个体化呼气末正压对胸外科手术患者肺功能的影响  

Effects of individualized positive end-expiratory pressure on pulmonary function in patients undergoing thoracic surgery

作　　者：李梦婷 卢静 LI Mengting;LU Jing(Department of Anesthesia,Shandong Second Medical University,Weifang,Shandong 261053,China;不详)

机构地区：[1]山东第二医科大学麻醉学院,山东潍坊261053 [2]徐州医科大学附属临沂市人民医院麻醉科,山东临沂276000

出　　处：《中国临床研究》2024年第12期1875-1880,共6页Chinese Journal of Clinical Research

基　　金：徐州医科大学附属医院科技发展基金面上项目(XYFM202221)。

摘　　要：目的评价依据肺静态顺应性(Cstat)为导向设定最佳呼气末正压(PEEP)对胸外科手术患者肺功能的影响。方法选取临沂市人民医院2022年9月至2023年5月择期行胸腔镜下肺叶切除术的患者60例,随机分为试验组和对照组,每组30例。试验组单肺通气后先行肺复张,然后依据Cstat为导向,采用PEEP递减法寻找最佳PEEP,对照组单肺通气后PEEP设为5 cmH_(2)O。记录4个时间点:麻醉诱导插管后(T_(1))、单肺通气开始即刻(T_(2))和PEEP设定后30 min(T_(3))、PEEP设定后60 min(T_(4)),记录各组各时间点的血流动力学指标[心率(HR)、平均动脉压(MAP)]以及呼吸力学指标[气道平台压(Pplat)、Cstat、驱动压(DP)],并于上述时间点抽取患者的动脉血和混合静脉血行血气分析,检测动脉血氧分压(PaO_(2))并计算氧合指数(OI)、肺内分流率(QS/QT)、死腔分数(VD/VT),分别于单肺通气开始时和结束后抽取动脉血检测炎症因子[白细胞介素-6(IL-6)、肿瘤坏死因子(TNF-ɑ)]水平。结果试验组Cstat达到最大时,PEEP值为(7.67±0.80)cmH_(2)O。两组患者由双肺通气转为单肺通气后,氧合指数下降,QS/QT增加,Cstat降低。单肺通气期间,相比于对照组,试验组在T_(3)、T_(4)时间点上的Cstat更高(P<0.05),DP更低(P<0.01),OI更高(P<0.05),QS/QT更低(P<0.05)。试验组在单肺通气结束后IL-6水平明显低于对照组(P<0.05)。结论胸外科手术单肺通气期间患者的氧合指数下降、肺内分流增加,肺顺应性降低;相比于固定PEEP(5 cmH_(2)O),依据Cstat设定的个体化PEEP值可显著减少肺内分流,改善术中氧合,降低DP,增加肺顺应性,抑制炎症反应。Objective To evaluate the effect of setting the optimal positive end-expiratory pressure(PEEP)based on static compliance(Cstat)on pulmonary function in patients undergoing thoracic surgery.Methods Sixty patients scheduled for elective video-assisted thoracoscopic lobectomy at Linyi People's Hospital from September 2022 to May 2023 were randomly divided into an experimental group and a control group,with 30 cases in each group.In the experimental group,after one-lung ventilation,lung recruitment was first performed,followed by finding the optimal PEEP using a decremental PEEP trial guided by Cstat.PEEP was set at 5 cmH_(2)O after one-lung ventilation in the control group.Hemodynamic parameters[heart rate(HR),mean arterial pressure(MAP)],and respiratory mechanics parameters[airway plateau pressure(Pplat),Cstat,driving pressure(DP)]were recorded at four time points:after induction of anesthesia and intubation(T_(1)),immediately after the start of one-lung ventilation(T_(2)),and 30 min(T_(3))and 60 min(T_(4))after PEEP setting.Arterial and mixed venous blood gas analyses were performed at these time points to measure pressure of arterial oxygen(PaO_(2))and calculate the oxygenation index(OI),intrapulmonary shunt fraction(QS/QT),and dead space fraction(VD/VT).Inflammatory cytokines[interleukin-6(IL-6),tumor necrosis factor-alpha(TNF-ɑ)]levels were also measured in arterial blood samples taken at the beginning and end of one-lung ventilation.Results When the Cstat of the experimental group reached its maximum,the PEEP value was(7.67±0.80)cmH_(2)O.After transitioning from two-lung to one-lung ventilation,both groups experienced a decrease in OI,an increase in QS/QT,and reduced Cstat.During one-lung ventilation,compared to the control group,the experimental group had higher Cstat(P<0.05),lower DP(P<0.01),higher OI(P<0.05),and lower QS/QT(P<0.05)at T_(3) and T_(4).The experimental group also had significantly lower IL-6 levels than the control group after one-lung ventilation ended(P<0.05).Conclusion During one-lung ven

关 键 词：单肺通气 呼气末正压 肺静态顺应性 肺内分流 肺保护性通气策略 

分 类 号：R614[医药卫生—麻醉学]