围术期肺保护性通气策略对食管癌腔镜术后患者肺功能、炎性反应及肺部并发症的影响研究
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摘要
背景食管癌术中高潮气量通气会增加术后肺部并发症发生风险,降低潮气量及增加呼气末正压通气可降低术后肺部并发症发生风险及死亡风险。目的探究围术期肺保护性通气策略对食管癌腔镜术后患者肺功能、炎性反应、肺部并发症的影响。方法选取2015年1月—2017年6月于新疆医科大学第三临床医学院(附属肿瘤医院)行腔镜手术的食管癌患者160例,采用随机数字表法分为对照组和试验组,每组80例。对照组患者围术期实施常规通气方案,试验组患者围术期实施肺保护性通气方案。比较两组患者术前(T_0)、气管插管后(T_1)、手术完毕时(T_2)及术后24 h(T_3)炎性因子[包括白介素6(IL-6)、白介素8(IL-8)、肿瘤坏死因子α(TNF-α)],T_3、术后48 h(T_4)、术后3 d(T_5)呼吸功能指标(包括氧合指数、肺泡-动脉血氧分压差及呼气末二氧化碳分压),并观察两组患者术后30 d内肺部并发症发生情况。结果(1)时间与方法在IL-6、IL-8、TNF-α上存在交互作用(P<0.05),时间、方法在IL-6、IL-8、TNF-α上主效应显著(P<0.05)。两组患者T_1、T_2、T_3时IL-6、IL-8、TNF-α高于T_0时(P<0.05);试验组患者T_1、T_2、T_3时IL-6、IL-8、TNF-α低于对照组(P<0.05)。(2)时间与方法在氧合指数、肺泡-动脉血氧分压差、呼气末二氧化碳分压上存在交互作用(P<0.05),时间、方法在氧合指数、肺泡-动脉血氧分压差、呼气末二氧化碳分压上主效应显著(P<0.05)。两组患者T_4、T_5时氧合指数高于T_3时,肺泡-动脉血氧分压差、呼气末二氧化碳分压低于T_3时(P<0.05);试验组患者T_4、T_5时氧合指数高于对照组,肺泡-动脉血氧分压差、呼气末二氧化碳分压低于对照组(P<0.05)。(3)试验组患者术后30 d内并发症发生率低于对照组(P<0.05)。结论围术期肺保护性通气策略能有效改善食管癌腔镜术后患者肺功能,减轻炎性反应并减少肺部并发症的发生。
Background Intraoperative high-tidal volume ventilation may increase the risk of postoperative pulmonary complications in patients with esophagus cancer,ventilation by reducing the tidal volume or increasing the positive end-expiratory pressure may reduce the risk of postoperative pulmonary complications and death. Objective To investigate the impact of perioperative lung protective ventilation strategy on pulmonary function,inflammatory reaction and pulmonary complications in postoperative esophagus cancer patients underwent endoscopic surgery. Methods A total of 160 esophagus cancer patients underwent endoscopic surgery were selected in the Third Clinical Medical College(the Affiliated Cancer Hospital)of Xinjiang Medical University from January 2015 to June 2017,and they were divided onto control group and test group according to random number table method,with 80 cases in each group. Patients in control group received perioperative conventional ventilation,while patients in test group received perioperative lung protective ventilation. Inflammatory cytokines(including IL-6,IL-8 and TNF-α)before surgery(T_0),immediately after endotracheal intubation(T_1),immediately after surgery(T_2)and 24 hours after surgery(T_3),respiratory function indicators(including oxygenation index,alveolar-arterial partial pressure difference and end-tidal carbon dioxide partial pressure)T_3,48 hours after surgery(T4)and 3 days after surgery(T5)were compared between the two groups,and incidence of pulmonary complications was observed within the 30 days after surgery. Results(1)There was statistically significant interaction between time and method in IL-6,IL-8 and TNF-α(P<0.05),main effects of time and method were statistically significant in IL-6,IL-8 and TNF-α(P<0.05). At T_1,T_2 and T_3,IL-6,IL-8 and TNF-α in the two groups were statistically significantly higher than those at T_0(P<0.05);IL-6,IL-8 and TNF-α in test group were statistically significantly lower than those in control group at T_1,T_2 and T_3(P<0.05).(2)There was statistically significant interaction between time and method in oxygenation index,alveolar-arterial partial pressure difference and end-tidal carbon dioxide partial pressure(P<0.05),main effects of time and method were statistically significant in oxygenation index,alveolar-arterial partial pressure difference and end-tidal carbon dioxide partial pressure(P<0.05). At T4 and T5,oxygenation index in the two groups was statistically significantly higher than that at T_3,respectively,while alveolar-arterial partial pressure difference and end-tidal carbon dioxide partial pressure were statistically significantly lower than those at T_3(P<0.05);at T4 and T5,oxygenation index in test group was statistically significantly higher than that in control group,respectively,while alveolar-arterial partial pressure difference and end-tidal carbon dioxide partial pressure in test group were statistically significantly lower than those in control group(P<0.05).(3)Incidence of postoperative pulmonary complications in test group was statistically significantly lower than that in control group within 30 days after surgery(P<0.05). Conclusion Perioperative lung protective ventilation strategy can effectively improve the pulmonary function,relieve the inflammatory reaction and reduce the risk of complications in postoperative esophagus cancer patients underwent endoscopic surgery.
