From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan.
Departments of Anesthesiology and Neurosurgery.
Anesth Analg. 2018 Feb;126(2):495-502. doi: 10.1213/ANE.0000000000002642.
Lung-protective ventilation (LPV) has been demonstrated to improve clinical outcomes in surgical patients. There are very limited data on the current use of LPV for patients undergoing 1-lung ventilation (1LV) despite evidence that 1LV may be a particularly important setting for its use. In this multicenter study, we report trends in ventilation practice for patients undergoing 1LV.
The Multicenter Perioperative Outcomes Group database was used to identify patients undergoing 1LV. We retrieved and calculated median initial and overall tidal volume (VT) for the cohort and for high-risk subgroups (female sex, obesity [body mass index >30 kg/m], and short stature), percentage of patients receiving positive end-expiratory pressure (PEEP) ≥5 cm H2O, LPV during 1LV (VT ≤ 6 mL/kg predicted body weight [PBW] and PEEP ≥5 cm H2O), and ventilator driving pressure (ΔP; plateau airway pressure - PEEP).
Data from 5609 patients across 4 institutions were included in the analysis. Median VT was calculated for each case and since the data were normally distributed, the mean is reported for the entire cohort and subgroups. Mean of median VT during 1LV for the cohort was 6.49 ± 1.82 mL/kg PBW. VT (mL/kg PBW) for high-risk subgroups was significantly higher; 6.86 ± 1.97 for body mass index ≥30 kg/m, 7.05 ± 1.92 for female patients, and 7.33 ± 2.01 for short stature patients. Mean of the median VT declined significantly over the study period (from 6.88 to 5.72; P < .001), and the proportion of patients receiving LPV increased significantly over the study period (from 9.1% to 54.6%; P < .001). These changes coincided with a significant decrease in ΔP during the study period, from 19.4 cm H2O during period 1 to 17.3 cm H2O in period 12 (P = .003).
Despite a growing awareness of the importance of protective ventilation, a large proportion of patients undergoing 1LV continue to receive VT PEEP levels outside of recommended thresholds. Moreover, VT remains higher and LPV less common in high-risk subgroups, potentially placing them at elevated risk for iatrogenic lung injury.
保护性通气（LPV）已被证明可改善手术患者的临床结果。尽管有证据表明 1 肺通气（1LV）可能是其使用的一个特别重要的环境，但目前关于 1LV 患者 LPV 使用的数据非常有限。在这项多中心研究中，我们报告了 1LV 患者通气实践的趋势。
使用多中心围手术期结局组数据库确定行 1LV 的患者。我们检索并计算了队列和高危亚组（女性、肥胖[体重指数>30kg/m]和身材矮小）的初始和总体潮气量（VT）中位数、接受呼气末正压（PEEP）≥5cmH2O 的患者百分比、1LV 期间的 LPV（VT≤6mL/kg 预测体重[PBW]和 PEEP≥5cmH2O）以及呼吸机驱动压（ΔP；平台气道压-PEEP）。
来自 4 个机构的 5609 名患者的数据纳入分析。为每个病例计算了中位 VT，由于数据呈正态分布，因此报告了整个队列和亚组的均值。整个队列 1LV 期间的中位 VT 平均值为 6.49±1.82mL/kg PBW。高危亚组的 VT（mL/kg PBW）明显更高；体重指数≥30kg/m 为 6.86±1.97，女性患者为 7.05±1.92，身材矮小患者为 7.33±2.01。研究期间，中位 VT 的均值显著下降（从 6.88 降至 5.72；P<0.001），接受 LPV 的患者比例也显著增加（从 9.1%增至 54.6%；P<0.001）。这些变化与研究期间ΔP 的显著下降相一致，从第 1 期的 19.4cmH2O 降至第 12 期的 17.3cmH2O（P=0.003）。
尽管人们越来越意识到保护性通气的重要性，但仍有很大一部分行 1LV 的患者的 VT-PEEP 水平超出了推荐阈值。此外，高危亚组的 VT 仍然较高，LPV 较少见，他们可能面临更高的医源性肺损伤风险。
