目的 探讨基于肺超声滴定最佳呼气末正压(PEEP)和肺复张吸气峰压(Ppeak)指导个体化肺保护性通气策略对老年结肠癌根治术患者围术期肺功能的影响.方法 选择择期全麻腹腔镜结肠癌根治术老年患者75 例,男46 例,女29 例,年龄65～85 岁,BMI 18.5～32.0 kg/m2,ASAⅡ或Ⅲ级,随机分为两组:个体化组(U组,n=37)和传统组(T组,n=38).两组均以固定的小潮气量 6 ml/kg通气.U组选择肺不张程度最重的肺窗作为肺超声滴定最佳PEEP 和Ppeak的扫查点,采用压力滴定法获取最佳PEEP和Ppeak,实施个体化肺保护性通气策略,间断进行持续 15s肺复张.T组实施传统的肺保护性通气策略,设置PEEP 5 cmH2 O,Ppeak 30 cmH2 O,间断进行持续15s肺复张.记录麻醉诱导前、气腹前即刻、气腹后 10 min、1、2 h和拔管后 30 min的氧合指数(OI)和呼吸指数(RI).记录气腹前即刻、气腹后 10 min、1、2 h的PETCO2、驱动压、PEEP、Ppeak和肺顺应性(Cdyn).记录术前最后 1 次Hb、术前 1d屏气时间、手术时间、术中出血量、输液量、拔管时间、住院时间和术后7d新增肺部并发症等情况.结果 与麻醉诱导前比较,T组拔管后 30 min OI明显降低,RI明显升高(P＜0.05).与 T 组比较,U 组气腹后 1、2 h、拔管后 30 min OI 明显升高,RI 明显降低(P＜0.05),气腹后 10 min、1、2 h PETCO2 明显降低,Cdyn明显升高(P＜0.05),气腹前即刻、气腹后 10 min、1 h PEEP明显降低(P＜0.05),气腹前即刻、气腹后 10 min、1、2 h驱动压、Ppeak明显降低(P＜0.05),拔管时间、术后住院时间明显缩短(P＜0.05),术后 7d内新增肺部并发症发生率明显降低(P＜0.05).结论 以肺超声指导下的个体化肺保护性通气策略,更利于老年腹腔镜结肠癌根治术患者围术期肺功能保护,可有效缩短术后早期拔管时间和住院时间,降低术后肺部并发症的发生.
Effect of individualized lung protective ventilation on perioperative pulmonary function in elderly patients
Objective To investigate the effect of individualized lung protective ventilation strategy guided by lung ultrasound titration of optimal end-positive respiratory pressure(PEEP)and peak inspiratory pressure(Ppeak)on perioperative lung function in elderly patients undergoing radical resection of colorectal cancer.Methods Seventy-five elderly patients undergoing laparoscopic radical resection of colon cancer in elective general anesthesia were collected,including 46 males and 29 females,aged 65-85 years,BMI 18.5-32.0 kg/m2,ASA physical statusⅡ orⅢ.Patients were randomly divided into groups:the individualized group(group U,n=37)and the traditional group(group T,n=38).Both groups were ventilated with a fixed low tidal volume,VT 6 ml/kg.In group U,the lung window with the most severe degree of atelectasis was selected as the optimal scanning point for lung ultrasound titration to determine the optimal PEEP and Ppeak,and an individualized lung protective ventilation strategy was implemented,with intermittent sus-tained lung recruitment for 15 seconds.The group T implemented the traditional lung protective ventilation strategy,setting PEEP at 5 cmH2 O and Ppeak at 30 cmH2 O,with intermittent lung recruitment lasting for 15 seconds.The oxygen index(OI)and respiratory index(RI)were recorded before anesthesia induction,immediately before pneumoperitoneum,10 minutes,1 hour,and 2 hours after pneumoperitoneum,and 30 minutes after extubation.The PET CO2,driving pressure,PEEP,Ppeak and dynamic lung compliance(Cdyn)were recorded immediately before pneumoperitoneum,10 minutes,1 hour,and 2 hours after pneu-moperitoneum.The last preoperative Hb level,preoperative breath-holding time on the day before surgery,duration of surgery,intraoperative blood loss,fluid administration,postoperative extubation time,postoper-ative length of hospital stay,and new pulmonary complications within the first seven days after surgery were recorded for all patients.Results Compared with before anesthesia induction,OI significantly decreased and RI significantly increased in group T 30 minutes after extubation(P＜0.05).Compared with group T,the OI significantly increased and RI significantly decreased 1 hour,and 2 hours after pneumoperitoneum,and 30 minutes after extubation in group U(P＜0.05),the PETCO2 significantly decreased10 minutes,1 hour,and 2 hours after pneumoperitoneum,while the Cdyn significantly increased in group U(P＜0.05),PEEP significantly decreased immediate before pneumoperitoneum 10 minutes and 1 hour after pneumoper-itoneum in group U(P＜0.05),driving pressure and Ppeak significantly decreased immediate before pneumoperitoneum,10 minutes,1 huor,and 2 hours after pneumoperitoneum in group U(P＜0.05),the time of extubation and hospitalization after surgery were significantly shortened(P＜0.05),the incidence of new pulmonary complications within 7 days postoperatively was significantly reduced in group U(P＜0.05).Conclusion The individualized lung-protective ventilation strategy guided by lung ultrasound is more conducive to the protection of lung function in elderly patients undergoing laparoscopic radical resction for colon cancer during the perioperative period,which can effectively shorten the early postoperative extuba-tion time and hospitalization time,and reduce the occurrence of postoperative pulmonary complications.
Lung ultrasoundIndividualizationLung protective ventilation strategyAgedPerio-perative lung function
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