Background Intraoperative high-tidal volume ventilation may increase the risk of postoperative pulmonary complications in patients with esophagus cancer,ventilation by reducing the tidal volume or increasing the positive end-expiratory pressure may reduce the risk of postoperative pulmonary complications and death. Objective To investigate the impact of perioperative lung protective ventilation strategy on pulmonary function,inflammatory reaction and pulmonary complications in postoperative esophagus cancer patients underwent endoscopic surgery. Methods A total of 160 esophagus cancer patients underwent endoscopic surgery were selected in the Third Clinical Medical College(the Affiliated Cancer Hospital)of Xinjiang Medical University from January 2015 to June 2017,and they were divided onto control group and test group according to random number table method,with 80 cases in each group. Patients in control group received perioperative conventional ventilation,while patients in test group received perioperative lung protective ventilation. Inflammatory cytokines(including IL-6,IL-8 and TNF-α)before surgery(T_0),immediately after endotracheal intubation(T_1),immediately after surgery(T_2)and 24 hours after surgery(T_3),respiratory function indicators(including oxygenation index,alveolar-arterial partial pressure difference and end-tidal carbon dioxide partial pressure)T_3,48 hours after surgery(T4)and 3 days after surgery(T5)were compared between the two groups,and incidence of pulmonary complications was observed within the 30 days after surgery. Results(1)There was statistically significant interaction between time and method in IL-6,IL-8 and TNF-α(P<0.05),main effects of time and method were statistically significant in IL-6,IL-8 and TNF-α(P<0.05). At T_1,T_2 and T_3,IL-6,IL-8 and TNF-α in the two groups were statistically significantly higher than those at T_0(P<0.05);IL-6,IL-8 and TNF-α in test group were statistically significantly lower than those in control group at T_1,T_2 and T_3(P<0.05).(2)There was statistically significant interaction between time and method in oxygenation index,alveolar-arterial partial pressure difference and end-tidal carbon dioxide partial pressure(P<0.05),main effects of time and method were statistically significant in oxygenation index,alveolar-arterial partial pressure difference and end-tidal carbon dioxide partial pressure(P<0.05). At T4 and T5,oxygenation index in the two groups was statistically significantly higher than that at T_3,respectively,while alveolar-arterial partial pressure difference and end-tidal carbon dioxide partial pressure were statistically significantly lower than those at T_3(P<0.05);at T4 and T5,oxygenation index in test group was statistically significantly higher than that in control group,respectively,while alveolar-arterial partial pressure difference and end-tidal carbon dioxide partial pressure in test group were statistically significantly lower than those in control group(P<0.05).(3)Incidence of postoperative pulmonary complications in test group was statistically significantly lower than that in control group within 30 days after surgery(P<0.05). Conclusion Perioperative lung protective ventilation strategy can effectively improve the pulmonary function,relieve the inflammatory reaction and reduce the risk of complications in postoperative esophagus cancer patients underwent endoscopic surgery.
引文
[1]MARRET E,CINOTTI R,BERARD L,et al.Protective ventilation during anaesthesia reduces major postoperative complications after lung cancer surgery:A double-blind randomised controlled trial[J].Eur J Anaesthesiol,2018,12(3):12-17.DOI:10.1097/EJA.0000000000000804.
[2]FUJITA H.Anesthesia of Torek's operation:the first successful resection of a cancer in the thoracic esophagus-an abridged translation of an essay in Japanese[J].Gen Thorac Cardiovasc Surg,2016,65(2):1-5.DOI:10.1007/s11748-016-0739-8.
[3]GHIBOUR A,SHAHEEN O.Breast Metastasis in Esophagus Cancer:Literature Review and Report on a Case[J].Case Rep Surg,2016:8121493.DOI:10.1155/2016/8121493.
