压力控制容量保证通气对老年患者胸腔镜肺部分切除术术后肺部并发症的影响

Effect of pressure control ventilation with volume guaranteed on postoperative pulmonary complication in elderly patients undergoing thoracoscopic pneumectomy

目的探讨压力控制-容量保证通气(pressure control ventilation with volume guarantee,PCV-VG)对老年患者胸腔镜肺部分切除术术后肺部并发症(postoperative pulmonary complication,PPC)的影响。方法选择行胸腔镜下肺段、肺叶切除术,年龄60岁以上,PPC中高风险的患者146例。采用随机数字表法将患者按1∶1分为两组(每组73例):PCV-VG组(P组)与容积控制通气(volume controlled ventilation,VCV)组(V组)。P组压力上升时间设置为0.5 s,V组不设吸气暂停时间。收集术后1~3 d PPC发生情况、术后简易咳嗽程度评分以及6 min步行试验Borg呼吸困难评分。记录:单肺通气前即刻(T_(1))、单肺通气30 min(T_(2))、单肺通气结束前即刻(T_(3))、单肺通气结束15 min(T_(4))时的MAP;T_(1)~T_(4)时的潮气量和气道峰压(peak airway pressure,P_(peak)),计算肺动态顺应性(峰值气道压力顺应性);T_(1)、T_(2)时的PaO_(2)。记录术中补液量、去氧肾上腺素用量、术后第1天血常规及C反应蛋白(C-reactive protein,CRP)、手术至出院时间。结果与V组比较:P组术后1、2 d轻度PPC发生率,简易咳嗽程度评分,6 min步行试验Borg呼吸困难评分,T_(1)~T_(4)时P_(peak),术后第1天CRP及中性粒细胞百分比降低(P<0.05);T_(2)、T_(3)时MAP及T_(1)~T_(4)时峰值气道压力顺应性升高(P<0.05);术中补液量及去氧肾上腺素用量减少(P<0.05);手术至出院时间缩短(P<0.05)。两组患者T_(1)、T_(2)时PaO_(2)及术中瑞芬太尼用量差异无统计学意义(P>0.05)。结论对于接受胸腔镜肺段、肺叶切除术的老年患者,PCV-VG可改善术后早期咳嗽及呼吸困难症状,并降低早期轻度PPC的发生率。

Objective To explore the effect of pressure control ventilation with volume guaranteed(PCV‑VG)on postoperative pulmonary complications(PPC)in elderly patient undergoing thoracoscopic pneumectomy.Methods A total of 146 patients who un‑derwent thoracoscopic segmental pneumonectomy or thoracoscopic lobectomy,with an age≥60 years and an intermediate/high risk for PPC were enrolled.According to the random number table method,they were randomly divided into two groups(n=73):a PCV‑VG group(group P)and a volume controlled ventilation group(group V).In group P,the pressure slope time was 0.5 s,while in group V,the inspiratory pause time was 0 s.The occurrence of PPC on postoperative days 1 to 3 was recorded.After surgery,the score of cough eval‑uation test and the Borg dyspnea score of the 6 min walking test were collected.Furthermore,the mean arterial pressure(MAP)was re‑corded immediately before single lung ventilation(T_(1)),30 min after single lung ventilation(T_(2)),immediately before the end of single lung ventilation(T_(3)),and 15 min after the end of single lung ventilation(T_(4)).The tidal volume and airway peak pressure(P_(peak))at T_(1)‒T_(4) were recorded,and dynamic lung compliance(peak airway pressure compliance)was calculated.The arterial partial pressure of oxygen(PaO_(2))was recorded at T_(1) and T_(2).The amount of intraoperative fluid replacement,deoxyepinephrine dosage,blood routine and C-reac‑tive protein(CRP)on postoperative 1 day,and the time from operation to discharge were recorded.Results Compared with group V,group P presented decreases in the incidence of mild PPC on postoperative days 1 and 2,simple cough degree score and Borg dyspnea score of 6 min walking test,P_(peak) at T_(1)‒T_(4),CRP on postoperative day 1 and percentage of neutrophils(P<0.05);increases in MAP at T_(2) and T_(3) and peak airway pressure compliance at T_(1)‒T_(4)(P<0.05);decreases in the amount of intraoperative fluid replacement and de‑oxyepinephrine dosage(P<0.05);and shortened time from operation to discharge(P<0.05).There was no statistical difference in PaO2 at T_(1) and T_(2) and the consumption of intraoperative remifentanil between the two groups(P>0.05).Conclusions For elderly patients undergoing thoracoscopic segmental pneumonectomy or thoracoscopic lobectomy,PCV‑VG can improve early postoperative cough and dyspnea symptoms,and reduce the incidence of early mild PPC.