肺开放策略减量滴定呼气末正压在食管癌根治术中的应用价值

doi:10.3877/cma.j.issn.2095-655X.2021.02.013

目的

探讨肺开放策略(OLS)减量滴定呼气末正压(PEEP)在食管癌根治术患者中的应用价值。

方法

选择2019年2月至2020年2月郑州大学第二附属医院胸外科择期单肺通气(OLV)下行食管癌根治术患者60例，按随机数字表法分为试验组(n＝30)和对照组(n＝30)。OLV时两组均以5 cmH₂O(1 cmH₂O＝0.098 kPa)作为初始PEEP值，待血流动力学稳定后试验组行OLS，检测到最高顺应性PEEP并应用至术毕；对照组以PEEP＝5 cmH₂O至术毕拔管。记录两组插管后(T₁)、OLV即刻(T₂)、OLS应用后30 min(T₃)、OLS应用后60 min(T₄)的气道平台压(Pplat)、气道峰压(Ppeak)、肺顺应性(Cdyn)；于上述各时点抽取动脉血行血气分析，记录动脉血氧分压(PaO₂)、动脉血二氧化碳分压(PaCO₂)，并计算氧合指数(OI)。采用重复测量的方差分析比较两组不同时点氧合及呼吸力学指标。

结果

T₁-T₄时试验组PaCO₂[(38.70±2.93)mmHg，(38.89±3.54)mmHg，(39.19±3.43)mmHg，(39.71±3.17)mmHg]与对照组[(39.72±3.19)mmHg，(40.35±3.71)mmHg，(39.66±3.47)mmHg，(39.54±3.42)mmHg]分别比较，均差异无统计学意义(F＝1.67，2.15，0.27，0.04；均P>0.05)。两组患者T₁-T₄时点OI、Pplat、Ppeak、Cdyn比较，均差异有统计学意义(F＝13.29，15.02，7.05，33.62；均P<0.05)。T₃、T₄时试验组OI[(259.30±30.68)mmHg，(267.39±33.81)mmHg]、Pplat[(17.98±2.56)cmH₂O，(17.09±2.87)cmH₂O] 、Ppeak[(27.74±4.68)cmH₂O，(27.27±3.03)cmH₂O] 、Cdyn[(33.44±2.74)ml/cmH₂O，(35.35±3.42)ml/cmH₂O]与对照组[(238.00±31.02)mmHg，(234.83±34.90)mmHg，(15.63±3.24)cmH₂O，(14.92±2.64)cmH₂O，(25.27±4.35)cmH₂O，(25.60±2.72)cmH₂O，(27.70±3.54)ml/cmH₂O，(28.20±3.69)ml/cmH₂O]分别比较，均明显增加(F＝7.15，13.47，9.75，9.20，4.48，5.03，49.23，60.51，均P<0.05)。T₃、T₄时试验组OI、Pplat、Ppeak、Cdyn与T₂时[(238.00±31.02)mmHg，(13.89±3.16)cmH₂O，(22.37±2.11)cmH₂O，(28.16±3.15)ml/cmH₂O]分别比较，均明显增加(t＝-2.43，-3.35，-5.74，-4.48，-6.82，-6.28，-5.55，-7.56；均P<0.05)。

结论

全身麻醉下食管癌根治术患者的OI降低，采用OLS滴定个体化PEEP的保护性通气策略可显著改善氧合作用，增加肺顺应性，有利于肺通气的保护作用。

关键词: 单肺通气, 肺开放策略, 正压呼吸, 氧合作用, 肺顺应性

Objective

To explore the application value of open lung strategy (OLS) in titration of positive end-expiratory pressure (PEEP) in patients undergoing radical esophagectomy.

Methods

From February 2019 to February 2020, 60 patients who planned to undergo radical resection of esophageal carcinoma under optional one-lung ventilation (OLV) in the Department of Thoracic Surgery, The Second Affiliated Hospital of Zhengzhou University, were randomly divided into experimental group (n=30) and control group (n=30) according to random number table method. In OLV, 5 cmH₂O (1 cmH₂O=0.098 kPa) was taken as the initial PEEP value in both groups. OLS was performed in the experimental group after hemodynamic stability, the highest compliance PEEP was detected and the catheter was applied until the end of the operation. In the control group, endotracheal catheter was extracted at PEEP=5 cmH₂O until the end of operation. Airway plateau pressure (Pplat), airway peak pressure (Ppeak), and lung dynamic compliance (Cdyn) were recorded in the two groups after intubation (T₁), OLV immediate (T₂), OLS 30 min after OLS application (T₃), OLS 60 min after OLS application (T₄). Arterial blood was extracted at the above time points for blood gas analysis, arterial oxygen partial pressure (PaO₂) and arterial carbon dioxide partial pressure (PaCO₂) were recorded, and the oxygenation index (OI) was calculated. Repeated measurement analysis of variance was used to compare oxygenation and respiratory dynamics indexes between the two groups at different time points above.

