保护性通气策略是否能降低肺癌手术后肺部并发症的风险？一项随机对照试验。

Does a protective ventilation strategy reduce the risk of pulmonary complications after lung cancer surgery?: a randomized controlled trial.

机构信息

Department of Anesthesiology and Pain Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea.

出版信息

Chest. 2011 Mar;139(3):530-537. doi: 10.1378/chest.09-2293. Epub 2010 Sep 9.

DOI:10.1378/chest.09-2293

PMID:20829341

Abstract

BACKGROUND

Protective ventilation strategy has been shown to reduce ventilator-induced lung injury in patients with ARDS. In this study, we questioned whether protective ventilatory settings would attenuate lung impairment during one-lung ventilation (OLV) compared with conventional ventilation in patients undergoing lung resection surgery.

METHODS

One hundred patients with American Society of Anesthesiology physical status 1 to 2 who were scheduled for an elective lobectomy were enrolled in the study. During OLV, two different ventilation strategies were compared. The conventional strategy (CV group, n=50) consisted of FIO2 1.0, tidal volume (Vt) 10 mL/kg, zero end-expiratory pressure, and volume-controlled ventilation, whereas the protective strategy (PV group, n=50) consisted of FIO2 0.5, Vt 6 mL/kg, positive end-expiratory pressure 5 cm H2O, and pressure-controlled ventilation. The composite primary end point included PaO2/FIO2<300 mm Hg and/or the presence of newly developed lung lesions (lung infiltration and atelectasis) within 72 h of the operation. To monitor safety during OLV, oxygen saturation by pulse oximeter (SpO2), PaCO2, and peak inspiratory pressure (PIP) were repeatedly measured.

RESULTS

During OLV, although 58% of the PV group needed elevated FIO2 to maintain an SpO2>95%, PIP was significantly lower than in the CV group, whereas the mean PaCO2 values remained at 35 to 40 mm Hg in both groups. Importantly, in the PV group, the incidence of the primary end point of pulmonary dysfunction was significantly lower than in the CV group (incidence of PaO2/FIO2<300 mm Hg, lung infiltration, or atelectasis: 4% vs 22%, P<.05).

CONCLUSION

Compared with the traditional large Vt and volume-controlled ventilation, the application of small Vt and PEEP through pressure-controlled ventilation was associated with a lower incidence of postoperative lung dysfunction and satisfactory gas exchange.

TRIAL REGISTRY

Australian New Zealand Clinical Trials Registry; No.: ACTRN12609000861257; URL: www.anzctr.org.au.

摘要

背景

保护性通气策略已被证明可减少 ARDS 患者的呼吸机相关性肺损伤。在这项研究中，我们质疑在接受肺切除术的患者中，与常规通气相比，保护性通气设置是否会在单肺通气（OLV）期间减轻肺损伤。

方法

本研究纳入了 100 名美国麻醉医师学会身体状况 1 至 2 级、计划行肺叶切除术的患者。在 OLV 期间，比较了两种不同的通气策略。常规策略（CV 组，n=50）包括 FIO2 1.0、潮气量（Vt）10 mL/kg、零呼气末正压和容量控制通气，而保护性策略（PV 组，n=50）包括 FIO2 0.5、Vt 6 mL/kg、呼气末正压 5 cm H2O 和压力控制通气。复合主要终点包括术后 72 小时内 PaO2/FIO2<300mmHg 和/或新出现的肺部病变（肺浸润和肺不张）。为了监测 OLV 期间的安全性，反复测量脉搏血氧饱和度（SpO2）、PaCO2 和吸气峰压（PIP）。

结果

在 OLV 期间，虽然 58%的 PV 组需要提高 FIO2 以维持 SpO2>95%，但 PIP 明显低于 CV 组，而两组的平均 PaCO2 值均保持在 35 至 40mmHg。重要的是，在 PV 组，肺部功能障碍的主要终点发生率明显低于 CV 组（PaO2/FIO2<300mmHg、肺浸润或肺不张的发生率：4% vs 22%，P<.05）。