肥胖患者术中肺保护性通气的最新进展

Recent Advances in Intraoperative Lung-Protective Ventilation in Obese Patients

摘要: 肥胖患者全身麻醉期间因功能残气量下降与胸壁顺应性降低，极易发生重力依赖区肺泡塌陷与区域通气失衡，进而增加术后肺部并发症(PPCs)的风险。传统的固定参数肺保护性通气策略难以兼顾肺泡开放、防止过度膨胀与维持血流动力学稳定。近年来，该人群术中肺保护策略已由“经验性参数设定”向“个体化精准优化”转变。本文结合最新文献，对小潮气量通气、呼气末正压(PEEP)个体化滴定、肺复张手法以及电阻抗断层成像(EIT)在通气优化中的应用进展进行综述。现有证据表明，小潮气量仍是该人群通气管理的基础；个体化PEEP滴定可显著改善氧合与呼吸力学，而EIT为识别肺内“塌陷与过度膨胀并存”的区域异质性提供了可视化依据；肺复张能带来短期生理学获益，但严重依赖后续PEEP的维持。目前该领域的最大挑战在于，术中生理学指标的改善尚未稳定转化为PPCs等硬性临床结局的获益。未来研究应聚焦于更精细的人群分层与特定的围术期场景，以进一步明确个体化通气策略的临床转归价值。

Abstract: Obese patients undergoing general anesthesia are highly susceptible to gravity-dependent alveolar collapse, regional ventilation heterogeneity, and subsequent postoperative pulmonary complications (PPCs) due to reduced functional residual capacity and decreased chest wall compliance. Conventional lung-protective ventilation strategies utilizing fixed settings often fail to strike an optimal balance among maintaining alveolar recruitment, preventing overdistension, and preserving hemodynamic stability. Recently, the focus of intraoperative ventilatory management in this population has shifted from empiric settings toward individualized precision optimization. This review summarizes the latest advances in low tidal volume ventilation, individualized positive end-expiratory pressure (PEEP) titration, recruitment maneuvers, and the application of electrical impedance tomography (EIT) in ventilatory optimization. Current evidence suggests that low tidal volume remains the cornerstone of ventilatory management in obese patients. Individualized PEEP titration significantly improves oxygenation and respiratory mechanics, while EIT provides a visual basis for identifying regional heterogeneity characterized by the coexistence of alveolar collapse and overdistension. Recruitment maneuvers offer short-term physiological benefits, though their sustained efficacy relies heavily on subsequent PEEP maintenance. The primary challenge in this field is that intraoperative physiological improvements have not yet consistently translated into tangible clinical outcome benefits, such as reduced PPCs. Future studies should focus on more precise patient stratification and specific perioperative scenarios to further elucidate the clinical value of individualized ventilation strategies on patient outcomes.