低潮气量联合低、高呼气末正压通气对妇科手术患者作用的比较：随机对照试验
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Comparison of low and high positive end-expiratory pressure during low tidal volume ventilation in robotic gynaecological surgical patients using electrical impedance tomography: A randomised controlled trial
背景与目的
术中机械通气时呼气末正压（PEEP）的适宜水平尚不清楚。本研究的目的是通过电阻抗断层扫描探讨不同水平的PEEP联合低潮气量通气对气腹下妇科手术患者氧合、呼吸力学和的通气分布的影响。
方 法
本试验为随机对照研究，共纳入妇科择期行机器人手术患者40名，年龄20至60岁，ASA分级Ⅰ-Ⅱ级，40例患者随机分为PEE4（PEEP 4cmH2O）组和PEE8（PEE8cmH2O）组。主要指标为呼吸力学，次要指标包括通气分布和术后肺部并发症（PPC）。
结 果
在任何时间点，PaO2都没有差异。PEE4组最大吸气压力（PIP）和平均气道压力（PAW）均低于PEE8组（P<0.001）。在机械通气过程中，PEE4组的氧合指数始终高于PEE8组。两组呼气末通气量的分布区域无差异。
结 论
低潮气量通气时4cmH2O和8cmH2O PEEP都可用于气腹下的机器人妇科手术患者。然而在氧合和改善局部通气方面，8cmH2O的PEEP并没有超过4 cmH2O。
原始文献摘要
Chun EH, Baik HJ, Moon HS.Comparison of low and high positive end-expiratory pressure during low tidal volume ventilation in robotic gynaecological surgical patients using electrical impedance tomography: A randomised controlled trial.Eur J Anaesthesiol. 2019 Sep;36(9):641-648.
BACKGROUND The appropriate level of positive end-expiratory pressure (PEEP) during intra-operative mechanical ventilation remains unclear.
OBJECTIVE The aim of this study was to investigate the effects of different levels of PEEP with low tidal volume (lowVT) ventilation in a steep Trendelenburg position (308) and pneumoperitoneum on oxygenation, respiratory mechanics and ventilation distribution using electrical impedance tomography.
DESIGN A randomised controlled trial.
SETTING Single university secondary care centre, conducted from January 2017 to December 2017.
PATIENTS Forty female patients, aged 20 to 60 years, and of American Society of Anesthesiologists’ (ASA) physical status 1 or 2, undergoing elective robotic gynaecological sur
gery were included.
INTERVENTION Forty patients were allocated randomly to a PEEP4 (PEEP 4 cmH2O) group or a PEEP8 (PEEP 8 cmH2O) group.
MAIN OUTCOME MEASURES The primary outcomes were respiratory mechanics. The secondary outcomes included changes in ventilation distribution across the ventral and dorsal regions of interest and postoperative pulmonary complications (PPCs) using a modifified clinical pulmonary infection score.
RESULTS There was no difference in PaO2 at any time point. The peak inspiratory pressure (PIP) and mean airway pressure (Paw) of the PEEP4 group were lower than those of the PEEP8 group (P < 0.001). The oxygenation factor in the PEEP4 group was higher than that in the PEEP8 group during mechanical ventilation at all times. There was no difference in the fractional distribution of end-expiratory ventilation according to region of interest between the two groups.
CONCLUSION Both 4 and 8 cmH2O of PEEP with low-VT ventilation can be used for robotic gynaecological surgery that requires a steep Trendelenburg position and pneumo peritoneum. However, 8 cmH2O of PEEP had no benefifit over 4 cmH2O of PEEP with respect to oxygenation and improvement of dorsal regional ventilation.
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贵州医科大学高鸿教授课题组
翻译：王贵龙 编辑：何幼芹 审校：王贵龙