保护性肺通气模式在结核性毁损肺全肺切除术麻醉中的价值

doi:10.3969/j.issn.1000-6621.2019.05.005

摘要/Abstract

摘要：

目的探讨小潮气量通气和呼气末正压通气(positive end expiratory pressure,PEEP)结合压力控制通气(pressure controlled ventilation,PCV)对结核性毁损肺(tuberculous destroyed lung,TDL)患者全肺切除术单肺通气(one-lung ventilation, OLV)呼吸力学、肺内分流(Qs/Qt)、PaO₂和术后肺部感染等的影响。方法经首都医科大学附属北京胸科医院医学伦理委员会批准,选取2016年8月至2018年3月在首都医科大学附属北京胸科医院接受择期开胸全肺切除手术的TDL患者为研究对象,共48例。采用随机数字表法将患者分为观察组和对照组,每组24例。观察组OLV期间潮气量6ml/kg,OLV开始即刻给予PCV通气,然后给予7cm H₂O(1cm H₂O=0.0098kPa)的PEEP通气;对照组OLV期间潮气量8ml/kg。记录OLV前(T₁)、OLV开始后30min(T₂)及全肺切除术后5min (T₃)时气道峰压(P_peak)和平台压(P_plat);T₁、T₂、T₃和术后6h(T₄)抽取动静脉血,测血气指标pH、PaCO₂和PaO₂,并计算Qs/Qt 值;术后第1天、第7天行临床肺部感染评分。计量资料组间比较,若方差齐,采用t检验,若方差不齐采用t'检验;组内比较采用重复测量设计的方差分析;计数资料比较采用χ²检验,均以P<0.05为差异有统计学意义。结果 T₂时与对照组比较,观察组P_peak明显降低[观察组:(21.0±2.2)cm H₂O;对照组:(22.4±2.2)cm H₂O;t=-2.446,P=0.021];T₂时与对照组比较,观察组 P_plat明显降低[观察组:(19.7±2.2)cm H₂O;对照组:(21.0±2.7)cm H₂O;t=-3.610,P=0.001];T₃时与对照组比较,观察组pH明显降低[观察组:7.3±0.053;对照组,7.37±0.047;t=-3.000,P=0.006];T₂时与对照组比较,观察组PaCO₂明显升高[观察组:(44.0±2.2)mm Hg (1mm Hg=0.133kPa);对照组:(35.7±4.0)mm Hg;t=7.091,P=0.000];T₂时与对照组比较,观察组Qs/Qt 明显降低[观察组:(21.4±5.4)%;对照组:(25.4±6.8)%;t=-0.256,P=0.020];T₄时与对照组比较,观察组PaO₂/FiO₂明显升高[观察组:(181.2±29.0)mm Hg;对照组:(159.1±25.2)mm Hg;t=2.938,P=0.009]。术后第1天,与对照组比较,观察组肺部感染评分明显降低[观察组:(4.7±0.6)分;对照组:(5.2±0.9)分;t=-2.567,P=0.017]。结论小潮气量和PEEP结合PCV的通气模式,在TDL患者开胸全肺切除手术OLV中可以较好的降低OLV期间气道压力、降低Qs/Qt,改善术后PaO₂,降低术后第1天肺部感染的评分。

关键词: 结核, 肺, 肺切除术, 麻醉, 全身, 肺通气, 对比研究

Abstract:

