本文選題：小潮氣量　切入點(diǎn)：機(jī)械通氣　出處：《河北醫(yī)科大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：目的:在腹腔鏡膽囊切除手術(shù)中,需要二氧化碳?xì)飧?其對(duì)呼吸功能影響較大,包括改變呼吸動(dòng)力學(xué),影響肺循環(huán)功能,二氧化碳吸收入血發(fā)生酸中毒等。術(shù)中呼吸管理時(shí),應(yīng)注重保護(hù)肺功能,維持適當(dāng)?shù)臍怏w交換,使組織氧合充分,減輕或避免干擾血流動(dòng)力學(xué)[1-2],降低呼吸機(jī)相關(guān)性肺損傷。在傳統(tǒng)的機(jī)械通氣中,潮氣量通常為10-15ml/kg,高于患者靜息狀態(tài)時(shí)的潮氣量(7-8ml/kg),容易引發(fā)肺泡的過度擴(kuò)張和吸氣壓增高,導(dǎo)致壓力-容量性肺損傷。而小潮氣量(6-8ml/kg)通氣可以避免此現(xiàn)象[3]。臨床上常選擇小潮氣量或小潮氣量聯(lián)合PEEP或肺復(fù)張的方法保護(hù)肺功能[4],既可避免肺部氣壓傷,又能減少肺不張、肺萎陷的發(fā)生,降低肺水含量,使呼氣末容積增加,改善肺順應(yīng)性,改善患者氧合[5]。嘆氣法屬于肺復(fù)張方法的一種,有研究在小潮氣量通氣的基礎(chǔ)上,采用嘆氣法對(duì)急性呼吸窘迫綜合征(ARDS)患者進(jìn)行肺復(fù)張治療時(shí)[6],發(fā)現(xiàn)持續(xù)的嘆氣可使患者的氧合狀態(tài)及胸肺順應(yīng)性得以明顯改善,且對(duì)血流動(dòng)力學(xué)影響輕微[7-8]。目前,人們對(duì)小潮氣量加手法嘆氣通氣作為肺保護(hù)性通氣策略在腹腔鏡膽囊切除術(shù)中應(yīng)用的研究還是比較少的。尚無研究證實(shí),術(shù)中持續(xù)控制通氣期間間斷給予嘆氣通氣,是否會(huì)對(duì)患者生命體征及血?dú)庵笜?biāo)產(chǎn)生積極的影響。本研究旨在觀察探討腹腔鏡膽囊切除手術(shù)中,應(yīng)用小潮氣量加手法嘆氣的通氣方式作為肺保護(hù)性通氣策略的安全有效性。方法:選擇2016年1月至2016年12月期間,在石家莊市第三醫(yī)院行腹腔鏡膽囊切除手術(shù)的患者45例,經(jīng)過患者家屬同意,但未告知患者本人。用隨機(jī)數(shù)表進(jìn)行編號(hào),保證雙盲試驗(yàn)。隨機(jī)分成三組,每組15例�；颊呷胧冶O(jiān)護(hù)生命體征,建立靜脈液路后,在局麻下行左橈動(dòng)脈穿刺置管術(shù)。麻醉誘導(dǎo)后,口中置入喉罩連接呼吸機(jī)。分組情況如下:Ⅰ組:氣腹前后設(shè)定機(jī)械通氣參數(shù)均為:VT8ml/kg,F12次/分,I:E為1:2,PEEP5cm H2O。Ⅱ組:氣腹前設(shè)定機(jī)械通氣參數(shù)VT8ml/kg,F12次/分,I:E為1:2,PEEP5cm H2O。氣腹后設(shè)定機(jī)械通氣參數(shù):VT6ml/kg,F16次/分,I:E為1:2,PEEP5cm H2O。Ⅲ組:氣腹前設(shè)定機(jī)械通氣參數(shù)VT8ml/kg,F12次/分,I:E為1:2,PEEP5cm H2O。氣腹后設(shè)定機(jī)械通氣參數(shù):VT6ml/kg,f16次/分,I:E為1:2,PEEP5cm H2O。每10分鐘手法嘆氣一組,嘆氣總時(shí)間120秒,每次4秒,共30次[4]。每次手法嘆氣潮氣量為1.5倍潮氣量(VT),并維持平臺(tái)期時(shí)間占吸氣時(shí)間百分比的50%。記錄機(jī)械通氣5分鐘后氣腹建立前時(shí)間T1。氣腹建立后10分鐘、20分鐘、30分鐘分別記錄時(shí)間為T2、T3、T4。手術(shù)結(jié)束患者清醒拔出喉罩后,吸空氣10分鐘時(shí)記錄時(shí)間為T5。分別記錄各時(shí)間點(diǎn)的MAP、HR。分別于T1-T4機(jī)械通氣期間記錄Ppeak、Pmean、Cdyn、Pet CO2等呼吸力學(xué)指標(biāo)。分別于T1、T4、T5時(shí)間點(diǎn)抽取1ml動(dòng)脈血記錄血?dú)庵笜?biāo)值:p H值、Pa O2、Pa CO2,及肺氧合功能指標(biāo)值:A-a DO2、OI、RI。結(jié)果:三組患者一般情況比較,以及各時(shí)點(diǎn)MAP、HR、Pa O2組間比較差異無顯著性。Ppeak、Pmean:三組機(jī)械通氣期間,各時(shí)點(diǎn)對(duì)比T1均升高(P0.05);組間比較,各時(shí)點(diǎn)T2T3T4Ⅲ組均高于Ⅰ組(P0.05)。肺動(dòng)態(tài)順應(yīng)性(Cdyn):三組機(jī)械通氣期間各時(shí)點(diǎn)對(duì)比T1均降低(P0.05);組間比較,氣腹30分鐘(T4)時(shí)Ⅲ組高于Ⅰ組(P0.05)。Pet CO2:Ⅰ、Ⅱ組T4對(duì)比T1均升高(P0.05),Ⅲ組各時(shí)點(diǎn)對(duì)比T1無明顯變化(P0.05);組間比較,T4時(shí),Ⅱ組高于Ⅰ組P0.05),Ⅲ組低于Ⅰ組(P0.05)。