[4]MEKONTSO D A,BOISSIER F,CHARRON C,et al.Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome:prevalence,predictors,and clinical impact[J].Intensive Care Med,2016,42(5):862-870.DOI:10.1007/s00134-015-4141-2.
[5]FULLER B M,IAN F,MOHR N M,et al.Lung-protective ventilation initiated in the emergency department(LOV-ED):a study protocol for a quasi-experimental,before-after trial aimed at reducing pulmonary complications[J].BMJ Open,2016,6(4):e010991.DOI:10.1136/bmjopen-2015-010991.
[6]中国抗癌协会食管癌专业委员会.食管癌规范化诊治指南[M].2版.北京:中国协和医科大学出版社,2013.
[7]聂彬,杨明华,陈一丽.双肺通气对胸腔镜联合腹腔镜下食管癌根治术高血压老年患者的影响[J].中国医药指南,2017,15(22):1-3.
[8]TOYAMA H,SAITO K,TAKEI Y,et al.Perioperative management of esophagectomy in a patient who previously underwent bilateral lung transplantation[J].JA Clin Rep,2016,2(1):15.DOI:10.1186/s40981-016-0041-x.
[9]PARK S H.Perioperative lung-protective ventilation strategy reduces postoperative pulmonary complications in patients undergoing thoracic and major abdominal surgery[J].Korean J Anesthesiol,2016,69(1):3-7.DOI:10.4097/kjae.2016.69.1.3.
[10]RUGGIERI F,BERETTA L,CORNO L,et al.Feasibility of Protective Ventilation During Elective Supratentorial Neurosurgery:A Randomized,Crossover,Clinical Trial[J].J Neurosurg Anesthesiol,2018,30(3):246-250.DOI:10.1097/ANA.0000000000000442.
[11]CHIUMELLOD,CONSONNID,COPPOLAS,etal.The occlusiontestsandend-expiratoryesophagealpressure:measurements and comparison in controlled and assisted ventilation[J].Ann Intensive Care,2016,6(1):13.DOI:10.1186/s13613-016-0112-1.
[12]GUERVILLY C,FOREL J M,HRAIECH S,et al.Effect of highfrequency oscillatory ventilation on esophageal and transpulmonary pressures in moderate-to-severe acute respiratory distress syndrome[J].Ann Intensive Care,2016,6(1):84.DOI:10.1186/s13613-016-0181-1.
[13]MCGETTIGAN M J,MENIAS C O,GAO Z J,et al.Imaging of Drug-induced Complications in the Gastrointestinal System[J]. Radiographics,2016,36(1):71-87.DOI:10.1148/rg.2016150132.
[14]FULLER B M,FERGUSON I T,MOHR N M,et al.LungProtective Ventilation Initiated in the Emergency Department(LOV-ED):A Quasi-Experimental,Before-After Trial[J].Ann Emerg Med,2017,70(3):406-418,e4.DOI:10.1016/j.annemergmed.2017.01.013.
[15]KUZKOV V V,RODIONOVA L N,ILYINA Y Y,et al.Protective Ventilation Improves Gas Exchange,Reduces Incidence ofAtelectases,andAffectsMetabolicResponseinMajor Pancreatoduodenal Surgery[J].Front Med(Lausanne),2016,3(2):24-27.DOI:10.3389/fmed.2016.00066.
[16]HYSINGER E B,PANITCH H B.Paediatric Tracheomalacia[J].Paediatr Respir Rev,2016,17:9-15.DOI:10.1016/j.prrv.2015.03.002.
[17]RUMAISA R,AYOUB S I,AHMAD B G,et al.Secondhand Smoking and the Risk of Esophageal Squamous Cell Carcinoma in a High Incidence Region, Kashmir, India[J].Medicine(Baltimore),2016,95(1):e2340.DOI:10.1097/MD.0000000000002340.
[18]SCHWEIGERT M,SOUSA H S,SOLYMOSI N,et al.Spotlight on esophageal perforation:A multinational study using the Pittsburgh esophageal perforation severity scoring system[J].J Thorac Cardiovasc Surg,2016,151(4):1002-1009.DOI:10.1016/j.jtcvs.2015.11.055.
[19]PATERNOT A,REPESSéX,VIEILLARD-BARON A.Rationale and Description of Right Ventricle-Protective Ventilation in ARDS[J].Respir Care,2016,61(10):1391-1396.DOI:10.4187/respcare.04943.
[2]FUJITA H.Anesthesia of Torek's operation:the first successful resection of a cancer in the thoracic esophagus-an abridged translation of an essay in Japanese[J].Gen Thorac Cardiovasc Surg,2016,65(2):1-5.DOI:10.1007/s11748-016-0739-8.
