食道压导向的呼气末正压通气对老年患者腹腔镜手术后肺功能的影响

Effect of positive end-expiratory pressure ventilation guided by esophageal pressure on pulmonary function after laparoscopic surgery in elderly patients

目的评价食道压(Pes)导向的呼气末正压通气(PEEP)对老年患者腹腔镜手术后肺功能的影响。方法择期行腹腔镜结直肠癌根治术患者60例,年龄≥65岁,性别不限,ASA分级Ⅱ或Ⅲ级,BMI16~28kg/m^2。采用随机数字表法分为2组(n=30):PEEP组(P组)和Pes导向的PEEP组(PP组)。麻醉诱导气管插管术后行机械通气,设定氧流量2ml/L,VT8ml/kg,吸呼比1.0∶(1.5~2.0),FiO260%,调节通气频率,维持PETCO235~45mmHg。P组设定PEEP5cmH2O;PP组根据Pes设置PEEP,维持5mmHg≤呼气末跨肺压≤10mmHg。分别于入室后(T0)、术后1、3和5d(T1-3)时测定第1秒用力呼气容积(FEV1)、用力肺活量(FVC)、最大通气容量(MVV),采集桡动脉血样行血气分析,记录PaO2、PaCO2,计算氧合指数(PaO2/FiO2);进行临床肺部感染评分(CPIS),记录术后肺部并发症(肺不张、气胸、呼吸衰竭、吸入性肺炎、呼吸道感染、胸腔积液、支气管哮喘)的发生情况。结果与P组比较,PP组T1~T3时FEV1、FVC、MVV、PaO2和PaO2/FiO2升高,CPIS、术后肺不张和呼吸道感染的发生率降低(P<0.05)。结论Pes导向的PEEP可改善老年患者腹腔镜手术后肺功能,减少肺部并发症。

Objective To evaluate the effect of positive end-expiratory pressure(PEEP)ventilation guided by esophageal pressure(Pes)on pulmonary function after laparoscopic surgery in elderly patients.Methods Sixty American Society of Anesthesiologists physical status Ⅱor Ⅲ patients of both sexes,aged≥65 yr,with body mass index of 16-28 kg/m^2,scheduled for elective laparoscopic radical resection of colorectal cancer,were divided into 2 groups(n=30 each)using a random number table method:PEEP group(group P)and Pes-guided PEEP group(group PP).After induction of anesthesia,the patients were tracheally intubated and mechanically ventilated.The fresh gas flow of oxygen was set at 2 ml/L,tidal volume(VT)was 8 ml/kg,inspiratory/expiratory ratio was 1.0∶(1.5-2.0),fraction of inspired oxygen was 60%,the respiratory rate was adjusted,and the end-tidal pressure of carbon dioxide was maintained at 35-45 mmHg.PEEP was set at 5 cm H2O in group P.PEEP was set according to Pes to maintain 5 mmHg≤transpulmonary end-expiratory pressure≤10 mmHg in group PP.Forced expiratory volume first second,forced vital capacity,and maximum ventilatory volume were determined after admission to the operating room and at 1,3 and 5 days after operation.Blood samples were collected from the radial artery for blood gas analysis,PaO2 and PaCO2 were recorded,and oxygenation index(PaO2/FiO2)was calculated.Clinical Pulmonary Infection Score was assessed.The development of postoperative pulmonary complications such as pulmonary atelectasis,pneumothorax,respiratory failure,aspiration pneumonia,respiratory infections,pleural effusion and bronchial asthma was recorded.Results Compared with group P,forced expiratory volume first second,forced vital capacity,and maximum ventilatory volume,PaO2 and PaO2/FiO2 were significantly increased at 1,3 and 5 days after operation,and the Clinical Pulmonary Infection Score and incidence of pulmonary atelectasis and respiratory infections were decreased in group PP(P<0.05).Conclusion Pes-guided PEEP can improve pulmonary function after laparoscopic surgery and decrease pulmonary complications in elderly patients.