【罂粟摘要】胸腔手术中采用驱动压力引导通气的术后肺部并发症发生率：一项多中心随机临床试验

胸腔手术中采用驱动压力引导通气的术后肺部并发症发生率：一项多中心随机临床试验

贵州医科大学    麻醉与心脏电生理课题组

翻译：柏雪  编辑：潘志军  审校：曹莹

背景：气道驱动压力很容易测量，即平台压力减去PEEP（呼气终末正压），是肺泡压力和张力的替代物。然而，其降低术后肺部并发症发生率的效果仍不清楚。

方法：在这项多中心试验中，接受肺切除手术的患者被随机分为两组，一组是接受肺泡复张和个性化PEEP的驱动压力组（n=650），以提供最低的驱动压力，另一组是固定PEEP为5cm H2O的传统保护性通气组（n = 650）。主要结果是术后7天内出现肺部并发症。

结果：改良的意向治疗分析包括1170名患者（平均值[标准差，SD]；年龄，63[10]岁；47%女性）。驱动压力组的平均驱动压为7.1 cm H2O vs 保护性通气组的平均驱动压为9.2 cm H2O（平均差值[95%可信区间，CI]；-2.1[-2.4 to -1.9]cm H2O；P<0.001）。两组肺部并发症的发生率无差异：驱动压力组（233/576，40.5%）vs保护性通气组（254/594，42.8%）（风险差异-2.3%；95%CI, -8.0% to -3.3%；P=0.42）。术中，驱动压力组的肺顺应性（平均[SD]，42.7[12.4]vs 33.5[11.1]ml cm   H2O -1；P<0.001）和Pao2（动脉氧分压）（中位数[四分位数范围]，21.5[14.5 to 30.4]vs 19.5[13.5to29.1]kPa；P=0.03）较高，补救通气的需要频率较低（6.8%vs 10.8%；P=0.02）。

结论：在肺切除手术中，与传统的保护性通气相比，驱动压力引导通气改善了术中的肺力学，但并没有降低术后肺部并发症的发生率。

原始文献来源：MiHye Park, Susie Yoon, Jae-Sik Nam,et,al. Driving pressure-guided ventilation and postoperative pulmonary complications in thoracic surgery: a multicentre randomised clinical trial. British Journal of Anaesthesia[J] 16 June 2022.

  英文原文

pressure-guided ventilation and postoperative pulmonary complications in thoracic surgery: a multicentre randomised clinical trial

Abstract

Background: Airway driving pressure, easily measured as plateau pressure minus PEEP, is a surrogate for alveolar stress and strain. However, the effect of its targeted reduction remains unclear.

Methods: In this multicentre trial, patients undergoing lung resection surgery were randomised to either a driving pressure group (n=650) receiving an alveolar recruitment/individualised PEEP to deliver the lowest driving pressure or to a conventional protective ventilation group (n=650) with fixed PEEP of 5 cm H2O. The primary outcome was a composite of pulmonary complications within 7 days postoperatively.

Results: The modified intention-to-treat analysis included 1170 patients (mean [standard deviation, SD]; age, 63 [10] yr; 47% female). The mean driving pressure was 7.1 cm H2O in the driving pressure group vs 9.2 cm H2O in the protective ventilation group (mean difference [95% confidence interval, CI]; -2.1 [-2.4 to -1.9] cm H2O; P<0.001). The incidence of pulmonary complications was not different between the two groups: driving pressure group (233/576, 40.5%) vs protective ventilation group (254/594, 42.8%) (risk difference -2.3%; 95% CI, -8.0% to 3.3%; P=0.42). Intraoperatively, lung compliance (mean [SD], 42.7 [12.4] vs 33.5 [11.1] ml cm H2O-1; P<0.001) and Pao2 (median [inter-quartile range], 21.5 [14.5 to 30.4] vs 19.5 [13.5 to 29.1] kPa; P=0.03) were higher and the need for rescue ventilation was less frequent (6.8% vs 10.8%; P=0.02) in the driving pressure group.

Conclusions: In lung resection surgery, a driving pressure-guided ventilation improved pulmonary mechanics intraoperatively, but did not reduce the incidence of postoperative pulmonary complications compared with a conventional protective ventilation.

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