肺保护通气策略对全身麻醉肺叶切除术后单肺通气患者肺损伤的作用研究

Effect of lung-protective ventilation strategy on postoperative lung injury in patients undergoing one-lung ventilation for lobectomy under general anesthesia

摘要:

目的 探讨肺保护通气策略中不同呼气末正压（PEEP）水平联合小潮气量对全身麻醉肺叶切除术后单肺通气患者肺损伤的作用，为临床优化通气方案提供依据。方法 选取2022年3月—2025年3月在邢台市中心医院进行肺叶切除术的200例患者，采用随机数字表法分为对照组与观察组，各100例。对照组患者接受低水平呼气末正压联合小潮气量治疗，观察组患者接受高水平呼气末正压联合小潮气量治疗。比较两组患者单肺通气前（T₀）、通气60 min（T₁）、手术结束时（T₂）、术后第1天（T₃）时的平均动脉压、心率、心指数（CI）、血管外肺水指数（EVLWI）。比较T₀、T₃时的第一秒用力呼气容积（FEV₁）和用力肺活量（FVC）。比较两组患者手术情况、单肺通气情况及围手术期手术相关指标。统计两组患者不良反应发生情况及总住院时间。结果 观察组与对照组T₀、T₁、T₂、T₃的平均动脉压、心率、CI、EVLWI比较，采用重复测量设计的方差分析，结果 ①不同时间点的平均动脉压比较，差异有统计学意义（P <0.05）；不同时间点的心率、CI、EVLWI比较，差异无统计学意义（P >0.05）。②两组的平均动脉压、心率、CI比较，差异有统计学意义（P <0.05），观察组平均动脉压、心率较低，CI较高，相对镇静效果较好；两组的EVLWI比较，差异无统计学意义（P >0.05）。③两组平均动脉压、心率、CI、EVLWI变化趋势比较，差异无统计学意义（P >0.05）。观察组与对照组T₀、T₃的FEV₁、FVC、FEV₁/FVC比较，采用重复测量设计的方差分析，结果 ①不同时间点的FEV₁、FVC、FEV₁/FVC比较，差异有统计学意义（P <0.05）；②两组的FEV₁、FVC、FEV₁/FVC比较，差异有统计学意义（P <0.05），观察组FEV₁、FVC、FEV₁/FVC较高，相对肺功能情况较好；③两组FEV₁、FVC、FEV₁/FVC变化趋势比较，差异有统计学意义（P <0.05）。对照组总住院时间和手术时间均高于观察组，对照组单肺通气时间低于观察组（P <0.05）。对照组潮气量、吸入氧浓度、气道峰压、气道平均压均高于观察组（P <0.05）。观察组与对照组T₁、T₃时的输液量、尿量、胸腔引流量比较，采用重复测量设计的方差分析，结果 ①不同时间点的输液量、尿量、胸腔引流量比较，差异有统计学意义（P <0.05）；②两组的输液量、尿量、胸腔引流量比较，差异有统计学意义（P <0.05），观察组输液量较高，观察组尿量、胸腔引流量较低，观察组围手术期恢复情况相对较好；③两组输液量、尿量变化趋势比较，差异有统计学意义（P <0.05），两组胸腔引流量变化趋势比较，差异无统计学意义（P >0.05）。观察组不良反应总发生率低于对照组（P <0.05）。结论 高水平呼气末正压联合小潮气量通气可显著降低肺叶切除术患者术后不良反应发生率，改善氧合功能及肺顺应性，缩短住院时间，其机制可能与降低驱动压、减少炎症因子释放及优化通气/血流比例有关。

Abstract:

Objective To investigate the preventive effect of different levels of positive end-expiratory pressure (PEEP) combined with low tidal volume, as part of a lung-protective ventilation strategy, on postoperative lung injury in patients undergoing one-lung ventilation (OLV) for lobectomy under general anesthesia, and to provide a basis for optimizing clinical ventilation protocols.Methods This prospective study enrolled 200 patients who underwent lobectomy at Xingtai Central Hospital from March 2022 to March 2025. Patients were randomly assigned to either the control group or the observation group (n = 100 per group). The control group received low PEEP combined with low tidal volume ventilation, while the observation group received high PEEP combined with low tidal volume ventilation. Mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), and extravascular lung water index (EVLWI) were recorded at four time points: before OLV (T₀), at 60 minutes of OLV (T₁), at the end of surgery (T₂), and on postoperative day 1 (T₃). Pulmonary function was compared between groups before surgery and on postoperative day 1. Surgical parameters, OLV duration, and perioperative indices were recorded, and the incidence of adverse events and total hospital stay were statistically analyzed.Results Comparisons of mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), and extravascular lung water index (EVLWI) at time points T₀, T₁, T₂, and T₃ between the observation group and the control group were performed using repeated - measures analysis of variance (ANOVA). The results were as follows: (1) Regarding MAP, there was a statistically significant difference among different time points (P < 0.05); however, no statistically significant differences were observed in HR, CI, or EVLWI among different time points (P > 0.05). (2) Statistically significant differences were found in MAP, HR, and CI between the two groups (P < 0.05). Specifically, the observation group had lower MAP and HR, as well as a higher CI, indicating a relatively better sedative effect. No statistically significant difference was detected in EVLWI between the two groups (P > 0.05). (3) There were no statistically significant differences in the change trends of MAP, HR, CI, or EVLWI between the two groups (P > 0.05). The differences in forced expiratory volume in 1 second (FEV₁), forced vital capacity (FVC), and FEV₁/FVC ratio at time points T₀ and T₃ between the observation group and the control group were also analyzed using repeated - measures ANOVA. The results showed: (1) Statistically significant differences were present in FEV₁, FVC, and FEV₁/FVC ratio among different time points (P < 0.05). (2) Inter - group comparisons revealed statistically significant differences in FEV₁, FVC, and FEV₁/FVC ratio between the two groups (P < 0.05). The observation group exhibited higher values of FEV₁, FVC, and FEV₁/FVC ratio, suggesting relatively better pulmonary function. (3) There were statistically significant differences in the change trends of FEV₁, FVC, and FEV₁/FVC ratio between the two groups (P < 0.05). The total hospital stay and operation time in the control group were both longer than those in the observation group, whereas the one - lung ventilation time in the control group was shorter than that in the observation group (P < 0.05). The tidal volume, inspired oxygen concentration, peak airway pressure, and mean airway pressure in the control group were all higher than those in the observation group (P < 0.05). The differences in fluid infusion volume, urine output, and thoracic drainage volume at time points T₁ and T₃ between the observation group and the control group were analyzed by repeated - measures ANOVA. The results were: (1) Statistically significant differences were found in fluid infusion volume, urine output, and thoracic drainage volume among different time points (P < 0.05). (2) Inter - group comparisons showed statistically significant differences in fluid infusion volume, urine output, and thoracic drainage volume between the two groups (P < 0.05). Specifically, the observation group had a higher fluid infusion volume, along with lower urine output and thoracic drainage volume, indicating a relatively better perioperative recovery. (3) There were statistically significant differences were observed in the change trends of fluid infusion volume and urine output between the two groups (P < 0.05), while no statistically significant difference was found in the change trend of thoracic drainage volume between the two groups (P > 0.05). The total incidence of adverse reactions in the observation group was lower than that in the control group (P < 0.05).Conclusion High PEEP combined with low tidal volume ventilation significantly reduced the incidence of postoperative adverse events in patients undergoing lobectomy, improved oxygenation and lung compliance, and shortened hospital stay. The underlying mechanisms may include reduced driving pressure, decreased release of inflammatory mediators, and optimized ventilation-perfusion matching.