术中潮气量与术后呼吸系统并发症的相关性取决于呼吸弹性：一项回顾性、多中心队列研究。
Association between intraoperative tidal volume and postoperative respiratory complications is dependent on respiratory elastance: a retrospective, multicentre cohort study.
机构信息
Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Boston, MA, USA; Center for Anaesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Centre, Boston, MA, USA; Department of Anaesthesia and Intensive Care, Faculty of Medicine, University of Jordan, Amman, Jordan.
Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil; Research and Education Institute, Hospital Sírio-Libanes, Sao Paulo, Brazil.
出版信息
Br J Anaesth. 2022 Aug;129(2):263-272. doi: 10.1016/j.bja.2022.05.005. Epub 2022 Jun 9.
BACKGROUND
The impact of high vs low intraoperative tidal volumes on postoperative respiratory complications remains unclear. We hypothesised that the effect of intraoperative tidal volume on postoperative respiratory complications is dependent on respiratory system elastance.
METHODS
We retrospectively recorded tidal volume (Vt; ml kg ideal body weight [IBW]) in patients undergoing elective, non-cardiothoracic surgery from hospital registry data. The primary outcome was respiratory failure (requiring reintubation within 7 days of surgery, desaturation after extubation, or both). The primary exposure was defined as the interaction between Vt and standardised respiratory system elastance (driving pressure divided by Vt; cm HO/[ml kg]). Multivariable logistic regression models, with and without interaction terms (which categorised Vt as low [Vt ≤8 ml kg] or high [Vt >8 ml kg]), were adjusted for potential confounders. Additional analyses included path mediation analysis and fractional polynomial modelling.
RESULTS
Overall, 10 821/197 474 (5.5%) patients sustained postoperative respiratory complications. Higher Vt was associated with greater risk of postoperative respiratory complications (adjusted odds ratio=1.42 per ml kg; 95% confidence interval [CI], 1.35-1.50]; P<0.001). This association was modified by respiratory system elastance (P<0.001); in patients with low compliance (<42.4 ml cm HO), higher Vt was associated with greater risk of postoperative respiratory complications (adjusted risk difference=0.3% [95% CI, 0.0-0.5] at 41.2 ml cm HO compliance, compared with 5.8% [95% CI, 3.8-7.8] at 14 ml cm HO compliance). This association was absent when compliance exceeded 41.2 ml cm HO. Adverse effects associated with high Vt were entirely mediated by driving pressures (P<0.001).
CONCLUSIONS
The association of harm with higher tidal volumes during intraoperative mechanical ventilation is modified by respiratory system elastance. These data suggest that respiratory elastance should inform the design of perioperative trials testing intraoperative ventilatory strategies.
背景
高与低术中潮气量对术后呼吸系统并发症的影响尚不清楚。我们假设术中潮气量对术后呼吸系统并发症的影响取决于呼吸系统顺应性。
方法
我们从医院登记数据中回顾性记录了接受择期非心胸手术患者的潮气量（Vt；ml kg 理想体重[IBW]）。主要结局是呼吸衰竭（术后 7 天内需要重新插管、拔管后缺氧或两者兼有）。主要暴露定义为 Vt 与标准化呼吸系统顺应性（驱动压除以 Vt；cm H2O/[ml kg]）之间的相互作用。多变量逻辑回归模型，包括和不包括交互项（将 Vt 分为低[Vt≤8 ml kg]或高[Vt>8 ml kg]），调整了潜在混杂因素。其他分析包括路径中介分析和分数多项式建模。
结果
共有 10821/197474（5.5%）例患者发生术后呼吸系统并发症。较高的 Vt 与术后呼吸系统并发症风险增加相关（调整后的优势比为每毫升公斤 1.42；95%置信区间[CI]，1.35-1.50]；P<0.001）。这种关联受到呼吸系统顺应性的修饰（P<0.001）；在顺应性较低（<42.4 ml cm H2O）的患者中，较高的 Vt 与术后呼吸系统并发症风险增加相关（在 41.2 ml cm H2O 顺应性时，调整后的风险差异为 0.3%[95%CI，0.0-0.5]，而在 14 ml cm H2O 顺应性时为 5.8%[95%CI，3.8-7.8]）。当顺应性超过 41.2 ml cm H2O 时，这种关联不存在。与高 Vt 相关的不良影响完全由驱动压介导（P<0.001）。
结论
术中机械通气时较高潮气量与伤害的关联受呼吸系统顺应性的调节。这些数据表明，呼吸顺应性应该为测试围手术期通气策略的术中试验设计提供信息。
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