以肺动态顺应性为导向靶控呼气末正压减少单肺通气肺内分流的临床研究  

Effect of target controlled positive end-expiratory pressure on intrapulmonary shunt during one lung ventilation according to lung dynamic compliance

作　　者：徐典 魏薇[1] 连明[1] 陈莲华[1] 李士通[1] XU Dian;WEI Wei;LIAN Ming;CHEN Lianhua;LI Shitong(Department of Anesthesiology,Shanghai First People’s Hospital,Shanghai Jiaotong University,Shanghai 200080,China)

机构地区：[1]上海交通大学附属第一人民医院麻醉科,上海200080

出　　处：《上海医学》2019年第10期577-582,共6页Shanghai Medical Journal

摘　　要：目的评价依据肺动态顺应性(Cdyn)调节呼气末正压(PEEP)减少单肺通气肺内分流,改善氧合的效应。方法选取上海交通大学附属第一人民医院择期行胸外科手术需单肺通气(OLV)的患者30例,随机分为试验组和对照组,每组15例。试验组将4 cmH2O(1 cmH2O=0.098 kPa)作为初始PEEP值,根据肺Cdyn滴定调节PEEP,每5 min增加1 cmH2O,当肺Cdyn达到最大时的PEEP值即最佳PEEP值;对照组PEEP值设为0。记录两组患者OLV开始(T1)、OLV后15 min(T2)、OLV后30 min(T3)、OLV后45 min(T4)、OLV后60 min(T5)时的平均动脉压(MAP)、心率、呼气末二氧化碳分压(petCO2),以及呼吸动力学指标气道峰压(ppeak)、平台压(pplat)、肺顺应性;并于上述各时间点抽取动脉、混合静脉血行血气分析,记录动脉血氧分压(paO2),计算肺内分流、死腔通气比。结果试验组T1至T5时间点间MAP的差异均无统计学意义(P值均>0.05);对照组T2、T3时间点的MAP均显著低于同组T1时间点(P值均<0.05),T4、T5时间点的MAP与同组T1时间点间的差异均无统计学意义(P值均>0.05)。试验组T5时间点的心率显著低于同组T1时间点(P<0.05),T2至T4时间点的心率与同组T1时间点间的差异均无统计学意义(P值均>0.05);对照组T1至T5时间点间心率的差异均无统计学意义(P值均>0.05)。试验组当肺Cdyn达最大时的PEEP值为(7.80±0.56) cmH2O。试验组T2至T5时间点的ppeak和pplat均显著高于同组T1时间点(P值均<0.05),T3至T5时间点的ppeak和pplat均显著高于同组T2时间点(P值均<0.05)。两组间T1至T5各时间点ppeak和pplat的差异均无统计学意义(P值均>0.05)。试验组T3至T5时间点的paO2均显著高于同组T1和T2时间点(P值均<0.05),T5时间点的肺内分流显著低于同组T2时间点(P<0.05),T1至T4时间点间肺内分流的差异均无统计学意义(P值均>0.05),T1至T5时间点间死腔通气比的差异均无统计学意义(P值均>0.05)。对照组T1至T5时间点间paO2的差异均无统计Objective To evaluate the effect and feasibility of target controlled positive end-expiratory pressure(PEEP) on the intrapulmonary shunt and oxygenation during one lung ventilation(OLV) according to lung dynamic compliance. Methods Thirty patients who underwent elective thoracic surgery under general anesthesia with OLV were enrolled in this study. They were randomly divided into 2 groups(n=15, respectively). In experiment group, 4 cmH2O(1 cmH2O=0.098 kPa) was taken as the starting point, PEEP was increased by 1 cmH2O every 5 minutes according to lung dynamic compliance;when the lung dynamic compliance reached the maximum, the PEEP value was determined to be the optimal one. In control group, PEEP value was set as 0. Mean arterial pressure(MAP), heart rate(HR), end tidal carbon dioxide partial pressure(petCO2), peak airway pressure(ppeak), plateau airway pressure(pplat), and lung compliance were measured and recorded at the beginning of OLV(T1), 15 minutes(T2), 30 minutes(T3), 45 minutes(T4) and 60 minutes(T5) after OLV. Arterial and venous blood samples were taken at each time point for blood gas analysis. The intrapulmonary shunt(Qs/Qt) and physiologic dead space/tidal volume ratio(VD/VT) was calculated. Results There was no significant difference in the MAP between different time points in the experiment group(all P>0.05). MAP values at T2 and T3 were significantly lower than that at T1 in the control group(both P<0.05);while as compared with that at T1, no significant difference was found in MAP at T4 or T5 in the control group(both P>0.05). HR at T5 was significantly lower than that at T1 in the experiment group(P<0.05), while as compared with that at T1, no significant difference was found in HR from T2 to T4(all P>0.05). There was no significant difference in the HR between different time points in the control group(all P>0.05). PEEP was(7.80±0.56) cmH2O when lung dynamic compliance reached the maximum in the experiment group. ppeak and pplat from T2 to T5 were significantly higher than those at T1 in the

关 键 词：正压呼吸 单肺通气 动态顺应性 肺内分流 氧合 靶控通气 

分 类 号：R614[医药卫生—麻醉学]