保护性肺通气对老年肺癌患者肺叶切除术围术期肺功能的影响

唐玉茹++李会++帅训军+候念果++孙明洁++徐堂文++滕娜++艾登斌

[摘要] 目的 探討保护性肺通气对老年肺叶切除术患者肺功能及术后并发症的影响。 方法 选取青岛市市立医院2014年1～12月择期行肺叶切除术的老年肺癌患者60例（ASA Ⅰ～Ⅱ级，年龄62～72岁，体重50～80 kg），采用随机数表法将患者分为传统肺通气（CV）组和保护性肺通气（PV）组，每组各30例。CV组潮气量为10 mL/kg，PV组压力控制通气（使潮气量达到6 mL/kg，呼气末正压6 cmH2O），两组的吸入氧浓度为100%，吸呼比1∶2，维持动脉血二氧化碳分压（PaCO2）为35～45 mmHg。在双肺通气15 min（T1）、单肺通气15 min（T2）、单肺通气60 min（T3）、恢复双肺通气15 min（T4）时点记录两组的气道峰压（PIP）、平台压（PPleatu）。记录两组术后拔除气管插管时间，并在T1、T2、T3、T4及术后2 h（POD0）、术后1 d晨（POD1）、术后2 d晨（POD2）抽取桡动脉血行血气分析记录两组的PaCO2和PaO2值，于POD2行胸部X线检查。 结果 两组患者的一般情况（性别、年龄、体重、吸烟史、术前肺功能）及手术时间、麻醉时间、手术径路、术后拔除气管插管时间差异无统计学意义（P > 0.05）。T2、T3时点PV组PIP及PPleatu明显低于CV组（P < 0.05），PaO2明显低于CV组（P < 0.05），PaCO2明显高于CV组（P < 0.05）。POD0、POD1、POD2时点PV组PaO2明显高于CV组（P < 0.05）。术后X线胸片显示PV组肺不张、肺部炎性病变发生率明显低于CV组（P < 0.05）。 结论 肺叶切除术中保护性肺通气能明显降低术中机械通气压力，改善术后肺氧合功能，减少了术后肺不张及肺部炎性病变的发生率。

[关键词] 保护性肺通气；肺叶切除术；单肺通气；肺功能

[中图分类号] R734.2 [文献标识码] A [文章编号] 1673-7210（2017）07（b）-0120-05

Effect of lung protective ventilation on perioperative pulmonary function in elderly patients received pulmonary lobectomy of lung cancer

TANG Yuru1，2 LI Hui2 SHUAI Xunjun2 HOU Nianguo2 SUN Mingjie2 XU Tangwen2 TENG Na2 AI Dengbin1，2

1.Graduate School， Taishan Medical University， Shandong Province， Tai′an 271016， China； 2.Department of Anesthesiology， Municipal Hospital of Qingdao Research Center of Clinical Anesthesiology of Qingdao， Shandong Province， Qingdao 266011， China

[Abstract] Objective To evaluate the effect of lung protective ventilation strategies on the pulmonary function and postoperative pulmonary complications in elderly patients with pulmonary lobectomy. Methods A total of 60 elderly patients with lung cancer of ASA physical status Ⅰ-Ⅱ， aged 62-72 year， weighing 50-80 kg， who underwent elective pulmonary lobectomy surgery in Municipal Hospital of Qingdao from January to December 2014 were seleced. All patients were divided into two groups （n=30）： protective ventilation group （group PV） and conventional ventilation group （group CV） according to random number table. In group CV， patients received volume-controlled ventilation and the VT was 10 mL/kg. In group PV， patients received pressure-controlled ventilation， the VT was 6 mL/kg， and the positive end-expiratory pressure （PEEP） was 6 cmH2O. The oxygen concentration was 100%， the inhalation and exhalation rate was 1∶2， and the partial pressure of end-tidal CO2 was 35-45 mmHg. The peak inspiratory pressure （PIP） and the plateau pressure （PPleatu） were compared and analyzed at the time of double lung ventilation （TLV） 15 min （T1）， one-lung ventilation （OLV） 15 min （T2）， OLV 60 min （T3）， and the restore TLV 15 min （T4）. The time from stopping anesthetic to extubating tracheal tube was also recorded and compared. Blood samples were collected from radial artery for blood gas analysis， the PaCO2 and PaO2 were compared and analyzed at the time of T1， T2， T3， T4， 2 h after pulmonary lobectomy surgery （POD0）， the morning of 1 days after surgery （POD1） and the morning of 2 days after surgery （POD2）. Chest X-ray in two groups was also compared and analyzed in POD2. Results There were no significant differences between the two groups in sex， age， weight， smoking history， preoperative pulmonary function， anesthesia time， operation time， surgical approach and duration of postoperative tracheal intubation （P > 0.05）. Compared with group CV， PIP， PPleatu and PaO2 were significantly decreased， PaCO2 was increased at T2， T3 in group PV， with statistically significant differences （P < 0.05）. Compared with group CV， PaO2 levles were significantly increased in group PV at POD0， POD1， POD2， with statistically significant differences （P < 0.05）. Compared with group CV， the incidence of postoperative pulmonary atelectasis， pulmonary infiltrates were significantly decreased in group PV （P < 0.05）. Conclusion The protective lung ventilation strategy can significantly reduce intraoperative mechanical ventilation pressure， improve postoperative pulmonary oxygenation function， reduce incidence rate of postoperative atelectasis and lung tissue infiltrates of elderly patients underwent pulmonary lobectomy.

[Key words] Lung protective ventilation； Pulmonary lobectomy； One lung ventilation； Pulmonary function

随着社会老龄化和医疗技术的发展，临床麻醉工作中将面临老年肺癌切除术患者增多的现状。由于老年患者在术后肺不张和低氧血症发生率明显高于普通患者[1-2]，使其围术期肺部并发症成为临床麻醉管理工作过程中普遍关注的问题[3]。保护性肺通气策略是近年来提出的机械通气中采用的新方法[4]。本研究将保护性肺通气用于老年患者肺叶切除术的单肺通气（one-lung ventilation，OLV）中，就保护性肺通气策略对老年肺癌患者术中及术后氧合功能及术后并发症的影响进行了探讨。