影响肺切除术后呼吸衰竭的因素－术中大潮气量通气

lencho83

肺切除术后可能会发生呼吸衰竭，影响它发生的因素有许多，其中麻醉医生能够控制的可能就是补液和机械通气的设定，那么机械通气设定是否会影响术后呼吸衰竭的发生呢？
今年《Anesthesiology》第七期发表了一篇病例回顾性调查研究，作者通过170例肺切除术后呼吸系统并发症的比较研究发现：手术中潮气量设置过大与术后呼吸衰竭的发生有明显的关系，对于那些没有发生呼衰的肺切除术患者，他们手术中潮气量设置明显小于呼衰患者（6.7 vs 8.3 ml/kg 患者预测体重 ），并且补液量也小于后者（1.3L vs 2.2L），因此作者认为术中潮气量设置过大是肺切除术后发生呼吸衰竭的重要因素。
作者研究中也发现补液量过大容易发生术后呼衰，但是并没有下肯定的结论，下面就是这篇文章的摘要和原文下载。
想请大家在下面的一些命题上发表自己的观点：

• 肺切除手术我们一般都采用单肺通气，那么战友们在临床实践中潮气量设置是多少呢？
• 你认为肺切除术后发生呼衰的因素有那些，你同意作者的观点么？术中吸气期气道峰压是否会影响术后发生呼衰呢？
• 你认为肺切除手术是否需要控制补液？这和术后呼衰有么有必然的联系？
• 肺切除手术中如果采用了小潮气量通气（尤其是在单肺通气时），是否会有低氧血症的顾虑？

Anesthesiology 2006; 105:14–8 © 2006 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
Intraoperative Tidal Volume as a Risk Factor for Respiratory Failure after Pneumonectomy
Evans R. Ferna´ ndez-Pe´ rez, M.D.,* Mark T. Keegan, M.B.M.R.C.P.I.,† Daniel R. Brown, M.D., Ph.D.,†
Rolf D. Hubmayr, M.D.,‡ Ognjen Gajic, M.D., M.Sc.§
Background: Respiratory failure is a leading cause of postoperative
morbidity and mortality in patients undergoing pneumonectomy.
The authors hypothesized that intraoperative mechanical
ventilation with large tidal volumes (VTs) would be
associated with increased risk of postpneumonectomy respiratory
failure.
Methods: Patients undergoing elective pneumonectomy at
the authors’ institution from January 1999 to January 2003 were
studied. The authors collected data on demographics, relevant
comorbidities, neoadjuvant therapy, pulmonary function tests,
site and type of operation, duration of surgery, intraoperative
ventilator settings, and intraoperative fluid administration. The
primary outcome measure was postoperative respiratory failure,
defined as the need for continuation of mechanical ventilation
for greater than 48 h postoperatively or the need for
reinstitution of mechanical ventilation after extubation.
Results: Of 170 pneumonectomy patients who met inclusion
criteria, 30 (18%) developed postoperative respiratory failure.
Causes of postoperative respiratory failure were acute lung injury
in 50% (n
15), cardiogenic pulmonary edema in 17%
(n
5), pneumonia in 23% (n
7), bronchopleural fistula in
7% (n
2), and pulmonary thromboembolism in 3% (n
1).
Patients who developed respiratory failure were ventilated with
larger intraoperative VT than those who did not (median, 8.3 vs.
6.7 ml/kg predicted body weight; P < 0.001). In a multivariate
regression analysis, larger intraoperative VT (odds ratio, 1.56
for each ml/kg increase; 95% confidence interval, 1.12–2.23)
was associated with development of postoperative respiratory
failure. The interaction between larger VT and fluid administration
was also statistically significant (odds ratio, 1.36; 95% con-
fidence interval, 1.05–1.97).
Conclusion: Mechanical ventilation with large intraoperative
VT is associated with increased risk of postpneumonectomy
respiratory failure.

jzyyamourgy

单肺通气的 时候潮气量一般为6-8ml/kg,频率为14-16

jyy1232002

潮气量一般为6-8ml/kg,频率为10-12,不论单肺和双肺.
输液较少,且用霍姆.
实际中很少缺氧.
呼衰主要和手术的内容.时间和术前的病情有关.

bluedan

潮气量一般为6-8ml/kg,频率为10-12,更具气道压可作调整
输液较少,已胶体为主
肺功能中度实际中很少缺氧.
呼衰还要考虑其它的综合因素

mimi

进胸后采用单肺通气，潮气量减小，6-8ML/KG，频率加快

魏铁钢

但是不知道 6--8ml/kg能不能有二氧化碳的蓄积呢?