Department of Surgery, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.
Ann Thorac Surg. 2010 Nov;90(5):1622-8. doi: 10.1016/j.athoracsur.2010.06.089.
Lung transplantation, definitive therapy for end-stage lung disease, is limited long-term by allograft dysfunction including bronchiolitis obliterans syndrome (BOS). Few modifiable risk factors for pulmonary transplant-related mortality are recognized. However, oropharyngeal dysphagia frequently occurs after thoracic surgical procedures, including lung transplantation, and increases morbidity. We evaluated the impact of oropharyngeal dysphagia on survival and BOS after lung transplantation.
A total of 263 consecutive lung transplant patients were reviewed. Each underwent clinical swallowing evaluation early after surgery; 149 patients underwent additional fiberoptic or videofluoroscopic swallowing evaluation (SE). Results of SE were correlated with BOS, defined by accepted criteria, and mortality using Kaplan-Meier survival curves. Cox proportional hazard modeling assessed preoperative and postoperative variables associated with development of BOS and mortality.
Mean follow-up was 920 ± 560 days. The SE identified tracheal aspiration and (or) laryngeal penetration in 70.5%. Preoperative tobacco abuse, gastroesophageal reflux, and cardiopulmonary bypass independently predicted oropharyngeal dysphagia. Peak FEV(1) (forced expiratory volume in the first second of expiration) alone independently predicted BOS (hazard ratio 0.98; confidence interval 0.975 to 0.992, p < 0.0001); oropharyngeal dysphagia was not associated with BOS. Independent predictors of mortality by multivariable analysis were ventilator dependence (p = 0.038) and peak FEV(1) (p < 0.0001); normal SE was associated with improved survival (hazard ratio 0.13; confidence interval 0.03 to 0.54, p = 0.03).
Oropharyngeal dysphagia, often overlooked on clinical examination, is common after lung transplantation. Normal deglutition may improve survival after lung transplantation, but oropharyngeal dysphagia does not independently affect BOS. Institution of protocols aimed at identifying previously unrecognized dysphagia may improve results of pulmonary transplantation.
肺移植是终末期肺病的根治疗法，但长期以来一直受到移植物功能障碍的限制，包括闭塞性细支气管炎综合征（BOS）。目前仅少数可改变的肺移植相关死亡风险因素得到了确认。然而，包括肺移植在内的胸外科手术后常发生口咽吞咽困难，且发病率较高。我们评估了肺移植后口咽吞咽困难对生存和 BOS 的影响。
共回顾了 263 例连续肺移植患者。所有患者均在术后早期接受临床吞咽评估；其中 149 例患者进一步接受了纤维光学或荧光透视吞咽评估（SE）。SE 的结果与接受标准定义的 BOS 和死亡率相关，采用 Kaplan-Meier 生存曲线进行分析。Cox 比例风险模型评估了与 BOS 和死亡率相关的术前和术后变量。
平均随访时间为 920±560 天。SE 发现 70.5%的患者存在气管内吸入和（或）喉内穿透。术前吸烟、胃食管反流和体外循环独立预测口咽吞咽困难。单独的第一秒用力呼气量（forced expiratory volume in the first second of expiration，FEV1）峰值可独立预测 BOS（风险比 0.98；置信区间 0.975 至 0.992，p＜0.0001）；口咽吞咽困难与 BOS 无关。多变量分析的死亡独立预测因素为呼吸机依赖（p=0.038）和 FEV1 峰值（p＜0.0001）；正常 SE 与生存改善相关（风险比 0.13；置信区间 0.03 至 0.54，p=0.03）。
肺移植后，口咽吞咽困难常被临床检查忽视，但较为常见。肺移植后正常吞咽功能可能改善生存，但口咽吞咽困难不会独立影响 BOS。制定旨在识别先前未被识别的吞咽困难的方案可能会改善肺移植的结果。
