目的 比较手法肺复张与压力控制法肺复张在腹腔镜手术中的治疗效果.方法 选择90例妇科择期行腹腔镜手术的患者,采用随机数字表法将患者分为3组(每组30例):空白对照组(A组)、手法肺复张组(B组)、压力控制法肺复张组(C组).3组患者均采用容量控制模式机械通气,呼吸机参数设置保持一致并在气管插管后每小时及术毕时进行肺复张操作(A组不进行肺复张、B组进行手法肺复张、C组进行压力控制法肺复张).监测并记录麻醉诱导前5min(T0)、插管后5 min(T1)、肺复张前(T2)、肺复张后10 min(T3)、术毕(T4)、拔管后15 min(T5)时的平均动脉压(MAP)、心率、脉搏血氧饱和度(SpO2);记录T1～T4时的动态肺顺应性(Cdyn)、气道峰压(Ppeak)、呼气末二氧化碳分压(PETCO2);T0、T5时进行肺超声检查并采用改良肺部超声检查评分(LUS)对肺复张效果进行评价;记录术后1d的临床肺部感染评分(CPIS)及术后7 d内3组患者术后肺部并发症(PPC)发生情况;记录手术时间、麻醉时间、拔管时间.结果 3组患者美国麻醉医师协会(ASA)分级、体重指数(BMI)、年龄、手术时间、麻醉时间、拔管时间比较,差异无统计学意义(均P＞0.05).A组T3、T4时MAP、心率、Ppeak、PETCO2高于B组、C组(均 P＜0.05),SpO2、Cdyn 低于 B 组、C 组(均 P＜0.05);C 组 T3、T4时MAP、心率、Cdyn 高于 B 组(均 P＜0.05),Ppeak 低于 B 组(均 P＜0.05).A组T5时改良LUS高于B组、C组(均P＜0.05),B组T5时改良LUS高于C组(P＜0.05);3组患者T5时改良LUS高于T0(均P＜0.05).A组术后1d CPIS及术后7dPPC发生率高于B组、C组(均P＜0.05).其余指标差异无统计学意义(均P＞0.05).结论 两种肺复张方法均可以改善患者术后肺不张程度,且一定程度上降低PPC的发生率.同时压力控制法肺复张对患者术中气道改善效果更好,对患者术中的血流动力学影响更小,术后肺不张发生率更低.
Comparison of the effect of manual versus pressure-controlled ventilations for lung recruitment maneuver on postoperative pulmonary complication during laparoscopic surgery
Objective To compare the therapeutic effect of manual versus pressure-controlled ventilations for lung recruit-ment maneuver during laparoscopic surgery.Methods A total of 90 patients undergoing elective laparoscopic gynecologic surgery were selected.According to the random number table method,they were divided into three groups(n=30):a blank control group(group A),a manual lung recruitment group(group B)and a pressure-controlled ventilation group(group C).All the patients were mechanically ventilated in the volume controlled mode,with consistent ventilator parameters,and lung recruitment was performed every hour after en-dotracheal intubation and at the end of the operation(group A did not have lung recruitment maneuver,group B received lung recruit-ment maneuver by manual ventilation,and group C was subject to lung recruitment maneuver by pressure-controlled ventilation).Then,their mean arterial pressure(MAP),heart rate and pulse oxygen saturation(SpO2)were recorded 5 min before anesthesia induction(T0),5 min after intubation(T1),before lung recruitment(T2),10 min after lung recruitment(T3),after the operation(T4),and 15 min after ex-tubation(T5).Furthermore,their dynamic lung compliance(Cdyn),peak airway pressure(Ppeak)and end-tidal carbon dioxide partial(PETCO2)at T1-T4 after endotracheal intubation were recorded.Pulmonary examination was performed at T0 and T5 and the effect of lung recruitment was evaluated by the modified Lung Ultrasound Score(LUS).The Clinical Pulmonary Infection Score(CPIS)on postopera-tive day 1 and the incidences of postoperative pulmonary complication(PPC)within seven days after the operation were recorded.Then,the operative time,and the times to anesthesia and extubation were recorded.Results There was no statistical difference in Ameri-can Society of Anesthesiologists(ASA)grade,body mass index(BMI),age,the operative time,and the times to anesthesia and extuba-tion among the three groups(all P＞0.05).Furthermore,group A showed higher MAP,heart rate,Ppeak,and PETCO2 and lower SpO2 and Cdyn than group B and group C at T3 and T4(all P＜0.05).In contrast,increased MAP,heart rate and Cdyn as well as decreased Ppeak were found in group C,compared with those in group B at T3 and T4(all P＜0.05).Group A presented a higher modified LUS than group B and group C at T5(all P＜0.05),while the modified LUS at T5 in group B was higher than that in group C(P＜0.05).Compared with those at T0,the three groups showed increases in modified LUS at T5(all P＜0.05).The CPIS score on postoperative day 1 and the inci-dence of PPC on postoperative day 7 in group A were higher than those in group B and group C(all P＜0.05).There was no statistical dif-ference in other indexes(all P＞0.05).Conclusions Each of the methods can improve the degree of postoperative atelectasis and re-duce the incidence of postoperative pulmonary inflammation to a certain extent.Meanwhile,pressure-controlled ventilation has im-proved effect on airway improvement,with reduced effect on hemodynamics and a decreased incidence of postoperative atelectasis.
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