PEEP对肺叶切除患者单肺通气中氧合及分流的影响

目的探讨肺叶切除患者单肺通气(OLV)时应用呼气末正压通气(PEEP)对氧合及分流的影响。方法将70例肺叶切除患者随机分为两组,每组35例,两组在OLV时潮气量6 ml/kg,呼吸频率16~18次/min,观察组同时应用PEEP 5 cm H2O,对照组不用PEEP,比较两组患者双肺通气时(T1)、单肺通气10 min(T2)及单肺通气30 min(T3)血气分析结果及平均肺动脉压(PAP)、平均动脉压(MAP)、心率(HR)、动脉血氧分压、混合静脉血氧饱和度(Sv O2)及肺内分流率(Qs/Qt)。结果对照组T2、T3时间点Pa O2较T1时下降(t=7.528、6.767,P=0.000、0.000),T2、T3时间点观察组Pa O2高于对照组(P=0.000),PH值、Pa CO2、BE、HCO-3各时间点组内、组间比较差异均无统计学意义;T2、T3时间点观察组Qs/Qt较分别较对照组降低(t=12.011、9.992,P=0.000、0.000),差异均有统计学意义,两组PAP、MAP、HR、Sv O2各时间点组间、组内比较差异均无统计学意义。结论肺叶切除手术OLV时应用PEEP可提高氧分压,降低肺内分流,是防治低氧血症的有效措施之一。     

肺表面活性物质异常在呼吸机所致肺损伤发生中作用的实验研究

目的 探讨肺表面活性物质(PS)异常在呼吸机所致肺损伤(VILI)发生中的作用.方法 40只成年SD大鼠随机分成5组,每组8只,对照组于手术完毕后处死,其余4组给予机械通气(MV)(1)P7组,设置吸气峰压(cmH2O)/频率(次/min)/吸呼比/呼气末正压(PEEP)(cm H2O)为7/40/11/0;(2)P45组,45/20/11/0;(3)PS组,经气道滴入PS100mg/kg,45/20/11/0;(4)PEEP组,45/20/11/10,20min后处死.观察动脉血氧(Pa02)、最大胸肺顺应性(Cmax)、支气管肺泡灌洗液(BALF)的总蛋白(TP)、总磷脂(TPL)、大小聚集体(LA、SA)和最小表面张力(STmin).结果 与P7组比较,P45组Pa02和Cmax均明显降低(P均＜0.01),BALF的TP、SA/LA和STmin显著增加,TPL/TP降低(P均＜0.01).PS组和PEEP组各指标均显著优于P45组(P＜0.05或P＜0.01).P7组和对照组间各指标均相近.结论 VILI时有明显的PS异常;外源性PS和PEEP均可恢复和维持PS结构和功能,减轻VILI,表明PS异常与VILI的发生密切相关.     

不同水平呼气末正压通气对肺内外源性急性呼吸窘迫综合征患者的影响

应用呼气末正压（PEEP）是急性呼吸窘迫综合征（ARDS）肺保护性通气策略之一,它可以促进氧合,防止呼气末肺泡萎陷,抑制炎性介质释放.而国外研究表明,ARDS患者对同样水平的PEEP反应并不一致,可能与导致ARDS的病因不同有关.我们观察了不同水平PEEP通气对肺内、外源性ARDS患者的影响.     

无创正压通气不同呼气末正压水平对慢性阻塞性肺疾病急性加重患者呼吸做功的影响

目的 探讨无创正压通气(NPPV)不同呼气末正压水平对慢性阻塞性肺疾病急性加重(AECOPD)患者的呼吸做功影响.方法 12例AECOPD患者接受相同压力支持和不同呼气末正压水平的NPPV,观察患者吸气肌肉用力和呼吸方式的变化.结果 ①与自主呼吸(SB)相比,4 cm H2O(L-PEEP)、6 cm H2O(PEEP...     

肺复张后呼气末正压通气不同模式对腹腔镜结直肠癌根治术肥胖患者呼吸力学和血流动力学的影响

目的探讨肺复张后呼气末正压通气(PEEP)不同模式对腹腔镜结直肠癌根治术肥胖患者呼吸力学和血流动力学的影响。方法 90例拟行腹腔镜结直肠癌根治术肥胖患者随机分为传统组、PEEP5组和PEEP10组,设置潮气量(VD)8 ml/kg,分别在肺复张后不给予PEEP、PEEP 5 cm H2O和PEEP 10 cm H2O。观察气腹建立前(T0)、气腹建立后10 min(T1)、气腹后头低足高位20 min(T2)和气腹结束(T3)时的气道峰压(Ppeak)、平台压(Pplat)、有效静态总顺应性(Cst)、气道阻力(Raw)、氧合指数(PaO_2/FiO_2)、死腔量(VD/VT)和肺内分流量。结果与传统组比较,PEEP5组和PEEP10组T1时Ppeak、Raw、VD/VT和Qs/Qt增加,Cst和PaO_2/FiO_2下降,T2和T3时VD/VT和Qs/Qt下降,PaO_2/FiO_2增加(P<0.05);与PEEP5组比较,PEEP10组T3时Ppeak、VD/VT和Qs/Qt下降,PaO_2/FiO_2增加(P<0.05)。结论肺复张后给予小VD(8 ml/kg)+PEEP可以改善腹腔镜结直肠癌根治术肥胖患者呼吸力学和血流动力学指标,且PEEP 10 cmH2O效果更优。     

