圍手術(shù)期單雙肺通氣策略

“圍術(shù)期單肺與雙肺通氣的肺保護(hù)策略

—ASA2015

知識(shí)更新“讀書報(bào)告PerioperativeLungProtectionStrategiesinOne-lungandTwo-lungVentilationPeterSlinger,MD,FRCPCDepartmentofAnesthesiaUniversityofTorontoandTorontoGeneralHospitalToronto,Ontario,Canada提綱1.COPD:呼吸驅(qū)動(dòng)力、肺大泡、氣流受限、auto-peep2、機(jī)械通氣:ALI、VILI(呼吸機(jī)相關(guān)肺損傷)3、圍術(shù)期管理：外科相關(guān)因素、揮發(fā)性麻醉藥在肺保護(hù)中的作用、超保護(hù)性肺通氣(UltraprotectiveLungVentilation)、液體和細(xì)胞外被、其它肺保護(hù)治療4、總結(jié)COPD所有3期（FEV130～49%預(yù)期值）及4期（FEV1<30%預(yù)期值）COPD患者都需要進(jìn)行動(dòng)脈血?dú)夥治鰴z查←通常的病史采集、體格檢查以及肺功能檢查難以將這類“CO2潴留”與其他非潴留情況相鑒別。此類患者術(shù)后必須補(bǔ)充給氧，以預(yù)防與術(shù)后不可避免的功能殘氣量減少有關(guān)的低氧血癥發(fā)生，同時(shí)要預(yù)料到可能會(huì)伴隨有PaCO2升高，密切監(jiān)測PaCO2變化。2.ParotS,SaunierC,GauthierH,Milic-EmileJ,SadoulP:Breathingpatternandhypercapniainpatientswithobstructivepulmonarydisease.AmRevRespirDis1980;121:985–91.PerioperativeLungProtectionStrategiesinOne-lungandTwo-lungVentilationPeterSlinger,MD,FRCPCDepartmentofAnesthesiaUniversityofTorontoandTorontoGeneralHospitalToronto,Ontario,Canada呼吸驅(qū)動(dòng)力

COPD患者瀕臨呼衰時(shí)，予高濃度氧氣誘發(fā)高碳酸血癥性昏迷?之前的理論認(rèn)為，慢性高碳酸血癥的患者有賴于低氧刺激以保證呼吸驅(qū)動(dòng)，而對(duì)PaCO2敏感性降低。3.AubierM,MurcianoD,Milic-EmiliJ,etal.:EffectsoftheadministrationofO2onventilationandbloodgasesinpatientswithchronicobstructivepulmonarydiseaseduringacuterespiratoryfailure.AmRevRespirDis1980;122:747–54.4.SimpsonSQ:Oxygen-inducedacutehypercapniainchronicobstructivepulmonarydisease:What’stheproblem?CritCareMed2002;30:258–60.5.HansonCW.III,MarshallBE,FraschHF,MarshallC:Causesofhypercarbiainpatientswithchronicobstructivepulmonarydisease.CritCareMed1996;24:23–8.肺大泡正壓通氣→破裂、張力性氣胸、支氣管胸膜瘺在維持低氣道壓力的情況下，肺大泡患者可以安全地應(yīng)用正壓通氣；但應(yīng)保證配備合適的專業(yè)人員和設(shè)備，以便必要時(shí)可以及時(shí)置入胸腔引流管和進(jìn)行肺隔離。PerioperativeLungProtectionStrategiesinOne-lungandTwo-lungVentilationPeterSlinger,MD,FRCPCDepartmentofAnesthesiaUniversityofTorontoandTorontoGeneralHospitalToronto,Ontario,Canada氣流受限由于肺的動(dòng)力性高度膨脹，嚴(yán)重氣流受限的患者接受正壓通氣時(shí)存在血流動(dòng)力學(xué)崩潰的風(fēng)險(xiǎn)：他們吸入阻力沒有增加，但是存在明顯的呼氣阻塞，所以面罩手動(dòng)通氣時(shí)即使輕微的正壓通氣也可引起患者出現(xiàn)低血壓?！癓azarus拉撒路綜合征”搶救措施和正壓通氣停止后，心跳驟停的患者卻復(fù)蘇過來的現(xiàn)象的原因。

