Different positive end expiratory pressure and tidal volume controls on lung protection and inflammatory factors during surgical anesthesia

BACKGROUND Mechanical ventilation can lead to the severe impairment of the metabolic pathway of alveolar surfactants,inactivating alveolar surfactants and significantly reducing lung-chest compliance.The cardiopulmonary function of elderly patients usually reduced to a certain extent,and there are lung complications after surgical anesthesia,just like lung barotrauma caused by mechanical ventilation,atelectasis and postoperative hypoxemia.AIM To investigate the effects of different positive end expiratory pressures(PEEPs)and tidal volumes(VTs)on respiratory function,the degree of the inflammatory response and hemodynamic indexes in patients undergoing surgery under general anesthesia.METHODS A total of 120 patients undergoing surgery for gastric or colon cancer under general anesthesia in Xinghua People's Hospital from January 2017 to January 2021 were randomly divided into Group A and Group B,with 60 cases in each group.The ventilation mode in Group A was VT(6.0 mL/kg)+PEEP(5.0 cmH_(2)O),while that in Group B was VT(6.0 mL/kg)+PEEP(8.0 cmH_(2)O).Blood gas parameters,respiratory mechanical parameters,inflammatory response indicators,hemodynamic indicators and related complications were compared between the two groups.RESULTS There were no significant differences in PaCO_(2),PaO_(2),oxygen or the examined indexes at T0 between group A and group B(P>0.05).The measured PaO_(2) value of patients in group A at T3 was higher than that in group B,and the difference was significant(P<0.05).There were no significant differences in peak airway pressure(P_(peak)),mean airway pressure or dynamic pulmonary compliance(Cdyn)at T0 between group A and group B(P>0.05).The measured P_(peak) value of patients in group A at T1 was higher than that in group B,and the difference was significant(P<0.05).The measured Cdyn value at T1 and T2 was greater than that in group B(P<0.05).Before surgery,there were no significant differences in tumor necrosis factor-α(TNF-α),interleukin(IL)-6 or IL-10 between group A and group B(P>0.05).After 4 h,the measured values of TNF-αand IL-6 in group A were lower than those in group B,and the differences were significant(P<0.05).The IL-10 Level in group A was higher than that in group B(P<0.05).At T0,there were no significant differences in cardiac output,cardiac index(CI),stroke volume index(SVI)or mean arterial pressure between group A and group B(P>0.05).The measured values of CI and SVI at T2 in patients in group A were higher than those in group B,and the differences were significant(P<0.05).CONCLUSION For patients undergoing surgery for gastric or colon cancer under general anesthesia,the VT(6.0 mL/kg)+PEEP(5.0 cmH_(2)O)regimen was more effective than the VT(6.0 mL/kg)+PEEP(8.0 cmH_(2)O)regimen in protecting the lung function and ventilatory function of patients,and it had better effects on maintaining hemodynamic stability and reducing inflammatory reactions.

The Respiratory Rehabilitation Effect and Mechanism of Action of Oscillating Positive Expiratory Pressure Devices

Chronic respiratory diseases are one of the major global health problems,and their treatment and management impose a huge burden on both patients’quality of life and healthcare resources.Respiratory rehabilitation,as a non-pharmacological treatment,has received increasing attention in recent years.Oscillating positive expiratory pressure(OPEP)devices,as a new type of respiratory rehabilitation device,show good application prospects in improving respiratory function,promoting sputum expectoration,and improving quality of life.The purpose of this paper is to review the effect and mechanism of OPEP in respiratory rehabilitation.

