Xuan Chenhao, Wang Dapeng, Jiang Shuyun, Wang Song, Li Zhiyu, Chen Jingyu, Xu Hongyang
Department of Critical Care Medicine, the Affiliated Wuxi People's Hospital of Nanjing Medical University (Wuxi People's Hospital), Wuxi 214023, Jiangsu, China.
Lung Transplant Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University (Wuxi People's Hospital), Wuxi 214023, Jiangsu, China. Corresponding author: Xu Hongyang, Email:
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2024 Dec;36(12):1249-1255. doi: 10.3760/cma.j.cn121430-20240407-00311.
To investigate the correlation between postoperative driving pressure (DP) and the prognosis of lung transplantation, and to further evaluate the value of early DP monitoring in lung transplantation.
A observational study was conducted. The patients after lung transplantation who admitted to the intensive care unit (ICU) of Wuxi People's Hospital from February 1, 2022 to February 1, 2023 were collected. They were divided into low DP group (DP≤15 cmHO, 1 cmHO ≈ 0.098 kPa) and high DP group (DP > 15 cmHO) according to DP within 2 hours after operation. The clinical data including general information, primary disease, chronic diseases, cardiopulmonary function, laboratory indicators, intraoperative condition, postoperative lactic acid (Lac) and ventilator parameters were collected. Primary outcomes included 28-day and 90-day survival, and secondary outcomes included occurrence of primary graft dysfunction (PGD), duration of extracorporeal membrane oxygenation (ECMO), duration of mechanical ventilation, weaning of mechanical ventilation, and length of ICU stay. The general data and observations between the two groups were compared. Kaplan-Meier curve analysis was conducted to analyze the situation of mechanical ventilation and 90-day survival. Receiver operator characteristic curve (ROC curve) was used to evaluate the predictive ability of DP for failed weaning of mechanical ventilation and 90-day death. The dose-response relationship between DP and 90-day death risk was determined by restricted cubic spline model. Univariate analysis was performed using Cox proportional hazards model.
A total of 101 patients were enrolled, with 68 patients (67.3%) in the low DP group and 33 patients (32.7%) in the high DP group. No statistically significant difference in general information, chronic diseases, primary diseases, cardiopulmonary function, laboratory indicators, intraoperative conditions, and postoperative Lac between the two groups was found. Compared with the low DP group, the patients in the high DP group had higher inspiratory pressure (Pinsp) and incidence of PGD with grade 3 at 24 hours after operation [Pinsp (cmHO): 21.0±0.6 vs. 20.0±0.7, PGD with grade 3 at 24 hours: 60.6% (20/33) vs. 39.7% (27/68), both P < 0.05], longer duration of ECMO, duration of mechanical ventilation, and the length of ICU stay [duration of ECMO (hours): 37 (21, 109) vs. 22 (14, 43), duration of mechanical ventilation (days): 3.1 (1.8, 10.7) vs. 1.9 (1.1, 3.2), length of ICU stay (days): 6 (3, 13) vs. 4 (3, 5), all P < 0.05], and lower successful weaning rate of mechanical ventilation [81.8% (27/33) vs. 95.6% (65/68), P < 0.05). The 28-day and 90-day survival rates in the high DP group were significantly higher than those in the low DP group [28-day: 69.7% (23/33) vs. 86.8% (59/68), 90-day: 63.6% (21/33) vs. 83.8% (57/68), both P < 0.05]. Kaplan-Meier curve showed that the patients in the low DP group were weaned and extubated earlier than high DP group, and the cumulative situation of weaning was better (Log-Rank test: χ = 14.054, P < 0.001), and the 90-day cumulative survival rate in the low DP group was significantly higher than that in the high DP group (Log-Rank test: χ = 4.791, P = 0.029). ROC curve analysis showed that the area under ROC curve (AUC) of DP for predicting 90-day death was 0.664 [95% confidence internal (95%CI) was 0.540-0.787, P = 0.017], and the AUC for predicting failed weaning of mechanical ventilation was 0.794 (95%CI was 0.667-0.921, P = 0.004). Results of restricted cubic spline model analysis showed that the 90-day death risk continued to increase with the DP < 18 cmHO; when DP≥18 cmHO, elevated DP did not continue to increase the 90-day death risk, showing a plateau effect. Univariate analysis showed that DP was independent risk factors of 90-day death, and the death risk increased by 9.3% for every 1 cmHO increase in DP [hazard ratio (HR) = 1.093, 95%CI was 1.007-1.186, P = 0.033].
DP is an independent risk factor of death after lung transplantation, and early postoperative DP may be used as a predictor of failed weaning of mechanical ventilation and 90-day death after lung transplantation.
探讨肺移植术后驱动压（DP）与预后的相关性，进一步评估早期DP监测在肺移植中的价值。
进行一项观察性研究。收集2022年2月1日至2023年2月1日入住无锡市人民医院重症监护病房（ICU）的肺移植术后患者。根据术后2小时内的DP将其分为低DP组（DP≤15 cmH₂O，1 cmH₂O≈0.098 kPa）和高DP组（DP>15 cmH₂O）。收集患者的临床资料，包括一般信息、原发疾病、慢性病、心肺功能、实验室指标、术中情况、术后乳酸（Lac）及呼吸机参数等。主要结局指标包括28天和90天生存率，次要结局指标包括原发性移植肺功能障碍（PGD）的发生情况、体外膜肺氧合（ECMO）持续时间、机械通气时间、机械通气撤机情况及ICU住院时间。比较两组间的一般资料和观察指标。采用Kaplan-Meier曲线分析机械通气情况和90天生存率。采用受试者工作特征曲线（ROC曲线）评估DP对机械通气撤机失败和90天死亡的预测能力。采用限制性立方样条模型确定DP与90天死亡风险的剂量反应关系。使用Cox比例风险模型进行单因素分析。
共纳入101例患者，低DP组68例（67.3%），高DP组33例（32.7%）。两组在一般信息、慢性病、原发疾病、心肺功能、实验室指标、术中情况及术后Lac方面差异均无统计学意义。与低DP组相比，高DP组患者术后24小时吸气压力（Pinsp）更高，PGD 3级发生率更高[Pinsp（cmH₂O）：21.0±0.6 vs. 20.0±0.7，术后24小时PGD 3级：60.6%（20/33）vs. 39.7%（27/68），均P<0.05]，ECMO持续时间、机械通气时间及ICU住院时间更长[ECMO持续时间（小时）：37（21，109）vs. 22（14，43），机械通气时间（天）：3.1（1.8，10.7）vs. 1.9（1.1，3.2），ICU住院时间（天）：6（3，13）vs. 4（3，5），均P<0.05]，机械通气撤机成功率更低[81.8%（27/33）vs. 95.6%（65/68），P<0.05]。高DP组28天和90天生存率均显著低于低DP组[28天：69.7%（23/33）vs. 86.8%（59/68），90天：63.6%（21/33）vs.