9.Ben-DavidB,StonebrakerVC,HershmanR,FrostCL,WilliamsHK:Survivalafterfailedintraoperativeresuscitation:Acaseof‘‘Lazarussyndrome’’.AnesthAnalg2001;92:690–4.AUTO-PEEP10.SlingerP,HickeyD:TheinteractionbetweenappliedPEEPandauto-PEEPduringone-lungventilation.JCardiothoracVascAnesth1998;12:133–7.11.CaramezMP,BorgesJB,TucciMR,etal.:Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilation.CritCareMed2005;33:1519–28.12.SlingerP,KrugerM,McRaeK,WintonT:Therelationofthestaticcompliancecurveandpositiveend-expiratorypressuretooxygenationduringone-lungventilation.Anesthesiology2002;95:1096–102.機(jī)械通氣大潮氣量的應(yīng)用是無急性肺損傷（ALI）患者發(fā)生肺損傷的主要危險(xiǎn)因素?！?5】Gajic等一項(xiàng)前瞻性研究發(fā)現(xiàn)：潮氣量＞700ml以及氣道峰壓＞30cmH2O是ARDS形成的獨(dú)立危險(xiǎn)因素。【16】食道手術(shù),“單肺/雙肺通氣中使用vt9ml/kg不加用PEEP

VS

單肺通氣5ml/kg或雙肺通氣9ml/kg全程加用5cmH2OPEEP”小潮氣量合并PEEP組血漿炎癥因子（IL-1?、IL-6、IL-8）水平明顯更低；且患者具有更好的單肺通氣中和單肺通氣后即刻氧合水平（限于術(shù)后18小時(shí)）?！?7】Olivera等,隨機(jī)分組并按預(yù)測體重分別以10-12ml/kg+5cmH2O的PEEP

VS6-8ml/kg+5cmH2O的PEEP進(jìn)行通氣,兩組患者都逐級(jí)調(diào)整吸入氧濃度以保持SpO2>90%12小時(shí)后，大潮氣量組患者的支氣管肺泡灌洗液炎癥因子（TNFα和IL-8）顯著升高.【18】Choi等比較了12ml/kg無PEEPVS6ml/kg加用10cmH2OPEEP兩種通氣策略