Results

From T₁ to T₄, there were no significant differences in PaCO₂ between the experimental group [(38.70±2.93)mmHg, (38.89±3.54)mmHg, (39.19±3.43)mmHg, (39.54±3.17)mmHg] and the control group [(39.72±3.19)mmHg, (40.35±3.71)mmHg, (39.66±3.47)mmHg, (39.54±3.42)mmHg] (F=1.67, 2.15, 0.27, 0.04, all P>0.05). Compare the OI, Pplat, Ppeak and Cdyn of two groups from T₁ to T₄, there were significant differences (F=13.29, 15.02, 7.05, 33.62, all P<0.05). At T₃ and T₄, OI [(259.30±30.68)mmHg, (267.39±33.81)mmHg], Pplat[ (17.98±2.56)cmH₂O, (17.09±2.87)cmH₂O], Ppeak[(27.74±4.68)cmH₂O, (27.27±3.03)cmH₂O], Cdyn[(33.44±2.74)ml/cmH₂O, (35.35±3.42)ml/cmH₂O] in experimental group were significantly increased when compared with those of the control group[(238.00±31.02)mmHg, (234.83±34.90)mmHg, (15.63±3.24)cmH₂O, (14.92±2.64)cmH₂O, (25.27±4.35)cmH₂O, (25.60±2.72)cmH₂O, (27.70±3.54)ml/cmH₂O, (28.20±3.69)ml/cmH₂O] (F=7.15, 13.47, 9.75, 9.20, 4.48, 5.03, 49.23, 60.51, all P<0.05). At T₃ and T₄, OI, Pplat, Ppeak, Cdyn in experimental group were significantly increased when compared with those at the T₂ [(238.00±31.02)mmHg, (13.89±3.16)cmH₂O, (22.37±2.11)cmH₂O, (28.16±3.15)ml/cmH₂O] (t=-2.43, -3.35, -5.74, -4.48, -6.82, -6.28, -5.55, -7.56, all P<0.05).

Conclusions

The oxygenation index of patients undergoing radical resection of esophageal cancer under general anesthesia is decreased. The protective ventilation strategy of using OLS to titrate individualized PEEP could significantly improve oxygenation and increase lung compliance, which is conducive to the protective effect of lung ventilation.

Key words: One-lung ventilation, Open lung strategy, Positive-pressure respiration, Oxygenation, Lung compliance

表1 两组行食管癌根治术患者一般情况比较

项目	试验组(n＝30)	对照组(n＝30)	统计量	P值
男/女(例)	21/9	23/7	χ²＝0.34	0.559
年龄(岁，±s)	59.47±6.69	59.67±5.40	t＝-0.13	0.899
ASA分级[Ⅱ/Ⅲ，例]	14/16	18/12	χ²＝1.07	0.301
BMI(kg/m²，±s)	21.78±2.28	22.39±1.94	t＝-1.12	0.267
OLV时间(min，±s)	138.67±11.48	139.73±10.81	t＝-0.37	0.712
手术时间(min，±s)	200.70±23.34	199.27±21.41	t＝ 0.25	0.805

表1 两组行食管癌根治术患者一般情况比较

项目	试验组(n＝30)	对照组(n＝30)	统计量	P值
男/女(例)	21/9	23/7	χ²＝0.34	0.559
年龄(岁，±s)	59.47±6.69	59.67±5.40	t＝-0.13	0.899
ASA分级[Ⅱ/Ⅲ，例]	14/16	18/12	χ²＝1.07	0.301
BMI(kg/m²，±s)	21.78±2.28	22.39±1.94	t＝-1.12	0.267
OLV时间(min，±s)	138.67±11.48	139.73±10.81	t＝-0.37	0.712
手术时间(min，±s)	200.70±23.34	199.27±21.41	t＝ 0.25	0.805

