[罂粟摘要]驱动压力引导与传统机械通气策略对体外循环心脏手术后肺部并发症的影响：一项随机临床试验

驱动压力引导与传统机械通气策略对体外循环心脏手术后肺部并发症的影响：一项随机临床试验

贵州医科大学  麻醉与心脏电生理课题

翻译:  潘志军  编辑:  严旭  审校: 曹莹

研究目的：术后肺部并发症在心脏外科患者中常见，且与术后预后不良相关。驱动压力引导的通气策略在降低肺部并发症方面的优势尚待明确。我们旨在探讨围术期驱动压力引导的通气策略与传统肺保护性通气策略在体外循环心脏手术后肺部并发症方面的影响。

设计：前瞻性、双臂、随机对照试验。

地点：中国四川省华西大学附属医院。

患者：本研究纳入了择期行体外循环心脏手术的成年患者。

干预措施：接受体外循环心脏手术的患者被随机分为两组，一组接受基于呼气末正压（PEEP）调节的驱动压力引导的通气策略，另一组接受固定5 cmH2O PEEP的传统肺保护性通气策略。

测量：主要结局为术后7天内发生的肺部并发症（包括急性呼吸窘迫综合征、肺不张、肺炎、胸腔积液和气胸），并进行前瞻性识别。次要结局包括肺部并发症严重程度、ICU住院时间、住院死亡率和术后30天死亡率。 

主要结果：2020年8月至2021年7月，我们纳入了694名符合条件的患者进行最终分析。驱动压力组有140例（40.3%）患者发生术后肺部并发症，传统组有142例（40.9%）（相对风险，0.99；95%置信区间，0.82–1.18；P=0.877）。按意向治疗分析显示，两组间主要结局发生率无显著差异。驱动压力组比传统组肺不张发生率低（11.5% vs 17.0%；相对风险，0.68；95%置信区间，0.47–0.98；P=0.039）。两组间次要结局无差异。 

结论：在接受体外循环心脏手术的患者中，使用驱动压力引导的通气策略与传统肺保护性通气策略相比，并未降低术后肺部并发症的风险。

原始文献来源  ：

Xue-Fei Li,Rong-Juan Jiang, Wen-Jie Mao ,et al.The effect of driving pressure-guided versus conventional mechanical ventilation strategy on pulmonary complications following on-pump cardiac surgery: A randomized clinical trial [J]. (J Clin Anesth 2023 Oct;89).

英文原文：

The effect of driving pressure-guided versus conventional mechanical ventilation strategy on pulmonary complications following on-pump cardiac surgery: A randomized clinical trial 

Abstract

Study objective: Postoperative pulmonary complications occur frequently and are associated with worse postoperative outcomes in cardiac surgical patients. The advantage of driving pressure-guided ventilation strategy in decreasing pulmonary complications remains to be definitively established. We aimed to investigate the effect of intraoperative driving pressure-guided ventilation strategy compared with conventional lung-protective ventilation on pulmonary complications following on-pump cardiac surgery. 

Design: Prospective, two-arm, randomized controlled trial. 

Setting: The West China university hospital in Sichuan, China. 

Patients: Adult patients who were scheduled for elective on-pump cardiac surgery were enrolled in the study. 

Interventions: Patients undergoing on-pump cardiac surgery were randomized to receive driving pressure-guided ventilation strategy based on positive end-expiratory pressure (PEEP) titration or conventional lung-protective ventilation strategy with fixed 5 cmH2O of PEEP. 

Measurements: The primary outcome of pulmonary complications (including acute respiratory distress syndrome, atelectasis, pneumonia, pleural effusion, and pneumothorax) within the first 7 postoperative days were prospectively identified. Secondary outcomes included pulmonary complication severity, ICU length of stay, and inhospital and 30-day mortality. 

Main results: Between August 2020 and July 2021, we enrolled 694 eligible patients who were included in the final analysis. Postoperative pulmonary complications occurred in 140 (40.3%) patients in the driving pressure group and 142 (40.9%) in the conventional group (relative risk, 0.99; 95% confidence interval, 0.82–1.18; P =

0.877). Intention-to-treat analysis showed no significant difference between study groups regarding the incidence of primary outcome. The driving pressure group had less atelectasis than the conventional group (11.5% vs 17.0%; relative risk, 0.68; 95% confidence interval, 0.47–0.98; P = 0.039). Secondary outcomes did not differ between groups. 

Conclusion: Among patients who underwent on-pump cardiac surgery, the use of driving pressure-guided ventilation strategy did not reduce the risk of postoperative pulmonary complications when compared with conventional lung-protective ventilation strategy.   

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