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摘要：
目的 探讨老年患者肺切除术后利用电阻抗断层成像（electrical impedance tomography, EIT）技术个体化设定呼气末正压（positive end‑expiratory pressure, PEEP）对苏醒期呼吸力学及氧合的影响。 方法 82例择期行胸腔镜肺切除术的老年患者，按随机数字表法分为对照组和个体化PEEP组（每组41例）。术后在苏醒室内采用同步间歇指令通气模式，潮气量8 ml/kg，对照组PEEP 5 cmH2O（1 cmH2O=0.098 kPa）；个体化PEEP组通过EIT确定PEEP值，取EIT监测图中表示肺过度膨胀和肺塌陷的曲线交叉均衡点作为最佳PEEP值。分析并记录进入苏醒室时（T1）、机械通气0.5 h（T2）、出苏醒室时（T3）的氧合指数（oxygenation index, OI），T1、T2时的肺动态顺应性（dynamic respiratory system compliance, Cdyn）、驱动压（driving pressure, ΔP）。将OI、Cdyn、ΔP作为主要观察指标，将气道峰压（peak airway pressure, Ppeak）、平均气道压（mean airway pressure, Pmean）、MAP、有无使用血管活性药物、pH、PaCO2、低氧血症发生率、拔管时间、苏醒室停留时间作为次要观察指标。 结果 EIT滴定的PEEP值（中位数9 cmH2O）高于对照组。与对照组比较，个体化PEEP组T2时OI、Cdyn升高，ΔP降低（P<0.05）。个体化PEEP组T2时Ppeak、Pmean高于对照组，术中血管活性药物的使用多于对照组（P<0.05），两组pH、MAP、PaCO2、MAP、术后拔管时间、低氧血症发生率差异无统计学意义（P>0.05）。 结论 老年患者肺切除术后，使用个体化设定PEEP可以改善苏醒期OI、降低ΔP、改善Cdyn，但对拔管时间、拔管后低氧血症发生率及苏醒室停留时间无明显影响。
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Abstract: Objective To discuss the effects of individualized setting of positive end‑expiratory pressure (PEEP) based on electrical impedance tomography (EIT) on the respiratory mechanics and oxygenation in elderly patients during the recovery period after lobectomy. Methods Eighty-two elderly patients who were scheduled for thoracoscopic lobectomy were divided into two groups (n=41), according to the random number table method: a control group and an individualized PEEP group. After surgery, synchronized intermittent mandatory ventilation was adopted in the postanesthesia care unit (PACU), with a tidal volume of 8 ml/kg. The PEEP value of the control group was set at 5 cmH2O (1 cmH2O=0.098 kPa). The PEEP value of the individualized PEEP group was determined based on EIT; the optimal PEEP value was considered as the crossing of the curves representing lung hyperinflation and collapse in the EIT monitoring chart. The oxygenation index (OI) at the time points of entering into PACU (T1), mechanical ventilation over 0.5 h (T2), and going out of PACU (T3), as well as dynamic respiratory system compliance (Cdyn) and driving pressure (ΔP) at T1 and T2 were recorded for analysis. The primary outcome measures included OI, Cdyn and ΔP. The secondary outcome measures were the peak airway pressure (Ppeak), mean airway pressure (Pmean), mean arterial pressure (MAP), the use of vasoactive agents, pH, PaCO2, the incidence of hypoxia, extubation time and the length of stay in PACU. Results The EIT-titrated PEEP (with a median of 9 cmH2O) was significantly higher than that of the control group. Compared with the control group, the individualized PEEP group had increased OI and Cdyn and decreased ΔP at T2 (P<0.05). The individualized PEEP group produced higher Ppeak and Pmean and used more doses of vasoactive agents than the control group (P<0.05). No statistical difference was found in pH, MAP, PaCO2, extubation time after surgery, and the incidence of hypoxia between the two groups (P>0.05). Conclusions Individualized PEEP setting in elderly patients after lobectomy can effectively improve OI, reduce ΔP and improve Cdyn in the recovery period, without significant effects on extubation time, the incidence of hypoxia and the length of stay in PACU.
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