PEEP联合手法复张对儿童腹腔镜手术中肺不张的影响

Effect of PEEP Combined with Recruitment Maneuvers on Atelectasis in Children Undergoing Laparoscopic Surgery

目的通过肺超声(LUS)(不同时间点)观察儿童腹腔镜手术肺不张的发生及呼气末正压(PEEP)联合手法复张对肺不张的影响.方法将收治的90例择期行腹腔镜手术的患儿随机分为PEEP组、联合组和对照组,每组30例.PEEP组(P组)PEEP为5 cm H 2 O,吸呼比为1∶2,通气频率为20~25次/min,压力控制模式;联合组采用PEEP+手法复张(P+RM组),对照组(C组)不采用PEEP,其余同PEEP组.分别于麻醉诱导后机械通气1 min(T 0)、手术结束时(T 1)和入麻醉复苏室30 min(T 2)行LUS检查,比较各组肺不张发生情况和严重程度.术后复苏采用密歇根大学镇静评分(UMSS)评估镇静状态.结果T 1时,联合组肺不张的发生率显著低于对照组(P<0.05).联合组T 0时,PEEP组T 0、T 1时,对照组T 0、T 1、T 2时后胸肺不张发生率明显高于前胸、侧胸(P<0.05).3组T 0~T 2时,LUS评分逐渐降低(P<0.05).T 1时,联合组LUS评分均显著低于对照组、PEEP组,PEEP组T 1时,LUS评分显著低于对照组(P<0.05).T 2时,3组UMSS评分比较差异均无统计学意义(P>0.05).结论儿童腹腔镜术中肺不张以后胸区域居多,PEEP联合手法复张可提高肺顺应性,降低肺不张,发挥良好肺保护效应;LUS对于评价围术期不同时间的肺不张及复张效果具有较好的临床价值.

Objective To observe the occurrence of atelectasis in children undergoing laparoscopic surgery and the influence of positive end-expiratory pressure(PEEP)combined with recruitment maneuvers on atelectasis by lung ultrasound(LUS)at different time points.Method A total of 90 children who underwent elective laparoscopic surgery were randomly divided into PEEP group,combined group and control group,30 cases in each group.PEEP group(group P)was given PEEP(5 cm H 2 O),the inhalation/respiration ratio was 1∶2,the ventilation frequency was 20~25 times/min with pressure control mode.The combined group was treated with PEEP+recruitment maneuvers,while the control group(group C)was not treated with PEEP,and the rest of the group were the same as the PEEP group.Pulmonary ultrasound(LUS)was performed at 1 min of mechanical ventilation after anesthesia induction(T 0),at the end of surgery(T 1)and 30 min of admission into the post anesthesia care unit(T 2),respectively,the occurrence and severity of atelectasis in each group were compared,postoperative resuscitation was evaluated by University of Michigan Sedation Score(UMSS).Results At T 1 moment,the incidence of atelectasis in the combined group was significantly lower than that in the control group(P<0.05).The incidence of atelectasis in the combined group at T 0,T 0 and T 1 in the PEEP group,T 0,T 1 and T 2 in the control group were significantly higher than thaose in the forechest and lateral chest(P<0.05).LUS score was gradually decreased from T 0 to T 2 moment in the three groups(P<0.05).At T 1 moment,the score of LUS in the combined group was significantly lower than that in the control group and PEEP group,and the score of LUS at T 1 in the PEEP group was significantly lower than that in the control group(P<0.05).At T 2 time,there was no significant difference in UMSS score among the three groups(P>0.05).Conclusion The atelectasis in preschoolers undergoing laparoscopic surgery is the majority in the thoracic area,PEEP combined with recruitment maneuvers can improve lung compliance,reduce atelectasis,and exert a good pulmonary protective effect,while LUS has a good clinical value in evaluating atelectasis and re-expansion effects at different times in perioperative period.