国际麻醉学与复苏杂志   2025, Issue (3): 0-0
    
单肺通气期间肺牵张指数对肺叶切除术后低氧血症的影响
张玉梅, 张滢莹, 向晋贤, 孔霞, 刘力, 王晓斌1()
1.西南医科大学附属医院
Lung stress index during one-lung ventilation is associated with postoperative hypoxemia in patients undergoing lobectomy
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摘要:

目的 探讨单肺通气期间肺牵张指数(stress index,SI)对肺癌患者行肺叶切除术后发生低氧血症的影响。 方法 采用前瞻性队列研究收集2022年7月1日至2022年12月31日在西南医科大学附属医院行电视胸腔镜辅助肺叶切除术患者。所有患者接受双腔气管导管插管、小潮气量肺保护性通气策略、呼气末正压(Positive end expiratory pressure,PEEP)递增法肺复张、同步间歇指令性通气培养自主呼吸,手术全程采用全凭静脉麻醉。采集单肺通气开始5分钟内 SI值,患者招募结束后根据SI平均值按照<0.9,0.9至1.1,>1.1分为低SI、适宜SI、高SI组。主要观察结局为术后第1天到第5天或出院时发生低氧血症的情况,次要观察结局非手术侧不同含气量肺组织的占比。结果 最终72例患者被纳入分析。术后低氧血症的发生率在低SI组为66.7%(24/36),适宜SI组38.1%(8/21),高SI组26.7%(4/15),低SI组发生率明显更高(P=0.029)。术后低氧血症发生风险与年龄、术前氧饱和度、单肺通气时长、肺顺应性、吸气阻力、气道压力、机械功率以及SI相关,其中SI每增加0.1,术后低氧血症发生风险降低30%。高SI组中患者术前和术后第二天过度充气肺组织含量更高,发生术后低氧血症的患者术前不张肺组织含量更高。结论 单肺通气时更低的SI值与更高的术后低氧血症发生率有关,以调控SI至适宜水平为目标的通气策略可能有助于改善胸科患者术后低氧血症的发生。

关键词: 单肺通气;肺牵张指数;肺叶切除术;术后低氧血症
Abstract:

Objective To investigate the association of lung stress index (SI) during one-lung ventilation with postoperative hypoxemia in patients undergoing lobectomy. Methods The prospective cohort study was conducted from July 1, 2022, to December 31, 2022, at the Affiliated Hospital of Southwest Medical University, involving patients undergoing video-assisted thoracoscopic surgery for pulmonary lobectomy. All patients received double-lumen endotracheal tube intubation, lung-protective ventilation strategy, PEEP incremental lung recruitment maneuver, and synchronized intermittent mandatory ventilation during anesthetic emergency. Total intravenous anesthesia was adopted for maintenance. Patients were grouped into low SI, medium SI, and high SI groups according to the mean values of SI recorded within the first 5 minutes during one-lung ventilation (0.9, 0.9 to 1.1, 1.1, respectively). The primary outcome was the occurrence of hypoxemia from postoperative day 1 to day 5 or at discharge, while the secondary outcome was the proportion of lung aeration compartments on the non-operative side. Results A total of 72 patients were finally entered into the analysis. The incidence of postoperative hypoxemia was 66.7% (24/36) in the low SI group, 38.1% (8/21) in the medium SI group, and 26.7% (4/15) in the high SI group, with a significantly higher incidence in the low SI group (P=0.029). The risk of postoperative hypoxemia was associated with age, preoperative oxygen saturation, duration of one-lung ventilation, lung compliance, inspiratory resistance, airway pressure, mechanical power, and SI, with a 30% decrease in risk for every 0.1 increase in SI. The proportion of hyper-aerated lung compartments was greater in patients with high SI, both preoperatively and postoperatively, while the proportion of atelectasis compartment was higher in patients who suffered postoperative hypoxemia. Conclusion Lower SI during one-lung ventilation was associated with a higher incidence of postoperative hypoxemia. Ventilation strategies aimed at maintaining SI at a medium level may reduce the risk of postoperative hypoxemia in patients undergoing thoracic surgery.

Key words: one-lung ventilation; lung stress index; pulmonary lobectomy; postoperative hypoxemia