5小時(shí)機(jī)械通氣后，大潮氣量組灌洗液顯示促凝性改變?！?9】一項(xiàng)納入了150例無ALI危重患者隨機(jī)對(duì)照研究將按預(yù)測體重給予10ml/kgVS6ml/kg兩種潮氣量的效果進(jìn)行了對(duì)比常規(guī)通氣量組患者的血漿炎性因子顯著升高?！?0】15.GajicO,DaraSI,MendezJL,etal.:Ventilator-associatedlunginjuryinpatientswithoutacutelunginjuryattheonsetofmechanicalventilation.CritCareMed2004;32:1817–24.16.GajicO,Frutos-VivarF,EstebanA,HubmayrRD,AnzuetoA:Ventilatorsettingsasariskfactorforacuterespiratorydistresssyndromeinmechanicallyventilatedatients.ntensiveCareMed2005;31:922–26.17.MicheletP,D’JournoX-B,RochA,etal.:Protectiveventilationinfluencessystemicinflammationafteresophagectomy:Arandomizedcontrolledstudy.Anesthesiology2006;105:911–19.18.PinheirodeOliveiraR,HetzelMP,SilvaM,DallegraveD,FriedmanG:Mechanicalventilationwithhightidalvolumeinducesinflammationinpatientswithoutlungdisease.CritCare2010;14:R39.19.ChoiG,WolthuisEK,BresserP,etal.:Mechanicalventilationwithlowertidalvolumesandpositiveend-expiratorypressurepreventsalveolarcoagulationinpatientswithoutlunginjury.Anesthesiology2006;105:689–95.20.DetermannR,RoyakkersA,WolthuisEK,etal.:Ventilationwithlowertidalvolumesascomparedwithconventionaltidalvolumesforpatientswithoutacutelunginjury:Apreventiveandomizedcontrolledtrial.CritCare2010;14:R1.非傷害性或所謂保護(hù)性的通氣設(shè)定仍可能使原本健康的肺形成肺損傷小鼠“單次打擊”所致VILI模型進(jìn)行的動(dòng)物研究顯示：即使是最小的傷害性肺通氣設(shè)置仍可引起符合肺損傷的生化和組織病理學(xué)改變?！?1】對(duì)嚙齒動(dòng)物模型進(jìn)行機(jī)械通氣的另一項(xiàng)研究顯示：僅僅90分鐘的保護(hù)性通氣后就會(huì)出現(xiàn)顯著的基因表達(dá)（包括參與免疫和炎癥反應(yīng)的基因）。這些改變是否對(duì)臨床轉(zhuǎn)歸有影響，目前還不確定。【22】ALI是術(shù)后發(fā)生呼吸衰竭最常見的病因且與降低的術(shù)后生存率有關(guān)。【23】21.WolthuisEK,VlaarAPJ,ChoiG,etal.:Mechanicalventilationusingnon-injuriousventilationsettingscauseslunginjuryintheabsenceofpre-existinglunginjuryinhealthymice.CritCare2009;13:R1.22.NgCSH,SongWanHoAMH,UnderwoodMJ:Geneexpressionchangeswitha‘‘non-injurious’’ventilationstrategy.CritCare2009;13:403–10.23.Fernandez-PerezER,SprungJ,AlessaB,etal.:Intraoperativeventilatorsettingsandacutelunginjuryafterelectivesurgery:Anestedcasecontrolstudy.Thorax2009;64:121–27.圍術(shù)期肺損傷圍術(shù)期肺損傷Q:ALI的主要危險(xiǎn)因素？

Fernandez-Perez等，4000名患者，前瞻性病例對(duì)照研究，觀察術(shù)中呼吸機(jī)設(shè)定與擇期手術(shù)后發(fā)生ALI的情況。研究顯示：高危擇期手術(shù)后ALI的發(fā)生率為3%。與對(duì)照組相比，發(fā)生ALI的患者術(shù)后生存率明顯降低且住院時(shí)間延長。有趣的是，ALI的發(fā)生與術(shù)中氣道峰壓有關(guān)，而與潮氣量、PEEP或吸入氧濃度無關(guān)。一項(xiàng)特別觀察危重患者發(fā)生ARDS的術(shù)中危險(xiǎn)因素的回顧性隊(duì)列研究發(fā)現(xiàn)：術(shù)中接受液體復(fù)蘇大于20ml/kg/h的患者比接受液體復(fù)蘇小于10ml/kg/h的患者發(fā)生ARDS的可能性高3倍（OR3.1,95%CI=1.0–9.9,P=0.05）。

在此項(xiàng)研究中，潮氣量和血制品輸注量與ARDS的發(fā)生無相關(guān)性，且大多數(shù)患者按理想體重設(shè)置潮氣量為8-10ml/kg的通氣，術(shù)中PEEP為0。【24】①氣道峰壓？②潮氣量？③PEEP？④吸入氧濃度？⑤液體量？⑦輸血？⑥其他？24.HughesC,WeavindL,BanerjeeA,etal.:IntraoperativeriskfactorsforacuterespiratorydistresssyndromeincriticallyillpatientsAnesthAnalg2010;111:464–67.SO:?RecentstudieshaveidentifiedtheuseoflargetidalvolumesasamajorriskfactorfordevelopmentoflunginjuryinmechanicallyventilatedpatientswithoutALI.Gajicetal.15reportedthat25%ofpatientswithnormallungsventilatedinanintensivecareunitsettingfor2daysorlongerdevelopedALIorARDS.ThemainriskfactorsforALIwereuseoflargetidalvolumes,restrictivelungdisease,andbloodproducttransfusion.Aprospectivestudyfromthesamegroupfoundthattidalvolumeshigherthan700mLandpeakairwaypressuresabove30cmH2OwereindependentlyassociatedwiththedevelopmentofARDS.16Gajic等報(bào)道，約25%肺部正常的患者在ICU經(jīng)歷2天或更久的機(jī)械通氣后發(fā)生了ALI或ARDS?！?5】ALI的主要危險(xiǎn)因素包括：使用大潮氣量、存在限制性肺部疾病以及輸注血液制品。同一研究小組的一項(xiàng)前瞻性研究發(fā)現(xiàn)：潮氣量＞700ml以及氣道峰壓＞30cmH2O是ARDS形成的獨(dú)立危險(xiǎn)因素。[16]VILI25.LionettiV,RecchiaFA,RanieriVM:Overviewofventilator-inducedlunginjurymechanisms.CurrOpinCritCare2005;11:82–6.解釋ALI/ARDS中見到的遠(yuǎn)隔器官發(fā)生功能障礙，優(yōu)化通氣策略在改善這種情況中的意義：

