[Effects of a lung recruitment maneuver combined with individualized positive end-expiratory pressure on postoperative pulmonary complications and perioperative hemodynamics in hypertensive patients undergoing pulmonary resection].
Researchers
Kechen Shi, Jingwen Gu, Hua Chai, Mingheng Liu, Huaishun Liu, Bingxin Chen, Jiru Zhang
Abstract
A lung recruitment maneuver (LRM) combined with a dynamic lung compliance-guided positive end-expiratory pressure (PEEP) strategy can reduce the risk of postoperative pulmonary complications (PPCs) in patients undergoing pulmonary resection. However, the lung-protective effects of this strategy and its impact on hemodynamics in patients with hypertension remain unclear. This study aims to evaluate the effects of an LRM combined with a dynamic lung compliance-guided PEEP strategy on PPCs and perioperative hemodynamics in hypertensive patients undergoing thoracoscopic pulmonary resection, thereby providing scientific evidence for the safe application of this strategy in this population. A total of 100 hypertensive patients scheduled to undergo thoracoscopic pulmonary resection with one-lung ventilation (OLV) at the Affiliated Hospital of Jiangnan University between November 28, 2024 and August 15, 2025 were enrolled. Using a random number table, the patients were assigned to a conventional protective ventilation group (control group) or an LRM combined with individualized PEEP group (intervention group), with 50 patients in each group. In the control group, intraoperative PEEP was set at 5 cmH<sub>2</sub>O (1 cmH<sub>2</sub>O=0.098 kPa). In the intervention group, an LRM followed by decremental PEEP titration was performed after the initiation of OLV, and the optimal PEEP was determined according to dynamic lung compliance. Before the end of OLV, an LRM was performed once in both groups. The primary outcome was the incidence of PPCs within 5 days after surgery. Secondary outcomes included the incidence of intraoperative hypotension, use of vasoactive drugs, incidence of arrhythmia and hypotension within 5 days after surgery, postoperative renal function indices, and length of postoperative hospital stay. There were no statistically significant differences in preoperative baseline characteristics between the control and intervention groups (all <i>P</i>>0.05). Compared with the control group, the intervention group had higher intraoperative PEEP, lower driving pressure, and slightly higher airway plateau pressure (Pplat), pulse oxygen saturation (SpO<sub>2</sub>), and dynamic lung compliance (all <i>P</i><0.05). The incidence of intraoperative hypotension was higher in the intervention group than in the control group [52% (26/50) vs 30% (15/50), <i>P</i><0.05], as was the intraoperative use of vasoactive drugs [54% (27/50) vs 20% (10/50), <i>P</i><0.05]. No statistically significant differences were observed between the 2 groups in surgical site, type of surgery, heart rate, mean arterial pressure (MAP), pulse pressure variation (PPV), intraoperative fluid volume, respiratory rate, or tidal volume (all <i>P</i>>0.05). The incidence of PPCs was lower in the intervention group than in the control group [22% (11/50) vs 42% (21/50), <i>P</i><0.05]. There were no statistically significant differences between the 2 groups in postoperative arrhythmia, postoperative hypotension, or length of hospital stay (all <i>P</i>>0.05). In both