驱动压导向的个体化呼气末正压通气对行腹腔镜胃癌根治术老年患者的肺保护作用

doi:10.11958/20230480

天津医药 ›› 2024, Vol. 52 ›› Issue (2): 188-192.doi: 10.11958/20230480

驱动压导向的个体化呼气末正压通气对行腹腔镜胃癌根治术老年患者的肺保护作用

钟晓倩(), 孙高悦, 张倩倩, 李云^△()

安徽医科大学第二附属医院麻醉与围术期医学科（邮编230601）

收稿日期:2023-04-17 修回日期:2023-07-25 出版日期:2024-02-15 发布日期:2024-01-26
通讯作者: ^△ E-mail：yunli_001@aliyun.com
作者简介:钟晓倩（1995），女，硕士在读，主要从事围手术期肺保护方面研究。E-mail：2089357502@qq.com
基金资助:
安徽高校自然科学研究项目(KJ2019ZD24)

Effect of individualized positive end-expiratory pressure guided by driving pressure on lung protection after laparoscopic radical gastrectomy in elderly patients

ZHONG Xiaoqian(), SUN Gaoyue, ZHANG Qianqian, LI Yun^△()

Department of Anesthesiology and Perioperative Medicine, the Second Hospital of Anhui Medical University, Hefei 230601, China

Received:2023-04-17 Revised:2023-07-25 Published:2024-02-15 Online:2024-01-26
Contact: ^△ E-mail: yunli_001@aliyun.com

钟晓倩, 孙高悦, 张倩倩, 李云. 驱动压导向的个体化呼气末正压通气对行腹腔镜胃癌根治术老年患者的肺保护作用[J]. 天津医药, 2024, 52(2): 188-192.

ZHONG Xiaoqian, SUN Gaoyue, ZHANG Qianqian, LI Yun. Effect of individualized positive end-expiratory pressure guided by driving pressure on lung protection after laparoscopic radical gastrectomy in elderly patients[J]. Tianjin Medical Journal, 2024, 52(2): 188-192.

摘要/Abstract

摘要：

目的探讨驱动压导向的个体化呼气末正压（PEEP）通气是否会对行腹腔镜胃癌根治术的老年患者的肺起到保护作用。方法选取择期行腹腔镜胃癌根治术的老年患者64例，按照随机数字表法分为驱动压导向的个体化PEEP组（试验组）和固定PEEP组（对照组），每组32例。对照组PEEP为5 cmH₂O；在气腹稳定后，试验组PEEP按照4~16 cmH₂O依次递增滴定，每次进行10次呼吸循环并记录各个PEEP值最后1次呼吸循环时的驱动压，滴定结束后选择最低驱动压对应的PEEP持续至拔管。记录插管后5 min（T₁）、PEEP滴定后即刻（T₂）、手术开始1 h（T₃）、手术开始2 h（T₄）、气腹释放后10 min（T₅）时的气道峰压（Ppeak）、气道平台压（Pplat）、PEEP；计算驱动压、肺动态顺应性（Cdyn）；记录患者T_1-5时的动脉血氧分压（PaO₂），计算氧合指数（OI）；评估患者术前及术后第1、3、5天的肺功能，记录术后第2天改良临床肺部感染评分（mCPIS）及术后7 d内肺部并发症（PPCs）的发生情况。结果与T₁时比较，T_2-5时2组Ppeak、Pplat、驱动压均升高、Cdyn均降低，T₄时对照组OI降低（P<0.05）。与对照组比较，T_2-5时试验组Ppeak、Pplat、Cdyn升高，驱动压降低，T_3-5时OI升高（P<0.05）。与术前比较，术后1 d、3 d、5 d 2组FVC均降低，术后1 d、3 d 2组FEV₁、最大呼气流量（PEF）均降低（P<0.05）。与对照组比较，试验组术后1 d用力肺活量（FVC）、FEV₁、PEF升高（P<0.05）。与术前比较，2组患者术后第2天mCPIS评分升高（P<0.05）；与对照组比较，试验组术后第2天mCPIS评分降低（P<0.05）。术后7 d内试验组PPCs发生率低于对照组（15.6% vs. 40.6%）。结论驱动压导向的个体化PEEP可提高肺顺应性，改善氧合功能和术后早期肺功能，并降低驱动压及术后肺部并发症的发生。