Effects of extrinsic positive end-expiratory pressure on cardiopulmonary function in patients with chronic obstructive pulmonary disease

Objective To choose one optimal extrinsic positive end-expiratory pressure (PEEPe) for ventilated patients with chronic obstructive pulmonary disease (COPD) and to compare two methods for choosing the optimal level of PEEPe.Methods Ten ventilated patients with COPD were included in the study. First, static intrinsic positive end-expiratory pressure (PEEPi,st) was measured when PEEPe was zero, and the PEEPi,st was called PEEPi,stz. PEEPe at 0%, 40%, 50%, 60%, 70%, 80%, 90% and 100% of PEEPi,stz, respectively, were applied randomly. Respiratory mechanics, hemodynamics, and oxygen dynamics were recorded 30 minutes after the level of PEEPe was changed.Results When PEEPe was not higher than 80% of PEEPi,stz, no measurement changed significantly. When PEEPe was increased to 90% and 100% of PEEPi,stz, PEEPi,st, peak inspiratory pressure, plateau pressure, pulmonary capillary wedge pressure and central venous pressure increased significantly, P<0.01. Cardiac output and left ventricular work index decreased significantly, P<0.01. Oxygen delivery decreased significantly, P<0.05. When PEEPe was increased to 100% of PEEPi,stz, the right ventricular work index decreased significantly, P<0.05.Conclusion Eighty percent of PEEPi,stz was the upper limit of PEEPe. The results of the two methods used to set the level of PEEPe were identical.

Effects of extrinsic positive end-expiratory pressure on work of breathing in patients with chronic obstructive pulmonary disease

Objective To investigate the effects of extrinsic positive end-expiratory pressure (PEEPe) on work of breathing in patients with chronic obstructive pulmonary disease (COPD) and their corresponding mechanism.Methods Ten ventilated patients with COPD were included in the study. A Bicore CP-100 pulmonary monitor (Bicore Monitoring System, USA) was used for monitoring respiratory mechanics. First, dynamic intrinsic positive end-expiratory pressure (PEEPi,dyn) was measured when PEEPe was zero, which was called PEEPi,dynz. Then the PEEPe was set randomly at 0%, 40%, 60%, 80% and 100% of PEEPi,dynz respectively. Pulmonary mechanics and other parameters (heart rate, blood pressure and blood gas analysis) were measured 30 minutes after the level of PEEPe was changed.Results Work of breathing patient (WOBp), pressure time product, difference of esophageal pressure and PEEPi,dyn decreased significantly when PEEPe was applied, and continued decreasing as PEEPe was increased. Work of breathing ventilator increased significantly when PEEPe was increased to 80% and 100% of PEEPi,dynz. Significantly positive linear correlation was found between the changes in WOBp and in PEEPi,dyn.Conclusions WOBp decreases gradually as PEEPe is increased. WOBp decreases by narrowing the difference between the alveolus pressure and the central airway pressure at the end of expiration when PEEPe is applied.

Positive End-expiratory Pressure Titration after Alveolar Flecruitment Directed by Electrical Impedance Tomography

Background： Electrical impedance tomography （EIT） is a real-time bedside monitoring tool, which can reflect dynamic regional lung ventilation. The aim of the present study was to monitor regional gas distribution in patients with acute respiratory distress syndrome （ARDS） during positive-end-expiratory pressure （PEEP） titration using EIT. Methods： Eighteen ARDS patients under mechanical ventilation in Department of Critical Care Medicine of Peking Union Medical College Hospital from January to April in 2014 were included in this prospective observational study. After recruitment maneuvers （RMs）, decremental PEEP titration was performed from 20 cmH20 to 5 cmH20 in steps of 3 cmH20 every 5-10 min. Regional over-distension and recruitment were monitored with EIT. Results： After RMs, patient with arterial blood oxygen partial pressure （PaO2） ＋ carbon dioxide partial pressure （PaCO2） 〉400 mmHg with 100% of fractional inspired oxygen concentration were defined as RM responders. Thirteen ARDS patients was diagnosed as responders whose PaO2 ＋ PaCO2, were higher than nonresponders （419 ± 44 mmHg vs. 170 ±73 mmHg, P 〈 0.0001）. In responders, PEEP mainly increased-recruited pixels in dependent regions and over-distended pixels in nondependent regions. PEEP alleviated global inhomogeneity of tidal volume and end-expiratory lung volume. PEEP levels without significant alveolar derecruitment and over-distension were identified individually. Conclusions： After RMs, PEEP titration significantly affected regional gas distribution in lung, which could be monitored with EIT. EIT has the potential to optimize PEEP titration.

