压力控制-容量保证通气模式下驱动压导向肺保护性通气策略对胸腹腔镜联合食管癌根治术患者的肺保护作用

Lung protective effect of driving pressure-guided lung protective ventilation strategy under PCV-VG mode in patients undergoing thoracoscopic and laparoscopic radical esophagectomy

摘要:

目的 探讨压力控制-容量保证通气（PCV-VG）模式联合驱动压（PD）导向肺保护性通气策略对行胸腹腔镜联合食管癌根治术患者的肺保护作用。方法 选取2023年5月－2024年3月于该院择期行胸腹腔镜联合食管癌根治术的患者70例，采用随机数表法分为常规肺保护性通气策略组（C组）和PCV-VG模式下DP导向肺保护性通气策略组（P组），各35例。比较两组患者气管插管后5 min（T₁）、气腹建立后30 min（T₂）、单肺通气（OLV）前即刻（T₃）、OLV后30 min（T₄）、OLV后60 min（T₅）和恢复双肺通气（TLV）后15 min（T₆）的气道峰压（Ppeak）、平台压（Pplat）、动态顺应性（Cdyn）和DP。记录两组患者麻醉诱导前（T₀）、T₂、T₃、T₄、T₅和T₆时点的血压（BP）、心率（HR）、动脉血氧分压（PaO₂）、动脉血二氧化碳分压（PaCO₂）和pH值，以及两组患者术后肺部并发症（PPCs）的发生情况。结果 与C组比较，P组T₁、T₂、T₄、T₅和T₆时点的Ppeak明显降低，Cdyn明显升高，差异均有统计学意义（P < 0.05）。P组T₁、T₄、T₅和T₆时点的DP明显低于C组，T₆时点的Pplat明显低于C组，差异均有统计学意义（P < 0.05）；P组T₄和T₅时点的PaO₂明显高于C组，T₆时点的PaCO₂明显高于C组，差异均有统计学意义（P < 0.05）；两组患者T₀、T₂、T₃、T₄和T₅时点的PaCO₂比较，差异均无统计学意义（P > 0.05）。两组患者各时点pH值比较，差异均无统计学意义（P > 0.05）。P组在T₄时点的收缩压（SBP）明显高于C组，T₆时点的舒张压（DBP）明显低于C组，差异均有统计学意义（P < 0.05）；两组患者T₀、T₂、T₃和T₅时点SBP和DBP比较，以及各时点HR比较，差异均无统计学意义（P > 0.05）。两组患者术后7 d内PPCs发生率比较，差异无统计学意义（P > 0.05）。结论 PCV-VG模式下DP导向肺保护性通气策略能够改善胸腹腔镜联合食管癌根治术患者术中的呼吸力学，提高OLV期间的氧合，且不会增加术后7 d内PPCs发生率。值得临床推广应用。

Abstract:

Objective To explore the lung protective effect of pressure controlled ventilation-volume guaranteed (PCV-VG) combined with driving pressure (DP) guided lung protective ventilation strategy in patients undergoing thoracoscopic and laparoscopic radical esophagectomy.Methods 70 patients scheduled for elective thoracoscopic and laparoscopic radical esophagectomy were allocated into two groups using a random number table method: Conventional lung protective ventilation strategy group (group C) and DP guided lung protective ventilation strategy under PCV-VG mode group (group P), 35 case in each group. Peak airway pressure (Ppeak), plateau pressure (Pplat), dynamic compliance (Cdyn) and DP were compared between the two groups at 5 minutes after intubation (T₁), 30 min after pneumoperitoneum established (T₂), just prior to one lung ventilation (OLV) (T₃), 30 min after OLV (T₄), 60 min after OLV (T₅) and 15 min from recovery of two lung ventilation (TLV) (T₆). The blood pressure (BP), heart rate (HR), arterial partial pressure of oxygen (PaO₂), partial pressure of carbon dioxide in arterial blood (PaCO₂) and pH were recorded before anesthesia (T₀), T₂, T₃, T₄, T₅ and T₆ time points. The occurrence of postoperative pulmonary complications (PPCs) also recorded.Results Compared with group C, Ppeak in group P at T₁, T₂, T₄, T₅ and T₆ time points was significantly decreased, and Cdyn was obviously increased, the differences were statistically significant (P < 0.05). At the T₁, T₄, T₅ and T₆ time points, the DP was lower in group P compared to group C, and Pplat at T₆ time point was lower than that in group C, the differences were statistically significant (P < 0.05). At the time points of T₄ and T₅, the PaO₂ in group P was higher than that in Group C, and the PaCO₂ at T₆ time point was also higher than that in group C, the differences were statistically significant (P < 0.05). The comparison of PaCO₂ at T₀, T₂, T₃, T₄ and T₅ time points of the two groups, the difference was not statistically significant (P > 0.05). Comparison of pH between the two groups, the difference was not statistically significant at all time points (P > 0.05). The systolic blood pressure (SBP) of group P was higher than that of group C at the T₄ time point, and the diastolic blood pressure (DBP) was lower than that of group C at T₆ time point, and the differences were statistically significant (P < 0.05); There were no significant differences in SBP and DBP at T₀, T₂, T₃ and T₅ time points, and HR at each time point between the two groups (P > 0.05). There was no statistically significant difference in the occurrence of PPCs within 7 d after operation between the two groups (P > 0.05).Conclusion DP guided lung protective ventilation strategy under PCV-VG mode can improve intraoperative respiratory mechanics, and increase oxygenation during OLV in patients undergoing thoracoscopic and laparoscopic radical esophagectomy, but it does not significantly affect the incidence of PPCs within 7 d after operation. It is worthy clinical significant.