跨肺压滴定个体化呼气末正压对行腹腔镜结直肠癌根治术患者肺功能的影响

Effect of transpulmonary pressure guided individualized positive end-expiratory pressure on lung function in patients undergoing laparoscopic radical resection of colorectal cancer

目的探讨跨肺压滴定个体化呼气末正压(PEEP)对腹腔镜结直肠癌根治术患者肺功能的影响。方法选择2021年11月至2022年8月于晋城市人民医院择期行腹腔镜结直肠癌根治术的70例患者为研究对象,根据机械通气中PEEP设置的不同将患者分为对照组和观察组,每组35例。对照组患者给予气腹且调整体位后,设置固定PEEP 5 cm H_(2)O并维持至手术结束。观察组患者在给予气腹且调整体位后采用阶梯PEEP法滴定个体化PEEP,并维持至手术结束。于术前(T_(0))及给予PEEP后1 h(T_(5))通过桡动脉导管采集动脉血标本,使用血气分析仪行血气分析,记录动脉血氧分压(PaO_(2))、动脉血二氧化碳分压(PaCO_(2)),并计算氧合指数(OI)、肺泡-动脉血氧分压差(A-aDO_(2))。记录气腹前(T_(1))、气腹后5 min(T_(2))、给予PEEP后5 min(T_(3))、给予PEEP后30 min(T_(4))、T_(5)、拔管前5 min(T_(6))时的肺动态顺应性(Cdyn)、气道峰压(Ppeak)、平均气道压(Pmean)、气道平台压(Pplat)、心率(HR)、平均动脉压(MAP)。于T_(0)及拔管后30 min(T 7)时,采用肺超声评分(LUS)法评估2组患者的肺不张程度。记录患者术后7 d内相关肺部并发症的发生情况。结果2组患者T_(5)时的OI、A-aDO_(2)均显著高于T_(0)时(P<0.05);2组患者T_(5)时的PaCO_(2)与T_(0)时比较差异无统计学意义(P>0.05);2组患者T_(0)时的PaCO_(2)、OI、A-aDO_(2)比较差异无统计学意义(P>0.05);T_(5)时观察组患者的OI显著高于对照组,A-aDO_(2)显著低于对照组(P<0.05)。T_(1)~T_(6)时,2组患者的Pplat、Ppeak、MAP、HR比较差异无统计学意义(P>0.05)。T_(3)~T_(6)时,观察组患者的Pmean显著高于对照组(P<0.05);T_(1)、T_(2)时,2组患者的Pmean比较差异无统计学意义(P>0.05)。T_(3)~T_(5)时,观察组患者的Cdyn显著高于对照组;T_(1)、T_(2)、T_(6)时,2组患者的Cdyn比较差异无统计学意义(P>0.05)。2组患者T 7时的LUS评分均显著高于T_(0)时(P<0.05);T_(0)时,2组患者的LUS评分比较差异无统计学意义(P>0.05);T 7时,观察组患者的LUS评分显著低于对照组(P<0.05)。术后7 d内,对照组和观察组患者的并发症发生率分别为14.7%(5/34)和11.8%(4/34),2组患者的术后并发症发生率比较差异无统计学意义(χ^(2)=0.128,P>0.05)。结论行腹腔镜结直肠癌根治术患者在给予气腹和调整体位后采用跨肺压滴定个体化PEEP可以改善患者的Cdyn、氧合情况及肺不张程度,具有一定的肺保护作用,且与固定PEEP值比较并未增加术后并发症发生率。

Objective To explore the effect of transpulmonary pressure guided individualized positive end-expiratory pressure(PEEP)on lung function in patients undergoing laparoscopic radical resection of colorectal cancer.Methods A total of 70 patients who underwent laparoscopic radical resection of colorectal cancer at Jincheng People′s Hospital from November 2021 to August 2022 were selected as the research subjects.According to the different settings of positive end expiratory pressure during mechanical ventilation,the patients were divided into the control group and the observation group,with 35 patients in each group.The patients in the control group were fixed with PEEP of 5 cm H_(2)O after administering pneumoperitoneum and adjusting their posture,and maintained until the end of the surgery.The patients in the observation group were titrated with individualized PEEP by the PEEP-step method after administering pneumoperitoneum and adjusting their posture,and maintained until the end of the surgery.Arterial blood samples were collected through the radial artery catheter before surgery(T_(0))and 1 hour after PEEP administration(T_(5)),and the blood gas analysis was performed using the blood gas analyzer;the partial pressure of oxygen in arterial blood(PaO_(2)),partial pressure of carbon dioxide in arterial blood(PaCO_(2))were recorded,and oxygenation index(OI)and alveolar-artery oxygen partial pressure gradient(A-aDO_(2))were calculated.The dynamic lung compliance(Cdyn),airway peak pressure(Ppeak),mean airway pressure(Pmean),airway plateau pressure(Pplat),heart rate(HR),and mean arterial pressure(MAP)were recorded before pneumoperitoneum(T_(1)),5 minutes after pneumoperitoneum(T_(2)),5 minutes after PEEP administration(T_(3)),30 minutes after PEEP administration(T_(4)),T_(5),and 5 minutes before extubation(T_(6)).At T_(0)and 30 minutes after extubation(T 7),the degree of atelectasis of patients in the two groups was evaluated by lung ultrasound score(LUS)method.The occurrence of related pulmonary complications of patients in the two groups was recorded within 7 days after surgery.Results The OI and A-aDO_(2)levels of patients in the two groups at T_(5)were significantly higher than those at T_(0)(P<0.05).There was no significant difference in PaCO_(2)of patients in the two groups between T_(5)and T_(0)(P>0.05).There was no significant difference in PaCO_(2),OI and A-aDO_(2)of patients between the two groups at T_(0)(P>0.05).At T_(5),the OI of patients in the observation group was significantly higher than that in the control group,and the A-aDO_(2)was significantly lower than that in the control group(P<0.05).At T_(1)to T_(6),there was no significant difference in Pplat,Ppeak,MAP and HR of patients between the two groups(P>0.05).At T_(3)to T_(6),the Pmean of patients in the observation group was significantly higher than that in the control group(P<0.05).At T_(1)and T_(2),there was no significant difference in Pmean between the two groups(P>0.05).At T_(3)to T_(5),the Cdyn of patients in the observation group was significantly higher than that in the control group(P<0.05).There was no significant difference in Cdyn of patients between the two groups at T_(1),T_(2)and T_(6)(P>0.05).The LUS scores of patients in the two groups at T 7 were significantly higher than those at T_(0)(P<005).At T_(0),there was no significant difference in LUS score of patients between the two groups(P>0.05).At T 7,the LUS score of patients in the observation group was significantly lower than that in the control group(P<0.05).Within 7 days after surgery,the incidence of complications of patients in the control group and observation group was 14.7%(5/34)and 11.8%(4/34),respectively;there was no significant difference in the incidence of postoperative complications of patients between the two groups(χ^(2)=0.128,P>0.05).Conclusion Transpulmonary pressure guided individualized PEEP after administering pneumoperitoneum and adjusting body position can improve the Cdyn,oxygenation and degree of atelectasis of patients undergoing laparoscopic colorectal cancer surgery;it has a certain lung protective effect and does not increase the incidence of postoperative complications compared to fixed PEEP.