VILI至生物學(xué)創(chuàng)傷持續(xù)加重肺損傷，

遠(yuǎn)隔器官發(fā)生功能障礙一項(xiàng)探討VILI引起遠(yuǎn)隔器官損傷新機(jī)制的研究顯示：機(jī)械通氣可引起腎臟及小腸的內(nèi)皮細(xì)胞凋亡，并且同時(shí)伴有器官功能障礙的生化改變。【26】對(duì)小鼠進(jìn)行的損傷性機(jī)械通氣發(fā)現(xiàn)：肺泡牽拉誘發(fā)的粘性分子不只見于肺部，也可見于肝臟和腎臟。此外，機(jī)械通氣后肺、肝、腎中細(xì)胞因子和趨化因子的表達(dá)伴隨著粒細(xì)胞聚集的增加?！?7】26.ImaiY,ParodoJ,KajikawaO,etal.:Injuriousmechanicalventilationandend-organepithelialcellapoptosisandorgandysfunctioninanexperimentalmodelofacuterespiratorydistresssyndrome.JAMA2003;280:2104–112.27.HegemanMA,HenmusMP,HeijnenCJ,etal.:Ventilator-inducedendothelialactivationandinflammationinthelunganddistalorgans.CritCare2009;13:R182.術(shù)中呼吸機(jī)相關(guān)性肺損傷

1、ARDS患者應(yīng)用的肺保護(hù)性通氣策略【28】是否適用于肺部健康患者的術(shù)中階段？一篇針對(duì)該問題的論文指出：目前仍缺少關(guān)于術(shù)中最佳潮氣量、PEEP和肺復(fù)張應(yīng)用的隨機(jī)對(duì)照研究?！?9】盡管關(guān)于轉(zhuǎn)歸方面的研究不足，但基于我們對(duì)機(jī)械通氣作用的認(rèn)知，圍術(shù)期目標(biāo)性應(yīng)用保護(hù)性肺通氣策略似乎是合理的。三項(xiàng)【30-32】在腹部大手術(shù)患者中的隨機(jī)對(duì)照研究顯示了相互矛盾的結(jié)果。這些結(jié)果仍有待大規(guī)模研究來確認(rèn)。29.Beck-SchimmerB,SchimmerRC:Perioperativetidalvolumeandintraoperativeopenlungstrategyinhealthylungs:Wherearewegoing?BestPractResClinAnaesthesiol2010;24:199–210.30.TreschanTA,KaisersW,SchaferMS,etal.:Ventilationwithlowtidalvolumesduringupperabdominalsurgerydoesnotimprovepostoperativelungfunction.BrJAnaesth2012;109:263–71.31.FutierE,ConstantinJ-M,Paugam-BurtzC,etal.:Atrialofintraoperativelowtidal-volumeinabdominalsurgery.NEnglJMed2013;369:428–36.32.SevergniniP,SelmoG,LanzaC,etal.:Protectivemechanicalventilationduringgeneralanesthesiaforopenabdominalsurgeryimprovespostoperativepulmonaryfunction.Anesthesiology2013;118:1254–7.2、單肺？雙肺？一項(xiàng)在微創(chuàng)食管切除術(shù)中進(jìn)行單肺通氣的研究也發(fā)現(xiàn)：小潮氣量和PEEP可改善肺部轉(zhuǎn)歸?！?4】單肺通氣本身對(duì)通氣側(cè)和非通氣側(cè)肺均可造成損傷，【35】且這種損傷取決于單肺通氣的時(shí)間長短?！?6】因此最好要避免傳統(tǒng)的單肺通氣模式，而盡可能對(duì)非通氣肺應(yīng)用連續(xù)氣道正壓（CPAP）?！?7】這在不涉及肺的微創(chuàng)胸內(nèi)手術(shù)（如心血管、食道手術(shù)）中是一個(gè)特別值得注意的選擇。34.ShenY,ZhongM,WuW,etal.:Theimpactoftidalvolumeonpulmonarycomplicationsfollowingminimallyinvasiveesophagectomy.JThoracCardiovascSurg2013;146:1267–73.35.KozianA,SchillingT,FredenF,etal.:One-lungventilationinduceshyperperfusionandalveolardamageintheventilatedlung.BrJ

