麻醉期间的保护性通气可降低肺癌手术后的主要术后并发症：一项双盲随机对照试验。

Protective ventilation during anaesthesia reduces major postoperative complications after lung cancer surgery: A double-blind randomised controlled trial.

机构信息

From the Department of Anaesthesia and Intensive Care and Intensive Care Medicine, Hôpital Tenon, AP-HP, UPMC-Paris 06, Paris (EM, FB), Department of Anaesthesia and Intensive Care Medicine, Hôtel Dieu, CHU de Nantes, Nantes Cedex (RC), Clinical Research Platform (URC-CRC-CRB), AP-HP Hôpital Saint-Antoine, Paris, France, INSERM, U-698, UPMC-Paris 06, Paris (LB), Critical Care and Anaesthesia Department, CHU Lyon Sud, University Lyon 1, Lyon, France (VP), Department of Anesthesia and Intensive Care Medicine, Princess Grace Hospital, Monaco (Principality), Monaco (JJ), Department of Anaesthesia and Intensive Care Medicine, University Hospital of Besancon, Besancon (BB), Department of Anaesthesia and Intensive Care Medicine, Hôtel Dieu and Cochin University Hospitals, AP-HP, Université Paris Descartes, Paris (DR) and Research Unit INSERM U1046, Saint Eloi University Hospital and Montpellier School of Medicine, Montpellier, France (SJ).

出版信息

Eur J Anaesthesiol. 2018 Oct;35(10):727-735. doi: 10.1097/EJA.0000000000000804.

DOI:10.1097/EJA.0000000000000804

PMID:29561278

Abstract

BACKGROUND

Thoracic surgery for lung resection is associated with a high incidence of postoperative pulmonary complications. Controlled ventilation with a large tidal volume has been documented to be a risk factor for postoperative respiratory complications after major abdominal surgery, whereas the use of low tidal volumes and positive end-expiratory pressure (PEEP) has a protective effect.

OBJECTIVE

To evaluate the effects of ventilation with low tidal volume and PEEP on major complications after thoracic surgery.

DESIGN

A double-blind, randomised controlled study.

SETTING

A multicentre trial from December 2008 to October 2011.

PATIENTS

A total of 346 patients undergoing lobectomy or pneumonectomy for lung cancer.

MAIN OUTCOME MEASURES

The primary outcome was the occurrence of major postoperative complications (pneumonia, acute lung injury, acute respiratory distress syndrome, pulmonary embolism, shock, myocardial infarction or death) within 30 days after surgery.

INTERVENTIONS

Patients were randomly assigned to receive either lung-protective ventilation (LPV group) [tidal volume 5 ml kg ideal body weight + PEEP between 5 and 8 cmH2O] or nonprotective ventilation (control group) (tidal volume 10 ml kg ideal body weight without PEEP) during anaesthesia.

RESULTS

The trial was stopped prematurely because of an insufficient inclusion rate. Major postoperative complications occurred in 23/172 patients in the LPV group (13.4%) vs. 38/171 (22.2%) in the control group (odds ratio 0.54, 95% confidence interval, 0.31 to 0.95, P = 0.03). The incidence of other complications (supraventricular cardiac arrhythmia, bronchial obstruction, pulmonary atelectasis, hypercapnia, bronchial fistula and persistent air leak) was also lower in the LPV group (37.2 vs. 49.4%, odds ratio 0.60, 95% confidence interval, 0.39 to 0.92, P = 0.02).The duration of hospital stay was shorter in the LPV group, 11 [interquartile range, 9 to 15] days vs. 12 [9 to 16] days, P = 0.048.

CONCLUSION

Compared with high tidal volume and no PEEP, LPV combining low tidal volume and PEEP during anaesthesia for lung cancer surgery seems to improve postoperative outcomes.

TRIALS REGISTRATION

ClinicalTrials.gov number: NCT00805077.

摘要

背景

肺切除术的胸外科手术与术后肺部并发症的发生率较高有关。大容量控制通气已被证明是腹部大手术后术后呼吸并发症的危险因素，而小潮气量和呼气末正压通气（PEEP）的使用具有保护作用。

目的

评估小潮气量和 PEEP 通气对胸外科手术后主要并发症的影响。

设计

双盲、随机对照研究。

地点

2008 年 12 月至 2011 年 10 月的多中心试验。

患者

共 346 例因肺癌行肺叶切除术或全肺切除术的患者。

主要观察指标

主要术后并发症（肺炎、急性肺损伤、急性呼吸窘迫综合征、肺栓塞、休克、心肌梗死或死亡）发生的时间为术后 30 天内。

干预措施

患者随机分配接受肺保护性通气（LPV 组）[潮气量 5ml/kg 理想体重+5-8cmH2O 的 PEEP]或非保护性通气（对照组）（潮气量 10ml/kg 理想体重无 PEEP）麻醉期间。

结果

由于纳入率不足，试验提前停止。LPV 组 172 例患者中有 23 例（13.4%）发生主要术后并发症，对照组 171 例患者中有 38 例（22.2%）（优势比 0.54，95%置信区间，0.31 至 0.95，P=0.03）。LPV 组其他并发症（室上性心律失常、支气管阻塞、肺不张、高碳酸血症、支气管胸膜瘘和持续性漏气）的发生率也较低（37.2%比 49.4%，优势比 0.60，95%置信区间，0.39 至 0.92，P=0.02）。LPV 组住院时间较短，11 [四分位距，9 至 15]天比 12 [9 至 16]天，P=0.048。