个体化呼气末正压滴定对气腹头低位时呼吸和血流动力学参数的影响：一项随机交叉生理试验。

Effects of individualised positive end-expiratory pressure titration on respiratory and haemodynamic parameters during the Trendelenburg position with pneumoperitoneum: A randomised crossover physiologic trial.

机构信息

From the Department of Anaesthesiology and Critical Care Medicine (CB, LS, JJS, AQ, GB, MT, TL, JK), Department of Urology and Urosurgery, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Theodor-Kutzer-Ufer 1-3, Mannheim, Germany (PH, KFK), Department of Surgical Sciences and Integrated Diagnostics, University of Genoa (PP), Department of Anesthesiology and Critical Care - San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy (PP) and Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Rio de Janeiro, Brazil (PRMR).

出版信息

Eur J Anaesthesiol. 2023 Nov 1;40(11):817-825. doi: 10.1097/EJA.0000000000001894. Epub 2023 Aug 30.

DOI:10.1097/EJA.0000000000001894

PMID:37649211

Abstract

BACKGROUND

The Trendelenburg position with pneumoperitoneum during surgery promotes dorsobasal atelectasis formation, which impairs respiratory mechanics and increases lung stress and strain. Positive end-expiratory pressure (PEEP) can reduce pulmonary inhomogeneities and preserve end-expiratory lung volume (EELV), resulting in decreased inspiratory strain and improved gas-exchange. The optimal intraoperative PEEP strategy is unclear.

OBJECTIVES

To compare the effects of individualised PEEP titration strategies on set PEEP levels and resulting transpulmonary pressures, respiratory mechanics, gas-exchange and haemodynamics during Trendelenburg position with pneumoperitoneum.

DESIGN

Prospective, randomised, crossover single-centre physiologic trial.

SETTING

University hospital.

PATIENTS

Thirty-six patients receiving robot-assisted laparoscopic radical prostatectomy.

INTERVENTIONS

Randomised sequence of three different PEEP strategies: standard PEEP level of 5 cmH 2 O (PEEP 5 ), PEEP titration targeting a minimal driving pressure (PEEP ΔP ) and oesophageal pressure-guided PEEP titration (PEEP Poeso ) targeting an end-expiratory transpulmonary pressure ( PTP ) of 0 cmH 2 O.

MAIN OUTCOME MEASURES

The primary endpoint was the PEEP level when set according to PEEP ΔP and PEEP Poeso compared with PEEP of 5 cmH 2 O. Secondary endpoints were respiratory mechanics, lung volumes, gas-exchange and haemodynamic parameters.

RESULTS

PEEP levels differed between PEEP ΔP , PEEP Poeso and PEEP5 (18.0 [16.0 to 18.0] vs. 20.0 [18.0 to 24.0]vs. 5.0 [5.0 to 5.0] cmH 2 O; P < 0.001 each). End-expiratory PTP and lung volume were lower in PEEP ΔP compared with PEEP Poeso ( P = 0.014 and P < 0.001, respectively), but driving pressure, lung stress, as well as respiratory system and dynamic elastic power were minimised using PEEP ΔP ( P < 0.001 each). PEEP ΔP and PEEP Poeso improved gas-exchange, but PEEP Poeso resulted in lower cardiac output compared with PEEP 5 and PEEP ΔP .

CONCLUSION

PEEP ΔP ameliorated the effects of Trendelenburg position with pneumoperitoneum during surgery on end-expiratory PTP and lung volume, decreased driving pressure and dynamic elastic power, as well as improved gas-exchange while preserving cardiac output.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00028559, date of registration 2022/04/27). https://drks.de/search/en/trial/DRKS00028559.

摘要

背景

手术中采用头高脚低位并气腹会促进背侧基底肺不张的形成，这会损害呼吸力学并增加肺应力和应变。呼气末正压（PEEP）可以减少肺不均匀性并保持呼气末肺容积（EELV），从而降低吸气应变并改善气体交换。术中最佳 PEEP 策略尚不清楚。

目的

比较个体化 PEEP 滴定策略对设定 PEEP 水平和相应跨肺压、呼吸力学、气体交换和血流动力学的影响，这些影响与头高脚低位并气腹有关。

设计

前瞻性、随机、交叉单中心生理试验。

地点

大学医院。

患者

接受机器人辅助腹腔镜前列腺根治术的 36 名患者。

干预

随机序列的三种不同 PEEP 策略：标准 PEEP 水平为 5cmH2O（PEEP5）、以最小驱动压为目标的 PEEP 滴定（PEEPΔP）和以呼气末跨肺压（PTP）为目标的食管压引导 PEEP 滴定（PEEP Poeso）（0cmH2O）。

主要观察指标

主要终点是根据 PEEPΔP 和 PEEP Poeso 设定的 PEEP 水平与 PEEP5 相比的差异。次要终点是呼吸力学、肺容积、气体交换和血流动力学参数。

结果

PEEPΔP、PEEP Poeso 和 PEEP5 之间的 PEEP 水平存在差异（18.0[16.0 至 18.0]比 20.0[18.0 至 24.0]比 5.0[5.0 至 5.0]cmH2O；P<0.001 各）。与 PEEP Poeso 相比，PEEPΔP 时的呼气末 PTP 和肺容积较低（P=0.014 和 P<0.001，分别），但使用 PEEPΔP 时，驱动压、肺应力以及呼吸系统和动态弹性功率最小化（P<0.001 各）。PEEPΔP 和 PEEP Poeso 改善了气体交换，但与 PEEP5 和 PEEPΔP 相比，PEEP Poeso 导致心输出量降低。