Effects of different levels of end-expiratory positive pressure on lung recruitment and protection in patients with acute respiratory distress syndrome

Background It is still controversial as to the implementation of higher positive end-expiratory pressure （PEEP） in patients with acute respiratory distress syndrome （ARDS）. This study was conducted to compare the lower and higher PEEP in patients with ARDS ventilated with low tidal volume, to investigate the relationship between the recruited lung volume by higher PEEP and relevant independent variables and to provide a bedside estimate of the percentage of potentially recruitable lung by higher PEEP. Methods Twenty-four patients with ARDS were studied. A lung recruiting maneuver was performed, then each patient was ventilated with PEEP of 8 cmH20 for 4 hours and subsequently with PEEP of 16 cmH20 for 4 hours. At the end of each PEEP level period, gas exchange, hemodynamic data, lung mechanics, stress index ＂b＂ of the dynamic pressure-time curve, intrinsic PEEP and recruited volume by PEEP were measured. Results Fourteen patients were recruiters whose alveolar recruited volumes induced by PEEP 16 cmH20 were （425_＋65） ml and 10 patients were non-recruiters. Compared with the PEEP 8 cmH20 period, after the application of the PEEP 16 cmH20, the PaO2/FiO2 ratio and static lung compliance both remained unchanged in non-recruiters, whereas they increased significantly in recruiters. Changes in PaO2/FiO2 and static lung compliance after PEEP increase were independently associated with the alveolar recruitment. Analyzing the relationship between recruiting maneuver （RM）-induced change in end-expiratory lung volume and the alveolar recruitment induced by PEEP, we found a notable correlation. Conclusions The results of this study indicated that the potential for alveolar recruitment might vary among the ARDS population and the higher PEEP levels should be limited to recruiters. Improving in PaO2/FiO2, static lung compliance after PEEP increase and the shape of the pressure-time curve could be helpful for PEEP application.

Alveolar stability under different combinations of positive end-expiratory pressure and tidal volume： alveolar microscopy in isolated injured rat lungs

Background High positive end-expiratory pressure （PEEP） and low tidal volume （VT） ventilation is thought to be a protective ventilation strategy. It is hypothesized that the stabilization of collapsible alveoli during expiration contributes to lung protection. However, this hypothesis came from analysis of indirect indices like the analysis of the pressure-volume curve of the lung. The purpose of this study was to investigate isolated healthy and injured rat lungs by means of alveolar microscopy, in which combination of PEEP and VT is beneficial with respect to alveolar stability （I-E%）. Methods Alveolar stability was investigated in isolated, non-perfused mechanically ventilated rat lungs. Injured lungs were compared with normal lungs. For both groups three PEEP settings （5, 10, 20 cmH20） were combined with three VT settings （6, 10, 15 ml/kg） resulting in nine PEEP-VT combinations per group. Analysis was performed by alveolar microscopy. Results In normal lungs alveolar stability persisted in all PEEP-VT combinations （I-E% （3.2±11.0）%）. There was no significant difference using different settings （P 〉0.01）. In contrast, alveoli in injured lungs were extremely instable at PEEP levels of 5 cmH20 （mean I-E% 100%） and 10 cmH2O （mean I-E% （30.7±16.8）%）; only at a PEEP of 20 cmH20 were alveoli stabilized （mean I-E% of （0.2±9.3）%）. Conclusions In isolated healthy lungs alveolar stability is almost unaffected by different settings of PEEP and VT. In isolated injured lungs only a high PEEP level of 20 cmH2O resulted in stabilized alveoli whereas lower PEEP levels are associated with alveolar instability.

