Shi Zhi-Guo, Geng Wan-Ming, Gao Guang-Kuo, Wang Chun, Liu Wei
Department of Anesthesia, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China.
J Thorac Dis. 2019 Feb;11(2):488-494. doi: 10.21037/jtd.2019.01.41.
The present study aims to evaluate the influence of alveolar recruitment strategy (ARS) and positive end-expiratory pressure (PEEP) combined with autoflow on respiratory mechanics, the oxygen index (OI), pulmonary shut [Qs/Qt(%)], and the concentrations of IL-6 and TNF-α in venous blood after surgery in obese patients who experienced thoracic surgery with one-lung ventilation (OLV).
A total of 36 obese patients with ASAII-III degree, who experienced selective pulmonary lobectomy, were within 36-74 years old, and had a BMI of 30-40 kg/m, were randomly divided into two groups: control group (C group) and protective ventilation group (P group). In the P group, ARS was given once when OLV began. Then, ventilation at 7 mmHg of PEEP and autoflow were given. The P before OLV (T), at 30 minutes after OLV (T), and at the 5 minutes after two-lung ventilation (TLV) (T), and the changes of P and Cdyn were recorded. Then, arteriovenous blood was drawn at T, T, T and T (6 hours after the operation), blood-gas indicators, including SPO, PaCO and PaO, were measured, and the value of Qs/Qt(%) was calculated. Afterwards, venous blood was collected at T and T (18 hours after surgery), and the concentrations of IL-6 and TNF-α were detected. The clinical pulmonary infection score (CPIS) was determined at the first day and seventh day after the operation.
In both groups, Cdyn and OI decreased, while P, P and Qs/Qt(%) increased (P<0.05) at T, when compared with those at T. At T and T, P and P decreased (P<0.05) in the P group, when compared with the C group. At T, T and T, OI increased (P<0.05) in the P group, when compared with the C group. At T, T and T, PaCO and Qs/Qt(%) decreased in the P group, when compared with the C group. The concentrations of IL-6 and TNF-α decreased in the P group, when compared with the C group.
The ventilation model of ARS and PEEP combined with autoflow can better reduce airway pressure and the production of injurious inflammatory cytokines in blood in obese patients. Furthermore, it can reduce Qs/Qt during and at 6 hours after thoracotomy, improve OI and maintain the acid-base balance of the internal environment, which may be applied in clinical work. This brings new enlightenment and needs to be clarified through further studies.
本研究旨在评估肺泡复张策略（ARS）和呼气末正压（PEEP）联合自动流量对肥胖患者单肺通气（OLV）行胸科手术后呼吸力学、氧合指数（OI）、肺内分流[Qs/Qt(%)]以及静脉血中白细胞介素-6（IL-6）和肿瘤坏死因子-α（TNF-α）浓度的影响。
选取36例年龄在36 - 74岁、ASAII - III级、体重指数（BMI）为30 - 40 kg/m²、择期行肺叶切除术的肥胖患者，随机分为两组：对照组（C组）和肺保护通气组（P组）。P组在OLV开始时给予一次ARS，然后给予7 mmHg的PEEP和自动流量通气。记录OLV前（T₁）、OLV后30分钟（T₂）、双肺通气（TLV）后5分钟（T₃）的气道峰压（P）和动态顺应性（Cdyn）变化。分别于T₁、T₂、T₃及术后6小时（T₄）采集动静脉血，检测血气指标，包括血氧饱和度（SPO₂）、动脉血二氧化碳分压（PaCO₂）和动脉血氧分压（PaO₂），并计算Qs/Qt(%)。术后18小时（T₅）采集静脉血，检测IL-6和TNF-α浓度。术后第1天和第7天测定临床肺部感染评分（CPIS）。
两组在T₂时，与T₁相比，Cdyn和OI均降低，而P、P₂和Qs/Qt(%)均升高（P<0.05）。在T₂和T₃时，P组的P和P₂较C组降低（P<0.05）。在T₂、T₃和T₄时，P组的OI较C组升高（P<0.05）。在T₂、T₃和T₄时，P组的PaCO₂和Qs/Qt(%)较C组降低。与C组相比，P组IL-6和TNF-α浓度降低。
ARS与PEEP联合自动流量的通气模式能更好地降低肥胖患者气道压力和血液中损伤性炎症细胞因子的产生。此外，它能降低开胸术中及术后6小时的Qs/Qt，改善OI并维持内环境酸碱平衡，可能应用于临床工作。这带来了新的启示，有待进一步研究阐明。
