superior to control group in the morbidity of hypoxemia（ 16 cases,30. 2% vs. 2 cases, 3.8% , P = 0. 0003 ） , pulmonary infection （4 cases, 7. 5% vs. 0 cases ,0% , P = O. 041 ） , delay of extubation （ 9 cases, 17% vs. 2 cases, 3.8% , P = 0. 026 ） , noninvasive mechanical ventilation after weaning from respirator （ 12 cases, 22. 6% vs. 3 cases, 5.7% , P =0. 012 ） and pulmonary atelectasis and pulmonary infections. There were no patients cease LRM because of unstable hemodynamics. Conclusions LRM in early period of postoperation could improve the oxygenation in elderly patients after OPCABG, shorten the ventilation time and reduce the morbidity of hypoxemia.