the intervention and control groups, serum creatinine (SCr) and blood urea nitrogen (BUN) levels on postoperative day 1 and BUN levels on postoperative day 3 were higher than their respective preoperative levels (all <i>P</i><0.05). No statistically significant between-group differences were observed in SCr or BUN levels preoperatively or on postoperative days 1, 3, and 5 (all <i>P</i>>0.05). After multivariable logistic regression adjustment for age, body mass index (BMI), hypertension grade, American Society of Anesthesiologists (ASA) physical status, and type of surgery, the risk of intraoperative hypotension in the intervention group was 2.8 times that in the control group (<i>OR</i>=2.8, 95% <i>CI</i> 1.2 to 6.9; <i>P</i><0.05). Subgroup analysis for intraoperative hypotension showed that patients aged ≥65 years, those with a BMI >24 kg/m<sup>2</sup>, grade 3 hypertension, ASA physical status III, or those scheduled to undergo segmentectomy were more likely to develop intraoperative hypotension when receiving the LRM combined with individualized PEEP strategy. An LRM combined with individualized PEEP can reduce the incidence of PPCs. Although this strategy is associated with a higher incidence of intraoperative hypotension, most episodes can be rapidly corrected with timely intervention, are of short duration, and do not adversely affect postoperative cardiac or renal function. Older patients, those with grade 3 hypertension, and overweight patients may be at greater risk of intraoperative hypotension; therefore, enhanced intraoperative hemodynamic monitoring and timely individualized management are warranted. <b>目的</b>: 肺复张策略(lung recruitment maneuver，LRM)联合肺动态顺应性导向的呼气末正压(positive end-expiratory pressure，PEEP)策略可降低肺切除术患者术后肺部并发症(postoperative pulmonary complications，PPCs)风险，然而该策略在高血压患者中的肺保护作用及其对血流动力学的影响尚不明确。本研究旨在评估LRM联合肺动态顺应性导向的PEEP策略对合并高血压的胸腔镜肺切除术患者PPCs和围手术期血流动力学的影响，以期为该策略在此类人群中的安全应用提供科学依据。<b>方法</b>: 选择2024年11月28日至2025年8月15日江南大学附属医院收治的合并高血压、拟在单肺通气下行胸腔镜肺切除术的100例患者，采用随机数字表法将其分为常规保护性通气组(对照组)和LRM联合个体化PEEP组(试验组)，每组50例。对照组术中PEEP设定为5 cmH<sub>2</sub>O (1 cmH<sub>2</sub>O=0.098 kPa);试验组于单肺通气开始后实施LRM联合递减PEEP滴定法，以肺动态顺应性确定最佳PEEP。在单肺通气结束前，2组患者均进行一次LRM操作。主要结局为术后5 d内PPCs发生率。次要结局包括术中低血压发生率、血管活性药物使用、术后5 d内心律失常和低血压发生率、术后肾功能指标及术后住院时间。<b>结果</b>: 对照组和试验组术前基线资料的差异均无统计学意义(均<i>P</i>>0.05)。试验组的术中PEEP高于对照组，驱动压低于对照组，气道平台压(plateau pressure，Pplat)、脉搏氧饱和度(pulse oxygen saturation，SpO<sub>2</sub>)、肺动态顺应性略高于对照组(均<i>P</i><0.05)。试验组术中低血压的发生率高于对照组[52%(26/50) vs 30%(15/50)，<i>P</i><0.05]，术中血管活性药物使用率也高于对照组[54%(27/50) vs 20%(10/50)，<i>P</i><0.05]。2组患者手术部位、手术类型、心率、平均动脉压(mean arterial pressure，MAP)、脉搏压变异度(pulse pressure variation，PPV)、术中补液量、呼吸频率、潮气量方面的差异无统计学意义(均<i>P</i>>0.05)。试验组的PPCs发生率较对照组降低[22%(11/50) vs 42%(21/50)，<i>P</i><0.05]，2组患者的术后心律失常、术后低血压及住院时间方面的差异均无统计学意义(均<i>P</i>>0.05)。试验组与对照组术后1 d的血肌酐(serum creatinine，SCr)和血尿素氮(blood urea nitrogen，BUN)、术后3 d的BUN均高于术前(均<i>P</i><0.05);2组术前与术后1、3、5 d的SCr与BUN差异均无统计学意义(均<i>P</i>>0.05)。经多因素Logistic回归校正年龄、体重指数(body mass index，BMI)、高血压分级、美国麻醉医师协会(American Society of Anesthesiologists，ASA)分级及手术类型后，试验组术中低血压的发生风险为对照组的2.8倍 (<i>OR</i>=2.8，95% <i>CI</i> 1.2~6.9;<i>P</i><0.05)。针对术中低血压的亚组分析显示，对于年龄≥65岁、BMI>24 kg/m<sup>2</sup>、高血压3级、ASA Ⅲ级或拟接受肺段切除手术的患者，在接受LRM联合个体化PEEP策略时更容易发生术中低血压。<b>结论</b>: LRM联合个体化PEEP策略可降低PPCs发生率，虽然术中低血压发生率较高，但经及时干预后多能迅速纠正，持续时间较短，未影响术后心肾功能。高龄、高血压3级及超重患者术中发生低血压的风险可能较高，需加强术中血流动力学监测，并及时进行个体化治疗。.Source: PubMed (PMID: 42763299)View Original on PubMed