From the Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine in Seoul, Korea (M.P., H.J.A., J.A.K., M.Y., B.Y.H., J.W.C., Y.R.K., S.H.L., H.J., S.J.C., I.S.S.) Kangwon National University School of Graduate Medicine in Chuncheon, Korea (M.P.).
Anesthesiology. 2019 Mar;130(3):385-393. doi: 10.1097/ALN.0000000000002600.
Driving pressure (plateau minus end-expiratory airway pressure) is a target in patients with acute respiratory distress syndrome, and is proposed as a target during general anesthesia for patients with normal lungs. It has not been reported for thoracic anesthesia where isolated, inflated lungs may be especially at risk.
In a double-blinded, randomized trial (292 patients), minimized driving pressure compared with standard protective ventilation was associated with less postoperative pneumonia or acute respiratory distress syndrome.
Recently, several retrospective studies have suggested that pulmonary complication is related with driving pressure more than any other ventilatory parameter. Thus, the authors compared driving pressure-guided ventilation with conventional protective ventilation in thoracic surgery, where lung protection is of the utmost importance. The authors hypothesized that driving pressure-guided ventilation decreases postoperative pulmonary complications more than conventional protective ventilation.
In this double-blind, randomized, controlled study, 292 patients scheduled for elective thoracic surgery were included in the analysis. The protective ventilation group (n = 147) received conventional protective ventilation during one-lung ventilation: tidal volume 6 ml/kg of ideal body weight, positive end-expiratory pressure (PEEP) 5 cm H2O, and recruitment maneuver. The driving pressure group (n = 145) received the same tidal volume and recruitment, but with individualized PEEP which produces the lowest driving pressure (plateau pressure-PEEP) during one-lung ventilation. The primary outcome was postoperative pulmonary complications based on the Melbourne Group Scale (at least 4) until postoperative day 3.
Melbourne Group Scale of at least 4 occurred in 8 of 145 patients (5.5%) in the driving pressure group, as compared with 18 of 147 (12.2%) in the protective ventilation group (P = 0.047, odds ratio 0.42; 95% CI, 0.18 to 0.99). The number of patients who developed pneumonia or acute respiratory distress syndrome was less in the driving pressure group than in the protective ventilation group (10/145 [6.9%] vs. 22/147 [15.0%], P = 0.028, odds ratio 0.42; 95% CI, 0.19 to 0.92).
Application of driving pressure-guided ventilation during one-lung ventilation was associated with a lower incidence of postoperative pulmonary complications compared with conventional protective ventilation in thoracic surgery.
驱动压（平台压减去呼气末气道压）是急性呼吸窘迫综合征患者的治疗靶点，并且在正常肺患者的全身麻醉中也被提议作为靶点。但是，在胸科麻醉中，驱动压尚未得到报道，因为孤立充气的肺可能特别容易受到影响。
在一项双盲、随机试验中（292 例患者），与标准保护性通气相比，最小化驱动压与术后肺炎或急性呼吸窘迫综合征的发生率降低相关。
最近，几项回顾性研究表明，与任何其他通气参数相比，肺并发症与驱动压的关系更密切。因此，作者比较了在胸科手术中驱动压指导通气与常规保护性通气，在这种手术中，肺保护至关重要。作者假设驱动压指导通气比常规保护性通气更能降低术后肺部并发症。
在这项双盲、随机、对照研究中，纳入了 292 例择期胸科手术患者进行分析。保护性通气组（n = 147）在单肺通气期间接受常规保护性通气：潮气量 6ml/kg 理想体重，呼气末正压（PEEP）5cmH2O，和肺复张手法。驱动压组（n = 145）接受相同的潮气量和肺复张手法，但采用个体化 PEEP，以产生单肺通气时最低的驱动压（平台压-PEEP）。主要结局是基于墨尔本组量表（至少 4 分）至术后第 3 天的术后肺部并发症。
驱动压组 145 例患者中有 8 例（5.5%）发生至少 4 分的墨尔本组量表评分，而保护性通气组 147 例患者中有 18 例（12.2%）（P = 0.047，比值比 0.42；95%CI，0.18 至 0.99）。驱动压组发生肺炎或急性呼吸窘迫综合征的患者数量少于保护性通气组（10/145[6.9%] vs. 22/147[15.0%]，P = 0.028，比值比 0.42；95%CI，0.19 至 0.92）。
与胸科手术中的常规保护性通气相比，在单肺通气期间应用驱动压指导通气与术后肺部并发症发生率降低相关。
