基于肺超声指导个体化肺保护通气对老年患者术后膈肌功能的影响

Effect of individualized lung protective ventilation guided by lung ultrasound on postoperative diaphragm function in elderly patients

目的探讨基于肺超声指导个体化肺保护性通气对老年患者术后膈肌功能的影响。方法选取2023年1—12月在泰州市人民医院行腹腔镜结肠癌根治术老年患者80例作为研究对象,采用随机数字表法将其分为传统肺保护性通气组(T-LP组)和基于肺超声个体化肺保护性通气组(U-LP组),各40例。T-LP组采用低潮气量(VT)、持续固定呼气末正压(PEEP)和固定手法膨肺(RM)压力实施传统模式肺保护性通气策略;U-LP组在T-LP组基础上基于肺超声滴定个体化PEEP和RM压力来实施个体化肺保护性通气策略。2组分别于全身麻醉诱导前、拔管后15 min、拔管后30 min和准备离开麻醉恢复室(PACU)时记录平静呼吸(QB)和深呼吸(DB)期间膈肌偏移(DE)[平静呼吸膈肌偏移(DEQ)、深呼吸膈肌偏移(DED)]、膈肌厚度(DT)[平静吸气膈肌厚度(DTQi)、平静呼气膈肌厚度(DTQe)、深吸气膈肌厚度(DTDi)、深呼气膈肌厚度(DTDe)]及膈肌增厚分数(DTF)[平静呼吸膈肌增厚分数(DTFQ)、深呼吸膈肌增厚分数(DTFD)]等膈肌超声监测指标,停用肌肉松弛药至4个成串刺激(TOFr)90%时间,拔管至Aldrete评分9分时间,以及需舒更葡糖钠拮抗肌松残余的病例数等。结果与全身麻醉诱导前比较,离开PACU时T-LP组DEQ、DED、DTQi、DTQe、DTFQ、DTDi、DTFD等膈肌超声指标均明显减少、变薄或降低(P<0.05),U-LP组DTDi指标明显变薄(P<0.05);与T-LP组比较,U-LP组离开PACU时DEQ明显增加(P<0.05),拔管后15、30 min和离开PACU时DED、DTDi、DTFD均明显增加或增厚(P<0.05),拔管后30 min和离开PACU时DTQi、DTQe、DTDe均明显增厚(P<0.05);拔管至Aldrete评分≥9分时间明显缩短(P<0.05)。结论U-LP对老年腹腔镜结肠癌根治术患者术后膈肌功能影响轻微,更利于术后膈肌功能恢复,缩短PACU内滞留时间。

Objective To investigate the effect of individualized lung protective ventilation guided by lung ultrasound on postoperative diaphragm function in elderly patients.Methods A total of 80 elderly patients who underwent laparoscopic radical resection of colon cancer at Taizhou People′s Hospital from January to December 2023 were selected as the research subjects.They were randomly divided into the traditional lung protective ventilation group(T-LP group)and the personalized lung protective ventilation group based on lung ultrasound(U-LP group)using a random number table method,with 40 cases in each group.The T-LP group implemented traditional mode lung protective ventilation strategy using low tidal volume(VT),sustained fixed positive end expiratory pressure(PEEP),and fixed lung recruitment maneuver(RM)pressure.The U-LP group implements personalized lung protective ventilation strategies based on lung ultrasound titration of individualized PEEP and RM pressure on the basis of the T-LP group.Before induction of general anesthesia,15 minutes after extubation,30 minutes after extubation,and preparation to leave the postanesthesia recovery unit(PACU),two sets of records diaphragmatic ultrasound monitoring indicators during quiet breathing(QB)and deep breathing(DB)include diaphragmtic excursion(DE)[quiet breathing diaphragm excursion(DEQ),deep breathing diaphragmtic excursion(DED)],diaphragmtic thickness(DT)[quiet inspiratory diaphragm thickness(DTQi),calm expiratory diaphragm thickness(DTQe),deep inspiratory diaphragm thickness(DTDi),deep expiratory diaphragm thickness(DTDe)],and diaphragmtic thickening fraction(DTF)[calm breathing diaphragmtic thickening fraction(DTFQ),deep breathing diaphragm thickening fraction(DTFD)].In addition,record the time it takes to stop using muscle relaxants when train of four ratio(TOFr)≥90%,the time it takes to remove the tube until the Aldrete score is greater than 9 points,and the number of cases requiring the reversal of residual muscle relaxants with sugammadex.Results Compared with before induction of general anesthesia,the diaphragm ultrasound indicators such as DEQ,DED,DTQi,DTQe,DTFQ,DTD;and DTFD in the T-LP group were significantly reduced,thinned,or decreased upon leaving the PACU(P<0.05),while the DTD;indicator in the U-LP group was significantly thinned(P<0.05).Compared with the T-LP group,the DEQ in the U-LP group increased significantly upon leaving the PACU(P<0.05),and the DED,DTD;and DTFD increased or thickened significantly at 15 and 30 minutes after extubation and upon leaving the PACU(P<0.05).The DTQi,DTQe,and DTDe increased significantly at 30 minutes after extubation and upon leaving the PACU(P<0.05),and the time for extubation to achieve an Aldrete score of≥9 was significantly shortened(P<0.05).Conclusion The implementation of individualized lung protective ventilation based on lung ultrasound has a slight impact on the postoperative diaphragm function in elderly patients with laparoscopic radical resection of colon cancer,which is more conducive to the recovery of postoperative diaphragm function,and shortens the retention time in PACU,which is worthy of clinical promotion.