保护性肺通气模式在结核性毁损肺全肺切除术麻醉中的价值  

The value of protective lung ventilation during anesthesia for tuberculous destructuve pneumonectomy

作　　者：史志国[1] 宋艳华[2] 李凌海[1] 翟文婷[1] 刘涛[1] 陈玢[1] SHI Zhi-guo;SONG Yan-hua;LI Ling-hai;ZHAI Wen-ting;LIU Tao;CHEN Bin(Department of Anesthesia , Beijing Chest Hospital, Capital Medical University , Beijing 101149, China)

机构地区：[1]首都医科大学附属北京胸科医院手术麻醉中心,101149 [2]首都医科大学附属北京胸科医院结核病二科,101149

出　　处：《中国防痨杂志》2019年第5期488-493,共6页Chinese Journal of Antituberculosis

摘　　要：目的探讨小潮气量通气和呼气末正压通气(positive end expiratory pressure,PEEP)结合压力控制通气(pressure controlled ventilation.PCV)对结核性毁损肺(tuberculous destroyed lung,TDL)患者全肺切除术单肺通气(one-lung ventilation, OLV)呼吸力学、肺内分流(Qs/Qt).PaO2和术后肺部感染等的影响。方法经首都医科大学附属北京胸科医院医学伦理委员会批准,选取2016年8月至2018年3月在首都医科大学附属北京胸科医院接受择期开胸全肺切除手术的TDL患者为研究对象,共48例。采用随机数字表法将患者分为观察组和对照组,每组24例。观察组0LV期间潮气量6 ml kg.OLV开始即刻给予PCV通气?然后给予7 cm H20( 1cm H20=0.0098 kPa)的PEEP通气;对照组OLV期间潮气量8 ml/kg。记录0LV前(T1)、0LV开始后30 min(T2)及全肺切除术后5 min (T3)时气道峰压(Ppek)和平台压(Pplat);T1、T2、T3和术后6 h(T4)抽取动静脉血,测血气指标pH、PaC02和PaQ,并计算Qs/Qt值;术后第1天、第7天行临床肺部感染评分。计量资料组间比较,若方差齐,采用t检验,若方差不齐采用t'检验;组内比较采用重复测量设计的方差分析;计数资料比较采用X^2检验,均以P<0. 05为差异有统计学意义。结果 T2时与对照组比较,观察组Ppek明显降低[观察组:(21.0 + 2.2) cm H:0;对照组:(22. 4±2. 2) cm H20;t=—2.446,P=0.021];T2时与对照组比较,观察组P嗣明显降低[观察组:(19.7+2.2) cm H2O;对照组:(21.0+2.7) cm H20;t=-3.610,P = 0.001];T3时与对照组比较,观察组pH明显降低[观察组:7.3±0.053;对照组,7.37±0. 047;r =- 3.000, P = 0.006];T2时与对照组比较,观察组PaCQ明显升高[观察组:(44.0±2.2) mm Hg (1 mm Hg=0.133 kPa);对照组:(35.7±4.0) mm Hg;t=7.091 ,P=0.000];T2 时与对照组比较,观察组Qs/Qt明显降低[观察组:(21.4 + 5.4)%;对照组:(25.4±6.8)%;t=-0.256,p=0.020];T4时与对照组比较,观察组Pa02/FiO2明显升高[观察组:(181.2 + 29.0) mm Hg;对照组:(159. 1 ±25. 2) mm Hg;r =2.9384=Objective To discuss the impact of respiratory mechanics,inlrapulmonary shunt (Qs Qt), PaO2 and postoperative pulmonary infection during one-lung ventilation (OLV) using small tidal volume and positive enclexpiratory pressure (PEEP) with pressure controlled ventilation ( PCV) in total pneumonectomy with tuberculous destroyed lung (TDL). Methods The present study was approved by the medical ethics committee of Beijing Chest Hospital affiliated to Capital Medical University. The study enrolled 48 TI)L patients rec&ving selective thoracotomic total pneumonectomy from August 2016 to March 2018. A random number table was nsec! to divide the patients into observation group and control group, 24 cases in each group. The tidal volume of the observation group was 6 ml/kg during OLV, and PCV was administered immediately from the beginning of OLV followed by PEEP at 7 cm H2O(1 cm H2 0=0. 0098 kPa). The tidal volume of the control group was 8 ml/kg during OLV. Airway peak pressure (Ppeak)and plateau pressure ( Ppiat) before OLV (T1),30 min after OLV ( T2) and 5 min after total pneumonectomy (T3) were recorded. Arterial and venous blood samples were collected at T1,T2, T3 and at 6 h after surgery (T4), the blood gas indicators pH, PaCC)2 and PaO2 were measured, and Qs/Qt ratio was calculated. Clinical pulmonary infection was scored at day 1 and day 7 after surgery. Measurements were compared between the two groups;paired "test was used for the comparison if there was homogeneity of variance;otherwise*/-test was used. Repeated-measures analysis of variance was performed for intragroup comparisons. Counting data were analyzed by X^2 test, P < 0. 05 was statistically significant. Results Compared with the control group, Ppeak (observation group:(21. 0±2. 2) cm H2O;control group:(22. 4±2. 2) cm H2O;t=2. 446, P=0. 021)and Ppiat (observation group:(19. 7±2. 2) cm H2O;control group:(21. 0±2. 7) cm H2O;t=3. 610, P = 0. 001) in the observation group decreased significantly at T2 and the pH value of the observation group at T3 decr

关 键 词：结核 肺 肺切除术 麻醉 全身 肺通气 对比研究 

分 类 号：R614[医药卫生—麻醉学]