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

doi:10.11958/20230480

Abstract

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

CLC Number:

R614.2

Figures/Tables 5

References 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