如何选择最佳PEEP治疗ARDS患者

综述治疗急性呼吸窘迫综合征患者时，使用呼气末正压的理论基础，选择最佳呼气末正压的方法以及这些方法的生理学和临床意义。提出选择最佳PEEP的最新观点和需要解决的问题。     

通气机导致急性肺损伤的机制及呼气末正压的保护作用研究

呼气末正压（ＰＥＥＰ）这一简单实用的机械通气手段在通气机导致的急性肺损伤（ｖｅｎｔｉｌａｔｏｒｉｎｄｕｃｅｄａｃｕｔｅｌｕｎｇｉｎｊｕｒｙ，ＶＩＡＬＩ）的预防中具有重要意义［１］。我们拟从细胞免疫、氧化损伤及组织细胞学角度探讨ＶＩＡＬＩ的发生机理及ＰＥＥＰ对ＶＩＡＬＩ的保护作用。材料和方法　健康雄性ＳＤ大鼠３０只，体重２５０ｇ～４００ｇ，平均３６０ｇ，随机分为３组，Ａ组为对照组，给常规机械通气；Ｂ组为大潮气量组，给大潮气量机械通气；Ｃ组为ＰＥＥＰ保护组，给大潮气量加ＰＥＥＰ通气。将大鼠麻醉后，行…     

短暂高水平PEEP对压力控制通气ARDS患者氧合和血液动力学的影响

目的观察短暂高水平呼气末正压通气(PEEP)对急性呼吸窘迫综合征(ARDS)患者氧合情况及血流动力学的影响。方法 40例ARDS患者,随机分为实验组22例和对照组18例。实验组给予压力控制通气+短暂高水平PEEP促进肺复张,对照组仅给予压力控制通气。观察并比较两组患者的氧合及血流动力学变化。结果通气13、7、d后实验组患者PaO2/FiO2明显优于对照组(P均<0.05);通气17、d时实验组患者动脉血pH、PaCO2明显低于对照组(P均<0.05);通气1 d时实验组患者PaO2明显低于对照组(P<0.05)。两组患者通气1、2、3 d时HR、MAP、CVP相比,P均>0.05。结论短暂高水平PEEP可改善ARDS患者的氧合,对血流动力学无明显影响。     

吸痰联合肺复张后不同PEEP水平对ARDS机械通气患者呼吸力学的影响

目的探讨吸痰联合肺复张后调整不同的呼气末正压(PEEP)水平对急性呼吸窘迫综合征(ARDS)机械通气患者呼吸力学的影响。方法选择22例ARDS机械通气患者,吸痰后给予肺复张,在原有PEEP水平(P0)基础上调整。于调整PEEP后10、30、60 min,监测患者各压力水平气道峰压(Ppeak)、平台压(Pplat)、肺实时顺应性(Cd)变化。结果与实验前比较,Cd在不同PEEP水平均显著升高(P均<0.05)。随着PEEP水平的不断增加,Cd也随之升高,与调整后其他PEEP水平相比,P0+4 cmH2O和P0+6 cmH2O测得Cd显著高于其他水平(P<0.05)。30 min Cd监测值显著高于10、60 min(P均<0.05)。与其他四组比较,P0+4 cmH2O和P0+6 cmH2O在30～60 min时段Cd下降趋势较小(P<0.05)。随着PEEP水平不断增加,Ppeak、Pplat也随之升高,但不同PEEP水平对Ppeak、Pplat的影响无统计学差异(P>0.05)。结论 ARDS机械通气患者在吸痰联合肺复张后选择在P0基础上增加4～6 cmH2O,有利于维持患者复张后肺顺应性,延缓肺泡去复张时间。     

Breath analysis during one-lung ventilation in cancer patients

Noninvasive breath analysis may provide valuable information for cancer recognition if disease-specific volatile biomarkers could be identified. In order to compare nondiseased and diseased tissue in vivo, this study took advantage of the special circumstances of one-lung ventilation (OLV) during lung-surgery. 15 cancer patients undergoing lung resection with OLV were enrolled. From each patient, alveolar breath samples were taken separately from healthy and diseased lungs before and after tumour resection. Volatile substances were pre-concentrated by means of solid-phase microextraction, and were separated, identified and quantified by means of gas chromatography-mass spectrometry. Different classes of volatile substances could be identified according to their concentration profiles. Due to prolonged fasting and activation of lipolysis, concentrations of endogenous acetone significantly increased during surgery. Exogenous substances, such as benzene or cyclohexanone, showed typical washout exhalation kinetics. Exhaled concentrations of potentially tumour associated substances, such as butane or pentane, were different for nondiseased and diseased lungs and decreased significantly after surgery. Separate analysis of volatile substances exhaled from healthy and diseased lungs in the same patient, together with thorough consideration of substance origins and exhalation kinetics offers unique opportunities of biomarker recognition and evaluation.     

