CAJ | 학술논문

目的评价慢性阻塞性肺疾病(COPD)患者行肺叶切除术时低潮气量通气的效果.方法择期行肺叶切除术的COPD患者28例,年龄65～84岁,ASA Ⅱ或Ⅲ级,随机分为常规潮气量组(TV组,n=14)和低潮气量组(LV组,n=14).均于气管插管后行机械通气,参数设置:TV组潮气量(VT)为10 ml/kg,呼气末正压(PEEP)为0;LV组Vr为5～6 ml/kg,PEEP为0～5 cm H2O.采用旁气流法监测气道峰压(Ppeak)、气道平台压(Pplat)、气道阻力(Raw)及动态肺顺应性(Cd).于平卧位双肺通气10 min(T1)、侧卧位单肺通气90 min(T2)、术毕平卧位双肺通气10 min(T3)及术后24 h(T4)时取桡动脉血样,行血气分析,计算氧合指数(OI)、肺泡.动脉血氧分压差[P(A-a)O2]及呼吸指数(RI);取颈内静脉血样,测定血清肿瘤坏死因子-α(TNF-α)及白细胞介素-6(IL-6)的浓度.结果与T1时比较,2组T2-4时血清TNF-α及IL-6浓度升高(P<0.05);与TV组比较,LV组T2-4时血清TNF-α及IL-6浓度降低(P<0.05),T1-3时Ppeak及Raw降低,T2.3时Cd升高(P<0.05).T1-4时2组OI、RI及P(A-a)O2差异无统计学意义(P0.05).结论低VT,通气可通过降低炎性反应,减轻COPD患者肺叶切除术时机械通气诱发的肺损伤.
목적 평개만성조새성폐질병(COPD)환자행폐협절제술시저조기량통기적효과.방법 택기행폐협절제술적COPD환자28례,년령65～84세,ASA Ⅱ혹Ⅲ급,수궤분위상규조기량조(TV조,n=14)화저조기량조(LV조,n=14).균우기관삽관후행궤계통기,삼수설치:TV조조기량(VT)위10 ml/kg,호기말정압(PEEP)위0;LV조Vr위5～6 ml/kg,PEEP위0～5 cm H2O.채용방기류법감측기도봉압(Ppeak)、기도평태압(Pplat)、기도조력(Raw)급동태폐순응성(Cd).우평와위쌍폐통기10 min(T1)、측와위단폐통기90 min(T2)、술필평와위쌍폐통기10 min(T3)급술후24 h(T4)시취뇨동맥혈양,행혈기분석,계산양합지수(OI)、폐포.동맥혈양분압차[P(A-a)O2]급호흡지수(RI);취경내정맥혈양,측정혈청종류배사인자-α(TNF-α)급백세포개소-6(IL-6)적농도.결과 여T1시비교,2조T2-4시혈청TNF-α급IL-6농도승고(P<0.05);여TV조비교,LV조T2-4시혈청TNF-α급IL-6농도강저(P<0.05),T1-3시Ppeak급Raw강저,T2.3시Cd승고(P<0.05).T1-4시2조OI、RI급P(A-a)O2차이무통계학의의(P0.05).결론 저VT,통기가통과강저염성반응,감경COPD환자폐협절제술시궤계통기유발적폐손상.
Objective To investigate the effects of mechanical ventilation with lower tidal volume in patients with chronic obstructive pulmonary disease (COPD) undergoing elective lung resection. Methods Twenty-eight ASA II or m patients with COPD aged 65-84 yr undergoing elective lung resection were randomly divided into 2 groups (n=14 each):traditional tidal volume group (TV) and low tidal volume group (LV). The patients were premedicated with intramuscular atopinc 0.5 mg and phenobarbital 100 rag. Anesthesia was induced with midazolam, fentanyl and propofol. Vecuronium was used to facilitate insertion of double-lumen tube (DLT). Correct DLT position was confirmed by fiberoptic hronchoscopy. Anesthesia was maintained with continuous infusion of remifentanil, propofol and vccuronium and inhalation of 1%-2% sevoflurane. The patients were mechanically ventilated (I:E=1:2). Tidal volume (VT) was set at 10 ml/kg (PEEP=0) in group TV and at 5-6 ml/kg (PEEP =0-5 cm H2O) in group LV. Airway peak pressure (Ppeak), airway plateau pressure (Pplat), airway resistance (Raw) and dynamic lung compliance (Cd) were monitored by side stream spirometry. Arterial and venous blood samples were taken at 10 min of two-lung ventilation (TLV) in supine position (T1), at 90 min of one-lung ventilation (OLV) in lateral position (T2), at 10 min of two-lung ventilation in supine position after the end of operation (T3) and 24 h after operation (T4) for blood gas analysis and determination of serum concentrations of TNF-a and IL-6. PaO2/FiO2, P(A-a)O2 and P(A-a)O2/PaO2 were calculated. Results The serum concentrations of TNF-α and IL-6 were significantly increased at T2-4 as compared with the baseline at T1 in both groups. The serum concentrations of TNF-α and IL-6 at T2.4, Ppeak, Pplat and Raw at T1-3 were significantly lower and Cd at T2.3 was significantly higher in group LV than in group TV. There was no significant difference in PaO2/FiO2, P(A-a)O2 and P(A-a)O2/PaO2 at T1-4 between the 2 groups. Conclusion Mechanical ventilation with lower tidal volume can ameliorate the lung injury induced by mechanical ventilation through inhibition of inflammatory response in COPD patients undergoing lung resection.