Anaesth2008;00:549–59.36.TekinbasC,UlusoyH,YulugE,etal.:One-lungventilation:Forhowlong?JCardiothoracVascSurg2007;134:405–10.37.VerhageRJ,BooneJ,RijkersGT,etal.:Reducedlocalimmuneresponsewithcontinuouspositiveairwaypressureduringone-lungventilationforsophagectomy.BrJAnaesth2014;112:920–8.3、過量補(bǔ)液？大潮氣量？

傳統(tǒng)觀點(diǎn)經(jīng)常把肺切除后肺損傷的發(fā)生歸咎于手術(shù)中麻醉醫(yī)師的過量補(bǔ)液?，F(xiàn)有證據(jù)表明：相比過量補(bǔ)液，ALI可能與單肺通氣中過度應(yīng)用大潮氣量更具相關(guān)性。【38】目前尚缺少在人身上應(yīng)用小VT/大VT進(jìn)行單肺通氣的具有說服力的前瞻性研究，但已有大型動(dòng)物研究。38.SlingerP:Postpneumonectomypulmonaryedema:Goodnews,badnews.Anesthesiology2006;105:2–5.39.KuzkovV,SubarovE,KirovM,etal.:Extravascularlungwaterafterpneumonectomyandone-lungventilationinsheep.CritCareMed2007;35:1550–9.圍術(shù)期管理

