小潮气量肺保护性通气策略与压力通气模式对妇科腹腔镜手术患者氧合功能的影响

Effects of low tidal volume protective lung ventilation versus pressure controlled ventilation on oxygenation in patients un-dergoing gynecologic laparoscopic surgery

目的:评价小潮气量肺保护性通气策略(protective lung ventilation mode,PLV)与压力通气模式(pressure con-trolled ventilation,PCV)在妇科腹腔镜手术中应用的有效性及安全性。方法:拟于我院择期行妇科腹腔镜手术的患者共计144例,按随机序列号分为PLV组和PCV组,每组72例。PLV组潮气量6 ml/kg,吸呼比1∶2,呼吸频率16次/min,呼气末正压5 cmH 2O(1 cmH 2O=0.098 kPa);PCV组设定通气压力维持潮气量8 ml/kg,吸呼比1∶2,呼吸频率12~16次/min。分别于气管插管后5 min(T1)、气腹后10 min(T2)、气腹后20 min(T3)、撤除气腹后10 min(T4)记录患者气道峰压(airway peak pressure,Ppeak)、平均气道压(mean airway pressure,Pmean),并计算动态肺顺应性(dynamic lung compliance,Cdyn)。于T3、T4时点行血气分析记录PaO 2、PaCO 2、肺泡-动脉氧分压差(alveoli-arterial oxygen partial pressure,A-aDO 2),并计算氧合指数(oxygenation index,OI)。结果:PLV组T3时点Ppeak、Pmean显著高于PCV组,但Cdyn低于PCV组,差异有统计学意义(P<0.05)。PLV组T4时点Ppeak显著高于PCV组,差异有统计学意义(P<0.05)。两组T2、T3时点Ppeak、Pmean较T1时点显著升高,而Cdyn显著低于T1时点,差异有统计学意义(P<0.05)。PLV组T3时点Ppeak、Pmean显著高于T2时点,Cdyn显著低于T2时点,差异有统计学意义(P<0.05)。PLV组T3时点PaO 2、OI显著高于PCV组,而PaCO 2、A-aDO 2显著低于PCV组,差异有统计学意义(P<0.05)。两组T4时点PaO 2、OI较T3时点显著升高,而PaCO 2、A-aDO 2较T3时点显著降低,差异有统计学意义(P<0.05)。两组T4时点PaO 2、PaCO 2、A-aDO 2、OI差异无统计学意义(P>0.05)。两组间各呼吸系统并发症发生情况及住院天数差异均无统计学意义(P>0.05)。结论:对妇科腹腔镜手术患者而言,PCV有助于维持患者呼吸动力学稳定,而小潮气量PLV有助于维持患者术中氧合功能,二者安全性差异无统计学意义。

Objective To evaluate the effectiveness and safety of low tidal volume protective lung ventilation(PLV)and pressure controlled ventilation(PCV)in patients undergoing gynecologic laparoscopic surgery.Methods A total of 144 patients who were scheduled for gynecologic laparoscopic surgery in our hospital were enrolled.According to the random number table method,they were divided into two groups(n=72):a PLV group and a PCV group.The PLV group used a tidal volume of 6 ml/kg,an inspiration and expiration ratio of 1∶2,a respiratory rate of 16 breaths per minute,and a positive end expiratory pressure of 5 cmH2O(1 cmH2O=0.098 kPa).In the PCV group,the ventilation pressure was maintained at a tidal volume of 8 ml/kg,with an inspiration and expiration ratio of 1∶2,and a respiratory rate of 12-16 breaths per minute.Their airway peak pressure(Ppeak)and mean airway pressure(Pmean)were recorded 5 min after tracheal intubation(T1),10 min after pneumoperitoneum(T2),20 min af-ter pneumoperitoneum(T3),and 10 min after pneumonectomy(T4),while dynamic lung compliance(Cdyn)was calculated.Blood gas analysis was performed at T3 and T4 to record arterial oxygen partial pressure(PaO2),arterial CO2 partial pressure(PaCO2),and alveolar-arterial oxygen partial pressure difference(A-aDO2),while oxygenation index(OI)was calculated.Results At T3,the PLV group presented remarkably increased Ppeak and Pmean and decreased Cdyn,compared with the PCV group(P<0.05).At T4,the PLV group showed significantly higher Ppeak than the PCV group(P<0.05).Both groups presented marked increases in Ppeak and Pmean but decreases in Cdyn at T2 and T3,compared with those at T1(P<0.05).The PLV group presented remarkable increases in Ppeak and Pmean and decreases in Cdyn at T3,compared with those at T2(P<0.05).At T3,the PLV group showed remarkably increased PaO2 and OI but decreased PaCO2 and A-aDO2,compared with the PCV group(P<0.05).At T4,both groups presented significantly increased PaO2 and OI and decreased PaCO2 and A-aDO2,compared with those at T3(P<0.05).There was no significant difference in PaO2,PaCO2,A-aDO2 and OI at T4 between the two groups(P>0.05).There was no significant differ-ence in the incidence of respiratory complications and the length of hospitalization stay between the two groups(P>0.05).Conclusions For patients undergoing gynecologic laparoscopic surgery,PCV is helpful to maintain stable respiratory dynamics,while low tidal volume PLV is helpful to maintain oxygenation function during surgery.There is no significant difference in safety be-tween the two types of treatment.