围术期局部通气再分布与术后肺部并发症
本公众号每天分享一篇最新一期Anesthesia & Analgesia等SCI杂志的摘要翻译，敬请关注并提出宝贵意见
Perioperative redistribution of regional ventilation and pulmonary function: a prospective observational study in two cohorts of patients at risk for postoperative pulmonary complications
背景与目的
术后肺部并发症（PPC）增加了外科病人的发病率和死亡率、住院时间和费用。术后背侧肺不张是一种常见的PPC，但其对患者影响的临床意义尚不清楚。肺电阻抗断层扫描（EIT）能够在床旁实时显示肺横切面的局部通气情况。背侧肺不张或积液可能导致腹侧换气重新分布。我们假设行腹部和外周手术自主呼吸患者恢复期间存在腹侧通气再分配，并且如果局部通气转移到腹侧肺区域，则肺活量降低。
方 法
本研究为前瞻性观察试验，纳入了预期PPC的风险为中或高级的69名择期腹部和外周手术成人患者。患者均接受全身麻醉复合或不复合区域麻醉。术前、术后第一天和第三天于休息时和肺活量测定时进行EIT测定肺背侧或腹侧的通气氧合情况。
结 果
两组患者术中均接受低潮气量通气。腹侧换气再分配（术前：16.5（16.0-17.3）；第一天：17.8（16.9-18.2），P<0.004；第三天：17.4（16.2-18.2），P=0.020），肺活量降低，占预测值的百分比（FVC%预测）（中位数：分别为93%、58%、64%）。此外，肺局部通气由背侧到腹侧转移与术后第三天预测的FVC%下降相关（r=-0.66；p<0.001）。外周手术后未观察到肺通气的重新分布。FVC%预测值仅在术后第一天下降（术前、术后第一天和第三天预测的中位FVC%分别为85%、81%和88%）。在10例患者中，腹部手术后出现肺部并发症的患者也有2例在外周手术后出现。
结 论
腹部手术后，腹侧换气的重新分布一直持续到术后第三天，并与肺活量下降有关。外周手术组患者肺部通气只有轻微改变。本研究提示手术部位可对术后肺通气再分布产生影响。
原始文献摘要
Bauer M, Opitz A, Filser J.Perioperative redistribution of regional ventilation and pulmonary function: a prospective observational study in two cohorts of patients at risk for postoperative pulmonary complications.BMC Anesthesiol. 2019 Jul 27;19(1):132.
Background: Postoperative pulmonary complications (PPCs) increase morbidity and mortality of surgical patients, duration of hospital stay and costs. Postoperative atelectasis of dorsal lung regions as a common PPC has been described before, but its clinical relevance is insufficiently examined. Pulmonary electrical impedance tomography (EIT) enables the bedside visualization of regional ventilation in real-time within a transversal section of the lung. Dorsal atelectasis or effusions might cause a ventral redistribution of ventilation. We hypothesized the existence of ventral redistribution in spontaneously breathing patients during their recovery from abdominal and peripheral surgery and that vital capacity is reduced if regional ventilation shifts to ventral lung regions.
Methods: This prospective observational study included 69 adult patients undergoing elective surgery with an expected intermediate or high risk for PPCs. Patients undergoing abdominal and peripheral surgery were recruited to obtain groups of equal size. Patients received general anesthesia with and without additional regional anesthesia. On the preoperative, the first and the third postoperative day, EIT was performed at rest and during spirometry (forced breathing). The center of ventilation in dorso-ventral direction (COVy) was calculated.
Results: Both groups received intraoperative low tidal volume ventilation. Postoperative ventral redistribution of ventilation (forced breathing COVy; preoperative: 16.5 (16.0–17.3); first day: 17.8 (16.9–18.2), p < 0.004; third day: 17.4
(16.2–18.2), p = 0.020) and decreased forced vital capacity in percentage of predicted values (FVC%predicted) (median: 93, 58, 64%, respectively) persisted after abdominal surgery. In addition, dorsal to ventral shift was associated with a
decrease of the FVC%predicted on the third postoperative day (r = − 0.66; p < 0.001). A redistribution of pulmonary ventilation was not observed after peripheral surgery. FVC%predicted was only decreased on the first postoperative
day (median FVC%predicted on the preoperative, first and third day: 85, 81 and 88%, respectively). In ten patients occurred pulmonary complications after abdominal surgery also in two patients after peripheral surgery.
Conclusions: After abdominal surgery ventral redistribution of ventilation persisted up to the third postoperative day and was associated with decreased vital capacity. The peripheral surgery group showed only minor changes in vital capacity, suggesting a role of the location of surgery for postoperative redistribution of pulmonary ventilation.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：王贵龙 编辑：何幼芹 审校：王贵龙