驱动压导向肺保护性通气策略对成人心脏瓣膜手术术后早期肺功能影响的随机对照研究

Effect of driving pressure-guided lung protective ventilation strategy on early postoperative pulmonary function in adults patients undergoing heart valve surgery: A randomized controlled study

目的旨在评估驱动压导向肺保护性通气策略对成人心脏瓣膜手术术后早期肺功能的影响。方法本研究为随机对照研究。纳入2020年7~10月于四川大学华西医院行择期经胸骨正中切口体外循环下瓣膜手术患者106例。将其随机分为两组,两组均采用容量控制通气模式,对照组(n=53)行传统肺保护性通气策略,呼气末正压(PEEP)=5 cm H2O、潮气量=7 mL/kg(预测体重)、肺复张手法;驱动压组(n=53)采用最小驱动压导向的肺保护性通气策略,PEEP为最小驱动压对应PEEP、潮气量=7 mL/kg(预测体重)、肺复张手法。主要结局指标为术后入ICU氧合指数(oxygen index,OI,根据术后入ICU 30 min内第一个血气结果计算),次要结局指标包括OI<300 mm Hg发生率、OI降低严重程度分级、术后7 d肺部并发症发生率及外科医生对术中机械通气满意度。结果入ICU 30 min内OI两组之间差异有统计学意义[(358.0±65.3)mm Hg vs.(273.5±75.5)mm Hg,95%CI–94.9~41.3,P=0.00]。术后OI<300 mm Hg发生率驱动压组低于对照组(16.9%vs. 49.0%,OR=0.21,95%CI0.08~0.52,P=0.00)。驱动压组OI降低严重程度分级低于对照组(P=0.00)。术后7 d肺部并发症发生率驱动压组与对照组差异无统计学意义(33.9%vs. 28.3%,OR=0.76,95%CI 0.33~1.75,P=0.48),肺不张发生率驱动压组低于对照组(15.0%vs. 1.0%,OR=0.10,95%CI 0.01~0.89,P=0.01)。两组外科医生对术中机械通气满意度差异无统计学意义(98.1%vs. 94.3%,OR=3.13,95%CI 0.31~32.0,P=0.31)。结论经胸骨正中切口体外循环下瓣膜手术患者术中使用驱动压导向的肺保护性通气策略与传统通气策略相比可以改善患者术后入ICU的OI、减少肺功能损伤。

Objective To evaluate the effect of driving pressure-guided lung protective ventilation strategy on lung function in adult patients under elective cardiac surgery with cardiopulmonary bypass.Methods In this randomized controlled trial,106 patients scheduled for elective valve surgery via median sternal incision under cardiopulmonary bypass from July to October 2020 at West China Hospital of Sichuan University were included in final analysis.Patients were divided into two groups randomly.Both groups received volume-controlled ventilation.A protective ventilation group(a control group,n=53)underwent traditional lung protective ventilation strategy with positive end-expiratory pressure(PEEP)of 5 cm H2 O and received conventional protective ventilation with tidal volume of 7 mL/kg of predicted body weight and PEEP of 5 cm H2 O,and recruitment maneuver.An individualized PEEP group(a driving pressure group,n=53)received the same tidal volume and recruitment,but with individualized PEEP which produced the lowest driving pressure.The primary outcome was oxygen index(OI)after ICU admission in 30 minutes,and the secondary outcomes were the incidence of OI below 300 mm Hg,the severity of OI descending scale(the Berlin definition),the incidence of pulmonary complications at 7 days after surgery and surgeons’satisfaction on ventilation.Results There was a statistical difference in OI after ICU admission in 30 minutes between the two groups(273.5±75.5 mm Hg vs.358.0±65.3 mm Hg,P=0.00).The driving pressure group had lower incidence of postoperative OI<300 mm Hg(16.9%vs.49.0%,OR=0.21,95%CI 0.08-0.52,P=0.00)and less severity of OI classification than the control group(P=0.00).The incidence of pulmonary complications at 7 days after surgery was comparable between the driving pressure group and the control group(28.3%vs.33.9%,OR=0.76,95%CI 0.33-1.75,P=0.48).The atelectasis rate was lower in the driving pressure group(1.0%vs.15.0%,OR=0.10,95%CI 0.01-0.89,P=0.01).Conclusion Application of driving pressure-guided ventilation is associated with a higher OI and less lung injury after ICU admission compared with the conventional protective ventilation in patients having valve surgery.