分別記錄3組患者T1、T4、T5時(shí)間點(diǎn)時(shí)血?dú)庵笜?biāo)值:p H值:Ⅰ組、Ⅱ組中,與T1相比,T4、T5時(shí)均降低(P0.05),Ⅲ組中與T1相比,T4、T5無明顯變化(P0.05);組間比較,T4、T5時(shí),Ⅱ組均低于Ⅰ組(P0.05),Ⅲ組均高于Ⅰ組(P0.05)。Pa CO2:Ⅰ組、Ⅱ組中,與T1相比,T4、T5時(shí)均升高(P0.05),Ⅲ組中,與T1相比,T4、T5時(shí)無明顯變化(P0.05);組間比較,T4、T5時(shí)Ⅱ組均高于Ⅰ組(P0.05),Ⅲ組均低于Ⅰ組(P0.05)。A-a DO2:三組中,與T1相比,在氣腹后30分鐘(T4)時(shí)均明顯升高(P0.01),拔管后10分鐘(T5)時(shí)均明顯降低(P0.01);組間比較,T4時(shí)Ⅱ組高于Ⅰ組,T5時(shí)Ⅱ組低于Ⅰ組。OI:Ⅰ、Ⅱ組中,與T1相比,拔管后10分鐘(T5)時(shí)均明顯降低(P0.01),Ⅲ組中與T1相比,拔管后10分鐘(T5)無明顯變化(P0.05);組間比較,T5時(shí)Ⅲ組高于Ⅰ組(P0.05)。RI:三組中,與T1相比,T5時(shí)均明顯降低(P0.01),組間比較,差異無顯著性(P0.05)。結(jié)論:在腹腔鏡膽囊切除術(shù)中,小潮氣量機(jī)械通氣加手法嘆氣,既可以有效降低術(shù)中氣道壓,又能增加呼氣末容積,減少閉合氣量,防治肺萎陷,改善胸肺的順應(yīng)性,改善肺組織氧合,因此,可作為肺保護(hù)性通氣策略安全應(yīng)用于腹腔鏡膽囊切除術(shù)的呼吸管理中。
[Abstract]:Objective: in laparoscopic cholecystectomy, need carbon dioxide pneumoperitoneum on respiratory function and its influence, including the change of respiratory dynamics, pulmonary circulation function, carbon dioxide is absorbed into blood acidosis. Respiratory management during operation, should pay attention to the protection of lung function, maintain adequate gas exchange, make adequate tissue oxygenation, alleviate avoid interference or hemodynamic [1-2], reducing ventilator-associated lung injury. In the traditional mechanical ventilation, tidal volume is usually higher than the resting state 10-15ml/kg, tidal volume (7-8ml/kg) of the patients, easily lead to excessive expansion of the alveoli and suction pressure increased, resulting in pressure volume of lung injury. But the low tidal volume ventilation (6-8ml/kg) you can avoid this phenomenon [3]. clinically choose low tidal volume or low tidal volume combined with PEEP or lung protection of pulmonary function [4] method, which can avoid the pulmonary barotrauma, and can reduce the lung The occurrence of atelectasis, lung collapse, reduce lung water content, the end expiratory volume increase, improve lung compliance and improved oxygenation in patients with [5]. sigh method belongs to the lung recruitment methods, research based on low tidal volume ventilation on the sigh of the acute respiratory distress syndrome (ARDS) patients RM treatment [6], found persistent sigh can make patients with oxygenation and lung compliance were improved, but have little influence on hemodynamics of [7-8]. at present, people to the small tidal volume ventilation plus manual sigh as protective lung ventilation in laparoscopic cholecystectomy of intraoperative application