Gao Shugeng, Zhang Zhongheng, Brunelli Alessandro, Chen Chang, Chen Chun, Chen Gang, Chen Haiquan, Chen Jin-Shing, Cassivi Stephen, Chai Ying, Downs John B, Fang Wentao, Fu Xiangning, Garutti Martínez I, He Jianxing, He Jie, Hu Jian, Huang Yunchao, Jiang Gening, Jiang Hongjing, Jiang Zhongmin, Li Danqing, Li Gaofeng, Li Hui, Li Qiang, Li Xiaofei, Li Yin, Li Zhijun, Liu Chia-Chuan, Liu Deruo, Liu Lunxu, Liu Yongyi, Ma Haitao, Mao Weimin, Mao Yousheng, Mou Juwei, Ng Calvin Sze Hang, Petersen René H, Qiao Guibin, Rocco Gaetano, Ruffini Erico, Tan Lijie, Tan Qunyou, Tong Tang, Wang Haidong, Wang Qun, Wang Ruwen, Wang Shumin, Xie Deyao, Xue Qi, Xue Tao, Xu Lin, Xu Shidong, Xu Songtao, Yan Tiansheng, Yu Fenglei, Yu Zhentao, Zhang Chunfang, Zhang Lanjun, Zhang Tao, Zhang Xun, Zhao Xiaojing, Zhao Xuewei, Zhi Xiuyi, Zhou Qinghua
Department of Thoracic Surgical Oncology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Cancer Center, Beijing 100021, China.
Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China.
J Thorac Dis. 2017 Sep;9(9):3246-3254. doi: 10.21037/jtd.2017.08.166.
Patients undergoing lobectomy are at significantly increased risk of lung injury. One-lung ventilation is the most commonly used technique to maintain ventilation and oxygenation during the operation. It is a challenge to choose an appropriate mechanical ventilation strategy to minimize the lung injury and other adverse clinical outcomes. In order to understand the available evidence, a systematic review was conducted including the following topics: (I) protective ventilation (PV); (II) mode of mechanical ventilation [e.g., volume controlled (VCV) versus pressure controlled (PCV)]; (III) use of therapeutic hypercapnia; (IV) use of alveolar recruitment (open-lung) strategy; (V) pre-and post-operative application of positive end expiratory pressure (PEEP); (VI) Inspired Oxygen concentration; (VII) Non-intubated thoracoscopic lobectomy; and (VIII) adjuvant pharmacologic options. The recommendations of class II are non-intubated thoracoscopic lobectomy may be an alternative to conventional one-lung ventilation in selected patients. The recommendations of class IIa are: (I) Therapeutic hypercapnia to maintain a partial pressure of carbon dioxide at 50-70 mmHg is reasonable for patients undergoing pulmonary lobectomy with one-lung ventilation; (II) PV with a tidal volume of 6 mL/kg and PEEP of 5 cmHO are reasonable methods, based on current evidence; (III) alveolar recruitment [open lung ventilation (OLV)] may be beneficial in patients undergoing lobectomy with one-lung ventilation; (IV) PCV is recommended over VCV for patients undergoing lung resection; (V) pre- and post-operative CPAP can improve short-term oxygenation in patients undergoing lobectomy with one-lung ventilation; (VI) controlled mechanical ventilation with I:E ratio of 1:1 is reasonable in patients undergoing one-lung ventilation; (VII) use of lowest inspired oxygen concentration to maintain satisfactory arterial oxygen saturation is reasonable based on physiologic principles; (VIII) Adjuvant drugs such as nebulized budesonide, intravenous sivelestat and ulinastatin are reasonable and can be used to attenuate inflammatory response.
接受肺叶切除术的患者发生肺损伤的风险显著增加。单肺通气是手术期间维持通气和氧合最常用的技术。选择合适的机械通气策略以尽量减少肺损伤和其他不良临床结局是一项挑战。为了了解现有证据，进行了一项系统综述，包括以下主题：（I）保护性通气（PV）；（II）机械通气模式[例如，容量控制通气（VCV）与压力控制通气（PCV）]；（III）治疗性高碳酸血症的应用；（IV）肺泡复张（肺开放）策略的应用；（V）呼气末正压（PEEP）的术前和术后应用；（VI）吸入氧浓度；（VII）非插管胸腔镜肺叶切除术；以及（VIII）辅助药物选择。II类推荐为非插管胸腔镜肺叶切除术可能是特定患者传统单肺通气的替代方法。IIa类推荐为：（I）对于接受单肺通气的肺叶切除术患者，将二氧化碳分压维持在50 - 70 mmHg的治疗性高碳酸血症是合理的；（II）根据现有证据，潮气量为6 mL/kg和PEEP为5 cmH₂O的PV是合理的方法；（III）肺泡复张[肺开放通气（OLV）]可能对接受单肺通气的肺叶切除术患者有益；（IV）对于接受肺切除术的患者，推荐使用PCV而非VCV；（V）术前和术后持续气道正压通气（CPAP）可改善接受单肺通气的肺叶切除术患者的短期氧合；（VI）对于接受单肺通气的患者，采用吸气与呼气比为1:1的控制机械通气是合理的；（VII）根据生理原则，使用最低吸入氧浓度以维持满意的动脉血氧饱和度是合理的；（VIII）雾化布地奈德、静脉注射西维来司他和乌司他丁等辅助药物是合理的，可用于减轻炎症反应。
