个体化肺开放通气策略对行机器人辅助腹腔镜前列腺癌根治术的老年患者术后肺不张的影响

Effect of Individualized Open-Lung Ventilation Strategy on Postoperative Atelectasis among Elderly Patients Receiving Robot-Assisted Radical Prostatectomy

摘要: 目的：探讨对行机器人辅助腹腔镜前列腺癌根治术的老年患者，应用个体化肺开放通气策略对其术后肺不张的影响。方法：前瞻性纳入2025年3月至2025年9月在安徽医科大学第二附属医院行机器人辅助腹腔镜前列腺癌根治术的老年患者72例。患者经随机数字表法被随机分配至个体化肺开放通气策略组(O组)或对照组(C组)。C组施加5 cm H₂O PEEP，O组采用PEEP递增法实施肺复张、然后以驱动压为导向滴定个体化PEEP。比较两组患者于麻醉诱导前(T0)、手术结束时(T5)、拔管后30 min (T6)、拔管后2 h (T7)的肺不张发生率及肺超声评分(LUS)，于麻醉诱导前(T0)、气腹-Trendelenburg体位建立后即刻(T1)、PEEP滴定完成后30 min (T2)、滴定完成后1 h (T3)、2 h (T4)、拔管后30 min (T6)的动脉血氧分压(PaO₂)、氧合指数(OI)、动脉血二氧化碳分压(PaCO₂)以及HR、MAP，T1~T4时的肺动态顺应性(Cdyn)、气道峰压(Ppeak)、气道平台压(Pplat)、驱动压(∆P)，术后1 d (D1)、3 d (D2)、7 d (D3)的肺功能指标。结果：O组36例，年龄(72.4 ± 4.3)岁，C组36例，年龄(71.3 ± 3.6)岁，两组年龄差异无统计学意义(P > 0.05)。O组T6、T7时肺不张发生率均低于C组[分别为19.4% (7/36)比41.7% (15/36)、5.6% (2/36)比25% (9/36)，均P < 0.05]。O组T5~T7时肺超声评分均低于C组，T2~T4时PaCO₂、Ppeak、Pplat、Cdyn均高于C组，T2~T4、T6时PaO₂和OI均高于C组，T2~T4时ΔP均低于C组，D1、D2时FEV1、FVC、FEV1/FVC、PEF均高于C组，差异均有统计学意义(均P < 0.05)。两组术中补液量、血管活性药使用比例差异均无统计学差异(均P > 0.05)。结论：对于行机器人辅助腹腔镜前列腺癌根治术的老年患者，个体化肺开放通气策略的应用能明显降低其术后肺不张发生率，且有效改善术后早期肺功能。

Abstract: Objective: To explore the impact of an individualized open-lung ventilation strategy on atelectasis after surgery among elderly patients following robot-assisted radical prostatectomy. Methods: A total of 72 elderly patients scheduled for robot-assisted laparoscopic radical prostatectomy at the Second Affiliated Hospital of Anhui Medical University from March 2025 to September 2025 were prospectively enrolled. Patients were randomly assigned using a random number table to either the individualized open-lung ventilation strategy group (group O) or the control group (group C). Group O was given the PEEP increment method for lung recruitment and individualized PEEP guided by driving pressure, while Group C was given 5 cm H₂O PEEP. The following parameters were compared between the two groups: the incidence of atelectasis and lung ultrasound score (LUS) before anesthesia induction (T0), at the end of surgery (T5), 30 minutes(T6) and 2 hours(T7) after extubation; arterial oxygen partial pressure (PaO₂), oxygenation index (OI), arterial carbon dioxide partial pressure (PaCO₂), heart rate (HR), and mean arterial pressure (MAP) before anesthesia induction (T0), immediately after establishing pneumoperitoneum-Trendelenburg position (T1), 30 minutes after PEEP titration completion (T2), 1 hour (T3), 2 hours (T4), and 30 minutes after extubation (T6); lung dynamic compliance (Cdyn), peak airway pressure (Ppeak), plateau airway pressure (Pplat), and driving pressure (ΔP) at T1 to T4; and pulmonary function indices on postoperative day 1 (D1), day 3 (D2), and day 7 (D3). Results There were 36 patients in Group O with an average age of (72.4 ± 4.3) years, while Group C included 36 patients aged (71.3 ± 3.6) years. There was no statistically significant difference in age between the two groups (P > 0.05). The incidence of atelectasis in Group O was lower than that in Group C at both T6 and T7 [19.4% (7/36) vs 41.7% (15/36) and 5.6% (2/36) vs 25% (9/36), respectively, all P < 0.05]. The lung ultrasound scores in Group O were lower than those in Group C at T5~T7. PaCO₂, Ppeak, Pplat, and Cdyn were higher in Group O than in Group C at T2~T4. PaO₂ and OI were higher in Group O than in Group C at T2~T4 and T6. ΔP was lower in Group O than in Group C at T2~T4. The forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), peak expiratory flow (PEF), and FEV1/FVC were higher in Group O than in Group C on D1 and D2. All these differences were statistically significant (all P < 0.05). There were no significant differences in intraoperative fluid volume or the proportion of vasoactive drug use between the two groups (all P > 0.05). Conclusion: In elderly patients undergoing robot-assisted laparoscopic radical prostatectomy, the use of an individualized open-lung ventilation strategy was associated with a marked decrease in postoperative atelectasis and enhanced early pulmonary function.