肺切除术后保护性肺通气与发病率的倾向性配对分析
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Protective Lung Ventilation and Morbidity After Pulmonary Resection: A Propensity Score-Matched Analysis.
背景与目的
通常推荐用保护性肺通气（PLV）来减少胸腔镜手术的单肺通气（OLV）期间的肺部并发症。然而，只有有限的数据结果来表明在OLV中运用PLV能够有效降低肺切除术后临床肺相关性疾病的发病率。
方 法
前瞻性收集了1080例OLV患者肺切除术，有意限制晶体输注和机械通气，以保持吸气峰值气道压力<30 cm H2O。其他呼吸机设置和麻醉管理的所有方面由麻醉护理团队酌情决定。我们将PLV和非PLV定义为<8或≥8mL / kg（预测体重）平均潮气量。主要指标是发生肺炎和/或急性呼吸窘迫综合征（ARDS）。倾向得分匹配用于产生具有相似特征的PLV和非PLV组。结果与PLV状态之间的关联通过精确的逻辑回归进行分析，在解剖性肺切除和非解剖性肺切除之间进行分类。
结 果
在倾向得分匹配分析中，与PLV组相比，具有解剖性肺切除术的患者中肺炎和/或ARDS的发生率为9/172（5.2％），与PLV组相比为7/172（4.1％;几率比值，1.29; 95％置信区间，0.48-3.45，P = .62）。接受非解剖性肺切除术患者的肺炎和/或ARDS发生率与非PLO组相比，非PLV组为3/118（2.5％），1/118（0.9％;优势比为3.00; 95％置信区间， 0.31-28.84，P = .34）。
结 论
在这项前瞻性观察性研究中，我们发现在潮气量<8或≥8mL / kg的肺切除患者之间肺炎和/或ARDS发生率无差异。我们的数据表明，当晶体限制和气道峰值压力有限时，PLV对该患者群体的临床影响很小。需要未来的随机试验来更好地了解OLV期间小潮气量策略对临床重要结局的益处。
原始文献摘要
AmarD,ZhangH,PedotoA,DesiderioDP,ShiW,TanKS.Protective Lung Ventilation and Morbidity After Pulmonary Resection: A Propensity Score-Matched Analysis.Anesth Analg. 2017 Jul;125(1):190-199. doi: 10.1213/ANE.0000000000002151.
BACKGROUND:
Protective lung ventilation (PLV) during one-lung ventilation (OLV) for thoracic surgery is frequently recommended to reduce pulmonary complications. However, limited outcome data exist on whether PLV use during OLV is associated with less clinically relevant pulmonary morbidity after lung resection.
METHODS:
Intraoperative data were prospectively collected in 1080 patients undergoing pulmonary resection with OLV, intentional crystalloid restriction, and mechanical ventilation to maintain inspiratory peak airway pressure <30 cm H2O. Other ventilator settings and all aspects of anesthetic management were at the discretion of the anesthesia care team. We defined PLV and non-PLV as <8 or ≥8 mL/kg (predicted body weight) mean tidal volume. The primary outcome was the occurrence of pneumonia and/or acute respiratory distress syndrome (ARDS). Propensity score matching was used to generate PLV and non-PLV groups with comparable characteristics. Associations between outcomes and PLV status were analyzed by exact logistic regression, with matching as cluster in the anatomic and nonanatomic lung resection cohorts.
RESULTS:
In the propensity score-matched analysis, the incidence of pneumonia and/or ARDS among patients who had an anatomiclung resection was 9/172 (5.2%) in the non-PLV compared to the PLV group 7/172 (4.1%; odds ratio, 1.29; 95% confidence interval, 0.48-3.45, P= .62). The incidence of pneumonia and/or ARDS in patients who underwent nonanatomic resection was 3/118 (2.5%) in the non-PLV compared to the PLV group, 1/118 (0.9%; odds ratio, 3.00; 95% confidence interval, 0.31-28.84, P= .34).
CONCLUSIONS:
In this prospective observational study, we found no differences in the incidence of pneumonia and/or ARDS between patients undergoing lung resection with tidal volumes <8 or ≥8 mL/kg. Our data suggest that when fluid restriction and peak airway pressures are limited, the clinical impact of PLV in this patient population is small. Future randomized trials are needed to better understand the benefits of a small tidal volume strategy during OLV on clinically important outcomes.
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