不同肺泡复张方法在同期双侧肺叶手术中的应用

Clinical application of two recruitment maneuvers in the simultaneous bilateral pulmonary lobectomy

目的探讨两种肺泡复张方法应用于同期双侧肺叶手术中的区别。方法选择同期行双侧肺叶手术的患者40例,均为先行肺叶楔形切除,翻身后行肺叶切除或肺叶楔形切除的患者,将其随机分入控制性肺膨胀(SI)组和压力控制通气(PCV)+呼气末正压通气(PEEP)组。SI组翻身后实施40cmH_2O(1cmH_2O=0.098kPa)峰压持续15sSI复张;PCV+PEEP组翻身后行PCV,设定压力为20cmH_2O,同时设置PEEP为5cmH_2O,10次机械通气后PEEP以每次5cmH_2O递增,直至20cmH_2O,通气20次。记录所有患者的术前肺功能和血气分析指标,手术情况,复张前、中、后的血压和中心静脉压(CVP)值,以及机械通气各时间点的呼吸参数,复张后数据均采集自复张结束即刻。结果两组间一般资料、术前肺功能和血气分析指标、手术时间、手术方式和手术类型的差异均无统计学意义(P值均>0.05)。两组间复张前收缩压的差异无统计学意义(P>0.05),PCV+PEEP组复张后的收缩压显著高于SI组同时间(P<0.01)。两组间复张前和复张后1h呼气末二氧化碳分压(petCO_2)、动脉血二氧化碳分压(paCO_2)与petCO_2差值(pa-etCO_2)的差异均无统计学意义(P值均>0.05);PCV+PEEP组复张后的petCO_2显著低于SI组同时间(P<0.01),pa-etCO_2显著高于SI组(P<0.05)。两组间复张前后舒张压、平均动脉压、CVP、心率、肺顺应性、呼吸频率、paCO_2、动脉血氧分压(paO2)和pH值的差异均无统计学意义(P值均>0.05)。结论在同期双侧肺叶手术翻身后,使用PCV加PEEP进行肺复张对循环的影响小,使用SI则可以得到较好的复张效果,但需要密切监测循环指标。

Objective To compare the difference between two alveolar recruitment maneuvers （RM） in the simultaneous bilateral pulmonary Iobectomy. Methods Forty patients undergoing simultaneous bilateral pulmonary Iobectomy were enrolled in this study. Lung wedge resection was performed in one side, and Iobectomy or wedge resection was done after turn-over. They were randomly allocated to sustained inflation （SI） group and pressure controlled ventilation （PCV） ＋ positive end expiratory pressure （PEEP） group. In the SI group, after turn-over, 40 cmH2O （1 cmH2 O = 0. 098 kPa） peak pressure continued for 15 s. In the PCV ＋ PEEP group, PCV was applied and the pressure was set at 20 cmH2O; meanwhile, the original pressure of PEEP was 5 cmH2O for 10 times, and then the pressure increased by 5 cmH2O every time until to 20 cmH2O for 20 times. Preoperative pulmonary function and arterial gas analysis, arterial pressure and central venous pressure （CVP）, and respiratory parameters before and after RM were recorded. Results There were no significant differences in terms of general information, preoperative pulmonary function, arterial gas analysis results, operation time, methods or types between two groups （all P〉0.05）. Neither was the systolic pressure before RM between two groups （P〉 0.05）. The systolic pressure of PCV-I-PEEP group was significantly higher than that of SI group after RM （P〈 0.01）. No significant difference was found in the end-tidal carbon dioxide partial pressure （p= CO2 ）, or the difference of arteria carbon dioxide partial pressure （p,CO2） and p= CO2 （Pa-et CO2 ） between two groups before RM or 1 hour after RM （all P〉0.05）. After RM, the petCO2 of PCV＋ PEEP group was significantly lower than that of SI group （P〈0.01）, while pa-et CO2 of PCV＋ PEEP group was significantly higher than that of SI group （P〈0.05）. There were no significant differences in the diastolic pressure, mean arterial pressure, CVP, heart rate, lung compliance, respiratory rate, paCO2, arterial oxygen pressure （paO2） or pH value between two groups both before and after RM （all P〉0. 05）. Conclusion In the bilateral simultaneous pulmonary Iobectomy, PCV＋ PEEP has less effect on hemodynamics during RM, while SI has more efficient alveolar recruitment and patient＇s vital signs need to be monitored.