Department of Anesthesiology, Intensive Care and Pain Therapy, IRCCS Regina Elena National Cancer Institute, Rome, Italy.
Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
J Clin Anesth. 2024 Nov;98:111569. doi: 10.1016/j.jclinane.2024.111569. Epub 2024 Aug 5.
During laparoscopic surgery, the role of PEEP to improve outcome is controversial. Mechanistically, PEEP benefits depend on the extent of alveolar recruitment, which prevents ventilator-induced lung injury by reducing lung dynamic strain. The hypotheses of this study were that pneumoperitoneum-induced aeration loss and PEEP-induced recruitment are inter-individually variable, and that the recruitment-to-inflation ratio (R/I) can identify patients who benefit from PEEP in terms of strain reduction.
Sequential study.
Operating room.
Seventeen ASA I-III patients receiving robot-assisted prostatectomy during Trendelenburg pneumoperitoneum.
Patients underwent end-expiratory lung volume (EELV) and respiratory/lung/chest wall mechanics (esophageal manometry and inspiratory/expiratory occlusions) assessment at PEEP = 0 cmHO before and after pneumoperitoneum, at PEEP = 4 and 12 cmHO during pneumoperitoneum. Pneumoperitoneum-induced derecruitment and PEEP-induced recruitment were assessed through a simplified method based on multiple pressure-volume curve. Dynamic and static strain changes were evaluated. R/I between 12 and 4 cmHO was assessed from EELV. Inter-individual variability was rated with the ratio of standard deviation to mean (CoV).
Pneumoperitoneum reduced EELV by (median [IqR]) 410 mL [80-770] (p < 0.001) and increased dynamic strain by 0.04 [0.01-0.07] (p < 0.001), with high inter-individual variability (CoV = 70% and 88%, respectively). Compared to PEEP = 4 cmHO, PEEP = 12 cmHO yielded variable amount of recruitment (139 mL [96-366] CoV = 101%), causing different extent of dynamic strain reduction (median decrease 0.02 [0.01-0.04], p = 0.002; CoV = 86%) and static strain increases (median increase 0.05 [0.04-0.07], p = 0.01, CoV = 33%). R/I (1.73 [0.58-3.35]) estimated the decrease in dynamic strain (p ≤0.001, r = -0.90) and the increase in static strain (p = 0.009, r = -0.73) induced by PEEP, while PEEP-induced changes in respiratory and lung mechanics did not.
Trendelenburg pneumoperitoneum yields variable derecruitment: PEEP capability to revert these phenomena varies significantly among individuals. High R/I identifies patients in whom higher PEEP mostly reduces dynamic strain with limited static strain increases, potentially allowing individualized settings.
在腹腔镜手术中，PEEP 改善结局的作用存在争议。从机制上讲，PEEP 的获益取决于肺泡复张的程度，通过减少肺动态应变，PEEP 可预防呼吸机引起的肺损伤。本研究的假设是，气腹引起的通气损失和 PEEP 引起的复张在个体间是不同的，并且复张/充气比（R/I）可以识别出从减少应变中获益的患者。
序贯研究。
手术室。
17 名接受机器人辅助前列腺切除术的 ASA I-III 患者，在头高脚低位气腹期间。
患者在气腹前和气腹后在 PEEP = 0 cmHO 时接受呼气末肺容积（EELV）和呼吸/肺/胸壁力学（食管测压和吸气/呼气闭塞）评估，在气腹时 PEEP = 4 和 12 cmHO。通过基于多压力-容积曲线的简化方法评估气腹引起的去复张和 PEEP 引起的复张。评估动态和静态应变变化。EELV 评估 12 至 4 cmHO 之间的 R/I。用标准差与平均值的比值（CoV）来评价个体间的变异性。
气腹使 EELV 减少（中位数[IQR]）410 毫升[80-770]（p < 0.001），使动态应变增加 0.04[0.01-0.07]（p < 0.001），个体间变异性高（CoV 分别为 70%和 88%）。与 PEEP = 4 cmHO 相比，PEEP = 12 cmHO 产生不同程度的复张（139 毫升[96-366]CoV = 101%），导致不同程度的动态应变减少（中位数减少 0.02[0.01-0.04]，p = 0.002；CoV = 86%）和静态应变增加（中位数增加 0.05[0.04-0.07]，p = 0.01，CoV = 33%）。R/I（1.73[0.58-3.35]）估计了 PEEP 引起的动态应变的降低（p≤0.001，r=-0.90）和静态应变的增加（p=0.009，r=-0.73），而 PEEP 引起的呼吸和肺力学的变化则没有。
头高脚低位气腹引起的复张程度不同：PEEP 恢复这些现象的能力在个体间差异很大。高 R/I 可识别出大多数 PEEP 主要降低动态应变，而静态应变增加有限的患者，这可能允许进行个体化设置。
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