保护性通气下后腹腔镜输尿管切开取石术病人呼气末正压处理后肺功能情况观察

Observation of the pulmonary function after positive end-expiratory pressure in patients treated with ureterolithotomy through retroperitoneal laparoscopic ureterolithotomy under protective ventilation

目的:探讨保护性通气下后腹腔镜输尿管切开取石术病人呼气末正压(PEEP)处理后的肺功能情况。方法:选取70例保护性通气下后腹腔镜输尿管切开取石术病人,分为2组。所有病人麻醉诱导插管后至气腹开始前后行间歇性正压通气,观察组潮气量10 mL/kg,通气频率15次/分,呼吸比1∶2,吸入氧浓度60%;气腹开始后对照组潮气量7 mL/kg,通气频率25次/分,呼吸比1∶1.5,维持PETCO_(2)35~45 mmHg;观察组在对照组基础上增加PEEP设定,参数为5 cmH_(2)O,采集桡动脉血样行血气分析,通过记录气腹前10 min和气腹10、30、60 min及气腹结束时、拔管前10 min的气道峰压(Ppeak)和平均气道压(Pmean),分析手术中和手术后动态肺顺应性(Cdyn)、氧合指数(PaO_(2)/FiO_(2))、死腔率(VD/VT)和肺泡-动脉血氧分压差(A-aDO_(2))的值。结果:与对照组比较,观察组在气腹10~60 min时Pmean升高,各时点的Ppeak和Cdyn无差异;与气腹前10 min相比,2组气腹10~60 min以及气腹结束时的Pmean升高,Ppeak升高,Cdyn降低(P<0.01)。与对照组比较,观察组在气腹30 min和去除导管前10 min时PaO_(2)/FiO_(2)升高,A-aDO_(2)和呼吸指数降低(P<0.05~P<0.01),VD/VT差异无统计学意义(P>0.05);与气腹前10 min比较,对照组在去除导管前10 min、观察组在气腹30 min时,PaO_(2)/FiO_(2)降低,A-aDO_(2)和呼吸指数升高(P<0.05~P<0.01)。结论:保护性通气下后腹腔镜输尿管切开取石术病人应用PEEP处理有利于肺功能的改善。

Objective:To investigate the pulmonary function after positive end-expiratory pressure(PEEP)in patients treated with ureterolithotomy through retroperitoneal laparoscopic ureterolithotomy under protective ventilation.Methods:Seventy patients treated with laparoscopic ureterolithotomy under protective ventilation were divided into the control group and observation group(35 cases in each group).All patients were treated with intermittent positive pressure ventilation from anesthesia-induced intubation to pneumoperitoneum,the tidal volume for 10 mL/kg,ventilation frequency for 15 times/min,respiratory ratio for 1∶2 and oxygen concentration for 60%in observation group were implemented,and the tidal volume for 7 mL/kg,ventilation frequency for 25 times/min,respiratory ratio for 1∶1.5 and PETCO_(2) for 35-45 mmHg in control group were implemented.The PEEP was additionally set in observation group on the basis of the control group,and the parameter was 5 cmH_(2)O.The blood gas analysis of arterial blood sample was performed.Before 10 min of pneumoperitoneum,after 10,30 and 60 min of pneumoperitoneum,at the end of pneumoperitoneum and before 10 min of extubation,the peak pressure(Ppeak)and mean airway pressure(Pmean)were observed,the intraoperative and postoperative dynamic lung compliance(Cdyn),oxygenation index(PaO_(2)/FiO_(2)),dead space rate(VO/VT)and alveolar-arterial oxygen partial pressure difference(A-aDO_(2))were analyzed.Results:Compared with the control group,the Pmean from 10 to 60 min of pneumoperitoneum increased,and the differences of the Ppeak and Cdyn at each time-point were not significant in observation group.Compared with before 10 min of pneumoperitoneum,the Pmean increased after 10 to 60 min and at the end of pneumoperitoneum,and the Ppeak increased,and the Cdyn decreased in observation group after 10 to 60 min of pneumoperitoneum(P<0.01).Compared with the control group,the PaO_(2)/FiO_(2) increased,the A-aDO_(2) and RI decreased(P<0.05 to P<0.01),and the difference of the VD/VT was not statistically significant in observation group after 30 min of pneumoperitoneum and before 10 min of extubation(P>0.05).Compared with before 10 min of pneumoperitoneum,the PaO_(2)/FiO_(2) decreased,and the A-aDO_(2) and RI increased in control group before 10 min of extubation and in observation group after 30 min of pneumoperitoneum(P<0.05 to P<0.01).Conclusions:The application of PEEP in patients treated with laparoscopic ureterolithotomy under protective ventilation is beneficial to the improvement of pulmonary function.