关键词: 正压呼吸, 腹腔镜检查, 胃肿瘤, 驱动压, 个体化, 老年

Abstract:

Objective To explore the effect of individualized positive end expiratory pressure guided by driving pressure on lung protection after laparoscopic radical gastrectomy for elderly patients. Methods A total of 64 patients underwent elective laparoscopic radical gastrectomy for gastric cancer in the Second Affiliated Hospital of Anhui Medical University were selected. According to the random number table method, patients were divided into the driving the pressure guided individualized positive end-expiratory pressure (PEEP) group (experimental group) and the fixed PEEP group (control group), 32 cases in each group. In the control group, PEEP = 5 cmH₂O. In the experimental group, PEEP titration was performed according to the increasing method, and the PEEP corresponding to the lowest driving pressure was selected until extubation. Peak airway pressure (Ppeak), plateau airway pressure (Pplat) and PEEP were recorded at 5 min after intubation (T₁), immediately after PEEP titration (T₂), 1 h after operation (T₃), 2 h after operation (T₄), and 10 min after pneumoperitoneum release (T₅). Driving pressure (ΔP) and lung dynamic compliance (Cdyn) were calculated. Arterial blood was collected at T_1-5 for blood gas analysis, arterial partial pressure of oxygen (PaO₂) was recorded, and oxygenation index (OI) was calculated. The occurrence of pulmonary complications (PPCs) within 7 days after operation was recorded. Modified clinical pulmonary infection score (mCPIS) was recorded on the second day after operation. The pulmonary function was evaluated before operation, 1 day, 3 days and 5 days after operation. Results Compared with T₁, Ppeak, Pplat and ΔP were increased and Cdyn was decreased at T_2-5, while OI was decreased at T₄ in control group (P<0.05). Compared with the control group, Ppeak, Pplat and Cdyn in the experimental group were increased at T_2-5, ΔP was decreased, and OI was increased at T_3-5 (P<0.05). Compared with the preoperative results, FVC at 1, 3 and 5 days after surgery was decreased, and FEV₁ and maximum expiratory flow (PEF) were decreased 1 and 3 days after surgery in the experimental groups (P<0.05). Compared with the control group, FVC, FEV₁ and PEF were higher 1 day after operation in the experimental group (P<0.05). Compared with the preoperative results, mCPIS scores of the two groups were higher on the second day after surgery (P<0.05). Compared with the control group, the mCPIS score was lower on day 2 after surgery in the experimental group (P<0.05). The incidence of PPCs within 7 days after surgery was lower in the experimental group than that in the control group (15.6% vs. 40.6%). Conclusion Individualized PEEP guided by drive pressure can improve lung compliance, reduce drive pressure, improve oxygenation function and early postoperative lung function, reduce the incidence of postoperative lung complications, and has a certain lung protection effect.

Key words: positive-pressure respiration, laparoscopy, stomach neoplasms, driving pressure, individualized, elderly

中图分类号:

R614.2

图/表 5

参考文献 22

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组别		男性		年龄/岁		ASA分级（Ⅰ/Ⅱ/Ⅲ）		高血压		心脏病
对照组		21（65.6）		71.0±3.6		12/18/2		13（40.6）		4（12.5）
试验组		22（68.8）		70.3±2.6		12/17/3		18（56.3）		4（12.5）
χ²或t		0.071		0.879		0.230		1.564		0.000
组别	脑梗死		吸烟史		手术时间/ min		术中输液量/ mL		去氧肾上腺素
对照组	5（15.6）		15（46.9）		267.1±50.6		2 215.6±483.3		20（62.5）
试验组	6（18.8）		14（43.8）		267.7±46.3		2 284.4±463.6		24（75.0）
χ²或t	0.110		0.063		0.052		0.581		1.164

