腹腔镜手术患者术中呼吸管理进展

Respiratory management during laparoscopic surgery

背景腹腔镜技术如火如荼的发展为术中呼吸管理提出了挑战，气腹以及机械通气对肺功能产生不利影响，术后肺部并发症（postoperative pulmonary complications, PPCs）严重影响患者预后，如何通过术中合理的通气管理尽可能降低PPCs的发生风险成为临床医师关注的焦点。目的主要阐述气腹及机械通气对肺功能的不利影响以及术中通气管理进展。内容阐述机械通气、麻醉因素、手术因素（气腹、体位）致肺损伤的相关机制，并详述小潮气量、呼气末正压（positive end expiratory pressure, PEEP）、肺复张策略（recruitment maneuver, RM）、压力控制通气（pressure-controlled ventilation, PCV）、反比呼吸、降低FiO2的肺保护作用及风险。趋向怎样合理搭配保护性通气措施的各要素以及肺保护性通气是否有利于患者长期预后还有待进一步研究。

Background Laparoscopy, a minimally invasive surgery, has been commonly applied to treat a variety of abdominal diseases. The process of this technique essentially requires pneumoperitoneum and mechanical ventilation, both increase risk of postoperative pulmonary complications （PPCs）. PPCs pose serious impact on the prognosis of patients. Therefore,better respiratory management is of great importance to reduce the risk of PPCs. Objective To discuss the adverse effects of pneumoperitoneum and mechanical ventilation on pulmonary function and currently available strategies for the ventilation management. Content Inappropriate settings for mechanical ventilation causes ventilator-induced lung injury （VILI）. In addition to skeletal muscle relaxant, general anesthesia further relaxes respiratory muscles, and commonly leads to atelectasis. Pneumoperitoneum is constructed by filling carbon dioxide into abdominal cavity to provide adequate space for laparoscopy. This process restricts pulmonary inflation and respiration. Additionally, carbon dioxide can penetrate into the blood, adversely affecting cardiovascular system. To avoid VILI, protective pulmonary ventilation is recommended. It provides low tidal volume to prevent overexpansion of aveoli, maintains medium positive end expiratory pressure （PEEP） to obtainproperopening sizes of aveoli, and applies intermittent pulmonary re-extension to recruit more aveoli. This strategy reduces the incidence of postoperative crisis that requires mechanical ventilation. Trend Further investigations are warranted to optimize protective pulmonary ventilation, and to clarify whether protective pulmonary ventilation is beneficial to patients＇ long-term prognosis.