超声评估反比通气对胸科术后膈肌功能的影响

Ultrasound evaluation of the effect of inverse ratio ventilation on diaphragmatic function after thoracic surgery

目的应用M型超声评价反比通气对胸科肺部手术术后膈肌功能的影响。方法选择择期行单侧单个肺叶切除术的患者86例,年龄18~65岁,18.5 kg/m^(2)<体重指数(BMI)<30.0 kg/m^(2),美国麻醉医师协会(ASA)分级Ⅰ、Ⅱ级,采用随机数字表法将患者分为常规通气组(C组)、反比通气组(F组),每组43例。支气管插管全身麻醉后,双肺通气时潮气量(VT)6~8 ml/kg,呼吸频率(RR)12~15次/min,吸入氧浓度50%,吸入氧流量1 L/min;单肺通气时F组吸呼比(I∶E)=2∶1,VT 6 ml/kg,呼气末正压(PEEP)5 cmH2O(1 cmH_(2)O=0.098 kPa),C组I∶E=1∶2,两组患者其他呼吸参数一致。记录患者一般资料(年龄、性别比、BMI、ASA分级、高血压、糖尿病)。记录麻醉前(T_(0))、单肺通气后5 min(T_(1))、单肺通气后1 h(T_(2))、术毕即刻(T_(3))患者心率、平均动脉压(MAP)、动脉血氧分压(PaO_(2))、动脉血二氧化碳分压(PaCO_(2));记录T_(1)、T_(2)、T_(3)时的气道峰压(Ppeak)、气道平台压(Pplat)、平均气道压(Pmean)和PEEP;应用M型超声采集T_(0)和拔管后即刻(T_(4))的双侧膈肌移动度(DE)及膈肌浅快呼吸指数(D‑RSBI),记录住院时间、膈肌功能障碍及术后5 d肺部并发症发生情况,并对膈肌功能障碍与术后5 d肺部并发症发生情况进行Spear‑man相关性分析;记录手术时间、单肺通气时间、气管拔管时间;术毕拔管后记录警觉/镇静观察评分。结果与C组比较:F组T4时术侧及非术侧DE较高、D‑RSBI较低(均P<0.05);DE差值、D‑RSBI差值较低(均P<0.05);T_(1)、T_(2)时PaO_(2)较高(均P<0.05);T_(1)、T_(2)、T_(3)时Ppeak、Pplat较低(均P<0.05),PEEP、Pmean较高(均P<0.05)。与T0时比较,两组患者T4时术侧及非术侧DE降低、D‑RSBI升高(均P<0.05)。与术侧比较,两组患者T4时非术侧DE较高、D‑RSBI较低(均P<0.05),DE差值、D‑RSBI差值较低(均P<0.05)。Spearman相关性分析显示,膈肌功能障碍发生情况与术后5 d肺部并发症发生情况呈正相关(r=0.65,P<0.05)。其余指标差异均无统计学意义(均P>0.05)。结论反比通气可改善膈肌功能,降低膈肌功能障碍的发生率。膈肌功能障碍是术后肺部并发症的一个关键因素。

Objective To evaluate the effect of inverse ratio ventilation on diaphragmatic function after thoracic lung surgery through M‑mode ultrasound.Methods A total of 86 patients,aged 18‒65 years,with body mass index(BMI)of 18.5 kg/m^(2) to 30.0 kg/m^(2),and American Society of Anesthesiologists(ASA)classification gradesⅠorⅡ,who were scheduled for unilateral single‑lung lobecto‑my,were selected.According to the random number table method,they were divided into two groups(n=43):a conventional ventilation group(group C)and an inverse ratio ventilation group(group F).After endotracheal intubation under general anesthesia,the tidal volume(VT)was set at 6‒8 ml/kg,respiratory rate(RR)at 12‒15 times/min,oxygen concentration at 50%,and oxygen flow at 1 L/min during double‑lung ventilation.For single‑lung ventilation,group F showed an inspiration‑to‑expiration ratio(I∶E)of 2∶1,with a VT of 6 ml/kg,and positive end‑expiratory pressure(PEEP)of 5 cmH2O(1 cmH2O=0.098 kPa),while group C had an I∶E ratio of 1∶2.Other respirato‑ry parameters were the same between the two groups.Then,record patient demographics(age,gender ratio,BMI,ASA classification,hy‑pertension,diabetes)and the heart rate,mean arterial pressure(MAP),arterial partial pressure of oxygen(PaO2),and arterial partial pressure of carbon dioxide(PaCO_(2))were recorded before anesthesia(T_(0)),5 min after single‑lung ventilation(T_(1)),1 h after single‑lung ventilation(T_(2)),and immediately after surgery(T_(3)).The airway peak pressure(Ppeak),plateau airway pressure(Pplat),mean airway pressure(Pmean),and PEEP were recorded at T_(1),T_(2),and T_(3).The M‑mode ultrasound was used to collect bilateral diaphragmatic ex‑cursion(DE)and diaphragmatic rapid shallow breathing index(D‑RSBI)at T_(0) and immediately after extubation(T_(4)).Hospital stay du‑ration,the incidence of diaphragmatic dysfunction and pulmonary complications within postoperative 5 d was recorded,and Spearman correlation analysis was conducted to evaluate the relationship between the incidence of diaphragmatic dysfunction and pulmonary com‑plications within postoperative 5 d.Surgical duration,single‑lung ventilation time,and extubation time were recorded,as well as Ob‑server's Assessment of Alertness/Sedation post‑extubation Results Compared with group C,group F showed increased DE and de‑creased D‑RSBI at T_(4) on both the operative and non‑operative sides(all P<0.05),reduction in DE differences and D‑RSBI differences(all P<0.05);increases in PaO_(2) at T_(1) and T_(2)(all P<0.05);reduction in Ppeak and Pplat at T_(1),T_(2),and T_(3)(all P<0.05),and increases PEEP and Pmean(all P<0.05).Compared with those at T_(0),both groups presented decreased DE and increased D‑RSBI at T_(4) on both the operative and non‑operative sides(all P<0.05).Compared with those at the operative side,both groups showed increased DE and de‑creased D‑RSBI at T_(4) on the non‑operative side(all P<0.05),and reduction in DE differences and D‑RSBI differences(all P<0.05).Spearman correlation analysis indicated that the incidence of diaphragmatic dysfunction was positively correlated with the incidence of pulmonary complications within postoperative 5 d(r=0.65,P<0.05).There were no statistical differences in other indicators(all P>0.05).Conclusions Inverse ratio ventilation can improve diaphragmatic function and reduce the incidence of diaphragmatic dys‑function.Diaphragmatic dysfunction is a key factor in postoperative pulmonary complications.