基于驱动压的肺保护性通气策略在婴儿单肺通气中的应用效果

目的探讨基于驱动压(Pd)个体化调节呼气末正压(PEEP)的保护性通气策略在婴儿单肺通气(OLV)中的临床效果。方法60例择期胸腔镜手术婴儿随机分成对照组(C组)和驱动压力组(DP组),每组30例。于OLV期间,比较两组婴儿人工气胸前(T0)、人工气胸后10 min(T_(1))、人工气胸后30 min(T_(2))、人工气胸后60 min(T_(3))和人工气胸结束(T4)时的MAP、HR、潮气量(Vt)、PEEP、Pd、气道峰压(Ppeak),肺静态顺应性(Cs),以及人工气胸前后的动脉血气分析结果。结果两组患儿在各时间点上的MAP、HR和Vt均差异无统计学意义(P>0.05)。与T0相比,两组患儿在T_(1)、T_(2)和T_(3)时的Pd和Ppeak均升高,Cs降低(P<0.05),在T_(2)时的Pa O_(2)和OI降低,Pa CO_(2)升高(P<0.05)。与C组相比,DP组在T_(1)、T_(2)和T_(3)时的Pd和Ppeak更低,PEEP和Cs更高(P<0.05),在T_(2)时Pa O_(2)和OI更高(P<0.05),Pa CO_(2)和FiO_(2)无明显差异(P>0.05)。OLV期间,DP组需要通气补救2例(6.9%)低于C组9例(32.4%)(P<0.05)。两组患儿术后并发症差异无统计学意义(P>0.05)。结论基于驱动压的肺保护性通气策略可个体优化婴儿OLV中PEEP设置,改善通气侧肺部顺应性和氧合。

肺复张在急性A型主动脉夹层术后低氧血症中的应用

目的 探讨肺复张治疗急性A型主动脉夹层(acute type A aortic dissection,ATAAD)术后低氧血症的疗效及安全性。方法 选取2019年11月至2022年5月广西医科大学第一附属医院ATAAD术后低氧血症患者56例,将其随机分为肺复张组(n=36)及常规治疗组(n=20)。常规治疗组患者在肺保护性通气基础上行常规机械通气,肺复张组患者采用呼气末正压通气(positive end expiratory pressure,PEEP)递增法进行肺复张。比较两组患者治疗前后的动脉血气分析、呼吸力学指标、血流动力学指标和血清白细胞介素(interleukin,IL)-6及IL-10水平。结果 治疗后12h、24h,两组患者的动脉血氧分压(arterial partial pressure of oxygen,PaO_(2))、氧合指数(oxygenation index,OI)、肺静态顺应性(C_(stat))及肺动态顺应性(C_(dyn))均显著高于本组治疗前,肺泡动脉氧分压差[PO_(2)(A-a)]、呼吸指数(respiratory index,RI)、气道峰压(P_(peak))及气道平台压(P_(plat))均显著低于本组治疗前(P<0.05);肺复张组患者的PaO_(2)、OI、C_(stat)及C_(dyn)均显著高于常规治疗组,PO_(2)(A-a)、RI、P_(peak)及P_(plat)均显著低于常规治疗组(P<0.05)。肺复张组患者肺复张过程中收缩压及平均动脉压有所下降(P<0.05),中心静脉压有所升高(P<0.05),肺复张结束后均恢复至基线水平。治疗后12h,两组患者的血清IL-6和IL-10水平均显著低于本组治疗前(P<0.05)。结论 PEEP递增法肺复张可改善ATAAD术后低氧血症患者的氧合及肺顺应性,但对血流动力学存在一过性影响,治疗时应进行严密监测。

不同潮气量和PEEP对脉搏轮廓法与经肺热稀释法测量巴马猪心排血量的影响

【目的】探究机械通气时不同潮气量和呼气末正压(PEEP)对脉搏轮廓法与经肺热稀释法测量巴马猪心排血量的影响。【方法】选取实验用巴马猪12只,随机分为对照组(肺动脉导管热稀释法)、研究组A(经肺热稀释法)和研究组B(脉搏轮廓法),各4只。建立模型,采用不同方法测量心排出量,分析其一致性,比较不同潮气量和PEEP对心排出量的影响。【结果】脉搏轮廓法与热稀释法测定猪心排血量的相关系数为r=0.754,两者具有正相关性。经肺热稀释法与热稀释法测定猪心排血量的相关系数为r=0.771,两者具有正相关性。脉搏轮廓法、与热稀释法测定猪心排血量相对误差为13.5%,两者具有一致性。经肺热稀释法与热稀释法测定猪心排血量相对误差为12.9%,两者具有一致性。随着潮气量增加,心排出量值明显降低,差异具有统计学意义(P<0.05)。随着PEEP增加,猪心排出量明显降低,差异具有统计学意义(P<0.05)。【结论】脉搏轮廓法、经肺热稀释法与热稀释法测定猪心排血量的一致性良好;当机械通气潮气量或PEEP增加时猪心排血量逐渐下降。

