不同潮气量双肺通气辅以二氧化碳气胸在胸腹腔镜下食管癌根治术的应用效果

Efficacy of two-lung ventilation with different tidal volume assisted by CO_(2) pneumothorax for airway management in patients undergoing radical resection of esophageal cancer using combined laparoscopic and thoracoscopic approach

目的:评价不同潮气量双肺通气辅以二氧化碳气胸在胸腔镜下食管癌根治术的应用效果。方法:选取郑州大学附属肿瘤医院2019年2至9月择期全身麻醉下行胸腹腔镜食管癌根治术患者180例,采用随机数字表法将其分为不同潮气量组(V_(1)~V_(3)组,n=60)。胸腔镜操作期间,V_(1)~V_(3)组潮气量分别为4、5、7 ml/kg。3组患者均经口插入单腔气管导管,持续人工CO_(2)正压气胸,CO_(2)压力为10 mmHg(1 mmHg=0.133 kPa),采用双肺通气,频率均为20次/min。记录胸腔镜操作前(T_(1))、胸腔镜操作开始后30 min(T_(2))、胸腔镜操作结束即刻(T_(3))、胸腔镜操作结束后常规双肺间歇正压通气后30 min(T_(4))的平均动脉压(MAP)、心率(HR);分别在T_(1)、T_(2)、T_(3)、T 4监测动脉血气;记录患者苏醒时间和意识恢复时间;记录患者术中肺萎陷情况。结果:T_(2)时V_(1)组患者MAP值为(81±10)mmHg,高于V_(2)组、V_(3)组的(69±7)和(71±8)mmHg,差异有统计学意义(F=9.270,P<0.05);T_(2)时V_(1)组患者HR值为(83±7)次/min,高于V_(2)组、V_(3)组的(68±6)和(71±7)次/min,差异有统计学意义(F=23.460,P<0.05);T_(2)时3组患者动脉血氧分压(PaO_(2))分别为(262±16)、(249±16)和(241±20)mmHg,差异无统计学意义(F=1.929,P>0.05);T_(3)时V_(3)组患者动脉血二氧化碳分压(PaCO_(2))为(46±5)mmHg,低于V_(1)组、V_(2)组的(63±9)和(62±10)mmHg,差异有统计学意义(F=20.890,P<0.05);T_(3)时V_(3)组患者pH值为(7.35±0.04),高于V_(1)组、V_(2)组的(7.28±0.04)和(7.32±0.04),差异有统计学意义(F=9.309,P<0.05);V_(3)组患者肺萎陷满意率为57.1%,低于V_(1)组、V_(2)组的94.7%和96.3%,差异有统计学意义(χ^(2)=7.601,P<0.05);3组患者苏醒及意识恢复时间差异均无统计学意义(F=1.020、1.110,均P>0.05)。结论:5 ml/kg潮气量双肺通气辅以二氧化碳气胸在血流动力学、手术野暴露方面具有优势,更适合作为胸腔镜下食管癌根治术呼吸管理的适宜剂量。

Objective To evaluate the efficacy of two-lung ventilation with different tidal volume assisted by CO_(2) pneumothorax for airway management in patients undergoing radical esophagectomy using combined thoracoscopic and laparoscopic approach.Methods One hundred and eighty patients undergoing radical esophagectomy using combined thoracoscopy and laparoscopy under general anesthesia from the Affiliated Cancer Hospital of Zhengzhou University between February and September 2019 were randomly divided into three groups(group V_(1),V_(2),V_(3),n=60)according to the tidal volume(TV)used.The TVs of group V_(1)-V_(3) were 4,5,7 ml/kg during thoracoscopic surgery,respectively.All the patients were intubated with a single-lumen endotracheal tube and underwent two-lung ventilation assisted by continuous positive pressure CO_(2) pneumothorax in group V_(1),V_(2) and V_(3),with the CO_(2) pressure of 10 mmHg(1 mmHg=0.133 kPa)and the frequency of 20 times/min.Mean arterial pressure(MAP)and heart rate(HR)were recorded before thoracoscopic surgery(T_(1)),30 minutes after thoracoscopic surgery(T_(2)),at the end of thoracoscopic surgery(T_(3)),after thoracoscopic surgery and 30 minutes after two-lung intermittent positive pressure ventilation,respectively.The results of arterial blood gas were collected at T_(1),T_(2),T_(3) and T_(4).Recovery time from anesthesia,consciousness recovery time,and lung collapse condition were recorded.Results At T_(2),the value of MAP in group V_(1) was(81±10)mmHg,which was higher than those of group V_(2)[(69±7)mmHg]and group V_(3)[(71±8)mmHg],with a statistically significant difference(F=9.270,P<0.05).Meanwhile,at T_(2),the value of HR in group V_(1) was(83±7)times/min,which was higher than those of group V_(2)[(68±6)times/min]and group V_(3)[(71±7)times/min],and there was a statistically significant difference(F=23.460,P<0.05).However,at T_(2),the values of arterial partial pressure of oxygen(PaO_(2))in three groups were(262±16),(249±16)and(241±20)mmHg,respectively,with no statistically significant difference(F=1.929,P>0.05).At T_(3),the value of arterial partial pressure of carbon dioxide(PaCO_(2))in group V_(3) was(46±5)mmHg,which was lower than those of group V_(1)[(63±9)mmHg]and V_(2)[(62±10)mmHg],with a statistically significant difference(F=20.890,P<0.05).Moreover,at T_(3),the value of pH in group V_(3) was(7.35±0.04),which was higher than those of group V_(1)(7.28±0.04)and V_(2)(7.32±0.04),and there was a statistically significant difference(F=9.309,P<0.05).Additionally,the satisfaction rates of lung collapse in group V_(3) was 57.1%,which was lower than those of group V_(1)(94.7%)and group V_(2)(96.3%),with a statistically significant difference(χ^(2)=7.601,P<0.05).There was no statistical significance in the time of awakening and consciousness recovery among three groups(F=1.020 and 1.110,both P>0.05).Conclusion The two-lung ventilation with 5 ml/kg tidal volume assisted by CO_(2) pneumothorax has advantages in terms of hemodynamics and surgical field exposure,and is more suitable as the appropriate dose for respiratory management in patients undergoing radical resection of esophageal cancer using combined thoracoscopic and laparoscopic approach.