Yoon Hyun-Kyu, Kim Bo Rim, Yoon Susie, Jeong Young Hyun, Ku Ja Hyeon, Kim Won Ho
Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul 03080, Korea.
Department of Urology, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul 03080, Korea.
J Clin Med. 2021 Feb 19;10(4):850. doi: 10.3390/jcm10040850.
For patients undergoing robot-assisted radical prostatectomy, the pneumoperitoneum with a steep Trendelenburg position could worsen intraoperative respiratory mechanics and result in postoperative atelectasis. We investigated the effects of individualized positive end-expiratory pressure (PEEP) on postoperative atelectasis, evaluated using lung ultrasonography. Sixty patients undergoing robot-assisted radical prostatectomy were randomly allocated into two groups. Individualized groups ( = 30) received individualized PEEP determined by a decremental PEEP trial using 20 to 7 cm HO, aiming at maximizing respiratory compliance, whereas standardized groups ( = 30) received a standardized PEEP of 7 cm HO during the pneumoperitoneum. Ultrasound examination was performed on 12 sections of thorax, and the lung ultrasound score was measured as 0-3 by considering the number of B lines and the degree of subpleural consolidation. The primary outcome was the difference between the lung ultrasound scores measured before anesthesia induction and just after extubation in the operating room. An increase in the difference means the development of atelectasis. The optimal PEEP in the individualized group was determined as the median (interquartile range) 14 (12-18) cm HO. Compared with the standardized group, the difference in the lung ultrasound scores was significantly smaller in the individualized group (-0.5 ± 2.7 vs. 6.0 ± 2.9, mean difference -6.53, 95% confidence interval (-8.00 to -5.07), < 0.001), which means that individualized PEEP was effective to reduce atelectasis. The lung ultrasound score measured after surgery was significantly lower in the individualized group than the standardized group (8.1 ± 5.7 vs. 12.2 ± 4.2, mean difference -4.13, 95% confidence interval (-6.74 to -1.53), = 0.002). However, the arterial partial pressure of the oxygen/fraction of inspired oxygen levels during the surgery showed no significant time-group interaction between the two groups in repeated-measures analysis of variance ( = 0.145). The incidence of a composite of postoperative respiratory complications was comparable between the two groups. Individualized PEEP determined by maximal respiratory compliance during the pneumoperitoneum and steep Trendelenburg position significantly reduced postoperative atelectasis, as evaluated using lung ultrasonography. However, the clinical significance of this finding should be evaluated by a larger clinical trial.
对于接受机器人辅助根治性前列腺切除术的患者，气腹联合头低脚高位可能会使术中呼吸力学恶化，并导致术后肺不张。我们研究了个体化呼气末正压通气（PEEP）对术后肺不张的影响，采用肺部超声进行评估。60例接受机器人辅助根治性前列腺切除术的患者被随机分为两组。个体化组（n = 30）通过使用20至7 cmH₂O的递减PEEP试验确定个体化PEEP，目标是使呼吸顺应性最大化，而标准化组（n = 30）在气腹期间接受7 cmH₂O的标准化PEEP。对胸部12个节段进行超声检查，并根据B线数量和胸膜下实变程度将肺部超声评分测量为0 - 3分。主要结局是麻醉诱导前和手术室拔管后即刻测量的肺部超声评分之间的差异。差异增加意味着肺不张的发生。个体化组的最佳PEEP确定为中位数（四分位间距）14（12 - 18）cmH₂O。与标准化组相比，个体化组的肺部超声评分差异显著更小（-0.5 ± 2.7 vs. 6.0 ± 2.9，平均差异 -6.53，95%置信区间（-8.00至 -5.07），P < 0.001），这意味着个体化PEEP对减少肺不张有效。个体化组术后测量的肺部超声评分显著低于标准化组（8.1 ± 5.7 vs. 12.2 ± 4.2，平均差异 -4.13，95%置信区间（-6.74至 -1.53），P = 0.002）。然而，在重复测量方差分析中，两组手术期间动脉血氧分压/吸入氧分数水平未显示出显著的时间 - 组交互作用（P = 0.145）。两组术后呼吸并发症综合发生率相当。气腹联合头低脚高位期间通过最大呼吸顺应性确定的个体化PEEP，采用肺部超声评估时显著降低了术后肺不张。然而，这一发现的临床意义应通过更大规模的临床试验进行评估。
