全麻下后腹腔镜手术中应用呼气末正压加高呼吸频率通气模式对呼吸功能的影响

Effects of positive end expiratory pressure ventilation combined with high respiratory rate on respiratory function in retroperitoneal laparoscopic surgery under general anesthesia

目的探讨术中呼气末正压(positive expiratory end pressure,PEEP)通气及高呼吸频率(high respiratory rate,HRR)能否安全有效地用于全麻下的后腹腔镜手术。方法 36例ASAⅠ-Ⅱ级,择期全麻下行后腹腔镜手术患者,随机均分为3组:对照组(control组),呼气末正压组(PEEP组),呼气末正压加高呼吸频率组(PEEP+HRR组),每组12例。常规麻醉诱导,气管插管后行机械通气,麻醉维持用药相同。气腹前,三组通气参数均设定为潮气量(VT)7 ml/kg,呼吸频率(RR)12次/min,吸呼比(I∶E)=1∶2。气腹后,对照组(n=12)同气腹前常规正压通气;PEEP组(n=12)VT=7 ml/kg,RR=12次/min,PEEP=4 cm H2O;PEEP+HRR组(n=12)VT=7 ml/kg,RR=18次/min,PEEP=4 cm H2O。在气腹前、气腹后30 min(PI30min)、气腹后60 min(PI60 min)、放气腹后5 min(PD1 min)、拔管后5 min(EX 5 min)、拔管后0.5 h(EX30 min)6个时点记录呼气末CO2(ETCO2)、动脉血Pa CO2、p H并计算动脉与呼气末CO2差值(D(a-e)CO2)。结果 PEEP组和PEEP+HRR组在PI30 min、PI60 min、PD5 min和EX5 min的Pa CO2均明显低于对照组(P<0.01),PEEP+HRR组在上述各时点其Pa CO2低于PEEP组(P<0.05);PEEP组与PEEP+HRR组在气腹后至EX5 min,其D(a-e)CO2均明显低于对照组(P<0.01),PEEP+HRR组在气腹后至EX5 min各时点,其D(a-e)CO2低于PEEP组(P<0.05)。结论后腹腔镜术中使用PEEP可有效减少动脉血和呼吸末的CO2差值;增加呼吸频率可有效加快动脉血CO2分压的下降并改善术后的氧合指数。呼气末正压加高呼吸频率通气模式可有效降低术中高碳酸血症的程度,减少后腹腔镜术中CO2蓄积,促进术后早期呼吸功能恢复。

Objectlve To explore the effect of posltlve end explratory pressure（ PEEP） and hlgh resplratory rate（ HRR） on resplratory functlon ln retroperltoneal laparoscoplc surgery under general anesthesla.Methods Slxty ASAⅠ-Ⅱpatlents undergolng retroperltoneal laparoscoplc surgery were randomly dlvlded lnto 3 groups wlth 12 cases ln each group.All the patlents recelved volume-controlled ventllatlon wlth 7 ml / kg tldal volume,resplratlon rate（ RR） of 12 tlmes / mln,and l ∶ E of 1 ∶ 2 before CO2 lnflatlon.After retroperltoneal CO2 lnflatlon,posltlve pressure ventllatlon was applled ln 20 patlents wlthout PEEP（ control group）,20 patlents wlth 4 cm H2 O PEEP only（ PEEP group）,and the other 20 patlents wlth comblnatlon of PEEP 4 cm H2 O and hlgh resplratory rate of 18 tlmes / mln（ PEEP ＋ HRR group）.End tldal CO2（ ETCO2） and arterlal blood gas analysls were measured before pneumoperltoneum,at 30 mln,60 mln after pneumoperltoneum,at 5 mln after deflatlon,at 5 mln,30 mln after extubatlon.The dlfference between Pa CO2 and ETCO2[D（ a-e） CO2]was calculated.Results Pa CO2 was slgnlflcantly lower ln PEEP group and PEEP ＋ HRR group than ln control group at 30 mln,60 mln after pneumoperltoneum,at 5 mln after deflatlon and at 5 mln after extubatlon（ P 〈0.01）,and Pa CO2 was lower ln PEEP ＋ HRR group than ln PEEP group at above-mentloned tlme polnts（ P 〈0.05）.D（ a-e） CO2 decreased slgnlflcantly ln PEEP group and PEEP ＋ HRR group from post-lnflatlon to 30 mln after extubatlon compared wlth control group（ P 〈0.01）,and D（ a-e） CO2 decreased ln PEEP ＋ HRR group at above-mentloned tlme polnts compared wlth PEEP group（ P 〈0.05）.Concluslons Posltlve end explratory pressure can avallably reduce the dlfference between ETCO2 and Pa CO2.Hlgh resplratory rate facllltate the dlmlnutlon of Pa CO2.Concluslon PEEP and hlgh resplratory rate can effectlvely decrease CO2 accumulatlon durlng retroperltoneal laparoscoplc surgery and facllltate the recovery of resplratory functlon after surgery.