驱动压导向呼气末正压通气对老年患者腹腔镜前列腺癌根治术后肺功能的影响

Effect of driving pressure-guided positive end-expiratory pressure ventilation on pulmonary function in elderly patients after undergoing laparoscopic radical prostatectomy

目的探讨驱动压导向的个体化呼气末正压(PEEP)通气对老年患者腹腔镜前列腺癌根治术后肺功能的影响。方法选择2021年8月至2022年6月行择期腹腔镜前列腺癌根治术的老年患者60例,年龄≥65岁,BMI 18~30 kg/m^(2),ASAⅡ或Ⅲ级。采用随机数字表法将患者分为两组:驱动压(ΔP)导向组(P组)和对照组(C组),每组30例。P组采用ΔP导向的PEEP,C组给予PEEP 5 cmH 2O。记录气腹-Trendelenburg体位建立后即刻(T_(0))、PEEP滴定完成后30 min(T_(1))、1 h(T_(2))、2 h(T_(3))、术后30 min(T_(4))时HR、MAP并行血气分析,记录PaO_(2)、PaCO_(2),计算氧合指数(OI)。记录T_(0)-T_(3)时的气道峰压(Ppeak)、气道平台压(Pplat)、动态肺顺应性(Cdyn)等呼吸力学指标并计算ΔP。于术前1 d(T_(5))、术后1 d(T_(6))、3 d(T_(7))、7 d(T_(8))测定第1秒用力呼气容积(FEV_(1))、用力肺活量(FVC)、1秒率(FEV_(1)/FVC)、呼气流量峰值(PEF)。记录术后1 d临床肺部感染评分(CPIS)和术后7 d肺部并发症的发生情况。结果与T_(0)时比较,P组和C组T_(4)时PaO_(2)和OI明显降低,T_(1)-T_(4)时PaCO_(2)明显升高,T_(1)-T_(3)时MAP明显降低,Ppeak、Pplat、Cdyn、ΔP均明显升高(P<0.05)。与T_(5)时比较,T_(6)-T_(8)时P组和C组FEV_(1)、FVC、PEF明显降低,T_(6)、T_(7)时C组FEV_(1)/FVC明显降低,T_(6)时P组FEV_(1)/FVC明显降低(P<0.05)。与C组比较,P组术中补液量和血管活性药使用发生率明显升高,T_(1)-T_(4)时PaO_(2)和OI、T_(1)-T_(3)时PaCO_(2)、Ppeak、Pplat、Cdyn明显升高,T_(1)-T_(3)时ΔP明显降低,T_(6)、T_(7)时FEV_(1)、FVC、FEV_(1)/FVC、PEF均明显升高,术后1 d CPIS评分和术后7 d肺部并发症发生率明显降低(P<0.05)。结论驱动压导向的个体化PEEP通气能明显改善老年腹腔镜前列腺癌根治术患者术后肺功能,降低术后肺部并发症发生率。

Objective To investigate the effect of driving pressure-guided individualized positive end-expiratory pressure(PEEP)ventilation on pulmonary function in elderly patients after undergoing laparoscopic radical prostatectomy.Methods A total of 60 elderly patients from August 2021 to June 2022,aged≥65 years,BMI 18-30 kg/m^(2),ASA physical statusⅡorⅢ,who undergoing elective laparoscopic radical prostatectomy were enrolled and divided into two groups:driving pressure-guided group(group P)and control group(group C),30 patients in each group.Group P was given PEEP guided by driving pressure and group C was given PEEP of 5 cmH 2O.The intraoperative fluid infusion volume and the use of vasoactive drugs were recorded after the operation.HR,MAP,blood gas analysis including PaO_(2)and PaCO_(2)were recorded,and oxygenation index(OI)was calculated immediately after the establishment of pneumoperitoneum-Trendelenburg position(T_(0)),30 minutes after the completion of PEEP titration(T_(1)),1 hour after the completion of PEEP titration(T_(2)),2 hours after the completion of PEEP titration(T_(3)),and 30 minutes after the operation(T_(4)).The respiratory mechanics indexes such as peak airway pressure(Ppeak),airway plateau pressure(Pplat),dynamic lung compliance(Cdyn)and the driving pressure was calculated at T_(0)-T_(3).The forced expiratory volume in 1 second(FEV_(1)),forced vital capacity(FVC),forced expiratory volume in 1 second/forced vital capacity(FEV_(1)/FVC)and peak expiratory flow(PEF)were measured 1 day before surgery(T_(5)),1 day after surgery(T_(6)),3 days after surgery(T_(7)),and 7 days after surgery(T_(8)).The clinical pulmonary infection score(CPIS)was performed 1 day after surgery,and the incidence of postoperative pulmonary complications(PPCs)within 7 days after surgery were recorded.Results Compared with T_(0),PaO_(2)and OI were significantly decreased at T_(4),PaCO_(2)were significantly increased at T_(1)-T_(4),MAP were significantly decreased while Ppeak,Pplat,Cdyn,andΔP were significantly increased at T_(1)-T_(3) in groups P and C(P<0.05).Compared with T_(5),FEV_(1),FVC and PEF were significantly decreased at T_(6)-T_(8) in groups P and C,FEV_(1)/FVC were significantly decreased at T_(6) and T_(7) in group C,FEV_(1)/FVC were significantly decreased at T_(6) in group P(P<0.05).Compared with group C,the intraoperative fluid infusion volume and the use of vasoactive drugs were significantly increased,PaO_(2)and OI at T_(1)-T_(4),PaCO_(2),Ppeak,Pplat,Cdyn at T_(1)-T_(3) were significantly increased whileΔP at T_(1)-T_(3) were significantly decreased,FEV_(1),FVC,FEV_(1)/FVC,and PEF were significantly increased at T_(6) and T_(7),the CPIS 1 day after operation and the incidence of PPCs 7 days after operation were significantly reduced in group P(P<0.05).Conclusion Individualized PEEP ventilation guided by driving pressure can significantly improve postoperative pulmonary function and reduce the incidence of postoperative pulmonary complications in elderly patients with laparoscopic radical prostatectom.