肺保护性通气联合围手术期呼吸功能锻炼对老年衰弱结直肠癌手术患者预后的影响

The effect of lung protective ventilation combined with perioperative breathing exercises on postoperative prognosis of frail elderly patients with colorectal cancer

摘要:

目的 探讨肺保护性通气联合围手术期呼吸功能锻炼对老年衰弱结直肠癌手术患者预后的影响。方法 选取2021年1月—2023年6月在内江市第一人民医院就诊的92例老年衰弱结直肠癌手术患者，按摸球法分为对照组和实验组，每组46例。对照组接受常规通气模式，实验组接受肺保护性通气联合围手术期呼吸功能锻炼。比较两组患者在气腹前（T₁）、气腹1 h（T₂）、拔管前（T₃）的呼吸力学指标［气道峰压（Ppeak）、平均气道压（Pmean）、肺顺应性（CL）］，在麻醉诱导前（T₀）、T₂、气管导管拔除后10 min（T₄）的氧合指标〔脉搏血氧饱和度（SpO₂）、动脉氧分压（PaO₂）、肺泡动脉血氧分压差［P（A-a）DO₂］〕的变化，比较两组患者血清肺表面活性蛋白质A（SP-A）水平、St George's呼吸疾病问卷评估量表（SGRQ）评分、术后肺部并发症（肺炎、低氧血症、呼吸衰竭、肺不张、肺栓塞）的状况。结果 两组患者T₁、T₂、T₃的Ppeak、Pmean和CL水平比较，结果 ①不同时间点Ppeak、Pmean和CL水平比较，差异均有统计学意义（P <0.05）；②两组患者Ppeak、Pmean和CL水平比较，差异均有统计学意义（P <0.05），实验组在T₂、T₃时刻Ppeak和Pmean水平低于对照组，实验组的CL水平在T₂、T₃时高于对照组；③两组患者Ppeak、Pmean水平变化趋势比较，差异均无统计学意义（P >0.05），两组患者CL水平变化趋势比较，差异有统计学意义（P <0.05）。两组患者T₀、T₂、T₄的SpO₂、PaO₂和P（A-a）DO₂比较，结果 ①不同时间点SpO₂、PaO₂和P（A-a）DO₂比较，差异均有统计学意义（P <0.05）；②两组患者SpO₂、PaO₂和P（A-a）DO₂比较，差异均有统计学意义（P <0.05），实验组SpO₂和PaO₂在T₂、T₄时高于对照组，实验组P（A-a）DO₂在T₂、T₄时低于对照组；③两组患者SpO₂、PaO₂变化趋势比较，差异均无统计学意义（P >0.05），两组患者P（A-a）DO₂变化趋势比较，差异有统计学意义（P <0.05）。两组患者术前、术后1 和7 d SP-A水平比较，结果 ①不同时间SP-A水平比较，差异有统计学意义（P <0.05）；②两组患者SP-A水平比较，差异有统计学意义（P <0.05），实验组在术后1 d和术后7 d的SP-A水平均低于对照组；③两组患者SP-A水平变化趋势比较，差异有统计学意义（P <0.05）。实验组治疗前后症状、活动能力和疾病影响的评分的差值均高于对照组（P <0.05）。实验组并发症总发生率低于对照组（P <0.05）。结论 肺保护性通气联合围手术期呼吸功能锻炼能有效降低老年衰弱结直肠癌术后患者的肺部并发症发生率，改善呼吸力学和氧合指标，提升患者术后生活质量，对于这类患者的围手术期管理具有重要价值。

关键词:结直肠癌;肺保护性通气;围手术期;呼吸功能锻炼;老年衰弱;并发症

Abstract:

Objective To investigate the effect of lung protective ventilation combined with perioperative breathing exercises on postoperative prognosis of frail elderly patients with colorectal cancer.Methods From January 2021 to June 2023, a total of 92 frail elderly patients undergoing surgery for colorectal cancer were enrolled at the First People's Hospital of Neijiang. Patients were assigned to control and experimental groups by drawing lots, with 46 cases in each group. The control group received conventional ventilation modes, while the experimental group received lung protective ventilation combined with perioperative breathing exercises. Comparisons were made between the two groups on respiratory mechanics indicators [peak airway pressure (Ppeak), mean airway pressure (Pmean), and compliance of lung (CL)] before pneumoperitoneum (T₁), 1 hour after pneumoperitoneum (T₂), and before extubation (T₃), and on oxygenation indicators [pulse oximetry saturation (SpO₂), partial pressure of oxygen in arterial blood (PaO₂), and alveolar-arterial oxygen gradient (P(A-a)DO₂) ] before anesthesia induction (T₀), at T₂, and 10 minutes after tracheal tube removal (T₄). Serum levels of surfactant protein A (SP-A), St. George's Respiratory Questionnaire (SGRQ) scores, and postoperative pulmonary complications (pneumonia, hypoxemia, respiratory failure, atelectasis, pulmonary embolism) were also compared between the two groups.Results The Ppeak, Pmean, and CL at T₁, T₂ and T₃ in the two groups were compared, which exhibited that they were different among the time points (P < 0.05) and between the two groups. The experimental group had lower Ppeak and Pmean and higher CL at T₂ and T₃ compared with the control group. There were no significant differences in the change trends of Ppeak and Pmean between the groups (P > 0.05), but significant differences in the change trends of CL were found between the groups (P < 0.05). Comparison of SpO₂, PaO₂ and P(A-a)DO₂ at T₀, T₂ and T₄ in the two groups revealed that they were different among the time points (P < 0.05) and between the groups (P < 0.05). The SpO₂ and PaO₂ at T₂ and T₄ were higher and P(A-a)DO₂ at T₂ and T₄ was lower in the experimental group than in the control group. There were no significant differences in the change trends of SpO₂ and PaO₂ between the groups (P > 0.05), but significant differences in the change trends of P(A-a)DO₂ were found between the groups (P < 0.05). The SP-A levels before surgery, 1 d and 7 d after surgery in the two groups were compared, suggesting that they were different among the time points (P < 0.05) and between the groups (P <0.05). SP-A levels 1 d and 7 d after surgery were significantly lower in the experimental group compared with the control group. There were significant differences in the change trends of SP-A levels between the groups (P < 0.05). The differences in scores of symptoms, activity level, and disease impact scores before and after treatment in the experimental groups were greater than those in the control groups (P < 0.05). The overall incidence of complications was significantly lower in the experimental group compared with the control group (P < 0.05).Conclusions Lung protective ventilation combined with perioperative breathing exercises effectively reduces the incidence of pulmonary complications, improves respiratory mechanics and oxygenation indicators, and enhances the postoperative quality of life for frail elderly patients with colorectal cancer. This approach holds significant value for the perioperative management of such patients.

Key words:colorectal cancer;lung protective ventilation;perioperative;breathing exercise;frail elderly;complication