The value of protective lung ventilation during anesthesia for tuberculous destructuve pneumonectomy

doi:10.3969/j.issn.1000-6621.2019.05.005

Abstract

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

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

Figures/Tables 5

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

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

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

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

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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