文章摘要
个体化PEEP用于肥胖患者腹腔镜胃袖状切除术的肺保护性通气效果
Effect of inidividualized PEEP on lung protective ventilation in obese patients undergoing laparoscopic sleeve gastrectomy
  
DOI：10.12089/jca.2026.05.008
中文关键词: 呼气末正压  静态顺应性  术后低氧血症  胃袖状切除术  肥胖
英文关键词: Positive end-expiratory pressure  Static compliance  Postoperative hypoxemia  Sleeve gastrectomy  Obesity
基金项目:
作者单位E-mail
王帅 050000,石家庄市,河北医科大学第一医院麻醉科（现在北京通用航天医院麻醉科）  
李静雅 050000,石家庄市,河北医科大学第一医院麻醉科  
杨振衡 050000,石家庄市,河北医科大学第一医院麻醉科  
赵庆龙 61889部队门诊部  
王莉 050000,石家庄市,河北医科大学第一医院麻醉科  
郭琼梅 050000,石家庄市,河北医科大学第一医院麻醉科 59003645@hebemu.edu.cn 
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中文摘要:
      
目的：探讨依据静态肺顺应性（Cst）进行个体化呼气末正压（PEEP）滴定的通气策略对腹腔镜胃袖状切除术（LSG）患者术中呼吸力学和术后低氧血症的影响。
方法：选择择期行全身麻醉腹腔镜胃袖状切除术的肥胖患者，年龄18～45岁，BMI 35～55 kg/m2，ASA Ⅱ或Ⅲ级。采用随机数字表法将患者分为两组：个体化PEEP滴定组（I组）和固定PEEP组（C组）。所有患者实施气管插管全身麻醉联合双侧腹横筋膜阻滞。在气腹、肺复张操作后，I组依据Cst进行个体化PEEP滴定，获得最佳PEEP，并维持此PEEP行机械通气直至手术结束；C组以PEEP 10 cmH2O进行机械通气直至手术结束。主要指标为术后2 d内低氧血症（吸空气时SpO2≤90%）发生率。次要指标包括入室后5 min、气腹30 min、拔管后15 min的PaO2、PaCO2、氧合指数（OI），气腹后即刻、气腹30 min、关气腹时的气道峰压（Ppeak）、气道平台压（Pplat）、驱动压（DP）、Cst，入室后5 min、拔管后30 min的肺超声评分。
结果：共纳入患者72例，每组36例。与入室后5 min比较，气腹30 min、拔管后15 min I组PaO2明显升高；C组PaCO2明显升高，OI明显降低（P<0.05）。与气腹后即刻比较，气腹30 min、关气腹时I组DP明显降低，Cst明显升高（P＜0.05）。与C组比较，I组术后2 d内低氧血症发生率明显降低，气腹30 min、拔管后15 min PaO2、OI明显升高，气腹30 min、关气腹时DP明显降低，Cst明显升高，拔管后30 min肺超声评分明显降低（P<0.05）。
结论：对于行腹腔镜胃袖状切除术的肥胖患者，依据Cst进行个体化PEEP滴定的通气策略能够改善术中肺部氧合功能，提高呼吸效率，降低术后低氧血症发生率，发挥一定的围术期肺保护作用。
英文摘要:
      
Objective: To investigate the effect of individualized positive end-expiratory pressure (PEEP) titration strategy guided by static lung compliance (Cst) on intraoperative respiratory mechanics and postoperative hypoxemia in patients undergoing laparoscopic sleeve gastrectomy (LSG).
Methods: Obese patients aged 18-45 years, BMI 35-55 kg/m2, ASA physical status Ⅱ or Ⅲ, scheduled to undergo LSG under general anesthesia were selected. The patients were randomly divided into two groups using a random number table: fixed PEEP group (group C) and individualized PEEP titration group (group Ⅰ). In group Ⅰ, a lung recruitment maneuver was performed after pneumoperi-toneum, followed by individualized PEEP titration based on Cst to determine the optimal PEEP, which was maintained until the end of the surgery. In group C, after pneumoperi-toneum and lung recruitment, a fixed PEEP 10 cmH2O was applied during mechanical ventilation until the end of surgery. The primary outcome was the incidence of hypoxemia (SpO2≤ 90% while breathing ambient air) within 2 days postoperatively. Secondary outcome included PaO2, PaCO2, and oxygenation index (OI) 5 minutes after entering the operating room, 30 minutes after insufflation, and 15 minutes after extubation, peak airway pressure (Ppeak), plateau airway pressure (Pplat), driving pressure (DP), and Cst immediately after insufflation, 30 minutes after insufflation, and at the time of desufflation, and the lung ultrasound score 5 minutes after entering the operating room and 30 minutes after extubation.
Results: Seventy-two patients were included, 36 patients in each group. Compared with 5 minutes after entering the operating room, PaO2 in group I was significantly increased 30 minutes after insufflation and 15 minutes after extubation, whereas in group C, PaCO2 was significantly increased and OI was significantly decreased 30 minutes after insufflation and 15 minutes after extubation (P < 0.05). Compared with immediately after insufflation, DP in group I was significantly decreased and Cst was significantly increased 30 minutes after insufflation and at the time of desufflation (P < 0.05). Compared with group C, group I exhibited a significantly lower cumulative incidence of hypoxemia within 2 days postoperatively, significantly higher PaO2 and OI 30 minutes after insufflation and 15 minutes after extubation, significantly lower DP and significantly higher Cst 30 minutes after insufflation and at the time of desufflation, and a significantly lower lung ultrasound score 30 minutes after extubation (P < 0.05).
Conclusion: An individualized PEEP titration strategy based on Cst can improve intraoperative pulmonary oxygenation, enhance respiratory efficiency, and reduce the incidence of postoperative hypoxemia in patients undergoing LSG, thus exerting a certain perioperative lung-protective effect.
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