肺复张后呼气末正压通气对肥胖患者腹腔镜术中呼吸力学和气体交换的影响  

Effects of positive end-expiratory pressure after recruitment maneuvers on respiratory mechanics and gas exchange during laparoscopy in obese patients

作　　者：蒋宗明[1] 郑羡河[1] 陈念平[1] 陈文迪[1] 陈忠华[1] 李玉红[1] 

机构地区：[1]绍兴市人民医院浙江大学绍兴医院麻醉科,312000

出　　处：《中华麻醉学杂志》2013年第8期967-971,共5页Chinese Journal of Anesthesiology

摘　　要：目的 探讨肺复张后呼气末正压（PEEP）通气对肥胖患者腹腔镜术中呼吸力学和气体交换的影响.方法 拟行腹腔镜直肠癌根治术患者63例,年龄42 ～ 64岁,ASA分级Ⅱ或Ⅲ级,BMI 30～ 40kg/m2.采用随机数字表法,将其分为3组（n=21）,PEEP0组：肺复张后不给予PEEP; PEEP5组：肺复张后给予PEEP 5 cm H2O;PEEP10组：肺复张后给予PEEP 10 cm H2O.3组气腹压力均为12mmHg.于气腹和体位变动前（T0）、气腹头低足高位20 min（T1）、肺复张后结束后10 min（T2）和气腹结束（T3）时记录呼吸力学指标：气道峰压（Ppeak）、平台压（Pplat）、胸壁平台压（PplatCW）、吸气气道阻力（Raw）、胸肺弹性阻力（ERS）、胸壁弹性阻力（ECW）和肺弹性阻力（EL）和气体交换指标：氧合指数（PaO2/FiO2）、动脉-呼气末二氧化碳分压差（Da-ETCO2）、肺泡-动脉血氧分压差（DA-aO2）、死腔率（VD/VT）.结果 与PEEP0组比较,PEEP5组T2时Da-ETCO2、ERS和Raw降低,T3时ECW和EL降低,PEEP10组T2,3时Da-ETCO2、VD/VT、DA-aO2、Pplatcw、Raw和EL降低,T2时PaO2/FiO2升高,T3时ECW降低（P＜0.05）.与PEEP5组比较,PEEP10组T2.3时Da-ETCO2、VD/VT降低,PaO2/FiO2升高,T2时Raw升高,EL降低（P＜0.01）.结论 肺复张后采用PEEP通气可改善肥胖患者腹腔镜术中呼吸力学和气体交换,且PEEP 10cm H2O的效果优于5cmH2O.Objective To investigate the effects of positive end-expiratory pressure （PEEP） after recruitment maneuvers （RM） on respiratory mechanics and gas exchange during laparoscopy in obese patients.Methods Sixty-three ASA physical status Ⅱ or Ⅲ patients,aged 42-64 yr,with body mass index 30-40kg/m2,were randomly allocated into 3 groups （n=21 each）：PEEP0 group,PEEP5 group and PEEP10 group.PEEP was not given after RM in PEEP0 group.In PEEP5 and PEEP10 groups,a recruiting maneuver was followed by PEEP 5 and 10 cm H2 O,respectively,until the end of pneumoperitoneum.The intraabdominal pressure was set at 12mmHg in the three groups.Parameters of respiratory mechanics including peak airway pressure （Ppeak）,airway plateau pressure （Peat）,chest wall plateau pressure （PplatCW）,airway resistance （Raw）,elastance of respiratory system （ERS）,elastanc of chest wall （ECW） and elastance of lung （EL） and parameters of gas exchange including oxygenation index （PaO2/FiO2）,arterial to end-tidal difference in carbon dioxide （Da-ETCO2）,alveolar-arterial oxygen tension difference （DA-aO2）,and dead space/tidal volume ratio （VD/VT） were measured before pneumoperitoneum （T0）,at 20 min of pneumoperitoneum （T1）,at 10 min after the end of recruitment （T2）,and at the end of pneumoperitoneum （T3）.Results Da-ETCO2,ERS and Raw were decreased at T2,ECW and EL were decreased at T3 in PEEP5 group,and Da-ETCO2,VD/VT,DA-aO2,Pplatcw Raw and EL were decreased at T2.3,and PaO2/FiO2 was increased at T2,ECW was decreased at T3 in group PEEP10 as compared with that in group PEEP0 （P ＜ 0.05）.Da-ETCO2 and VD/VT were decreased and PaO2/FiO2 was increased at T2,3,Raw was increased and EL was decreased at T2 in group PEEP10 as compared with that in group PEEP5 （P ＜ 0.01）.Conclusion PEEP after RM can improve respiratory mechanics and gas exchange during laparoscopy in obese patients and PEEP maintained at 10 cm H2O after RM provides better efficacy than PEEP at 5 cm H2 O.

关 键 词：正压呼吸 呼吸力学 肺换气 肥胖症 腹腔镜检查 

分 类 号：R614[医药卫生—麻醉学]