单肺通气后不同膨肺方式在肺叶切除术中的临床研究

发布时间：2018-06-08 22:07

本文选题：单肺通气 + 肺复张策略　；参考：《广西医科大学》2015年硕士论文

【摘要】：目的对比肺叶切除术麻醉患者单肺通气(one-lung ventilation、OLV)后运用四种不同的膨肺方式对肺换气、呼吸力学及术后肺功能的影响。方法将40例开胸行右肺叶切除术患者随机分为A、B、C、D组,在OLV结束后分别用潮气量(Tidal volume, VT) 8 mL/kg (A组)、VT8 mL/kg+呼气末正压(positive end expiratory pressure, PEEP) 5 cmH20 (B组)、VT12 mL/k g (C组)及VT12 mL/kg+PEEP 5 cmH2O(D组)的方式膨肺。监测OLV前(T1)、OLV后40 min(T2)、膨肺过程(T3)、膨肺后10 min (T4)及3Omin(T5)的血压(blood pressure, BP)和心率(heart rate, HR)。观察T1、T2、T4及T。的气道峰压(peak airway pressure, Ppeak) 、气道平台压(airway pressure platform, Pplat)和动态顺应性(dynamic compliance, Cdyn)。在T1、T2、T5、T5及膨肺后50 min(T6)记录动脉血氧分压(partial pressure of oxygen in artery, PaO2)、肺泡动脉血氧分压差(Alveolar-arterial oxygen difference, P(A-a)O2)、肺内分流率(intrapulmonary shunt fraction,Qs/Qt)及无效腔气量与潮气量之比(the dead-space to tidal volume ratio,VD/VT)。并观察患者清醒拔管后30 min (T7)的P aO2、P(A-a)O2。记录术前及术后第7天肺功能指标：用力肺活量占预计值百分比(percentage of predicted Forced Vital Capacity, FVC%pred)、第一秒用力肺活量占预计值百分比(percentage of predicted forced vital expiratory volume in 1 second, FEV1%pred)、第一秒用力呼气量占用力肺活量的百分比(percentage of FEV1/FVC ratio, FEV1/FVC%)、用力呼气中期流速占预测值百分比(percentage of predicted maximal mid expiratory flow, MMF%pred)。结果术中血压、心率无明显变化(P0.05)。术中呼吸力学指标：四组患者膨肺后组间及组内(与T1相比)比较Ppeak、Pplat、Cdyn差异无统计学意义(P0.05)。术中肺换气指标：D组与A组相比,VD/VT在T4时明显降低(P0.05)；D组与A、B组相比,Pa02在T4、T5时明显升高,VD/VT在T5时明显降低,P(A-a)02在T4和T6时明显降低,Qs/Qt在T6时明显降低(P0.05)；与余三组相比,D组PaO2及VD/VT在T6时差异有统计学意义(P0.05)；与T,相比,D组中VD/VT在T4、T6、T6时明显降低(P0.05)。术后肺换气指标：T,时间点时,D组患者Pa02与A、B、C组比较有统计学意义(P0.05),P(A-a)O2各组间比较无统计学差异(P0.05)。肺功能指标：各组患者术后第七天FVC%pred、 FEV1%pred、MMF%pred与术前相比明显降低(P0.05),FEV1/FVC%指标达术前水平(P0.05)；术后第七天各肺功能指标组间比较无统计学意义(P0.05)。结论OLV后按理想体重给予潮气量12mL/kg+PEEP 5 cmH20的膨肺方式可改善肺换气,但对呼吸力学、术后肺功能影响甚微。
[Abstract]:Objective to compare the effects of four different ways of pulmonary expansion on lung ventilation, respiratory mechanics and postoperative pulmonary function after one-lung ventilation (OLVL) in patients undergoing lobectomy. Methods A total of 40 patients undergoing right lobectomy were randomly divided into two groups: group A: Tidal volume (VT) 8 mL / kg (VT) 8 mL / kg + positive end expiratory pressure, peep (5 cmH20B) and VT12 mL / kg peep 5 cm H _ 2O _ D (n = 10) and VT12 mL / kg peep 5 cm H _ 2O _ D group (n = 10), and VT12 mL / kg PEEP-5 cmH _ 2O _ D group (n = 10) were randomly divided into two groups: VT12 mL / kg peep 5 cm H _ 2O _ D group (n = 10). The patients were divided into two groups: VT12 mL / kg peep 5 cm H _ 2O _ D group. Blood pressure, heart rate and heart rate were measured at 40 min after OLV and 10 min after T4) and 3Omin T5 (P < 0.05). T _ 1, T _ 2, T _ 4 and T _ 2 were observed. The peak airway pressure (peak airway pressure), airway plateau pressure (Ppek), and dynamic compliance, Cdynberg. The partial oxygen pressure (pressure of oxygen in artery, Pao _ 2), the alveolar arterial oxygen pressure difference (Alveolar-arterial oxygen difference), the intrapulmonary shunt rate (intrapulmonary shunt fraction) and the ratio of the dead-space to tidal volume to the tidal volume were recorded at T _ (1) T _ (2) T _ (2) T _ (5) and 50 min (T _ (6) after pulmonary inflation). The Pao _ 2 and A-A O _ 2 of the patients were observed 30 min after extubation. Lung function indexes were recorded before and 7 days after operation: percentage of forced vital capacity of predicted forced vital capacity, percent of forced vital capacity in the first second, percentage of forced vital capacity 1 second, FEV1 second volume, forced expiratory volume in the first second. The percentage of forced vital capacity of FEV1 / FVC ratio, FEV1 / FVC ratio of FEV1 / FVC, the percentage of forced midexpiratory flow rate to predicted value was 100%. Results there was no significant change in blood pressure and heart rate during operation. Intraoperative respiratory mechanics index: there was no significant difference of Ppeakia platplatCdyn between the four groups after pulmonary expansion and within the group (compared with T1). Lung ventilation index in group D: 1 was significantly lower than that in group A at T4, and P0.05 / VT in group D was significantly higher than that in group A (P 0.05), and the level of VD- / VT in group A was significantly higher than that in group A at T5, and that in group T4 and group T6 was significantly lower than that in group A at T6, and that in group D was significantly lower than that in group A at T6, and that in group A was significantly lower than that in group A at T6, and that in group A was significantly lower than that in group A at T6, and that in group A was significantly lower than that in group A at T6. The difference of Pao 2 and VD / VT in group D at T6 was statistically significant (P 0.05), and that of VD / VT in group D was significantly lower than that in group D at T4 (T4) and T6 (T6). There was no significant difference between group D and group A (P 0.05) in lung ventilation index: 1. There was no significant difference between group D and group A (P 0.05) and between group A (P 0.05) and group A (A) (P 0.05), but there was no significant difference between group A (P 0.05) and group A (P 0.05). Pulmonary function index: on the 7th day after operation, FVCpred, FEV1 predder and MMFpred significantly decreased P0.05% FEV1 / FVC% index to the preoperative level (P0.05%), but on the 7th day after operation, there was no significant difference among the lung function index groups (P0.05). Conclusion Tidal volume of 12ml / kg peep 5 cmH20 after OLV can improve pulmonary ventilation, but it has little effect on respiratory mechanics and postoperative pulmonary function.
【学位授予单位】：广西医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R614

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