腹腔镜手术中呼气末二氧化碳分压监测在临床麻醉中的应用

目的探讨呼气末二氧化碳分压(PETCO_(2))监测能否准确反映全麻下腹腔镜手术在二氧化碳气腹下动脉血二氧化碳水平。方法回顾性分析2021年1月至2023年2月襄阳职业技术学院附属医院收治的80例全麻下腹腔镜手术患者的临床资料,监测二氧化碳气腹前后患者PETCO_(2)与动脉血二氧化碳分压(PaCO_(2))的变化,分析二者的相关性,同时记录手术期间发现不良事件的能力。结果患者二氧化碳气腹前后PETCO_(2)与PaCO_(2)的变化均有显著性差异(P<0.05);而发现术中不良事件的能力方面,PETCO_(2)灵敏性明显优于PaCO_(2),二者比较有极显著性差异(P<0.01)。结论临床麻醉中应用PETCO_(2)监测全麻下腹腔镜手术可以有效反映二氧化碳水平变化,具有连续性,亦能更及时发现手术中不良事件,有较高的临床价值。

个体化PEEP通气策略对围手术期肺保护、肺不张及血流动力学的影响:系统性评价及荟萃分析

目的 在全麻患者术中使用不同的方法(电阻抗断层成像、肺部超声、动/静态肺顺应性、驱动压、跨肺压)确定个体化呼吸末正压(PEEP),与传统的固定PEEP相比是否引起肺损伤、肺不张及血流动力学不稳定。方法 计算机检索PubMed、clinicaltrials.gov、Web of Science、Cochrane Library及中国知网,并筛选所有选定文章的参考列表和类似文献,搜索截至2023年1月的所有中英文出版物,使用Revman 5.3软件进行Meta分析。结果 研究了45篇文献,共3 767患者。Meta分析显示个体化PEEP组CC-16浓度、肺部超声评分及肺部并发症发生率与传统PEEP组相比明显降低(P<0.05)。个体化PEEP与术中更高的动态肺顺应性和更低的驱动压有关(P<0.000 01)。同时,个体化PEEP组相较于传统PEEP组对MAP(P=0.13)和HR(P=0.94)差异无统计学意义。结论 与传统PEEP相比,术中使用个体化PEEP增加了患者围手术期肺保护效应,降低了围手术期肺不张的发生率和严重程度。同时,并不引起围手术期血流动力学紊乱。

肺动态顺应性指导个体化PEEP滴定对颅面重建术患儿术后肺不张的影响

目的探讨肺动态顺应性(Cdyn)指导个体化PEEP滴定对颅面重建术患儿术后肺不张的影响。方法选择全麻下行颅面重建术患儿80例,男52例,女28例,年龄≤1岁,ASAⅠ或Ⅱ级,麻醉时间≥2 h。采用随机数字表法将患儿分为两组:Cdyn导向个体化PEEP组(I组)和固定PEEP组(P组),每组40例。I组在插管后5 min肺部超声评分(LUS)后进行PEEP滴定,Cdyn最高值对应的PEEP为个体化PEEP;P组PEEP固定为6 cmH_(2)O。记录插管后5 min和手术结束时胸膜旁实变评分、B线评分、LUS总评分和肺不张发生情况。记录插管后5 min和PEEP建立后Cdyn、气道峰压(Ppeak)、HR、MAP。记录插管后5 min和手术结束时氧合指数(OI)和术后72 h肺部并发症的发生情况。结果I组滴定过程中Cdyn最高值时对应个体化PEEP滴定值中位数为9 cmH_(2)O。与插管后5 min比较,两组手术结束时胸膜旁实变总评分、后胸部胸膜旁实变评分、B线总评分和前、侧、后胸部B线评分、LUS总评分均明显降低(P<0.05)。与P组比较,I组手术结束时胸膜旁实变评分、后胸部胸膜旁实变总评分、B线总评分、后胸部B线评分、LUS总评分、肺不张发生率明显降低(P<0.05),I组PEEP建立后Cdyn和Ppeak明显升高(P<0.05),手术结束时OI明显升高(P<0.05),术后72 h肺部并发症总发生率明显降低(P<0.05)。结论术中应用Cdyn指导个体化PEEP滴定能有效降低颅面重建术患儿手术结束时LUS评分和肺不张发生率,改善氧合功能,降低术后肺部并发症发生率。

