个体化PEEP联合定期肺复张对行腹腔镜结直肠癌根治术老年患者术后肺不张的影响

doi:10.11958/20230235

天津医药 ›› 2024, Vol. 52 ›› Issue (2): 182-187.doi: 10.11958/20230235

个体化PEEP联合定期肺复张对行腹腔镜结直肠癌根治术老年患者术后肺不张的影响

江洪洋(), 樊世文, 刘铁龙, 谢丽萍^△()

石河子大学第一附属医院麻醉科（邮编832000）

收稿日期:2023-02-27 修回日期:2023-04-03 出版日期:2024-02-15 发布日期:2024-01-26
通讯作者: ^△ E-mail：xielipingmazui@163.com
作者简介:江洪洋（1992），男，硕士在读，主要从事临床麻醉应用研究。E-mail：jiangma0621@163.com

Effect of individualized PEEP combined with regular lung recruitment maneuvers on atelectasis after laparoscopic radical resection of colorectal cancer in elderly patients

JIANG Hongyang(), FAN Shiwen, LIU Tielong, XIE Liping^△()

Department of Anesthesiology, the First Affiliated Hospital, Shihezi University, Shihezi 832000, China

Received:2023-02-27 Revised:2023-04-03 Published:2024-02-15 Online:2024-01-26
Contact: ^△ E-mail: xielipingmazui@163.com

江洪洋, 樊世文, 刘铁龙, 谢丽萍. 个体化PEEP联合定期肺复张对行腹腔镜结直肠癌根治术老年患者术后肺不张的影响[J]. 天津医药, 2024, 52(2): 182-187.

JIANG Hongyang, FAN Shiwen, LIU Tielong, XIE Liping. Effect of individualized PEEP combined with regular lung recruitment maneuvers on atelectasis after laparoscopic radical resection of colorectal cancer in elderly patients[J]. Tianjin Medical Journal, 2024, 52(2): 182-187.

摘要/Abstract

摘要：

目的评估肺超声下驱动压（ΔP）引导的个体化呼气末正压通气（PEEP）联合定期肺复张对Trendelenburg体位下行腹腔镜结直肠癌根治术的老年患者术后肺不张的影响。方法纳入年龄65~85岁、美国麻醉医师协会分级Ⅰ—Ⅲ级，拟行腹腔镜下结直肠癌根治术的患者62例并分为试验组和对照组（各31例）。2组均在气腹开始后进行第1次肺复张，随后立即以最低ΔP滴定个体化PEEP，气腹结束后进行第2次肺复张。试验组自气腹开始每30 min额外进行一次肺复张，对照组则不干预。以麻醉诱导前（T₀）、气腹后30 min（T₁）、气腹后90 min（T₂）、手术结束时（T₃）、进入麻醉复苏室（PACU）45 min后（T₄）为观察记录时间点。记录T₀、T₃和T₄时肺超声评分（LUS）；T₁—T₃时肺动态顺应性（Cdyn）；T₀—T₄时间点氧合指数（OI）、平均动脉压（MAP）、心率（HR）；记录肺复张期间低血压、PACU中低氧饱和事件以及术后7 d内肺部并发症（POPC）发生率。结果与对照组相比，试验组在T₃和T₄时LUS下降（P<0.05），T₂、T₃时OI和Cdyn升高（P<0.05）。试验组在PACU中低氧饱和事件发生率较对照组下降（P<0.05）。2组患者肺复张期间低血压发生率和术后7 d内POPC发生率差异无统计学意义（P>0.05）。结论个体化PEEP联合定期肺复张可有效减少老年患者腹腔镜结直肠癌根治术后即刻和PACU中的肺不张。

关键词: 肺不张, 腹腔镜, 老年人, 个体化呼气末正压, 驱动压

Abstract:

Objective To evaluate the effect of driving pressure (ΔP)-guided individualized positive end-expiratory pressure (PEEP) combined with regular lung recruitment maneuvers (RMs) on atelectasis in elderly patients undergoing laparoscopic surgery in the Trendelenburg position using lung ultrasound. Methods A total of 62 patients aged 65-85 years old and classified by ASA status Ⅰ-Ⅲ undergoing laparoscopic radical resection of colorectal cancer were included and randomly divided into the experimental group (n=31) and the control group (n=31). Both groups received one RM after the beginning of pneumoperitoneum, followed immediately by titration of individualized PEEP with the lowest ΔP, and both groups received another RM after the end of pneumoperitoneum. The experimental group received additional RM every 30 min from the beginning of pneumoperitoneum, while the control group received no intervention. Recording time points for observation were: before induction of anesthesia (T₀), 30 min after pneumoperitoneum (T₁), 90 min after pneumoperitoneum (T₂), at the end of surgery (T₃) and 45 min after entering the postanesthesia care unit (PACU, T₄). Lung ultrasound score (LUS) was recorded at T₀, T₃ and T₄. Dynamic lung compliance (Cdyn) was recorded at T₁-T₃. Oxygenation index (OI), mean arterial pressure (MAP) and heart rate (HR) were recorded at T₀-T₄. Hypotension during RM, hypoxic saturation events in PACU and the incidence of pulmonary complications (POPC) within the first 7 days after surgery were recorded. Results Compared with the control group, LUSs at T₃ and T₄were significantly decreased in the experimental group (P < 0.05), and OI and Cdyn at T₂ and T₃ were significantly increased (P < 0.05). In addition, the incidence of hypoxia saturation events in PACU was lower in the experimental group than that in the control group (P < 0.05). There were no significant differences in the incidence of hypotension during lung recruitment and the incidence of POPC within 7 days after surgery between the two groups. Conclusion The individualized PEEP combined with regular RMs can effectively reduce the atelectasis observed by lung ultrasound immediately after laparoscopic radical resection of colorectal cancer and in PACU in elderly patients.

Key words: pulmonary atelectasis, laparoscopes, aged, individualized positive end-expiratory pressure, driving pressure

中图分类号:

