食管癌术后急性肺损伤/急性呼吸窘迫综合征的危险因素分析

Analysis of risk factors for acute lung injury/acute respiratory distress syndrome after esophagectomy

目的:分析食管癌患者手术后急性肺损伤(acute lung injury,ALI)/急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)的发生情况及相关危险因素。方法:回顾性分析北京大学肿瘤医院重症医学科自2010年1月至2016年12月连续收治的422例食管癌手术患者,统计其术后ALI/ARDS的发生情况。以是否发生ALI/ARDS把患者分为ALI/ARDS组和对照组,对比分析两组间临床资料的差异,将差异有统计学意义的因素作为自变量进行Logistic后退法回归分析,探寻ALI/ARDS的独立危险因素。结果:术后共有41例患者发生ALI/ARDS,占所有患者的9. 7%(41/422),ALI/ARDS组与对照组在平均住院天数[(18. 9±9. 7) d vs.(14. 8±3. 6) d,P=0. 011]、需要进行机械通气的患者比例[51. 2%(21/41) vs. 9. 4%(36/381),P <0. 001]、院内死亡率[31. 7%(13/41) vs. 5. 0%(19/381),P <0. 001]方面差异有统计学意义。单因素分析结果显示,吸烟史(P=0. 064)、术前1秒用力呼气容积/用力肺活量(forced expiratory volume in one second/forced vital capacity,FEV1/FVC)(P=0. 020)、肺一氧化碳弥散量(diffusing capacity of the lung for carbon monoxide,DLCO)(P=0. 011)、体重指数(body weight index,BMI)(P=0. 044)、美国麻醉医师协会(American Society of Anesthesiologists,ASA)麻醉风险分级(P=0. 049)及术中单肺通气时间(P=0. 008)在ALI/ARDS组与对照组之间差异有统计学意义。进一步行Logistic多因素回归分析显示,术前FEV1/FVC(OR=1. 053,95%CI 1. 010～1. 098,P=0. 016)、ASA分级(OR=2. 392,95%CI 1. 073～5. 335,P=0. 033)、术中单肺通气时间(min)(OR=0. 994,95%CI 0. 989～0. 999,P=0. 028)是食管癌术后发生ALI/ARDS的独立危险因素。结论:ALI/ARDS是食管癌术后不容忽视的严重并发症,一旦发生将明显增加患者的住院时间及死亡率,术前FEV1/FVC、ASA分级、术中单肺通气时间是食管癌术后发生ALI/ARDS的独立危险因素。术前对患者的充分评估和准备,术中控制单肺通气时间是预防食管癌术后ALI/ARDS发生的关键。

Objective： To explore the incidence and risk factors for the acute lung injury（ ALI）/acute respiratory distress syndrome（ ARDS） after resection of esophageal carcinoma. Methods： We retrospectively analyzed 422 consecutive patients admitted to the Department of Critical Care Medicine with esophageal carcinoma undergoing esophagectomy from January 2010 to December 2016 in Peking University Cancer Hospital. ALI/ARDS were diagnosed,the patients were divided into ALI/ARDS group and control group without ALI/ARDS,the differences of clinical features were contrasted between the two groups,and the multivariate Logistic regression modeling was used to identify the independent risk factors for ALI/ARDS. Results： In the study,41 ALI/ARDS cases were diagnosed,making up 9. 7%（ 41/422） of all the enrolled patients undergoing esophagectomy. Comparisons of the ALI/ARDS group and the control group indicated significant statistical differences in the average length of their hospital stay[（ 18. 9 ± 9. 7） d vs.（ 14. 8 ± 3. 6） d,P = 0. 011],the proportion of the patients who needed mechanical ventilation support [51. 2%（ 21/41） vs. 9. 4%（ 36/381）,P〈0. 001] and in-hospital mortality[31. 7%（ 13/41） vs. 5. 0%（ 19/381）,P〈0. 001]. Univariate analysis showed significant differences between the patients with ALI/ARDS and without ALI/ARDS in smoking history（ P = 0. 064）,preoperative forced expiratory volume in one second/forced vital capacity（ FEV1/FVC）（ P = 0. 020）,diffusing capacity of the lung for carbon monoxide（ DLCO）（ P = 0. 011）,body weight index（ BMI）（ P =0. 044）,American Society of Anesthesiologists（ ASA） physical status classification（ P = 0. 049） and one lung ventilation duration（ P = 0. 008）,while multivariate Logistic regression analysis indicated that preoperative FEV1/FVC（ OR = 1. 053,P = 0. 016,95% CI 1. 010-1. 098）,ASA physical status classification（ OR = 2. 392,P = 0. 033,95% CI 1. 073-5. 335） and one lung ventilation duration（ OR =0. 994,P = 0. 028,95% CI 0. 989-0. 999） were the independent risk factors for ALI/ARDS after esophagectomy. Conclusion： ALI/ARDS was a serious complication in patients undergoing esophagectomy associated with increment in length of hospital stay and in-hospital mortality. Multivariate Logistic regression analysis indicated that preoperative FEV1/FVC,ASA classification and one lung ventilation duration were the independent risk factors for ALI/ARDS after esophagectomy. Carefully assessing the patient before operation,shortening one lung ventilation duration were the key points in preventing ALI/ARDS after esophagectomy.