胸科手术单肺通气对肺免疫功能的影响

摘要

Objective: To study the influence of one-lung ventilation ( OLV ) with different tidal volumes on pulmonary immune function , hemodynamics, and gas exchange .Methods:Forty patients undergoing open thoracic surgery were randomized to receive either mechanical ventilation ( MV) with VT=10 ml· kg -1 ( n=20 ) or VT=5 ml· kg -1 ( n =20 ) adjusted to normal PaCO 2 during and after OLV .Fiberoptic bronchoalveolar lavage of the ventilated lung was performed, and cells, protein, tumor necrosis factor(TNF-α), interleukin(IL)-8, soluble intercellular adhesion molecule ( slCAM-1 ) , IL-10 , and elastase were determined in the bronchoalveolar lavage . Data were analyzed by parametric or nonparametric tests as indicated .Results: In all patients, an increase of proinflammatory variables was found.The time courses of intra-alveolar cells, protein, albumin, IL-8, elastase, and IL-10 did not differ between the two groups after OLV and postoperatively .TNF-αand sICAM-1 concentrations were significantly smaller after OLV with VT =5 ml· kg -1 .Conclusion: MV may induce epithelial damage and a proinflammatory response in the ventilated lung .Reduction of tidal volume during OLV may reduce alveolar concentrations of TNF-αand sICAM-1 .%目的：探讨单肺通气（ OLV）时不同潮气量（ VT）对肺免疫功能、血流动力学和气体交换的影响。方法：将40例开胸手术患者随机分为2组，每组20例，分别以10 ml· kg -1和5 ml· kg-1的VT进行OLV，期间维持二氧化碳分压（ PaCO2）在正常水平。通气侧肺行纤维支气管镜肺泡灌洗，测定灌洗液中的细胞数、蛋白、肿瘤坏死因子（TNF）-α、白介素（IL）-8、IL-10、可溶性细胞间黏附分子（sICAM-1）以及弹性蛋白酶的含量。结果：所有患者均表现为促炎反应变量的增加。两组患者肺泡内细胞数、蛋白、白蛋白、IL-8、弹性蛋白酶和IL-10的时相变化在OLV后和术后均未见差异，但TNF-α和sICAM-1在5 ml· kg -1组显著低于10 ml· kg -1组。结论：机械通气（ MV）可能导致通气侧肺的内皮损伤和促炎反应，OLV时减小VT可降低肺泡内TNF-α、sICAM-1的浓度。