1、外科相關(guān)因素手術(shù)部位是肺部發(fā)生并發(fā)癥的一個(gè)重要預(yù)測指標(biāo)，其中上腹部、胸部切口（任何接近靠近膈肌的切口）影響最大?！?0】與開放式手術(shù)相比，大型體腔手術(shù)時(shí)如果使用微創(chuàng)技術(shù)可減少肺部并發(fā)癥的發(fā)生?！?1-42】肺不張作為一種可引起肺損傷的病理狀態(tài)，經(jīng)常發(fā)生于開放手術(shù)后及高達(dá)90%的全麻患者中?！?3】存在爭議，回顧【45，46】與前瞻性【47】研究均顯示合適的胸段硬膜外鎮(zhèn)痛能減少腹部大手術(shù)及胸部手術(shù)后呼吸并發(fā)癥（肺不張、肺炎以及呼衰）的發(fā)生。硬膜外鎮(zhèn)痛的獲益程度似乎與患者潛在肺部疾病的嚴(yán)重程度直接成正比，如合并COPD的患者看起來是從硬膜外鎮(zhèn)痛中獲益最多的?！?8】尚未對(duì)高危患者進(jìn)行特別的研究，但是通過對(duì)胸外科手術(shù)患者應(yīng)用椎旁阻滯和硬膜外鎮(zhèn)痛進(jìn)行比較顯示：椎旁阻滯與硬膜外鎮(zhèn)痛效果相當(dāng)，而椎旁阻滯副作用和并發(fā)癥更少?！?9，50】對(duì)于腹部大手術(shù)后出現(xiàn)早期氧飽和度下降的患者，術(shù)后階段積極進(jìn)行物理治療并結(jié)合應(yīng)用CPAP可降低嚴(yán)重呼吸并發(fā)癥的發(fā)生。【51】40.SmetanaGW:Postoperativepulmonarycomplications:Anupdateonriskassessmentandreduction.CleveClinJMed2009;76:S60–5.41.WellerWE,RosatiC:Comparingoutcomesoflaparoscopicversusopenbariatricsurgery.AnnSurg2008;248:10–15.42.RamivohanSM,KamanL,JindalR,SinghR,JindalSK:Postoperativepulmonaryfunctioninlaparoscopicversusopencholecystectomy:Prospective,comparativestudy.IndianJGastroenterol2005;24:6–8.43.DugganM,KavanaghB:Pulmonaryatelectasis:Apathogenicperioperativeentity.Anesthesiology2005;102:834–54.44.TusmanG,BohmSH,Suarez-ShipmanF:Alveolarrecruitmentimprovesventilatoryefficiencyofthelungsduringanesthesia.CanJAnaesth2004;51:723–7.45.BallantyneJC,CarrDB,deFerrantiS:Thecomparativeeffectsofpostoperativeanalgesictherapiesonpulmonaryoutcome:Cumulativemeta-analysisofrandomized,controlledtrials.AnesthAnalg1998;86:598–612.46.LiuSS,WuCL:Effectofpostoperativeanalgesiaonmajorpostoperativecomplications:Asystematicupdateoftheevidence.AnesthAnalg2007;3:689–702.47.RiggJ,JamrozikK,MylesP,etal.:Epiduralanaesthesiaandanalgesiaandoutcomeaftermajorsurgery:Arandomizedtrial.Lancet2002;359:1276–82.48.LickerMJ,WidikkerI,RobertJ,etal.:Operativemortalityandrespiratorycomplicationsafterlungresectionforcancer:Impactofchronicobstructivepulmonarydiseaseandtimetrends.AnnThoracSurg2006;81:1830–8.49.ScarciM,JoshiA,AttiaR:Inpatientsundergoingthoracicsurgeryisparavertebralblockaseffectiveasepiduralanalgesiaforpainmanagement.InteractCardiovascThoracSurg2010;10:92–6.50.DaviesRG,MylesPS,GrahamJM:Acomparisonoftheanalgesicefficacyandsideeffectsofparavertebralvs.epiduralblockadeforthoracotomy—Asystematicreviewandmeta-analysisofrandomizedtrials.BrJAnaesth2006;96:418–26.51.SquadroneV,CohaM,CeruttiE,etal.:Continuouspositiveairwaypressureforthetreatmentofpostoperativehypoxemia:Arandomizedcontrolledtrial.JAMA2005;293:589–95.2、揮發(fā)性麻醉藥在肺保護(hù)中的作用揮發(fā)性麻醉藥具有免疫調(diào)節(jié)功能。近期對(duì)單肺通氣中ALI模型及肺缺血再灌注損傷病例的研究顯示：揮發(fā)性麻醉藥可以作為預(yù)處理或后處理藥物通過抑制促炎調(diào)節(jié)因子的表達(dá)來實(shí)現(xiàn)肺保護(hù)作用【52】。對(duì)內(nèi)毒素介導(dǎo)的動(dòng)物ALI模型進(jìn)行異氟醚預(yù)處理，多型核白細(xì)胞集聚及微血管蛋白漏出的減少證明預(yù)處理產(chǎn)生了保護(hù)作用?！?3】對(duì)活體大鼠ALI模型進(jìn)行七氟醚后處理減輕了肺損傷的程度并保護(hù)了肺功能?！?4】在一項(xiàng)前瞻性研究中，應(yīng)用單肺通氣接受胸外科手術(shù)的患者被隨機(jī)分為丙泊酚組和七氟醚組。通過比較非通氣側(cè)的肺部炎癥標(biāo)志物水平，研究者發(fā)現(xiàn)七氟醚組患者具有較輕的炎癥反應(yīng)?！?5】值得注意的是，七氟醚組患者有更好的臨床轉(zhuǎn)歸且總體不良事件發(fā)生率明顯更低?！?6】一項(xiàng)比較了單肺通氣中分別應(yīng)用地氟醚和丙泊酚麻醉并檢測了通氣側(cè)肺部炎癥反應(yīng)的研究表明：地氟醚組患者的炎癥標(biāo)志物如IL-8,IL-10,PMNelastase和TNFα均明顯更低。