[3]GHIBOUR A,SHAHEEN O.Breast Metastasis in Esophagus Cancer:Literature Review and Report on a Case[J].Case Rep Surg,2016:8121493.DOI:10.1155/2016/8121493.
[4]MEKONTSO D A,BOISSIER F,CHARRON C,et al.Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome:prevalence,predictors,and clinical impact[J].Intensive Care Med,2016,42(5):862-870.DOI:10.1007/s00134-015-4141-2.
[5]FULLER B M,IAN F,MOHR N M,et al.Lung-protective ventilation initiated in the emergency department(LOV-ED):a study protocol for a quasi-experimental,before-after trial aimed at reducing pulmonary complications[J].BMJ Open,2016,6(4):e010991.DOI:10.1136/bmjopen-2015-010991.
[6]中国抗癌协会食管癌专业委员会.食管癌规范化诊治指南[M].2版.北京:中国协和医科大学出版社,2013.
[7]聂彬,杨明华,陈一丽.双肺通气对胸腔镜联合腹腔镜下食管癌根治术高血压老年患者的影响[J].中国医药指南,2017,15(22):1-3.
[8]TOYAMA H,SAITO K,TAKEI Y,et al.Perioperative management of esophagectomy in a patient who previously underwent bilateral lung transplantation[J].JA Clin Rep,2016,2(1):15.DOI:10.1186/s40981-016-0041-x.
[9]PARK S H.Perioperative lung-protective ventilation strategy reduces postoperative pulmonary complications in patients undergoing thoracic and major abdominal surgery[J].Korean J Anesthesiol,2016,69(1):3-7.DOI:10.4097/kjae.2016.69.1.3.
[10]RUGGIERI F,BERETTA L,CORNO L,et al.Feasibility of Protective Ventilation During Elective Supratentorial Neurosurgery:A Randomized,Crossover,Clinical Trial[J].J Neurosurg Anesthesiol,2018,30(3):246-250.DOI:10.1097/ANA.0000000000000442.
[11]CHIUMELLOD,CONSONNID,COPPOLAS,etal.The occlusiontestsandend-expiratoryesophagealpressure:measurements and comparison in controlled and assisted ventilation[J].Ann Intensive Care,2016,6(1):13.DOI:10.1186/s13613-016-0112-1.
[12]GUERVILLY C,FOREL J M,HRAIECH S,et al.Effect of highfrequency oscillatory ventilation on esophageal and transpulmonary pressures in moderate-to-severe acute respiratory distress syndrome[J].Ann Intensive Care,2016,6(1):84.DOI:10.1186/s13613-016-0181-1.
[13]MCGETTIGAN M J,MENIAS C O,GAO Z J,et al.Imaging of Drug-induced Complications in the Gastrointestinal System[J]. Radiographics,2016,36(1):71-87.DOI:10.1148/rg.2016150132.
[14]FULLER B M,FERGUSON I T,MOHR N M,et al.LungProtective Ventilation Initiated in the Emergency Department(LOV-ED):A Quasi-Experimental,Before-After Trial[J].Ann Emerg Med,2017,70(3):406-418,e4.DOI:10.1016/j.annemergmed.2017.01.013.
[15]KUZKOV V V,RODIONOVA L N,ILYINA Y Y,et al.Protective Ventilation Improves Gas Exchange,Reduces Incidence ofAtelectases,andAffectsMetabolicResponseinMajor Pancreatoduodenal Surgery[J].Front Med(Lausanne),2016,3(2):24-27.DOI:10.3389/fmed.2016.00066.
[16]HYSINGER E B,PANITCH H B.Paediatric Tracheomalacia[J].Paediatr Respir Rev,2016,17:9-15.DOI:10.1016/j.prrv.2015.03.002.
[17]RUMAISA R,AYOUB S I,AHMAD B G,et al.Secondhand Smoking and the Risk of Esophageal Squamous Cell Carcinoma in a High Incidence Region, Kashmir, India[J].Medicine(Baltimore),2016,95(1):e2340.DOI:10.1097/MD.0000000000002340.
[18]SCHWEIGERT M,SOUSA H S,SOLYMOSI N,et al.Spotlight on esophageal perforation:A multinational study using the Pittsburgh esophageal perforation severity scoring system[J].J Thorac Cardiovasc Surg,2016,151(4):1002-1009.DOI:10.1016/j.jtcvs.2015.11.055.
[19]PATERNOT A,REPESSéX,VIEILLARD-BARON A.Rationale and Description of Right Ventricle-Protective Ventilation in ARDS[J].Respir Care,2016,61(10):1391-1396.DOI:10.4187/respcare.04943.