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呼气末正压通气并头高足低俯卧位对伴有吸入性肺损伤灼伤患者全麻中呼吸功能的影响
Effect of positive end expiratory pressure ventilation with prone position but upper torso is raised and legs are lowered on respiratory function during general anaesthesia in burn patients with in

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DOI:
作者:
范秋维 龚玲 薛庆生 于布为
FAN Qiu-wei, GONG Ling, XUE Qing-sheng, YU Bu-wei
作者单位:
上海交通大学医学院附属瑞金医院麻醉科
Department of Anaesthesiology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200025 P.R.China
关键词:
　　　呼气末正压；吸入性肺损伤；灼伤患者；俯卧位；呼吸功能
　　Positive end expiratory pressure; Burn patients; Inhalational lung injury; Prone position; Respiratory function
摘要:
　　　目的 评价呼气末正压通气同时头高足底15~20度俯卧位对伴有吸入性肺损伤的灼伤患者全麻中呼吸功能的影响。方法 选择伴有不同程度的吸入性肺损伤，并带有气管插管或气管造口，拟择期行扩创和自体皮取植术患者45例，性别不限，年龄20~48岁，ASA III~IV级，随机分为A、B、C三组，每组15例。 A组以IPPV模式水平俯卧位通气；B 组以IPPV+PEEP模式水平俯卧位通气；C 组以IPPV+PEEP模式并以头高足低15~20度俯卧位通气，三组病人均麻醉维持中控制氧浓度为80%，潮气量以9 ml·kg-1，呼吸频率为12bpm，B 组和C组，PEEP 值为5 cmH2O。 结果 经皮血氧饱和度（SpO2）、动脉血氧分压（PaO2）在麻醉诱导后5分钟、俯卧位后5分钟、30分钟、60分钟、120分钟均有明显的提升，提升的程度为C 组最高(P<0.05)；而动脉血二氧化碳分压（PaCO2）和呼气末二氧化碳分压（PetCO2）在麻醉诱导后5分钟、俯卧位后5分钟、30分钟、60分钟、120分钟均有明显的下降，下降的程度为C 组最明显(P<0.05)。气道峰压（Ppeak） 、气道平台压（Pplat）在俯卧位后5分钟、30分钟、60分钟、120分钟C 组与A组、C 组与B组同一时间点比较均明显降低(P<0.05), B组与A组同一时间点比较差异无统计学意义(P>0.05)；胸肺动态顺应性（Cdyn）在俯卧位后5分钟、30分钟、60分钟、120分钟C 组与A组、C 组与B组同一时间点比较均明显升高(P<0.05)，B组与A组同一时间点比较差异无统计学意义(P>0.05)。三组心率（HR）、平均动脉压(MAP)和总尿量(Urine Output)组间同一时间点比较差异无统计学意义(P>0.05)。结论 伴有吸入性肺损伤的灼伤患者俯卧位全麻中以IPPV+PEEP模式同时头高足低15~20度俯卧位通气，可更有效地改善病人通气和换气，即改善低氧血症和高二氧化碳血症，使气道压力明显降低，胸肺动态顺应性提高，对血流动力学影响在可接受范围内，是三种俯卧位全麻中最有效的呼吸治疗方法。
　　Objective To investigate the effects of positive end expiratory pressure (PEEP) ventilation in the prone position with the upper torso raised and the legs lowered (15~20°) on respiratory function during general anaesthesia in burn patients with inhalational lung injury. Methods Forty-five ASA III or IV burn patients with inhalational lung injury treated with oral tracheal intubation or tracheostomy ventilation, aged 20-48 yrs scheduled for early excision and grafting of burned areas (excision of the burn wound by using temporary biologic dressings, either allografts or xenografts), were randomly divided into 3 groups (n=15 each): group A: Intermittent positive pressure ventilation (IPPV) in the horizontal prone position; group B: IPPV+PEEP ventilation in the horizontal prone position and group C: IPPV+PEEP ventilation in the prone position but with the upper torso raised and the legs lowered (15~20°). Anaesthesia was induced with midazolam, propofol, and fentanyl followed by vecuronium. Anaesthesia was maintained with sevoflurane (MAC0.8-1.0) and intermittent intravenous boluses of fentanyl and vecuronium. Following induction of anaesthesia, IPPV (VT 9 ml/kg, RR 12 bpm, I:E 1:1.5, FiO2 80%) was performed with all patients in the supine position. After 5 minutes all patients were transferred into the prone position. Patients in group A were mechanically ventilated with IPPV in the horizontal prone position with the abdomen raised above the bed. Patients in group B were mechanically ventilated with IPPV and PEEP (5 cmH2O) in the horizontal prone position. Patients in group C were mechanically ventilated with IPPV and PEEP in the prone position but with the upper torso raised and the legs lowered (15~20°). The percutaneous oxygen saturation (SpO2), end tidal carbon dioxide pressure (PetCO2), Peak and plateau airway pressure (Ppeak and Pplat), chest wall and lung dynamic compliance (Cdyn) were monitored and recorded during anaesthesia. Arterial blood samples were taken before induction of anaesthesia with the patients awake breathing ambient air for 5 minutes (baseline) and at 30, 60 and 120 minutes after changing from supine to prone position. Results The values of SpO2 and PaO2 in group C were significantly highest at 5 minutes after induction of anaesthesia and at 5, 30, 60 and 120 minutes after changing into the prone position in all three groups ( P <0.05 ). The values of PaCO2 and PetCO2  in group C were significantly lowest at 5 minutes after induction and at 5, 30, 60 and 120 minutes after changing into the prone position in all three groups ( P <0.05 ). The levels of Ppeak and Pplat in group C were significantly lowest at 5 , 30 , 60 and 120 minutes after changing into the prone position in all three groups ( P <0.05). The level of Cdyn in group C was significantly highest at 5, 30, 60 and 120 minutes after changing into the prone position in all three groups ( P <0.05 ). However, there was no statistically significant difference in the level of Ppeak, Pplat and Cdyn between groups A and B. And there was no statistically significant difference in the level of HR, MAP and Urine Output among the three groups. Conclusion The gas exchange and compliance of burn patients with inhalational lung injury receiving general anaesthesia with IPPV and PEEP ventilation in the prone position is improved when the upper torso is raised and the legs are lowered (15~20°).  　　

 

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