Objective To discuss the impact of respiratory mechanics, intrapulmonary shunt (Qs/Qt), PaO₂ and postoperative pulmonary infection during one-lung ventilation (OLV) using small tidal volume and positive end-expiratory pressure (PEEP) with pressure controlled ventilation (PCV) in total pneumonectomy with tuberculous destroyed lung (TDL). Methods TThe present study was approved by the medical ethics committee of Beijing Chest Hospital affiliated to Capital Medical University. The study enrolled 48 TDL patients receiving selective thoracotomic total pneumonectomy from August 2016 to March 2018. A random number table was used to divide the patients into observation group and control group, 24 cases in each group. The tidal volume of the observation group was 6 ml/kg during OLV, and PCV was administered immediately from the beginning of OLV followed by PEEP at 7cm H₂O (1cm H₂O=0.0098kPa). The tidal volume of the control group was 8 ml/kg during OLV. Airway peak pressure (P_peak) and plateau pressure (P_plat) before OLV (T₁), 30 min after OLV (T₂) and 5 min after total pneumonectomy (T₃) were recorded. Arterial and venous blood samples were collected at T₁, T₂, T₃ and at 6h after surgery (T₄), the blood gas indicators pH, PaCO₂ and PaO₂ were measured, and Qs/Qt ratio was calculated. Clinical pulmonary infection was scored at day 1 and day 7 after surgery. Measurements were compared between the two groups; paired t-test was used for the comparison if there was homogeneity of variance; otherwise, t'-test was used. Repeated-measures analysis of variance was performed for intragroup comparisons. Counting data were analyzed by χ² test, P<0.05 was statistically significant. Results Compared with the control group, P_peak (observation group: (21.0±2.2)cm H₂O; control group: (22.4±2.2)cm H₂O; t=-2.446, P=0.021)and P_plat (observation group: (19.7±2.2)cm H₂O; control group: (21.0±2.7)cm H₂O; t=-3.610, P=0.001) in the observation group decreased significantly at T₂ and the pH value of the observation group at T₃ decreased significantly (observation group: 7.34±0.053; control group: 7.37±0.047; t=-3.000, P=0.006). At T₂, PaCO₂ of the observation group was significantly higher than that of the control group (observation group: (44.0±2.2)mm Hg (1mm Hg=0.133kPa); control group: (35.7±4.0)mm Hg; t=7.091, P=0.000), while Qs/Qt ratio decreased significantly (observation group: (21.4±5.4)%; control group: (25.4±6.8)%; t=-0.256, P=0.020). Compared with the control group at T₄, the PaO₂/FiO₂ ratio of the observation group increased significantly (observation group: (181.2±29.0)mm Hg; control group: (159.1±25.2)mm Hg; t=2.938, P=0.009). At the first day post operation, the pulmonary infection scores of the observation group decreased significantly compared with that of the control group (observation group: 4.7±0.6; control group: 5.2±0.9; t=-2.567, P=0.017).Conclusion Small tidal volume and PEEP with PCV could effectively reduce airway pressure and Qs/Qt ratio during OLV for thoracotomic total pneumonectomy, and improve PaO₂ and pulmonary infection scores of TDL patients at the first day postoperative.

Key words: Tuberculosis, pulmonary, Pneumonectomy, Anesthesia, general, Pulmonary ventilation, Comparative study

史志国,宋艳华,李凌海,翟文婷,刘涛,陈玢. 保护性肺通气模式在结核性毁损肺全肺切除术麻醉中的价值[J]. 中国防痨杂志, 2019, 41(5): 488-493. doi: 10.3969/j.issn.1000-6621.2019.05.005

Zhi-guo SHI,Yan-hua SONG,Ling-hai LI,Wen-ting ZHAI,Tao LIU,Bin CHEN. The value of protective lung ventilation during anesthesia for tuberculous destructuve pneumonectomy[J]. Chinese Journal of Antituberculosis, 2019, 41(5): 488-493. doi: 10.3969/j.issn.1000-6621.2019.05.005

图/表 5

表1

不同临床特征在两组患者中的比较

临床特征	观察组(24例)	对照组(24例)	检验值	P值
性别[例(构成比,%)]			0.483^a	0.800
男	13(54.2)	16(66.7)
女	11(45.8)	8(33.3)
年龄(岁, $x ˉ$ ±s)	40.8±14.5	38.8±13.2	0.681^b	0.503
体质量指数( $x ˉ$ ±s)	21.2±3.0	20.7±2.5	0.676^b	0.496
AS分级[例(构成比,%)]			0.483^a	0.800
Ⅱ	16(66.7)	13(54.2)
Ⅲ	8(33.3)	11(45.8)
FEV1/FVC(%,$\bar{x}$±)	72.0±8.8	71.1±9.7	0.802^b	0.431
MVV(%,$\bar{x}$±)	51.5±5.94	52.1±6.5	-0.455^b	0.653
麻醉时间(min,$\bar{x}$±s)	233.1±73.1	248.2±67.1	-1.606^b	0.123
OLV时间(min,$\bar{x}$±s)	191.0±71.4	207.0±65.4	1.579^b	0.114
尿量(ml,$\bar{x}$±s)	281.3±180.7	303.4±153.2	-1.507^b	0.132
术中输血(ml,$\bar{x}$±s)	818.3±238.1	872.6±324.5	-0.394^b	0.694
术中出血(ml, $\bar{x}$±s)	1181.8±650.3	1147.3±567.9	-1.071^b	0.284
输液量(ml, $x ˉ$ ±s)	3444.1±742.7	3471.5±731.4	-1.320^b	0.113

