CAJ | 학술논문

背景与目的：部分拟行肺叶切除术的患者术前可能存在明显的通气功能障碍，术中单肺通气时如采用容量控制(volume-controlled，VC)通气模式可能会诱发肺损伤。压力调节容量控制(pressure-regulated volume controlled，PRVC)通气模式是一新型通气模式，可减少呼吸机相关肺损伤的发生。本研究拟探讨肺叶切除术中单肺通气时应用PRVC模式对患者气道压、氧合指数、肺内炎症指标以及预后的影响。方法：采用随机数字表法将40例ASAⅡ~Ⅲ、术前检查提示肺功能中-重度障碍、择期行肺叶切除术的患者随机分为VC组和PRVC组，每组20例。单肺通气期间，VC组先采用PRVC模式通气5 min，而后转为VC模式通气；而PRVC组则先采用VC模式通气5 min，然后再转为PRVC模式通气，直至手术结束。更改模式时不改变呼吸机参数。记录两组患者在不同通气模式下的气道峰压、气道平台压、肺静态顺应性、血气分析结果以及血流动力学的变化。单肺通气结束时，收集患者通气侧肺肺泡灌洗液(bronchoalveolar lavage fluid，BALF)以及血清学标本，分别测量TNF-α、IL-1β、IL-6和IL-8，记录患者术后肺部并发症情况及住院时间。结果：与VC模式相比，应用PRVC模式后气道压明显降低(P<0.01)，肺静态顺应性明显升高(P<0.05)，但两组间术中血气分析结果、血流动力学参数以及术后肺部并发症方面差异无统计学意义(P>0.05)。PRVC组患者BALF中TNF-α、IL-1β和IL-6水平均明显低于VC组(P<0.05)，但两组患者血清学炎症因子水平差异无统计学意义(P>0.05)。结论：对于术前肺功能不佳的拟行肺叶切除术的患者，术中单肺通气期间采用PRVC通气模式可有效降低气道压、减少肺内炎症因子的分泌，是一种安全有效的保护性通气模式。
배경여목적：부분의행폐협절제술적환자술전가능존재명현적통기공능장애，술중단폐통기시여채용용량공제(volume-controlled，VC)통기모식가능회유발폐손상。압력조절용량공제(pressure-regulated volume controlled，PRVC)통기모식시일신형통기모식，가감소호흡궤상관폐손상적발생。본연구의탐토폐협절제술중단폐통기시응용PRVC모식대환자기도압、양합지수、폐내염증지표이급예후적영향。방법：채용수궤수자표법장40례ASAⅡ~Ⅲ、술전검사제시폐공능중-중도장애、택기행폐협절제술적환자수궤분위VC조화PRVC조，매조20례。단폐통기기간，VC조선채용PRVC모식통기5 min，이후전위VC모식통기；이PRVC조칙선채용VC모식통기5 min，연후재전위PRVC모식통기，직지수술결속。경개모식시불개변호흡궤삼수。기록량조환자재불동통기모식하적기도봉압、기도평태압、폐정태순응성、혈기분석결과이급혈류동역학적변화。단폐통기결속시，수집환자통기측폐폐포관세액(bronchoalveolar lavage fluid，BALF)이급혈청학표본，분별측량TNF-α、IL-1β、IL-6화IL-8，기록환자술후폐부병발증정황급주원시간。결과：여VC모식상비，응용PRVC모식후기도압명현강저(P<0.01)，폐정태순응성명현승고(P<0.05)，단량조간술중혈기분석결과、혈류동역학삼수이급술후폐부병발증방면차이무통계학의의(P>0.05)。PRVC조환자BALF중TNF-α、IL-1β화IL-6수평균명현저우VC조(P<0.05)，단량조환자혈청학염증인자수평차이무통계학의의(P>0.05)。결론：대우술전폐공능불가적의행폐협절제술적환자，술중단폐통기기간채용PRVC통기모식가유효강저기도압、감소폐내염증인자적분비，시일충안전유효적보호성통기모식。
Background and purpose:Obvious pulmonary dysfunction may exsist preoperatively in part of the patients undergoing pulmonary lobectomy. Volume-controlled ventilation (VC) during one-lung ventilation (OLV) may lead to lung injury in lung cancer patients with preoperative pulmonary dysfunction. However, pressure-regulated volume-controlled (PRVC) ventilation mode is a new type of ventilation mode, and can alleviate ventilation-induced lung injury. This study explored the effect of PRVC on respiratory mechanics, oxygenation index, pulmonary inlfam-matory response, and clinical outcomes in patients undergoing pulmonary lobectomy during OLV compared with VC mode.Methods:Forty ASAⅡ-Ⅲ patients with moderate to severe pulmonary dysfunction undergoing pulmonary lobectomy were randomly divided into group VC and group PRVC (n=20).PRVC ventilation mode was performed for patients in group VC during the ifrst 5 minutes after OLV, and then ventilation mode was switched to VC ventilation mode till the end of surgery. In the other group, ventilation modes were performed in reverse order. Ventilation settings remained unchanged when ventilation mode was switched. Respiratory mechanics, static lung compliance, hemody-namic parameters and arterial blood gas were obtained during the surgery. Blood samples and bronchoalveolar lavage (BALF) in ventilated lung were collected to determine the level of TNF-α, IL-1β, IL-6 and IL-8 at the end of surgery.Results:Both the peak expiratory pressure and static lung compliance in group PRVC were signiifcantly lower than those in group VC (P<0.01). However, there were no statistical difference in hemodynamic parameters (heart rate and blood pressure) and arterial blood gas analysis (pH,paO2andpaCO2) between the two groups during OLV, as well as postoperative pulmonary complications and length of hospital stay. The levels of TNF-α, IL-1β and IL-6 in BALF in group PRVC were signiifcantly lower than those in group VC (P<0.05), while there was no difference in blood sample. Conclusion:PRVC mode during OLV may relieve the extravagant airway pressure and then reduce the release of inlfammatory factors in ventilation lung, which might prevent acute lung injury induced by lung barotraumas, especially for those patients with pulmonary dysfunction preoperatively. Therefore, PRVC mode is a safe and effective ventilation mode for high-risk patients undergoing pulmonary lobectomy.