不同通气模式对老年患者腹腔镜结直肠手术呼吸参数的影响

Effect of different ventilation modes on intraoperative respiratory parameters in elderly patients undergoing laparoscopic colorectal surgery

目的观察小潮气量容量控制通气(VCV)联合呼气末正压通气(PEEP)和压力控制通气(PCV)联合PEEP对老年患者呼吸参数的影响。方法选择行腹腔镜直肠、乙状结肠手术患者51例,男25例,女26例,年龄65~80岁,BMI 18~30kg/m2,ASAⅠ或Ⅱ级,随机分为两组:VP组(VCV+PEEP)和PP组(PCV+PEEP),每组25例。气腹期间VP组以VT6 ml/kg+5cmH2O PEEP模式通气,PP组将VT设为6 ml/kg通气3 min后切换为PCV并加用5cmH2O PEEP进行通气。记录气管插管VCV通气5min(T1)、建立人工气腹5 min(T2)、建立人工气腹35min(T3)、建立人工气腹65min(T4)、手术结束(T5)、拔管前(T6)时VT、动态肺顺应性(Cdyn)、RR、气道峰压(Ppeak)、气道平台压(Pplat)和PETCO2。记录T1、T3、T4和离开PACU(T7)时PaO2、PaCO2,并计算肺泡-动脉血氧分压差(PA-aDO2)、氧合指数(OI)、呼吸指数(RI);记录术后5d内肺部并发症(PPCs)情况。结果与VP组比较,T2-T4时PP组VT明显升高、Cdyn明显增大(P<0.05),T3-T5时PP组RR明显减慢(P<0.05),T2-T5时PP组Ppeak和Pplat明显降低(P<0.05),T4时PP组PETCO2和PA-aDO2明显降低、PaO2明显升高、RI明显减小、OI明显增大(P<0.05)。术后随访两组患者PPCs差异无统计学意义。结论PCV联合PEEP通气模式明显降低Ppeak和Pplat、增高VT和增大Cdyn,同时明显改善气腹65min时肺氧合功能,所以老年患者腹腔镜结直肠手术术中应优先考虑使用。

Objective To observe the effects of low tidal volume control ventilation（VCV）combined with positive end expiratory pressure（PEEP）and pressure controlled ventilation（PCV）combined with PEEP on respiratory parameters of elderly patients.Methods Fifty-one undergoing laparoscopic surgery for rectal and sigmoid colon,25 male,26 female,aged 65-80 years,ASA physical stutesⅠ orⅡ,with BMI between 18-30 kg/m2,were randomly divided into 2 groups：group VP（VCV＋PEEP,n=26）and group PP（PCV＋PEEP,n=25）.During the pneumoperitoneum period,group VP was ventilated with VT6 ml/kg combined with 5 cmH2 O PEEP.In group PP,the VT was set to 6 ml/kg for 3 min ventilation,then switched to PCV and added with 5 cmH2 O PEEP.The tidal volume（VT）,dynamic lung cdyniance（Cdyn）,respiratory rate（RR）,airway peak pressure（Ppeak）,airway pressure platform（Pplat）and end-tidal carbon dioxide pressure（PETCO2）were recorded at six different time points：tracheal intubation VCV ventilation 5 min（T1）,establishment of artificial pneumoperitoneum 5 min（T2）,establishment of artificial pneumoperitoneum 35 min（T3）,establishment of artificial pneumoperitoneum 65 min（T4）,end of surgery（T5）,and before extubation（T6）,and calculated oxygenation index（OI）,respiratory index（RI）,alveolar-arterial oxygen partial pressure（PA-aDO2）were calculated at T1,T3,T4 and the leaving PACU（T7）.The postoperative pulmonary complications（PPCs）were recorded within 5 days after surgery.Results Compared with group VP,the VT and Cdyn in group PP were significantly higher from T2 to T4（P〈0.05）,the RR in group PP were significantly slower from T3 to T5（P〈0.05）,the Ppeak and Pplat in group PP were significantly lower from T2 to T5（P〈0.05）,and the PETCO2 and PA-aDO2 were significantly decreased,PaO2 was significantly increased,RI was significantly decreased,and OI was significantly increased in group PP at T4（P〈0.05）.There was no statistical difference in the incidence of PPCs between the two groups.Conclusion PCV ventilation mode combined with PEEP significantly reduced Ppeak and Pplat,increased VTand Cdyn,and significantly improved pulmonary oxygenation at 65 minutes of pneumoperitoneum,so should be given priority in elderly patients undergoing laparoscopic colorectal surgery.