R563.4

图/表 10

参考文献 23

[1]	ZENG C, LAGIER D, LEE J W, et al. Perioperative pulmonary atelectasis:Part I. biology and mechanisms[J]. Anesthesiology(Philadelphia), 2022, 136(1):181. doi:10.1097/ALN.0000000000003943.
[2]	SHONO A, KATAYAMA N, FUJIHARA T, et al. Positive end-expiratory pressure and distribution of ventilation in pneumoperitoneum combined with steep trendelenburg position[J]. Anesthesiology, 2020, 132(3):476-490. doi:10.1097/ALN.0000000000003062.
[3]	LAGIER D, ZENG C, FERNANDEZ-BUSTAMANTE A, et al. Perioperative pulmonary atelectasis:Part II. clinical implications[J]. Anesthesiology, 2022, 136(1):206-236. doi:10.1097/ALN.0000000000004009.
[4]	FERNANDEZ-BUSTAMANTE A, FRENDL G, SPRUNG J, et al. Postoperative pulmonary complications,early mortality,and hospital stay following noncardiothoracic surgery:a multicenter study by the perioperative research network investigators[J]. JAMA Surg, 2017, 152(2):157-166. doi:10.1001/jamasurg.2016.4065.
[5]	中华医学会麻醉学分会“围术期肺保护性通气策略临床应用专家共识”工作小组. 围术期肺保护性通气策略临床应用专家共识[J]. 中华麻醉学杂志, 2020, 40(5):513-519.
	Chinese society of anesthesiology task force on clinical application of perioperative lung-protective ventilation strategies. Expert consensus on clinical application of perioperative lung-protective ventilation strategies[J]. Chin J Anesthesiol, 2020, 40(5):513-519. doi:10.3760/cma.j.cn131073.20200402.00501.
[6]	YOUNG C C, HARRIS E M, VACCHIANO C, et al. Lung-protective ventilation for the surgical patient:International expert panel-based consensus recommendations[J]. Br J Anaesth, 2019, 123(6):898-913. doi:10.1016/j.bja.2019.08.017.
[7]	ZHOU L, LI H, LI M, et al. Individualized positive end-expiratory pressure guided by respiratory mechanics during anesthesia for the prevention of postoperative pulmonary complications:a systematic review and meta-analysis[J]. J Clin Monit Comput, 2023, 37(2):365-377. doi:10.1007/s10877-022-00960-9.
[8]	MONASTESSE A, GIRARD F, MASSICOTTE N, et al. Lung ultrasonography for the assessment of perioperative atelectasis:a pilot feasibility study[J]. Anesth Analg, 2017, 124(2):494-504. doi:10.1213/ANE.0000000000001603.
[9]	MINI G, RAY B R, ANAND R K, et al. Effect of driving pressure-guided positive end-expiratory pressure (PEEP) titration on postoperative lung atelectasis in adult patients undergoing elective major abdominal surgery:a randomized controlled trial[J]. Surgery, 2021, 170(1):277-283. doi:10.1016/j.surg.2021.01.047.
[10]	ÖSTBERG E, THORISSON A, ENLUND M, et al. Positive end-expiratory pressure alone minimizes atelectasis formation in nonabdominal surgery:a randomized controlled trial[J]. Anesthesiology, 2018, 128(6):1117-1124. doi:10.1097/ALN.0000000000002134.
[11]	UKERE A, MARZ A, WODACK K H, et al. Perioperative assessment of regional ventilation during changing body positions and ventilation conditions by electrical impedance tomography[J]. Br J Anaesth, 2016, 117(2):228-235. doi:10.1093/bja/aew188.
[12]	O'GARA B, TALMOR D. Perioperative lung protective ventilation[J]. BMJ, 2018, 362:k3030. doi:10.1136/bmj.k3030.
[13]	GÉNÉREUX V, CHASSÉ M, GIRARD F, et al. Effects of positive end-expiratory pressure/recruitment manoeuvres compared with zero end-expiratory pressure on atelectasis during open gynaecological surgery as assessed by ultrasonography:a randomised controlled trial[J]. Br J Anaesth, 2020, 124(1):101-109. doi:10.1016/j.bja.2019.09.040.
[14]	FRASSANITO L, SONNINO C, PITONI S, et al. Lung ultrasound to monitor the development of pulmonary atelectasis in gynecologic oncologic surgery[J]. Minerva Anestesiol, 2020, 86(12):1287-1295. doi:10.23736/S0375-9393.20.14687-X.
[15]	刘彬彬, 温晓晖, 唐小芳, 等. 全麻人工气腹下老年患者肺不张发生的特点及其与膈肌抑制程度的关系[J]. 中华麻醉学杂志, 2021, 41(6):670-673.
	LIU B B, WEN X H, TANG X F, et al. Characteristics of atelectasis and its relationship with degree of diaphragm inhibition in elderly patients with artificial pneumoperitoneum under general anesthesia[J]. Chin J Anesthesiol, 2021, 41(6):670-673. doi:10.3760/cma.j.cn131073.20201221.00608.
[16]	JO Y Y, LEE K C, CHANG Y J, et al. Effects of an alveolar recruitment maneuver during lung protective ventilation on postoperative pulmonary complications in elderly patients undergoing laparoscopy[J]. Clin Interv Aging, 2020, 15:1461-1469. doi:10.2147/CIA.S264987.
[17]	GARCÍA-FERNÁNDEZ J, ROMERO A, BLANCO A, et al. Recruitment manoeuvres in anaesthesia:How many more excuses are there not to use them?[J]. Rev Esp Anestesiol Reanim (Engl Ed), 2018, 65(4):209-217. doi:10.1016/j.redar.2017.12.006.
[18]	WEI K, MIN S, CAO J, et al. Repeated alveolar recruitment maneuvers with and without positive end-expiratory pressure during bariatric surgery:a randomized trial[J]. Minerva Anestesiol, 2018, 84(4):463-472. doi:10.23736/S0375-9393.17.11897-3.
[19]	JUNG K, KIM S, KIM B J, et al. Comparison of positive end-expiratory pressure versus tidal volume-induced ventilator-driven alveolar recruitment maneuver in robotic prostatectomy:a randomized controlled study[J]. J Clin Med, 2021, 10(17):3921. doi:10.3390/jcm10173921.
[20]	SEVERAC M, CHIALI W, SEVERAC F, et al. Alveolar recruitment manoeuvre results in improved pulmonary function in obese patients undergoing bariatric surgery:a randomised trial[J]. Anaesth Crit Care Pain Med, 2021, 40(3):100775. doi:10.1016/j.accpm.2020.09.011.
[21]	ACOSTA C M, SARA T, CARPINELLA M, et al. Lung recruitment prevents collapse during laparoscopy in children:a randomised controlled trial[J]. Eur J Anaesthesiol, 2018, 35(8):573-580. doi:10.1097/EJA.0000000000000761.
[22]	COSTA L A, HAJJAR L A, VOLPE M S, et al. Effect of intensive vs moderate alveolar recruitment strategies added to lung-protective ventilation on postoperative pulmonary complications:a randomized clinical trial[J]. JAMA, 2017, 317(14):1422-1432. doi:10.1001/jama.2017.2297.
[23]	CUI Y, CAO R, LI G, et al. The effect of lung recruitment maneuvers on post-operative pulmonary complications for patients undergoing general anesthesia:a meta-analysis[J]. PLoS One, 2019, 14(5):e217405. doi:10.1371/journal.pone.0217405.