表2 两组行食管癌根治术患者不同时点PaCO₂及OI比较(mmHg，±s)

组别	例数	PaCO₂				F值	P值
组别	例数	T₁	T₂	T₃	T₄	F值	P值
试验组	30	38.70±2.93	38.89±3.54	39.19±3.43	39.71±3.17	1.88	0.176
对照组	30	39.72±3.19	40.35±3.71	39.66±3.47	39.54±3.42	1.88	0.176
组别	例数	OI				F值	P值
组别	例数	T₁	T₂	T₃	T₄	F值	P值
试验组	30	433.00±39.61	238.00±31.02	259.30±30.68^ab	267.39±33.81^ab	13.29	0.001
对照组	30	423.43±36.09	230.57±33.21	238.00±31.02	234.83±34.90	13.29	0.001

表2 两组行食管癌根治术患者不同时点PaCO₂及OI比较(mmHg，±s)

组别	例数	PaCO₂				F值	P值
组别	例数	T₁	T₂	T₃	T₄	F值	P值
试验组	30	38.70±2.93	38.89±3.54	39.19±3.43	39.71±3.17	1.88	0.176
对照组	30	39.72±3.19	40.35±3.71	39.66±3.47	39.54±3.42	1.88	0.176
组别	例数	OI				F值	P值
组别	例数	T₁	T₂	T₃	T₄	F值	P值
试验组	30	433.00±39.61	238.00±31.02	259.30±30.68^ab	267.39±33.81^ab	13.29	0.001
对照组	30	423.43±36.09	230.57±33.21	238.00±31.02	234.83±34.90	13.29	0.001

表3 两组行食管癌根治术患者不同时点呼吸力学指标比较(±s)

组别	例数	Pplat(cmH₂O)				F值	P值
组别	例数	T₁	T₂	T₃	T₄	F值	P值
试验组	30	10.38±2.36	13.89±3.16	17.98±2.56^cd	17.09±2.87^cd	15.02	0.000
对照组	30	10.66±1.62	12.87±3.03	15.63±3.24^d	14.92±2.64^d	15.02	0.000
组别	例数	Ppeak(cmH₂O)				F值	P值
组别	例数	T₁	T₂	T₃	T₄	F值	P值
试验组	30	21.81±3.11	22.37±2.11	27.74±4.68^cd	27.27±3.03^cd	7.05	0.010
对照组	30	21.46±2.32	21.75±2.36	25.27±4.35^d	25.60±2.72^d	7.05	0.010
组别	例数	Cdyn(ml/cmH₂O)				F值	P值
组别	例数	T₁	T₂	T₃	T₄	F值	P值
试验组	30	46.43±5.02	28.16±3.15	33.44±2.74^cd	35.35±3.42^cde	33.62	0.000
对照组	30	47.29±3.67	27.44±3.41	27.70±3.54	28.20±3.69	33.62	0.000

表3 两组行食管癌根治术患者不同时点呼吸力学指标比较(±s)

组别	例数	Pplat(cmH₂O)				F值	P值
组别	例数	T₁	T₂	T₃	T₄	F值	P值
试验组	30	10.38±2.36	13.89±3.16	17.98±2.56^cd	17.09±2.87^cd	15.02	0.000
对照组	30	10.66±1.62	12.87±3.03	15.63±3.24^d	14.92±2.64^d	15.02	0.000
组别	例数	Ppeak(cmH₂O)				F值	P值
组别	例数	T₁	T₂	T₃	T₄	F值	P值
试验组	30	21.81±3.11	22.37±2.11	27.74±4.68^cd	27.27±3.03^cd	7.05	0.010
对照组	30	21.46±2.32	21.75±2.36	25.27±4.35^d	25.60±2.72^d	7.05	0.010
组别	例数	Cdyn(ml/cmH₂O)				F值	P值
组别	例数	T₁	T₂	T₃	T₄	F值	P值
试验组	30	46.43±5.02	28.16±3.15	33.44±2.74^cd	35.35±3.42^cde	33.62	0.000
对照组	30	47.29±3.67	27.44±3.41	27.70±3.54	28.20±3.69	33.62	0.000

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Application value of open lung strategy in titration of positive end-expiratory pressure in radical esophagectomy

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Application value of open lung strategy in titration of positive end-expiratory pressure in radical esophagectomy