Yan Ting, Yu Qing, Li Chun-Qing, Xu Zhen-Zhen, Ma Jia-Hui, Xie Min, Zhu Sai-Nan, Wang Dong-Xin, Li Shuang-Ling
Department of Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China.
Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, China.
Ann Intensive Care. 2025 Aug 18;15(1):121. doi: 10.1186/s13613-025-01531-2.
Postoperative pulmonary complications (PPCs) after major upper abdominal surgery are an important cause of morbidity and mortality. However, existing preoperative risk models inadequately address perioperative factors. Although diaphragmatic ultrasonography offers real-time assessment of respiratory muscle function, its predictive utility for PPCs remains underexplored. This study aimed to evaluate the predictive value of diaphragmatic ultrasound parameters for PPCs and to identify the optimal index among them.
This prospective observational cohort study included patients aged ≥ 50 years who underwent elective upper abdominal surgery under general anesthesia. Right-sided diaphragmatic ultrasound evaluations were performed on preoperative day 1 (PreD1) and on postoperative day 1 (POD1), and measured diaphragm thickening fraction (DTF) and diaphragmatic excursion (DE) during quiet, deep, and sniff breathing. Patients were followed up for 14 days after surgery to assess the incidence of PPCs. Receiver operating characteristic (ROC) analysis and multivariate logistic regression were used to evaluate predictive performance and adjust for confounders.
Among the 223 patients enrolled, 37 (16.6%) developed PPCs. In the entire cohort, all parameters of diaphragmatic ultrasound showed significant postoperative reductions on POD1 compared to preoperative values (P < 0.001). A composite index (post-RDS-DE), calculated as the sum of right DEs during deep breathing and sniff breathing on POD1, demonstrated a moderate predictive ability for PPCs (AUC = 0.680, 95% CI: 0.587-0.773). At a cutoff value of post-RDS-DE < 3.55 cm, the negative predictive value reached 90.6%. After multivariable adjustment, post-RDS-DE < 3.55 cm remained an independent predictor of PPCs (adjusted OR = 2.547, 95% CI: 1.067-6.080; P = 0.035). Integration of diaphragmatic ultrasound index (post-RDS-DE < 3.55 cm) with the ARISCAT significantly improved predictive performance (AUC = 0.751 with integrated model vs. 0.643 with ARISCAT alone; DeLong's P = 0.004).
Postoperative maximal inspiratory diaphragmatic ultrasound measurements during deep and sniff breathing (quantified by a composite index, the post-RDS-DE) effectively predict PPCs following upper abdominal surgery. Integration of post-RDS-DE with preoperative ARISCAT markedly enhances predictive accuracy, suggesting diaphragmatic ultrasonography as a bedside tool for perioperative respiratory risk assessment.
上腹部大手术后的术后肺部并发症（PPCs）是发病和死亡的重要原因。然而，现有的术前风险模型未能充分考虑围手术期因素。尽管膈肌超声可实时评估呼吸肌功能，但其对PPCs的预测效用仍未得到充分探索。本研究旨在评估膈肌超声参数对PPCs的预测价值，并确定其中的最佳指标。
这项前瞻性观察性队列研究纳入了年龄≥50岁、在全身麻醉下接受择期上腹部手术的患者。在术前第1天（PreD1）和术后第1天（POD1）进行右侧膈肌超声评估，测量安静呼吸、深呼吸和嗅气呼吸时的膈肌增厚分数（DTF）和膈肌移动度（DE）。术后对患者进行14天随访，以评估PPCs的发生率。采用受试者操作特征（ROC）分析和多因素逻辑回归来评估预测性能并校正混杂因素。
在纳入的223例患者中，37例（16.6%）发生了PPCs。在整个队列中，与术前值相比，POD1时膈肌超声的所有参数术后均显著降低（P<0.001）。一个复合指数（术后RDS-DE），计算为POD1时深呼吸和嗅气呼吸时右侧DE之和，对PPCs具有中等预测能力（AUC=0.680，95%CI：0.587-0.773）。当术后RDS-DE<3.55 cm时，阴性预测值达到90.6%。多变量调整后，术后RDS-DE<3.55 cm仍然是PPCs的独立预测因素（调整后OR=2.547，95%CI：1.067-6.080；P=0.035）。将膈肌超声指数（术后RDS-DE<3.55 cm）与ARISCAT相结合可显著提高预测性能（综合模型的AUC为0.751，而单独使用ARISCAT时为0.643；DeLong检验P=0.004）。
术后深呼吸和嗅气呼吸时的最大吸气膈肌超声测量值（通过复合指数术后RDS-DE量化）可有效预测上腹部手术后的PPCs。将术后RDS-DE与术前ARISCAT相结合可显著提高预测准确性，提示膈肌超声可作为围手术期呼吸风险评估的床边工具。
