CAJ | 학술논문

目的针对腹腔镜术后肺功能损害的高发人群肥胖患者,从预防气压伤角度研究机械通气时多呼吸参数(三因素三水平)的组合选用,以求减小或避免多呼吸参数的不当组合引起的较高气道压,从而获得"较低气道压力同时又能维持良好通气"的肺保护效应,以完善肥胖患者腹腔镜术后呼吸功能障碍的预防措施.方法按公认的"30≤BMI<40"肥胖指数筛选ASAⅠ～Ⅱ肥胖患者,随机作为样本病例;取麻醉机上最基本的呼吸频率(f)、潮气量(VT)、吸呼比(I:E)三参数作为三因素A、B、C,取f=15、12、9次/min,VT=8、10、12 mL/kg,I:E=1:2.5、1:2.0、1:1.5为相应的三水平;选用L9(3~4)K=3重复正交试验设计表归纳数据,检验、分析各因素及水平变化影响呼末二氧化碳分压(P_(ET)CO_2)、气道峰压(PIP)、气道平均压(P_(mean))和内源性呼末气道压(PEEPi)的统计学意义.采用方差分析方法分析数据.结果本研究9组试验的(k=3,n=27)腹腔镜手术全麻中,患者生命体征平稳,h SpO_2 100%.整个实验过程中PEEPi监测值为3 cmH_2O.三因素三水平呼吸参数间的不同组合对P_(ET)CO_2、PIP、P_(mean)的影响如下:①对P_(ET)CO_2的影响:f、VT各水平的选用均有显著统计学意义(P<0.01);I:E的选用无统计学意义(P>0.05).②对PIP的影响:f的改变有统计学意义(0.01<P<0.05);VT、I:E的改变均有显著统计学意义(P<0.01).③对P_(mean)的影响,三因素三水平呼吸参数的选用均有显著统计学意义(P<0.01).结论多呼吸参数的最佳组合方式是A3B1C2,即f=9次/min、VT=8 mL/kg、I:E=1:2.0,非小潮气量快频率,也非大潮气量慢频率.如此才能获得肥胖患者全麻气腹状态"较低气道压力同时又能维持良好通气"的肺保护效应.值得注意的是:①I:E对气道压(PIP、P_(mean))的影响,即对肺保护的影响有着重要意义;②I:E对PIP和P_(mean)的影响具有相向性.
목적 침대복강경술후폐공능손해적고발인군비반환자,종예방기압상각도연구궤계통기시다호흡삼수(삼인소삼수평)적조합선용,이구감소혹피면다호흡삼수적불당조합인기적교고기도압,종이획득"교저기도압력동시우능유지량호통기"적폐보호효응,이완선비반환자복강경술후호흡공능장애적예방조시.방법 안공인적"30≤BMI<40"비반지수사선ASAⅠ～Ⅱ비반환자,수궤작위양본병례;취마취궤상최기본적호흡빈솔(f)、조기량(VT)、흡호비(I:E)삼삼수작위삼인소A、B、C,취f=15、12、9차/min,VT=8、10、12 mL/kg,I:E=1:2.5、1:2.0、1:1.5위상응적삼수평;선용L9(3~4)K=3중복정교시험설계표귀납수거,검험、분석각인소급수평변화영향호말이양화탄분압(P_(ET)CO_2)、기도봉압(PIP)、기도평균압(P_(mean))화내원성호말기도압(PEEPi)적통계학의의.채용방차분석방법분석수거.결과 본연구9조시험적(k=3,n=27)복강경수술전마중,환자생명체정평은,h SpO_2 100%.정개실험과정중PEEPi감측치위3 cmH_2O.삼인소삼수평호흡삼수간적불동조합대P_(ET)CO_2、PIP、P_(mean)적영향여하:①대P_(ET)CO_2적영향:f、VT각수평적선용균유현저통계학의의(P<0.01);I:E적선용무통계학의의(P>0.05).②대PIP적영향:f적개변유통계학의의(0.01<P<0.05);VT、I:E적개변균유현저통계학의의(P<0.01).③대P_(mean)적영향,삼인소삼수평호흡삼수적선용균유현저통계학의의(P<0.01).결론 다호흡삼수적최가조합방식시A3B1C2,즉f=9차/min、VT=8 mL/kg、I:E=1:2.0,비소조기량쾌빈솔,야비대조기량만빈솔.여차재능획득비반환자전마기복상태"교저기도압력동시우능유지량호통기"적폐보호효응.치득주의적시:①I:E대기도압(PIP、P_(mean))적영향,즉대폐보호적영향유착중요의의;②I:E대PIP화P_(mean)적영향구유상향성.
Objective Pulmonary dysfunction is common in the obese patients after laparoscopic surgery. To reduce or avoid this complication caused by improper combination of mechanical ventilatory parameters,we conducted the following trial of 3 factors with 3 levels of mechanical ventilation in order to explore the optimal combination with low airway pressure. Methods Patients were randomly allocated into 9 groups (k=3,n=27) according to the "30≤BMI<40" obesity index (ASAⅠ-Ⅱ). Anesthesia machine parameters were set as follows: respiratory frequency (f), tidal volume (VT), respiratory ratio (I:E) as the three factors of A, B, C, with 3 levels of f=15, 12, 9 (bpm), VT=8, 10, 12 (mL/kg), I:E=1:2.5, 1:2.0, 1:1.5. By using L9(3~4)K=3 repeat orthogonal experimental design and analysis table, the variable factors that affect the respiratory index such as the end tidal carbon dioxide pressure (P_(ET)CO_2), peak airway pressure (PIP), mean airway pressure (P_(mean)), and the end of endogenous airway pressure (PEEPi) were analyzed. Results In this study, 27 cases undergoing laparoscopic surgery under general anesthesia were allocated into 9 experimental groups. The hemodynamics of these patients was stable, SPO_2 was kept at 100 percent during the operation. The results of different combinations were described as follows: ①P_(ET)CO_2: f and VT with different level had great impact on P_(ET)CO_2 (P<0.01), I:E had no significant difference in three levels (P>0.05);② PIP: f had great effect on PIP (P<0.05);VT and I:E in three levels also had significant effect on PIP(P<0.01);③ P_(mean): all the ventilation parameters with different combination had significant effect on P_(mean)(P<0.01). Conclusions The best combination of respiratory parameters is A3B1C2, i.e., f=9 bpm, VT=8 mL/kg, and I:E=1:2.0, which indicates that neither small tidal volume and faster frequency, nor slow frequency large tidal volume is a good choice. In order to let obese patients under general anesthesia obtain the best lung protective effect by low airway pressure with good ventilation, it is worth noting that: ①I:E has a great effect on airway pressure (PIP, P_(mean)), which is important for lung protection;②I:E has the opposite effect on PIP and P_(mean).