不同通气模式对Trendelenburg体位腹腔镜手术患者PaO_2和PaCO_2的影响

目的探讨压力控制通气（PCV）联合呼气末正压（PEEP）在Trendelenburg体位腹腔镜手术中对PaO_2和PaCO_2的影响。方法腹腔镜直肠癌根治术患者40例,年龄35~55岁,随机分为两组,每组20例。A组采用容量控制通气模式（VCV）通气[VT=体重（kg）×10ml]20min后,改用PCV模式通气20min,返回VCV模式继续通气20min后,采用PCV＋低PEEP（5cm H_2O）模式通气20min。B组则将PCV与PCV＋PEEP的顺序调换。在切换通气模式时行动脉血气分析。结果两组VCV模式时PaO_2均明显低于PCV模式及PCV＋PEEP模式（P〈0.05）。PCV模式时PaO_2明显低于PCV＋PEEP模式（P〈0.05）;VCV模式时PaCO_2明显高于PCV模式和PCV＋PEEP模式（P〈0.05）,而PCV模式和PCV＋PEEP模式时PaCO_2差异无统计学意义。VCV模式时动脉血pH值明显低于PCV和PCV＋PEEP模式（P〈0.05）,PCV和PCV＋PEEP模式时动脉血pH值差异无统计学意义。结论 Trendelenburg体位腹腔镜手术时采用PCV＋PEEP通气模式,与单纯VCV或单纯PCV模式比较,在提高PaO_2以及降低PaCO_2方面更具优势。

肺动态顺应性指导个体化呼气末正压通气对老年患者腹腔镜结直肠癌术中肺功能的影响

目的观察肺动态顺应性(Cdyn)指导个体化呼气末正压通气(PEEP)对老年患者腹腔镜结直肠癌术中肺功能的影响。方法选择择期行腹腔镜结直肠癌根治术的老年患者68例,男37例,女31例,年龄65~79岁,BMI<30 kg/m^(2),ASAⅡ或Ⅲ级。采用随机数字表法将患者分为两组:个体化PEEP组(P组)和对照组(C组),每组34例。P组在插管完成即刻、气腹-屈氏体位建立即刻、气腹结束即刻行肺复张及PEEP滴定试验,C组设置固定PEEP 5 cmH_(2)O。记录P组3次滴定时最佳PEEP和实际VT。记录气管插管完成后10 min(T_(1))、气腹-屈氏体位建立后10 min(T_(2))、60 min(T_(3))、手术结束拔管前(T_(4))PaO_(2)、PaCO_(2)、PETCO_(2),计算氧合指数(OI)、死腔/潮气量比值(Vd/VT)、肺泡-动脉血氧分压差(A-aDO_(2))、驱动压和Cdyn。采用ELISA法测定麻醉诱导前(T0)、拔管后10 min(T5)的白细胞介素-8(IL-8)、肿瘤坏死因子-α(TNF-α)、肺Clara细胞分泌蛋白(CC16)及肺泡表面活性物质-D(SP-D)的浓度。记录术后肺部并发症(PPCs)的发生情况。结果P组滴定最佳PEEP的中位数为4 cmH_(2)O。与C组比较,P组T_(4)时PaO_(2)、OI明显升高,T_(1)、T_(3)、T_(4)时Cdyn明显升高,T_(1)—T_(4)时驱动压明显降低,T5时CC16血清浓度明显降低(P<0.05)。两组T_(1)—T_(4)时PaCO_(2)、PETCO_(2)、A-aDO_(2)、Vd/VT差异无统计学意义。两组术后3 d均未发生严重PPCs。结论在老年患者腹腔镜结直肠癌根治术中,采用压力控制通气下肺动态顺应性指导个体化PEEP的肺保护通气策略,可提高患者术中肺动态顺应性,降低驱动压,改善手术结束时氧合,降低术后CC16血清浓度,改善术中肺功能。

