​使用喉罩通气时呼气末正压对气体泄漏和氧合的影响：一项随机试验

使用喉罩通气时呼气末正压对气体泄漏和氧合的影响：一项随机试验

贵州医科大学     麻醉与心脏电生理课题组

翻译：陈锐   编辑：张中伟  审核：曹莹

罂 粟 摘 要 

背景：使用喉罩气道 (LMA) 面罩通气期间呼气末正压 (PEEP)在维持氧合中的作用尚不清楚。为了阐明使用 ProSeal LMA® 面罩在正压通气期间应用PEEP 的潜在益处或危害，我们比较了PEEP与零呼气末压力 (ZEEP) 对气体泄漏和氧合的影响。我们假设与ZEEP相比，8mbar (8.2 cmH2O) 的PEEP与气体泄漏发生率增加有关。

方法：我们设计了一项前瞻性、对照、随机、单盲、多中心的临床试验。年龄 > 18 岁，ASA评分为I/II且无误吸风险增加的患者，计划在全身麻醉下使用LM面罩的行择期手术的患者将被纳入研究。患者被随机分配到使用ZEEP管理的对照组或使用8 mbar PEEP管理的干预组。两组均接受正压通气。主要终点是发生气体泄漏。采用T检验和χ2检验进行统计分析。

结果：ZEEP组共入组174例患者，PEEP组入组208例。两组的气体泄漏发生率没有统计学差异（ZEEP：23/174，13.2%；PEEP：42/208，20.2%；P = .071；优势比 [OR]，1.611；95% 可信区间 [CI ]，0.954–2.891)。然而，PEEP组中有更多患者需要重新调整LMA喉罩（ZEEP：5/174，2.9%；PEEP：18/208，8.7%；P = .018；OR，3.202；95% CI，1.164–8.812）. 需要气管插管的患者在各组之间没有差异（ZEEP：2/174，1.1%；PEEP：7/208，3.4%；P = .190；OR，2.995；95% CI，0.614-14.608）。正压通气 25 分钟后，平均外周血氧饱和度（SpO2) 在PEEP组中高于ZEEP组（98.5 [1.9]% vs 98.0 [1.4]%；P = .01）。峰值压（PIP；16 [2] vs 12 [4] mbar；P < .001）和动态顺应性（57 [14] vs 49 [14] mL/mbar；P < .001）在PEEP组中均较ZEEP组高

结论：使用PEEP不影响气体泄漏的总体发生率。然而，与ZEEP相比，PEEP确实导致重新插入LMA的发生率更高，而抢救插管的发生率在各组之间没有差异。我们得出的结论是，在使用LMA喉罩进行正压通气期间，8 mbar的 PEEP 不会增加整体气体泄漏，但略微改善了气体交换和顺应性。总体而言，本研究研究的数据没有为在择期手术中使用LMA面罩通气期间使用PEEP提供有力的支持或反对的证据。

原始文献来源：Ullmann, Hannah*; Renziehausen, Laura MD*; Geil, Dominik MD†; et.al.Compatibility of left-sided double-lumen endobronchial tubes with tracheal and bronchial dimensions: a retrospective comparative study.[J].Anesthesia&Analgesia:June20,2022-Volume-Issue-10.1213/ANE.0000000000006115doi: 10.1213/ANE.0000000000006115

英文原文

The Influence of Positive End-Expiratory Pressure on  Leakage and Oxygenation Using a Laryngeal Mask  Airway: A Randomized Trial

BACKGROUND: The value of positive end-expiratory pressure (PEEP) in maintaining oxygenation  during ventilation with a laryngeal mask airway (LMA) mask is unclear. To clarify the potential  benefit or harm to PEEP application during positive pressure ventilation with a ProSeal LMA® mask, we compared the effect of PEEP versus zero end-expiratory pressure (ZEEP) on gas leakage and oxygenation. We hypothesized that a PEEP of 8 mbar (8.2 cm H2O) would be associated  with an increased incidence of gas leakage compared to ZEEP. 

METHODS: We designed a prospective, controlled, randomized, single-blinded, multicenter clinical trial. Patients >18 years of age with an American Society of Anesthesiologists (ASA) physical  status I/II without increased risk of aspiration were enrolled if they were scheduled for elective  surgery under general anesthesia with an LMA mask. Patients were randomized to a control  group managed with ZEEP or an intervention group managed with a PEEP of 8 mbar. Both groups  received positive pressure ventilation. The primary end point was the occurrence of gas leakage. The Student t test and χ2 test were used for statistical analysis. 

RESULTS: A total of 174 patients were enrolled in the ZEEP group, and 208 were enrolled in the PEEP  group. The incidence of gas leakage did not differ between the 2 groups (ZEEP: 23/174, 13.2%;  PEEP: 42/208, 20.2%; P = .071; odds ratio [OR], 1.611; 95% confidence interval [CI], 0.954–2.891).  However, more patients required reseating of the LMA mask in the PEEP group (ZEEP: 5/174, 2.9%;  PEEP: 18/208, 8.7%; P = .018; OR, 3.202; 95% CI, 1.164–8.812). The need for endotracheal intubation did not differ between groups (ZEEP: 2/174, 1.1%; PEEP: 7/208, 3.4%; P = .190; OR, 2.995;  95% CI, 0.614–14.608). After positive pressure ventilation for 25 minutes, the mean peripheral  oxygen saturation (Spo2) was higher in the PEEP than in the ZEEP group (98.5 [1.9]% vs 98.0 [1.4]%;  P = .01). Peak inspiratory pressure (PIP; 16 [2] vs 12 [4] mbar; P < .001) and dynamic compliance  (57 [14] vs 49 [14] mL/mbar; P < .001) were both higher in the PEEP group than in the ZEEP group. CONCLUSIONS: Use of PEEP did not affect the overall incidence of gas leakage. However,  PEEP did result in a higher incidence of attempts to reseat the LMA mask compared to ZEEP,  whereas the incidence of rescue intubation did not differ between groups. We concluded that  a PEEP of 8 mbar did not increase overall gas leakage during positive pressure ventilation with  an LMA mask, but it did slightly improve gas exchange and compliance. Overall, our study does  not provide strong arguments for using PEEP during ventilation with an LMA mask in elective  surgery.

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