组别		男性		年龄/岁		ASA分级（Ⅰ/Ⅱ/Ⅲ）		高血压		心脏病
对照组		21（65.6）		71.0±3.6		12/18/2		13（40.6）		4（12.5）
试验组		22（68.8）		70.3±2.6		12/17/3		18（56.3）		4（12.5）
χ²或t		0.071		0.879		0.230		1.564		0.000
组别	脑梗死		吸烟史		手术时间/ min		术中输液量/ mL		去氧肾上腺素
对照组	5（15.6）		15（46.9）		267.1±50.6		2 215.6±483.3		20（62.5）
试验组	6（18.8）		14（43.8）		267.7±46.3		2 284.4±463.6		24（75.0）
χ²或t	0.110		0.063		0.052		0.581		1.164

组别			Ppeak/cmH₂O
组别			T₁				T₂							T₃						T₄						T₅							F
对照组			14.9±1.8				21.3±3.1^a							22.7±2.7^a						25.0±2.3^a						18.2±2.5^a							147.427^＊＊
试验组			15.2±2.1				25.9±2.3^a							26.9±1.9^a						28.5±1.8^a						21.4±2.3^a							344.957^＊＊
t			0.456								6.686^＊＊			7.245^＊＊						6.697^＊＊						5.239^＊＊
组别		Pplat/cmH₂O
组别		T₁				T₂									T₃					T₄					T₅								F
对照组		14.7±1.7				21.0±2.9^a									22.2±2.5^a					24.9±2.2^a					18.2±2.5^a								149.266^＊＊
试验组		14.9±1.8				25.1±2.0^a									26.1±1.8^a					27.7±1.6^a					21.0±2.0^a								375.639^＊＊
t		0.423								6.523^＊＊		7.223^＊＊						5.929^＊＊											5.408^＊＊
组别				ΔP/cmH₂O
组别				T₁					T₂						T₃						T₄						T₅							F
对照组				10.0±1.6					15.6±2.6^a						16.0±2.6^a						16.8±2.6^a						14.7±1.9^a							74.668^＊＊
试验组				9.9±1.7					14.3±1.9^a						14.4±1.8^a						15.1±1.9^a						13.8±1.6^a							51.065^＊＊
t				0.297					2.234^＊						2.852^＊＊						2.903^＊＊									2.234^＊
组别			Cdyn/（mL/cmH₂O）
组别			T₁				T₂						T₃						T₄					T₅									F
对照组			41.3±6.2				26.7±4.7^a						25.6±4.6^a						24.0±4.3^a					37.3±5.9^a									525.593^＊＊
试验组			41.9±5.9				30.9±5.3^a						30.0±5.0^a						28.8±5.2^a					40.4±6.0^a									622.894^＊＊
t			0.353								3.428^＊＊		3.639^＊＊						4.032^＊＊									2.124^＊
组别	OI/mmHg
组别	T₁							T₂								T₃						T₄									T₅				F
对照组	470.6±87.0							452.5±53.3								426.6±58.7						409.0±58.8^a									432.6±55.9				8.388^＊＊
试验组	476.2±78.6							468.4±51.6								459.1±47.6						438.6±53.6									460.7±42.7				2.880
t	0.270				1.210												2.432^＊						2.105^＊									2.259^＊