表1

表2

表3

不同时间点呼吸力学各项指标变化在两组患者中的比较

指标	观察组 (24例)	对照组 (24例)	观察组组内同T₁比较		对照组组内同T₁比较		两组间比较
指标	观察组 (24例)	对照组 (24例)	F值	P值	F值	P值	t值	P值
P_peak(cm H₂O, $x ˉ$ ±s)
T₁	20.6±2.4	19.8±2.5					1.027	0.315
T₂	21.0±2.2	22.4±2.2	1.611	0.217	4.821	0.039	-2.446	0.021
T₃	20.4±2.5	20.4±2.3	1.000	0.328	3.189	0.087	0.077	0.939
P_plat (cm H₂O, $x ˉ$ ±s)
T₁	19.3±2.8	18.5±2.6					1.349	0.198
T₂	19.7±2.2	21.0±2.7	0.461	0.564	7.031	0.014	-3.610	0.001
T₃	19.3±2.4	18.9±2.8	0.249	0.623	0.263	0.613	0.723	0.477
SVV(%, $x ˉ$ ±s)
T₁	10.9±1.9	11.3±1.6					-0.991	0.332
T₂	6.0±2.1	6.9±1.5	87.932	0.000	131.612	0.000	-1.722	0.098
T₃	9.0±1.5	8.7±1.4	11.220	0.003	22.881	0.000	0.890	0.351
CI[L/(min·m²), $x ˉ$ ±s]
T₁	4.0±0.4	4.2±0.5					-1.483	0.152
T₂	2.8±0.7^a	2.9±0.4	38.738	0.000	74.741	0.000	-0.943	0.356
T₃	3.0±0.6	3.1±0.4	34.585	0.000	60.528	0.000	-0.672	0.508
CVP(mm Hg, $x ˉ$ ±s)
T₁	9.6±1.6	10.3±1.4					-1.794	0.086
T₂	9.3±1.2	8.9±1.7	0.456	0.506	11.514	0.002	0.954	0.350
T₃	8.7±1.1	8.5±1.5	4.879	0.037	20.509	0.000	0.607	0.550
MAP(mm Hg, $x ˉ$ ±s)
T₁	81.7±7.8	79.8±6.3					1.287	0.211
T₂	70.9±8.8	66.6±9.5	23.858	0.000	50.263	0.000	-1.576	0.129
T₃	74.2±10.3	70.7±7.3	8.240	0.009	21.033	0.000	-1.395	0.176

表3

表4

不同时间点动脉血气各项指标变化在两组患者中的比较

指标	观察组 (24例)	对照组 (24例)	观察组组内同T₁比较		对照组组内同T₁比较		组间比较
指标	观察组 (24例)	对照组 (24例)	F值	P值	F值	P值	t值	P值
pH( $x ˉ$ ±s)
T₁	7.4±0.0	7.4±0.0					0.960	0.347
T₂	7.4±0.0	7.4±0.0	4.634	0.053	3.260	0.084	1.565	0.131
T₃	7.3±0.1	7.4±0.0	8.142	0.009	0.303	0.587	-3.000	0.006
T₄	7.4±0.0	7.4±0.0	7.416	0.012	3.464	0.076	0.383	0.705
PaCO₂(mm Hg, $x ˉ$ ±s)
T₁	39.3±5.0	37.8±4.4					0.961	0.350
T₂	44.0±2.2	35.7±4.0	36.823	0.000	89.223	0.000	7.091	0.000
T₃	37.8±4.3	36.9±3.8	1.468	0.238	1.292	0.267	0.832	0.414
T₄	37.3±4.5	35.2±3.7	3.105	0.091	5.241	0.032	1.563	0.116
Qs/Qt(%, $x ˉ$ ±s)
T₁	10.7±2.9	11.0±4.0					-0.372	0.713
T₂	21.4±5.4	25.4±6.8	63.110	0.000	89.202	0.000	-0.256	0.020
T₃	17.3±5.8	17.2±4.1	43.124	0.000	16.145	0.001	-0.652	0.521
T₄	7.5±2.6	8.8±3.2	15.755	0.001	6.402	0.019	-1.656	0.111
PaO₂/FiO₂(mm Hg, $x ˉ$ ±s)
T₁	426.1±33.8	415.6±42.7					0.791	0.440
T₂	196.8±51.3	215.4±97.7	344.437	0.000	81.539	0.000	-0.677	0.507
T₃	450.4±24.4	437.2±36.3	10.544	0.000	2.825	0.106	1.422	0.173
T₄	181.2±29.0	159.1±25.2	695.727	0.000	1308.484	0.000	2.938	0.009

表4

表5

术后第1天和第7天两组患者肺部感染指数评分

时间	观察组(分, $x ˉ$ ±s)	对照组(分, $x ˉ$ ±s)	t值	P值
术后第1天	4.7±0.6	5.2±0.9	-2.567	0.017
术后第7天	4.2±0.9	4.0±0.7	-0.806	0.428

