不同肺保护性通气策略对肺切除术术中通气和术后肺部并发症的影响

Effects of different lung protective ventilation strategies on intraoperative ventilation and postoperative pulmonary complications in patients undergoing thoracoscopic pneumonectomy

目的:评估小潮气量联合不同水平呼气末正压(positive end-expiratory pressure,PEEP)对胸腔镜下肺切除术患者通气氧合和术后肺部并发症(postoperative pulmonary complications,PPCs)的影响。方法:选取空军军医大学唐都医院2019年12月至2020年12月择期行胸腔镜下肺切除患者100例,采用随机数字表法分为两组:低水平PEEP组(LP组)和高水平PEEP组(HP组);LP组于单肺通气(one lung ventilation,OLV)时设置潮气量(tidal volume,V_(T))6 mL/kg,PEEP≤5 cmH_(2)O,HP组于相同时间点设置V_(T) 6 mL/kg,PEEP 6~10 cmH_(2)O。分别于OLV前(T1)、OLV 60 min(T2)、手术结束(T3)采取桡动脉血液行血气分析;记录T1、T2、T3的心率(heart rate,HR)、脉搏血氧饱和度(pulse oxygen saturation,SpO_(2))、收缩压/舒张压(systolic blood pressure/diastolic blood pressure,SBP/DBP)、呼气末二氧化碳分压(partial pressure of end-expiratory carbon dioxide,P_(ET)CO_(2))、V_(T)、吸气峰压(peak pressure,Ppeak)、平台压(plateau pressure,Pplat);记录术后7 d内PPCs、胸腔引流管拔除时间、术后3 d内胸腔引流管引流量及术后住院时间。结果:与T1时比较,T2、T3时两组患者HR无明显变化;T2时平均动脉压(mean arterial pressure,MAP)明显降低(P<0.05);两组Ppeak、Pplat明显升高,动态肺顺应性(dynamic compliance,Cdyn)明显降低(P<0.05);两组患者氧合指数(oxygenation index,OI)明显降低,肺泡气-动脉血氧分压差(alveolar gas-arterial oxygen partial pressure difference,A-aDO_(2))明显升高;T2时两组呼吸指数(respiratory index,RI)明显升高,T3时LP组RI明显升高(P<0.05)。与LP组比较,T2时HP组Ppeak明显升高;T2、T3时,HP组Pplat明显升高,驱动压(driving pressure,DP)明显降低,Cdyn明显增高(P<0.05);T2、T3时HP组OI明显升高,A-aDO_(2)、RI明显降低(P<0.05)。两组术后7 d PPCs及住院时间差异无统计学意义。结论:小潮气量6 mL/kg联合较高水平PEEP 6~10cmH_(2)O可改善胸腔镜下肺切除术患者OLV时通气氧合情况,利于术中麻醉管理。

Objective:To evaluate the effects of low tidal volume combined with different positive end-expiratory pressure(PEEP)on intraoperative ventilation and postoperative pulmonary complications(PPCs)in patients undergoing thoracoscopic pneumonectomy.Methods:A total of 100 patients who underwent thoracoscopic pneumonectomy in Tangdu Hospital from December 2019 to December 2020 were randomly divided into two groups:low PEEP group(group LP)and high level PEEP group(group HP);LP group was set with tidal volume(V_(T))6 mL/kg and PEEP≤5 cmH_(2)O during one lung ventilation(OLV),while HP group was set with V_(T) 6 mL/kg and PEEP 6–10 cmH_(2)O.Blood gas analysis was performed by radial artery blood before OLV(T1),at OLV 60 min(T2),and at the end of operation(T3).Heart rate(HR),pulse oxygen saturation(SpO_(2)),systolic blood pressure/diastolic blood pressure(SBP/DBP),partial pressure of end-expiratory carbon dioxide(P_(ET)CO_(2)),V_(T),peak pressure(Ppeak),plateau pressure(Pplat)of T1,T2 and T3 were recorded.PPCs within 7 days after the operation,removal time of thoracic drainage tube,drainage volume of thoracic drainage tube within 3 days after the operation and postoperative hospital stay were recorded.Results:Compared with T1,there was no significant change in HR at T2 and T3.At T2,mean arterial pressure(MAP)decreased significantly(P<0.05).In both groups,Ppeak and Pplat were significantly increased,while dynamic compliance(Cdyn)was significantly decreased(P<0.05).Oxygenation index(OI)was significantly decreased and alveolar gas-arterial oxygen partial pressure difference(A-aDO_(2))was significantly increased in both groups.At T2,respiratory index(RI)was significantly increased in both groups,while at T3,RI was significantly increased in LP group(P<0.05).Compared with LP group,Ppeak of HP group was significantly increased at T2.At T2 and T3,Pplat,driving pressure(DP)and Cdyn in HP group were significantly increased(P<0.05).At T2 and T3,OI and A-aDO_(2) and RI in HP group were significantly increased,while A-aDO_(2) and RI were significantly decreased(P<0.05).There was no significant difference in PPCs and length of stay between the two groups within 7 days after surgery.Conclusion:Low V_(T) 6 mL/kg combined with higher PEEP 6–10 cmH_(2)O can improve aeration and oxygenation during OLV in patients undergoing thoracoscopic pneumonectomy,which is beneficial for anesthesia management.