组别			Ppeak/cmH₂O
组别			T₁				T₂							T₃						T₄						T₅							F
对照组			14.9±1.8				21.3±3.1^a							22.7±2.7^a						25.0±2.3^a						18.2±2.5^a							147.427^＊＊
试验组			15.2±2.1				25.9±2.3^a							26.9±1.9^a						28.5±1.8^a						21.4±2.3^a							344.957^＊＊
t			0.456								6.686^＊＊			7.245^＊＊						6.697^＊＊						5.239^＊＊
组别		Pplat/cmH₂O
组别		T₁				T₂									T₃					T₄					T₅								F
对照组		14.7±1.7				21.0±2.9^a									22.2±2.5^a					24.9±2.2^a					18.2±2.5^a								149.266^＊＊
试验组		14.9±1.8				25.1±2.0^a									26.1±1.8^a					27.7±1.6^a					21.0±2.0^a								375.639^＊＊
t		0.423								6.523^＊＊		7.223^＊＊						5.929^＊＊											5.408^＊＊
组别				ΔP/cmH₂O
组别				T₁					T₂						T₃						T₄						T₅							F
对照组				10.0±1.6					15.6±2.6^a						16.0±2.6^a						16.8±2.6^a						14.7±1.9^a							74.668^＊＊
试验组				9.9±1.7					14.3±1.9^a						14.4±1.8^a						15.1±1.9^a						13.8±1.6^a							51.065^＊＊
t				0.297					2.234^＊						2.852^＊＊						2.903^＊＊									2.234^＊
组别			Cdyn/（mL/cmH₂O）
组别			T₁				T₂						T₃						T₄					T₅									F
对照组			41.3±6.2				26.7±4.7^a						25.6±4.6^a						24.0±4.3^a					37.3±5.9^a									525.593^＊＊
试验组			41.9±5.9				30.9±5.3^a						30.0±5.0^a						28.8±5.2^a					40.4±6.0^a									622.894^＊＊
t			0.353								3.428^＊＊		3.639^＊＊						4.032^＊＊									2.124^＊
组别	OI/mmHg
组别	T₁							T₂								T₃						T₄									T₅				F
对照组	470.6±87.0							452.5±53.3								426.6±58.7						409.0±58.8^a									432.6±55.9				8.388^＊＊
试验组	476.2±78.6							468.4±51.6								459.1±47.6						438.6±53.6									460.7±42.7				2.880
t	0.270				1.210												2.432^＊						2.105^＊									2.259^＊

组别	FVC/L
组别	术前		术后1 d				术后3 d		术后5 d		F
对照组	3.1±0.6		1.5±0.4^a				2.4±0.5^a		2.8±0.5^a		257.755^＊＊
试验组	3.2±0.7		1.9±0.6^a				2.6±0.5^a		3.1±0.6^a		73.412^＊＊
t	0.584		3.292^＊＊		1.766			1.748
组别		FEV₁/L
组别		术前		术后1 d		术后3 d			术后5 d	F
对照组		2.4±0.4		1.2±0.3^a		1.8±0.4^a			2.3±0.4	306.783^＊＊
试验组		2.5±0.6		1.4±0.5^a		2.0±0.3^a			2.4±0.4	108.703^＊＊
t		0.745		2.331^＊		1.535			0.798
组别		PEF/（L/s）
组别		术前		术后1 d		术后3 d			术后5 d	F
对照组		6.2±0.8		2.1±0.5^a		3.7±0.6^a			6.0±0.9	311.625^＊＊
试验组		6.3±1.0		2.4±0.5^a		3.9±0.4^a			6.1±0.8	338.180^＊＊
t		0.256		2.182^＊		1.113			0.215

驱动压导向的个体化呼气末正压通气对行腹腔镜胃癌根治术老年患者的肺保护作用

Effect of individualized positive end-expiratory pressure guided by driving pressure on lung protection after laparoscopic radical gastrectomy in elderly patients

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参考文献 22

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组别	mCPIS评分
组别	术前	术后第2天	F
对照组	1.1±0.7	2.3±0.8	110.714^＊＊
试验组	1.0±0.7	1.9±0.6	148.404^＊＊
t	0.360	2.064^＊

组别	PPCs（+）	PPCs类型
组别	PPCs（+）	肺不张	胸腔积液	肺部感染
对照组	13（40.6）	11（34.4）	2（6.3）	2（6.3）
试验组	5（15.6）	4（12.5）	0	1（3.1）
χ²	4.947^＊	4.267^＊	0.516	0.000

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