静态压力-容量曲线指导个体化保护性肺通气在老年患者开胸手术中的作用  

The Effect of Lung Protective Ventilation Strategy Based on Quarsi-static Press-volume Curve in Aged Patients Undergoing Thoracic Surgery

作　　者：史志国[1,2] 郑晖[1,2] 刘志东[1,2] 耿万明[1,2] 韩毅[1,2] 

机构地区：[1]北京市结核病胸部肿瘤研究所 [2]首都医科大学附属北京胸科医院麻醉科,北京101149

出　　处：《中国医药导刊》2012年第4期556-558,563,共4页Chinese Journal of Medicinal Guide

摘　　要：目的:评价静态压力-容量(P-V)曲线指导个体化保护性肺通气在老年患者开胸手术中的作用。方法:96例择期行肺叶切除术的老年肺癌患者,按术前肺功能分为2组:N组为肺功能正常组,D组为肺功能异常组。再根据通气方式将每组随机分为2个亚组:对照组(NC、DC组)和保护性肺通气组(NP、DP组)。NC组和NP组各30例,均为肺功能正常患者,DC组和DP组各18例,均为肺功能异常患者。NC和DC组设定单肺通气(OLV)潮气量9ml/kg,NP和DP组设OLV定潮气量6ml/kg,并在健侧肺采用呼气末正压(PEEP)通气,以P-V曲线低位拐点对应压力(Pinfs)+2cmH2O确定PEEP值,术侧肺采用持续气道正压(CPAP)通气,压力为5cmH2O。记录OLV前侧卧位(T1)、OLV开始后30 min(T2)、OLV开始后60 min(T3)的平台压(Pplat)、峰压(Ppeak)、肺顺应性(Cdyn);T1、T2、T3和关胸5min(T4)时抽取动脉血测血气指标,计算出肺内分流率(Qs/Qt);T1、T4和术后18h(T5)时抽取静脉血,检测IL-6、TNF-a浓度;监测术后1、3、5天胸部体征、血常规、胸片变化以判断预后。结果:T2、T3时,与DC、NC组比较,DP、NP组Pplat、Ppeak降低,Cdyn增加(P<0.05);T2、T3、T4时,与DC组比较,DP组Qs/Qt降低,PaO2升高(P<0.05);T4、T5时,与NC、DC组比较,NP、DP组IL-6、TNF-α浓度降低(P<0.05)。术后NP、DP组并发症减少(P<0.05)。结论:采用6 ml/kg潮气量,根据静态P-V曲线Pinfs+2cmH2O设置PEEP,术侧辅以5cmH2O的CPAP及容许性高碳酸血症(PH)的肺通气方式有助于减少老年患者开胸手术中低氧血症发生,减轻肺损伤,减少围术期肺部并发症发生;在老年肺功能异常患者中作用更明显。Objective： To evaluate the effect of lung protective ventilation strategy based on quarsi-static press-volume curve in aged patients undergoing thoracic surgery.Methods： 96 undergoing lobectomy aged patients were divided into group N（normal） and group D（decreased） according to the pulmonary function before operation.These two groups were randomly divided into two subgroups： controlgroup（NC,n=30;DC,n=18） and protective lung ventilation group（NP,n=30;DP,n=18）.During OLV,Vt was set at 9ml/kg in group NC and DC,meanwhile Vt was set at 6ml/kg,PEEP at Pinfs ＋2cmH2O and CPAP at 5cmH2O in group NP and DP.Plateau airway pressure（Pplat）,peak airway pressure（Ppeak） and lung compliance（Cdyn） were measured and recorded at 5 minutes before OLV（T1）,30 minutes（T2）,60minutes after OLV（T3）.Arterial blood samples were taken at T1,T2,T3 and 5 minutes after TLV（T4） for blood gas analysis.Venous blood samples were collected at T1,T4 and 18h after thoracotomy surgery（T5） for the determination of plasma concentration of TNF-α and IL-6（by ELISA）.Chest feature,chest radiographic feature,blood routine were monitored on 1,3,5 days after thoracic surgery.Results： Compared with group DC and NC,Pplat,Ppeak in group DP and NP decreased significantly during T2 and T3.Compared with group DC,Qs/Qt decreased,and PaO2 increased in group DP at T2,T3.Compared with group DC and NC,concentration of TNF-α、IL-6 in group NP and DP then decreased respectively at T4 and T5.Complications reduced in group NP and DP after thoracic surgery.Conclusion： Mechanical ventilation with Vt at 6ml/kg,PEEP at Pinfs ＋2cmH2O,CPAP at 5cmH2O and PH provides best ventilation efficacy for OLV.It is more effective in aged patients with abnormal pulmonary function.

关 键 词：单肺通气 保护性肺通气策略 呼气末正压通气 持续气道正压通气 

分 类 号：R655[医药卫生—外科学]