胸外科手术中的驱动压力：一项随机临床试验
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Driving Pressure during Thoracic Surgery: A Randomized Clinical Trial
背景与目的
最近，一些回顾性研究表明肺部并发症与驱动压力的关系比其他任何通气参数都要大。因此，作者比较了胸外科手术中驱动压力指导通气和传统的保护性通气与肺部并发症的关系，因为在胸部手术中，肺保护是最重要的。作者假设驱动压力指导通气比传统的保护性通气更能减少术后肺部并发症。
方 法
在这项双盲、随机、对照研究中，共纳入292例择期行开胸手术的患者。保护性通气组(n=147)在单肺通气时采用传统保护性通气：潮气量6 ml/kg理想体重，呼气末正压(PEEP)5 cm H2O，并进行手法肺复张。驱动压力组(n=145)接受相同的潮气量和肺复张，但伴随有个性化的PEEP，其在单肺通气时能产生最低的驱动压力(平台压-PEEP)。主要观察指标是根据墨尔本量表(至少4分)评估术后肺部并发症，直到术后第3天。
结 果
驱动压力组145名患者中有8例（5.5%）出现墨尔本量表≥4分，而保护性通气组147名患者中则有18例（12.2%）（P=0.047，比值比为0.42；95%CI为0.18-0.99）。在驱动压力组发生肺炎或急性呼吸窘迫综合征的患者少于保护性通气组（10/145[6.9%]vs.22/147 [15.0%]，P=0.028，比值比为0.42；95%CI为0.19-0.92）。
结 论
与传统的肺保护性通气相比，在胸外科单肺通气中应用驱动压力引导通气的术后肺部并发症发生率较低。
原始文献摘要
Park M, Ahn HJ, Kim JA, et al. Driving Pressure during Thoracic Surgery: A Randomized Clinical Trial[J]. Anesthesiology, 2019, 130: 385-393.
Background: Recently, several retrospective studies have suggested that pulmonary complication is related with driving pressure more than any other ventilatory parameter. Thus, the authors compared driving pressure–guided ventilation with conventional protective ventilation in thoracic surgery, where lung protection is of the utmost importance. The authors hypothesized that driving pressure–guided ventilation decreases postoperative pulmonary complications more than conventional protective ventilation.
Methods: In this double-blind, randomized, controlled study, 292 patients scheduled for elective thoracic surgery were included in the analysis. The protective ventilation group (n = 147) received conventional protective ventilation during one-lung ventilation: tidal volume 6ml/kg of ideal body weight, positive end-expiratory pressure (PEEP) 5 cm H2O, and recruitment maneuver. The driving pressure group (n = 145) received the same tidal volume and
recruitment, but with individualized PEEP which produces the lowest driving pressure (plateau pressure–PEEP) during one-lung ventilation. The primary outcome was postoperative pulmonary complications based on the Melbourne Group Scale (at least 4) until postoperative day 3.
Results: Melbourne Group Scale of at least 4 occurred in 8 of 145 patients (5.5%) in the driving pressure group, as compared with 18 of 147 (12.2%) in the protective ventilation group (P = 0.047, odds ratio 0.42; 95% CI, 0.18 to 0.99). The number of patients who developed pneumonia or acute respiratory distress syndrome was less in the driving pressure group than in the protective ventilation group (10/145 [6.9%] vs. 22/147 [15.0%], P = 0.028, odds ratio 0.42; 95% CI, 0.19 to 0.92).
Conclusions: Application of driving pressure–guided ventilation during one-lung ventilation was associated with a lower incidence of postoperative pulmonary complications compared with conventional protective ventilation in thoracic surgery.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：何幼芹 编辑：冯玉蓉 审校：王贵龙