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摘要：
目的 探讨肥胖患者妇科腹腔镜手术中，实施基于压力‑容积曲线（pressure‑volume curves, P‑V曲线）个体化肺保护性通气策略（lung protective ventilation strategy, LPVS）的可行性。 方法 择期行妇科腹腔镜手术的肥胖患者60例，采用随机数字表法分为对照组（A组）和研究组（B组），每组30例。所有患者均采用静吸复合全身麻醉，气管插管后行LPVS。A组：潮气量（tidal volume, VT）为6~8 ml/kg（理想体重），呼气末正压（positive end expiratory pressure, PEEP）为3~10 cmH2O（1 cmH2O=0.098 kPa）。B组：根据P‑V曲线行个体化通气参数设置。在气腹前（T1）、气腹后10 min（T2）、气腹后1 h（T3）及术毕（T4）4个时点分别记录循环、呼吸参数和氧合指标，包括心率、有创平均动脉压（invasive mean arterial pressure, IMAP）、气道峰压（peak airway pressure, Ppeak）、pH、PaO2、PaCO2、动态肺顺应性（lung dynamic compliance, Cdyn）及氧合指数（oxygenation index, OI）。以Cdyn、OI及Ppeak作为主要观察指标，心率、IMAP、PaO2及PaCO2作为次要观察指标。 结果 与T1时比较，两组患者T2~T4时心率、IMAP差异无统计学意义（P>0.05），T3、T4时PH下降，T2、T3时PaO2、OI降低，T3时PaCO2升高，T2、T3时Ppeak升高、Cdyn下降（P<0.05）；与A组比较，B组患者T3时PaO2、PaCO2、OI及Cdyn均较高，且Ppeak较低（P<0.05）。 结论 肥胖患者妇科腹腔镜手术中，基于P‑V曲线的个体化LPVS有利于维持肺顺应性，改善氧合。
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Abstract: Objective To investigate the feasibility of individualized lung protective ventilation strategy (LPVS) based on pressure‑volume (P‑V) curve in obese patients undergoing gynecologic laparoscopic surgery. Methods A total of 60 obese patients who were scheduled for gynecologic laparoscopic surgery were enrolled. According to the random number table method, they were divided into two groups (n=30): a control group (group A) and a research group (group B). All the patients received intravenous‑inhalation combined anesthesia and LPVS was performed after tracheal intubation. Group A: the tidal volume (VT) was 6‒8 ml/kg (ideal body weight), the positive end‑expiratory pressure (PEEP) was 3‒10 cmH2O (1 cmH2O=0.098 kPa). Group B: individualized ventilation parameters were set based on P‑V curve. Then, circulatory and respiratory parameters, and oxygenation indexes, such as heart rate, invasive mean arterial pressure (IMAP), peak air pressure (Ppeak), pH, arterial partial pressure of oxygen (PaO2) and arterial partial pressure of carbon dioxide (PaCO2), lung dynamic compliance (Cdyn) and oxygen index (OI) were recorded before pneumoperitoneum (T1), 10 min after pneumoperitoneum (T2), 1 h after pneumoperitoneum (T3) and at the end of surgery (T4). The primary outcomes were Cdyn, OI and Ppeak. The secondary outcomes were heart rate, IMAP, pH, PaO2 and PaCO2. Results Compared with those at T1, there was no statistical difference in heart rate and IMAP between the two groups from T2 to T4 (P>0.05), while decreased pH was found at T3 and T4, decreased PaO2 and OI were found at T2 and T3, increased PaCO2 was found at T3; increased Ppeak and decreased Cdyn were found at T2 and T3 (P<0.05). Compared with group A, group B presented increased PaO2, PaCO2, OI and Cdyn but decreased Ppeak at T3 (P<0.05). Conclusions Individualized LPVS based on P‑V curve in obese patients undergoing gynecologic laparoscopic surgery is useful to maintain lung compliance and improve oxygenation.
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