个体化保护性肺通气策略对老年患者全身麻醉肺通气效果的影响  

Effect of individualized protective pulmonary ventilation strategy on pulmonary ventilation in elderly patients under general anesthesia

作　　者：张才军 谢俊然[1] 肖旺频[2] 郁丽娜 周红梅 胡立 Zhang Caijun;Xie Junran;Xiao Wangpin;Yu Lina;Zhou Hongmei;Hu Li(Department of Anesthesiology, Sir Run Run Shaw Hospital Affiliated to Zhejiang University, Hongzhou 310016, China;Department of Anesthesiology, the Second Hospital of Jiaxing University, the Second Hospital of Jiaxing City, Jiaxing 314000, China;Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University, Hongzhou 310009, China)

机构地区：[1]浙江大学附属邵逸夫医院麻醉科,杭州310016 [2]嘉兴学院附属嘉兴市第二医院麻醉科,314000 [3]浙江大学附属第二医院麻醉科,杭州310009

出　　处：《中华实验外科杂志》2019年第8期1475-1478,共4页Chinese Journal of Experimental Surgery

基　　金：浙江省科技厅项目(2016C33155).

摘　　要：目的通过滴定最佳呼气末正压(PEEP)制定个体化通气策略,观察老年患者全身麻醉机械通气的效果.方法择期髋关节置换患者42例,随机数字表法分为2组,并在术中全肺复张(RMs)后分别实施两种不同的通气策略,策略A:小潮气量(VT)8 ml/kg[理想体重(IBW)]±RMs±最佳PEEP,策略B:小VT 8 ml/kg(IBW)± RMs.并在第二次RAMs结束后交换通气策略,采用前瞻性交叉设计研究观察通气效果.应用SPSS 22.0统计软件分析,正态分布计量资料以均值±标准差(Mean±SD)表示,采用t检验,交叉表计量资料多因素方差分析,计数资料采用x2检验,非正态分布计量资料采用非参数秩和检验.结果两种通气策略A与B比较:氧合指数(499.40±85.08比437.20±68.86)、气道压[20(18 ~22) cmH2O(1 cmH2O=0.098 kPa)比17(15 ~ 18) cmH2O]、呼吸末正压[8 (6 ~ 10) cmH2O比3(1 ·4) cmH2O]、肺顺应性[(38.520±4.779) ml/cmH2O比(31.640 ±4.632) ml/cmH2O]升高差异有统计学意义,而无效腔气量[(87.36±21.43) ml比(110.60±23.87) ml]、气体驱动压[12(11 ~ 14) cmH2O比14(13 ~ 16) cmH2O]、气道阻力[(11.520±2.167 Hp比(13.230±2.261) Hp]降低,差异均有统计学意义(P<0.01).氧合指数与肺顺应性呈正相关(R =0.529,P<0.01);与气道阻力呈负相关(R=-0.514,P<0.01);与最佳PEEP、气道压、无效腔气量、气体驱动压呈负相关(R=-0.127、-0.086、-0.215、-0.262).结论小VT、全肺复张后联合个体化最佳PEEP的策略可改善老年骨关节置换术全身麻醉患者的氧合指数,减少生理无效腔,增加术中肺通气顺应性、降低气体驱动压.Objective Individualized ventilation strategy was formulated by titrating the best PEEP to observe the effect of mechanical ventilation under general anesthesia in elderly patients. Methods Forty-two patients undergoing selective hip arthroplasty were randomly divided into two groups. Two different ventilation strategies were implemented after total lung recruitment. Strategy A: small tidal volume (VT) 8 ml/kg (IBW)+ RMs+ best PEEP, strategy B: small VT 8 ml/kg (IBW)+ RMs. At the end of the second RMs, the exchange ventilation strategy was adopted and the ventilation effect was observed by Prospective cross-control study. Results Two ventilation strategies A compared with B: Oxygenation index (499.40±85.08 vs. 437.20±68.86), airway pressure [20 (18 to 22) cmH2O (1 cmH2O=0.098 kPa) vs. 17(15 to 18) cmH2O], positive end-respiratory pressure [8 (6 to 10) cmH2O vs. 3 (1 to 4) cmH2O], pulmonary compliance [(38.520±4.779) ml/cmH2O vs.(31.640±4.632) ml/cmH2O] were increased significantly, but the dead space [(87.36±21.43) ml vs.(110.60±23.87) ml], gas driving pressure (12 (11 to 14) cmH2O vs.(14 (13 to 16) cmH2O], airway resistance [(11.520±2.167) Hp vs.(13.230±2.261) Hp] were decreased. All the difference was significantsignificantly (all P<0.01). Oxygenation index were positively middle correlated with lung compliance (R=0.529, P<0.01), negatively middle correlated with airway resistance (R=-0.514, P<0.01), and weakly negatively correlated with optimal PEEP, airway pressure, dead space and gas driving pressure (R=-0.127,-0.086,-0.215,-0.262). Conclusion The individualized optimal PEEP+ low tidal volume+ RMs strategy can improve the oxygenation index, reduce the physiological dead space, increase the intraoperative pulmonary ventilation compliance and reduce the gas driving pressure in elderly patients undergoing general anesthesia for osteoarthroplasty.

关 键 词：老年患者 氧合指数 最佳呼吸末正压 小潮气量 肺复张策略 

分 类 号：R614.2[医药卫生—麻醉学]