反比通气对腹腔镜膀胱癌根治术老年患者呼吸力学及术后肺部并发症的影响

Effect of inverse ratio ventilation on respiratory mechanics and postoperative pulmonary complications in elderly patients undergoing laparoscopic radical cystectomy

摘要

目的 探讨反比通气（IRV）对腹腔镜膀胱癌根治术（LRC）老年患者呼吸力学及术后肺部并发症的影响。方法 选取接受 LRC 的老年患者 90 例。按随机数字表法分为三组：对照组、等比组和反比组，每组 30 例。三组患者均采用压力控制容量保证通气模式（PCV-VG），设置潮气量（VT） 6～8 mL/kg（理想体重），5 cmH₂O 呼气末正压（PEEP），吸呼比（I∶E）为 1∶2，吸入氧浓度（FiO₂）为 60%，初始呼吸频率（RR）为 12 次/min。气腹和 Trendelenburg 体位建立后，调整等比组 I∶E 为 1∶1、反比组 I∶E 为 2∶1，对照组 I∶E 仍为 1∶2，至机械通气结束。记录气管插管后 5 min（T₁）、Trendelenburg 体位后 5 min（T₂）、Trendelenburg 体位后 60 min（T₃）、Trendelenburg 体位后 120 min（T₄）、气腹停止即刻（T₅）、术毕即刻（T₆）的气道峰压（Ppeak）、平均气道压（Pmean）、驱动压（ΔP）、呼气末二氧化碳分压（P_ETCO₂）。记录麻醉诱导前（T₀）、T₁～T₆、拔管后 30 min（T₇）的心率（HR）和平均动脉压（MAP）。记录 T₁、T₃、T₆ 三个时点的动脉血氧分压（PaO₂）、动脉血二氧化碳分压（PaCO₂）和酸碱度（pH），计算氧合指数（OI）。记录 T₀ 及 T₇ 时点肿瘤坏死因子 α（TNF-α）、白介素 6（IL-6）水平、克拉拉细胞蛋白 16（CC16）、肺表面活性物质相关蛋白 D（SP-D）的表达含量。记录术后第 1、2、7 天的肺部并发症发生情况。结果 与对照组和等比组相比，反比组 T₁～T₆ 的 Pmean、PaO₂、OI 均有所升高，Ppeak、平台压（Pplat）均有所下降（P＜0.05）；三组间 P_ETCO₂、HR 及 MAP 比较，差异均无统计学意义（P＞0.05）。与 T₀ 时相比，T₇ 时各组 TNF-α、IL-6、CC16、SP-D 水平均升高，差异有统计学意义（P＜0.05）；与对照组和等比组相比，反比组术后各指标升高幅度均更小，差异均有统计学意义（P＜0.05）。三组患者术后肺部并发症（PPCs）发生率差异无统计学意义（P＞0.05）。结论 在老年患者腹腔镜膀胱癌根治术中应用 IRV，可降低术中 Ppeak、提高 Pmean，改善呼吸力学；促进氧合及气体交换；减轻肺损伤和炎症反应，避免术中低氧血症的发生，具有一定的肺保护作用。但并未降低术后肺部并发症的发生率。