高水平呼气末正压通气联合肺复张在肥胖患者全麻俯卧位手术中的应用研究

目的评价高水平呼末正压通气(PEEP)联合肺复张(RM)在肥胖患者全麻俯卧位手术中的应用效果。方法选择60例BMI≥28 kg/m^(2)择期拟行全麻下腰骶椎手术的肥胖患者,采用随机数字表法分为两组:对照组(A组)和实验组(B组),每组30例。A组设置PEEP=5 cmH_(2)O,B组设置PEEP=10 cmH_(2)O联合肺复张手法。观察并记录两组患者麻醉前(T0)、气管插管后仰卧位机械通气10 min(T1)、气管插管后俯卧位机械通气10 min(T2)、俯卧位机械通气1 h(T3)和气管拔管后脱氧30 min(T4)的血流动力学指标、呼吸力学指标、动脉血气分析指标、T0、T4和术后1 d(T5)时肺部超声评分(LUS)总分以及术后5 d内呼吸系统并发症的发生情况。结果两组患者心率(HR)、平均动脉压(MAP)比较差异无统计学意义;B组在T2、T3、T4时刻的氧合指数(OI)均显著高于A组,肺泡动脉氧分压差(A-aDO_(2))均低于A组(P<0.05);与T1时刻相比,T2、T3时刻两组患者的气道峰压(Ppeak)和驱动压(ΔP)呈上升趋势,肺动态顺应性(Cdyn)呈下降趋势(P<0.05)。B组术中的Ppeak、Cdyn相比于A组明显升高,而ΔP均低于A组(P<0.05);B组LUS评分在T4和T5时刻低于A组(P<0.05);两组术后5 d内呼吸系统并发症发生率比较差异无统计学意义。结论对于需行全麻俯卧位手术的肥胖患者,高水平PEEP联合肺复张有助于改善肺顺应性和氧合状态,提高患者氧储备和肺功能的恢复能力,但并未发现能够降低患者术后呼吸系统并发症的发生率。

COPD急性加重老年患者拔管后行主动循环呼吸联合振动正压呼气训练效果观察

目的探讨慢性阻塞性肺疾病急性加重(Acute Exacerbation of Chronic Obstructive Pulmonary Disease,AECOPD)老年患者拔管后应用主动循环呼吸技术联合振动正压呼气技术行呼吸功能训练的效果。方法将收治于重症医学科及呼吸内科监护室的72例AECOPD老年患者随机分为对照组(35例)与试验组(37例),对照组气管插管拔管后采用主动循环呼吸技术进行呼吸功能训练,试验组在主动循环呼吸技术基础上联合振动正压呼气技术进行呼吸功能训练,比较两组拔管后48 h内再次气管插管事件、咳嗽咳痰及呼吸困难症状改善情况、肺功能及血气指标。结果两组48 h内再次气管插管率比较差异无统计学意义(P>0.05)。干预后试验组咳嗽咳痰评分、呼吸困难评分显著低于对照组,PaO 2显著高于对照组,而PaCO 2显著低于对照组(均P<0.05);试验组拔管后ICU停留时间显著短于对照组(P<0.05)。结论对AECOPD老年患者增加振动正压呼气技术辅助呼吸功能训练,可以有效促进呼吸道分泌物排出,改善临床症状,缩短ICU住院时间。

