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摘要：
目的 探讨压力调节容积控制通气（pressure‑regulated volume control, PRVC）模式下肺保护性通气（lung‑protective ventilation, LPV）对合并慢性阻塞性肺疾病（chronic obstructive pulmonary disease, COPD）腹腔镜结直肠手术患者的肺保护效应。 方法 选择择期全身麻醉下行腹腔镜结直肠癌根治术的患者50例，年龄52~70岁，BMI<30 kg/m2，性别不限，ASA分级Ⅱ、Ⅲ级，所有患者均伴有中度COPD。将患者按照随机数字表法、双盲分为肺保护性通气组（LPV组）和压力调节容积控制通气联合肺保护性通气组（PRVC组），每组25例。于诱导前（T0）、插管后10 min（T1）、气腹后60 min（T2）、气腹结束后10 min（T3）采集桡动脉血行血气分析，记录PaO2、PaCO2、肺泡‑动脉血氧分压差（alveolar‑arterial oxygen difference, PA‑aO2），并计算呼吸指数（respiratory index, RI）。于T₁、T2、T3时记录患者气道峰压（airway peak pressure, Ppeak）、气道平台压（airway platform pressure, Pplat），计算动态肺顺应性（dynamic pulmonary compliance, Cdyn）。测量患者术后1、3、5 d的第1秒用力肺活量（forced expiratory volume in one second, FEV1）、用力肺活量（forced vital capacity, FVC）、第1秒用力肺活量占用力肺活量的百分比（FEV1/FVC）及残气量占肺总量的百分比（residual volume/total lung capacity, RV/TLC）。记录术中及术后7 d内并发症（肺炎、肺不张、呼吸衰竭等）的发生率，术后2、7 d临床肺部感染评分（Clinical Pulmonary Infection Score, CPIS）及术后出院时间。 结果 T3时PRVC组PaO2较LPV组升高（P<0.05），PA‑aO2、RI较LPV组降低（P<0.05）。T1、T2、T3时PRVC组Ppeak、Pplat较LPV组降低（P<0.05），Cdyn较LPV组升高（P<0.05）。术后1 d时，PRVC组FEV1、FVC较LPV组升高（P<0.05），RV/TLC较LPV组降低（P<0.05），术后3 d时FEV1较LPV组升高（P<0.05）。术后2、7 d时CPIS评分PRVC组较LPV组降低（P<0.05）。其余指标差异无统计学意义（P>0.05）。 结论 PRVC模式下LPV策略能改善合并COPD腹腔镜结直肠癌根治术患者的肺氧合功能和Cdyn，优化肺保护效应。
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Abstract: Objective To discuss the effects of lung‑protective ventilation (LPV) under pressure‑regulated volume control (PRVC) model on the lung in patients with chronic obstructive pulmonary disease (COPD) during laparoscopic colorectal surgery. Methods A total of 50 patients with moderate COPD, aged 52 to 70 years, with body mass index (BMI)<30 kg/m², American Society of Anesthesiologists (ASA) Ⅱ or Ⅲ , were enrolled, who were scheduled for laparoscopic radical resection of colorectal cancer under general anesthesia. According to the random number table and double blind methods, the patients were divided into two groups (n=25): a lung‑protective ventilation group (group LPV) and a PRVC combined with LPV group (group PRVC). Then, the radial artery blood samples were collected for blood gas analysis before anesthesia induction (T0), 10 min after intubation (T1), 60 min after pneumoperitoneum (T2), and 10 min after the end of pneumoperitoneum (T3). Meanwhile, arterial partial pressure of oxygen (PaO2), arterial partial pressure of carbon dioxide (PaCO2) and alveolar‑arterial oxygen difference (PA‑aO2) were recorded, and the respiratory index (RI) was calculated. The airway peak pressure (Ppeak) and the airway platform pressure (Pplat) at T1, T2, and T3 were recorded, while dynamic pulmonary compliance (Cdyn) was recorded. The forced expiratory volume in one second (FEV1), forced vital capacity (FVC), FEV1/FVC, and residual volume/total lung capacity (RV/TLC) 1, 3 and 5 days after surgery were measured. The incidence of complications (pneumonia, atelectasis, and respiratory failure, etc) during surgery and 7 days after surgery, as well as clinical pulmonary infection score (CPIS) 2 and 5 days after surgery and discharge time were recorded. Results Compared with group LPV, group PRVC presented increases in PaO2 (P<0.05) and decreases in PA‑aO2 and RI at T3 (P<0.05). Compared with group LPV, group PRVC produced decreased Ppeak and Pplat (P<0.05), as well as increased Cdyn at T1, T2 and T3 (P<0.05). Compared with group LPV, group PRVC showed increases in FEV1 and FVC (P<0.05) as well as decreases in RV/TLC (P<0.05) 1 day after surgery, and increases in FEV1 3 days after surgery (P<0.05). Compared with group LPV, group PRVC presented decreased CPIS scores 2 and 7 days after surgery (P<0.05). There was no statistical difference in other indicators. Conclusions Under the PRVC model, LPV strategy can improve pulmonary oxygenation function and Cdyn in COPD patients during laparoscopic colorectal surgery, and optimize lung protection effects.
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