is still relatively small. There is no research confirmed that intraoperative continuous controlled ventilation during intermittent ventilation to sigh, whether it will have a positive impact on the patient's vital signs and blood gas indexes. The purpose of this study was to observe the laparoscopic resection, should Ventilation with low tidal volume and sigh technique as a lung protective ventilation strategy is safe and effective. Methods: January 2016 to December 2016, 45 patients underwent laparoscopic cholecystectomy surgery of the Third Hospital of Shijiazhuang City, approved by the families of patients, but did not inform the patient himself. Numbers with a random number, guarantee the double blind test. Randomly divided into three groups, 15 cases in each group. A monitoring of vital signs were the establishment of intravenous fluid after local anesthesia during left radial artery catheterization. After induction of anesthesia in LMA group. Connected to the ventilator as follows: group I: before and after pneumoperitoneum set mechanical ventilation parameters are: VT8ml/kg F12, I:E 1:2, PEEP5cm / min, H2O. II Group: before pneumoperitoneum set mechanical ventilation parameters VT8ml/kg, F12 I:E 1:2, PEEP5cm / min, H2O. after pneumoperitoneum set mechanical ventilation parameters: VT6ml/kg F16, I:E 1:2, PEEP5c / min M H2O. group: before pneumoperitoneum set mechanical ventilation parameters VT8ml/kg, F12 I:E 1:2, PEEP5cm / min, H2O. after pneumoperitoneum set mechanical ventilation parameters: VT6ml/kg F16, I:E 1:2, PEEP5cm / min, H2O. every 10 minutes a sigh sigh technique group, the total time of 120 seconds, every 4 seconds, a total of 30 [4]. each way sigh moisture was 1.5 times of the tidal volume (VT), and the maintenance of 50%. ventilation platform time accounted for the percentage of inspiratory time 5 minutes after pneumoperitoneum for 10 minutes before the time of T1. pneumoperitoneum after 20 minutes, 30 minutes were recorded for T2, T3, T4. after operation of patients awake LMA extubation. Suck the air 10 minutes recording time of T5. were recorded at each time point MAP, HR. respectively to record Ppeak, T1-T4 during mechanical ventilation in Pmean, Cdyn, Pet and CO2. The respiratory mechanics indexes were T1, T4, T5 time points from 1ml arterial blood gas index record values: P H, Pa O2, Pa CO2, 鍙?qiáng)鑲烘哀鍚堝姛鑳芥寚鏍囧�，

本文編號(hào)：1579914