监测FRC指导最佳PEEP用于肺癌根治术患者肺复张的价值

Monitoring FRC to guide the value of optimal PEEP for lung revascularization in patients undergoing radical lung cancer surgery

目的研究监测功能残气量(FRC)指导最佳呼气末正压(PEEP)用于肺癌根治术患者肺复张的价值。方法前瞻性选择2017年1月至2020年1月邯郸市中心医院收治的217例肺癌根治术患者作为研究对象,使用随机数字表法将其分为A组(n=55)、B组(n=54)、C组(n=54)、对照组(n=54)。对患者进行充分肺复张,对照组使用基础呼吸机设置,在PEEP下调过程中A、B、C组分别使用最佳氧合法、功能残气量(FRC)、最大顺应性法确定PEEP。记录4组的最佳PEEP值,并记录各组取得最佳PEEP时的呼吸力学指标[静态肺顺应性(Cst)、气道平台压(Pplat)、死腔分数(Vd/Vt)];记录肺复张治疗前和治疗后1 h的4组气体交换指标[氧输送(DO_(2))、动脉血二氧化碳分压(PaCO_(2))、血氧饱和度(SaO_(2))]和氧合指数(PaO_(2)/FiO_(2))水平;检测不同时点血清氧化应激指标[丙二醛和超氧化物歧化酶(SOD)水平]和血流动力学指标[平均动脉压(MAP)、心率、中心静脉压(CVP)]。结果4组最佳PEEP相比,A、B、C组均高于对照组,并且B组高于A、C组,其中B组最佳PEEP高于A、C组,差异均有统计学意义(P<0.05)。4组Pplat相比,B组Pplat高于对照组,A、C两组均低于对照组,差异均有统计学意义(P<0.05)。4组Cst相比,A、B、C组均高于对照组,B组低于A、C组,差异均有统计学意义(P<0.05)。4组Vd/Vt相比,A、B、C组均低于对照组,B组高于A、C组,差异均有统计学意义(P<0.05)。治疗后,与对照组相比,A、B、C组DO_(2)水平较低,并且B组低于A、C组,A、B、C组PaO_(2)/FiO_(2)水平较高,并且B组高于A、C组,差异均有统计学意义(P<0.05)。治疗后,4组SOD水平比较,A、B、C组均高于对照组,并且B组高于A、C组,4组丙二醛水平比较,A、B、C组均低于对照组,并且B组低于A、C组,差异均有统计学意义(P<0.05)。治疗前后4组MAP、心率、CVP水平比较,差异无统计学意义(P>0.05)。结论与最佳氧合法和最大顺应法相比,FRC指导的最佳PEEP水平最高,用于肺癌根治术患者术后肺复张可改善肺顺应性,提高PaO_(2)/FiO_(2),减轻氧化应激反应,可能有利于减轻气道受损,并且对血流动力学影响较小,但也可能导致DO_(2)水平降低,临床应当综合考量。

Objective To study the value of monitoring functional residual volume(FRC)to guide optimal positive end expiratory pressure(PEEP)for lung revastigation in patients undergoing radical lung cancer surgery.Methods A total of 217 patients with lung cancer undergoing radical operation admitted to Handan Central Hospital from January 2017 to January 2020 were selected as the research subjects,and they were divided into group A(n=55),group B(n=54),group C(n=54)and control group(n=54)by random number table method.The patients underwent full lung extension,and the control group was set up with basic ventilator.During the reduction of PEEP,optimal oxygen method,functional residual volume(FRC)and maximum compliance method were used to determine PEEP in group A,B and C,respectively.The optimal PEEP value of the four groups was recorded,and the respiratory mechanical indexes[static lung compliance(Cst),airway plateau pressure(Pplat),dead chamber fraction(Vd/Vt)]were recorded.The levels of oxygen transport(DO_(2)),arterial partial pressure of carbon dioxide(PaCO_(2)),oxygen saturation(SaO_(2))and oxygenation index(PaO_(2)/FiO_(2))in four groups were recorded before and 1h after lung extension treatment.Serum oxidative stress index[malondialdehyde(MDA)and superoxide vaporase(SOD)levels]and hemodynamic index[mean arterial pressure(MAP),heart rate(HR),central venous pressure(CVP)]were detected at different time points.Results The optimal PEEP of group A,B and C was higher than that of the control group,and group B was higher than that of group A and C,the optimal PEEP of group B was higher than that of group A and C,the differences were statistically significant(P<0.05).Compared with the control group,Pplat in group B was higher than that in group A and C,the Cst of group A,B and C was higher than that of control group,and group B was lower than that of group A and C,the differences were statistically significant(P<0.05).The Vd/Vt ratio of group A,B and C was lower than that of control group,and group B was higher than that of group A and C,the differences were statistically significant(P<0.05).After treatment,compared with the control group,DO_(2) level of group A,B and C was lower,and group B was lower than group A and C,PaO_(2)/FiO_(2) level of group A,B and C was higher,and group B was higher than group A and C,the differences were statistically significant(P<0.05).After treatment,the level of SOD in group A,B and C was higher than that in control group,and group B was higher than that in group A and C,the differences were statistically significant(P<0.05);the level of MDA in group A,B and C was lower than that in control group,and group B was lower than that in group A and C,the differences were statistically significant(P<0.05).There were no significant differences in MAP,HR and CVP levels among the four groups before and after treatment(P>0.05).Conclusion Compared with the optimal oxygen method and the maximum compliance method,the optimal PEEP level guided by FRC is the highest.The method used for patients with lung cancer undergoing radical operation postoperative lung answer sheets improve lung compliance,improve PaO_(2)/FiO_(2),reduce oxidative stress,may help reduce the damage,the airway and less influence on hemodynamics,but could also lead to lower DO_(2),Clinical should be considered comprehensively.