Liu Wenjun, Huang Qian, Lin Duomao, Zhao Liyun, Ma Jun
Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China.
Department of Respiratory Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China.
J Thorac Dis. 2018 May;10(5):2760-2770. doi: 10.21037/jtd.2018.04.90.
Mechanical ventilation, especially large tidal volume (Vt) one-lung ventilation (OLV), can cause ventilator-induced lung injury (VILI) that can stimulate cytokines. Meanwhile, cytokines are considered very important factor influencing coronary heart disease (CHD) patient prognosis. So minimization of pulmonary inflammatory responses by reduction of cytokine levels for CHD undergoing lung resection during OLV should be a priority. Because previous studies have demonstrated that lung-protective ventilation (LPV) reduced lung inflammation, this ventilation approach was studied for CHD patients undergoing lung resection here to evaluate the effects of LPV on pulmonary inflammatory responses.
This is a single center, randomized controlled trial. Primary endpoint of the study are plasma concentrations of tumor necrosis factor-α (TNF-α), interleukin (IL)-6, IL-10 and C-reactive protein (CRP). Secondary endpoints include respiratory variables and hemodynamic variables. 60 CHD patients undergoing video-assisted thoracoscopic lung resection were randomly divided into conventional ventilation group [10 mL/kg Vt and 0 cmHO positive end-expiratory pressure (PEEP), C group] and protective ventilation group (6 mL/kg Vt and 6 cmHO PEEP, P group; 30 patients/group). Hemodynamic variables, peak inspiratory pressure (Ppeak), dynamic compliance (Cdyn), arterial oxygen tension (PaO) and arterial carbon dioxide tension (PaCO) were recorded as test data at three time points: T1-endotracheal intubation for two-lung ventilation (TLV) when breathing and hemodynamics were stable; T2-after TLV was substituted with OLV when breathing and hemodynamics were stable; T3-OLV was substituted with TLV at the end of surgery when breathing and hemodynamics were stable. The concentrations of TNF-α, IL-6, IL-10 and CRP in patients' blood in both groups at the very beginning of OLV (beginning of OLV) and the end moment of the surgery (end of surgery) were measured.
The P group exhibited greater PaO, higher Cdyn and lower Ppeak than the C group at T2, T3 (P<0.05). At the end moment of the surgery, although the P group tended to exhibit higher TNF-α and IL-10 values than the C group, the differences did not reach statistical significance(P=0.0817, P=0.0635). Compared with C group at the end moment of the surgery, IL-6 and CRP were lower in P group, the differences were statistically significant (P=0.0093, P=0.0005). There were no significant differences in hemodynamic variables between the two groups (P>0.05).
LPV can effectively reduce the airway pressure, improve Cdyn and PaO, reduce concentrations of IL-6 and CRP during lung resection of CHD patients. The trial was registered in the Chinese Clinical Trial Registry.
机械通气，尤其是大潮气量（Vt）单肺通气（OLV），可导致呼吸机诱导的肺损伤（VILI），进而刺激细胞因子产生。同时，细胞因子被认为是影响冠心病（CHD）患者预后的非常重要的因素。因此，对于接受肺切除术的冠心病患者，在OLV期间通过降低细胞因子水平来最小化肺部炎症反应应是首要任务。由于先前的研究表明肺保护性通气（LPV）可减轻肺部炎症，故在此对接受肺切除术的冠心病患者研究这种通气方法，以评估LPV对肺部炎症反应的影响。
这是一项单中心随机对照试验。研究的主要终点是血浆肿瘤坏死因子-α（TNF-α）、白细胞介素（IL）-6、IL-10和C反应蛋白（CRP）的浓度。次要终点包括呼吸变量和血流动力学变量。60例接受电视辅助胸腔镜肺切除术的冠心病患者被随机分为传统通气组[Vt为10 mL/kg，呼气末正压（PEEP）为0 cmH₂O，C组]和保护性通气组（Vt为6 mL/kg，PEEP为6 cmH₂O，P组；每组30例患者）。在三个时间点记录血流动力学变量、吸气峰压（Ppeak）、动态顺应性（Cdyn）、动脉血氧分压（PaO）和动脉血二氧化碳分压（PaCO）作为测试数据：T1——双肺通气（TLV）气管插管结束时，呼吸和血流动力学稳定；T2——TLV被OLV替代后，呼吸和血流动力学稳定时；T3——手术结束时OLV被TLV替代，呼吸和血流动力学稳定时。测量两组患者在OLV开始时（OLV开始）和手术结束时（手术结束）血液中TNF-α、IL-6、IL-10和CRP的浓度。
在T2、T3时，P组的PaO更高、Cdyn更高且Ppeak更低，与C组相比差异有统计学意义（P<0.05）。在手术结束时，尽管P组的TNF-α和IL-10值有高于C组的趋势，但差异未达到统计学意义（P = 0.0817，P = 0.0635）。与手术结束时的C组相比，P组的IL-6和CRP更低，差异有统计学意义（P = 0.0093，P = 0.0005）。两组间血流动力学变量无显著差异（P>0.05）。
LPV可有效降低冠心病患者肺切除术中的气道压力，改善Cdyn和PaO，降低IL-6和CRP浓度。该试验已在中国临床试验注册中心注册。
