肺内压力监测联合开胸前肺萎陷技术用于胸腔镜手术的效果

Effect of intrapulmonary pressure monitoring combined with the pre-thoracotomy lung collapse technique in thoracoscopic surgery

摘要:

目的 评价肺内压力监测（IPM）联合开胸前肺萎陷技术（PTLCT）用于胸腔镜手术的效果。方法 选择择期行胸腔镜左肺叶楔形切除术的患者96例，性别不限，年龄30～79岁，体重指数（BMI） < 30 kg/m²，美国麻醉医师协会分级（ASA）为Ⅰ级或Ⅱ级，采用随机数表法分为4组（n = 24）：PTLCT组（C组）、-5～5 mmHg IPM联合PTLCT组（P₁组）、-15～-6 mmHg IPM联合PTLCT组（P₂组）、 < -15 mmHg IPM联合PTLCT组（P₃组）。PTLCT采用双肺纯氧通气并在侧卧位前封堵术侧支气管，单肺通气10 min后打开胸膜并胸腔镜进胸。P₁组、P₂组、P₃组分别在PTLCT的基础上，在IPM达到相应压力段时打开胸膜并胸腔镜进胸。记录每组侧卧位即时（T₀）和打开胸膜前（T₁）的心率（HR）、收缩压（SBP）、舒张压（DBP）、经皮动脉血氧饱和度（SpO₂）、动脉血氧分压（PaO₂）和动脉血二氧化碳分压（PaCO₂），并且到时间点后即刻进胸，胸腔镜直视下观察肺萎陷情况。结果 P₁组有8例患者在达到肺内压力段时未能完成进胸前准备；P₂组有2例患者未能达到所需肺内压力段；P₃组有1例患者在进胸前的单肺通气期间发生低氧血症（SpO₂ < 90%），2例患者未能达到所需肺内压力段。与C组比较，P₁组患者肺萎陷评分（LCS）下降（P < 0.05），P₂组、P₃组患者LCS差异无统计学意义（P > 0.05）。在T₁时，与P₁组比较，P₃组SpO₂ 降低（P < 0.05）；与C组比较，P₁组PaO₂升高（P < 0.05）；与P₁组比较，P₂组、P₃组PaO₂降低（P < 0.05）；与P₂组比较，P₃组PaO₂降低（P < 0.05）。结论 IPM联合PTLCT可以避免肺组织损伤；在-15～-6 mmHg肺内压力段时进胸，既可以达到良好的开胸前肺萎陷效果，又可以保持良好的SpO₂，适合作为胸腔镜进胸时机。

Abstract:

Objective To evaluate the effect of intrapulmonary pressure monitoring (IPM) combined with the pre-thoracotomy lung collapse technique (PTLCT) in thoracoscopic surgery.Methods 96 American Society of Anesthesiologists physical status I or II patients, aged 30~79 yr, BMI < 30 kg/m², underwent elective thoracoscopic left lung surgery, were randomized into 4 groups (n = 24): PTLCT group (C group), -5 ~ 5 mmHg IPM combined with PTLCT group (P₁ group), -15 ~ -6 mmHg IPM combined with PTLCT group (P₂ group), < -15 mmHg IPM combined with PTLCT group (P₃ group). PTLCT was treated by using the double lung ventilation with FiO₂ = 1.0 and the operative bronchus was blocked before the patients’ change into the lateral position. And after 10 min of one lung ventilation (OLV), the pleura was opened and thoracoscope was put into the chest. P₁ group, P₂ group, and P₃ group were treated by opening the pleura when intrapulmonary pressure was -5 ~ 5 mmHg, -15 ~ -6 mmHg, < -15 mmHg based on PTLCT. HR, SBP, DBP, SpO₂, and PaO₂, PaCO₂ were recorded in each group at the time point of after changing position (T₀) and before opening the pleura (T₁). The operated lung was evaluated using lung collapse score (LCS) immediately after opening the pleura.Results 8 patients in P₁ group were failed to complete the preparation of opening the pleura before reaching intrapulmonary pressure; 2 patients in P₂ group failed to achieve the required intrapulmonary pressure; 1 patient in P₃ group happened hypoxemia (SpO₂ < 90%) during OLV, 2 patients failed to reach the required intrapulmonary pressure. Compared with C group, the LCS of P₁ group was significantly decreased (P < 0.05), and no significant change was found in LCS in P₂ group and P₃ group (P > 0.05). At T₁, compared with P₁ group, the SpO₂ of P₃ group was significantly decreased (P < 0.05); Compared with C group, the PaO₂ of P₁ group was significantly increased (P < 0.05); Compared with P₁ group, the PaO₂ was significantly decreased in P₂ and P₃ group (P < 0.05); Compared with P₂ group, the PaO₂ of P₃ group was significantly decreased (P < 0.05).Conclusion IPM combined with PTLCT can avoid lung tissue injury; Opening the pleura at -15 ~ -6 mmHg of intrapulmonary pressure section can not only achieve a good effect of lung collapse, but also maintain good SpO₂, which is suitable time for opening the pleura in thoracoscopic surgery.