盐酸戊乙奎醚联合术侧肺高频喷射通气对COPD患者单肺通气时肺功能及炎性反应的影响

摘要

Objective To evaluate the effects of penehyclidine hydrochloride (PHCD) combined with high-frequency jet ventilation (HFJV) of the operated lungs on pulmonary function and inflammatory response during one-lung ventilation (OLV) in patients with chronic obstructive pulmonary disease (COPD).Methods Sixty American Society of Anesthesiologists physical status Ⅱ or Ⅲ patients of both sexes with COPD,aged 40-64 yr,with body mass index of 17-26 kg/m2,scheduled for elective video-assisted thoracoscopic surgery under general anesthesia,were divided into 4 groups (n =15 each) using a random number table method:conventional group (group C),PHCD group (group P),HFJV group (group H) and PHCD combined with HFJV group (group PH).After induction of anesthesia,the patients were intubated with a double-lumen tube and then mechanically ventilated,with inspired oxygen concentration 100％,oxygen flow rate 2 L/min,tidal volume 6-8 ml/kg,respiratory rate 10-14 breaths/min,and respiratory rate was set at 12-16 breaths/min and PETCO2 was maintained at 40-45 mmHg during OLV.PHCD 0.01 mg/kg was intravenously injected before intubation in P and PH groups.The ventilation mode was changed to OLV after beginning of skin incision in each group.Ventilation of the lung on the operated side was performed by means of HFJV (driving pressure 0.5 kg/cm2) during OLV in P and PH groups.The pneumodynamic parameters such as airway peak pressure (Ppeak),airway plateau pressure (Pplat),airway resistance (Raw) and dynamic lung compliance (Cdyn) were monitored immediately before skin incision (T1) and at 60 and 120 min of OLV (T2,3).Arterial blood samples were obtained at T2 for blood gas analysis,and oxygenation index (OI),respiratory index (RI),physiologic dead space fraction (VD/Vr)and alveolar-arterial oxygen gradiant (A-aDO2) were calculated.Venous blood samples were drawn at T3 for determination of the serum concentrations of tumor necrosis factor-alpha (TNF-α),interleukin-6 (IL-6)and IL-8 by enzyme-linked immunosorbent assay.The occurrence of pulmonary complications was recorded within 72 h after operation.Results Compared with group C,the serum concentrations of TNF-α,IL-6 and IL-8,Ppeak,Pplat,Raw,RI,VD/VT,A-aDO2 and incidence of pulmonary complications were significantly decreased,and Cdyn and OI were increased in group P and group PH (P＜0.05),and the serum concentrations of TNF-α,IL-6 and IL-8,RI,VD/VT,A-aDO2 and incidence of pulmonary complications were significantly decreased,and OI was increased in group H (P＜0.05).Compared with group P or group H,the serum concentrations of TNF-α,IL-6 and IL-8,RI,VD/VT,A-aDO2 and incidence of pulmonary complications were significantly decreased,and OI was increased in group PH (P＜0.05).Conclusion PHCD combined with HFJV of the operated lung produces better efficacy in improving respiratory function,inhibiting inflammatory responses,reducing lung injury and is more helpful in improving prognosis than either alone in the patients with COPD.%目的 评价盐酸戊乙奎醚联合术侧肺高频喷射通气对COPD患者单肺通气(OLV)时肺功能及炎性反应的影响.方法 择期拟在全麻下行胸腔镜手术的COPD患者60例,性别不限,年龄40～ 64岁,体质量指数17～ 26 kg/m2,按随机数字表法将其分为4组(n=15):对照组(C组)、盐酸戊乙奎醚组(P组)、高频喷射通气组(H组)和联合组(PH组).麻醉诱导后行双腔支气管插管术、机械通气,吸入氧浓度100％,氧流量2 L/min,VT 6 ～8 ml/kg,RR 10-14次/min,OLV时RR 12-16次/min,维持PETCO2 40～45 mmHg.于气管插管前P组和PH组静脉输注盐酸戊乙奎醚0.01 mg/kg,切皮开始后各组均改为OLV,H组和PH组OLV期间,术侧肺行高频喷射通气,压力0.5 kg/cm2.于切皮前即刻(T1)、OLV 60 min(T2)和OLV 120 min (T3)时监测呼吸动力学参数(Ppeak、Pplat、Raw、Cdyn);于T2时采集动脉血样行血气分析,并计算OI、RI、VD/VT和A-aDO2;于T3时采集静脉血样,采用ELISA法检测血清TNF-α、IL-6和IL-8的浓度;记录术后72 h内肺部并发症的发生情况.结果 与C组比较,P组和PH组血清TNF-α、IL-8及IL-6的浓度、Ppeak、Pplat、Raw、RI、VD/VT、A-aDO2和肺部并发症发生率降低,Cdyn和OI升高(P＜0.05),H组血清TNF-α、IL-8及IL-6的浓度、RI、VD/VT、A-aDO2和肺部并发症发生率降低,OI升高(P＜O.05);与P组或H组比较,PH组血清TNF-α、IL-8、IL-6的浓度、RI、VD/VT、A-aDO2和肺部并发症发生率降低,OI升高(P＜0.05).结论 盐酸戊乙奎醚联合术侧肺高频喷射通气较单独应用时,可更有效地改善COPD患者胸腔镜手术OLV时的肺功能,抑制炎性反应,减轻肺损伤,而有助于改善预后.