Biomarkers of lung injury after one-lung ventilation for lung resection

Background and objective: Acute lung injury contributes to the mortality of patients after lung resection and one‐lung ventilation (OLV). The objective of this study was to characterise the effect of lung resection and OLV on proposed biomarkers of lung injury in exhaled breath condensate (EBC) and plasma. Methods: In adults undergoing lung resection, EBC was collected before and at 30‐min intervals during OLV. Inflammatory mediators were assayed in plasma samples taken preoperatively, immediately postoperatively and 24 h postoperatively. Results: EBC pH decreased from 6.51 ± 0.43 preoperatively, to 6.17 ± 0.78 and 6.09 ± 0.83 at 30 and 60 min, respectively (mean ± SD, P = 0.034, n = 20). Plasma concentrations of the receptor for advanced glycation end‐products, von Willebrand factor and interleukin‐6 increased comparing preoperative and postoperative samples (all P < 0.001, n = 30). By contrast, levels of Krebs von den Lungen‐6 and surfactant protein‐D decreased (P < 0.001, n = 30), and correlated inversely with the extent of lung resected. Conclusions: Lung resection and OLV was associated with a rapid reduction in EBC pH and differential changes in plasma biomarkers of lung injury. Further investigation of EBC pH as a marker of ventilator‐induced lung injury is warranted.     

Identifying biomarkers of ventilator induced lung injury during one-lung ventilation surgery: a scoping review

BackgroundVentilator-induced lung injury (VILI) can occur as a result of mechanical ventilation to two lungs. Thoracic surgery often requires one-lung ventilation (OLV). The potential for VILI is likely higher in OLV. The impact of OLV on development of post-operative pulmonary complications is not well understood. We aimed to perform a scoping review to determine reliable biomarkers of VILI after OLV.MethodsA scoping review was performed using Cochrane Collaboration methodology. We searched Medline, EMBASE and SCOPUS. Gray literature was searched. Studies of adult human or animal models without pre-existing lung damage exposed to OLV, with biomarker responses analyzed were included.ResultsAfter screening 5,613 eligible papers, 89 papers were chosen for full text review, with 29 meeting inclusion. Approximately half (52%, n=15) of studies were conducted in humans in an intra-operative setting. Bronchoalveolar lavage (BAL) & serum analyses with enzyme-linked immunosorbent assay (ELISA)-based assays were most commonly used. The majority of analytes were investigated by a single study. Of the analytes that were investigated by two or more studies (n=31), only 16 were concordant in their findings. Across all sample types and studies 84% (n=66) of the 79 inflammatory markers and 75% (n=6) of the 8 anti-inflammatory markers tested were found to increase. Half (48%) of all studies showed an increase in TNF-α or IL-6.ConclusionsA scoping review of the state of the evidence demonstrated that candidate biomarkers with the most evidence and greatest reliability are general markers of inflammation, such as IL-6 and TNF-α assessed using ELISA assays. Studies were limited in the number of biomarkers measured concurrently, sample size, and studies using human participants. In conclusion these identified markers can potentially serve as outcome measures for studies on OLV.     

双侧肺同期手术中不同体位和单肺通气对病人呼吸力学的影响

目的观察双侧肺同期手术中体位改变和单肺通气时对病人呼吸力学的影响。方法选取我院2007年6月至2010年12月双侧肺同期手术病人142例,经气道旁路采用旁气流通气连续监测病人PIP、Pplat、Raw、Cdyn等呼吸力学指标,监测SpO2、PETCO2指标,分别在双腔支气管导管定位后,平卧改侧卧,单肺通气及改换通气方式后10 min抽取动脉血进行血气分析。结果病人双肺通气改变体位和单肺通气后,病人PIP、Pplat、Raw升高,Cdyn减少,PH值降低,PETCO2、PaCO2升高、SpO2、PaO2降低(P<0.05);双肺通气改换通气方式后,病人PIP、Pplat、Raw降低,Cdyn增加,PH值降低,PaO2、SpO2、PaCO2、PETCO2升高(P<0.05)。单肺通气38例病人改换通气方式后,病人PIP、Pplat、Raw降低,Cdyn增加,PH值、PaO2、SpO2升高,PaCO2、PETCO2降低(P<0.05)。结论双侧肺同期手术麻醉中不同体位和单肺通气对病人的呼吸力学影响较大,改换通气方式可改变病人呼吸力学指标。     