Abstract

Objective To investigate the effects of inverse ventilation on respiratory mechanics and postoperative pulmonary complications in elderly patients undergoing laparoscopic radical cystectomy. Methods A total of 90 elderly patients undergoing laparoscopic radical cystectomy were enrolled. Patients were randomly assigned using a random number table to three groups: control group, equal-ratio group, and inverse ratio group, with 30 patients in each group. All patients received pressure-controlled volume-guaranteed ventilation (PCV-VG) with tidal volume (VT) set at 6-8 mL/kg (ideal body weight) and positive end-expiratory pressure (PEEP) of 5 cmH₂O, an inspiratory-to-expiratory ratio (I∶E) of 1∶2, inspired oxygen concentration (FiO₂) to 60%, and initial respiratory rate (RR) to 12 breaths/min. After pneumoperitoneum and Trendelenburg position were established, the I∶E ratio was adjusted to 1∶1 in the equal-ratio group and 2∶1 in the inverse-ratio group, while the control group remained at 1∶2 until the end of mechanical ventilation. Parameters including peak airway pressure (Ppeak), mean airway pressure (Pmean), driving pressure（ΔP）, and end-tidal carbon dioxide pressure (P_ETCO₂) were recorded at the following time points: 5 minutes post-intubation (T₁), 5 minutes post-Trendelenburg position (T₂), 60 minutes post-Trendelenburg position (T₃), 120 minutes post-Trendelenburg position (T₄), immediately after pneumoperitoneum cessation (T₅), and immediately post-surgery (T₆). Heart rate (HR) and mean arterial pressure (MAP) were recorded at pre-induction (T₀), T₁-T₆, and 30 minutes post-extubation (T₇). Arterial partial pressure of oxygen (PaO₂), arterial partial pressure of carbon dioxide (PaCO₂), and pH were recorded at three time points (T₁, T₃, and T₆), and the oxygenation index (OI) was calculated. Tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), Clara cell secretory protein 16 (CC16), and pulmonary surfactant-associated protein D (SP-D) expression levels were recorded at T₀ and T₇. The incidence of pulmonary complications was recorded on postoperative days 1, 2, and 7. Results Compared with the control and equal-ratio groups, the inverse-ratio group exhibited increased Pmean, PaO₂, and OI from T₁ to T₆, and decreased Ppeak and Pplat (P＜0.05). There were no statistically significant differences in P_ETCO₂, HR, or MAP among the three groups (P＞0.05). Compared with T₀, the levels of TNF-α, IL-6, CC16, and SP-D were all elevated at T₇ in all groups, with statistically significant differences (P＜0.05). Compared with the control group and equal-ratio group, the increase of these indicators in the inverse group after surgery was smaller, and the differences were statistically significant (P＜0.05). There was no statistically significant difference in postoperative pulmonary complication incidence among the three groups (P＞0.05). Conclusion In elderly patients undergoing laparoscopic radical cystectomy for bladder cancer, the application of inverse ratio ventilation for respiratory management can reduce peak airway pressure and increase mean airway pressure during surgery, thereby improving respiratory mechanics. It promotes oxygenation and gas exchange, mitigates lung injury and inflammatory response, prevents intraoperative hypoxemia, and provides certain lung protection. However, it does not reduce the incidence of postoperative pulmonary complications.

关键词

反比通气 / 机械通气 / 老年 / 呼吸力学 / 肺部并发症

Key words

inverse ratio ventilation / mechanical ventilation / old age / respiratory mechanics / pulmonary complications

参考文献

[1] Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J]. CA A Cancer J Clin, 2024, 74(3): 229-263. DOI: 10.3322/caac.21834.

[2] 王阳, 杨立新, 李征, 等. 基于年龄—时期—队列模型的 1990—2021 年中国膀胱癌发病与死亡动态及预测[J]. 实用肿瘤杂志, 2025, 40(6): 546-552. DOI: 10.13267/j.cnki.syzlzz.2025.078.

[3] Dyrskjøt L, Hansel DE, Efstathiou JA, et al. Bladder cancer[J]. Nat Rev Dis Primers, 2023, 9: 58. DOI: 10.1038/s41572-023-00468-9.

[4] Guo L, Zhang T, Liang TS, et al. Laparoscopic radical cystectomy with ileal orthotopic neobladder for bladder cancer: current indications and outcomes[J]. Urol Int, 2024, 108(3): 242-253. DOI: 10.1159/000535032.

[5] Huang D, Zhou SJ, Yu ZJ, et al. Lung protective ventilation strategy to reduce postoperative pulmonary complications (PPCs) in patients undergoing robot—assisted laparoscopic radical cystectomy for bladder cancer: a randomized double blinded clinical trial[J]. J Clin Anesth, 2021, 71: 110156. DOI: 10.1016/j.jclinane.2020.110156.

[6] Zhang YN, Cai FC, Ruan ZQ. Respiratory training reduces postoperative pulmonary complications in elderly gynecological patients undergoing general anesthesia[J]. Am J Transl Res, 2025, 17(6): 4612-4621. DOI: 10.62347/VXSR1449.

[7] Yang YC, Huai Q, Cui SZ, et al. Effects of inverse ratio ventilation combined with lung protective ventilation on pulmonary function in patients with severe burns for surgery[J]. Libyan J Med, 2020, 15(1): 1767276. DOI: 10.1080/19932820.2020.1767276.

