Song Benqin,Wang Xiaomei,Zhang Bin,et al.Lung protective effects of dynamic lung compliance-guided titration of individualized positive end-expiratory pressure during lobectomy/segmentectomy in infants with congenital pulmonary airway malformations[J].Journal of Clinical Pediatric Surgery,2026,(01):64-69.[doi:10.3760/cma.j.cn101785-202408036]
婴儿胸腔镜下肺叶(段)切除术中基于肺动态顺应性的个体化PEEP对单肺通气的肺保护效应研究
- Title:
- Lung protective effects of dynamic lung compliance-guided titration of individualized positive end-expiratory pressure during lobectomy/segmentectomy in infants with congenital pulmonary airway malformations
- Keywords:
- Hypnosis; Anesthetic; Thoracoscopy; Cystic Adenomatoid Malformation of Lung; Congenital; Airway Management; Infant; Small for Gestational Age
- 摘要:
- 目的 在婴儿胸腔镜下肺叶(段)切除术中以肺动态顺应性(dynamic lung compliance,Cdyn)为导向,进行呼气末正压(positive end-expiratory pressure,PEEP)滴定,观察个体化PEEP应用对婴儿单肺通气(one-lung ventilation,OLV)肺保护效应的影响。方法 本研究为前瞻性随机对照研究,选择2018年10月至2022年12月于山东大学附属儿童医院麻醉科择期行胸腔镜下肺叶切除术(包含肺叶切除、肺解剖节段切除或楔形切除)的婴儿先天性肺气道畸形(congenital pulmonary airway malformation,CPAM)患者90例作为研究对象,采用随机数字表法将患儿分为两组;对照组OLV期间设定PEEP为5 cm H2O;试验组OLV期间使用Cdyn导向滴定设定个体化PEEP。观察双肺通气后15 min(T1)、PEEP设定后30 min(T2)、PEEP设定后60 min(T3)、侧卧位恢复双肺通气后15 min(T4)的平均动脉压(mean pressure,MAP)、心率(mean pressure,HR)、气道峰压(peak airway pressure,Ppeak)、气道平台压(plateau pressure,Pplat)、肺动态顺应性(dynamic lung compliance,Cdyn)、氧合指数(oxygenation index,PaO2/FiO2)、肺泡动脉氧分压差[difference of alveolar arterial oxygen partial pressure,P(A-a) O2]、肺内分流率(intrapulmonary shunt rate,Qs/Qt)。结果 试验组和对照组PPCs发生率分别为5.0%(2/40)和22.5%(9/40);两组T2~T3的Cdyn值[(3.80±0.39) mL/cmH2O和(4.70±0.62) mL/cmH2O、(3.72±0.45) mL/cmH2O和(4.60±0.64) mL/cmH2O],两组T2~T4的PaO2/FiO2值[(251.30±42.23) mmHg和(267.45±37.28) mmHg、(252.93±42.03) mmHg和(273.07±39.87) mmHg、(298.59±49.18) mmHg和(332.74±41.64) mmHg]、P(A-a) O2值[(153.40±33.94) mmHg和(131.96±19.44) mmHg、(156.66±24.13) mmHg和(146.71±17.86) mmHg、(93.28±14.01) mmHg和(81.49±15.87) mmHg]、Qs/Qt值[(22.74±3.45)%和(20.40±3.31)%、(22.11±3.19)%和(19.54±3.70)%、(8.01±2.02)%和(6.76±1.40)%]的差异均有统计学意义(P<0.05)。两组T1和T4的Cdyn值[(7.77±0.79) mL/cmH2O和(8.03±0.74) mL/cmH2O、(7.70±0.83) mL/cmH2O和(7.93±0.67) mL/cmH2O],两组在T1时的PaO2/FiO2值[(377.26±46.31) mmHg和(373.31±45.72) mmHg]、P(A-a)O2值[(75.67±19.29) mmHg和(74.98±16.29) mmHg]、Qs/Qt值[(5.16±0.89)%和(4.97±0.87)%]差异均无统计学意义(P>0.05)。结论 在CPAM婴儿肺叶(段)切除术中使用Cdyn导向个体化PEEP设定,有助于改善患儿OLV期间肺氧合功能,优化呼吸力学参数,降低PPCs的发生率。
- Abstract:
- Objective To explore the impact of individualized positive end-expiratory pressure (PEEP) titration guided by dynamic lung compliance (Cdyn) during one-lung ventilation (OLV) during infantile thoracoscopic lobectomy (segmentectomy) on lung-protective effects by observing the incidence of postoperative pulmonary complications (PPCs). Methods This prospective study included 90 infants with congenital pulmonary airway malformations (CPAM) undergoing thoracoscopic lobectomy (including lobectomy,anatomical segmentectomy or wedge resection) at Department of Anesthesiology,Shandong University Children’s Hospital from October 2018 to December 2022.They were randomized into observation group implementing a lung-protective ventilation strategy with Cdyn-guided individualized PEEP titration during OLV and control group with a fixed PEEP of 5 cm H2O.Hemodynamic parameters of mean arterial pressure (MAP),heart rate (HR),peak airway pressure (Ppeak),plateau pressure (Pplat),dynamic lung compliance (Cdyn),oxygenation index (PaO2/FiO2),alveolar-arterial oxygen difference[P(A-a)O2]and intrapulmonary shunt rate (Qs/Qt) were recorded at 15 min after double-lung ventilation (T1),30 min after PEEP setting (T2),60 min after PEEP setting (T3) and 15 min after resuming double-lung ventilation in lateral position (T4).The incidence of in-hospital pulmonary complications from surgery to discharge was also documented. Results When comparing different PEEP setting strategies,the incidence of PPCs was 5.0%(2/40) in experimental group and 22.5%(9/40) in control group; Cdyn values at T2-T3 for two groups were[(3.80±0.39) vs.(4.70±0.62) mL/cmH2O,(3.72±0.45) vs.(4.60±0.64) mL/cmH2O]; PaO2/FiO2 values at T2-T4 for two groups were[(251.30±42.23) vs.(267.45±37.28) mmHg,(252.93±42.03) vs.(273.07±39.87) mmHg,(298.59±49.18) vs.(332.74±41.64) mmHg]; P(A-a)O2 values[(153.40±33.94) vs.(131.96±19.44) mmHg,(156.66±24.13) vs.(146.71±17.86) mmHg,(93.28±14.01) vs.(81.49±15.87) mmHg]and Qs/Qt values[(22.74±3.45)% vs.(20.40±3.31)%,(22.11±3.19)% vs.(19.54±3.70)%,(8.01±2.02)% vs.(6.76±1.40)%]all showed statistically significant differences.Cdyn values at T1 and T4 for two groups were[(7.77±0.79) vs.(8.03±0.74) mL/cmH2O,(7.70±0.83) vs.(7.93±0.67) mL/cmH2O]; PaO2/FiO2 value at T1[(377.26±46.31) vs.(373.31±45.72) mmHg],P(A-a)O2 value[(75.67±19.29) vs.(74.98±16.29) mmHg]and Qs/Qt value[(5.16±0.89)% vs.(4.97±0.87)%]showed no statistically significant differences. Conclusions In CPAM infants undergoing lobectomy (segmentectomy),Cdyn-guided individualized PEEP titration during OLV can improve lung oxygenation during OLV,optimize respiratory mechanic parameters and lower the incidence of PPCs.
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备注/Memo
收稿日期:2024-8-23。
基金项目:济南市卫生和计划生育委员会科技计划项目(2024304018)
通讯作者:王公明,Email:tagmwang1971@163.com