摘要
目的 应用M型超声评价反比通气对胸科肺部手术术后膈肌功能的影响.方法 选择择期行单侧单个肺叶切除术的患者86例,年龄18～65岁,18.5 kg/m2＜体重指数(BMI)＜30.0 kg/m2,美国麻醉医师协会(ASA)分级Ⅰ、Ⅱ级,采用随机数字表法将患者分为常规通气组(C组)、反比通气组(F组),每组43例.支气管插管全身麻醉后,双肺通气时潮气量(VT)6～8ml/kg,呼吸频率(RR)12～15次/min,吸入氧浓度50％,吸入氧流量1 Umin;单肺通气时F组吸呼比(I:E)=2:1,VT 6 ml/kg,呼气末正压(PEEP)5 cmH2O(1 cmH2O=0.098 kPa),C组I∶E=1∶2,两组患者其他呼吸参数一致.记录患者一般资料(年龄、性别比、BMI、ASA分级、高血压、糖尿病).记录麻醉前(T0)、单肺通气后5min(T1)、单肺通气后1h(T2)、术毕即刻(T3)患者心率、平均动脉压(MAP)、动脉血氧分压(PaO2)、动脉血二氧化碳分压(PaCO2);记录T1、T2、T3时的气道峰压(Ppeak)、气道平台压(Pplat)、平均气道压(Pmean)和PEEP;应用M型超声采集T0和拔管后即刻(T4)的双侧膈肌移动度(DE)及膈肌浅快呼吸指数(D-RSBI),记录住院时间、膈肌功能障碍及术后5 d肺部并发症发生情况,并对膈肌功能障碍与术后5 d肺部并发症发生情况进行Spear-man 相关性分析;记录手术时间、单肺通气时间、气管拔管时间;术毕拔管后记录警觉/镇静观察评分.结果 与C组比较:F组T4时术侧及非术侧DE较高、D-RSBI较低(均P＜0.05);DE差值、D-RSBI差值较低(均P＜0.05);T1、T2时PaO2较高(均P＜0.05);T1、T2、T3时Ppeak、Pplat较低(均P＜0.05),PEEP、Pmean较高(均P＜0.05).与T0时比较,两组患者T4时术侧及非术侧DE降低、D-RSBI升高(均P＜0.05).与术侧比较,两组患者T4时非术侧DE较高、D-RSBI较低(均P＜0.05),DE差值、D-RSBI差值较低(均P＜0.05).Spearman相关性分析显示,膈肌功能障碍发生情况与术后5 d肺部并发症发生情况呈正相关(r=0.65,P＜0.05).其余指标差异均无统计学意义(均P＞0.05).结论 反比通气可改善膈肌功能,降低膈肌功能障碍的发生率.膈肌功能障碍是术后肺部并发症的一个关键因素.
Abstract
Objective To evaluate the effect of inverse ratio ventilation on diaphragmatic function after thoracic lung surgery through M-mode ultrasound.Methods A total of 86 patients,aged 18-65 years,with body mass index(BMI)of 18.5 kg/m2 to 30.0 kg/m2,and American Society of Anesthesiologists(ASA)classification grades Ⅰ or Ⅱ,who were scheduled for unilateral single-lung lobecto-my,were selected.According to the random number table method,they were divided into two groups(n=43):a conventional ventilation group(group C)and an inverse ratio ventilation group(group F).After endotracheal intubation under general anesthesia,the tidal volume(VT)was set at 6-8 ml/kg,respiratory rate(RR)at 12-15 times/min,oxygen concentration at 50％,and oxygen flow at 1 Umin during double-lung ventilation.For single-lung ventilation,group F showed an inspiration-to-expiration ratio(I∶E)of 2∶1,with a VT of 6 ml/kg,and positive end-expiratory pressure(PEEP)of 5 cmH2O(1 cmH2O=0.098 kPa),while group C had an I∶E ratio of 1:2.Other respirato-ry parameters were the same between the two groups.Then,record patient demographics(age,gender ratio,BMI,ASA classification,hy-pertension,diabetes)and the heart rate,mean arterial pressure(MAP),arterial partial pressure of oxygen(PaO2),and arterial partial pressure of carbon dioxide(PaCO2)were recorded before anesthesia(T0),5 min after single-lung ventilation(T1),1 h after single-lung ventilation(T2),and immediately after surgery(T3).The airway peak pressure(Ppeak),plateau airway pressure(Pplat),mean airway pressure(Pmean),and PEEP were recorded at T1,T2,and T3.The M-mode ultrasound was used to collect bilateral diaphragmatic ex-cursion(DE)and diaphragmatic rapid shallow breathing index(D-RSBI)at T0 and immediately after extubation(T4).Hospital stay du-ration,the incidence of diaphragmatic dysfunction and pulmonary complications within postoperative 5 d was recorded,and Spearman correlation analysis was conducted to evaluate the relationship between the incidence of diaphragmatic dysfunction and pulmonary com-plications within postoperative 5 d.Surgical duration,single-lung ventilation time,and extubation time were recorded,as well as Ob-server's Assessment of Alertness/Sedation post-extubation Results Compared with group C,group F showed increased DE and de-creased D-RSBI at T4 on both the operative and non-operative sides(all P＜0.05),reduction in DE differences and D-RSBI differences(all P＜0.05);increases in PaO2 at T1 and T2(all P＜0.05);reduction in Ppeak and Pplat at T1,T2,and T3(all P＜0.05),and increases PEEP and Pmean(all P＜0.05).Compared with those at T0,both groups presented decreased DE and increased D-RSBI at T4 on both the operative and non-operative sides(all P＜0.05).Compared with those at the operative side,both groups showed increased DE and de-creased D-RSBI at T4 on the non-operative side(all P＜0.05),and reduction in DE differences and D-RSBI differences(all P＜0.05).Spearman correlation analysis indicated that the incidence of diaphragmatic dysfunction was positively correlated with the incidence of pulmonary complications within postoperative 5 d(r=0.65,P＜0.05).There were no statistical differences in other indicators(all P＞0.05).Conclusions Inverse ratio ventilation can improve diaphragmatic function and reduce the incidence of diaphragmatic dys-function.Diaphragmatic dysfunction is a key factor in postoperative pulmonary complications.
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