現(xiàn)有結(jié)果確實(shí)已經(jīng)指明：無論是在損傷前、損傷中、還是損傷后應(yīng)用，揮發(fā)性麻醉藥都具有減輕發(fā)生在肺部和受損器官的促炎癥反應(yīng)的作用。52.FujinagaT,NakamuraT,FukuseT,etal.:Isofluraneinhalationaftercirculatoryarrestprotectsagainstwarmischemiareperfusioninjuryofthelungs.Transplantation2006;82:1168–74.53.ReutershanJ,ChangD,HayesJK,LeyK:Protectiveeffectsofisofluranepretreatmentinendotoxin-inducedlunginjury.Anesthesiology2006;104:511–7.54.VoigtsbergerS,LachmannRA,LeutertAC,etal.:Sevofluraneamelioratesgasexchangeandattenuateslungdamageinexperimentallipopolysaccharide-inducedlunginjury.Anesthesiology2009;111:1238–48.55.DeConnoE,SteurerMP,WittlingerM,etal.:Anesthetic-inducedimprovementoftheinflammatoryresponsetoone-lungventilation.Anesthesiology2009;110:1316–26.56.SchillingT,KozianA,KretzschmarM,etal.:Effectsofpropofolanddesfluraneanaesthesiaonthealveolarinflammatoryresponsetoonelungventilation.BrJAnaesth2007;99:368–75.3、超保護(hù)性肺通氣(ULTRAPROTECTIVELUNGVENTILATION)概念：由ALI/ARDS中的保護(hù)性肺通氣發(fā)展而來，應(yīng)用體外肺支持裝置以及近似靜止通氣（near-staticventilation）策略。[57]ARDSNet及動(dòng)物研究數(shù)據(jù)顯示更小的潮氣量（3ml/kg，相比6-12ml/kg）可顯著減輕內(nèi)皮細(xì)胞和上皮細(xì)胞損傷。[58,59]換言之，“保護(hù)性”潮氣量仍可誘發(fā)VILI，而應(yīng)用更小潮氣量時(shí)，存在二氧化碳清除和氧合的問題。Novalung:一種無泵裝置，可在顯著減少分鐘通氣量的同時(shí)糾正PaCO2和pH。一項(xiàng)使用Novalung（潮氣量2.2ml/kg，呼吸頻率每分鐘6次）進(jìn)行通氣的肺切除后ARDS的動(dòng)物模型研究顯示：與傳統(tǒng)的肺保護(hù)性通氣策略相比，Novalung可明顯改善患者的轉(zhuǎn)歸。[60]一系列不同病情的人類病例報(bào)道結(jié)果：Novalung使潮氣量不高于3mL/kg、低吸氣平臺(tái)壓、高PEEP以及低呼吸頻率通氣都成為可能，這減少了VILI和繼發(fā)性遠(yuǎn)隔器官衰竭的發(fā)生。[61]一項(xiàng)對(duì)嚴(yán)重ARDS患者進(jìn)行的隨機(jī)研究顯示：與應(yīng)用常規(guī)通氣策略的患者生存率（47%）相比，應(yīng)用有泵的ECMO結(jié)合保護(hù)性肺通氣可明顯增加患者的生存率（達(dá)63%）。[62]57.TheCardiothoracicSurgeryNetworkwebsite.Availableat:www.CTSN.AccessedJanuary30,2015.58.HagerDN,KrishnanJA,HaydenDL,BrowerRG.ARDSClinicalTrialsNetwork.Tidalvolumereductioninpatientswithacutelunginjurywhenplateaupressuresarenothigh.AmJRespirCritCareMed2005;10:1241–5.59.FrankJA,GutierrezJA,JonesKD,etal.:Lowtidalvolumereducesepithelialandendothelialinjuryinacid-injuredratlungs.AmJRespirCritCareMed2002;165:242–9.60.IglesiasM,JungebluthP,PetitC,etal.:Extracorporeallungmembraneprovidesbetterlungprotectionthanconventionaltreatmentforseverestpneumonectomynoncardiogenicacuterespiratorydistresssyndrome.JThoracCardiovascSurg2008;6:1362–71.61.MallickA,ElliotS,McKinlayJ,BodenhamA:ExtracorporealcarbondioxideremovalusingtheNovalunginapatientwithintracranialbleeding.Anaesthesia2007;62:72–4.62.PeekGJ,MugfordM,TiruvoipatiR,etal.:Efficacyandeconomicassessmentofconventionalventilatorysupportversusextracorporealmembraneoxygenationforsevereadultrespiratoryfailure(CESAR):Amulticentrerandomisedcontrolledtrial.Lancet2009;374:1351–63.4、補(bǔ)液過量靜脈補(bǔ)液一直以來被認(rèn)為可促使患者發(fā)生ALI。麻醉醫(yī)師擔(dān)心胸外科手術(shù)中限制液體可能導(dǎo)致術(shù)后腎功能不全，曾有報(bào)道腎功能不全與高達(dá)19%的死亡率相關(guān)。[63]一項(xiàng)近期對(duì)肺切除患者的回顧性研究發(fā)現(xiàn)：按“急性腎損傷（AKI）Network”的標(biāo)準(zhǔn)，AKI的發(fā)生率為67/1129（6%）。與無AKI發(fā)生的患者相比，AKI并沒有顯示出與死亡率升高存在有顯著統(tǒng)計(jì)學(xué)差異的相關(guān)（3%vs1%）。[64]“第三間隙”很可能并不存在，它可能是早期人體液體腔室研究中測量誤差產(chǎn)生的結(jié)果。[66]胸段硬膜外鎮(zhèn)痛可改善患者的臨床轉(zhuǎn)歸，易導(dǎo)致低血壓。[68]低血壓會(huì)造成腸吻合口缺血，過量補(bǔ)液治療低血壓可能加重這一問題。[69]許多外科醫(yī)生關(guān)注血管收縮藥物對(duì)腸吻合口血流的影響，[70]但是動(dòng)物研究顯示：在正常循環(huán)容量情況下，使用去甲腎上腺素治療術(shù)中低血壓并不會(huì)減少腸道血流。[71，72]68.PathakD,PennefatherSH,RussellGN,etal.:Phenylephrineinfusionimprovesbloodflowtothestomachuringoesophagectomyinthepresenceofathoracicepiduralanalgesia.EurJCardiothoracSurg2013;44:130–3.69.HolteK,SharrockNE,KehletH:Pathophysiologyandclinicalimplicationsofperioperativefluidexcess.BrJAnaesth2002;89:622–32.70.TheodorouD,DrimousisPG,LarentzakisA,etal.:Theeffectsofvasopressorsonperfusionofgastricgraftafteresophagectomy.JGastrointestSurg2008;12:1497–501.71.KlijnE,NiehofS,deJongJ,etal.:Theeffectofperfusionpressureongastrictissuebloodflowinanperimentalgastrictubemodel.AnesthAnalg2010;110:541–6.72.HiltebrandLB,KoepfliE,KimbergerO,SigurdssonGH,BrandtS:Hypotensionduringfluidrestrictedabdominalsurgery.Anesthesiology2011;114:557–64.補(bǔ)液反應(yīng)：接近Frank-Starling曲線的上部轉(zhuǎn)折點(diǎn)時(shí)，心輸出量的很小增加就會(huì)引起肺水含量的大量增加；當(dāng)存在毛細(xì)血管通透性增加的情況下（如膿毒癥時(shí)），這種效應(yīng)可能進(jìn)一步加重?！?6】影響因素：數(shù)量、時(shí)間、液體種類【77】低容量血癥時(shí)，膠體液的血管內(nèi)滯留可達(dá)到90%，正常容量下，這個(gè)數(shù)值僅僅是40%?！?6】76.MarikPE,LemsonJ:Fluidresponsiveness:Anevolutionofourunderstandin