个体化呼气末正压降低患者术中机械通气的机械功率:一项随机对照研究数据的二次分析

Individualized positive end-expiratory pressure reduces mechanical power during mechanical ventilation in patients undergoing surgery: A secondary analysis of data from a randomized controlled trial

  • 摘要:
    背景 机械功率(mechanical power,MP)作为评估机械通气(mechanical ventilation,MV)对肺部呼吸力学影响的一个新兴综合指标,可反映MV过程中总体能量传递,且与肺损伤的发生及患者预后关系密切。目的 观察电阻抗断层成像(electrical impedance tomography,EIT)指导下的个体化呼气末正压(positive end-expiratory pressure,PEEP)对机器人辅助腹腔镜手术患者所受到的MP的影响。方法 对前期一项72例肝胆胰机器人手术患者随机对照研究资料进行二次分析。研究分别采用EIT指导(PEEPEIT组)与传统方法(PEEP5 cmH2O组)进行手术患者的PEEP设置,在诱导后10 min、气腹过程中(PEEP滴定后 60 min)、气腹结束后 10min 采集潮气量(tidal volume,Vt)、呼吸频率(respiratory rate,f)、气道峰压(peak airway pressure,Ppeak)、平台压(plateau pressure,Pplat)、呼吸系统顺应性(respiratory compliance,Crs)、驱动压(driving pressure,DP)等指标,计算两组患者不同时间点呼吸系统所接受的MP并对比差异。结果 PEEPEIT组48例,男性26例,女性22例,平均年龄(53.7±14.0)岁;PEEP5 cmH2O组24例,男性10例,女性14例,平均年龄(57.3±14.5)岁,两组年龄、性别差异无统计学意义(P>0.05)。PEEPEIT组MP在气腹前(4.54±1.53) J/min vs (5.49±1.23) J/min、气腹中(6.68±2.35) J/min vs (7.81±2.23) J/min和气腹后(5.24±1.70) J/min vs (6.09±1.55) J/min均显著低于 PEEP5 cmH2O组(P<0.05);Crs 在气腹中(44.27±11.33) mL/cmH2O vs (31.88±6.58) mL/cmH2O和气腹后(63.56±13.06) mL/cmH2O vs (48.13±10.59) mL/cmH2O均高于PEEP5 cmH2O组,差异有统计学意义(P<0.05);DP在气腹中(11.50±2.08) cmH2O vs (13.96±2.37) cmH2O和气腹后(7.60±1.92) cmH2O vs (9.75± 2.17) cmH2O均低于PEEP5 cmH2O组(P<0.05)。结论 在肝胆胰机器人手术患者中,采用EIT指导的个体化PEEP可降低MP,其原因可能与改善Crs、降低DP有关。

     

    Abstract:
    Background Mechanical power (MP), as a new comprehensive index to evaluate the effect of mechanical ventilation (MV) on pulmonary respiratory mechanics, can reflect the overall energy transfer in the process of MV, and is closely related to the occurrence of lung injury and the prognosis of patients.Objective To examine the impact of individualized positive end-expiratory pressure (PEEP) guided by electrical impedance tomography (EIT) on the MP in patients undergoing robot-assisted laparoscopic surgery.Methods A secondary analysis of a previous randomized controlled study of 72 patients undergoing robotic hepatobiliary and pancreatic surgery was performed. PEEP settings of patients undergoing surgery were respectively conducted using EIT guidance (PEEPEIT group) and conventional methods (PEEP5 cmH2O group). Respiratory parameters of patients 10 minutes after induction, 60 minutes after PEEP titration with pneumoperitoneum and 10 minutes after deflation were screened from the data, including tidal volume (Vt), respiratory rate (f), peak airway pressure (Ppeak), plateau pressure (Pplat), respiratory compliance (Crs), driving pressure (DP), etc. MP and mechanical energy per breath (MEper breath) received by the respiratory system at different time points of both groups were calculated and compared.Results There were 48 cases in the PEEPEIT group, including 26 males and 22 females, with the mean age of 53.7±14.0 years, in the PEEP5 cmH2O group, there were 24 cases, including 10 males and 14 females, with the mean age of 57.3±14.5 years. No significant difference was found in age and gender between the two groups (P>0.05). The PEEPEIT group exhibited significantly lower MP than the PEEP5 cmH₂O group at all time points: before pneumoperitoneum (4.54± 1.53 J/min vs 5.49±1.23 J/min), during pneumoperitoneum (6.68±2.35 J/min vs 7.81±2.23 J/min), and after pneumoperitoneum (5.24±1.70 J/min vs 6.09±1.55 J/min) (all P<0.05). Crs was significantly higher in the PEEPEIT group compared to the PEEP5 cmH₂O group during pneumoperitoneum (44.27±11.33 mL/cmH₂O vs 31.88±6.58 mL/cmH₂O) and after pneumoperitoneum (63.56±13.06 mL/cmH₂O vs 48.13±10.59 mL/cmH₂O, both P<0.05). DP was significantly lower in the PEEPEIT group during pneumoperitoneum (11.50±2.08 cmH₂O vs 13.96±2.37 cmH₂O) and after pneumoperitoneum (7.60±1.92 cmH₂O vs 9.75±2.17 cmH₂O) (both P<0.05).Conclusion Individualized PEEP guided by EIT can reduce MP in patients undergoing robotic-assisted hepatobiliary and pancreatic surgery, which may be related to the optimization of Crs and DP.

     

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