[8] Wu JH, Niu X, Li M. The effect of inverse ratio ventilation on cardiopulmonary function in obese laparoscopic surgery patients: a systematic review and meta—analysis[J]. Saudi J Anaesth, 2024, 18(1): 77-85. DOI: 10.4103/sja.sja_135_23.

[9] Degeorge KC, Holt HR, Hodges SC. Bladder cancer: diagnosis and treatment[J]. Am Fam Physician, 2017, 96(8): 507-514.

[10] Michalik T, Wróbel M, Fedorowicz S, et al. Bladder cancer in geriatric patients[J]. Med Pr Work Health Saf, 2025, 76(3): 233-239. DOI: 10.13075/mp.5893.01621.

[11] Wen C, Qi Y, Xiang YY, et al. Effect of pressure—controlled ventilation and volume—controlled ventilation for laparoscopic surgery in the Trendelenburg position: a systematic review and meta—analysis[J]. Perioper Med, 2025, 14(1): 56. DOI: 10.1186/s13741-025-00540-w.

[12] 吴京华, 牛雄, 李敏. 反比机械通气对肥胖患者腹腔镜手术肺功能影响的 meta 分析[J]. 重庆医学, 2024, 53(14): 2194-2201. DOI: 10.3969/j.issn.1671-8348.2024.14.022.

[13] 楼海霞, 徐丽丽, 李伟燕. 反比通气在肥胖患者妇科腔镜手术中对呼吸功能的影响[J]. 浙江医学, 2021, 43(16): 1765-1767. DOI: 10.12056/j.issn.1006-2785.2021.43.16.2021-984.

[14] Rahman NNAA, Singh DKA, Lee R. Correlation between thoracolumbar curvatures and respiratory function in older adults[J]. Clin Interv Aging, 2017, 12: 523-529. DOI: 10.2147/CIA.S110329.

[15] 王凡, 唐旺, 陈丽莉, 等. 反比通气对俯卧位腰椎后路手术肺部呼吸力学及术后并发症的影响[J]. 医学研究杂志, 2023, 52(9): 173-177. DOI: 10.11969/j.issn.1673-548X.2023.09.034.

[16] Grieco DL, Russo A, Anzellotti GM, et al. Lung—protective ventilation during Trendelenburg pneumoperitoneum surgery: a randomized clinical trial[J]. J Clin Anesth, 2023, 85: 111037. DOI: 10.1016/j.jclinane.2022.111037.

[17] Gong Y, Liu L, Zhang W. Pressure—controlled inverse ratio ventilation improves gas exchange in obese children undergoing laparoscopic surgery: a randomized controlled study[J]. Am J Transl Res, 2023, 15(11): 6551-6557.

[18] Kim KM, Choi JJ, Lee D, et al. Effects of ventilatory strategy on arterial oxygenation and respiratory mechanics in overweight and obese patients undergoing posterior spine surgery[J]. Sci Rep, 2019, 9: 16638. DOI: 10.1038/s41598-019-53194-2.

[19] Park JH, Lee JS, Lee JH, et al. Effect of the prolonged inspiratory to expiratory ratio on oxygenation and respiratory mechanics during surgical procedures[J]. Medicine, 2016, 95(13): e3269. DOI: 10.1097/md.0000000000003269.

[20] Hsieh MH, Chen PC, Hsu HY, et al. Surfactant protein D inhibits lipid—laden foamy macrophages and lung inflammation in chronic obstructive pulmonary disease[J]. Cell Mol Immunol, 2023, 20(1): 38-50. DOI: 10.1038/s41423-022-00946-2.

[21] Yan T, Li HX, Sun YL, et al. Preventing pulmonary complications after laparoscopic colorectal surgery: a lung—protective protocol vs. standard care: a randomised controlled trial [J]. Eur J Anaesthesiol, 2025, 42(9): 826-839. DOI: 10.1097/eja.0000000000002161.

基金资助

内蒙古自治区卫生健康委 2023 年首府地区公立医院高水平临床专科建设科技项目(2023SGGZ086)

内蒙古自治区自然科学基金项目(2019MS08091)