表5

参考文献 16

[1]	Mandell LA,Wunderink RG,Anzueto A,et al.Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults.Clin Infect Dis, 2007,44(2):27-72.
[2]	蒋良双,吴邦贵,龚胜,等. 487例结核性毁损肺外科治疗的效果分析.中国防痨杂志,2018, 12(40):1296-1301. doi: 10.3969/j.issn.1000-6621.2018.12.011 URL
[3]	Yum HK,Park IN.Effect of inhaled tiotropium on spirometric parameters in patients with ttuberculous destroyed lung. Tuberc Respir Dis, 2014, 77(4): 167-171. doi: 10.4046/trd.2014.77.4.167 URL pmid: 4217032
[4]	洪征, 白连启, 阎东杰,等. 肺结核全肺切除近期并发症的治疗. 中华结核和呼吸杂志, 2011, 34(8):582-585. doi: 10.3760/cma.j.issn.1001-0939.2011.08.011 URL
[5]	Kothari A, Baskaran D.Pressure-controlled volume guaranteed mode improves respiratory dynamics during laparoscopic cholecystectomy a comparison with conventional modes. Anesth Esiaessays Res, 2018, 12(1):206-212. doi: 10.4103/aer.AER_96_17 URL pmid: 29628583
[6]	卞清明, 许仄平, 王丽君, 等. 右美托咪定联合肺保护性通气对胸科手术病人的肺保护作用. 中华麻醉学杂志, 2017, 37(9):1061-1065. doi: 10.3760/cma.j.issn.0254-1416.2017.09.009 URL
[7]	Lin F, Pan L,Huang B, et al.Pressure-controlled versus volume-controlled ventilation during one-lung ventilation in elderly patients with poor pulmonary function. Ann Thorac Med, 2014, 9(4): 203-208. doi: 10.4103/1817-1737.140125 URL pmid: 4166066
[8]	方建超. PCV与VCV对人工气胸食管癌根治术患者肺功能影响的研究. 郑州:郑州大学,2018.
[9]	闫丽娟, 李文志. 胸科手术的单肺通气策略. 国际麻醉学与复苏杂志, 2016, 37(1):49-53. doi: 10.3760/cma.j.issn.1673-4378.2016.01.012 URL
[10]	Blank RS, Colquhoun DA,Durieux ME, et al.Management of one-lung ventilation: impact of tidal volume on complications after thoracic surgery. Anesthesiology, 2016, 124(6): 1286-1295. doi: 10.1097/ALN.0000000000001100 URL pmid: 27011307
[11]	陈梦媛, 高巨, 郭唯真, 等. 保护性肺通气联合PCV-VG对单肺通气老年患者的肺保护效应.中华麻醉学杂志, 2017, 37(8):902-906. doi: 10.3760/cma.j.issn.0254-1416.2017.08.002 URL
[12]	方向志, 张扬, 高巨. 肺保护性通气对食管癌根治术病人的肺保护效应.中华麻醉学杂志, 2015, 35(3):283-286. doi: 10.3760/cma.j.issn.0254-1416.2015.03.004 URL
[13]	Della Rocca G, Coccia C.Acute lung injury in thoracic surgery. Cur Opin Anesthesiol, 2013, 26(1): 40-46. doi: 10.1097/ACO.0b013e32835c4ea2 URL pmid: 23235524
[14]	Jeon K, Yoon JW, Suh GY, et al.Risk factors for post-pneumonectomy acute lung injury/acute respiratory distress syndrome in primary lung cancer patients. Anaesth Intensive Care, 2009, 37(1):14-19. doi: 10.1111/j.1365-2044.2008.05828.x URL pmid: 19157340
[15]	Yeh PH, Hsu PK.An alternative method to achieve one-lung ventilation by surgical pneumothorax in difficult lung isolation patient: a case report. J Anesth, 2015, 30(2):328-330. doi: 10.1007/s00540-015-2125-6 URL pmid: 26721826
[16]	陈旭, 谢言虎, 柴小青. 肥胖患者单肺通气期间的通气策略.国际麻醉学与复苏杂志, 2016, 37(9):818-821. doi: 10.3760/cma.j.issn.1673-4378.2016.09.012 URL

项目	0分	1分	2分
体温(℃)	36~	38~	>39或<36
白细胞计数(×10⁹/L)	4~	11~	>17或<4
OI(mm Hg)	≥250	-^a	<250
分泌物	无痰或少许	中到大量非脓性痰	中到大量脓性痰
胸片显示浸润影	无	斑片状	融合片状