基于肺超声评分评估压力控制容量保证通气模式对腹腔镜胃癌根治术患者肺通气的影响

Effect of pressure-controlled ventilation-volume guaranteed model on lung ventilation in patients undergoing laparoscopic radical gastrectomy by lung ultrasound score

目的探讨基于肺超声评分(LUS)评估压力控制容量保证通气(PCV-VG)模式与容量控制通气(VCV)模式对腹腔镜胃癌根治术患者通气功能及术后肺部并发症(PPCs)的影响。方法选择择期行腹腔镜胃癌根治术患者80例,男67例,女13例,年龄45~75岁,ASAⅡ或Ⅲ级。采用随机数字表法将患者分为两组:VCV通气模式组(V组)和PCV-VG通气模式组(P组),每组40例。所有患者常规麻醉诱导,采用保护性通气策略:V_(T)7 ml/kg,呼气末正压(PEEP)5 cmH_(2)O,FiO_(2)40%。采用床旁肺超声评估患者双侧肺部共12个区域的LUS。记录入室时(T_(0))、麻醉诱导气管插管后20 min(T_(1))、建立人工气腹后30 min(T_(2))、气管导管拔除后15 min(T_(5))的LUS评分。行血气分析记录PaO_(2)、PaCO_(2)。记录T_(1)、T_(2)、气腹后1 h(T_(3))、手术结束时(T_(4))的气道峰压(Ppeak)、平台压(Pplat)、气道平均压(Pmean)、动态肺顺应性(Cdyn)、V_(T)。记录术后3、7 d内PPCs的发生情况。结果与T_(0)时比较,T_(1)、T_(2)、T_(5)时P组整体、前部、外侧、后部、左肺、右肺、上肺及下肺LUS明显降低(P<0.05);T_(2)时V组整体及部分区域(后部、下肺及右肺)LUS明显降低,T_(5)时V组整体及部分区域(外侧、下肺及左肺)LUS明显升高(P<0.05)。与V组比较,T_(1)、T_(2)、T_(5)时P组整体及各区域LUS评分均明显降低,PaO_(2)明显升高,T_(1)、T_(5)时PaCO_(2)明显降低,T_(1)—T_(4)时Ppeak明显降低,Pmean、Cdyn明显升高,T_(4)时Pplat明显降低(P<0.05)。术后3 d内P组PPCs发生率明显低于V组[4例(10%)vs 11例(28%),P<0.05]。结论LUS能够显示手术期间PCV-VG模式和VCV模式下肺通气的非均匀性和体位性变化。肺保护性通气策略下,PCV-VG模式明显改善了腹腔镜胃癌根治术患者术中肺通气及氧合功能。

Objective To investigate the effects of pressure-controlled ventilation-volume guaranteed(PCV-VG)mode and volume control ventilation(VCV)mode based on lung ultrasound score(LUS)on ventilation function and pulmonary complications in patients undergoing laparoscopic radical gastrectomy.Methods Eighty patients undergoing elective laparoscopic radical gastrectomy,67 males and 13 females,aged 45-75 years,ASA physical statusⅡorⅢ,were randomly divided into two groups:VCV mode group(group V)and PCV-VG mode group(group P),40 patients in each group.All patients underwent routine anesthesia induction.A protective ventilation strategy was adopted,with V_(T)7 ml/kg,positive end-expiratory pressure of 5 cmH_(2)O,FiO_(2)40%.VCV mode was adopted in group V and PCV-VG mode was adopted in group P.Bedside ultrasound was used to evaluate the LUS in 12 areas of bilateral lungs upon entering the room(T_(0)),20 minutes after anesthesia induction endotracheal intubation(T_(1)),30 minutes after the establishment of artificial pneumoperitoneum(T_(2)),15 minutes after extubation of endotracheal tube(T_(5)).PaO_(2) and PaCO_(2) were measured by blood gas analysis.The peak airway pressure(Ppeak),plateau airway pressure(Pplat),mean airway pressure(Pmean),dynamic lung compliance(Cdyn),and V_(T) of T_(1),T_(2),1 h after pneumoperitoneum(T_(3)),and at the end of the operation(T_(4))were recorded.The incidences of pulmonary complications(PPCs)within 3 and 7 days after operation were recorded.Results Compared with T_(0),the LUS of the whole and each region in group P was lower at T_(1),T_(2),and T_(5)(P<0.05),the LUS of the whole and partial areas(posterior side,lower side and right lung)in group V was lower at T_(2),and the LUS of the whole and partial areas(lateral side,lower side and left lung)in group V was significantly higher at T_(5)(P<0.05).Compared with group V,the overall and regional LUS of group P were lower at T_(1),T_(2),and T_(5)(P<0.05),PaO_(2) at T_(1),T_(2),and T_(5)in group P was significantly higher(P<0.05),PaCO_(2) at T_(1)and T_(5)was lower(P<0.05),from T_(1)-T_(4),Ppeak in group P was significantly lower,whereas Pmean and Cdyn were significantly higher,Pplat at T_(4)in group P was significantly lower(P<0.05).The incidence of PPCs within 3 days after operation in group P was lower than in group V[4 cases(10%)vs 11 cases(28%),P<0.05].Conclusion LUS in the PCV-VG mode and VCV mode demonstrates the heterogeneity and positional changes of pulmonary ventilation during operation.The PCV-VG mode under the lung-protective ventilation strategy significantly improves the intraoperative lung ventilation and oxygenation function of patients undergoing laparoscopic radical gastrectomy.