肺切除术单肺通气期间小潮气量通气策略与术后肺部并发症的减少没有相关性
贵州医科大学 麻醉与心脏电生理课题组
翻译：黄祥 编辑：柏雪 审校：曹莹
背景：保护性肺通气策略可能改善接受大手术患者的预后。然而，在单肺通气的情况下，这种策略是否可使患者获益尚未得到证实。本文作者假设单肺通气时使用推荐的保护性通气策略与胸外科手术后肺部并发症发生率的降低独立相关。
方法：本文作者合并了胸外科学会数据库和多中心围手术期数据库中行单肺通气肺切除术的数据，囊括了2012年至2016年间5个医疗中心的数据资料。本文将单肺保护性通气策略定义为中位潮气量≤5 ml / kg（预测体重）且呼气末正压≥5 cm H2O。主要结局指标为术后30天内严重肺部并发症。
结果：本文共3,232例病例纳入分析。在研究期间，潮气量随时间降低（6.7-6.0 ml/kg，P<0.001），呼气末正压随时间增加（4-5 cm/H2O，P<0.001）。尽管应用肺保护性通气策略的患者比例有增长趋势（2012年 5.7% vs. 2016年 17.9%），肺部并发症的发生率并没有明显的变化（11.4%-15.7%, P=0.147）。在倾向性评分匹配队列中（381对匹配病例），保护性通气（平均潮气量6.4 ml/kg vs. 4.4 ml/kg）与术后肺部并发症的减少并没有相关性（校正比值比 [odds ratio, OR]，0.86；95% 置信区间 [confidence interval, CI]，0.56-1.32）。在未匹配队列中，作者并没有找到减少术后肺部并发症的潮气量和呼气末正压的特定组合。
结论：本文通过对胸科手术单肺通气患者的多中心回顾性观察性分析，发现小潮气量肺保护性通气策略与术后肺部并发症并无独立相关性。
原始文献来源 Colquhoun DA,Leis AM,Shanks AM, et al. A Lower Tidal Volume Regimen during One-lung Ventilation for Lung Resection Surgery Is Not Associated with Reduced Postoperative Pulmonary Complications. Anesthesiology. 2021;134 (4):562-576.
A Lower Tidal Volume Regimen during One-lung Ventilation for Lung Resection Surgery Is Not Associated with Reduced Postoperative Pulmonary Complications
Abstract
Background: Protective ventilation may improve outcomes after major surgery. However, in the context of one-lung ventilation, such a strategy is incompletely defined. The authors hypothesized that a putative one-lung protective ventilation regimen would be independently associated with decreased odds of pulmonary complications after thoracic surgery.
Method: The authors merged Society of Thoracic Surgeons Database and Multicenter Perioperative Outcomes Group intraoperative data for lung resection procedures using one-lung ventilation across five institutions from 2012 to 2016. They defined one-lung protective ventilation as the combination of both median tidal volume 5 ml/kg or lower predicted body weight and positive end-expiratory pressure 5 cm H2O or greater. The primary outcome was a composite of 30-day major postoperative pulmonary complications.
Results: A total of 3,232 cases were available for analysis. Tidal volumes decreased modestly during the study period (6.7 to 6.0 ml/kg; P < 0.001), and positive end-expiratory pressure increased from 4 to 5 cm H2O (P < 0.001). Despite increasing adoption of a "protective ventilation" strategy (5.7% in 2012 vs. 17.9% in 2016), the prevalence of pulmonary complications did not change significantly (11.4 to 15.7%; P = 0.147). In a propensity score matched cohort (381 matched pairs), protective ventilation (mean tidal volume 6.4 vs. 4.4 ml/kg) was not associated with a reduction in pulmonary complications (adjusted odds ratio, 0.86; 95% CI, 0.56 to 1.32). In an unmatched cohort, the authors were unable to define a specific alternative combination of positive end-expiratory pressure and tidal volume that was associated with decreased risk of pulmonary complications.
Conclusion: In this multicenter retrospective observational analysis of patients undergoing one-lung ventilation during thoracic surgery, the authors did not detect an independent association between a low tidal volume lung-protective ventilation regimen and a composite of postoperative pulmonary complications.
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