微创二尖瓣置换术中单肺通气策略  

The strategies of single lung ventilation in minimally in vasive mitral valve replacement

作　　者：肖文[1] 刘锴 高扬 宋来春[1] 凌中义[1] 黄维勤[1] XIAO Wen;LIU Kai;GAO Yang(Department of Anesthesia, Wuhan Asia Heart Hospital, Wuhan 430022, Chin)

机构地区：[1]武汉亚洲心脏病医院麻醉科

出　　处：《中国心血管病研究》2018年第6期542-545,共4页Chinese Journal of Cardiovascular Research

摘　　要：目的探讨微创二尖瓣置换术中不同肺通气策略对呼吸功能和呼吸力学的影响。方法纳入120例择期行微创二尖瓣手术的患者，根据术中采用不同的单肺通气策略分为两组：容量控制性单肺通气组（60例）及保护性单肺通气＋肺复张组（60例）。两组患者均采用双腔气管插管进行单肺通气；容量控制性通气组采用传统容量控制性通气策略（6～8ml／kg），保护性肺通气组采用低潮气量（5ml／kg）＋5cmH20PEEP肺通气＋肺复张技术。记录两组患者单肺通气前，体外循环停用后15min、30min及术后双肺通气4个时间点的气道峰压、气道阻力、胸肺顺应性、氧合指数，以及术后低氧血症的发生、机械通气时间、ICU时间、肺不张和肺部感染等的发生情况。结果与容量控制性单肺通气组相比较，保护性单肺通气＋肺复张组患者在CPB停用后15min（121．3±40．5）比（148．2±36．6）]、CPB停用后30min[（112．4±36．2）比（138．2±28．5）]、及双肺通气时[（322．4±46．1）比（340．5±33．6）]氧合指数明显升高（P〈0．01）；CPB后15min、30min时肺顺应性明显增加[（31．8±6．9）ml／cmH20比（35．6±5．2）ml／cmH20；（30．4±4．1）ml／cmH2O比（33．8±4．9）ml／cmH2O]，气道阻力[（19．8±3．7）cmH2O·L^-1·S^-1比（16．9±3．9）cmH2O·L^-1·S^-1；（19．8±3．6）cmH2O·L^-1·S^-1比（17．9±3．2）cmH2O·L^-1·s^-1]、气道峰压[（22．9±2．7）cmH2O比（22．8±2．1）cmH2O；（23．4±3．8）cmH2O比（22．I±3．8）cmH2O]明显降低（P〈0．05）。保护性单肺通气＋肺复张组患者术后低氧血症、肺不张及延迟拔除气管导管的发生率均明显降低（P〈0．05）。肺部感染两组比较未见统计学差异（P=0．68）。结论微创二尖瓣手术中采用低潮气量（5ml／kg）＋5cmH2O PEEP＋肺复张保护性肺通气策略是安全可行的，不仅可明显提高肺顺应性�Objective To investigate the strategies of single lung ventilation on oxygenation and respiratory mechanics in patients underwent minimally invasive mitral valve replacement. Methods 120 patients underwent minimally invasive mitral valve replacement were recruited. They were divided into two different groups depended on different single lung ventilation strategies： Volume control ventilation Group （n=60）, lung recruitment maneuvers（LRM）＋pressure controlled ventilation＋5 cm H20 PEEP Group（n=60）. Peak airway pressure, airway resistance, lung thorax compliance, oxygenation index were recorded in four different time. Meanwhile, postoperative data including hypoxemia, ICU stay, the duration of ventilation, atelectasis and pulmonary infection were recorded. Results Compared with Volume control ventilation Group, OI increased significantly during post-CPB 15 min [（121.3±40.5） vs. （148.2±36.6）], 30 rain [（112.4±36.2） vs. （138.2±28.5）] and complete lung ventilation [（322.4±46.1） vs. （340.5±33.6）]（P〈0.01）; Cdyn increased during post-CPB 15 min, 30 min [（31.8±6.9） ml/cm H2O vs. （35.6±5.2）ml/cm H20;（30.4±4.1）ml/cm H2O vs. （33.8±4.9）ml/cm H20] and Ppeak [（22.9±2.7）cm H2O vs. （22.8±2.1）cm H2O; （23.4±3.8）cm H2O vs. （22.1±3.8）cm H2O] and Raw[ （19.8±3.7）cm H2O·L^-1·S^-1 vs. （ 16.9±3.9 ）cm H2O ·L^-1·S^-1; （ 19.8±3.6）cm H2O·L^-1·S^-1 vs. （ 17.9±3.2）cm H2O·L^-1·S^-1] decreased（P〈0.05 ）. Compared with Volume control ventilation Group, the incidence of hypoxemia, atelectasis and delaying extubation was lowerin another group（P〈0.05 ）. There was no difference in the incidence of pulmonary infection in two groups （P=0.68）. Conclusion The single lung ventilation strategy of LRM＋PVC＋5 cm H20 PEEP is safe and feasible, which could improve the compliance of lung and oxygenation, reduce the complications and improve the prognosis obviously.

关 键 词：微创 二尖瓣置换 单肺通气 

分 类 号：R654.2[医药卫生—外科学]