个体化PEEP联合定期肺复张对行腹腔镜结直肠癌根治术老年患者术后肺不张的影响

目的评估肺超声下驱动压(ΔP)引导的个体化呼气末正压通气(PEEP)联合定期肺复张对Trendelenburg体位下行腹腔镜结直肠癌根治术的老年患者术后肺不张的影响。方法纳入年龄65~85岁、美国麻醉医师协会分级Ⅰ—Ⅲ级,拟行腹腔镜下结直肠癌根治术的患者62例并分为试验组和对照组(各31例)。2组均在气腹开始后进行第1次肺复张,随后立即以最低ΔP滴定个体化PEEP,气腹结束后进行第2次肺复张。试验组自气腹开始每30 min额外进行一次肺复张,对照组则不干预。以麻醉诱导前(T_(0))、气腹后30 min(T_(1))、气腹后90 min(T_(2))、手术结束时(T_(3))、进入麻醉复苏室(PACU)45 min后(T_(4))为观察记录时间点。记录T_(0)、T_(3)和T_(4)时肺超声评分(LUS);T_(1)—T_(3)时肺动态顺应性(Cdyn);T_(0)—T_(4)时间点氧合指数(OI)、平均动脉压(MAP)、心率(HR);记录肺复张期间低血压、PACU中低氧饱和事件以及术后7 d内肺部并发症(POPC)发生率。结果与对照组相比,试验组在T_(3)和T_(4)时LUS下降(P<0.05),T_(2)、T_(3)时OI和Cdyn升高(P<0.05)。试验组在PACU中低氧饱和事件发生率较对照组下降(P<0.05)。2组患者肺复张期间低血压发生率和术后7 d内POPC发生率差异无统计学意义(P>0.05)。结论个体化PEEP联合定期肺复张可有效减少老年患者腹腔镜结直肠癌根治术后即刻和PACU中的肺不张。

呼气末正压联合俯卧位通气治疗重症肺炎伴急性呼吸窘迫综合征的临床效果

目的:探讨呼气末正压(PEEP)联合俯卧位通气治疗重症肺炎伴急性呼吸窘迫综合征的临床效果。方法:选取2022年5月—2023年4月柳州市柳铁中心医院收治的重症肺炎伴急性呼吸窘迫综合征患者90例作为研究对象,采取随机数字表法分为两组,各45例。对照组采用仰卧位机械通气治疗,观察组采用PEEP联合俯卧位通气治疗。比较两组治疗效果。结果:治疗前,两组氧分压(PO_(2))、血氧饱和度(SO_(2))、二氧化碳分压(PCO_(2))水平比较,差异无统计学意义(P>0.05);治疗后,两组PO_(2)、SO_(2)高于治疗前,且观察组高于对照组,两组PCO_(2)低于治疗前,且观察组低于对照组,差异有统计学意义(P<0.05)。治疗前,两组第1秒用力呼气容积(FEV_(1))、最大肺活量(FVC)、FEV_(1)/FVC比较,差异无统计学意义(P>0.05);治疗后,两组FEV_(1)、FVC、FEV_(1)/FVC高于治疗前,且观察组高于对照组,差异有统计学意义(P<0.05)。观察组治疗总有效率高于对照组,差异有统计学意义(P=0.015)。观察组住院时间短于对照组,差异有统计学意义(P<0.001)。结论:PEEP联合俯卧位通气治疗重症肺炎伴急性呼吸窘迫综合征的临床效果显著,可改善患者呼吸功能及肺部功能,缩短住院时间。

2023年欧洲重症医学学会与美国胸科协会急性呼吸窘迫综合征新指南之异同

随着科学研究和临床实践的进展,近5年急性呼吸窘迫综合征(ARDS)的诊治策略取得了长足发展。基于此,2023年欧洲重症医学学会(ESICM)和美国胸科协会(ATS)在2017年ARDS临床实践指南(CPG)的基础上,分别对ARDS治疗策略进行了更新和修订。ESICM新指南从ARDS定义、表型和呼吸支持策略3大主题的9个关键领域提出了21项推荐意见。ATS新指南则在2017 CPG的基础上,纳入了关于糖皮质激素、静脉-静脉体外膜氧合、神经肌肉阻断剂以及呼气末正压应用的新证据,并进行了条件限制性推荐。在特定临床问题的推荐意见上存在差异除外,两者总体上保持一致。该文对ESICM新指南和ATS新指南进行比较分析,以期为在临床实践中进行合理的循证决策提供可靠依据。