组别	n	年龄/岁	性别（男/女）	BMI/（kg/m²）	吸烟史
对照组	31	72（67，76）	20/11	23.7±2.7	15/14/2
试验组	31	74（70，79）	15/16	23.5±2.4	19/11/1
Z、χ²或t		1.637	1.640	0.345	1.243

组别	n	年龄/岁	性别（男/女）	BMI/（kg/m²）	吸烟史
对照组	31	72（67，76）	20/11	23.7±2.7	15/14/2
试验组	31	74（70，79）	15/16	23.5±2.4	19/11/1
Z、χ²或t		1.637	1.640	0.345	1.243

组别	n	高血压	糖尿病	FEV1/FVC	Hb/（g/L）	ASA分级（Ⅰ/Ⅱ/Ⅲ）	ARISCAT评分（26~44/>44）
对照组	31	13（41.9）	4（12.9）	74.9±7.9	120.8±14.4	4/24/3	8/23
试验组	31	16（51.6）	7（22.6）	77.6±8.0	117.5±12.9	3/23/5	11/20
Z、χ²或t		0.583	0.995	1.316	0.939	0.728	0.683

组别	n	高血压	糖尿病	FEV1/FVC	Hb/（g/L）	ASA分级（Ⅰ/Ⅱ/Ⅲ）	ARISCAT评分（26~44/>44）
对照组	31	13（41.9）	4（12.9）	74.9±7.9	120.8±14.4	4/24/3	8/23
试验组	31	16（51.6）	7（22.6）	77.6±8.0	117.5±12.9	3/23/5	11/20
Z、χ²或t		0.583	0.995	1.316	0.939	0.728	0.683

组别	n	PEEP/ cmH₂O	气腹时间/ min	手术时间/ min	苏醒时间/ min	手术类型（直肠癌/结肠癌）	输液量/ mL	估计失血量/ mL	尿量/ mL
对照组	31	9（8，10）	162（137，185）	201（183，221）	13.9±3.5	16/15	2 000（1 600，2 300）	150（100，150）	350（200，550）
试验组	31	9（7，10）	180（145，209）	211（180，238）	13.4±3.5	13/18	2 000（1 500，2 500）	150（100，200）	420（200，620）
Z、χ²或t		0.857	1.352	0.514	0.647	0.583	0.542	0.670	0.789

个体化PEEP联合定期肺复张对行腹腔镜结直肠癌根治术老年患者术后肺不张的影响

Effect of individualized PEEP combined with regular lung recruitment maneuvers on atelectasis after laparoscopic radical resection of colorectal cancer in elderly patients

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参考文献 23

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组别	n	T₀	T₃	T₄
对照组	31	0（0，2）	10（8，10）	9（8，11）
试验组	31	1（0，2）	8（6，9）	6（5，8）
Z		0.238	3.481^＊＊	3.962^＊＊

组别	T₁	T₂	T₃
对照组	24.9±3.9	22.4±3.3	35.5±7.7
试验组	24.1±3.6	24.2±3.8	39.7±6.7
t	0.894	2.033^＊	2.273^＊

组别		T₀		T₁
对照组		338.1±20.1		390.1±87.0
试验组		343.4±26.2		373.7±84.7
t		0.889		0.752
组别	T₂		T₃		T₄
对照组	392.5±64.1		398.8±54.0		329.1±22.4
试验组	435.9±69.3		462.6±57.5		338.9±30.3
t	2.560^＊		4.508^＊＊		1.444

组别		MAP/mmHg
组别		T₀		T₁	T₂		T₃			T₄
对照组		90.1±9.1		85.8±9.7	87.1±8.8		89.6±7.8			91.2±9.2
试验组		89.2±10.1		81.8±6.9	85.1±7.7		88.4±10.0			90.3±8.4
组别	HR/（次/min）
组别	T₀		T₁			T₂		T₃	T₄
对照组	74.1±8.3		71.7±7.1			69.5±8.1		72.9±8.9	76.6±8.8
试验组	77.0±10.6		72.1±10.0			69.2±9.2		74.0±8.8	79.2±10.5

组别	n	肺复张期间低血压	术中血管活性药总体使用	PACU中低氧饱和事件
对照组	31	2（6.5）	17（54.8）	10（32.3）
试验组	31	6（19.4）	20（64.5）	3（9.7）
χ²		1.292	0.603	4.769^＊

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组别	咳嗽并咳痰	术后低氧血症	肺炎	肺不张	胸腔积液
对照组	10（32.3）	2（6.5）	1（3.2）	4（12.9）	5（16.1）
试验组	13（41.9）	0	0	2（6.5）	2（6.5）
χ²或P	0.622	0.517	0.999^▲	0.185	0.644

组别	咳嗽并咳痰	术后低氧血症	肺炎	肺不张	胸腔积液
对照组	10（32.3）	2（6.5）	1（3.2）	4（12.9）	5（16.1）
试验组	13（41.9）	0	0	2（6.5）	2（6.5）
χ²或P	0.622	0.517	0.999^▲	0.185	0.644