肺开放策略减量滴定呼气末正压在食管癌根治术中的应用价值

Application value of open lung strategy in titration of positive end-expiratory pressure in radical esophagectomy

目的探讨肺开放策略(OLS)减量滴定呼气末正压(PEEP)在食管癌根治术患者中的应用价值。方法选择2019年2月至2020年2月郑州大学第二附属医院胸外科择期单肺通气(OLV)下行食管癌根治术患者60例,按随机数字表法分为试验组(n=30)和对照组(n=30)。OLV时两组均以5 cmH_(2)O(1 cmH_(2)O=0.098 kPa)作为初始PEEP值,待血流动力学稳定后试验组行OLS,检测到最高顺应性PEEP并应用至术毕;对照组以PEEP=5 cmH_(2)O至术毕拔管。记录两组插管后(T_(1))、OLV即刻(T2)、OLS应用后30 min(T3)、OLS应用后60 min(T_(4))的气道平台压(Pplat)、气道峰压(Ppeak)、肺顺应性(Cdyn);于上述各时点抽取动脉血行血气分析,记录动脉血氧分压(PaO2)、动脉血二氧化碳分压(PaCO2),并计算氧合指数(OI)。采用重复测量的方差分析比较两组不同时点氧合及呼吸力学指标。结果T_(1)-T_(4)时试验组PaCO2[(38.70±2.93)mmHg,(38.89±3.54)mmHg,(39.19±3.43)mmHg,(39.71±3.17)mmHg]与对照组[(39.72±3.19)mmHg,(40.35±3.71)mmHg,(39.66±3.47)mmHg,(39.54±3.42)mmHg]分别比较,均差异无统计学意义(F=1.67,2.15,0.27,0.04;均P>0.05)。两组患者T_(1)-T_(4)时点OI、Pplat、Ppeak、Cdyn比较,均差异有统计学意义(F=13.29,15.02,7.05,33.62;均P<0.05)。T3、T_(4)时试验组OI[(259.30±30.68)mmHg,(267.39±33.81)mmHg]、Pplat[(17.98±2.56)cmH_(2)O,(17.09±2.87)cmH_(2)O]、Ppeak[(27.74±4.68)cmH_(2)O,(27.27±3.03)cmH_(2)O]、Cdyn[(33.44±2.74)ml/cmH_(2)O,(35.35±3.42)ml/cmH_(2)O]与对照组[(238.00±31.02)mmHg,(234.83±34.90)mmHg,(15.63±3.24)cmH_(2)O,(14.92±2.64)cmH_(2)O,(25.27±4.35)cmH_(2)O,(25.60±2.72)cmH_(2)O,(27.70±3.54)ml/cmH_(2)O,(28.20±3.69)ml/cmH_(2)O]分别比较,均明显增加(F=7.15,13.47,9.75,9.20,4.48,5.03,49.23,60.51,均P<0.05)。T3、T_(4)时试验组OI、Pplat、Ppeak、Cdyn与T2时[(238.00±31.02)mmHg,(13.89±3.16)cmH_(2)O,(22.37±2.11)cmH_(2)O,(28.16±3.15)ml/cmH_(2)O]分别比较,均明显增加(t=-2.43,-3.35,-5.74,-4.48,-6.82,-6.28,-5.55,-7.56;均P<0.05)。结论全身麻醉下食管癌根治术患者的OI降低,采用OLS滴定个体化PEEP的保护性通气策略可显著改善氧合作用,增加肺顺应性,有利于肺通气的保护作用。

Objective To explore the application value of open lung strategy(OLS)in titration of positive end-expiratory pressure(PEEP)in patients undergoing radical esophagectomy.Methods From February 2019 to February 2020,60 patients who planned to undergo radical resection of esophageal carcinoma under optional one-lung ventilation(OLV)in the Department of Thoracic Surgery,The Second Affiliated Hospital of Zhengzhou University,were randomly divided into experimental group(n=30)and control group(n=30)according to random number table method.In OLV,5 cmH_(2)O(1 cmH_(2)O=0.098 kPa)was taken as the initial PEEP value in both groups.OLS was performed in the experimental group after hemodynamic stability,the highest compliance PEEP was detected and the catheter was applied until the end of the operation.In the control group,endotracheal catheter was extracted at PEEP=5 cmH_(2)O until the end of operation.Airway plateau pressure(Pplat),airway peak pressure(Ppeak),and lung dynamic compliance(Cdyn)were recorded in the two groups after intubation(T_(1)),OLV immediate(T2),OLS 30 min after OLS application(T3),OLS 60 min after OLS application(T_(4)).Arterial blood was extracted at the above time points for blood gas analysis,arterial oxygen partial pressure(PaO2)and arterial carbon dioxide partial pressure(PaCO2)were recorded,and the oxygenation index(OI)was calculated.Repeated measurement analysis of variance was used to compare oxygenation and respiratory dynamics indexes between the two groups at different time points above.Results From T_(1) to T_(4),there were no significant differences in PaCO2 between the experimental group[(38.70±2.93)mmHg,(38.89±3.54)mmHg,(39.19±3.43)mmHg,(39.54±3.17)mmHg]and the control group[(39.72±3.19)mmHg,(40.35±3.71)mmHg,(39.66±3.47)mmHg,(39.54±3.42)mmHg](F=1.67,2.15,0.27,0.04,all P>0.05).Compare the OI,Pplat,Ppeak and Cdyn of two groups from T_(1) to T_(4),there were significant differences(F=13.29,15.02,7.05,33.62,all P<0.05).At T3 and T_(4),OI[(259.30±30.68)mmHg,(267.39±33.81)mmHg],Pplat[(17.98±2.56)cmH_(2)O,(17.09±2.87)cmH_(2)O],Ppeak[(27.74±4.68)cmH_(2)O,(27.27±3.03)cmH_(2)O],Cdyn[(33.44±2.74)ml/cmH_(2)O,(35.35±3.42)ml/cmH_(2)O]in experimental group were significantly increased when compared with those of the control group[(238.00±31.02)mmHg,(234.83±34.90)mmHg,(15.63±3.24)cmH_(2)O,(14.92±2.64)cmH_(2)O,(25.27±4.35)cmH_(2)O,(25.60±2.72)cmH_(2)O,(27.70±3.54)ml/cmH_(2)O,(28.20±3.69)ml/cmH_(2)O](F=7.15,13.47,9.75,9.20,4.48,5.03,49.23,60.51,all P<0.05).At T3 and T_(4),OI,Pplat,Ppeak,Cdyn in experimental group were significantly increased when compared with those at the T2[(238.00±31.02)mmHg,(13.89±3.16)cmH_(2)O,(22.37±2.11)cmH_(2)O,(28.16±3.15)ml/cmH_(2)O](t=-2.43,-3.35,-5.74,-4.48,-6.82,-6.28,-5.55,-7.56,all P<0.05).Conclusions The oxygenation index of patients undergoing radical resection of esophageal cancer under general anesthesia is decreased.The protective ventilation strategy of using OLS to titrate individualized PEEP could significantly improve oxygenation and increase lung compliance,which is conducive to the protective effect of lung ventilation.