Propofol and alfentanil anesthesia during one-lung ventilation

A total intravenous anesthesia technique, using a combination of propofol, alfentanil, and ventilation with 100% oxygen, was studied in a group of 14 patients scheduled for a lobectomy or pneumonectomy. Alfentanil was given at a constant rate, and propofol was administered to adjust the depth of anesthesia. The technique provided an effective and easily controllable anesthetic. Systolic and diastolic blood pressures and pulse rates remained stable throughout the procedure, including during one-lung ventilation. After induction, the mean blood pressure decreased 25% for a short period of time. Blood gas values and oxygen saturation remained satisfactory during the entire procedure. Recovery characteristics were good. Calculations of the shunt fraction showed a smaller increase during one-lung ventilation than expected.     

Individualized positive end-expiratory pressure (PEEP) during one-lung ventilation for prevention of postoperative pulmonary complications in patients undergoing thoracic surgery: A meta-analysis

Background:Positive end-expiratory pressure (PEEP) is an important part of the lung protection strategies for one-lung ventilation (OLV). However, a fixed PEEP value is not suitable for all patients. Our objective was to determine the prevention of individualized PEEP on postoperative complications in patients undergoing one-lung ventilation.Method:We searched the PubMed, Embase, and Cochrane and performed a meta-analysis to compare the effect of individual PEEP vs fixed PEEP during single lung ventilation on postoperative pulmonary complications. Our primary outcome was the occurrence of postoperative pulmonary complications during follow-up. Secondary outcomes included the partial pressure of arterial oxygen and oxygenation index during one-lung ventilation.Result:Eight studies examining 849 patients were included in this review. The rate of postoperative pulmonary complications was reduced in the individualized PEEP group with a risk ratio of 0.52 (95% CI:0.37–0.73; P = .0001). The partial pressure of arterial oxygen during the OLV in the individualized PEEP group was higher with a mean difference 34.20 mm Hg (95% CI: 8.92–59.48; P = .0004). Similarly, the individualized PEEP group had a higher oxygenation index, MD: 49.07mmHg, (95% CI: 27.21–70.92; P < .0001).Conclusions:Individualized PEEP setting during one-lung ventilation in patients undergoing thoracic surgery was associated with fewer postoperative pulmonary complications and better perioperative oxygenation.     

单肺通气方式对围术期炎性细胞因子的影响

目的观察单肺通气（OLV）方式对患者围术期炎性细胞因子影响。方法拟行肺叶切除术肺癌患者36例,随机分为长时间组（Ⅰ组）和间断的双肺通气组（Ⅱ组）,每组18例。两组患者分别在麻醉诱导后（T1）、OLV 45 min（T2）、90min（T3）及术后2h（T4）采取静脉血,测定血清肿瘤坏死因子-α（TNF-α）、白细胞介素（IL）-6、IL-8、IL-10浓度。结果两组TNF-α、IL-6、IL-8和IL-10于T2时明显上升（P〈0．05）,Ⅱ组T3、T4时TNF-α、IL-6和IL-8均明显低于Ⅰ组（P〈0．05）,而IL-10高于Ⅰ组（P〈0．05）。结论单肺通气期间间断双肺通气可减轻炎性反应。     

术前雾化吸入盐酸戊乙奎醚对单肺通气时非通气侧肺损伤的影响及作用机制研究

目的 探讨术前雾化吸入盐酸戊乙奎醚在减轻单肺通气(OLV)时非通气侧肺损伤的影响及作用机制。方法 招募2021年3月至2022年5月于郑州大学附属洛阳中心医院择期行胸腔镜下肺癌根治术患者60例,采用随机数字表法将其分为观察组和对照组,每组30例。麻醉诱导后即刻,对照组予雾化吸入异丙托溴铵,观察组予雾化吸入盐酸戊乙奎醚。于全身麻醉诱导后即刻(T₀),以及OLV开始后0.5 h(T₁)、1 h(T₂)、2 h(T₃)时检测血氧分压(PaO₂)和二氧化碳分压(PaCO₂)。术中切取肿瘤周边的正常肺组织标本进行病理学检查,计算肺损伤评分。采用TUNEL法计算细胞凋亡指数(AI)。采用Western blot法检测肺组织细胞凋亡和自噬标志性蛋白的表达水平。结果 光镜下可见对照组肺组织形态、结构发生明显损伤,而观察组肺组织损伤显著减轻。在观察时间内,两组PaO₂均呈下降趋势,PaCO₂呈上升趋势,且观察组变化幅度较小(P&l...